While every situation is unique, Christina Steinorth, MFT, a psychotherapist and author of Cue Cards for Life: Thoughtful Tips for Better Relationships, offered her suggestions for helping aging parents.

1. Empathize with your parents.

Sometimes you might be taken aback by your parents’ frustration, moody behavior or neediness. In fact, on some days, they might be downright unpleasant to be around. But it’s important to be empathetic and understand where they’re coming from. According to Steinorth, “Aging is a series of losses — loss of employment, health and energy, friends, mobility, and independence.” Consider how you’d feel if you were in their situation, she said.

2. Call them regularly.

When Steinorth was researching her master’s thesis, the number one thing aging parents wanted from their kids was simply to hear from them. She suggested setting a reminder on your phone to check in with your parents and see how they’re doing.

3. Get other family involved.

When helping your parents, don’t take on all the responsibility yourself, unless you have to, Steinorth said. For instance, she knows of one family who emails updates to each other any time a sibling visits their parents. This not only provides information on their parents’ health and current situation, but it also makes it easier to coordinate visits and share responsibilities, she said.

Communication among family members also is key when parents need financial help. “Sometimes siblings will help offset expenses by giving your parents a little bit of money every month — they just need to know what the financial need is in order to be able to make the decision to help,” Steinorth said. (She also suggested seeing a financial advisor who specializes in elder care issues to discuss your options.)

4. Seek out potential problems.

Walk around your parents’ home, and scrutinize the surroundings for any necessary repairs or changes. For instance, look out for uneven flooring, handrails and well-lit hallways and stairs, she said. Also, check if essential items are within reach and emergency contact information is next to the phone. If something major requires repair, find out if your state offers low-interest loans to seniors, Steinorth added. She suggested visiting this website for more information.

5. Advocate for them.

If your parent has an illness, make sure both of you have a good grasp of what that means and what treatment entails. For instance, know the medications they’re taking and when they’re supposed to be taken. If you’re accompanying them to appointments, ask questions, and take notes, she said.

6. Encourage them to be active.

Many aging parents tend to be isolated, because they stop driving, get tired easily or have hearing or vision loss, Steinorth said. She stressed the importance of helping parents stay both socially and physically active.

“Talk to them about their friends, senior groups, and church or synagogue members. Find out what parks, the library, museums, nearby universities, and community centers offer in the way of organized activities.”

Physical activity is key for improving mood, endurance, balance and strength and delaying cognitive decline, she said. For instance, aging parents can walk, or participate in exercise programs for seniors.

7. Help them downsize without being bossy.

When helping your parents downsize, don’t tell them what they should and shouldn’t keep or toss anything unless you have their permission, she said. “Realize that your parents have many memories and treasure things that remind them of relatives and happy events — these are specific to the individual and just because you don’t see the value in certain items, doesn’t mean your parent shares your view.”

8. Help them create a memory book.

It’s common for seniors to experience short-term memory problems, according to Steinorth. Reminiscing might help. She suggested creating a scrapbook for your parents, filled with photos and names of the people, places and pets from their past. If you have time, work on the scrapbook together, she added.

What To Do When Parents Don’t Want Help

It’s not uncommon for parents to refuse their kids’ help. Try to have this conversation before your parents need immediate assistance, Steinorth said. If they’re not open to your help right now, over time, they might change their minds, she said.

Another approach is to ask others to intervene. For instance, you might ask your siblings, close relatives or even their doctor to talk to your parents, she said. “Sometimes hearing the need for additional help from an outside source can help your parents really hear what is being said and therefore may also make them more open to your help.”

Finally, if your parents are a danger to themselves or others and still refuse your help, contact the department of social services to step in, Steinorth said. Be prepared for your parents to be upset with you. But their anger will probably dissipate, she said, because they’ll be less emotional and understand you had their best interests and safety in mind (and in your heart).

We stay silent. We say stupid things. We go from being sensitive, sensible, kind adults to rambling niceties or making downright rude remarks.

Illness, understandably, makes us nervous.

Fortunately, Pogrebin’s book helps us navigate the muddied waters of illness and mortality. It’s packed with practical tips and valuable insights.

Pogrebin was inspired to write the book after observing the varied reactions from her own friends to her breast cancer diagnosis. Some friends misunderstood her needs and acted awkwardly. Others were supportive and compassionate.

In the book, she shares these personal experiences, along with powerful accounts of people offering support to others. She also shares the words of almost 80 of her fellow patients at Memorial Sloan Kettering Cancer Center. She interviewed these individuals to find out how they really wanted to be treated.

Here’s a snippet from Pogrebin’s book on communicating with a sick friend.

What Not To Say To A Sick Friend

Pogrebin advises against saying phrases like “Everything happens for a reason” and “You need to be strong for your kids.”

Even seemingly positive statements become anything but. For instance, let’s say you’re trying to cheer up a friend who just received a cancer diagnosis. You might say something like, “I know ten women who’ve had breast cancer, and they’re all doing fine” or “My sister had a double mastectomy, and she’s climbing mountains!”

One cancer patient told Pogrebin that these comments were insulting and dismissive. They also didn’t mean anything to her: “Every woman and every cancer is different,” she said.

Another seemingly positive but problematic phrase is “You look great.” According to Pogrebin, when you focus on your friend’s appearance, it can discourage them from telling you how they truly feel; if they don’t look good, they won’t believe anything you say; and if you don’t compliment their appearance in the future, they might assume they look worse.

What To Say To A Sick Friend

Pogrebin stressed the importance of being honest with your sick friends. She also notes that everyone should be able to say these three statements: “Tell me what’s helpful and what’s not;” “Tell me if you want to be alone and when you want company;” and “Tell me what to bring and when to leave.”

In addition to honesty, it’s also important to express empathy and availability. Pogrebin includes a list of seven phrases that sick people want to hear. All of these include empathy or availability or both elements.

• “I’m so sorry this happened to you.”
• “Tell me how I can help.”
• “I’m here if you want to talk.”
• “Just give me my marching orders.”
• “That sounds awful; I can’t even imagine the pain.”
• “I’m bringing dinner.”
• “You must be desperate for some quiet time. I’ll take your kids on Saturday.”

The Commandments of Conversing

In her book, Pogrebin features a list of 10 commandments for conversing with sick friends. For instance, she suggests celebrating your friend’s good news and not downplaying their bad news. This doesn’t mean sugarcoating or “slapp[ing] a happyface decal on a grim diagnosis,” she writes. Instead you can say, “Tell me what I can do to make things easier for you — I really want to help.”

Also, treat your friends the same way you always have, but don’t forget their new circumstances. For instance, tease and joke around with them, but “indulge their occasional hissy fits.”

Talk about other things. According to Pogrebin, this helps “speed the journey from the morass of illness to the miracle of the ordinary.”

Similarly, emphasize their skills and talents, which will help them feel valued. This can be anything from asking a poker aficionado for pointers on playing to asking a retired teacher for guidance on college applications for your teen.

Unless you’ve been there, avoid talking about yourself or telling your friend that you understand what they’re going through. Avoid complaining about comparatively small things. (“Don’t tell someone with congestive heart failure that you have a migraine headache, as painful as it may be,” Pogrebin writes.)

Before saying anything, make sure you know the facts of your friend’s sickness and situation. Pogrebin shares the story of one woman who had three friends tell her that they were glad the cancer was caught early. It wasn’t.

Don’t treat your friend like a child or pressure them into being positive. Positive thinking can help people endure tests and treatments, but it’s not a cure. Don’t imply that negative thinking caused or exacerbated their illness. As Pogrebin says, the last thing your friend needs to be doing is blaming themselves.

When thinking about how best to approach a sick friend, Pogrebin quotes Hillel’s famous words: “Do not say unto others what you would not have them say unto you. All the rest is commentary.”

Then, I walk into the lab next door for a blood test and the line I hear is: “Oh, your blood pressure was high, let me see if I can draw your blood now.”

Wait, what? Do they actually think that these comments will make me feel more relaxed?

I’ve also experienced more direct unpleasantries from doctors who project an icy, or even a rude demeanor. A poor bedside manner does affect a patient’s emotional disposition; it does heighten any anxiety, and it certainly ensures difficulty in forming a positive bond with a professional who’s in a field that’s supposed to alleviate illness.

“A bedside manner refers most often to the way a medical professional interacts and communicates with patients,” a 2012 post on Wisegeek stated. The post stresses that a doctor with a good bedside manner demonstrates empathy,¹ and emits an aura of ease for the patients, while also involving them in health decisions. On the flip side, poor bedside manners reflect rudeness, cold attitudes, inadequate listening skills, and a complete disregard for the patient’s fears.

Why are such mannerisms prominent in the medical field?

Lorianna De Giorgio’s 2012 article in the Toronto Star discusses why positive relationships between patients and doctors may be lacking in the profession.

Adam Waytz, assistant professor of management and organizations at Northwestern University, explained that a process of “dehumanization” lies behind an unfortunate patient-doctor rapport. Dehumanization may occur due to psychological demands placed on practitioners, and from ongoing advances in technology as well. Waytz determined that a bulk of medical decision-making gives way to a very mechanical method of thinking; problems are often solved and issues are fixed without recognizing the patient’s feelings.

While many individuals enter the medical field for humane reasons, “they get into the system, and the system is so stressful that sometimes the humanity is just beaten out of them,” notes Marjorie Stanzler, senior director of programs at the Schwartz Center for Compassionate Healthcare.

Waytz and Stanzler advocate that a proper bedside manner would result in improved psychological and physical outcomes for the patients in treatment.

A 2008 blog post entitled What Bad Bedside Manners Really Mean reviews the negative impact and consequences of these adverse behaviors:

“Doctors are supposed to be in the line of work of helping people. With this profession comes a lot of responsibility. The medical field is not supposed to be simply diagnosing a problem, handing out a few pills, and moving onto the next patient. It means much more. It means being a physician, and a physician means being a healer.”

I could not agree more. Patients may feel naturally anxious, waiting on an impending prognosis (especially if the condition has the potential to be serious). Do they really need aloofness on top of that?

“If the doctor seems disinterested in what you are telling him, there are greater chances of him missing something that you said,” the post stated. “If he seems put-out or preoccupied, the patient might be more likely to leave out pertinent information.” Furthermore, if the doctor is disrespectful, it may discourage patients from seeking medical assistance altogether.

Due to a distressing environment and technological developments, I can understand why medical practitioners may harbor some poor bedside manners, but that doesn’t make their etiquette right or beneficial.

I think it’s important for them to remember why they’ve entered the field in the first place; if it’s because they sincerely want to help people, it’s crucial to know how to relate to patients on an emotional level.

1. l personally think medical schools should have official courses on being more empathetic

The challenges facing a person who is married or in a relationship with someone who has untreated Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (ADD or ADHD) can be difficult to navigate.

These challenges may be completely hidden to the rest of the world. No one seems to understand what you struggle with. Your spouse is such a “great guy” and may appear “together” to everyone else.

This article attempts to address some of the predictable patterns that one may experience being married to someone with ADD or ADHD and why it creates such difficulty. 

Being married to someone with untreated ADD is often fraught with a predictable progressive pattern that goes from happy to confused to angry, and finally, to hopeless. How does this happen and why is this so predictable in couples whose spouses have untreated ADD or ADHD?

In an attempt to answer that question let’s look at some of the patterns that typically come up in these kinds of relationships.  It is important to recognize the symptoms of ADD/ADHD, especially if you suspect your relationship might struggle due to this disorder.

In the beginning phase of the courtship between you and your ADD spouse, you may have been completely swept off your feet or ravished with both attention and affection, while being the primary focus of your partner’s life. His “hyperfocus” on the relationship probably felt intoxicating and romantic. But, this feeling faded over time.

When someone with ADD enters into a new romantic relationship, the initial excitement feels so stimulating to the ADD brain (which is being flooded with adrenaline and endorphins) that it causes the person to completely turn their attention to you. However, this kind of excitement diminishes over time, along with the adrenaline rush as the ADD spouse looks elsewhere for stimulation.

Of course, this is not conscious on his part, and he may not even be aware that this has happened. However, as time goes on, the non-ADD partner may experience the following seven feelings associated with his/her spouse’s need to find stimulation in places outside of the marital relationship:

1. A sense of rejection. Individuals with ADD may often be distracted and find it difficult to pay attention to their partner. This may lead you to feel neglected or it may be interpreted as disinterest on the part of your spouse.

2. Loneliness. If your partner seems disinterested in what you are saying or appears to ignore you, it would be easy to understand that one might feel lonely.

3. Feeling ignored. Partners of individuals with ADD often get the feeling that all their good advice and suggestions are not taken to heart. This may cause the non – ADD partner to feel ignored, disrespected or offended.

4. Frustration or anger. The same kinds of problems keep presenting themselves over and over again. It is difficult to understand how you can have discussions around a problem, think that you are being understood and still the same problem persists.

Resentment and anger become pervasive when one feels disregarded, disrespected, ignored and often alone in the relationship. Some spouses will become irate and scream at their partner, while others will shut down and block all emotions. This will leave a partner in the cold. Either way, one can see how this pattern becomes increasingly destructive.

5. Exhaustion. As the non-ADD spouse tries to compensate for the lack of equal sharing or follow through in responsibilities, you can often feel depleted. As if no amount of effort seems to resolve these same issues that continue to plague your marriage.

Due to the inconsistency in your spouse’s ability to follow through and remember to do things, the feelings of being burdened with more of your fair share of responsibilities can create more feelings of stress.

6. A sense of hopelessness. When one’s best effort to resolve these problems go nowhere, the sense of sadness and lack of hope may pervade the relationship and lead to a separation or divorce. 

There is hope. With understanding and knowledge, one can transcend these feelings and find a new way of being in the relationship. Learning all you can about ADD and how it affects your partner is vital. It is important to remember that even though your partner may no longer be hyper-focused on you and your relationship, that does not mean he does not still love you.

Since he probably isn’t even aware that your relationship has changed, he might not understand why you are always so angry and demanding. Your increasing frustration, anger and demands only further damage any chances of communication or intimacy, as your partner feels that he can never please you and that he is not enough.

He might feel unloved. Patterns of frustration and anger can be avoided when both partners understand the way the ADD symptoms are affecting your marriage. You must learn different behaviors to heal these kinds of wounds through education, communication and counseling.

More marriage advice from YourTango Experts: 

• 4 Skills You Need Before Getting Married
• Why Do Men Get Married? [VIDEO]

For more articles and help with these kinds of issues, please visit my blog at addadults.net/blog.

At school, teachers face varying forms of misbehavior: A child may wander around the classroom when he is supposed to be working at his desk, or talk out of turn when she is supposed to raise her hand. 

Parents often confront issues such as siblings squabbling at dinnertime, or children whining or throwing tantrums when they don’t get their way.

Parents, teachers and caregivers often respond to misbehavior by verbally correcting the child and doling out consequences. But some teachers are being taught a strategy called active ignoring. They overlook disruptive behavior and either focus on a child who is behaving, or wait until the misbehaving child exhibits a desirable behavior.  For example, a teacher may ignore a child calling out an answer and call on the student who is raising her hand.

These techniques are taught in a program called teacher-child interaction therapy (TCIT), which is based on a similar program for parents. Early studies suggest that these approaches, whether in the classroom or at home, improve children’s behavior.

Parent-child interaction therapy (PCIT) is designed for children with emotional and behavioral disorders.  Its aim is to change the quality of the relationship between parents and children by changing the way they interact.

When children misbehave or have more serious behavior problems, such as violent outbursts and tantrums, it is easy for parents and caregivers to react with anger and frustration or harsh limits.

The goal of PCIT is to help parents show greater warmth, responsiveness, and sensitivity to their child’s behaviors. Studies indicate a quality parent-child relationship helps children develop a secure sense of their relationships and more effective emotional and behavioral regulation. Contingency management is the underlying principle. Contingencies — two events that tend to occur together — can have a great effect on how children act.

PCIT and TCIT advocate altering the paired events.  Instead of pairing misbehavior and attention, these programs pair positive behavior and attention.  The assumption is that children want and need adult attention. That makes it a reinforcer — something that, when paired with an action, makes that action more likely.

For example, a parent might respond to a child when out running errands by saying “you stayed right by me in the store, and you talked nicely, so we’re going to stop and get an ice cream cone on the way out.” In this instance, the parent is pairing both positive attention and a reward (ice cream) with the positive behavior.

Pair attention with misbehavior and you get more misbehavior. 

But if you ignore the misbehavior and wait for a desired behavior, with time, you increase the desired behavior. While waiting can certainly be difficult, it may be worth it to learn a little extra patience to help your children grow.

More information about PCIT can be found here.

Most of us know someone who has mental illness. For some of us, it is a loved one or a family member. For others, it may be a friend, classmate or co-worker. People who suffer everything from depression and bipolar disorder, to severe anxiety and even schizophrenia.

Some of us live closely with such folks, responsible for their care and their very lives.

Sadly, there just aren’t a lot of resources or support for such caregivers. What information and support that is out there is often lacking. I hope this blog by Tamara Hill, MS can change things.

This blog is primarily about the challenges facing family, friends, and caregivers who have a family member with an untreated or severe mental illness.

Here’s an example Tamara will talk more about:

In the state of PA (where I am), it is VERY difficult to get an individual with a severe, untreated mental illness involuntarily committed if that individual has not threatened harm to him/herself or another person. In the case of John Shick at Western Psychiatric Institute and Clinic (the man who opened fire on staff in 2012), he was turned away from the hospital a day prior because there weren’t enough beds. Assisted Outpatient Treatment (AOT) laws may have prevented the incident.

Tamara’s new blog is intended to help offer social service resources and inform family, caregivers, and friends about challenges and holes in the system. Tamara says, “I will use a lot of videos, news reports, and questions to stimulate discussion.”

“I’m of the firm belief that knowledge is empowering and many families lack knowledge, which leads to a lack of empowerment,” notes Tamara.

I couldn’t agree more. Please give Tamara a warm Psych Central welcome over on her blog today, Caregivers, Family & Friends.

You can send your kids off to the movies — and they may get shot. Or they might go to hang out at the mall — and risk getting shot. Or to high school or college — where they might get shot. Kids get kidnapped on their way home from school and abducted out of their beds.

Now 20 first graders have been gunned down in their first grade classrooms.

In the last few years, our national sense of safety has been repeatedly shaken. We can’t take it for granted that when innocent kids do innocent, everyday things, they will risk nothing more than a belly ache from eating too much popcorn or an argument with a friend.

What do we tell ourselves? What do we tell the kids? For the last few days the networks have been turning to psychiatrists and psychologists for advice. They emphasize that we need to remember that such events as the shooting in Newtown, Conn. are rare. They tell us to put aside our own fear and be there for our kids. It’s wise advice but it is easier said than done.

These tragedies no longer seem so “rare.” Statistical probability is cold comfort when watching yet another clip of anxious and grieving parents on TV. We may do our best to hide our horror and grief but kids are sensitive little creatures who get even more anxious when they think we’re hiding something. Navigating ourselves and our children through such senseless and horrible news isn’t easy.

To the words of advice coming over the airwaves, I can only add these reminders:

Turn off the TV. Little kids don’t understand that they are seeing the same event over and over and over. Three news stories of those kids running from their school may seem to them like three different groups of kids under attack, which makes the world seem even more unsafe. Repeatedly watching the news may not be so good for the adults either. Another viewing probably won’t help you make any more sense of a senseless event. It may even trigger more grief and anger and pain.

Think carefully about what you are going to tell your kids. An explanation this important deserves some preparation. Tell kids only what they are ready to hear and what you know they can manage. Most teens can certainly handle the whole truth. They’re going to be reading about it and may need your help to sort through their feelings. But little kids under age 10 need us to be sensitive to what they can and can’t process. It’s enough for most to say that a very bad man killed some kids and everyone is very, very sad and mad. You don’t need to tell them the specifics of how the children were killed and how many were lost. You don’t need to go into details as they come through the news. When in doubt, take your cues from what the kids want to know. Give them only the information they ask for.

Emphasize stories of survival. One teacher hid her kids in closets and the kids stayed very quiet. Other kids ran away. Still others held each other’s hands to help themselves stay calm. Let your children know that even little kids can be brave and helpful.

Share your feelings. It’s okay to let kids see some of our tears and our anger. It’s important that they understand that crying about sad things and being mad about bad things is both appropriate and a way to get through. Children need help in naming their feelings and managing them. You are an important role model for doing so.

But stay in control of your feelings. Our kids need the grownups to be their most grown up at times like these. They need us to show them that even when we are sad, we are there for them first. When adults acknowledge what is happening but manage to stay calm and in control, the kids can relax.

Compartmentalize. Neither you nor your children can sit with those feelings all the time. After talking about what happened, suggest that enough has been shared for now and that it is time to do something to get everyone’s mind off it for awhile. Let the kids know you are willing to talk about it again later if they want to but it’s important to take a break. (Do keep that promise.) Then suggest something you can all do together that reaffirms normal life. Make cookies. Go for a walk. Read some stories.

Reassure. Help the children understand that when tragedies do happen, the story is very big because it is very bad. If you live in a community where such things are in fact rare, remind the kids that they are lucky to live in a place where people are usually safe. If, however, you live in a community where children have been abducted or harmed, do let them know all the ways you and the people around them are working to protect them.

Go over safety rules. Finally, this is a good time calmly to review the rules of safety. Brainstorm with the kids all the things you do with them to keep them from harm. Doors get locked at night. Children who are home alone shouldn’t answer the door. Wearing a seatbelt in the car and a helmet when riding a bike isn’t optional. There are rules about where they can go by themselves. There are rules about how often to check in with you when they are out or they have been left home alone. Tone is important. This isn’t a time for lecturing or scolding about rules. It’s a time for helping our children feel secure in a world that isn’t always predictable or safe.

Caregivers are so vulnerable to depression because they often sacrifice their own needs while tending to their loved one and because of the constant stress involved.

So here are 12 tips to help protect you from anxiety and depression and to guide you toward good mental health as you care for a relative.

1. Acknowledge it.

If you haven’t already, say this out loud: “This sucks.” Call a spade a spade. Granted, you don’t want to ruminate on negative thoughts for too long. But suppressing your emotions — forcing that positive cap on each and every thought — can actually do more harm than good. For example, a recent study in the journal “Psychological Science” reported that people with low self-esteem who told themselves positive statements (“I’m good enough, I’m smart enough, Gosh darn it, people like me!”) actually ended up grumpier and with less self-esteem than before they started. What does this mean? Sometimes the best thing that we can do for our mental health is to be honest. And if you’re a caretaker, that means acknowledging that your situation, well, simply sucks.

2. Educate yourself.

Relieve some of your stress by reading up on your loved one’s condition. I say that because if you’re like me, you’re probably scared. You don’t know what’s coming down the pike. You detest surprises, and ever since your loved one fell ill, your life has been full of these shockers.

There’s no way of eliminating all the surprises, of course, but if you understand the illness(es) of the person you’re nursing, then you can better predict his behavior, and can prepare yourself for what may happen in a month or in a year. You might also consider attending a caregiver training program. A recent study showed significant improvement in the quality of life of caregivers who received training. Finally, two books I recommend are “The Caregiver Handbook: Powerful Tools for Caregiving” and “Caregiving: The Spiritual Journey of Love, Loss, and Renewal.”

3. Grab your own oxygen mask.

It always goes back to the ten-second spiel you get right before your plane takes off (or crashes). “In the event of an emergency, an oxygen mask will drop from the compartment above you. Please fasten your own mask before assisting others.” Or, on Southwest airlines, they say, “Now would be a good time to choose your favorite kid.”

Taking caring of your own needs is really as important as grabbing your oxygen mask first because you’ll be running out of breath early in the inning if you hold off on breathing until everyone is well. A study published in the “Journal of the American Medical Association” found that stressed-out older caretakers tending to a sick spouse had a 63 percent risk of death compared to the non-stressed-out caregivers or to lucky folks who don’t have to fetch anyone a glass of water all day long.

4. Schedule a break.

Give yourself a break every day. That DOES NOT mean that you go about your day and grab whatever free 15 minutes you can get –before the meatloaf is done or the jello is solid – at which time you sit down to read some depressing headlines in the paper, hoping for no interruptions. That DOES mean scheduling one half-hour every day at the same time of day that you can, guilt-free, put out your “Off Duty” sign, and during that break no one is allowed to bother you with requests. By taking the same half-hour every day, you have a better shot at convincing your ill loved one that you really are serious about needing some time to yourself.

5. Label your guilt.

I’m not going to tell you to get rid of your guilt. Get real, I’m Catholic! But I am going to advise you to label your guilt as helpful or unhelpful, because I bet you think you’re supposed to own all of it. The negative intrusive thoughts that tell you that you are a loser for not doing more for your loved one? Bye-bye. The voice that says you could be managing all of this mayhem a tad more effectively? Try to tease out some specific suggestions. They might help you come up with ways to better delegate responsibilities or to clean up messes without using so many cuss words.

6. Get organized.

If caregiving is anything like parenting — and I think it is, except for the fact that kids eventually grow up (a truth that I cling to in moments of desperation) — a small bit of organization can go a long way.

My June Cleaver role became a tad easier when I implemented some simple household rules like: no TV before 5 pm, one treat a day, no snacks after dinner, and so on. I initially resisted this kind of structure–it’s so not my style–but I have found that it really does facilitate managing kids (and I’ll add in sick ones) … because they both want things all the time, and that can become very wearisome. If my kids know they can’t watch SpongeBob SquarePants before 5 pm – and I follow up consistently on that rule (the hard part) – then they will eventually stop asking. The same goes with a sick mother or wife: if she knows dinner is at 6 every evening, and that Wednesday is pizza day, then you’ve just given her one less thing to whine about. Theoretically, of course.

However, they show that some abusers slipped through the cracks, others were given a second chance and include evidence of some failures to take proper steps to report suspected abuse to authorities.

The Boy Scouts have issued an acknowledgement that in some incidents their response was “insufficient, inappropriate and wrong” and have apologized for their mishandling of certain situations.

And let’s not forget that generations of boys have had healthy, positive, life-affirming experiences with the Boy Scouts.  This current report, which involves a small fraction of the millions of volunteers over the years, should not discount the positive aspects of the organization, the skills it has taught and positive values it has instilled in many boys

At the same time, are there lessons to be learned from the report?

It’s not possible to compare incidence and handling of sex abuse in the Boy Scouts to other, similar, organizations, because so few keep detailed records.  But these records give us an opportunity to review and, hopefully, apply lessons learned.

According to Jason Felch, an investigative reporter for the Los Angeles Times, in an interview by Neil Cohen on NPR, the files include handwritten notes from young men. The notes discuss abuse by troop leaders, provide detailed, although sometimes incomplete, accounts of allegations that have emerged over time, and contain some police reports about the allegations as well as discussions among Scouts officials regarding how best to handle allegations.

Awareness of  “acquaintance molestation,” which is what most frequently occurred in the Boy Scouts, crystallized with experts and the general population in the 1980s.  This data, dating from well before that, might help to better understand how these predators operate and is vital to preventing this type of abuse, which may account for as much as two-thirds of sexual abuse.

One aspect of sexual abuse revealed in these files is grooming behavior.  That is, innocent-appearing behaviors often set the stage for abuse.  Felch describes grooming behaviors as often involving predators allowing boys to break rules, then progressing to driving cars, drinking alcohol and watching pornography together.  They escalate to skinny dipping and sharing tents and then culminate in abuse.

Grooming behaviors make it less likely that a victim will report the abuse, because they feel culpable.

Although it’s unlikely that the Boy Scouts will be held criminally responsible for their handling (and in some cases, mishandling) of allegations of abuse, it is likely that many young men who experienced abuse will be triggered by the release of these documents.  It is common, in cases of sexual abuse, that victims face the abuse only years after it has occurred.

This type of abuse often has a lifelong impact on the victims, particularly if victims don’t receive support.  It can alter the course of a young person’s life, lead to other life problems such as various types of addiction, and can cause victims to participate in abuse themselves when they reach adulthood.

What can we learn from the Boy Scouts about stopping this sort of abuse? Kelly Clark, a lawyer who sought for these files to be open, says that child abuse thrives in secrecy.  Opening the files brings the abuse to light and hopefully allows other organizations to learn from it.  For example, in the files, Clark points out cases that were insufficiently investigated or those in which one boy came forward and a leader was removed, but no one questioned whether the abuse went further than that one boy.

The following is a link to the National Sexual Abuse Hotline, a confidential hotline offering counseling and information on rape and sexual abuse.

Although there is no sure fire way to prevent sexual assault, the hotline offers tips to help protect your children here.

I certainly don’t pretend to have reached any final “truth” in the matter of physician-assisted suicide (PAS). At the same time, I believe that Dr. Grohol’s conclusions (1) rest on several misapprehensions regarding my own position; the ethical responsibilities of physicians; and the relevant medical facts pertaining to terminally ill patients.

Dr. Grohol argues that the debate is really “…about patient empowerment, human dignity and choice.”

I fully agree with Dr. Grohol that the patient’s autonomy is of great importance; indeed, autonomy is considered one of the four cardinal principles of medical ethics, along with benevolence, nonmalfeasance and justice (2).

But sometimes, medical ethics must set limits on a patient’s autonomous requests, even in the context of an understandable choice on the patient’s part. Thus, a patient may feel completely justified and “empowered” in requesting that the dose of her pain medication be doubled, even though that would be extremely dangerous to her health.

Governed by the principle of nonmalfeasance, the physician will wisely decline the patient’s request, and explain why that is necessary. So, too, in my view, with a dying patient’s request for lethal medication or “assisted suicide.” As Dr. Barbara Rockett, President of American Medical Association’s Foundation, cogently noted:

Centuries ago the physician Hippocrates wrote the Hippocratic Oath, which many of us took when we became physicians and guides us in the ethical practice of medicine. It states that when treating patients, physicians will “First do no harm.” It goes on to state that “I will give no deadly medicine to anyone if asked nor suggest any such counsel.” Physician-assisted suicide is in direct conflict with this statement which, when followed, has protected the patient, physician, society and the family, and at the same time has committed doctors to compassion and human dignity. (3)

Similarly, Dr. Lisa S. Lehmann, director of the Center for Bioethics at Brigham and Women’s Hospital, commented that, “Writing a prescription that allows a patient to acquire a lethal dose of a medication with the explicit intention of ending their own life really goes beyond the accepted norms of what physicians do…” (4) Proponents of so-called “death with dignity” laws need to ask themselves why only two states in the U.S. have adopted such laws; and why the American Medical Association, the Massachusetts Medical Society, the American Nursing Association, and the Massachusetts Academy of Family Physicians (5) all oppose physician-assisted suicide.¹ A partial answer is likely to be found in the foregoing statements by Dr. Rockett and Dr. Lehmann.

As regards “human dignity,” reasonable and compassionate people will differ on what, exactly, constitutes “dignity” and a “dignified death.” For some, a “dignified” death is one in which pain is endured with stoic resignation. My late mother, for example—a strong-willed and very independent-minded psychiatric social worker—frequently refused pain-relieving medication during her final days, much to the consternation of her physician son. But that was her idea of a “dignified” death. For other terminally ill patients, death with “dignity” may involve refusing any further food or drink. Indeed, as my medical ethicist (and theologian) colleague, Dr. Cynthia Geppert points out (personal communication, 10/3/12), refusing food and drink during the final days of life has long been considered a dignified way of dying in virtually all the world’s major religious faiths. (Importantly, declining appetite is a natural, bodily process during the final days of the dying process). I will return to this much misunderstood (and frequently misrepresented) option later. For now, I’ll simply say that I am not persuaded that ending one’s life with a prescribed medication is more “dignified” than declining further sustenance—which requires nobody’s authorization or prescription, and has been considered a morally acceptable way to end one’s life for many centuries.

That said, Dr. Grohol and I stand shoulder to shoulder as regards the physician’s absolute responsibility to alleviate the suffering associated with a terminal illness. And, it must be acknowledged that physicians — until very recently in medical history — have fallen woefully short in their willingness to alleviate the suffering that often attends a terminal illness. Unfortunately, this failure has helped fuel the understandable fear, on the part of the general public, that they will endure great suffering during their final days and therefore ought to be allowed to take a lethal overdose to end their lives. (Loss of autonomy and being a “burden” on others are also very common fears).

Probably every psychiatrist who has consulted in terminal illness cases has a horror story about the attending physician who was afraid to use adequate doses of pain medication in treating the patient nearing death, for fear of “addicting” the individual! But I believe that with the emergence of palliative care medicine as a subspecialty, this picture is beginning to change, and that expert palliative care represents a better and more ethical alternative to so-called “physician-assisted suicide” or “physician-assisted dying.” Indeed, Dr. Ezekiel Emanuel and colleagues concluded that “Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.” (6)

Contrary to Dr. Grohol’s impression, no conscientious physician—and certainly, not this writer—feels it is “…perfectly okay for a physician to let his or her patient die of willful starvation and dehydration.” (1). For me, as for most physicians, any decision to end one’s life, or hasten one’s death, requires scrupulous examination and represents an occasion of profound sadness and loss—hardly an event to feel “perfectly okay” about.

But it is not a question of “letting” a competent patient refuse food or drink during the dying process. It is not a physician’s prerogative to “let” or not “let” a patient choose that route, assuming the patient is mentally competent (i.e., not psychotic, delirious, severely depressed, and also apprised of the risks and benefits of all available options). No physician’s order is required to allow a competent patient to refuse food and drink, nor can a physician countermand a competent patient’s decision to do so. While there is no recognized “right” to commit suicide in this country, competent, terminally ill patients are at liberty to stop eating and drinking.²

This is not necessarily what I or many other physicians would counsel or recommend; indeed, I would consider it my duty to explore with the patient every appropriate palliative care option. But it is not in the physician’s purview to prevent a competent, dying patient from refusing sustenance.

More broadly, in the U.S., competent patients have a legal right to decline intrusive or “heroic” measures that artificially prolong the dying process. Indeed,

“…the law already permits patients or their surrogates to withhold or withdraw unwanted medical treatment even if that increases the likelihood that the patient will die. Thus, no one needs to be hooked up to machines against their will. Neither the law nor medical ethics requires that “everything be done” to keep a person alive. Insistence, against the patient’s wishes, that death be postponed by every means available is contrary to law and practice. It is also cruel and inhumane.” (7)

Just so. As physician and ethicist Dr. Fred Rosner has observed, for the physician, “To prolong life is a [commandment], to prolong dying is not.” (8)

1. In 1997, the AMA was joined by the American Psychiatric Association, the American Nurses Association, and nearly 50 other health care-related organizations when it filed an amicus curiae (“friend of the court”) brief with the U.S. Supreme Court opposing PAS. [Nair S. Virtual Mentor Ethics. Journal of the American Medical Association December 2005, Volume 7, Number 12]
2. It is important to distinguish “rights” from “liberties,” as well as “reciprocal obligation” from “compulsion.” As Szasz notes (Fatal Freedom, p. 113), rights require an “obligor” who must fulfill the right; a liberty is exercised without any other party’s direct, active involvement. It is also crucial to understand that neither rights nor obligations are absolute; they are always balanced against competing rights and obligations. People in this country have a right to free speech, and, in general, government has an obligation to protect it. But people do not have a right to yell “Fire!” in a crowded theater, nor is the government obligated to protect such behavior. There is no recognized “right” to kill oneself in the U.S., but mentally competent people, in my view, ought to be at liberty to end their own lives, even though I would almost always counsel against it.

   Most recognized obligations in this country have “opt out” provisions; e.g., in general, there is a recognized “right” to abortion, and physicians are, in general, “obligated” to respect and fulfill that right—but they are not compelled by law to do so. Similarly, if we make PAS a “right,” as the Massachusetts bill would effectively do, we would confer a generalized reciprocal obligation on physicians to respect and fulfill that putative right, all other things being equal. This is not the same as compelling physicians to carry out a PAS request; however, it might well open the door to frivolous litigation against physicians who “denied me my right to a PAS prescription”—even though such lawsuits would almost certainly be dismissed.

While survival rates for many cancers have improved, there are quality of life issues following the diagnosis, including the emotional difficulty of coping with the anniversary date.  Survival rates are measured in 1-, 5- and 10-year markers.  This often creates an emotional conflict as the diagnosis date approaches.  Each year provides a measure both of success and trepidation.  Diagnosis day is when the war on cancer begins in your body.  It is sometimes shortened to military lingo for the day an attack or operation is launched: D-Day.

As with most traumas, people can tell you the vivid details of their diagnosis. They remember the time, what was said, what they did, and what they felt.  D-day is etched in their psyche, and as the anniversary date approaches, so does the anxiety.

But one woman, Jen Cunningham Butler, has done something different. In honor of breast cancer awareness month I wanted to tell you her story.

“I called home to see if the biopsy results are in,” she says. “The doctor tells me to page him.  I do.  He tells me: You have breast cancer.”

“I was in my office about to walk out into the adolescent hum of opening night of the eighth-grade play,” she continues. “The seventh-grade ushers were waiting for me and their final instructions before parents and friends arrived. They needed me to help them, and I needed to drive home and tell my husband I had cancer. Dr Meyer had given me the number for Larry Shulman, head of breast oncology at Dana-Farber Cancer Institute. “In the event of an emergency please page me at…”

I hung up. Was this an emergency?

When I reached Larry he pulled up the pathology on his computer: “It’s invasive,” he told me. We agreed to speak the next morning to form a plan. I got ready to go out into the hall, trying to figure out what to do next.

It was Tuesday, March 8, 2005. 5:30 pm.

Over the next several days, weeks and months Jen lived in two different worlds of coping with work and home and the agony of additional biopsies, MRIs, CT scans then the surgery, the radiation, and the recovery.

“I could tell you of moments of jagged fear, the comfort of “to do” lists, the beauty of the people who steadied me,” she told me. “I could tell you how simply breathing became a gift of release and how the things I could do physically, like riding my bike (even though I was slow) with my cycling friends, calmed and settled me.”

But as D-day approached, Jen knew there was a predictability of anxiety based on what others had told her. But she was determined: “I needed to find a way to turn the day around.”

She did just that.

“Coming into that first-year anniversary, I thought about how much being strong, healthy and well meant to me. I thought about the doctors, nurses, radiation therapists and others who took part in my treatment. I thought about Ellen Moore, who listened to a healthy-looking young woman’s assertion that a very small lump was of concern and took it seriously. I thought about Dr. Meyer (if someone has to tell you that you have cancer, it should be him – professional, knowledgeable, kind, gentle, matter-of-fact).

“Ultimately, I decided that Diagnosis Day was a day to give back to the people who helped me through that time. They gave me my life, and I was grateful,” she said.  “As a teacher, every once in a while you get a letter or email saying, “You made a difference in my life.” The idea for Diagnosis Day undoubtedly came from that – from how we feel when a former student lets us know that the work we do is worthwhile. I knew I didn’t choose cancer, but I knew I could choose some parts of the journey.”

But Jen did much more than this.  She acted on her thoughts of gratitude for the team that worked with her, and became an ambassador of hope.  On March 8, 2006 she baked heart-shaped, individual chocolate cakes for the women in the radiation waiting room and wrote a note saying she was healthy and well a year out and hoped the same for them.

“I also bought presents for Dr. Meyer, Ellen Moore, Dr. Shulman, nurse Anne Kelly, and my wonderful surgeon, Dr. Beth-Ann Lesnikoski (with whom discussing options like “lumpectomy or mastectomy?” could feel like a conversation over coffee with an old friend). With the presents went notes that thanked each for their contributions to my care.”

Each year since 2005, March 8 has been a day of gratitude and service. She says there is still an undertone of shakiness as the day approaches, but the day itself has transformed.

“I go to Dana-Farber with presents for my doctors, radiation therapists and nurses and bring a tray of goodies and a note to the women currently in radiation. On year five, I wrote notes to the people who helped me in myriad ways, for the colleague who saw me emerge from my office that night in 2005 and took over the play ushers for me, to the school nurse who kept my confidences and helped me manage day-to-day life at work, to the friends who rode with me even though my pace didn’t match their training plans, to my husband who stayed true and kind and loving throughout. Each year is a little different. Each year I think of who or what continues to resonate. One year it was the Dana-Farber parking attendants who got a big bag of organic lollipops; their smiles and help during treatment meant more than they’ll ever know.”

But what struck me about Jen’s inspirational story was the fact that much of the good feeling she generated in herself and others was actually part of well-documented research on gratitude.  Jen had attended one of my Power of Positive Being workshops where I discussed the research on the gratitude visit.  Jen’s intuition about how to turn D-day around mirrored what we know about outcome studies in gratitude.  She came up to me after the workshop at Kripalu, a spiritual retreat in Western Massachusetts and the largest residential facility for holistic education and well-being in North America, and related her story.

In part two, I’ll discuss the research on gratitude and how Jen intuitively followed all of the principles scientists have determined help improve our well-being.  But for now I just want to celebrate a woman with courage: The courage to heal, the courage to change, and the courage to be grateful.

“On average, a person with depression is at least 50 percent more disabled than someone with angina, arthritis, asthma or diabetes,” according to this report by The Centre for Economic Performance’s Mental Health Policy Group.

The good news is that treatments for mental illness are highly effective. The bad news is that only one out of three people might actually seek help. And some research suggests that the people who need help the most are typically the least likely to get it.

People understand that you can’t treat a lump in your breast on your own, Dr. Komrad said. But that same understanding doesn’t extend to mental illness.

Self-reliance is deeply imbedded in our society’s psyche, he said. That becomes problematic when anything that’s the opposite of self-reliance — such as dependency — is viewed as weakness and something to be ashamed of.

People might worry about appearing weak if they seek counseling — and they might turn that stigma inward and see themselves as weak, Komrad said.

Another big deterrent is lack of insight. Many people with mental illness simply don’t think they’re sick.

That’s why it’s critical for families and friends to step in and help their loved one realize they need to seek counseling. Don’t worry about “meddling” in their lives, Komrad said. Rather, you have the opportunity and power to improve – and in some cases, save — their lives.

Warning Signs

In You Need Help! Komrad lists the specific signs — along with real-life examples — that signal an individual needs help. These are some of the signs:

• Behavior that scares you, such as a significant temper.
• Problems taking care of themselves or regulating their behavior, such as ignoring basic hygiene, engaging in reckless acts or drinking and acting aggressively.
• Problems with thinking, such as becoming disoriented, seeing or hearing things that no one else does or forgetting important facts.
• Intense feelings, such as profound anxiety about leaving the house.
• Problems interacting with others, such as withdrawing from the people they love.
• Inability to work, such as not holding down a job or diminishing grades or effort in school.
• Experiencing trauma, such as abuse or the death of a child.

Ultimately, the key is to look for what Komrad calls “a change in baseline.” In other words, is your loved one acting differently in any area of their life, including work or home? Komrad said that it’s not unusual to see a person unraveling at home first.

Approaching Your Loved One in the Early Stages

Komrad suggested the following ways to approach your loved one about seeking help in the early stages of mental illness.

• Let your loved one know that you need to have an important conversation with them. According to Komrad, this helps to focus their attention and implies they should take it seriously.
• Pick a good time and place. For instance, avoid talking during family gatherings or when you’re fighting.
• Approach them with empathy. You might say something like “I know this is really hard for you, but I’m talking to you because I love you. If I didn’t care, we wouldn’t be having this talk.”
• Be prepared for the person to be upset – and try not to get defensive.
• Use “I” statements, such as “I’m concerned about you.”
• Ask for a gift – literally. Ask your loved one to give you the gift of seeking help, whether it’s for your anniversary, a holiday or your kids’ birthdays. Here’s an example from Komrad’s book:
  

  “Getting a consultation with a psychiatrist about your mood swings would be the best thing you could do for our little girl’s birthday. It’s better than anything else that you could possibly give her. Please, do it for her. She, more than anyone, needs you to get some direction and proper help, more help than I know how to give you.”

• Facilitate the process by finding a professional and scheduling an appointment. Even if they refuse to go, see the practitioner anyway. Talk to them about helping your loved one. Komrad said that 15 percent of his practice is meeting with clients about their loved ones.
• Offer to pay for the appointment, if possible. A common excuse is that therapy is too pricey.
• Don’t use words like “crazy” or “abnormal.”

Taking Stronger Measures

When your loved one has little insight into their illness – their “rationality is diminished” – or refuses to get help, you’ll need to take stronger measures. Komrad calls these strategies “therapeutic coercion,” which is akin to tough love.

An especially powerful tool, he said, is to explain to your loved one that families come with certain privileges – and responsibilities. For instance, if you’re a parent who’s financially supporting your adult child, leverage these privileges to get them to seek a professional evaluation.

If that doesn’t work and your loved one is a danger to themselves or someone else or is very ill, contact the authorities, Komrad said. Research your city’s laws on involuntary evaluation. And show up at every step of the process, he said.

“Don’t just call the authorities and wait.” Show up to the ER and the court hearing. “When you do show up, tell the story.” In fact, tell the ugliest parts, he said. Talk about the facts that substantiate the seriousness of the situation.

If you’re feeling unsafe for any reason, articulate that to the authorities. If you’re uneasy about bringing your loved one home, communicate that as well. As Komrad said, you don’t want to give the system an easy way out. You want to make sure they grasp the gravity.

Supporting Your Loved One Long-Term

Supporting your loved one through treatment is “a long-term project,” Komrad said. Check in with them regularly about their treatment and how you can help.

Also, realize that “a change in them is a change in you,” he said. In other words, as they’re making changes in their life, you might want to seek professional help as well. You might even realize that your relationship is part of the problem. As Komrad said, “Sometimes relationships can be sick, too.”

As a family member or close friend, you have a lot of power in helping your loved one. Use it.

Learn more about Dr. Mark Komrad at his website and about his must-read book at youneedhelpbook.com.

But in making this analogy, I believe we’re removing all context and logic from the decision behind wanting to end your own life because of a terminal illness. For the patient, it’s not about the act of suicide or ending their lives — it’s about alleviating suffering from the disease and choosing one’s own way of dying with a little dignity. It’s about patient empowerment, human dignity and choice.

That’s why in the two states where it is legal for doctors to help patients with a terminal illness, it’s referred to as the Death with Dignity law.

Because the alternative takes much of the dignity out of dying in today’s modern medical system.

“Physicians have no more business helping patients kill themselves with lethal drugs than they do helping patients jump off bridges,” says Dr. Pies.

Most would agree physicians have little business helping a person jump to their death. But it appears that Dr. Pies undermines his own argument when he suggests it is perfectly okay for a physician to let his or her patient die of willful starvation and dehydration. His rationale? Death this way is solely in the patient’s hands, and isn’t as painful as we imagine it to be. He points to the scientific evidence, because there have been studies assessing patients’ pain and suffering as they’re dying through starvation and dehydration. Well, no, not quite. The evidence he points to is a single study that surveyed — not patients — but hospice nurses.

Now while I have great respect for the work and opinions of hospice nurses, let’s not confuse their opinions with data that would be more helpful – from the patients themselves. But there is no such data. So we don’t honestly know — and can’t say — whether a patient whose doctor is okay with letting them starve themselves to death is in greater or lesser pain than one whose doctor has voluntarily prescribed a medication to hasten a terminal patient’s death.

Dr. Pies seems to be splitting hairs here. His objection appears to be that patients can end their lives if done solely on their own, because physicians shouldn’t help patients along to their death — especially with a prescription. Yet he’s okay with a patient starving themselves to death — something no physician would ever be okay with in any other situation (such as a patient who had anorexia). ¹

Physicians of such starving patients don’t just leave at that point. They too actively help the patient starve themselves by alleviating the discomfort associated with starving and dehydration. Physicians do this by prescribing a sedative, a practice known as terminal sedation or palliative sedation.

It’s not that starving to death isn’t a painful process (it is) — it’s because the patient has been prescribed drugs — by a physician — to make their “natural” death less painful.

Last, Dr. Pies argues it is not a right to die with dignity at the end of our lives, in the time and manner of our choosing. But nobody is coercing physicians to comply with the proposed law in Massachusetts. Just as most physicians do not perform abortions, I suspect many physicians will also not be interested in prescribing drugs to help a person at the end of their life hasten their own death.

We need such a law not to compel physicians or mess with their moral code, but because government has determined that the people cannot be trusted to have access to certain medications. Because government has restricted our access to such drugs, it is necessary to seek access to them through the government- and guild-defined methods imposed.²

If my liberty to purchase and administer such drugs wasn’t restricted in the first place, we wouldn’t need such laws. But since my liberty has been restricted, a law is needed. This law would not impose an obligation on physicians to prescribe such medications to any patient who asked, as it would be completely voluntary for physicians to participate:

(2) Participation in this chapter shall be voluntary. If a health care provider is unable or unwilling to carry out a patient’s request under this chapter, and the patient transfers his or her care to a new health care provider, the prior health care provider shall transfer, upon request, a copy of the patient’s relevant medical records to the new health care provider.

One of a physician’s primary purposes is to help alleviate suffering. Suggesting a patient starve themselves over a period of one to two weeks, while being prescribed and administered a sedative, hardly seems in the spirit of this purpose.

For me, it’s not about a physician’s rights — it’s about a human being’s inalienable rights and having the right to choose. So I will be voting “Yes” on Question 2 for the Death with Dignity Act in Massachusetts. Because I believe that people with a terminal illness have a right to die at a time and place of their own choosing — with the dignity deserving of a human life.

Further Reading

• Merciful Assistance or Physician-Assisted Killing?- Dr. Ron Pies
• The proposed Death with Dignity Act in Massachusetts (PDF)

1. Imagine someone presents to an ER severely dehydrated and emaciated. Would any physician stand idly by and let that person die of dehydration and starvation?
2. In this case, that means gaining access to the drugs largely through a physician, because that’s the way the American Medical Association, the physician’s guild in the U.S., wants it.

Fortunately, he is still well enough to walk, and finds himself one night near a tall bridge. Having contemplated the suffering he believes will attend his final days, he decides to end his life by jumping off the bridge. However, he is too weak to hoist himself up atop the protective railing.

Suddenly, he sees his very own physician, Dr. Jones, walking by. He begs Dr. Jones to help him climb atop the railing, adding, “Don’t worry, Doc, it will be my decision to jump.” The doctor is taken aback, but quickly determines that his patient is not psychotic or severely depressed, and is capable of making a rational decision regarding suicide. The doctor tries to persuade your dad that pain and suffering can usually be well-controlled during the final days, but the patient is insistent: he wants to end his life.

Would you agree that Dr. Jones is fulfilling his obligations as a physician by assisting your father in jumping off the bridge?

If not, would you support the doctor’s providing your father with a lethal dose of medication?

From the standpoint of medical ethics, I see no fundamental moral difference in a doctor’s assisting a patient to jump off a bridge — without, of course, pushing him off — and a doctor’s prescribing a lethal dose of medication to “assist” in the patient’s suicide. The main difference is that, whereas anybody can assist a suicidal patient in climbing over a bridge railing, only physicians and a few other health care professionals are authorized by law to prescribe medication — and, in Oregon and Washington state, to prescribe lethal medication for “physician-assisted suicide” (PAS).

Of course, there are important procedural differences between my bridge scenario and the way PAS is handled in these states. There are numerous procedural safeguards in place to ensure that dying patients are thoroughly evaluated, and not pressured or coerced into requesting lethal medication — though the evidence is mixed as to how effective these safeguards have been. One study of physician-assisted suicide in Oregon and the Netherlands found no evidence that disadvantaged groups (such as the elderly or disabled) are being disproportionately affected by the laws (Battin et al). On the other hand, another study (Finlay and George) concluded that, “…there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS.”

From a strictly ethical perspective, I believe physicians have no more business helping patients kill themselves with lethal drugs than they do helping patients jump off bridges — regardless of how “voluntary” the patient’s decision may be. Clearly, neither action is compatible with the traditional role of the physician as healer. Indeed, psychiatrist and ethicist Dr. Thomas Szasz has argued that “physician-assisted suicide” is merely a euphemism for “medical killing.” For these reasons, I am opposed to the November ballot initiative in Massachusetts for a measure that would allow terminally ill patients to be prescribed lethal drugs.

And yet, as always, there are two sides to the story. When my 89-year-old mother was in her final days, she was in a good deal of discomfort much of the time. Despite having first-rate home hospice care, and the availability of powerful pain relievers — which my mother often refused to take — her dying was not an easy or peaceful process, for her or for our family.

There were times when I wondered if I could ever bring myself to provide her with the Oregon “solution.”  Fortunately, my mother never requested this, and overall, I believe my family made her final days as dignified and comfortable as she would permit.

The debate over PAS often is clouded by a mistaken understanding of the dying process. Some advocates of the Oregon and Washington approach argue that the dying patient who wants to end her life has no recourse but to take a lethal drug prescribed by her physician. But in truth,  competent, dying patients may end their lives by simply refusing food and drink. Indeed, medical ethicist Cynthia Geppert MD, PhD informs me that voluntary refusal of food and drink is now considered an accepted approach to dying, in palliative care medicine.

Many readers will instinctively recoil from this claim. “How could you let your loved one die of hunger and thirst?” they will understandably ask. But we usually ask this based on our own unpleasant experiences of hunger and thirst, as healthy, active persons. For the dying patient, voluntary refusal of food and fluids does not result in an agonizing or painful death, as a report in the July 24, 2003 New England Journal of Medicine concluded. According to the 307 hospice nurses surveyed in this study, most patients will die a “good” death within two weeks after voluntarily stopping food and fluids.

We may agree, as a society, that competent adults ought to be at liberty to end their own lives. But this is not the same as asserting their “right” to commit suicide, much less insisting that physicians should be complicit in fulfilling such a right. Unlike liberties, rights impose reciprocal obligations on others. And, in my view, the physician’s obligation during a patient’s final days is to do everything medically possible to relieve pain and suffering — not to relieve the patient of his life.

Acknowledgement: Thanks to Bret Stetka MD and Medscape for permitting use of some material contained in my essay, “Do We Need ‘Thanaticians’ for the Terminally Ill?”, available at: http://www.medscape.com/viewarticle/771274.

References:

Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-Philipsen BD: Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. J Med Ethics. 2007 Oct;33(10):591-7.

Finlay IG, George R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups–another perspective on Oregon’s data. J Med Ethics. 2011 Mar;37(3):171-4. Epub 2010 Nov 11.

Ganzini L, Goy ER, Miller LL et al. Nurses’ Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death. N Engl J Med 2003; 349:359-365 Accessed at: http://www.nejm.org/doi/full/10.1056/NEJMsa035086

Further Reading

• Death with Dignity: Why I Don’t Want to Have to Starve Myself to Death – Dr. John Grohol

• The proposed Death with Dignity Act in Massachusetts (PDF)
• Pies R: End-of-life care and contingent vs. non-contingent duties: contributions from WD Ross’s ethics and the Judaic tradition. Accessed at: www.hektoeninternational.org/End-of-life-care-and-contingent.html
• Szasz T. Fatal freedom: the ethics and politics of suicide. Syracuse: Syracuse University Press; 1999.
• Arehart-Treichel J: A Few Psychiatrists Choose Path Strewn With ‘Heartbreaking Work.’ Psychiatric News,  2012;47:8-25. Accessed at: http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1217914

According to a recent report in the Journal of the American Geriatrics Society, depression is one of the major causes of decline in the health-related quality of life for senior citizens.

Why all the depression?

Rafi Kevorkian, M.D. calls them the five D’s: disability, decline, diminished quality of life, demand on caregivers, and dementia. To combat senior depression, then, requires coming up with creative methods to counter the five D’s.

Here are 12 strategies to do just that: help people break free from the prison of depression and anxiety in their senior years.

1. Separate the illness from depression.

Depression in seniors is more complicated to identify and treat than that of younger folks because of all the other illnesses involved. For example, Parkinson’s disease directly effect brain chemistry and can exacerbate depressive symptoms. Estimates show that 25 percent of cancer patients are depressed and as many as 50 percent of stroke patients suffer from depression.

Karen Swartz, M.D., Director of Clinical Programs at Johns Hopkins, maintains that patients with co-existing depression and chronic illnesses tend to focus more on the physical ailment, and therefore delay or impede full recovery from a mood disorder. Her advise? “Treat both the depression and the chronic illness simultaneously, setting aggressive treatment goals for both…. Do not settle for substandard treatment results — if one or both conditions is/are not responding to treatment, intensify or switch approaches.” Also be sure there is cooperation and clear communication between your doctor and your mental health provider.

2. Watch the drinks.

Did you think teenagers were most at risk for substance abuse? Actually, alcohol and drug abuse are very prevalent among people over age 60, affecting 17 percent of older adults. It’s not uncommon for seniors to self-medicate with alcohol and drugs as a way of coping with their loneliness or dealing with chronic pain. Hell, I can’t say I blame them.

But it’s bad, bad news. For one, alcohol is a depressive and is going to depress you even more (once you come down from the buzz of course). Popping sedatives can be lethal, especially when taken in combination with alcohol. Alcohol and drugs can also interfere with the effects of medications taken for diabetes, heart disease, and other common conditions among seniors. And finally, substance abuse increases the risk of suicide, especially in older men.

In other words, pour with caution.

3. Try Tai Chi.

Because disability and diminished quality of life are two of the D’s of senior depression, older people would be smart to invest in some fall insurance–to do whatever they can to prevent falls. The fear of falling is legitimate among the elderly because approximately 33 percent of Americans ages 65 or older fall at least once a year. And when you consider the rates of osteoporosis, arthritis, and weak cardiopulmonary systems among elderly, healing from a fracture isn’t so easy.

Therefore, take up an exercise program like Tai Chi, a martial art that teaches agility, slow movement, and coordination between body and mind. Tai Chi has been proven to prevent falls among seniors because it builds balance, core strength, and confidence. Strength training with either free weights or resistance rubber bands is also beneficial. And yoga, too.

4. Treat any insomnia.

Here’s an interesting trivia fact from David N. Neubauer, M.D., author of “Understanding Sleeplessness: Perspectives on Insomnia”: “As we age, we typically spend less time in the deepest levels of non-REM sleep (Stage 3 and Stage 4) and more time in the lighter levels. Consequently, older people often suffer from fragmented sleep, waking up more often during the night and early in the morning. In response to these changing sleep patterns, many [older] people develop poor sleep habits that compound the problem.”

Dr. Neubauer reports that 80 percent of people who are depressed experience sleeplessness, and that the more depressed someone is, the more likely it is that he or she will have sleep problems. And vice versa! So absolutely essential to a senior’s depression treatment is addressing any sleep problems and to practice good sleep hygiene: like going to bed at the same time every night, waking at the same time in the morning, and cutting down on or eliminating caffeine.

5. Distinguish grief from depression.

By the age of 65, half of American women will be widows. And in 10 to 15 percent of spouses, the loss of their loved one leads to chronic depression. The questions is: what’s normal grief and what’s depression? Kay Redfield Jamison, Ph.D., Professor of Psychiatry at the Johns Hopkins University School of Medicine, distinguishes the two in this way: “The sadness of grief usually comes in waves, with varying degrees of intensity and bouts of crying, and feelings of intense sadness, guilt, anger, irritability, or loneliness. A person experiencing grief, however, can enjoy some of life’s activities. Grief is generally time limited and resolves on its own. Depression is a more persistent and unremitting sadness.”

In other words, a depressed person is unable to enjoy life activities, merely slogging through life. She may also start to abuse alcohol or other drugs, experience difficulty eating (or overeating), and suffer from sleep disturbances.

6. Carry some photos.

Here’s a simple way you can buffer yourself from the beast of depression: carry photos of your loved ones and friends in your wallet. Yep! A new study by UCLA psychologists found that by simply looking at a photograph of their significant others, a group of women reported less pain to the heat stimuli to their forearms than when they looked at pictures of an object or a stranger. Says study co-author Naomi Eisenberger: “The mere reminder of one’s partner through a simple photograph was capable of reducing pain. The study fits with other work emphasizing the importance of social support for physical and mental health.”

7. Make new friends.

Even better than photos are actual people! Countless studies have demonstrated that people with strong social networks are more resilient to depression and anxiety, especially in their senior years. And since losing friends and family is part of growing older, it is especially important for seniors to make an effort to meet new people. In my piece “13 Ways to Make Friends,” I offer a few suggestions: trying out a book club, volunteering, taking a night class, and connecting with your alumni association. Psych Central’s Dr. John Grohol proposes 10 more in his “10 More Ways to Make Friends,” such as joining a bowling league, getting involved in your church, or making a local restaurant or coffee shop your place to hang out.

8. Get online.

According to a new report issued by the Phoenix Report, spending time online reduced depression by 20 percent in senior citizens. The study’s co-author, Sherry G. Ford, makes an excellent point: “Maintaining relationships with friends and family at a time in life when mobility becomes increasingly limited is challenging for the elderly. Increased Internet access and use by senior citizens enables them to connect with sources of social support when face-to-face interaction becomes more difficult.”

9. Exercise.

Let’s say you’re 84 years old and have never worn a pair of tennis shoes. You don’t like to move fast. Let’s say you eat steak and fries every night, the fries being the only vegetable to go near your mouth. Are you really going to benefit from exercise at this point in your life? Had I not read the September 14 issue of Archives of Internal Medicine, I would have said, “hell no.” Alas, I stand corrected. Senior citizens who exercise — even if they take it up at age 85 — live longer, healthier, and happier lives. The seniors who exercised regularly experienced fewer declines in their quality of life, were less lonely, and were more likely to stay independent.

10. Review your options.

I can imagine how I’d feel if a well-intentioned family member stole my car keys, said the stove was off limits anymore, and dropped off a friendly “guest” (or spy) who would be staying with me for the rest of my life. NOT happy.

It’s no wonder why those seniors who lose their independence and mobility end up depressed. In fact, the Journal of Leisure Research recently published a study by four researchers that confirmed a very basic theory: humans thrive when they have choices and feel in control. When they don’t? They become helpless and lose the will to live.

So a good exercise is to take inventory of our options: the brand of toothpaste we brush our teeth (or dentures) with, the websites we visit, the novels we read, the cereals we eat, the tv shows we watch, the people we talk to, the coffee we drink, the activities we pursue, the crossword puzzles we attempt. Okay, you get the point. Even in the midst of limited options, we always have some control, a plethora of possibilities. Simply take note of them.

11. Get a purpose.

According to author and life coach Richard Leider, “Purpose is the glue that holds the good life together.” Met Life, the insurance company, wanted to find out if that was really true, so they asked 1000 people between the ages 45 and 74 the big question: “Hey guys, why do you get up in the morning? What really matters in the end?” Contrary to the message we get blasted everyday in the media, folks reported that a sense of purpose was what was truly important. Even more so than money or health. And as people age, a sense of purpose becomes even more important.

So get a purpose, no matter how big or small: recycling the plastic bags of everyone in your apartment complex, providing free babysitting for your daughter so she can have a date night with her husband, spoiling your grandchildren with ice-cream, or visiting a lonely neighbor once a week. It doesn’t have to require lots of time, energy, money, or brain power. All you need is a little motivation and a touch of kindness.

12. Go with the pain.

Look. There is no escaping all the pain of growing older. When you consider all the physical ailments and chronic conditions experienced by seniors, it is understandable that so many are depressed and anxious. Not to mention the agonizing process of losing loved ones to death. When experiencing acute loneliness, I like to remember these words by spiritual author Henri Nouwen: “It is the absence itself, the emptiness within you, that you have to be willing to experience, not the one who could temporarily take it away. You have to own your loneliness and trust that it will not always be there. The pain you suffer now is meant to put you in touch with the place where you most need healing, your heart.” In other words, sometimes the best the thing to do with our pain is simply to surrender to it, and go with it.