WHERE DO I RECEIVEPALLIATIVE CARE?

DOES MY INSURANCEPAY FOR PALLIATIVE CARE?

HOW DO I KNOW IF PALLIATIVECARE IS RIGHT FOR ME?

WHAT CAN I EXPECT FROMPALLIATIVE CARE?

WHO PROVIDESPALLIATIVE CARE?

HOW DO I GETPALLIATIVE CARE?

HOW DOES PALLIATIVE CARE WORK WITH MY OWN DOCTOR?

Palliative Care What You Should Know

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To learn more about palliative care, go to getpalliativecare.org

1Palliative care can be provided in a variety of settings including the hospital, outpatient clinic and at home.

2

7You have to ask for it! Just tell your doctors and nurses that you would like to see the palliative care team.

4You can expect relief from symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and di�culty sleeping. Palliative care helps you carry on with your daily life. It improves your ability to go through medical treatments. It helps you better under-stand your condition and your choices for medical care. In short, you can expect the best possible quality of life.

5Palliative care is provided by a team includingpalliative care doctors, nurses and other specialists.

6�e palliative care team works in partnership with your own doctor to provide an extra layer of support for you and your family. The team provides expert symptom manage-ment, extra time for communication about your goals and treatment options and help navigating the health system.

Palliative Care (pronounced pal-lee-uh-tiv) is specialized medical care for peoplewith serious illness. This type of care is focused on providing relief from the symptomsand stress of a serious illness. The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a specially-trained team of doctors, nurses and otherspecialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness, andit can be provided along with curative treatment.

Most insurance plans, including Medicare andMedicaid, cover palliative care. If costs concernyou, a social worker from the palliative care team can help you.

3Palliative care may be right for you if you su�er from pain, stress or other symptoms due to a serious illness. Serious illnesses may include cancer, heart disease, lung disease, kidney disease, Alzheimer’s, HIV/AIDS, amyotrophic lateral sclerosis (ALS), multiple sclerosis, Parkinson's and more. Palliative care can be provided at any stage of illness and along with treatment meant to cure you.

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What Is Palliative Care?

Definition

Palliative care (pronounced pal-lee-uh-tiv) isspecialized medical care for people with seriousillness. This type of care is focused on providingrelief from the symptoms and stress of a seriousillness. The goal is to improve quality of life forboth the patient and the family.

Palliative care is provided by a specially-trainedteam of doctors, nurses and other specialists whowork together with a patient’s other doctors toprovide an extra layer of support. It is appropriateat any age and at any stage in a serious illness,and it can be provided along with curativetreatment.

Improves Quality of Life

Palliative care teams specialize in treating peoplesuffering from the symptoms and stress of seriousillnesses such as cancer, congestive heart failure (CHF),

chronic obstructive pulmonary disease (COPD), kidneydisease, Alzheimer’s, Parkinson’s, Amyotrophic LateralSclerosis (ALS) and many more. This type of care treats

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y yppain, depression, shortness of breath, fatigue,constipation, nausea, loss of appetite, difficultysleeping, anxiety and any other symptoms that may becausing distress.

The team will help you gain the strength to carry onwith daily life. In short, palliative care will helpimprove your quality of life.

Close Communication

The palliative care team will also spend time talking toyou and listening. They will make sure you understandall of your treatment options and choices. By deeplyexploring your personal goals, the palliative care teamwill help you match those goals and options. They willalso make sure that all of your doctors are coordinatedand know and understand what you want. This givesyou more control over your care.

A Partnership of Palliative Care Team,Patient and Family

Palliative care teams are specialists who work togetherwith you, your family and your other doctors. Theyprovide an extra layer of support when you need itmost. In addition to treating your symptoms, thepalliative care team spends as much time as necessarycommunicating with both you and your family. Theysupport you every step of the way.

Talking to Your Doctor

If you or a loved one is facing a serious illness, you maybenefit from palliative care. You can have palliativecare at any point in your illness. Take the quiz if you’renot sure. Then speak to your doctor, and ask for it.Bring the handout with you!

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Frequently Asked Questions

How do I know if palliative care is right for me?

What does the palliative care team do?

What can I expect from palliative care?

Will my insurance cover palliative care?

Do I have to give up my own doctor?

Can I have curative treatment together withpalliative care?

Who else, besides the patient, can benefit?

Where do I get palliative care?

Who provides palliative care?

How does palliative care help me choose thebest treatment option?

When should I ask for palliative care?

How do I get palliative care?

1. How do I know if palliative care is right for

me?

Palliative care may be right for you if you have aserious illness. Serious illnesses include but are notlimited to: cancer, heart disease, lung disease, kidneydisease, Alzheimer’s, amyotrophic lateral sclerosis(ALS) and many more. Palliative care is appropriate atany stage of a serious illness. You can also have this

type of care at the same time as treatment meant tocure you.

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If you’re not sure, take the quiz.

2. What does the palliative care team do?

Palliative care (pronounced pal-lee-uh-tiv) isspecialized medical care that focuses on providingrelief from the symptoms and stress of a seriousillness. It is provided by a specially-trained team ofdoctors, nurses and other specialists who worktogether with your other doctors to provide an extralayer of support. The goal is to improve your quality oflife.

To do this, the palliative care team will:

Relieve your symptoms and distress

Help you better understand your disease anddiagnosis

Help clarify your treatment goals and options

Understand and support your ability to cope withyour illness

Assist you with making medical decision

Coordinate with your other doctors

3. What can I expect from palliative care?

In short, you can expect that your quality of life will beimproved. You will have relief from symptoms such aspain, shortness of breath, fatigue, constipation,nausea, loss of appetite and difficulty sleeping. You canalso expect close communication and more controlover your care.

Palliative care will help you carry on with daily life. Itwill improve your ability to go through medicaltreatments. And it will help you to match your goals toyour treatment choices.

4. Will my insurance cover palliative care?

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Most insurance plans cover all or part of palliativecare, just as with other hospital and medical services.This is also true of Medicare and Medicaid. If costsconcern you, a social worker or financial consultantfrom the palliative care team can help you withpayment options.

5. Do I have to give up my own doctor?

No. The palliative care team provides an extra layer ofsupport and works in partnership with your primarydoctor.

6. Can I have curative treatment together with

palliative care?

Yes, absolutely. Your treatment choices are up to you.You can have palliative care at the same time astreatment meant to cure you.

7. Who else, besides the patient, can benefit?

Everyone involved! Patients as well as familycaregivers are the special focus of palliative care. Yourdoctors and nurses benefit too, because they knowthey are meeting your needs by providing care andtreatment that reduces your suffering and improvesyour quality of life.

8. Where do I get palliative care?

Palliative care is available in a number of places. Moreand more, palliative care is available outside of thehospital in the places where you live.

You, your doctor and the palliative care team candiscuss outpatient palliative care or palliative care athome. Some hospitals also offer outpatient palliative

care even if you have not been in the hospital. Checkwith your doctor.These include hospitals, outpatientclinics and at home.

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9. Who provides palliative care?

A team of specialists, including palliative care doctorsand nurses provide this type of care.

10. How does palliative care help me choose

the best treatment option?

The palliative care team will also spend time talkingand listening to you and your family. They will makesure you completely understand all of your treatmentoptions and choices. By deeply exploring yourpersonal goals, the palliative care team will help youmatch those goals to the options. They will also makesure that all of your doctors are coordinated and knowand understand what you want. This gives you morecontrol over your care.

11. When should I ask for palliative care?

You can have it at any age and any stage of an illness,but early in your illness is recommended.

Recent cancer guidelines say that cancer patientsshould receive palliative care early and together withtheir other treatments. People who are newlydiagnosed with advanced cancer should receive apalliative care consult within 8 weeks of theirdiagnosis.

12. How do I get palliative care?

Ask for it! You have to start by talking with your doctoror nurse.

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Disease Types and PalliativeCare

The goal of palliative care is to improve quality of life.Palliative care specialists treat people suffering frommany serious disease types and chronic illnesses,including cancer, cardiac disease such as congestiveheart failure (CHF), chronic obstructive pulmonarydisease (COPD), kidney failure, Alzheimer’s,Parkinson’s, Amyotrophic Lateral Sclerosis (ALS) andmany more.

Focusing on the symptoms of both the disease and thetreatment, palliative care helps you with a wide rangeof issues, including pain, depression, anxiety, fatigue,shortness of breath, constipation, nausea, loss ofappetite and difficulty sleeping. It also helps you gainthe strength to carry on with daily life. It improvesyour ability to tolerate medical treatments. And ithelps you have more control over your care byimproving your understanding of your choices fortreatment.

It also helps your family caregivers and providespractical support. Learn more about how palliativecare helps when you and your family are facing aserious illness:

ALS

Alzheimer’s Disease

Breast Cancer

Bone Marrow Transplant

Cancer

Chronic Obstructive Pulmonary Disease (COPD)

Colon Cancer

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Colon Cancer

Congestive Heart Failure

Dementia

Eosinophil Associated Disease (EAD)

Head and Neck Cancer

HIV/AIDS

Huntington’s Disease

Kidney Disease

Leukemia and Lymphoma

Liver disease

Lung Cancer

Multiple Myeloma

Multiple Sclerosis

Ovarian Cancer

Pancreatic Cancer

Parkinson’s Disease

Prostate Cancer

Pulmonary Fibrosis

Sickle Cell Anemia

Stroke

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diagnosis or

treatment.

1

For More Information: National Association of Chronic Disease Directors: Carol Tangum, 404-377-4061 ctangum@mindspring.com CDC Healthy Aging Program: cdcinfo@cdc.gov Health Benefits ABCs: William F. Benson, 202-255-2001 bbenson@healthbenefitsabcs.com

Advance Care Planning: Ensuring Your Wishes Are Known and Honored

If You Are Unable to Speak for Yourself Did you know… Most people say they would prefer to die at home, yet only about one-third of adults have

an advance directive expressing their wishes for end-of-life care (Pew 2006, AARP 2008). Among those 60 and older, that number rises to about half of older adults completing a directive.

Only 28 percent of home health care patients, 65 percent of nursing home residents and 88 percent of hospice care patients have an advance directive on record (Jones 2011).

Even among severely or terminally ill patients, fewer than 50 percent had an advance directive in their medical record (Kass-Bartelmes 2003).

Between 65 and 76 percent of physicians whose patients had an advance directive were not aware that it existed (Kass-Bartelmes 2003).

Advance care planning is about doing what you can do to ensure that health care treatment

you may receive is consistent with your wishes and preferences should you be unable to make

your own decisions or speak for yourself. There are several written documents available for us to

express our care wishes and/or appoint a surrogate decision-maker if we become unable to make

our own decisions. Equally important is making sure that our surrogate knows and understands

our care preferences.

WHAT IS ADVANCE CARE PLANNING? “Advance care planning is about planning for the ‘what ifs’ that may occur

across the entire lifespan.” — Joanne Lynn, MD

Whether someone is facing an acute illness, a long-term chronic illness or a terminal illness,

advance care planning can help alleviate unnecessary suffering, improve quality of life and

provide better understanding of the decision-making challenges facing the individual and his or

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her caregivers. An advance care plan can be used at any stage of life and should be updated as

circumstances change.

“Advance care plans can be developed at any time, whether you are sick or well,” said

Joanne Lynn, MD, a geriatrician and hospice physician who heads the Center on Elder Care and

Advanced Illness for the Altarum Institute. “Once you are sick and disabled with a progressive

illness that will last until death, you really need a comprehensive care plan that considers your

social supports, your preferences, and your likely course. Advance care planning is an essential

part of such a plan.”

Advance care planning is about planning for the “what ifs” that may occur across the entire

lifespan, such as being maimed in a motorcycle crash at a young age, and not just for older adults

approaching the end of their lives, Dr. Lynn said. Those plans can be revised and updated

throughout the person’s life as health status and living circumstances change, she added.

Comprehensive advance care planning involves discussion of disease trajectory and multiple

conditions, said Kathleen Tschantz Unroe, MD, Assistant Research Professor of Medicine,

Indiana University Center for Aging Research. “The patient and family need to understand the

patient’s medical and functional condition and what that might look like over the next months or

a year and try to anticipate events that can happen. The goal is to try to more proactively make

decisions and understand patient values rather than just reacting to changes in condition,” Dr.

Unroe said.

Advance care planning is especially important if a patient does not want aggressive treatment,

Dr. Unroe said. “The default in our medical system is aggressive care unless there is a clearly

written, in-your-face, advance directive.” Otherwise, “a 95-year old who is unresponsive is

getting coded [a reference to a “code blue” patient status in a hospital when a team quickly moves

to revive a patient without a heartbeat]. If they can get a pulse back and get them into the ICU,

that is what is going to happen. That is the American culture and the American medical culture,”

she said.

BARRIERS TO ADVANCE CARE PLANNING “Denial about death does a disservice of not dealing with life-review and

life-closure issues that some people would choose to do if they were thinking about dying as part of this last phase.” — Judith Peres, MSW

So why have only one-third of adults prepared an advance directive?

Lack of Awareness. While advance directives are supported by state laws, there is still no

clear process to allow an individual’s wishes to be known and ensure that care is tied to those

documents. The SUPPORT study, sponsored by the Robert Wood Johnson Foundation, found

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that nearly a third of terminally ill participants did not want cardiopulmonary resuscitation (CPR),

but less than half of their physicians knew of their preference. Even when patients had written

advance directives, their instructions had been discussed with a physician in only 42 percent of

the cases (Teno 1997).

Denial. A key part of the problem is our society’s denial of death and dying, and of being in a

circumstance in which we are unable to make our own decisions and speak for ourselves. “We

don’t really acknowledge the waning days of life like we do with a birth,” Peres said. “Denial

about death does a disservice of not dealing with life-review and life closure issues that some

people would choose to do if they were thinking about dying as part of this last phase,” Peres

said. “Instead, if we obfuscate it and talk around it, like the elephant in the room, people really

don’t get the opportunity to deal with it.”

Confusion. Despite a strong preference for quality of life at the end of life, many Americans

worry about potential conflicts between palliative care and doing whatever it takes to extend a

patient’s life, a Regence Foundation/National Journal poll found (Regence 2011). Almost half (47

percent) of respondents said they worry that emphasizing palliative and end-of-life care options

could interfere with doing whatever it takes to help patients extend their lives as long as possible.

One way around end-of-life denial has been to discuss palliative care (which may or may not

involve end-of-life care) much earlier in a person’s disease process or life. “If we move palliative

care way upstream through symptom management, communication and inclusion of patient-

centered care earlier, then by definition it would include what people needed at the end,” Peres

said.

Cultural Differences. The majority of Medicare beneficiaries of all racial and ethnic groups

say that in the event of a terminal illness with less than a year to live, they would want to die at

home and would not want to receive life-prolonging drugs with uncomfortable side effects or

mechanical ventilation to extend their life for a week or a month. However, researcher Amber

Barnato, MD, MPH, and colleagues have reported differences in the distribution of preferences

for end-of-life medical treatment by race/ethnicity even after controlling for potentially mediating

or confounding demographic and sociocultural variables (Barnato 2007). For example, compared

to whites, blacks are more likely to die in the hospital and to use intensive care and life-sustaining

treatments such as mechanical ventilation, hemodialysis and feeding tubes, according to the

research reported by Barnato, who is with the Center for Research on Health Care, University of

Pittsburgh. Blacks also incur higher medical care costs in their last 12 months than whites. While

some of these differences are due to regions with higher end-of-life care treatment costs, some

differences may be due to minorities’ lower usage of hospice services and advance care planning

4

documents. Barnato found that, among community-dwelling Medicare beneficiaries age 65 or

older:

• Blacks (18 percent) were more likely than Hispanic (15 percent) and non-Hispanic whites (8 percent) to want to die in the hospital.

• More blacks (28 percent) and Hispanics (21percent) than whites (15 percent) want life-extending drug treatment even if it has uncomfortable side effects.

• Fewer blacks (49 percent) and Hispanics (57 percent) than whites (74 percent) want palliative medications that might be life shortening.

• More black (24 percent) and Hispanic (22 percent) than white (13 percent) respondents said they would want mechanical ventilation for life extension of one week. Asked about mechanical ventilation for one month, the responses in favor were blacks (36 percent wanted), Hispanics (29 percent wanted), whites (21 percent wanted).

CHRONIC CONDITIONS AND ADVANCE CARE PLANNING Successful public health strategies and medical advancements have contributed to increased

life expectancy for Americans, such that now the average person will live to be about 76 years

old. While some older adults remain healthy and robust until very close to death, it is more likely

that an older individual will have lived for two or more years with one or more chronic diseases

and experienced substantial disability before dying. Along the way, he or she, and the family, will

have to make what are sometimes difficult choices about health care. Considering those choices,

and talking about what should or should not be done, is at the heart of advance care planning

(Lynn 2003, IOM 1997).

“Throughout our lives, but especially when we are older and facing increased risk of serious

illness, we need a plan about what services are essential to living well and meaningfully,” Dr.

Lynn said.

The data below show the proportion of older Americans impacted by health problems:

• 70 percent of Americans (more than 1.7 million) die of a chronic disease (Kung 2008).

• About 62 percent of all deaths each year are due to five chronic diseases – heart disease, cancer, stroke, chronic obstructive pulmonary disease and diabetes (Minino 2011).

• Alzheimer’s disease is the sixth-leading cause of death across all ages in the United States and the fifth-leading cause of death for those ages 65 and older (Xu 2007).

• 42 percent of Medicare enrollees age 65 and over have functional limitations (Forum 2010).

• 25 percent of people receive hospice services at the end of their lives (Casarett 2005). • 24 percent of noninstitutionalized persons age 65+ report having fair/poor health

(CDC 2010a). • 7 percent of noninstitutionalized persons age 65+ and 19 percent of persons age 85+

report needing help with personal care from other persons (CDC 2010b).

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The reality of more people living with, declining from, and ultimately dying of a chronic

condition raises complexities and challenges that require new ways of thinking about death and

dying. Toward the end of the twentieth century, several news items related to these challenges

caught the public’s attention. Well-publicized cases of terminally ill people – who were kept alive

by artificial means while their families argued over what care options the patient would have

wanted – got more people thinking about their own end-of-life wishes.

Gallup Polls conducted in the mid-1990s found nine out of 10 respondents reported they

would prefer to be cared for at home if they were terminally ill with six months or less to live

(IOM 1997).

Most Americans (71 percent) believe it is more important to enhance the quality of life for

seriously ill patients, even if it means a shorter life, than to extend the life of seriously ill patients

through every medical intervention possible (23 percent), according to the Regence poll (Regence

2011).

The Regence poll also showed that 97 percent of respondents agree that educating patients

and their families about these issues is important; 78 percent believe there should be more of an

open debate about public policies regarding palliative care options and 81 percent think these

discussions should be fully covered by Medicare.

Professionals in the fields of public health and aging services are in positions to help older

adults and their families address important issues related to advance care planning, such as

completing legal or other written documents. However, the key responsibility falls on individuals

and their families to have “The Conversation” about what care they would like to receive if they

become unable to make their own decisions. Thus, the most important tasks are to appoint a

surrogate decision maker; ensure that a person’s family and caregivers understand the

individual’s attitude about life, death and dying; and engage in a conversation about the person’s

wishes for care under various scenarios that might occur.

END-OF-LIFE CARE AS A PUBLIC HEALTH ISSUE “Is not the logical conclusion of healthy aging a ‘good’ death?

Is not this an important part of public health work?” — Myra Christopher

The Centers for Disease Control and Prevention (CDC) recognizes the public health

opportunity to educate Americans, and especially older adults, about advance care planning and

to improve their quality of care at the end of life. Planning for the end of life is increasingly being

viewed as a public health issue, given its potential to prevent unnecessary suffering and to support

an individual’s decisions and preferences related to the end of life (CDC 2010c).

6

Advance care planning also meets other criteria that define a public health issue. According

to Lynda Anderson, PhD, Director, Healthy Aging Program, Division of Population Health at

CDC, advance care planning: (1) can potentially affect a large number of people [2.3 million

people die each year (Hogan 2001)]; (2) can reduce unwanted and expensive treatment [the 5

percent of Medicare beneficiaries who die in a given year account for about one-quarter of that

year’s Medicare spending (Hogan 2001, Austin 2003)]; and (3) can meet public demand to

change the way care has been addressed in the past.

Proponents of advance care planning note that it took time for the medical profession and

public health community to understand the importance of advance care planning. After all, health

care professionals are typically focused on ensuring a healthy long life and saving lives at any

cost. Therefore death – or preparing for death – has not been viewed as compatible with what

health care providers do.

“Is not the logical conclusion of healthy aging a ‘good death’? Is not this an important part of

public health work?” commented Myra J. Christopher, the Kathleen M. Foley Chair of the Center

for Practical Bioethics.

A 1997 Institute of Medicine (IOM) report defined a “good death” as “good care at the end of

life.” This good death “depends on strong interpersonal skills, clinical knowledge and technical

proficiency, and it is informed by scientific evidence, values and personal and professional

experience” (IOM 1997).

WHAT ARE CARE NEEDS AT THE END OF LIFE? “People need to be comfortable, people need to be respected and people need to be told the truth.” — Judith Peres, MSW

Defining end-of-life care needs is not easy because “We are still essentially a death-denying

culture,” said Judith Peres, MSW, a policy consultant in palliative care and long-term services

and supports who serves on the board of the Social Work, Hospice and Palliative Care Network.

“People don’t want to have an honest conversation, nor are the acute care providers used to

having the conversation.”

In addition, people vary greatly in what they want at the end of their life. Some patients want

to continue aggressive treatment up to the time of death. Others are willing to endure treatment

side effects and hospitalization in the hope of gaining weeks or months of additional life. Some

prefer to focus on their quality of life. They may choose to concentrate on closure; comfort care

in familiar surroundings, including pain control and relief from uncomfortable disease symptoms;

and retaining their dignity.

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A survey (Steinhauser 2000) of more than 1,400 patients, family members or professionals

involved with end-of-life care revealed that their most important goals are:

• Pain and symptom management • Preparation for death • Achieving a sense of completion • Decisions about treatment preferences • Being treated as a “whole person”

In addition, patients strongly rated the importance of being mentally aware, having funeral

arrangements made, helping others, coming to peace with God and not being a burden.

Participants ranked freedom from pain as most important and dying at home as least important

among nine criteria (Steinhauser 2000).

Clearly, “people need to be comfortable, people need to be respected and people need to be

told the truth,” Peres said. Some recent research shows that good pain and symptom management

control and attention to psycho-social-spiritual needs not only reduces suffering, but also extends

life. “This message seems to be getting lost a lot in an effort to coordinate care and save money,”

Peres added.

DEFINING ‘PALLIATIVE CARE’ AND ‘END OF LIFE’ CARE The definitions of and relationship between end-of-life care and palliative care vary among

experts, patients and providers (Moon 2002).

End-of-life care and hospice care are for people who are expected to die soon, whereas

palliative care provides pain relief and comfort care to anyone who is seriously ill regardless of

prognosis. Both palliative care and end-of-life care emphasize relief of suffering and improved

quality of life. Palliative care can be offered as part of hospice or end-of-life care, or it can be

offered along with treatments meant to cure illness (NINR 2011).

According to the Center to Advance Palliative Care, “Palliative care is a medical specialty

that helps people facing serious and chronic illness be more comfortable by alleviating pain,

treating a host of other symptoms and focusing on their quality of life. It is appropriate at any age

and any stage of a serious illness and can be provided along with curative treatment.”

Findings from a 2011 Public Opinion Strategies survey found that most Americans believe

palliative care should be made available at all hospitals. However, the concept of “palliative care”

and “advance care planning” are not as well understood by the public as the more-familiar

concept of “hospice care.” Once informed about palliative care, 92 percent of respondents said

they would consider it for a seriously ill loved one (CAPC 2011).

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Another key difference is that hospice care is covered by Medicare for someone who is

certified to be in the last six months of life, while palliative care is financed on a physician fee-

for-service basis.

MEDICARE HOSPICE BENEFIT “Greater physician engagement is needed

in the process of certifying and recertifying patients' eligibility for the Medicare hospice benefit.” — Medicare Payment Advisory Commission

Medicare began to cover hospice care in 1983 for beneficiaries who have been certified by a

physician as having a life expectancy of six months or less (Hoyer 1996). The Medicare hospice

benefit offers psychological and social services, pain management, respite care, and spiritual and

bereavement counseling on an as-needed basis up to 24 hours a day. It also covers outpatient

prescription drugs for symptom relief (but not for treating the terminal illness) with a 5 percent

copay, and medical supplies and equipment. Medicare requires hospice programs to have a

physician, nurse, a hospice aide, a social worker and a chaplain available to hospice patients.

Medicare requires hospice beneficiaries to forego curative prescription drugs and treatments

(CMS 2011).

In 2010, 82.7 percent of hospice patients were 65 years of age or older; more than one-third

of all hospice patients were 85 years of age or older, according to data from the National Hospice

and Palliative Care Organization (NHPCO 2011). They were predominantly white (90.7 percent)

and not of Hispanic or Latino origin (91.9 percent) (NCHS 2011).

For-Profit Trend. Since around 2000, there has been a trend of more for-profit hospices

programs being created, Peres said. “Fifty-one percent of hospice providers are now for-profits,”

Peres said. There are no hard data on whether quality of care is impacted by a hospice’s profit or

non-profit status.

Location of Care. Most hospice patients (66.7 percent) receive their care at “home,” which

includes private housing, nursing homes and residential facilities (NHPCO 2011). NHPCO data

show 21.9 percent of hospice patients received care in a hospice inpatient facility and 11.4

percent received care in acute care hospitals in 2010.

The majority (58.0 percent) of hospices are independent, freestanding agencies (NHPCO

2011). The remaining agencies are either part of a hospital system (21.3 percent), home health

agency (19.2 percent) or nursing home (1.4 percent).

There were more than 3,500 Medicare-certified hospice agencies in 2010 (NHPCO 2011).

NHPCO data show the Medicare hospice benefit is the predominate source of payment for

hospice care – 83.8 percent of all hospice payments. Other payment sources were managed

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care/private insurance (7.9 percent), Medicaid hospice benefit (4.9 percent), uncompensated or

charity care (1.5 percent) and self-pay (1.1 percent).

Hospice Utilization. During 2007, there were 1.0 million hospice patients, a 68 percent

increase since 2000 when there were 621,000 patients (NCHS 2011). Medicare payments for

hospice grew from almost $3 billion in 2000 to $12 billion in 2009 (MedPAC 2011).

Length of stay. Ironically, research on hospice patient length of stay at Massachusetts

General Hospital showed that lung cancer patients, who received palliative care and hospice care

at an earlier stage, lived longer by a couple months (Temel 2010). “Similar longevity has been

shown with a number of other diagnoses, such as heart failure and COPD” (chronic obstructive

pulmonary disease), said Dr. Anthony Riley, the Medical Director at Gilchrist Hospice Care in

Baltimore, Md. “So there is accumulating evidence that hospice care can extend life.” Dr. Riley

cited two possible reasons for this phenomenon: (1) hospice protects patients from harmful

medical interventions that shorten their life and (2) hospice helps relieve the stress of the medical

illness and that translates into survival benefit.

Medicare Payments. Medicare makes a daily payment, regardless of the amount of services

provided on a given day and on days when no services are provided, according to MedPAC.

Payments are made according to a fee schedule for four categories of care. For 2012, the base

payment rates were: $151/day for routine home (or assisted living) care; $156/day for inpatient

respite care (in a nursing home or other facility when their usual caregiver is unavailable);

$672/day for general inpatient care (in a hospice or hospital hospice for those who are very

symptomatic, such as intractable pain or vomiting); and $881/day for continuous (24/7) home

care. The rates are updated annually (MedPAC 2011).

Some providers state that the fixed Medicare daily rate is insufficient to cover services. This

is especially true for patients who have short hospice stays with extraordinary expenses. The first

and last few days in hospice are the most costly, because that is when the most care is provided,

Dr. Riley said. Thus, for shorter stays, there are fewer less costly days to offset the more costly

ones, resulting in higher costs for the hospice program (Austin 2003).

Predicting Death. The other problem with hospice economics is the difficulty of selecting

patients who will die within the six-month window. “The trajectory for someone with even very

advanced dementia, people who are no longer able to walk or speak, could be shorter or it could

be a few years,” Dr. Unroe said.

“Most of us die having lived with a set of eventually fatal illnesses that are stable two weeks

ahead of death,” Dr. Lynn said. “People living with these illnesses are often just one complication

away from death. Planning for what to do when these complications arise is essential to good

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advance care planning.” A study looking at more than a dozen prognostic indices used to predict

risk of death in older adults in a variety of clinical settings, such as in nursing homes and

hospitals, found that there is insufficient evidence to recommend the widespread use of these

indices in clinical practice (Yourman 2012).

Concurrent Care. Currently, Medicare patients give up curative treatment to receive hospice

services. However, some hospices serving non-Medicare patients provide interventions such as

IV antibiotics, radiation therapy, and chemotherapy In addition, curative treatment and palliative

care can overlap. For example, radiation can be used to ease the pain of cancer, yet it is also a

treatment for some forms of cancer.

“Additionally, asking patients from certain cultures (Hispanics and African-Americans in

particular) to choose comfort care to the exclusion of life-prolonging treatment may be

incongruent with their culture and beliefs,” according to the American Society of Law, Medicine

& Ethics (Cerminara 2012).

The U.S. Department of Health and Human Services has been authorized to conduct a three-

year Medicare hospice concurrent care demonstration to measure the quality of hospice care

compared to conventional care. As many as 15 hospice programs nationwide will be participating

in the study to determine whether patients benefit when Medicare authorizes payment for receipt

of curative treatment at the same time they are receiving hospice care.

DETERMINING QUALITY OF HOSPICE CARE “Quality in end-of-life care is difficult to measure,” Dr. Riley said. “There are no ready or

easily usable tools to measure quality. We can’t use mortality as a measure of quality care,” since

hospice patients generally die. “It is hard to use the quality argument if you don’t have any

quality numbers.” So measurements tend to focus on hospice utilization, rather than quality of

care, he said.

There is currently a movement to ensure more rigorous hospice quality management through

metrics such as pain controlled within 24 hours. “That is a clinical, patient-centered outcome that

is a meaningful metric that measures how fast you can get the patient comfortable,” Dr. Riley

said.

“In recognition of the need for quality measurement and improvement, and in anticipation of

the time when payment will be linked to quality hospice care, the Centers for Medicare &

Medicaid Services (CMS) has recently requested that hospices submit quality metrics that should

be considered for adoption by CMS. Metrics such as patient comfort measures and family

evaluation of hospice care and bereavement services are likely to receive the most consideration,”

Dr. Riley said.

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Another way to analyze hospice care is to look at how programs approach different cultures and

communities with regard to having the conversation, Peres said. “The first tenant of social work is

‘begin where the client is.’ So any nurse, social worker, physician, or person working in palliative

and end-of-life care, if they are not first soliciting a person’s belief system, then they are going in

the wrong direction.”

ADVANCE CARE PLANNING DOCUMENTS “Advance care planning gives us a way to have a voice, to make a choice

as to what we want from the people who will make decisions for us if we are no longer able to.” — Lynda Anderson, PhD

There are two overriding goals for advance care planning: establishing a surrogate decision-

maker, which is a legal activity; and expressing your values, treatment goals and wishes, which is

a communications task, explained Charles Sabatino, JD, Director, Commission on Law and

Aging at the American Bar Association (ABA). “In addition to whatever advance care planning

documents someone has filled out, the surrogate decision maker should be guided by information

shared during focused conversations between the agent and the patient and family,” according to

ABA documents.

Advance directives can only work if the individual understands the document, his or her

surrogate understands the individual’s wishes, the physician is aware of the document’s existence,

the physician complies with the surrogate’s instructions, and the document is revised as an

individual’s condition and goals changes.

“Everybody approaches the topic of advance care planning in a very personalized, unique

way,” Sabatino said. “Fortunately there are a lot of tools, such as the CDC advance care planning

training course [see section below on Role of CDC], that are helping people to know how to have

structured discussions and help them think through what all the issues are in connecting with

those discussions, so that they do more effective advance care planning.”

Living Will. The first planning documents were proposed in 1967 (Glick 1991). The living

will was based on the legal premise that a patient cannot be subjected to treatment without his or

her consent. A living will provides a way for an individual to instruct a physician or other health

care provider as to when to use, withhold or withdraw life-sustaining treatment when that person

no longer has the capacity to make decisions about life-sustaining treatment.

Durable Power of Attorney. Because living wills only applied to a narrow range of

decisions, lawyers and others began recommending durable powers of attorney, which designate

someone else to make health-care decisions when you cannot do so. The document states the

types of treatments that you do and do not want, but allows the decision-maker to make decisions

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beyond those listed in the document. To create a stronger document that would be directly

applicable to health care, states enacted statutes creating durable powers of attorney for health

care. By the end of 1997, every state had enacted some version of a health care power of attorney

statute (ABA 1998).

Do Not Resuscitate Order. In the early 1990s, the need for additional legislation for do-not-

resuscitate (DNR) protocols became apparent to address the unwanted resuscitation of terminally

ill patients. Without this document, emergency medical service providers were obligated to try to

resuscitate someone whose heart or breathing had stopped. By the end of 1999, 42 states had

statewide DNR protocols in place, usually created by legislation (Sabatino 1999).

Communications Approach. Instead of relying solely on legalistic documents, a 1997

Institute of Medicine (IOM) report on end-of-life care said that people were beginning to adopt a

communications approach that involved “discussions with family members and physicians about

what the future may hold for people with serious illnesses, how patients and families want their

beliefs and preferences to guide decisions ... , and what steps could alleviate concerns related to

finances, family matters, spiritual questions and other issues that trouble seriously ill or dying

patients and their families”(IOM 1997).

Useful, consumer-oriented materials based on communication-based approaches were

developed for individuals and their family members. Among these were the Five Wishes “living

will” created by the organization Aging with Dignity, and the Caring Conversations workbook

developed by the Center for Practical Bioethics to help individuals and their families share

meaningful conversation while making practical preparations for end-of-life decisions (see

Resources list), among other similar models.

“In most situations, having the conversation and coming to some conclusions is more

important than worrying about how you document it,” Dr. Lynn said. Sometimes patients just

write a letter to their kids, she said. “No judge is going to overturn a parent’s final letter to the

kids.” The communications approach – having the conversation – allows people to address things

that are not in an advance directive and other standard forms, such as a living will, Dr. Lynn said.

“You might want to address other issues, such as your desire that the family make peace, that you

don’t want to bankrupt your surviving spouse, that you don’t want to incur excessive medical

costs when there is no hope for a cure.”

POLST. Oregon was the first state to develop the Physician Orders for Life-Sustaining

Treatment (POLST) Paradigm Program for seriously ill patients (Sabatino 2010). This tool does

not serve the same purpose as an advance directive and is best supplemented with other advance

care planning. It is a tool that requires a discussion between the patient and/or surrogate with the

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treating physician to determine the patient’s end-of-life care goals and wishes, which are then

incorporated into the physician’s orders regarding resuscitation; artificial nutrition and hydration;

and issues of comfort care versus more aggressive treatment. Some states include additional

decisions such as whether to use antibiotics or ventilation. These orders are reviewed and updated

as needed when the patient’s condition changes. One of the primary benefits of the POLST form

is that it moves with the patient through various institutions (hospital, nursing care, home care)

and is to be recognized by all health care professionals.

About 15 states and cities have authorized the use of POLST forms, Sabatino said, and many

more are developing similar programs.

Default Surrogates. Meanwhile, states are gradually adopting ways to make decisions in the

absence of any kind of advance directive. Today 44 states and the District of Columbia have

default surrogate consent or family consent laws, although the laws vary considerably among

states (ABA 2009a). These laws create a list of permissible surrogates, usually starting with the

spouse and then a next-of-kin (child, sibling, etc.) priority list. Many states also allow a domestic

partner or close friend to make health care decisions for someone who is unable to do so.

Advance Directive. The multitude of complex documents and options outlined above led

many states to try to merge their various documents into one advance directive. As of the latest

data available, 25 states had statutes expressly recognizing such documents (ABA 2009b), but

regardless of one’s state, it is common to use a single, comprehensive advance directive. The

main purpose of an advance directive is to appoint a surrogate to act on your behalf when you

cannot. “You also can give instructions about the kind of health care you do or do not want,”

according to ABA.

In addition, in 1993, the National Conference of Commissioners on Uniform State Laws

adopted the Uniform Health-Care Decisions Act, which created basic rules for recognizing almost

any kind of written or oral statement as an advance directive. States that have adopted this model

law have added a requirement that the statement be witnessed.

Congressional Action. The Patient Self-Determination Act passed in 1990 requires Medicare

and Medicaid providers to educate staff and patients about health care decision-making, to ask

patients whether they have an advance directive, and to comply with the requirements of state law

respecting advance directives. The law stops short of actually requiring providers to assist in

completing an advance directive (Sabatino 2010).

In 2008, Congress added “end-of-life planning” to the “Welcome to Medicare” physical exam

available to newly enrolled Medicare beneficiaries. The term “end-of-life planning” is defined as

verbal or written information “regarding an individual’s ability to prepare an advance directive in

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the case that an injury or illness causes the individual to be unable to make health care decisions;

and whether or not the physician is willing to follow the individual’s wishes as expressed in an

advance directive” (42 U.S. Code §1395(x)vv(3).).

Bare Bones Power of Attorney. State law variations make it nearly impossible to have a

national advance directive, Sabatino said, but in 2011 the American Bar Association developed a

guide that is usable in all but five states. ABA’s Commission on Law and Aging released a “bare

bones” healthcare power of attorney document, applicable in 45 states, in an effort “to make the

legal side of this more manageable and understandable,” Sabatino said. It is designed to focus

more simply on the single most important task – naming a health care agent. The form contained

in the ABA guidance document, Giving Someone a Power of Attorney for Your Health Care, is

designed as an easy-to-use legal form for all adults and avoids specific instructions about medical

treatments. (See Resources list.)

“Only five states have laws so inflexible and cumbersome that the bare bones power of

attorney will not work – Indiana, New Hampshire, Ohio, Texas and Wisconsin,” he said.

The ABA document requires the individual to do three things: 1) think carefully about whom

you want as your health care agent; 2) provide guidance to the agent through more effective

communication resources than a legal form; and 3) fill out the power of attorney form and sign in

the presence of two witnesses.

Resolving Conflicts. Advance care planning is not perfect and sometimes family members

will disagree over what a loved one would have wanted. “The best defense is having a good

offense and that means having good support services in the health care environment that

constitute good counseling and support for the family” to help them get through the situation,

Sabatino said. Hospitals vary a lot in how much support they provide family members. “Some are

pretty good at it and some leave family members hanging in the lurch,” which means more

problems are likely to occur. “For some families, there is nothing you can do and in the end

litigation may be the only course of action, but that doesn’t happen a lot and it shouldn’t happen a

lot.” Many institutions and all hospitals have some form of ethics committee that can provide

consultation and support to both the doctor and hopefully the family.”

Unfortunately, “thirty years of research shows that even if you have an advance directive,

most of the time it doesn’t get into the patient’s medical record,” Sabatino said. “Even if it gets

into the medical record, it is not very visible and is not likely to be consulted when decisions need

to be made. The most important task is the appointment of an agent to ensure your wishes, in

whatever way they are communicated (via an advance directive or verbally), are carried out.”

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Not all of the advance-directive compliance problems are due to poor communication with

health care providers. “We now hear more anecdotes of providers who want to go along with a

patient’s wishes, but the agent or family says ‘No, we want all treatment’,” Sabatino said. That

puts the provider in both an ethical and legal dilemma. “Ethically their first obligation is to

respect the patient and the patient’s wishes, but legally the health care agent may have legal

authority, yet they are not acting properly in the fiduciary role that they have, because the agent is

obligated to follow the patient’s wishes.”

ROLE OF CDC “We are seeing a lot of multiple chronic conditions that people are dealing with and, as they learn to manage those, advance care planning should be a natural

and logical part of effective chronic disease self-management.” — Lynda Anderson, PhD

With its focus on disease prevention and health promotion, CDC would like to see

advance care planning become part of the self-management approach to living with

multiple chronic diseases. “We are seeing a lot of multiple chronic conditions that people

are dealing with, and, as they learn to manage those, advance care planning should be a

natural and logical part of effective chronic disease self-management,” Anderson said.

“Just as we plan for how to manage a chronic condition – go to a physician, learn about

the treatment, learn how to improve our quality of life – advance care planning is part of

that, not something separate.”

For example, the Chronic Disease Self-Management Program (Stanford 2012) – a facilitated

workshop that teaches patients how to manage their disease – discusses advance directives. With

the Administration on Aging and the Arthritis Foundation promoting the Chronic Disease Self-

Management Program (CDSMP), it has reached 50,000 people (HHS 2010). Among participants in

the CDSMP, durable power of attorney completion increased from a rate of 48 percent at baseline

to a rate of 58 percent three years after completion of the course, according to a research paper

(McGuire 2007).

Public Health Education. In 2002, CDC collaborated with the National Association of Chronic

Disease Directors to identify public health priorities for addressing end-of-life care issues. More than

200 stakeholders from a variety of disciplines participated in a “concept mapping” process that led to

the identification of two priorities that focus on public health education: (1) educate the public about

the importance of advance directives and (2) educate the public about the availability of hospice and

palliative care.

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Advance Care Planning Module. In fall 2011, CDC’s Healthy Aging Program, in

partnership with Christopher at the Center for Practical Bioethics and with the Directors of Health

Promotion and Education, developed a modular, online course on advance care planning

specifically designed for public health and aging network professionals. (“Advance Care

Planning: An Introduction for Public Health and Aging Services Professionals,”

www.cdc.gov/aging/advancecareplanning/index.htm.) Offered free of charge, the course

addresses the importance of advance care planning, describes the unique role of public health and

aging services professionals and defines key terms and types of documents. The course, using

content provided by Christopher, was piloted in workshops hosted by the local AAAs in Wichita,

Kansas (2009) and Seattle, Washington (2009), and by the state health department in Boston,

Massachusetts (2010). As of the end of 2011, almost 90 health professionals had completed the

course and 40 more were registered to take it (CDC 2010d).

Annette Graham, LSCSW, Executive Director, Central Plains (KS) Area Agency on Aging

(AAA), one of the early sites for pilot-testing the course, described it this way: “The training

educates the professional about the topic, why it is important, the details and intricacies involved.”

Attendees included senior volunteers and parish nurses, as well as representatives from the

Alzheimer’s Association, county health departments, Kansas Health Ethics, senior centers, wellness

centers, Wichita State University, medical services bureaus, mental health centers and area agencies

on aging. “By bringing this diverse group together – a group that often didn’t cross paths – this was

an opportunity to make some connections and have a better understanding of what the other

organizations did,” Graham said.

“The course was so much more in-depth and provided a higher level of knowledge than they had

ever encountered. It allowed for discussions about the factual stuff and data around end of life, what

really happens, how many people are cognitively able to make their own decisions, what are the

medical treatments that are available, how it impacts quality of life, and discussion about your own

thoughts, and how to have this discussion with other people.” Following the course, the AAA

provided advance care planning education to its staff, did presentations on the topic, issued press

releases and newspaper articles that reached 80,000 households, and participated in a proclamation for

National Healthcare Decisions Day. The AAA notified local senior centers that health ethics

professionals were available to discuss advance care planning.

DEMENTIA CARE People with dementia often die with inadequate pain control, with feeding tubes in place and

without the benefits of hospice care (Sachs 2004). More than 50 percent of residents in assisted

living and nursing homes have some form of dementia or cognitive impairment (AA 2007), and

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67 percent of dementia-related deaths occur in nursing homes (Mitchell 2005). Yet only 6 percent

of people admitted to hospice care in 2008 had a primary diagnosis of Alzheimer’s disease

(60,488 people) and an additional 11 percent of people admitted had a primary diagnosis of non-

AD dementia (113,204 people) (AA 2011c).

For an individual with Alzheimer’s disease, advance planning is essential to fulfilling end-of-

life care wishes, according to the Alzheimer’s Association. Physicians and other members of the

health care team play an important role in initiating discussion with the individual and family

regarding these wishes (AA 2011a). The association recommends discussion of these issues at an

early stage – when the individual’s cognitive and communication abilities are least impaired – to

help to clarify the person’s wishes. “Discussions about end-of-life care are ongoing and always

involve the person, proxy decision maker and family to the degree possible,” Elizabeth Gould,

MSW, Director of State Programs at the Alzheimer’s Association, said. “Regular advance

planning discussions with the care team provide an opportunity to revisit care decisions that have

been made to see if they are still appropriate.” The recommendations are based on evidence-based

care guidelines resulting from the association’s quality of care campaign, and are endorsed by 30

leading health and senior care organizations (AA 2011b).

People with early-stage Alzheimer’s disease may be living well with dementia and be in

denial that Alzheimer’s is a fatal disease, according to Mike Splaine with Splaine Consulting.

“Taking control of our own lives and charting your own destiny are classic boomer culture,” he

said. “You can’t ignore the invasion of culture into these attitudes. So one of the benefits of

earlier diagnosis is people being able to provide direction and input for future health care

decisions,” said Splaine, who is a former Director of State Affairs for the Alzheimer’s

Association.

In addition, once a person has moderate-to-severe dementia, it is difficult to assess whether

they have decision-making capacity for advance directives and other end-of-life care. “When do

people living with Alzheimer’s have capacity to make up their minds about an advance directive,

and when are they no longer able to do so? Capacity is a judgment call, and a legal call in some

cases when doing surrogate decision making,” Splaine said.

The unpredictable course of dementia “renders it a poor fit for the six-month life-expectancy

requirement of the Medicare hospice benefit,” Diane Meier wrote in a 2010 issue of “Health

Affairs” (Meier 2010). Meier is a professor of geriatrics and palliative care medicine at Mount

Sinai School of Medicine, New York City. She argues that regardless of life expectancy,

palliative care should be offered to people with dementia and other chronic or life-threatening

illnesses.

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FUTURE DIRECTIONS “We are moving in the right direction, for all the wrong reasons,

but we are going where we need to be.” — Myra Christopher Most Americans living today will cope with one or more chronic conditions for an extended

period of time, spend some years living with disabilities (functional and/or cognitive impairment)

at the end of life, and face decisions that will affect the timing and quality of death (Hogan 2001,

Lynn 2004). Public policy and health care systems must continue to develop more effective ways

to ensure that advance care planning is routine for all adults, addresses the various

communication styles of individuals, and ensures that patients’ goals and wishes are reflected in

treatment plans (Lynn 2004).

Clearly the public needs better education about the terms palliative care and advance care

planning. While the Regence Foundation/National Journal poll showed most people understood

the terms “end of life care” (65 percent said that term was familiar) and “hospice care” (86

percent), the newer term of “palliative care” was familiar to only 24 percent of those polled

(Regence 2011).

Advance care planners must teach others to embrace dying as part of life, Peres said. That

would include defining what a good death looks like, and trying to use the other parts of the system

to make it clear that the high-tech care that we are able to deliver is not necessarily the care that is

needed at the end of life.

Future of Hospice. Hospice care has become more integrated with mainstream medicine, and

“we don’t need it in the way we have known it in past years,” Christopher said.

“Some say ‘hospice is dead.’ Hospice has accomplished what we set out to do in the mid-70s,

to help people understand that there is a better model for caring for people at the end of life, than the

intensive-care, acute-care, full-court press approach,” she explained.

But the Hospice Association of America argues that “The need for hospice services will

continue to rise due to the growing aging population and the rising health care costs. More

importantly, medical professionals, as well as the general public are choosing hospice over other

forms of health care delivery because of its holistic, patient-family, in-home centered

philosophy.”

“The lines that we have tried to create between community-based palliative care, hospital-based

palliative care, hospice, acute inpatient hospice – those lines are blurring and as we see the emergence

of accountable care organizations and bundled payments, those lines are going to get fuzzier and

fuzzier. This has really intellectually and conceptually been embraced and now the economics will

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drive it,” Christopher said. “We are moving in the right direction, for all the wrong reasons, but we are

going where we need to be.”

Palliative Care Movement. “The palliative medicine movement is good for hospice because

it brings attention to end-of-life issues and broadens the definition of end-of-life beyond the six

months that makes a patient eligible for the hospice benefit.” Dr. Riley said. However, he

expressed concern that patients and families may choose to be “palliative” and never get to the

“hospice” stage. In those cases, referrals to hospice will end up being made too close to the time

of death and prevent the patient and family from receiving counseling, bereavement and other

benefits of hospice.

Better support for those trying to navigate advance care planning is a goal of a recently

formed organization, the Coalition to Transform Advanced Care (C-TAC), a nonprofit, non-

partisan organization based in Washington, D.C. It is funded in part by grants from the Peter G.

Peterson Foundation, the SCAN Foundation, and its members. Members include experts and

organizations in all fields that affect advance care planning, including national patient and

caregiver advocates, leading provider groups and health systems, innovative health plans, hospice

and palliative care organizations, home care, long-term care, clinicians, faith-based organizations,

and academia.

The Center for Practical Bioethics is enthusiastic about this new organization and believes

that it will help ensure for those who do advance care planning that their goals and values will be

integrated into care and treatment plans regardless of their ability to speak for themselves,

Christopher said.

C-TAC is calling for reforms to make it easier for people to navigate the complex issues

related to advanced illnesses, such as cancer, heart disease, COPD, diabetes, stroke, and

dementia.

Nursing Homes. Since 25 percent of Americans die in nursing homes, and that number is

predicted to increase with an aging population, nursing homes need to be in the business of

providing high quality palliative and end-of-life care, Dr. Unroe said. “There is an assumption

that patients in long-term care have robust advance care planning, that their care preferences are

clearly documented and followed, and that nursing homes would be very adept at caring for and

managing dying patients and managing distressing symptoms like pain. But this is absolutely not

standard practice. Some facilities are excellent at end-of-life care and palliative care and some are

not.” While many nursing homes partner with hospices for end-of-life care for their patients,

“there is a lot of opportunity for facilities to develop internal expertise in providing this care,” she

said. “Broad segments of the nursing home population would benefit from comprehensive

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palliative care, including understanding disease processes and prognosis, setting goals of care and

symptom assessment and management.”

Role for Aging Services Network. Aging services professionals “could help promote the

need to do advance care planning and clearly articulate your wishes for what you want toward the

end of your life,” Peres said. Events held at senior centers or publicizing National Healthcare

Decisions Day (April 16th each year) can be used to promote the importance of advance care

planning. “The whole aging services network could step up and be leaders in that sort of thing,”

Peres said.

Graham suggested that advance care planning could be built into the Options Counseling

services now offered by the Aging and Disability Resource Center Program (AoA 2011), a

collaborative effort of the Administration on Aging and the Centers for Medicare & Medicaid

Services. Options Counseling helps people look at their long-term care options.

This document is available online at www.cdc.gov/aging/publications/briefs.htm. It was written by Nancy Aldrich. William F. Benson was senior editor and project manager. This brief should be cited as follows: Benson WF and Aldrich N. Advance Care Planning: Ensuring Your Wishes Are Known and Honored If You Are Unable to Speak for Yourself, Critical Issue Brief, Centers for Disease Control and Prevention. 2012. www.cdc.gov/aging.

STORY IDEAS FOR JOURNALISTS

1) Interview people who have and have not completed advance care planning documents and write about why or why not they took that action. Interview families who have been involved with a hospice program when someone in the family died. Write about how hospice services helped them.

2) National Healthcare Decisions Day is observed in mid-April each year to inspire, educate & empower the public and providers about the importance of advance care planning. Write a story on advance care planning to be published near the time of that event (April 16 in 2012). (For more info, go to www.nhdd.org/.)

3) National Hospice and Palliative Care Month is observed in November. That can also be an opportunity to write a story about advance care planning.

4) Look at the state-by-state report card on palliative care (prepared by the Center to Advance Palliative Care and the National Palliative Care Research Center) and write about your state’s data and how it compares to other states. Examine ways that care in your state could be improved. Go to www.capc.org/reportcard/. The key findings from the study were published in the October 2011 issue of Journal of Palliative Medicine.

5) Write a story about your state laws on advance care planning and explain how they differ from other states. Investigate whether the laws could be improved.

REFERENCES AND RESOURCES

JOURNALS AND REFERENCES CITED: AA 2007: Alzheimer’s Association Campaign for Quality Residential Care. Dementia Care Practice:

Recommendations for Assisted Living Residences and Nursing Homes Phase 3 End of Life Care. 2007. www.alz.org/national/documents/brochure_DCPRphase3.pdf

AA 2011a: Alzheimer’s Association. End-of-Life Decisions. 2011. www.alz.org/professionals_and_researchers_end_of_life.asp

AA 2011b: Alzheimer’s Association. Dementia Care Practice Recommendations. www.alz.org/professionals_and_researchers_dementia_care_practice_recommendations.asp

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AA 2011c: Alzheimer’s Association. 2011 Alzheimer's Disease Facts and Figures. Alzheimer's & Dementia: The Journal of the Alzheimer's Association. March 2011; 7:208-44. www.alz.org/national/documents/Facts_Figures_2011.pdf

AARP 2008. AARP Bulletin Poll. “Getting Ready to Go,” Executive Summary. January 2008. http://assets.aarp.org/rgcenter/il/getting_ready.pdf

ABA 1998: American Bar Association Commission on Law and Aging. End-of-Life Care Legislative Trends—1998, BIFOCAL 19(2):5–9. Washington, DC: American Bar Association.

ABA 2009a: American Bar Association Commission on Law and Aging. Default Surrogate Consent Statutes as of November 2009. http://new.abanet.org/aging/Pages/HealthDecisions.aspx

ABA 2009b: American Bar Association Commission on Law and Aging. Health Care Power of Attorney and Combined Advance Directive Legislation: Selected Features Compared—December 2009. http://new.abanet.org/aging/Pages/HealthDecisions.aspx

AoA 2011: Administration on Aging. Facts: Aging and Disability Resource Center. www.aoa.gov/AoARoot/Press_Room/Products_Materials/fact/pdf/ADRC.pdf

Austin 2003: Austin B, Fleisher L. Financing End-of-Life Care Challenges for an Aging Population. AcademyHealth. February 2003. www.hcfo.org/pdf/eolcare.pdf

Barnato 2007: Barnato AE et al. Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences? A Study of the US Medicare Population. Medical Care 2007;45:386-93. www.ncbi.nlm.nih.gov/pmc/articles/PMC2686762/

CAPC 2011. Center to Advance Palliative Care. Palliative Care State-by-State Report Card Released to Congress. Press release, Oct. 5, 2011. www.capc.org/news-and-events/releases/10-05-11)

Casarett 2005: Casarett D et al. Making Difficult Decisions About Hospice Enrollment: What Do Patients and Families Want to Know? February 2005 Journal of the American Geriatrics Society (Volume 53, Issue 2, pages 249-254). http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2005.53110.x/abstract;jsessionid=0E46DA9BA08B21AA3D6E42A393712486.d04t01?systemMessage=Wiley+Online+Library+will+be+disrupted+14+Jan+from+10-12+GMT+for+monthly+maintenance

CDC 2010a: Centers for Disease Control and Prevention. Health, United States, 2010. February 2011. Table 56. www.cdc.gov/nchs/data/hus/hus10.pdf

CDC 2010b: Centers for Disease Control and Prevention. Early release of selected estimates based on data from the 2010 National Health Interview Survey. Figure 12.2. Released June 2011. www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201106.pdf

CDC 2010c. Centers for Disease Control website. End of Life Preparedness: An Emerging Public Health Priority. February 2010. www.cdc.gov/aging/endoflife/

CDC 2010d: Centers for Disease Control and Prevention. WB1791 - Advance Care Planning: An Introduction for Public Health and Aging Services Professionals (Web-based). Communication.

Cerminara 2012: Cerminara K. Health Care Reform at the End of Life: Giving With One Hand but Taking with the Other. Undated. American Society of Law, Medicine & Ethics. www.aslme.org/print_article.php?aid=460404&bt=ss

CMS 2011: Centers for Medicare & Medicaid Services. Medicare Hospice Benefits. CMS Product No. 02154. Revised August 2011. www.medicare.gov/Publications/Pubs/pdf/02154.pdf

Forum 2010: Federal Interagency Forum on Aging-Related Statistics. Older Americans 2010: Key Indicators of Well Being. www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2010_Documents/Docs/OA_2010.pdf

Glick 1991: Glick HR. The Right-to-Die: State Policymaking and the Elderly. Journal of Aging Studies. 1991 5:283–307.

HHS 2010. Department of Health and Human Services. Promoting Prevention and Wellness: Communities Putting Prevention to Work – Implementation Plan, p. 4. June 2010. www.hhs.gov/recovery/reports/plans/pdf20100610/CDC_CPPW%20%20June%202010.pdf

Hogan 2001: Hogan C et al. Medicare Beneficiaries’ Costs of Care in the Last Year of Life. Health Affairs, 20, no.4 (2001):188-195. http://content.healthaffairs.org/content/20/4/188.full.pdf

Hoyer 1996: Hoyer TA. History of the Medicare Hospice Benefit. In A Good Dying: Shaping Health Care for the Last Months of Life. Briefing book for symposium sponsored by The George Washington University Center to Improve Care of the Dying and the Corcoran Gallery of Art, April 30, 1996.

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IOM 1997: Institute of Medicine Committee on Care at the End of Life. Approaching Death: Improving Care at the End of Life, ed. M.J. Field and C.K. Cassel. 1997. Washington, DC: National Academy Press.

Jones 2011: Jones AL et al. Use of Advance Directives in Long-Term Care Populations. NCHS Data Brief, No 54. Hyattsville, MD: National Center for Health Statistics. 2011. www.cdc.gov/nchs/data/databriefs/db54.pdf

Kass-Bartelmes 2003: Kass-Bartelmes BL. U.S. Agency for Healthcare Research and Quality. Advance Care Planning: Preferences for Care at the End of Life. Research in Action Issue 12. 2003. www.ahrq.gov/research/endliferia/endria.htm

Kung 2008: Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: final data for 2005. National Vital Statistics Reports 2008;56(10). http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf

Lynn 2003: Lynn J, Adamson D. Living Well at the End of Life: Adapting Health Care to Serious Chronic Illness in Old Age. Rand Health White Paper WP-137 (2003). http://medicaring.org/whitepaper/

Lynn 2004: Lynn J. Sick to Death and Not Going to Take It Anymore! Reforming Health Care for the Last Years of Life. Berkeley: 2004. University of California Press, New York: Milbank Memorial Fund.

McGuire 2007: McGuire LC et al. Completion of a Durable Power of Attorney for Health Care: What Does Cognition Have to Do with It? The Gerontologist. 2007. Vol. 47(4): 457-467. Citing K.R. Lorig, unpublished data, December 12, 2005).

MedPAC 2011: Medicare Payment Basics: Hospice Services Payment System. October 12, 2011. www.medpac.gov/documents/MedPAC_Payment_Basics_11_hospice.pdf

Meier 2010: Meier D. Raising the Standard: Palliative Care in Nursing Homes. Health Affairs No. 1 (2010): 136–140. http://content.healthaffairs.org/content/29/1/136.abstract

Minino 2011: Minino AM, Murphy SL, et al. Deaths: Final Data for 2008. National Vital Statistics Reports, Vol. 59, No. 10, Dec. 7, 2011. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf

Mitchell 2005: Mitchell SL et al. A National Study of the Location of Death for Older Persons with Dementia. Journal of the American Geriatric Society 2005; 53(2):299-305

Moon 2002: Moon M, Boccuti C. Medicare and End-of-Life Care. Urban Institute. 2002. www.urban.org/UploadedPDF/1000442_medicare.pdf

NCHS 2011: National Center for Health Statistics. Home Health Care and Discharged Hospice Care Patients: United States, 2000 and 2007. National Health Statistics Report No. 38. April 2011. http://www.cdc.gov/nchs/data/nhsr/nhsr038.pdf

NHPCO 2011: National Hospice and Palliative Care Organization. Facts and Figures: Hospice Care in America. Alexandria, VA. January 2012. www.nhpco.org/files/public/Statistics_Research/2011_Facts_Figures.pdf

NINR 2011: National Institute of Nursing Research. Palliative Care: The Relief You Need When You are Experiencing the Symptoms of Serious Illness, NIH publication #11-6415, May 2011, www.ninr.nih.gov/NR/rdonlyres/01CC45F1-048B-468A-BD9F-3AB727A381D2/0/NINR_PalliativeBrochure_Brochure_12_Layout_Version_508.pdf

Pew 2006: Pew Research Center 2006: Pew Research Center for the People & the Press. Strong Public Support for Right to Die: More Americans Discussing — and Planning — End-of-Life Treatment. Telephone survey of 1,500 older adults conducted Nov. 9-27, 2005 under the direction of Princeton Survey Research Associates International. January 2006. http://people-press.org/report/266/strong-public-support-for-right-to-die

Regence 2011: Regence Foundation/National Journal. Living Well at the End of Life: A National Conversation. March 2011, www.regencefoundation.org/docs/FDRegenceNationalJournalSurveyResults.pdf

Sabatino 1999: Sabatino CP. Survey of State EMS-DNR Laws and Protocols. 1999. Washington, DC: American Bar Association, Commission on Law and Aging.

Sabatino 2010: Sabatino C. The Evolution of Health Care Advance Planning Law and Policy. The Milbank Quarterly, Vol. 88, No. 2, June 2010 (pp. 211–239). www.americanbar.org/content/dam/aba/uncategorized/2011/2011_aging_hcdec_art_evolutionhclp.authcheckdam.pdf

Sachs 2004: Sachs GA et al. Barriers to Excellent End-of-Life Care for Patients with Dementia. Journal of General Internal Medicine 2004; 19(10): 1057.

Stanford 2012: Stanford Patient Education Research Center, Stanford University. Chronic Disease Self-Management Program. 2012. http://patienteducation.stanford.edu/programs/cdsmp.html

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Steinhauser 2000: Steinhauser KE et al. Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers. JAMA (2000) 284:2476-2482. http://jama.ama-assn.org/content/284/19/2476.full

Temel 2010: Temel J et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. N Engl J Med 2010; 363:733-742August 19, 2010. www.nejm.org/doi/full/10.1056/NEJMoa1000678?query=TOC

Teno 1997: Teno J et al. Advance Directives for Seriously Ill Hospitalized Patients: Effectiveness with the Patient Self-Determination Act and the SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Journal of the American Geriatrics Society. April 1997; 45(4):500-7. www.ncbi.nlm.nih.gov/pubmed/9100721

Yourman 2012: Yourman LC. Prognostic Indices for Older Adults: A Systematic Review. January 11 JAMA. 2012;307[2]:182-192. http://jama.ama-assn.org/content/307/2/182.short

Xu 2007: Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. National vital statistics reports. Hyattsville, MD: NCHS; 2010. Deaths: Final data for 2007. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf

ADDITIONAL RESOURCES: Advance Care Planning & Advance Directives,

www.healthinaging.org/public_education/pef/advance_directives.pdf Advance Care Planning Conversation Guide, www.coalitionccc.org/_pdf/Conversation_Guide.pdf Advance Care Planning: An Introduction for Public Health and Aging Services Professionals, CDC course,

www.cdc.gov/aging/advancecareplanning/about.htm Aging with Dignity (Five Wishes), www.agingwithdignity.org Agency for Healthcare Research and Quality, www.ahrq.gov/research/endliferia/endria.htm Alzheimer’s Association HelpLine, 800-272-3900, www.alz.org Center for Practical Bioethics, http://practicalbioethics.org/about/model-and-methodology/making-your-

wishes-known-for-end-of-life-care/; Caring Conversations, www.practicalbioethics.org/FileUploads/FINAL.Caring%20Conversations%20Workbook%202010.pdf

Center to Advance Palliative Care, www.capc.org/ Choosing a Quality Hospice, www.caringinfo.org/files/public/brochures/Choosing_Hospice.pdf Consumer's Tool Kit for Health Care Advance Planning,

http://apps.americanbar.org/aging/publications/docs/consumer_tool_kit_bk.pdf End-of-Life Care: Questions and Answers, www.cancer.gov/cancertopics/factsheet/Support/end-of-life-

care Get Palliative Care, www.getpalliativecare.org/about Giving Someone a Power of Attorney for Your Health Care: A Guide with an Easy-to-Use, Legal Form for

All Adults, www.americanbar.org/content/dam/aba/uncategorized/2011/2011_aging_hcdec_univhcpaform.authcheckdam.pdf)

Hospice Association of America, www.hospice-america.org/ Hospice Education Institute, www.hospiceworld.org/ Hospice Foundation of America, www.hospicefoundation.org/ ; www.hospicedirectory.org/ Improving Advanced Illness Care: The Evolution of State POLST Programs,

http://assets.aarp.org/rgcenter/ppi/cons-prot/POLST-InBrief-04-11.pdf National Hospice and Palliative Care Organization, http://nhpco.org/ National Palliative Care Research Center, www.npcrc.org Shape Your Health Care Future with Health Care Advance Directives,

http://apps.americanbar.org/aging/publications/docs/shape_your.pdf Social Work, Hospice and Palliative Care Network, www.swhpn.org/ The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm,

www.ohsu.edu/polst/about/index.htm EXPERTS QUOTED: Annette Graham, LSCSW, Executive Director, Central Plains (KS) Area Agency on Aging, 316-660-5120,

agraham@sedgwick.gov

24

Anthony Riley, MD, Medical Director, Gilchrist Hospice Care, 443-849-8200, WRILEY@GilchristHospice.org

Charles Sabatino, J.D., Director, American Bar Association Commission on Law and Aging, 202-662-8690, charles.sabatino@americanbar.org

Elizabeth Gould, MSW, Director of State Programs at the Alzheimer’s Association, 312-335-4078, media@alz.org

Joanne Lynn, MD, Director, Center for Elder Care and Advanced Illness, Altarum Institute, 202-297-9773, drjoannelynn@gmail.com

Judith Peres, MSW, clinical social worker and policy consultant, 301-455-5140, judyperes@aol.com Kathleen Tschantz Unroe, MD, Asst. Research Professor of Medicine, Geriatrics, Indiana University

Center for Aging Research, 317-423-5600, kunroe@iupui.edu Mike Splaine, Splaine Consulting, 443-630-9226, mikesplaine@verizon.net Myra J. Christopher, President and CEO, Center for Practical Bioethics, 816-221-1100,

MChristopher@practicalbioethics.org

11/2/2018 How to Master the Art of Listening

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How to Master the Art of Listening

Genevieve Conti / December 8, 2016

Listening is the unsung hero of communication. We love to praise great

orators and recite lines from famous speeches, and rightly so. Words are

powerful. But listening can be equally so.

If you improve your listening skills, you’ll probably never win an award for it or

make it into the history books for being a great listener. But that’s OK. Good

listeners don’t listen because they want a pat on the back. They recognize that

the bene�ts of listening well are much greater. As columnist and editor Doug

Larson said, "Wisdom is the reward you get for a lifetime of listening when

you'd have preferred to talk."

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y p

Despite the bene�ts that good listening o�ers, however, many people struggle

with truly listening when others are speaking. To build a better foundation for

personal and professional success, master the art of listening with the tips

below.

Why Listening Takes Work

"Most people do not listen with the intent to

understand; they listen with the intent to reply"- Stephen R. Covey

How many times have you walked into a meeting or conference and thought,

"Oh good, I can relax now because I only have to listen?" Or maybe someone

thanked you for letting them talk, and you responded with something like “No

problem, all I did was listen.”

We mistake listening as easy because it looks passive and instinctive, but in

reality it’s hard work. Really listening (and not just appearing to listen) requires

intense concentration and a good deal of mental energy.

Listening can be di�cult for a few reasons. Perhaps the hardest is that we

think three to four times faster than people speak. That means we could listen

at a rate of up to 450 words per minute, but the average person speaks only

125-175 words per minute, making it easy to become impatient or let your

i d d

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mind wander.

Listening is also di�cult because when we’re in a conversation, our tendency is

to do one of four things, according to The 7 Habits of Highly E�ective People

author Stephen Covey:

Evaluate: You judge what someone is saying and agree or disagree.

Probe: You ask questions from your own frame of reference.

Advise: You give counsel, advice, and solutions to problems.

Interpret: You analyze others' motives and behaviors based on your own

experiences.

“If you're like most people, you probably seek �rst to be understood,” Covey

writes. “You want to get your point across. And in doing so, you may ignore the

other person completely, pretend that you're listening, selectively hear only

certain parts of the conversation, or attentively focus on only the words being

said, but miss the meaning entirely.”

The good news is, anyone can learn to become a better listener.

What Makes a Great Listener?

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Great listeners share a few important qualities:

They ask great questions

I used to have a teacher who loved to say, “The word listen has the same

letters as the word silent.” Silence is indeed a part of listening, but good

listeners don’t have to be completely quiet.

In a study on the di�erences between great and average listeners, researchers

found that people who ask questions that promote insight and discovery are

perceived as better listeners.

Good questions act as evidence that you’re listening and show that you’re

interested in building on what you heard. And beyond mere perceptions,

those questions might help you learn more from what the speaker is saying.

They pay attention to more than what’s being said

How someone says something (Are their arms crossed? Brow furrowed? Pitch

higher than normal?) is just as important as the words they say.

“Words are important but words don’t always match perfectly to meaning or

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Words are important, but words don t always match perfectly to meaning or

action,” writes Meta S. Brown, author of Data Mining for Dummies. “Superior

listeners gather more information than just the words that people say, and

use all of that information to infer meaning.”

They don’t take word-for-word notes

If you spend all your mental energy trying to capture what someone says

word-for-word, it’s harder to be an engaged listener.

Typing notes, especially, can make us worse listeners. Good listeners often

forgo taking detailed notes so they can pay better attention.

Use an app instead to catch the details. UberConference and Zoom, among

other conferencing apps, include a record feature, while Ecamm can record

your Skype calls. Many notes apps, including OneNote and Evernote, also

include recording tools. Let those apps—or even the Voice Recorder app built

into your phone—do the work, so you can pay attention to ideas and context.

They listen with the intent to understand, not the intent torespond

As Stephen Covey wrote in our section-opening quote, “Most people do not

listen with the intent to understand; they listen with the intent to reply.”

Good listeners instead focus on understanding what’s being said, rather than

thinking of what they want to say next.

“You listen to yourself as you prepare in your mind what you are going to say,

the questions you are going to ask, etc,” Covey writes. “You �lter everything

you hear through your life experiences, your frame of reference. You check

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y g y p y

what you hear against your autobiography and see how it measures up. And

consequently, you decide prematurely what the other person means before

he/she �nishes communicating.”

They make people feel heard

Part of listening is making others feel like you’re listening. In fact, research

shows that people who feel listened to are more likely to engage in future

interactions with you.

Lack of eye contact during a conversation makes listeners seem insincere,

found one study. And being distracted by background noises makes listeners

seem inattentive.

What's more surprising is that your level of attentiveness can even a�ect how

the speaker talks. Researchers at the University of Massachusetts conducted

an experiment in a college classroom and found that when students didn’t

display behavior that indicated they were listening—including an interested

posture and eye contact—the professor’s lecture was uneventful, spoken from

notes with a more monotone voice. However, when the students displayed

interested behavior, the professor became more lively, gesturing more often

and speaking at an increased verbal rate.

They follow up on what matters

It feels really good when someone remembers something you said and brings

it up with you later. Good listeners make a point to circle back around to follow

up on key points or important issues.

“N h d li l dibili if f il f ll

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“No matter how good a listener you are, you lose credibility if you fail to follow

up on an issue raised in a conversation,” according to Poynter Institute's Jill

Geisler. “It may be one of a long, long list of things you have to handle, but it is

likely at the top of the other person's agenda. Telling people when you will get

back to them is a commitment worth making–and keeping.”

How to Practice and Sharpen Your Listening Skills

Good listening skills can be learned and improved, and there are plenty of

opportunities every day to practice.

Here are a few things you can do to improve:

Practice mindfulness

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Practice mindfulness

Part of being a good listener is being able to be fully present and aware.

To listen with thoughtful attention, Marie-Claire Dean, designer manager at

Atlassian, suggests a simple daily exercise:

1. Sit comfortably

2. Close your eyes (it will be easier if you withdraw the other senses)

3. Listen to the sounds that are furthest away from you.

4. Listen to the sounds that are closest to you.

5. Now listen to the sounds that are somewhere in between.

Dean says you should be able to sit comfortably for 20 minutes without:

Fidgeting

Your mind wandering & losing concentration

Hearing the sound of your own voice inside your head

Having a conversation with yourself

Waiting for this exercise to end

Labelling all of the sounds individually

E�ort

The exercise might be di�cult at �rst, but the more you do it, the easier it’ll

get.

Treat it like a test

To practice comprehending what you hear act like there’s going to be a test on

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To practice comprehending what you hear, act like there s going to be a test on

what you understood.

This might be a bit tortuous for one-on-one conversations, but if you’re in a

large meeting or at a conference, this could help you retain a lot of more of

what’s said. That frame of mind will help you pay better attention and think

about the right questions to ask.

Mind the gap

One reason listening is so di�cult is the gap between how fast we think and

how fast people talk.

To make up for that gap, as you’re listening, review and summarize the

speaker's main points. Then, when they are �nished, you can restate the

points and ask the speaker if you've understood the message by saying things

like, "What I hear you saying is…" or "When you say that, do you mean…?"

Clarify and paraphrase to better process information and make people feel

heard—and to force yourself to pay more attention to what they mean.

Try just one day

Challenge yourself to one day of listening, suggests Robin Sharma, founder of

The Titan Summit.

“Today, just for a day, make the decision to listen masterfully,” Sharma writes.

“Don’t interrupt. Don’t rehearse your answer while the other person is

speaking. And don’t dare check your email or search for text messages while

another human being is sharing their words. Just listen. Just hear. Just be there

for that person ”

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for that person.

Listening can do a great deal for you as a professional and in your personal

relationships. Research shows that good listening skills make us better

collaborators. They also make us better at lots of other things, like making

small talk, managing people, understanding our customers’ needs, moving up

in our careers, and negotiating.

Becoming a great listener will make others enjoy being around you more and

help you learn more from them. With some attention and practice, you can

learn how to be a better listener and apply those skills in so much of your

work and everyday life.

Keep Learning

Sometimes conversations are less consequential—but you still need to be

a good listener. Here's how to master small-talk conversations to make

new connections and learn from others during social and professional

events.

Listening matters in design and development, too. With a touch of

anthropology background, here's how to listen to your customers and

design better products.

Are you the one speaking? Learn how to make every word count and nail

your next presentation.

Title photo by Fey Ilyas via Flickr. Listen image by ky_olsen. Listening man image by �equi.

11/2/2018 How to Master the Art of Listening

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About the Author

Genevieve Colman is a User Experience Manager who enjoys

uncomplicating complex language and �nding the perfect GIF for every

situation.

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11/1/2018 Being empathetic is good, but it can hurt your health - Chicago Tribune

https://www.chicagotribune.com/lifestyles/health/ct-being-empathetic-affects-health-20170926-story.html 1/4

Y

Being empathetic is good, but it can hurt yourhealth

By Jennifer Breheny WallaceSpecial to The Washington Post

SEPTEMBER 26, 2017, 8:29 AM

our husband was just passed over for a promotion, and he's depressed. Your friend's breast cancer has

returned. As a supportive spouse and friend, you feel their pain. Growing research suggests there's a cost

to all that caring.

Empathy - the ability to tune into and share another person's emotion from their perspective - plays a crucial

role in bringing people together. It's the joy you feel at a friend's wedding or the pain you experience when you

see someone suffering.

It's an essential ingredient for building intimacy in relationships, says Robin Stern, associate director of the

Yale Center for Emotional Intelligence. "When someone feels seen and heard by you," she says, "they begin to

trust you."

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But this seemly positive emotion can also have a downside, particularly if someone gets so consumed by

another's feelings that they neglect their own feelings and needs. Stern says those who regularly prioritize

others' emotions over their own are more susceptible to experiencing anxiety or low-level depression.

"When we think of empathy fatigue, we usually think about those in helping professions, like nurses, doctors,

social workers - but all of us are often in the role of helpers or caretakers, whether it's caring for a sick parent, a

child or a friend during a difficult time," says Jamil Zaki, an assistant professor of psychology at Stanford

University. "Being supportive of those we care about is among our most cherished and important roles," Zaki

says, "but it's also one that's fraught: We want to be there for someone but not lose ourselves."

In a study published last year in the journal Health Psychology, researchers looked at the effects of parental

empathy on 247 pairs of parents and adolescents. Through blood tests, questionnaire responses and daily diary

entries, researchers found that parental empathy was highly correlated with better psychological and

physiological well-being in adolescents. The parents in the study benefited, too, with highly empathic parents

reporting greater self-esteem and a deeper sense of purpose in their lives than those who reported lower levels

of empathy.

But it wasn't all good news. The more empathic the parent, the researchers found, the more likely that person

was to be experiencing chronic low-grade inflammation. The researchers speculate, "Parents who readily

engage with the struggles and perspectives of others may leave themselves vulnerable to additional burdens,

expending physiological resources in order to better help others."

Is there a healthier way to empathize?

Psychologists describe empathy in three ways: You can think it, feel it or be moved by it, Zaki says.

With cognitive empathy, you understand what someone else is thinking and feeling, as when you relate to a

character in a novel or take someone's perspective during a business negotiation.

With emotional empathy, you actually put yourself in someone else's shoes and feel their emotion. This is the

type of response that, left unchecked, can lead to caretaker burnout, says Zaki.

And then there's compassionate empathy, where you feel concern about another's suffering, but from more of a

distance and with a desire to help the person in need.

Which perspective we take when responding to someone else's suffering can affect our own health and well-

being. In an upcoming study in the Journal of Experimental Social Psychology, researchers assigned more than

200 college students to act as a helper to what they were told was a fellow student going through personal crisis.

Each participant was asked to read a personal essay detailing the supposed student's financial struggles and

stress upon becoming the primary caregiver for a younger sibling after the death of their mother.

While reading the text, a third of the volunteers were asked to think about how that person must be feeling

(compassionate empathy) and a third were asked to imagine how they would feel if they were that person

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(emotional empathy). A control group was asked to stay detached and remain objective.

Researchers then measured the participants for various physiological markers, including hormone stress levels,

heart rates and blood pressure. They found that those who put themselves in the other person's shoes had

significantly higher "fight-or-flight" responses, as though they, too, were going through a stressful experience.

"Over time," lead researcher Anneke Buffone notes, "the chronic activation of the stress hormone cortisol could

lead to a variety of serious health issues like cardiovascular problems, a finding that is particularly meaningful

for health professionals who are confronted with others' pain and suffering daily."

But the researchers also discovered that those who were asked to react to the essay with compassion - who

thought about how the other person might be feeling but didn't share the emotion - had a positive, invigorating

arousal response, as if they were confronting a challenge that was achievable or offering advice that might help

improve the student's situation.

"People assume that any kind of empathy is associated with positive health benefits and behaviors, but for the

first time we have physical evidence that not all empathy is alike, that its positive or negative effects depend on

the perspective you take," Buffone says.

"Neuroscientific research on empathy shows that if you're empathizing with a person who is in pain, anxious or

depressed, your brain will show activation of very similar circuits as the brain of the person with whom you're

empathizing," notes Richard Davidson, a professor of psychology and psychiatry at the University of Wisconsin

at Madison.

Compassion, on the other hand, activates a different part of the brain, areas associated with motivation and

reward. So, where emotional empathy can cause pain and burnout, compassion drives you to want to help.

While it's possible to feel all three types of empathy at once, emotional empathy is often the gateway to feeling

compassion, Davidson says. This doesn't mean there can't be a mix of emotions, he says, but feeling another

person's pain and suffering is often a prerequisite to feeling compassion.

Psychologists say that we can learn to regulate our empathy, as we do other emotions, and even transform

excessive emotional empathy into less stressful compassion. "You want to 'feel' with another person, but you

don't need to stay there," Stern says.

One way to keep empathy in check is through compassionate meditation, Davidson says.

"Start by envisioning someone you know who may be in pain or may have gone through a stressful event," he

says, "and then envision them being relieved of that suffering." He says it may be helpful to repeat a phrase

silently in your mind, such as: May you be happy and be free of suffering.

"Encouraging the focus on the person's well-being and happiness, instead of their distress, actually shifts our

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says. "It's this process that helps us to detach from their suffering."

"Research shows that these simple exercises actually affect your actions in the real world, making you more

likely to be pro-social and helpful," he says.

Transforming initial emotional empathy into compassion doesn't mean you care less about the person,

Davidson says. After all, "mirroring the emotional state of another person who is suffering is not all that helpful

- what kind of assistance can you provide if you're now suffering, too?"

He adds: "For the most part, people don't actually want you to feel their pain. What they want is your help and

compassion."

Copyright © 2018, Chicago Tribune

This article is related to: Mental Health Research, Medical Research, Breast Cancer, University of Wisconsin-Madison

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11/1/2018 Living with Dementia: Coping Tips & Strategies for Both You and Your Family

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HELPGUIDE.ORGTrusted guide to mental, emotional & social health

Living with DementiaCoping Tips & Strategies for Both You and Your Family

When you don’t seem to be remembering things as well as you did in the past, it can be extremelyupsetting, even frightening. Facing up to the possibility of memory loss or dementia inevitably shiftsyour perceptions, relationships, and priorities. But experiencing symptoms of dementia doesn’t haveto mean the end of your normal life. Certain types of dementia can be slowed or even reversed ifcaught in time. The first step is to understand what distinguishes normal memory loss from dementiasymptoms, and how to identify the different types of dementia. The more you understand aboutdementia, the more you can do to improve the outcome and preserve your sense of control.

What are the signs and symptoms of dementia?

As we age, many of us experience lapses in memory. It can be worrying and confusing to realizethat something you once took for granted isn’t working as well as it used to. But learning todifferentiate the signs and symptoms of dementia from normal aging can help to either set your mindat rest or encourage you to begin taking steps to slow or reverse the condition.

What is dementia?

Dementia is a collection of symptoms including memory loss, personality change, and impairedintellectual functions that result from disease or trauma to the brain. These changes are not part ofnormal aging and are severe enough to impact daily living, independence, and relationships. WhileAlzheimer’s disease is the most common type of dementia, there are also many other forms,including vascular and mixed dementia.

With dementia, there will likely be noticeable decline in communication, learning, remembering, andproblem solving. These changes may occur quickly or very slowly over time.

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The progression and outcome of dementia vary, but are largely determined by the type of dementiaand which area of the brain is affected. Whatever the diagnosis, there can be plenty of things youcan do to help slow or prevent symptoms of dementia and continue to enjoy a full and rewarding life.

Common dementia signs and symptoms

Someone with dementia symptoms may

repeatedly ask the same questionsbecome lost or disoriented in familiar placesbe unable to follow directionsbe disoriented about the date or time of daynot recognize or be confused about familiar peoplehave difficulty with routine tasks such as paying the billsneglect personal safety, hygiene, and nutrition

Normal memory changes vs. dementia symptoms

It’s something we all have to face but the inevitable changes of aging can still be both humbling andsurprising. But while experiencing wrinkling skin, fading hair color, and mild, short-term memory lossis common as we age, severe and rapid memory loss is definitely NOT a part of normal aging. Infact, many people are able to preserve their brainpower as they get older by staying mentally andphysically active and making other healthy lifestyle choices.

Normal memory changes associated with aging may include:

Memory loss

Impaired judgement

Difficulties with abstract thinking

Faulty reasoning

Inappropriate behavior

Loss of communication skills

Disorientation to time and place

Gait, motor, and balance problems

Neglect of personal care and safety

Hallucinations, paranoia, agitation

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Slower thinking and problem solving – The speed of learning slows down; short-term memorytakes longer to function; reaction time increases.

Decreased attention and concentration – More distractedness. All of the interruptions makelearning more difficult.

Slower recall – A greater need for hints to jog the memory.

Distinguishing between normal memory loss and dementia symptoms is not an exact science butthere are some clues to look for:

Are memory changes typical aging or symptoms of dementia?

Typical aging: Symptoms of dementia:

You or a loved one complain about memoryloss but are able to provide detailed examplesof forgetfulness

Complain of memory loss only if asked; unableto recall specific instances

Occasionally search for words Frequent word-finding pauses, substitutions

May have to pause to remember directions, butdon’t get lost in familiar places

Get lost in familiar places and takes excessivetime to return home

Remember recent important events;conversations are not impaired

Notable decline in memory for recent eventsand ability to converse

Interpersonal social skills are at the same levelas they've always been

Loss of interest in social activities; may behavein socially inappropriate ways

Adapted from: The American Medical Association

What causes dementia?

In a healthy brain, mass and speed may decline in adulthood, but this miraculous organ continues toform vital connections throughout life. However, when connections are lost through inflammation,disease, or injury, neurons eventually die and dementia can develop (/harvard/whats-causing-your-memory-loss.htm). While the prospect of literally losing one's self can be extremely traumatic, earlyintervention can dramatically alter the outcome.

In the past 20 years, scientists have greatly demystified the origins of dementia. Genetics mayincrease your risks, but scientists believe a combination of hereditary, environmental, and lifestylefactors are also at work.

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Dementia can be caused by:

Medical conditions that progressively attack brain cells and connections, most commonlyseen in Alzheimer's disease, Parkinson's disease, or Huntington's disease.

Medical conditions such as strokes that disrupt oxygen flow and rob the brain of vitalnutrients. Additional strokes may be prevented by reducing high blood pressure, treating heartdisease, and quitting smoking.

Poor nutrition, dehydration, and certain substances, including drugs and alcohol. Treatingconditions such as insulin resistance, metabolic disorders, and vitamin deficiencies may reduce oreliminate symptoms of dementia.

Single trauma or repeated injuries to the brain. Depending on the location of the brain injury,cognitive skills and memory may be impaired.

Infection or illness that affects the central nervous system, including Creutzfeldt-Jakob diseaseand HIV. Some conditions are treatable, including liver or kidney disease, depression-inducedpseudo dementia, and operable brain tumors.

Types of dementia

All dementias involve cognitive decline that impacts daily living. However, it's important to pinpointthe specific type of dementia in order to optimize treatment. More than 50 conditions involvedementia, with the most common types being Alzheimer's disease and vascular dementia.

Alzheimer's disease

This is the most common form of dementia, accounting for up to two-thirds of all diagnosed cases. Ifyour dementia symptoms are the result of Alzheimer's disease, medications can delay the onset ofmore debilitating symptoms. Early diagnosis can prolong independence and is the first step towardstreatment, management, and continuing to enjoy a full life.

(/harvard/whats-causing-your-memory-loss.htm)What's Causing Your Memory Loss? (/harvard/whats-causing-your-memory-loss.htm) It'sNot Necessarily Alzheimer's

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10 Warning signs of Alzheimer's disease

1. Memory loss sufficient to disrupt daily life - Such as forgetting recently learnedinformation, important dates or events, asking for the same information over and over, relyingmore and more on memory aides or family members.

2. Problem-solving difficulties - An inability to follow plans, work with numbers, follow recipes,or keep track of bills.

3. Trouble completing daily tasks - Such as driving to a familiar location, remembering rulesto a game, completing assignments at work.

4. Confusion over time or place - Losing track of dates and seasons, or forgetting where youare or how you got there.

5. Difficulty understanding visual images - Trouble reading, judging distances, colors, orcontrast, or recognizing your own reflection.

6. Problems with spoken or written words - Difficulties following a conversation, finding theright word, or calling things by the right name.

7. Misplacing things - Putting things in unusual places, unable to retrace steps, accusingothers of stealing.

8. Poor judgement - Decline in decision making, giving away large sums of money, paying lessattention to personal grooming.

9. Withdrawal from work or social activities - Trouble remembering how to complete a workproject or favorite hobby, avoiding sports or social events.

10. Changes in mood - Becoming confused, depressed, suspicious, fearful, or anxious. Easilyupset when out of comfort zone.

Source: Alzheimer's Association

Vascular dementia

Vascular dementia results from a series of small strokes or changes in the brain's blood supply. Asudden onset of symptoms can indicate vascular dementia, and while it severely impacts memoryand cognitive functioning, there are ways to prevent and reduce its severity.

Mixed dementia

This is a condition in which Alzheimer's disease and vascular dementia occur simultaneously. Thecombination of the two types of dementia most commonly occurs in advanced senior years, oftenindicated by cardiovascular disease and dementia symptoms that get worse slowly over time.

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Less common forms of dementia

Pick's Disease affects personality, orientation and behavior. It may be more common in women andoccurs at an early age.

Creutzfeldt-Jakob Disease progresses rapidly along with mental deterioration and involuntarymovements.

Huntington's Disease is an inherited, degenerative disease. The disease causes involuntarymovement and usually begins during mid-life.

Parkinson's Dementia can develop in the later stages of Parkinson's disease, a progressivedisorder of the central nervous system.

Lewy Body Dementia causes symptoms similar to Alzheimer's disease. People with Lewy Bodydementia experience hallucinations and can become fearful.

What is mild cognitive impairment (MCI) or early dementia?

Early dementia, also known as mild cognitive impairment (MCI), involves problems with memory,language, or other cognitive functions. But unlike those with full-blown dementia, people with MCIare still able to function in their daily lives without relying on others.

Many people with MCI eventually develop Alzheimer's disease or another type of dementia.However, others plateau at a relatively mild stage of decline and are able to live independently.Some people with mild cognitive impairment even return to normal.

It is not yet fully understood why MCI progresses to Alzheimer's disease in some, while remainingstable in others. The course is difficult to predict, but in general, the greater the degree of memoryimpairment, the greater the risk of developing Alzheimer's down the line. According to The MayoClinic's Dr. Ronald Peterson, roughly fifteen percent of the population between ages 70 and 90experience minimal cognitive impairment.

Symptoms of MCI include:

Frequently losing or misplacing things

Frequently forgetting conversations, appointments, or events

Difficulty remembering the names of new acquaintances

Difficulty following the flow of a conversation

What to do if you have symptoms of dementia

Because dementia symptoms can be caused by any number of conditions, obtaining an accuratediagnosis is critical for management and treatment. The sooner you address the problem, the better,so make an appointment with your doctor right away.

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Your doctor can assess your personal risk factors, evaluate your symptoms, offer tips on healthylifestyle adjustments, and help you obtain appropriate care.

If you suspect dementia:

Report your dementia symptoms to your doctor as soon as possible and schedule regularfollow up visits.

Keep a list of your symptoms and concerns and ask family members for their observations.Write down specific information about the frequency, nature, and setting of your memory,cognitive, or behavior concerns.

Take charge by learning as much about dementia as you can. Knowing what to expect willhelp you plan, adjust, and live life as fully as possible.

Why early intervention is so important

When dementia symptoms appear suddenly, it is critical to seek medical attention. Conditionssuch as stroke, drug interactions, tumors, and seizures should be treated immediately. Timelyintervention may also control or eliminate symptoms from other physical and psychologicalfactors.

Preventing or delaying dementia

Recent research suggests that healthy lifestyle habits and mental stimulation may prevent dementia(/articles/alzheimers-dementia-aging/preventing-alzheimers-disease.htm) altogether or at least delayits onset. Just as physical exercise keeps you physically fit, exercising your mind and memory canhelp you stay mentally sharp, no matter how old you are. These strategies can help reduce your riskof dementia.

The 6 pillars of dementia prevention:

1. Regular exercise. Starting a regular exercise routine, including cardio and strength training, mayreduce your risk of developing dementia by up to 50 percent.

2. Social engagement. The more you connect face-to-face with others, the stronger your memoryand cognition is likely to be.

3. Healthy diet. Brain-healthy eating habits can help reduce inflammation, protect neurons, andpromote better communication between brain cells.

4. Mental stimulation. By continuing to learn new things and challenge your brain, you canstrengthen your cognitive skills and stay mentally sharp.

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5. Quality sleep. Getting quality sleep can flush out brain toxins and avoid the build-up of damagingplaques.

6. Stress management. Unchecked stress takes a heavy toll on the brain, shrinking a key memoryarea, hampering nerve cell growth, and worsening dementia symptoms.

Dementia treatment, planning, and care

"I thought my life was over. I knew about dementia but I never thought it could happen to me." Thissentiment reflects the fear, disbelief, and dismay many people experience after a dementiadiagnosis. While dealing with dementia is a major life challenge, the above pillars of dementiaprevention can be used to help slow the onset of more debilitating dementia symptoms. You canalso use the following guidelines to help ease your journey and preserve your way of life:

Emotional connection can make a positive difference. As you deal with dementia symptoms,make sure you get the emotional support you need. Turn to close family members and friends, join adementia support group, or talk to a therapist, counselor, or clergyman.

Make important decisions early. Avoid future medical, financial, and legal confusion bycommunicating your wishes and creating a plan. Discuss and document treatment and end-of-lifepreferences with your doctors and family members and appoint someone you trust to makedecisions for you in case you can no longer make them for yourself. Although these conversationsmay be difficult, making your wishes known can also be empowering.

Watch for treatable changes. Depression, sleep disturbances, and medication interactions canmake dementia symptoms worse and limit independence. Treating them may require someexperimentation with lifestyle changes and medication, but can be well worth the effort.

Create a dementia-friendly environment. Preserve your health and autonomy for as long aspossible by taking simple actions: encourage memories with pictures and familiar objects; removetripping hazards; increase lighting; and organize a caregiving network. Planning and flexibility cankeep you one step ahead of your changing needs.

(/articles/alzheimers-dementia-aging/preventing-alzheimers-disease.htm)Preventing Alzheimer's Disease: (/articles/alzheimers-dementia-aging/preventing-alzheimers-disease.htm) What You Can Do to Prevent Dementia

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HelpGuide.org REPRINT

©Helpguide.org. All rights reserved. The content of this reprint is for informational purposes onlyand NOT a substitute for professional advice, diagnosis, or treatment.

Savor positive experiences. Even when dementia is at an advanced stage and you sense yourmind may be half-gone, try to see it as half-present. With appropriate support and understanding,people with dementia are still capable of experiencing and providing enjoyment and connection—even through the final stages of the disease.

Authors: Monika White, Ph.D., Jeanne Segal, Ph.D., and Melinda Smith, M.A.Last updated: September 2018.

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11/1/2018 Volunteering and its Surprising Benefits: How Giving to Others Makes You Healthier and Happier

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HELPGUIDE.ORGTrusted guide to mental, emotional & social health

Volunteering and its Surprising BenefitsHow Giving to Others Makes You Healthier and Happier

With busy lives, it can be hard to find time to volunteer. However, the benefits of volunteering areenormous to you, your family, and your community. The right match can help you to reduce stress,find friends, reach out to the community, learn new skills, and even advance your career. Giving toothers can also help protect your mental and physical health. Learn more about the many benefitsof helping others and find tips on getting started.

Why volunteer?

Volunteering offers vital help to people in need, worthwhile causes, and the community, but thebenefits can be even greater for you, the volunteer. Volunteering and helping others can help youreduce stress, combat depression, keep you mentally stimulated, and provide a sense of purpose.While it’s true that the more you volunteer, the more benefits you’ll experience, volunteering doesn’thave to involve a long-term commitment or take a huge amount of time out of your busy day. Givingin even simple ways can help others those in need and improve your health and happiness.

Benefits of volunteering: 4 ways to feel healthier and happier

1. Volunteering connects you to others2. Volunteering is good for your mind and body3. Volunteering can advance your career4. Volunteering brings fun and fulfillment to your life

Benefit 1: Volunteering connects you to others

One of the better-known benefits of volunteering is the impact on the community. Volunteeringallows you to connect to your community and make it a better place. Even helping out with thesmallest tasks can make a real difference to the lives of people, animals, and organizations in need.

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And volunteering is a two-way street: It can benefit you and your family as much as the cause youchoose to help. Dedicating your time as a volunteer helps you make new friends, expand yournetwork, and boost your social skills.

Make new friends and contacts

One of the best ways to make new friends (/articles/relationships-communication/making-good-friends.htm) and strengthen existing relationships is to commit to a shared activity together.Volunteering is a great way to meet new people, especially if you are new to an area. It strengthensyour ties to the community and broadens your support network, exposing you to people withcommon interests, neighborhood resources, and fun and fulfilling activities.

Increase your social and relationship skills

While some people are naturally outgoing, others are shy and have a hard time meeting newpeople. Volunteering gives you the opportunity to practice and develop your social skills, since youare meeting regularly with a group of people with common interests. Once you have momentum, it’seasier to branch out and make more friends and contacts.

Volunteering as a family

Children watch everything you do. By giving back to the community, you show them firsthandhow volunteering makes a difference and how good it feels to help other people and animalsand enact change. It’s also a valuable way for you to get to know organizations in thecommunity and find resources and activities for your children and family.

Benefit 2: Volunteering is good for your mind and body

Volunteering provides many benefits to both mental and physical health.

Volunteering helps counteract the effects of stress, anger, and anxiety. The social contactaspect of helping and working with others can have a profound effect on your overall psychologicalwell-being. Nothing relieves stress better than a meaningful connection to another person. Workingwith pets (/articles/mental-health/mood-boosting-power-of-dogs.htm) and other animals has alsobeen shown to improve mood and reduce stress and anxiety.

Volunteering combats depression. Volunteering keeps you in regular contact with others andhelps you develop a solid support system, which in turn protects you against depression.

Volunteering makes you happy. By measuring hormones and brain activity, researchers havediscovered that being helpful to others delivers immense pleasure. Human beings are hard-wired togive to others. The more we give, the happier we feel.

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Volunteering increases self-confidence. You are doing good for others and the community, whichprovides a natural sense of accomplishment. Your role as a volunteer can also give you a sense ofpride and identity. And the better you feel about yourself, the more likely you are to have a positiveview of your life and future goals.

Volunteering provides a sense of purpose. Older adults, especially those who have retired or losta spouse, can find new meaning and direction in their lives by helping others. Whatever your age orlife situation, volunteering can help take your mind off your own worries, keep you mentallystimulated, and add more zest to your life.

Volunteering helps you stay physically healthy. Studies have found that those who volunteerhave a lower mortality rate than those who do not. Older volunteers tend to walk more, find it easierto cope with everyday tasks, are less likely to develop high blood pressure, and have better thinkingskills. Volunteering can also lessen symptoms of chronic pain and reduce the risk of heart disease.

I have limited mobility—can I still volunteer?

People with disabilities or chronic health conditions can still benefit greatly from volunteering. In fact,research has shown that adults with disabilities or health conditions ranging from hearing and visionloss to heart disease, diabetes or digestive disorders all show improvement after volunteering.

Whether due to a disability, a lack of transportation, or time constraints, many people choose tovolunteer their time via phone or computer. In today's digital age many organizations need help withwriting, graphic design, email, and other web-based tasks. Some organizations may require you toattend an initial training session or periodical meetings while others can be done completelyremotely. In any volunteer situation, make sure that you are getting enough social contact, and thatthe organization is available to support you should you have questions.

Benefit 3: Volunteering can advance your career

If you’re considering a new career, volunteering can help you get experience in your area of interestand meet people in the field. Even if you’re not planning on changing careers, volunteering givesyou the opportunity to practice important skills used in the workplace, such as teamwork,communication, problem solving, project planning, task management, and organization. You mightfeel more comfortable stretching your wings at work once you’ve honed these skills in a volunteerposition first.

Teaching you valuable job skills

Just because volunteer work is unpaid does not mean the skills you learn are basic. Manyvolunteering opportunities provide extensive training. For example, you could become anexperienced crisis counselor while volunteering for a women’s shelter or a knowledgeable arthistorian while donating your time as a museum docent.

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Volunteering can also help you build upon skills you already have and use them to benefit thegreater community. For instance, if you hold a successful sales position, you raise awareness foryour favorite cause as a volunteer advocate, while further developing and improving your publicspeaking, communication, and marketing skills.

Gaining career experience

Volunteering offers you the chance to try out a new career without making a long-term commitment.It is also a great way to gain experience in a new field. In some fields, you can volunteer directly atan organization that does the kind of work you’re interested in. For example, if you’re interested innursing, you could volunteer at a hospital or a nursing home.

Your volunteer work might also expose you to professional organizations or internships that could beof benefit to your career.

When it comes to volunteering, passion and positivity are the only requirements

While learning new skills can be beneficial to many, it’s not a requirement for a fulfillingvolunteer experience. Bear in mind that the most valuable skills you can bring to any volunteereffort are compassion, an open mind, a willingness to do whatever is needed, and a positiveattitude.

Benefit 4: Volunteering brings fun and fulfillment to your life

Volunteering is a fun and easy way to explore your interests and passions. Doing volunteer workyou find meaningful and interesting can be a relaxing, energizing escape from your day-to-dayroutine of work, school, or family commitments. Volunteering also provides you with renewedcreativity, motivation, and vision that can carry over into your personal and professional life.

(/articles/healthy-living/finding-the-right-career.htm)Finding the Right Career: (/articles/healthy-living/finding-the-right-career.htm) How to FindJob Satisfaction

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Many people volunteer in order to make time for hobbies outside of work as well. For instance, if youhave a desk job and long to spend time outdoors, you might consider volunteering to help plant acommunity garden, walk dogs for an animal shelter, or help out at a children's camp.

Consider your goals and interests

You will have a richer and more enjoyable volunteering experience if you first take some time toidentify your goals and interests. Think about why you want to volunteer. What would you enjoydoing? The opportunities that match both your goals and your interests are most likely to be fun andfulfilling.

Tips for getting started

First, ask yourself if there is something specific you want to do.

For example, do I want… …to make it better around where I live …to meet people who are different from me …to try something new …to do something with my spare time …to see a different way of life and new places …to have a go at the type of work I might want to do as a full-time job …to do more with my interests and hobbies …to do something I’m good at

The best way to volunteer is to match your personality and interests. Having answers to thesequestions will help you narrow down your search.

Source: World Volunteer Web

How to find the right volunteer opportunity

There are numerous volunteer opportunities available. The key is to find a volunteer position thatyou would enjoy and are capable of doing. It’s also important to make sure that your commitmentmatches the organization’s needs. Ask yourself the following:

Would you like to work with adults, children, animals, or remotely from home?

Do you prefer to work alone or as part of a team?

Are you better behind the scenes or do you prefer to take a more visible role?

How much time are you willing to commit?

What skills can you bring to a volunteer job?

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What causes are important to you?

Consider several volunteer possibilities

Don’t limit yourself to just one organization or one specific type of job. Sometimes an opportunitylooks great on paper, but the reality is quite different. Try to visit different organizations and get afeel for what they are like and if you click with other staff and volunteers.

Where to find volunteer opportunities

Community theatres, museums, and monuments

Libraries or senior centers

Service organizations such as Lions Clubs or Rotary Clubs

Local animal shelters, rescue organizations, or wildlife centers

Youth organizations, sports teams, and after-school programs

Historical restorations, national parks, and conservation organizations

Places of worship such as churches or synagogues

Online databases such as those contained in the Resources section below

How much time should you volunteer?

Volunteering doesn’t have to take over your life to be beneficial. In fact, research shows that just twoto three hours per week, or about 100 hours a year, can confer the most benefits—to both you andyour chosen cause. The important thing is to volunteer only the amount of time that feelscomfortable to you. Volunteering should feel like a fun and rewarding hobby, not another chore onyour to-do list.

Getting the most out of volunteering

You’re donating your valuable time, so it’s important that you enjoy and benefit from yourvolunteering. To make sure that your volunteer position is a good fit:

Ask questions. You want to make sure that the experience is right for your skills, your goals, andthe time you want to spend. Sample questions to your volunteer coordinator might address yourtime commitment, if there’s any training involved, who you will be working with, and what to do if youhave questions during your experience.

Make sure you know what’s expected. You should be comfortable with the organization andunderstand the time commitment. Consider starting small so that you don’t over commit yourself atfirst. Give yourself some flexibility to change your focus if needed.

11/1/2018 Volunteering and its Surprising Benefits: How Giving to Others Makes You Healthier and Happier

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Don’t be afraid to make a change. Don’t force yourself into a bad fit or feel compelled to stick witha volunteer role you dislike. Talk to the organization about changing your focus or look for a differentorganization that’s a better fit.

If volunteering overseas, choose carefully. Some volunteer programs abroad can cause moreharm than good if they take much-needed paying jobs away from local workers. Look for volunteeropportunities with reputable organizations.

Enjoy yourself. The best volunteer experiences benefit both the volunteer and the organization. Ifyou’re not enjoying yourself, ask yourself why. Is it the tasks you’re performing? The people you’reworking with? Or are you uncomfortable simply because the situation is new and familiar?Pinpointing what’s bothering you can help you decide how to proceed.

Authors: Jeanne Segal, Ph.D. and Lawrence Robinson. Last updated: September2018.

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