6 Months or Less Diagnose for a Loved One.

Knowing how to offer comfort and support to a loved one who has a terminal illness can be challenging. What can you say or do? How can you help your loved one cope? How will you deal with your own grief? Get the facts about supporting a loved one who is terminally ill.My loved one has been diagnosed with a terminal illness. How might our relationship change?Your relationship with your loved one might not necessarily change because he or she has a terminal illness. If you're concerned, try to build on your relationship's strengths. It's also important to be open to new possibilities. A loved one's terminal diagnosis might improve your relationship. Or unresolved conflicts might present new challenges.Remember that your loved one is still the same person and will still have the same needs and desires as he or she had before the terminal illness. Many people facing terminal illness want to be treated as normally as possible, without always focusing on the illness.How can I help my loved one cope with a terminal illness?Let your loved one know that you're willing to listen to his or her concerns — and never underestimate the value of your presence. Even if it feels as if you're not doing anything, your presence sends an important message. Don't, however, try to be a counselor.Is there a typical emotional process that a person who has a terminal illness experience?Dying isn't a science. Don't assume that a loved one who has a terminal illness is going to go through a methodical process of coming to terms with death. It might not happen that way.Acceptance or accommodation might be the most desirable outcome of the grieving process — learning to live as fully as possible while accepting the presence of a terminal illness.But does your loved one have to accept that he or she has a terminal illness? Does your loved one have to accept that he or she is going to die before he or she expected? No. There's no right or wrong way to come to terms with death.How do you help a loved one who's in denial about his or her impending death?Denial is an important coping mechanism. Your loved one might be in denial because the reality is too frightening, too overwhelming, or too much of a threat to his or her sense of control. A denial is a form of natural protection that can allow your loved one to let reality in bit by bit and continue living as he or she contemplates death.As long as denial isn't causing your loved one significant harm — such as causing him or her to seek out painful treatments of no therapeutic value — then denial isn't necessarily bad.Your loved one might be afraid of pain. Perhaps your loved one is afraid of losing control of his or her bodily functions, mind or autonomy. Your loved one might also fear failing family or become a burden to others.To provide emotional and spiritual support to your loved one, invite him or her to talk about his or her fears. Sometimes, however, it's easier for a dying person to share what he or she fears and explore it with someone other than a family member, such as a Bereavement Professional as Dr. Nicholas Losito, Ph.D.

What Every Woman Should Know - Cultural Considerations

Major depression and dysthymia affect twice as many women as men. This two-to-one ratio exists regardless of racial and ethnic background or economic status. The same ratio has been reported in ten other countries all over the world. Men and women have about the same rate of bipolar disorder (manic-depression), though its course in women typically has more depressive and fewer manic episodes. Also, a greater number of women have the rapid cycling form of bipolar disorder, which may be more resistant to standard treatments.
A variety of factors unique to women's lives are suspected to play a role in developing depression. Research is focused on understanding these, including: reproductive, hormonal, genetic or other biological factors; abuse and oppression; interpersonal factors; and certain psychological and personality characteristics. And yet, the specific causes of depression in women remain unclear; many women exposed to these factors do not develop depression. What is clear is that regardless of the contributing factors, depression is a highly treatable illness.

The Many Dimensions of Depression in Women

Investigators are focusing on the following areas in their study of depression in women:

The Issues of Adolescence

Before adolescence, there is little difference in the rate of depression in boys and girls. But between the ages of 11 and 13 there is a precipitous rise in depression rates for girls. By the age of 15, females are twice as likely to have experienced a major depressive episode as males. This comes at a time in adolescence when roles and expectations change dramatically. The stresses of adolescence include forming an identity, emerging sexuality, separating from parents, and making decisions for the first time, along with other physical, intellectual, and hormonal changes. These stresses are generally different for boys and girls, and may be associated more often with depression in females. Studies show that female high school students have significantly higher rates of depression, anxiety disorders, eating disorders, and adjustment disorders than male students, who have higher rates of disruptive behavior disorders.

Adulthood: Relationships and Work Roles

Stress in general can contribute to depression in persons biologically vulnerable to the illness. Some have theorized that higher incidence of depression in women is not due to greater vulnerability, but to the particular stresses that many women face. These stresses include major responsibilities at home and work, single parenthood, and caring for children and aging parents. How these factors may uniquely affect women is not yet fully understood.
For both women and men, rates of major depression are highest among the separated and divorced, and lowest among the married, while remaining always higher for women than for men. The quality of a marriage, however, may contribute significantly to depression. Lack of an intimate, confiding relationship, as well as overt marital disputes, have been shown to be related to depression in women. In fact, rates of depression were shown to be highest among unhappily married women.

Reproductive Events

Women's reproductive events include the menstrual cycle, pregnancy, the postpregnancy period, infertility, menopause, and sometimes, the decision not to have children. These events bring fluctuations in mood that for some women include depression. Researchers have confirmed that hormones have an effect on the brain chemistry that controls emotions and mood; a specific biological mechanism explaining hormonal involvement is not known, however.
Many women experience certain behavioral and physical changes associated with phases of their menstrual cycles. In some women, these changes are severe, occur regularly, and include depressed feelings, irritability, and other emotional and physical changes. Called premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), the changes typically begin after ovulation and become gradually worse until menstruation starts. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.
Postpartum mood changes can range from transient "baby blues" immediately following childbirth to an episode of major depression to severe, incapacitating, psychotic depression. Studies suggest that women who experience major depression after childbirth very often have had prior depressive episodes even though they may not have been diagnosed and treated.
Pregnancy (if it is desired) seldom contributes to depression, and having an abortion does not appear to lead to a higher incidence of depression. Women with infertility problems may be subject to extreme anxiety or sadness, though it is unclear if this contributes to a higher rate of depressive illness. In addition, motherhood may be a time of heightened risk for depression because of the stress and demands it imposes.
Menopause, in general, is not asssociated with an increased risk of depression. In fact, while once considered a unique disorder, research has shown that depressive illness at menopause is no different than at other ages. The women more vulnerable to change-of-life depression are those with a history of past depressive episodes.

Specific Cultural Considerations

As for depression in general, the prevalence rate of depression in African American and Hispanic women remains about twice that of men. There is some indication, however, that major depression and dysthymia may be diagnosed less frequently in African American and slightly more frequently in Hispanic than in Caucasian women. Prevalence information for other racial and ethnic groups is not definitive.
Possible differences in symptom presentation may affect the way depression is recognized and diagnosed among minorities. For example, African Americans are more likely to report somatic symptoms, such as appetite change and body aches and pains. In addition, people from various cultural backgrounds may view depressive symptoms in different ways. Such factors should be considered when working with women from special populations.

Victimization

Studies show that women molested as children are more likely to have clinical depression at some time in their lives than those with no such history. In addition, several studies show a higher incidence of depression among women who have been raped as adolescents or adults. Since far more women than men were sexually abused as children, these findings are relevant. Women who experience other commonly occurring forms of abuse, such as physical abuse and sexual harassment on the job, also may experience higher rates of depression. Abuse may lead to depression by fostering low self-esteem, a sense of helplessness, self-blame, and social isolation. There may be biological and environmental risk factors for depression resulting from growing up in a dysfunctional family. At present, more research is needed to understand whether victimization is connected specifically to depression.

Poverty

Women and children represent seventy-five percent of the U.S. population considered poor. Low economic status brings with it many stresses, including isolation, uncertainty, frequent negative events, and poor access to helpful resources. Sadness and low morale are more common among persons with low incomes and those lacking social supports. But research has not yet established whether depressive illnesses are more prevalent among those facing environmental stressors such as these.

Depression in Later Adulthood

At one time, it was commonly thought that women were particularly vulnerable to depression when their children left home and they were confronted with "empty nest syndrome" and experienced a profound loss of purpose and identity. However, studies show no increase in depressive illness among women at this stage of life.
As with younger age groups, more elderly women than men suffer from depressive illness. Similarly, for all age groups, being unmarried (which includes widowhood) is also a risk factor for depression. Most important, depression should not be dismissed as a normal consequence of the physical, social, and economic problems of later life. In fact, studies show that most older people feel satisfied with their lives.
About 800,000 persons are widowed each year. Most of them are older, female, and experience varying degrees of depressive symptomatology. Most do not need formal treatment, but those who are moderately or severely sad appear to benefit from self-help groups or various psychosocial treatments. However, a third of widows/widowers do meet criteria for major depressive episode in the first month after the death, and half of these remain clinically depressed 1 year later. These depressions respond to standard antidepressant treatments, although research on when to start treatment or how medications should be combined with psychosocial treatments is still in its early stages.













Even severe depression can be highly responsive to treatment. Indeed, believing one's condition is "incurable" is often part of the hopelessness that accompanies serious depression. Such individuals should be provided with the information about the effectiveness of modern treatments for depression in a way that acknowledges their likely skepticism about whether treatment will work for them. As with many illnesses, the earlier treatment begins, the more effective and the greater the likelihood of preventing serious recurrences. Of course, treatment will not eliminate life's inevitable stresses and ups and downs. But it can greatly enhance the ability to manage such challenges and lead to greater enjoyment of life.
The first step in treatment for depression should be a thorough examination to rule out any physical illnesses that may cause depressive symptoms. Since certain medications can cause the same symptoms as depression, the examining physician should be made aware of any medications being used. If a physical cause for the depression is not found, a psychological evaluation should be conducted by the physician or a referral made to a mental health professional.

Types of Treatment for Depression

The most commonly used treatments for depression are antidepressant medication, psychotherapy, or a combination of the two. Which of these is the right treatment for any one individual depends on the nature and severity of the depression and, to some extent, on individual preference. In mild or moderate depression, one or both of these treatments may be useful, while in severe or incapacitating depression, medication is generally recommended as a first step in the treatment.³ In combined treatment, medication can relieve physical symptoms quickly, while psychotherapy allows the opportunity to learn more effective ways of handling problems.

Antidepressant Medications

There are several types of antidepressant medications used to treat depressive disorders. These include newer medications-chiefly the selective serotonin reuptake inhibitors (SSRIs)-and the tricyclics and monoamine oxidase inhibitors (MAOIs). The SSRIs-and other newer medications that affect neurotransmitters such as dopamine or norepinephrine-generally have fewer side effects than tricyclics. Each acts on different chemical pathways of the human brain related to moods. Antidepressant medications are not habit-forming. Although some individuals notice improvement in the first couple of weeks, usually antidepressant medications must be taken regularly for at least 4 weeks and, in some cases, as many as 8 weeks, before the full therapeutic effect occurs. To be effective and to prevent a relapse of the depression, medications must be taken for about 6 to 12 months, carefully following the doctor's instructions. Medications must be monitored to ensure the most effective dosage and to minimize side effects. For those who have had several bouts of depression, long-term treatment with medication is the most effective means of preventing recurring episodes.
The prescribing doctor will provide information about possible side effects and, in the case of MAOIs, dietary and medication restrictions. In addition, other prescribed and over-the-counter medications or dietary supplements being used should be reviewed because some can interact negatively with antidepressant medication. There may be restrictions during pregnancy.
For bipolar disorder, the treatment of choice for many years has been Lithium, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one can be relatively small. However, lithium may not be recommended if a person has pre-existing thyroid, kidney, or heart disorders or epilepsy. Fortunately, other medications have been found helpful in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol^®) and valproate (Depakene^®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Studies conducted in Finland in patients with epilepsy indicate that valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. ¹¹ Therefore, young female patients should be monitored carefully by a physician. Other anticonvulsants that are being used now include lamotrigine (Lamictal^®) and gabapentin (Neurontin^®); their role in the treatment hierarchy of bipolar disorder remains under study.
Most people who have bipolar disorder take more than one medication. Along with lithium and/or an anticonvulsant, they often take a medication for accompanying agitation, anxiety, insomnia, or depression. Some research indicates that an antidepressant, when taken without a mood stabilizing medication, can increase the risk of switching into mania or hypomania, or of developing rapid cycling, in people with bipolar disorder. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Herbal Therapy

In the past few years, much interest has risen in the use of herbs in the treatment of both depression and anxiety. St. John's wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has recently aroused interest in the United States. St. John's wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies. Today in Germany, Hypericum is used in the treatment of depression more than any other antidepressant. However, the scientific studies that have been conducted on its use have been short-term and have used several different doses.
To address increasing American interests in St. John's wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight-week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one-third to a commonly prescribed SSRI, and one-third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression.¹³ Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.
Other research has shown that St. John's wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.

Psychotherapy for Depression

Several types of psychotherapy-or "talk therapy"-can help people with depression.
In mild to moderate cases of depression, psychotherapy is also a treatment option. Some short-term (10 to 20 week) therapies have been very effective in several types of depression. "Talking" therapies help patients gain insight into and resolve their problems through verbal give-and-take with the therapist. "Behavioral" therapies help patients learn new behaviors that lead to more satisfaction in life and "unlearn" counter-productive behaviors. Research has shown that two short-term psychotherapies, interpersonal and cognitive-behavioral, are helpful for some forms of depression. Interpersonal therapy works to change interpersonal relationships that cause or exacerbate depression. Cognitive-behavioral therapy helps change negative styles of thinking and behaving that may contribute to the depression.

Electroconvulsive Therapy

For individuals whose depression is severe or life threatening or for those who cannot take antidepressant medication, electroconvulsive therapy (ECT) is useful.³ This is particularly true for those with extreme suicide risk, severe agitation, psychotic thinking, severe weight loss or physical debilitation as a result of physical illness. Over the years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. At least several sessions of ECT, usually given at the rate of three per week, are required for full therapeutic benefit.

Treating Recurrent Depression

Even when treatment is successful, depression may recur. Studies indicate that certain treatment strategies are very useful in this instance. Continuation of antidepressant medication at the same dose that successfully treated the acute episode can often prevent recurrence. Monthly interpersonal psychotherapy can lengthen the time between episodes in patients not taking medication.

The Path to Healing

Reaping the benefits of treatment begins by recognizing the signs of depression. The next step is to be evaluated by a qualified professional. Although depression can be diagnosed and treated by primary care physicians, often the physician will refer the patient to a psychiatrist, psychologist, clinical social worker, or other mental health professional. Treatment is a partnership between the patient and the health care provider. An informed consumer knows her treatment options and discusses concerns with her provider as they arise.
If there are no positive results after 2 to 3 months of treatment, or if symptoms worsen, discuss another treatment approach with the provider. Getting a second opinion from another health or mental health professional may also be in order.
Here, again, are the steps to healing:

• Check your symptoms against this list.
• Talk to a health or mental health professional.
• Choose a treatment professional and a treatment approach with which you feel comfortable.
• Consider yourself a partner in treatment and be an informed consumer.
• If you are not comfortable or satisfied after 2 to 3 months, discuss this with your provider. Different or additional treatment may be recommended.
• If you experience a recurrence, remember what you know about coping with depression and don't shy away from seeking help again. In fact, the sooner a recurrence is treated, the shorter its duration will be.

Depressive illnesses make you feel exhausted, worthless, helpless, and hopeless. Such feelings make some people want to give up. It is important to realize that these negative feelings are part of the depression and will fade as treatment begins to take effect.

Self-Help for Treatment of Depression

Along with professional treatment, there are other things you can do to help yourself get better. If you have depression, it may be extremely difficult to take any action to help yourself. But it is important to realize that feelings of helplessness and hopelessness are part of the depression and do not accurately reflect actual circumstances. As you begin to recognize your depression and begin treatment, negative thinking will fade.
To help yourself:

• Engage in mild activity or exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed. Participate in religious, social or other activities.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

 

Not the Panacea

Almost 19 million Americans have periods where they feel a lack of pleasure or interest in what was once pleasurable and interesting. They feel tired and heavy, potentially overly emotional or numb, and experience an onslaught of negative and self defeating thoughts that can keep  invading the mind over and over again. The more periods of this depressed mood we have in life, the more likely we are to fall back into them again. Why does this relapse occur and how can mindfulness offer hope?

Falling into a depression feels traumatic and just like getting bit by a dog causes us to be fearful of and oversensitive to dogs, our minds and bodies become oversensitive to associations with the depression causing our brains to flinch at any sign of a relapse.

Feeling low mood is normal for everyone, but if we’ve experienced depression in the past, this may be a trigger for a relapse. If we feel tired or if we notice sadness, the mind pops up with the worry “uh oh, that is how I felt when I was depressed, maybe I’m getting depressed”. Our minds begin to go in overdrive with negative self judgments, “I am a failure” or “I am weak” or “I am worthless”. It then tries to solve the mystery as to why we are becoming depressed again and the more it tries to solve this puzzle, the deeper it sinks into depression. Think of a worried, judging person coming at you trying to solve your problems when you’re already not feeling well. Probably not what you’re looking for. You see, it’s not the low mood that’s the problem here, it’s the way we get stuck in habitually relating to it that pours kerosene on the fire, with our minds continuing to fan the flame rolling us into a full blown depression.

The practice of mindfulness teaches us a different way to relate to our thoughts, feelings, and emotions as they arise. It is about learning to approach and acknowledge whatever is happening in the present moment, setting aside our lenses of judgment and just being with whatever is there, rather than avoiding it or needing to fix it. It’s the mind’s attempt to avoid and fix things in this moment that fuels the negative mood.

With Uncomfortable Emotions

If sadness is there, instead of trying to fix it or figure it out, we might just acknowledge the sadness, let it be and get a better understanding of what we need in the moment.

With Self-Judgments

If self-judgments arise (e.g., I am weak, I am a loser) out of past sensitivities to having been depressed before, we can acknowledge that they are associations from the past, let them be, and then gently bring ourselves back to whatever we were doing. In doing this, we’re stopping the ruminative cycle that might occur between our thoughts, feelings, physical sensations and behaviors that can play off one another leading into another relapse (I call this “The Depression Loop” in the upcoming book Uncovering Happiness).

Now, this is easier said than done and it takes practice.

Confidence with Rumination Practice:

Let’s get our hands (or minds) into it. One way to practice mindfulness is to use the breath as an object of awareness. You can place attention at the tip of the nose or the belly and as you breathe in, just acknowledge the breath coming in and as you breathe out just acknowledge the breath going out. As if you were greeting and saying goodbye to an old friend. When the mind wanders, as it will always do, just say to yourself “wandering” and then gently bring your attention back to the breath just noticing it coming in and going out. Most of us catch the mind wandering and gently bring it back billions of times, so know that it is normal for the mind to wander often. You can do this for as little as 1 minute or as much as 30 minutes or more.

Practice this when you’re feeling well and you’ll be better able to recognize when your mind wanders off to ruminations and self judgments when you’re not feeling well.

What does this have to do with gaining confidence over rumination?

Like learning an instrument, you can develop more skill as you practice. When you’re not feeling well and the mind begins to ruminate, as you practiced with the breath, just label it as “ruminating” and then gently bring your attention back to whatever you were doing. Being more present may also give you the ability see the space between stimulus and response and see the “choice point” to  be more flexible and call a friend or do something that then gives you pleasure or connection with others.  This is what I’ve referred to as The Now Effect. 

Know that practicing is an act of self care and helps stop the cycle of rumination and cultivates more patience, compassion, and peace.  

Mindfulness is not a panacea for depression, but it’s a good foundation for preventing relapse.

As always, please write below with any comments, questions, thoughts, or additions that arise after reading this. Your comments below help provide a living wisdom for us all to share and benefit from.

What is “Palliative Care”?

The World Health Organization defines palliative care (PC) as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention of and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.” To meet these multidimensional needs, PC is usually provided by a team including physicians, nurses, social workers, and chaplains. Patients can receive PC at any time along the trajectory of a serious or life-threatening illness. (This is distinguished from hospice care, a subset of PC that is reserved for end of life treatment.) PC can also be provided in conjunction with treatments aimed at life prolongation. For example, a patient with metastatic breast cancer may be treated by an oncologist who focuses on cancer treatment while a PC team focuses on management of symptoms (pain, nausea, shortness of breath, depression, anorexia, fatigue, spiritual distress, etc) and assists with advance care planning.

In the United States, PC is generally provided as an inpatient or outpatient consultation. Providers may request a PC consultation to assist with clarification of the patient’s goals of medical care, symptom management, communication between the medical team(s) and the patient and family, prognostication in advanced illness, advance care planning, and end of life (EOL) care. For instance, a common consultation is to help a patient with advanced liver disease to understand the severity of the illness and treatment options, and to manage pain, shortness of breath, and nausea.

The ultimate goals of consultation are to treat symptoms of advanced illness and to assist patients and families in understanding their prognosis, in expressing the goals (or most important factors) in their medical care, and in receiving medical care that is aimed at achieving their goals of care. For example, is the patient with liver disease more interested in staying in the hospital to receive intravenous therapies of marginal benefit or in returning home to spend time with family and friends?

Hospice Care
Hospice care, by contrast, is a specific type of palliative care for patients nearing the end of life. In the United States, hospice refers to a healthcare benefit provided through Medicare Part A or private insurance. A patient is eligible to receive hospice care if two physicians certify that he or she has a life expectancy of six months or less if the “disease runs its usual course.” In addition, the patient must choose to trade standard Medicare Part A (inpatient) coverage for the hospice benefit, which covers medical care that is usually provided in the home and is focused on comfort and relief of suffering rather than life prolongation. Patients with any end-stage disease (heart failure, dementia, COPD, HIV, cancer) are appropriate for hospice referral. Hospice care is the form of PC that most physicians are familiar with; however PC is a much broader discipline.

Discussing End of Life Care with Patients
In addition to focusing on the relief of suffering, palliative providers are often involved in discussions about advance care planning and EOL care. For example, we may discuss prognosis, current treatment options, and options for future care with a patient with end-stage COPD. Specifically we would talk about what is most important to the patient in the time they have left to live and how their medical care can help them to achieve these goals. We would review if the patient is interested in intubation/ICU care or care that is entirely focused on their comfort in the event of a future COPD exacerbation.

There is a robust body of literature demonstrating that the majority of patients want to have these discussions with their providers, yet fewer than 50% of patients actually do (Reilly et al, Arch Intern Med 1994:154(20):2299–2308). Providers often cite barriers to having these conversations, such as a lack of training, lack of time, and concern that such discussions may harm patients or “take away their hope.”

Multiple studies have evaluated the effects of these conversations on patients’ treatment choices, quality of life, and mental health in addition to the effects on caregivers’ quality of life, mental health, and perception of the patient’s death. The Coping With Cancer study was a multisite prospective cohort study of 332 patients with metastatic cancer who progressed through first-line chemotherapy, and their caregivers (Wright et al, JAMA 2008:300(14):1665–1673). The 37% of patient/caregiver dyads who reported having a discussion about end of life care with their providers were compared to the dyads who reported not having these conversations. The patients who had the discussions were more likely to prefer medical care focused on relief of pain and suffering over life-extending treatments. These patients also were more likely to complete a DNR order and less likely to be admitted to the ICU, receive mechanical ventilation, or undergo a resuscitation attempt. Interestingly, patients who received less aggressive care experienced a better quality of life without a decrement in survival time. EOL discussions were not associated with patients feeling depressed, sad, terrified, or worried or meeting DSM criteria for a psychiatric disorder.

Their caregivers benefitted, too. Caregivers of patients who received aggressive care in the last week of life were more likely to develop major depressive disorder, experience regret, feel unprepared for the patient’s death, and report poorer quality of life and health after the patient’s death. This study supports the concept that EOL discussions and less aggressive EOL medical care are associated with better quality of life among patients and their caregivers.

Patients report that the manner in which EOL discussions are held is as important as the content of the discussions. According to current research, cancer patients in Western countries want realistic, truthful information that is delivered with a focus on what can be done (symptom management, emotional support, practical support, and maintenance of dignity). They value discussions in which the provider explores realistic goals as a means of fostering hope. Such goals might include control of pain and shortness of breath so patients can spend more time talking with their families. Patients feel that a discussion of what the future may hold should be well-timed. They want the information to be given when loved ones can be present and when the provider can spend an adequate amount of time with them. Lastly, patients value respect for their emotional state and an acknowledgement of the emotional, spiritual, and existential impact of having a life-threatening illness.

TCPR’S VERDICT: Given the heavy emotional burden associated with advanced illness, there has always been a significant role for psychiatry in PC. An important demonstration of this role is the inclusion of psychiatry as a specialty supporting the subspecialty of Hospice and Palliative Medicine. The challenge ahead is to further develop strategies for advancing the collaboration between providers of palliative and psychiatric care.

Working the Positive Path

Being with the Most Positive Thoughts have been being in front of Christ our God in the Most Holy Blessed Sacrament of the Altar. 

Being with Christ our God Is the Most Beneficial means to remain positive during the days of Celebration of His Holy Birth and beyond into the New Year.  

He is our Enteral Physician ! 

Consequently, you can add these items as well into your path of Happiness.

I want to share my path to positive thinking. Maybe the steps I took can help you reach your goal of bringing more positivity into your life.

• I surrounded myself with like-minded positive people and had to actively shift some of my relationships. I brought those with positive energy closer and devoted less time to those who were bringing me down.
• Instead of looking at tasks as a burden, I started to make things fun. The have-to’s can be exciting. Instead of dreading the gym, I rented a bike and explored New York City. Rather than avoiding chores, I make them a game and wound up smiling the whole time.
• I became grateful. Instead of looking at the past with regret, I have tried to reprogram my thoughts. I am now grateful for many of the experiences because they have taught me so much. I remind myself about what I learned from the friendship/relationship that ended. I look for the things that I am thankful for and appreciative of and remind myself of these things when I am feeling a wave of negativity. It shifts my mindset.
• I found purpose. I began finding and attracting others who shared my mindset, not in a therapeutic sense, but who desired to make the world a more positive place. I have friends who are not in the helping profession, yet make it their intention everyday to do something that can change the world in some way, and maintain positive thinking. A friend of mine is an illustrator. She helps authors make their stories come to life. Another is a consultant. He helps small businesses become profitable. Their intentions are to find positivity in their work. This energy is exuded to those around them.

Some tools may work for you, others may not, but be gentle with yourself. Try shifting your negative mindset subtly. Remember, the goal is to find your path to positive thinking that lasts a lifetime.

Identifying Negative Thought Patterns

As we are in the second week advent. Let us all work on becoming better with our thoughts for the Birth of Christ fast approaching the us in 15 days.  When in doubt please contact your local mental health provider and or call Dr. Nicholas at 877 867 8556 during the Emergency Room moment.  

Most of all let us rely on Christ our God for the most informable healing and guidance during the of His Birth. 

Notice if you have any of the following negative thoughts about yourself or others. Then identify when these negative thoughts come up most often; particular places, people, or events may be associated with them.

Do you…

1. Reject yourself or others’ ideas or experiences? Say “no” more than “yes”?
2. Criticize yourself or others about thoughts and choices made?
3. Blame yourself or others for your current situation? Do you take responsibility for your current mindset and where you are in your life?
4. Cling to your point of view? Find it hard to see the other side of the story?
5. Cause Conflicts and find that in a disagreement you continue to raise the conflict or bring up more issues that leave things messier than when you started? Are you unable to “let it go”?
6. Resent by being unwilling to forgive yourself or another; get stuck in how it “should be” rather than what it is?
7. Jump the gun and future trip about what negative events will occur or predict that you or someone else will fail?
8. Judge by casting judgement or blame on others, discounting your role in things and/or making unrealistic expectations for yourself or another?

Psalm 63:3

Understanding How the Mind Works

 
What Is an Aberration?
 
One of the most useful things you can learn about is how your own mind works. Without this knowledge, you cannot understand yourself, you do not know why you do the things you do, and you have a hard time correcting yourself. When you know how your own mind works, you can get rid of negative thinking and learn to harness your own mind's infinite potentials.
 
In this week's Understanding How the Mind Works newsletter, you'll learn about “aberration.”
 
Definition
 
ABERRATION: Any deviation or departure from rationality
 
Here is an example: Mary wants to have a happy marriage. She loves her husband a lot, but she could not stop herself from getting angry at him every other day. She knows she would rather resolve differences with him by communication instead of arguments, but she could not control her own temper. This is an example of Mary's aberration.  Something in Mary's mind is out her own control, causing her to react with anger with her husband.  This is a a "deviation or departure from rationality," Therefore it is aberration.

Here is another example of an aberration; Jeff wants to be a very successful entrepreneur. Ever since he was little he wanted to start his own business to develop a lot of money.  However, every time he started to focus, his business distractions developed. Something in his life provided a cause to lose focus and goals of becoming successful.

Jeff has an aberration with his consistency and persistence from escaping from rational conduct.

In order to be happy and successful in life, we must learn to overcome our own aberrations. If you can identify and resolve your own aberrations, your whole life will change.
 
What aberrations have you seen in people around you? Do you know someone who is always angry? Do you know someone who feels insecure for no reason? Do you know someone who is always tense and cannot relax?
 
What are some of your aberrations? What do you do which is irrational? Do you have a fear of crowds? Do you suffer from anxiety or depression? Do you have a hard time expressing your feelings? Do you procrastinate?
 
Accurate self assessment is vital. Once you identified your own aberrations, you are in a better position to improve yourself and your life.
 
I hope this bit of information about the mind helps.