The U.S. population is aging; thus, many consequences of such pheonomenon are arising. Among these are the mounting incidences of chronic illness which, apart form accidents and infections, are the most widespread causes of death among older adults. At present, “end of life” situations have drastically changed from a period of devastating illness which normally last minutes or days to a gradual period of deterioration brought about by chronic illnesses that may persist for months or even years. Health professionals especially nurses and caregivers, therefore, should be prepared to deal with the issues related with chronic medical conditions as well as the dilemmas  related to their dying patients and even deaths (Matso, 2004).

The Six Common Causes of Death among American Adults

According to the Federal Interagency Forum on Aging-Related Statistics, there are six leading causes of death among Americans ages 65 years or older. The most common cause is the heart disease which comprises 44 percent of deaths from these six causes. Cancer takes on 29 percent. 11 percent of American death is caused by stroke. Chronic obstructive pulmonary disease or COPD causes 8 percent of these deaths, while influenza and pneumonia cause 4 percent of deaths and the remaining 4 percent is caused by diabetes. Between 1984 and 1995, the occurrence of each of these illnesses among the same age group has increased—stroke increased by 1%; diabetes by 2%; heart disease by 5%; and cancer by 7%. Five of these six causes are known as chronic illnesses that are usually long-drawn-out and most often involved chronic disabilities which are not only financially grueling to the patients and their families but also strenuous to the health care system (Matzo, 2004).

Aside from the aforementioned causes, older adults are also at an increased risk for developing a long-term illness called Alzheimer’s disease, which was recently noted that as the 4th leading cause of death in older adults. Moreover, 80 percent of Medicare patients who are enrolled in hospice are suffering from cancer (Matzo, 2004). Only 3 percent have chronic obstructive pulmonary disease or COPD, whereas only less than 3 percent of nation’s hospice census consist of Alzheimer’s disease patients (Hartford Institute for Geriatric Nursing, 2008).

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Mental Health and Aging

            Aging signifies a new achievement, opening and trials like getting to face mental health problems.  The Children, Youth and Family Consortium or CYFC (2003) stated that though dealing with mental health is already a fundamental aspect of aging, it has always been ignored.  Fortunately, this has been changing as people have finally realized that the fitness and welfare of aging people is composed of both mental and physical health.  However, older adults are still not the favorable group of people to search for treatment, thus, people who care about them should just look after them.

            According to CYFC (2003), the most frequent disorders from adults that are 55 years old and older are anxiety disorders, severe cognitive impairment, mood disorders, schizophrenia and substance abuse. There may be services available for these mental illnesses; however, they are under-utilized because of stigma; lack of recognition or denial; under-recognition by professionals; shortage of mental health professionals; symptoms itself; and the caregivers themselves. Mental disorders that are uncured can cause encumbrance to society for they signify high rates of physical illness, greater functional disability and health care utilization. Older adults may not realize that they are already experiencing symptoms of mental disorders or may not be well-informed that it may be cured; thus, they become dependent on other people like their children, friends and caretakers (CYFC, 2003).

End-of-Life Psychological Adjustments

Very limited delineation has been made concerning the route encircling psychological adjustment to losses caused by ensuing and end-stage illness. Dying persons undergo compound, accruing, and extreme losses of purposes, skills, roles, and relationships. Many people in this stage who seek advice regarding these losses may be able to further achieve quality of life in all aspects; whereas, those who do otherwise get along unsatisfactorily (Knight & Emanuel, 2007).

The Study to Understand Prognosis and Preference for Outcomes and Risks of Treatment (SUPPORT) conducted in 1995 at five major U.S. medical centers—a $28 million study commissioned by the Robert Wood Johnson Foundation where 9,000 critically ill patients were involved—had confirmed that there exists a crisis in the manner of how Americans are taken cared of at the end of life. Majority of these patients died in ICUs frequently suffering pain and are not granted the kind of treatment they prefer. The developments that were made in home care or the expansion of hospice in the past two decades did not do justice to remedy the situation (Twohig & Byock, 2004, p.2).

In another study using qualitative research analysis, chronically ill patients, recently bereaved family members, and experienced clinicians were interviewed.  The result epitomized that seriously ill patients and their families thought of pain and symptom management with great value—as well as, coherent decision making, foundation for death and life completion, an impression of contributing to others, and assertion as a whole person. Still, in a yet another qualitative study, it was revealed that patients and families look up to clinicians who openly discuss their patients’ conditions, delicately break bad news, encourage questions and are insightful as to when patients are prepared to speak about death (Twohig ; Byock, 2004, p.3).

Matso (2004) viewed dying and death as a process comparable to pregnancy and birth as processes. Matso (2004) called this the “perinatal period” which comprises a sequence of biologic changes, symptoms, and signs, and induces various beliefs and responses at each of its varying stages. These are the same aspects and stages that the process of dying and death evokes. The final hours of life that include the symptoms and experiences undergone by the patients and their caregivers prior to the occurrence of death, as well as death itself, the declaration of death by a qualified physician, and the procedures done to the physical body after death, can be regarded as the “perideath period”(Matso, 2004).

The first phase of the perideath period, according to Matso (2004) takes place when death becomes imminent.  During this time, the need for comfort care is undeniable and life-preserving interventions are withdrawn. All throughout this stages, holistic nursing care is deemed necessary. This activity involves taking into account the process involved in death in terms of specific themes such as denial, fear, anger, and spiritual concerns provide the avenue for the attending health professional to recognize and deal with such progress as they arise during the course of illness and dying. Clinical issues which include pain, fatigue, and depression should also be considered by the one taking care of the dying patients to build better rapport. Lastly, the needs of the patient and caregiver which consist of home care, spiritual care, and caregiver support should be addressed to establish more stable relationships (Matso, 2004).

Providing Chronic Disease and End-of-Life Care

            According to Zallman, Sanchez, Choi and Selwyn (2003), the US health care system struggles to meet the essential needs of older and critically ill adults whose population is dramatically increasing. The main cause of the adults’ death is the long period of time of enduring chronic illness. Adult patients who have progressive illness are not being given the necessary services they need on time, more so, not at all.  Services which patients who have progressive and incurable diseases seriously need are pain relief, symptom control, spiritual and psychosocial support and total chronic disease management (Zallman, et al., 2003).  This had been the case in most community-based settings where the excellence and accessibility of end-of-life and chronic disease care are said to be lacking unlike, somehow, in primary care settings.

In primary care settings, advance care directives and care planning which are fundamental aspects of inclusive approach to chronic and progressive illness are being commenced even though it is in a manner which lacks consistency (Zallman, et al., 2003). Patients prefer this approach for they like it better to have early discussion of the treatment they could undergo.  Moreover, to patients who have terminal diseases, they would rather choose to have care which provides comfort over one that would prolong their life. Thus, the family practice sites are requesting the community-based settings to provide complete assessment and interventions in all the patients who have chronic illness and the elderly in general (Zallman, et al., 2003). This is due to the fact that family physicians use patient-centered approach, hence, they are used to including both the families of the patients and the patients themselves regarding treatment decisions. Moreover, family physicians are familiar with coordinating with a multidisciplinary team, hence, working with a management centering on progressive and terminal illness with very intricate mixtures of specialty involve is natural for them.  Additionally, they are also more experienced regarding extensive treatment modalities; thus, they are well-equipped in providing comprehensive care for patients who have critical conditions (Zallman, et al., 2003).

A study conducted by Zallman, et al., (2003) about meeting the needs of the patient who have chronic disease and are already at the end-of-life stage by the health care centers in the Bronx, New York concluded that primary care settings are more capable of meeting the needs of the patients with chronic disease and the elders. Primary care settings are also more advantageous especially to those who are financially disadvantaged.

            Furthermore, even the World Trade Organization prefers palliative care to be the means to enhance the quality of life of the seriously ill patients and also their families.  In a study by Borgsteede, et al. (2006), which explored the aspects that the general practitioners and the patients values in the end-of-life care at home, they have found that the general practitioners and the patients have similar views when it comes to end-of-life care which are availability of the general practitioners, medical proficiency and collaboration with other professionals, and the focus and permanence of caring.

            A study by Wenger and Rosenfeld (2001) have identified fourteen quality indicators of end-of-life care.  Quality indicators 1 and 2 are surrogate decision makers and advance directives which will assist in decision making for a patient who have no capacity to make any decisions.  Quality indicators 3 and 4 are documentation of care preferences because these preferences could reflect the values of the patients that will serve as guide for life-sustaining care. Quality indicator 5 is eliciting patient preferences concerning future health states since the physicians and surrogate decision makers most of the time does not know the patients’ preferences for care.  Quality indicator 6 is advanced directive continuity due to their capacity to guide; hence, their presence should not be ignored. Quality Indicator 7 is patient preferences for mechanical ventilation since mechanical ventilation can only be operated if it is in line with the goals of the patients. Quality indicator 8 is patient participation in life-sustaining care decisions since the patients who still have the capacity to decide may still wish to participate, thus, their values should be protected and cared. Quality indicator 9 is care consistency with documented care preferences, hence, the medical care should be practiced according to the preference of the patients.  Quality indicator 10 is management of ventilator withdrawal, along with this is their entitling to opiate and benzodiazepine or barbiturate infusion to lessen dyspnea.  Lastly, quality indicators 11, 12, 13 and 14 are care of the dying patient – there should be treatment of dyspnea and pain, further notice to the spiritual needs of the patients and search for the next of kin (Wenger ; Rosenfeld, 2001).

The life expectancy in the US has tremendously improved from the 1900s to the new millennium due to the improvement of the country’s healthcare system. Unfortunately, the health care system is still unable to catch up with the diseases and disability that plague the older population in their end-of-life stages (Lynn ; Adamson, 2003).

Services should be modified in order to adapt with the end-of-life phase of the older adults. Planning for the constant course should be done in order to catch up with the course of the illness. Permanence and fullness of care should be provided along with the versatility to adapt with the resources of the patient and their family, symptoms, and preferences. There should be special arrangement for care in order to attend to gravity of the symptoms. Programs and policies that are meant to enhance the care for chronic illness should put in the possibility of death.  Lastly, formulating dependable health care systems must be done as early as possible since the older adults who are seriously ill and are in their end-of-life phase should be given a more appropriate system than the existing one (Lynn ; Adamson, 2003).

End-of-Life Clinical Treatment

On being given highly advanced medical treatments that may not be coherent with their preferences for care and are not warranted by its expected benefit, evidences insinuate that many Americans face death in physical agony—a circumstance abundantly documented in published studies and alleged in disturbing testimonies of many who have undergone the suffering of losing a loved one (Twohig ; Byock, 2004, p.2).

Palliative Care

Palliative care, according to Knight and Emanuel (2007), is a continuing education program that involves medical treatment for chronically ill patients, premeditated to alleviate the symptoms of the diseases that instigate suffering. However, it is not intended to heal. This program aims for healthcare professionals to be trained in being more at ease in caring for patients with terminal illness and be able to put into application effective and compassionate end-of-life care procedures. In addition to this, palliative care concentrates on the procedures undertaken by health professionals that are concerned in servicing this type of treatment—that is, focusing on providing assistance and support to people who are at the end stage of their lives, as well as to their family systems.

Matso (2004) agreed to this by stating that the focal point of care is both the dying adult and her family when it comes to providing end-of-life care during the dying process. When the death takes place, the task of providing care is not finished for the mere reason that the family of the deceased person is still in need of palliative care and interventions. Postdeath nursing care starts by preparing the body for the morgue or funeral home and assisting the family in making decisions concerning autopsy and burial. The major objective of postdeath nursing care is to promote best possible adjustment and to lend a hand to the family and significant others to face the tasks of bereavement.

The term “family system” extensively encompasses the clients’ significant other(s), their immediate and extended family members, as well as friends. In some instances, it may even comprise the entire community they belong to. The clients identify those who are included in their respective family systems which will vary from one person to another. It is important to remember that in all instances, it is the clients and their family systems that institute the main concern for care and it is the role of the health professionals to support the family systems in achieving their unique goals—that is, to relieve the sufferings of the patients (Knight ; Emanuel, 2007).

Patients 65 years and over often have under-treated or untreated pain and other symptoms (Hartford Institute for Geriatric Nursing, 2008). While patients over 80 years of age consulted for palliative care have lesser interventions for pain, nausea, anxiety and other symptoms. Older palliative care patients are usually the ones to suffer and die from chronic illnesses preceded by a long period of decline and functional impairment. They are of higher risk for developing multiple chronic and life-threatening diseases such as cancer, stroke, heart disease, respiratory diseases (Evers, Meier, ; Morrison, 2002).

In general, health professionals are in perfect positions to provide assistance, and even suggest alternative standpoints to the person in their care, as well as, to make ways for their client to become open about feelings regarding their current situation. This is true particularly for caregivers. Opportunities are open for momentous interactions can be notably evident when administering personal care to the patients in their homes as certain intimate relationships can be established while assisting a patient with the usual and ordinary acts of concern such as preparing meals, performing some housekeeping activities, and carrying out personal care (Knight ; Emanuel, 2007).

Geriatric Palliative Care

Morrison and Meier (2003) discussed geriatric palliative care as a facility intended to care for the chronically ill and frail elderly centering on the quality of life, the assistance for functional independence, and strengthening of the patient’s values and experiences in determining the goals of medical care. It is an integrative approach utilizing interdisciplinary delivery of care aiming to relieve pain and suffering and to make the quality of life for elderly patients and their families better. The founding principles are comprehensive patient/family unit centered that develop functional independence and quality of life adjustments between stages of care (Morrison & Meier, 2003).

Geriatric palliative care patients have various needs and some of these are continuous and coordinated care that is required by episodic and long-term chronic illnesses; administration of multiple chronic illnesses; aid in navigating a complicated medical system; upholding functional independence; guidance in decision making regarding care and treatment, pain and symptom control; discerning risks against the benefits of treatment; home support for family caregivers; and the resource information and access assistance within the community (Morrison and Meier, 2003).

Symptom Management

Nausea, vomiting, anorexia, pain, skin breakdown and decubitus ulcers, urinary and bowel irregularities, and respiratory problems are some of the symptoms that confront healthcare professionals while giving palliative care. These cause an intense degree of discomfort to patients which, if ineffectively managed in the comfort of their home, are provided with short-term inpatient care for symptom control, respite care, or terminal care (in cases of impending death). Due to this reason, symptom management in most cases is considered as the most essential procedure in providing care to a client. As symptoms will vary from one person to another—not to mention their respective health problems or diagnoses—the intensity, frequency and duration of these symptoms also changes as the disease progresses. Managing symptoms in the client goes a long way from painstakingly paying attention to what the client is saying, monitoring and gauging changes from the baseline status, to alertly impeding the pain early on (Knight & Emanuel, 2007). Pain, weakness, fatigue, immobility, a lack of interest in eating or drinking, drowsiness, dyspnea, and delirium are symptoms that may not occur during the final stages of the dying process (Matso, 2004).

Persons over age 80 have fewer interventions for symptom management (Evers, Meier, & Morrison, 2002).

Hospice Care

Regardless of age or underlying diagnosis, hospice care is available to any person who is at the end of life stage; however, these services are for the most part intended for people with cancer diagnoses. Persons with terminal, nonmalignant lung diseases are very much unlikely to be given hospice or palliative care. In one survey conducted to Medicare patients enrolled in hospice programs, it was found out that 80 percent are diagnosed with a cancer and only 3 % are diagnosed with chronic obstructive pulmonary disease or COPD despite the fact that it is the fourth primary cause of death in the United States. First class palliative care embarks on an intensive knowledge of disease processes and trajectories, endstage disease indicators, and the nursing skills required at each phase of the dying process (Matso, 2004).

Pediatric Critical Care

Numerous end-of-life issues are encountered by pediatric critical care nurses on a daily basis. Also required, on top of meeting the needs of critically ill children, is the preparation to meet the needs of the children’s family members within the context of providing family-centered care. Included in a young patient’s family are the parents or guardians, siblings, and extended family. Each of these individuals is expected to have their respective needs. Preferably, in times that death is anticipated, the “do-not-resuscitate” orders are already in place and a plan for the withdrawal of support is already laid. This is for the purpose of initiating a more “peaceful” or “good” death for the patient and the patient’s family. Manifold issues often arise in the course of these times, which may include arrangement and employment of palliative care, explanation of brain death, and contribution of options of organ donation to patients’ families. Additionally, health personnel in this situation should be able to meet their own self-care needs for them to cope up with the challenges of imparting family-centered care to these patients who are apparently at the end-of-life stage together with their families (Roberts and Boyle, 2005).

Markers for Initiation of Palliative Care in Geriatrics
Core end-stage indicators verify the terminal phase of chronic illness are characterized by physical decline, weight loss, multiple comorbidities, and a serum albumin of <2.5 g/dL. Sole dependence on physica aids even with most common activities of daily living and a score in the Karnofsky Performance which is less than 50 percent (Matzo, 2004).

On the other hand, non-disease specific indicators includes frailty, functional dependence, cognitive impairment and family support needs.  Frailty refers to the excessive vulnerability to morbidity and mortality due to continuous decline in function and physiological reserve. Frequent falls, disability, susceptibility to acute illness and reduced ability to recover are conditions of frailty. Functional dependence is relying on others to carry out activities of daily life. Cognitive impairment showcases changes in memory, attention, thinking, language, praxis, and executive function.lastly, the family support needs refers to the emotional support, information and educational support unique to each patient/family and/or caregivers. Moreover, there are still those disease specific markers which includes symptomatic CHF,  dementia, stroke, cancer, recurrent infections and degenerative joint disease resulting to functional impairment and chronic pain  (Morrison and Meier (2003).

Effects of Palliative Care
The prevalence of unexpected and premature deaths leads to pre-industrial cultures to centers on death fears on individuals’ postmortem fates. The fears of death in the modern cultures are more likely to concentrate on the processes of dying itself. Henceforth, the contemporary fears of dying includes the anxieties of dying within institutional settings, where often life is frameworked for the convenience of staff and where residents suffer both physical and psychological pain in their depersonalization (Mead).

A large number of Americans who die every year are more than 65 years of age. Many will encounter a lengthy life-threatening illness with either a relatively predictable stable progression, a rather brief terminal phase such as cancer, or a very slow decline exacerbated by periodic dilemma signified by a slow decline and eventual death. Diseases such as CHF, emphysema and Alzheimer’s are examples of the latter (Hartford Institute for Geriatric Nursing, 2008).

The National Hospice and Palliative Care Organization (2003) had computed that in 2001 approximately 775,000 out of the 2.4 million people who died that year received hospice care. A comprehensive Institute of Medicine document in 1997 indicates that most patients and families who are presently living with a life-threatening illness can anticipated to have multiple physical as well as psychological, social, and spiritual problems. The same is true for people with severe acute or chronic mental illness. In the arena of prolonged suffering and unmanaged symptoms, the methods used for coping with illness, disability, loss of control, and lack of ability to do things are usually meaningful and varied. In some patients, distress becomes noticeable if suffering is not relieved. Accordingly, the re-surfacing of psychiatric symptoms has been the medium in which the chronically mentally ill have dealt with burdensome distress. Caregivers should be aware that any chronically ill patient can develop self-destructive behaviors, may consider suicide as the last recourse, or may seek help to die by means of physician-assisted suicide. As caring for patients with a life-threatening illness has been transferred into institutions, a general lack of understanding of the end of life  process and death has evolved. Palliative care provides expertise and standards of practice designed to improve the quality of patients’ lives and provide dying patients the tools to remain in control of their lives as well as their deaths (Hartford Institute for Geriatric Nursing, 2008).

Religion and Spirituality

            Schneider (1999, as cited by Koenig, 2002) described the future of health care as unpleasant – acute care hospitals will appear like intensive care units where only the most terminally ill patients will be attended to; nursing home will turn into acute care hospitals where the patients who have been stabilized will be brought to; then the aged and the dying patients will be brought back to their respective communities since nursing homes would no longer be able to accommodate other patients; lastly, those who lack family will be forced to roam around public places.  Hence, patients who are in their end-of-life stage are no longer capable of controlling the turn of events that would occur to them.

However, there are those who chose to hold on to their religious faith and turn towards their spiritual community to gain control internally than having external control over what is happening to them (Koenig, 2002). Their religious faith enables them to forget about regaining control over the situation and giving the wanted control to God.  To these people, they are not looking for a home but they are waiting to be brought back to their real home – the idea of Heaven where all of their relatives that have died reside.  The prevalence of religious needs among dying older patients is huge – according to Fitchett, Burton and Sivan (1997 as cited by Koenig, 2002), there were 76% of medical-surgical inpatients in a hospital at Chicago with religious needs; moreover there were nearly 90% of medical inpatients that are older than 60 who used religion in order to help them cope and keep on going even to just a moderate extent (Koenig, 1998, as cited by Koenig, 2002).

According to Koenig (2002), there are four important focuses that need to be attended to by health care providers for a dying person – (1) alleviating excruciating physical symptoms, (2) allowing the patient to be as attentive and aware as much as possible, (3) easing the depression, apprehension and psychotic symptoms, and (4) meeting the spiritual needs of the patients – where the fourth focus is the most important according to Koenig (2002).  This is also the care with dying patients that are nonreligious.  Nonreligious patients are around 10% to 15% in the USA, however, it is said that emotional needs may have greater weight than spiritual needs in their case.  On the other hand, the amount of attention and care should be greater in the case of the dying patients who do not have any family both in the emotional and spiritual aspect.  This is truer for those nonreligious patients since they do not have religious communities to turn to.

            Findings have stated that spiritual and religious viewpoints are capable of stimulate the people’s understanding and attitudes towards illness and end-of-life decision-making (Robinson, Thiel, Backus ; Meyer, 2006).  Thus, they also expect that the health care practitioners will also uphold their spirituality.  However, in the case of parents who have their child in the Pediatric Intensive Care Unit (PICU) have insufficient spiritual care as recent studies have stated that 60% to 80% parents who have their children hospitalized have unmet spiritual needs.

            In a study conducted by Robinson, et al. (2006), they were able to found out what spiritual themes helps them out greatly and the themes that they would likely share to others when it comes to end-of-life.  These themes are divided into two – the explicit and the implicit.  The explicit spiritual themes are prayer, faith, access to and care from clergy, and belief in the transcendent quality of the parent-child relationship that endures beyond death.  On the other hand, the implicit spiritual themes are insight and wisdom, reliance on values, and virtues.  Hospital staffs, chaplains and the community clergy are required to only provide explicit spiritual needs.

Handling Emotions during End-of-Life Care

            There are certain emotions and feelings that are being experienced of those that are providing end-of-life care services.   According to Thieman (2008), it is normal to experience worry and anxiety, sadness, denial or disbelief, bargaining, anger, bitterness, occasional impatience, guilt, depression, and loneliness, emptiness and self-pity.

Worry and anxiety occur as people prepare themselves of the coming death and the changes in their life that might take place.  Sadness, subsequently, fills them up as they watch their loved one slowly die and as they go along the painful journey of letting go.  The usual way of thinking that the situation is unreal makes way for denial or disbelief, they also resolve to bargaining, they bargain with their dying loved one and even with God in order for the situation to change.  Anger also surfaces due to the feel of powerlessness and helplessness that their loved one feels for not being able to do anything to help their dying loved one.  Along with anger is bitterness that is brought by the transpiring feeling of being left alone and abandoned, this bitterness could be directed towards themselves, the dying loved one and God.  Occasionally, when they have already accepted the death of their loved one, they grow impatient as they could no longer wait when their loved one will be relieved out from their suffering.  Still in relation with anger is guilt which is not only being felt by the loved ones of the dying patient but also by the caregivers as they start to think numerous “what ifs.”  Depression could also be experience by caregivers; it is even the most prominent emotion that they acquire.  Along with depression are loneliness, emptiness and self-pity which are caused by lack of sleep, loss of appetite and diminished focus (Thieman, 2008).

            The abovementioned emotions are capable of affecting the behavior and process of healing, thus, coping with them is required to lessen the burden (Thieman, 2008).  It is advised to explore, express and acknowledge the said feelings and permit them to experience and work all through them. Taking care of themselves is also important due to mental, physical and spiritual exhaustion.  In line with giving themselves the appropriate care, patients should also anticipate and endure a decline in energy and effectiveness. They should also confide their feelings to other people like their friends, spiritual adviser and other family members. It also advisable to cry alone as it can permit patients to let out without inhibitions, through it, the coping process can happen fast enough. Reminiscing is also favorable since it can enable them to relive happy memories and laugh. Similar to confiding, it is also alright to ask for help regarding personal, caregiving and even homemaking matters.  Just like taking time alone in crying, it is also helpful to meditate, pray and take time alone. In addition, the feelings they have inside should also be expressed not only through crying but also in other means like in music, dance, drawing or writing.  Lastly, they should express what is in their heart to their dying loved one regardless if they can or cannot hear them (Thieman, 2008).

Controllable and Uncontrollable Elements

            In taking care of people who are dying, there are aspects that one can and cannot control.  According to Erickson (2008a), the only things that can be controlled by people are themselves.  People are capable of taking care of themselves and they should do so, so that they could keep up with the task of caregiving. Their pacing could also be handled by them, taking breaks occasionally from caregiving is helpful since it can recharge their energy in order keep up with the caregiving tasks and reorient their lifestyle away from being a caregiver. Additionally, though it is hard, they should already begin to visualize their life without their dying loved one so that they can take charge of their own life since they have to be responsible for themselves.  Consequently, despite the need to rebuild their lives without their loved one, they should also keep all of their memories since these will serve as their comfort before and after the death of their loved one.

            On the other hand, the things they cannot control is the direction of their loved one’s illness, the physical and emotional distress that they and their loved ones feel, and the avoidance of resurfacing of unsettled family dynamics.  No one can go against the natural course of life, it is natural for people to wish that they could put off the illness and agony that their loved ones are going through, however, they must learn to accept that they cannot do anything about it.  They should also accept that they and their loved ones that are dying are going to experience painful emotions.  Lastly, other unavoidable occurrences are the disputes that are going to resurface due to the disagreements that will arise regarding the means of approaching the illness and the demise of their loved ones.  However, they should try to take control of their emotions to avoid heightening family tensions for the sake of their dying loved one (Erickson, 2008b).


            Grieving may cause one person to feel revulsion against the things he or she used to love to do.  They are incapable of finding pleasure from anything and the feeling that they are alone  dominates them. It is also natural for them to long for their lost loved one and to feel as if the pain they are going through will never be gone. However, they should keep in mind that life should go on, thus, despite of the grief, they should continue to function (Erickson, 2008c).

            Erickson (2008c) gave five do’s and five don’ts when grieving.  For the do’s, people should be patient with themselves as it will take a very long time before they could go back to their old lifestyle, thus, in order to cope up from grief, they should share their grief to other people and ask for their help.  Next is to find a people who will listen, people who will not tell them to let the pain and grief go or say anything like any advices or stories.  Consequently, since they are letting go of a vital aspect of their life, they should expect that grieving is a long process that will not be over easily and its end is uncertain.  Next is that they should talk, cry and sit with it and after all of it, they will just realize that coping with their loss have finally ended and they are ready to get back to being who they were before the loss.  Lastly, they should keep in mind that other people can never feel what they are feeling; however, they should not keep themselves away from other people.

On the contrary, Erickson (2008) does not advise for them to be too strong for their own good, thus, they should surround themselves with people so that they do not have to pretend.  They also should not push themselves if they are already tired; they should take enough rest until they return to how they were.  In addition, they should not only expect that they are going to feel one single emotion because grieving can bring a wide-ranging of feelings. Moreover, they should not blame themselves for what happened though it is normal to feel that way for a short while, however, if it goes on, they will be able to heal. Lastly, they should not alienate themselves because grieving is already a lonesome process in itself.


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