rtb2008-02

Advance Directives and Do Not Resuscitate Orders

 

What is an advance directive?

An advance directive tells your doctor what kind of care you would like to have if you become unable to make medical decisions (if you are in a coma, for example). If you are admitted to the hospital, the hospital staff will probably talk to you about advance directives.

A good advance directive describes the kind of treatment you would want depending on how sick you are. For example, the directives would describe what kind of care you want if you have an illness that you are unlikely to recover from, or if you are permanently unconscious. Advance directives usually tell your doctor that you don't want certain kinds of treatment. However, they can also say that you want a certain treatment no matter how ill you are.

Advance directives can take many forms. Laws about advance directives are different in each state. You should be aware of the laws in your state.

 

What is a living will?

A living will is one type of advance directive. It is a written, legal document that describes the kind of medical treatments or life-sustaining treatments you would want if you were seriously or terminally ill. A living will doesn't let you select someone to make decisions for you.

 

What is a durable power of attorney for health care?

A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA states whom you have chosen to make health care decisions for you. It becomes active any time you are unconscious or unable to make medical decisions. A DPA is generally more useful than a living will. But a DPA may not be a good choice if you don't have another person you trust to make these decisions for you.

Living wills and DPAs are legal in most states. Even if they aren't officially recognized by the law in your state, they can still guide your loved ones and doctor if you are unable to make decisions about your medical care. Ask your doctor, lawyer or state representative about the law in your state.

 

What is a do not resuscitate order?

A do not resuscitate (DNR) order is another kind of advance directive. A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. (Unless given other instructions, hospital staff will try to help all patients whose heart has stopped or who have stopped breathing.) You can use an advance directive form or tell your doctor that you don't want to be resuscitated. In this case, a DNR order is put in your medical chart by your doctor. DNR orders are accepted by doctors and hospitals in all states.

 

Should I have an advance directive?

By creating an advance directive, you are making your preferences about medical care known before you're faced with a serious injury or illness. This will spare your loved ones the stress of making decisions about your care while you are sick. Any person 18 years of age or older can prepare an advance directive.

People who are seriously or terminally ill are more likely to have an advance directive. For example, someone with terminal cancer might write that she does not want to be put on a respirator if she stops breathing. This action can reduce her suffering, increase her peace of mind and increase her control over her death. However, even if you are in good health, you might want to consider writing an advance directive. An accident or serious illness can happen suddenly, and if you already have a signed advance directive, your wishes are more likely to be followed.

 

How can I write an advance directive?

You can write an advance directive in several ways:

 
  • Use a form provided by your doctor.
  • Write your wishes down by yourself.
  • Call your health department or state department on aging to get a form.
  • Call a lawyer.
  • Use a computer software package for legal documents.
 
Advance directives and living wills do not have to be complicated legal documents. They can be short, simple statements about what you want done or not done if you can't speak for yourself. Remember, anything you write by yourself or with a computer software package should follow your state laws. You may also want to have what you have written reviewed by your doctor or a lawyer to make sure your directives are understood exactly as you intended. When you are satisfied with your directives, the orders should be notarized if possible, and copies should be given to your family and your doctor.

 

Can I change my advance directive?

You may change or cancel your advance directive at any time, as long as you are considered of sound mind to do so. Being of sound mind means that you are still able to think rationally and communicate your wishes in a clear manner. Again, your changes must be made, signed and notarized according to the laws in your state. Make sure that your doctor and any family members who knew about your directives are also aware that you have changed them.

If you do not have time to put your changes in writing, you can make them known while you are in the hospital. Tell your doctor and any family or friends present exactly what you want to happen. Usually, wishes that are made in person will be followed in place of the ones made earlier in writing. Be sure your instructions are clearly understood by everyone you have told.
 

Artificial Hydration and Nutrition

 

When do people need artificial hydration and nutrition?

If a patient isn't able to swallow because of a medical problem, he or she can be given fluids and nutrition in ways other than by mouth. This is referred to as artificial hydration and nutrition. This is sometimes done when someone is recovering from a temporary problem. It may also be done when someone has an advanced, life-threatening illness and is dying.

 

What is involved in artificial nutrition and hydration?

An intravenous (IV) catheter (a thin plastic tube that slides in over a needle) may be placed in the vein under the patient's skin. Fluids and sometimes nutrition are given through the catheter.

Another method of artificial nutrition and hydration is through a plastic tube called a nasogastric tube (also called an NG tube). This tube is put through the nose, down the throat and into the stomach. It can only be left in for a short time, usually 1 to 4 weeks. If the tube has to be in longer, a different kind of feeding tube may be used. It's placed into the wall of the stomach (also called a PEG tube or g-tube).

 

What happens if artificial hydration or nutrition are not given?

Persons who don't receive any food or fluids will eventually fall into a deep sleep (coma) and usually die in 1 to 3 weeks.

What are the benefits?

A person with a temporary illness who can't swallow needs nutrients and water. A feeding tube can help. Sometimes a person may become confused because of dehydration. Dehydration is when the body doesn't get enough fluids. Giving a patient fluids through a tube help dehydration and may lessen his or her confusion. Giving fluids and nutrition helps the patient as he or she is recovering.

For a patient with an advanced life-threatening illness who is dying, artificial hydration and nutrition may not provide many benefits. Artificial hydration and nutrition in these patients may make the patient live a little longer, but not always.

 

What are the risks?

There's always a risk when someone is fed through a tube. Liquid might enter the lungs. This can cause coughing and pneumonia. Feeding tubes may feel uncomfortable. They can become plugged up, causing pain, nausea and vomiting. Feeding tubes may also cause infections. Sometimes, patients may need to be physically restrained or sedated to keep them from pulling out the feeding tube.
 

How do we decide whether to use artificial hydration and nutrition?

The patient and his or her family should talk with the doctor about the patient's medical condition and risks and benefits of giving artificial hydration and nutrition. Each situation is different. Your doctor can help you make the decision that is right for the patient and family

Artificial Hydration

 

What is artificial hydration?

Artificial hydration is a way to replace fluids that have been lost through vomiting, sweating or diarrhea. It may be necessary when a person is too sick to drink enough water or eat enough food.

 
 

Why do our bodies need fluid?

Our bodies are made mostly of water. Almost 60 percent of our body weight comes from water. In order to be healthy, the body needs water just as it needs food. We lose water everyday in two ways: by going to the bathroom (about 45 ounces a day) and by sweating and breathing (at least 21 ounces a day). We have to eat food and drink fluids every day to get the amount of water our bodies need.

How are fluids replaced?

There are two ways to replace fluids in someone who needs them. The first way is to put the fluid right into a vein. This is called intravenous (IV) fluid replacement. The other way is to put the fluid under the skin. This is called hypodermoclysis, or subcutaneous fluid replacement.

With IV fluid replacement, doctors and nurses need to watch the person very closely in a hospital. But a family member or other caregiver can do hypodermoclysis at home after a doctor or nurse shows him or her how to do it.

 

How safe is hypodermoclysis?

This way of replacing fluid has been used safely for many years. It is used most often on older people and in people who have cancer.

How does hypodermoclysis work?

A bag of fluid is connected to a plastic tube and to a long needle. The needle is put under the skin and taped in place, usually on the chest, abdomen or thighs.

A "drip chamber," or small window, in the tube shows how fast the fluid is dripping. The speed of the drip can be controlled by using a roller clamp. A nurse or doctor should replace the needle every 4 to 7 days so the flesh around the needle does not become infected.

Your doctor will decide how fast the fluid should drip. Your doctor will show you how to control the drip and tell you when to check it at home. You can ask your doctor for help if you have questions or problems.

 

What are the common problems with hypodermoclysis and what should I do?

Most of the time, hypodermoclysis is safe. Sometimes though, there can be problems. Here are a few things that might happen during hypodermoclysis:

 
  1. The speed of the drip changes or the drip stops. Your doctor will show you how to control the flow rate by rolling the roller clamp.
  2. The site where the needle is inserted will swell. If you gently rub the skin there, the fluid will soak in better. Your doctor will show you how. Call your doctor for help if the swelling continues or does not get better.
  3. The site where the needle is inserted becomes painful. Check the skin for redness. Tell your doctor if the skin is red. It may be time to find a different place to insert the needle.
  4. Blood collects in the tube. This means the needle has gone into a vein. Call your doctor if this happens.
  5. The person has trouble breathing or is feeling much worse. If this is the case, call your doctor.

End-of-Life Care: Cardiopulmonary Resuscitation (CPR)

 

When is CPR important?

CPR may be done when a person stops breathing or the heart stops beating (like when a person has a heart attack). When it's possible that the person may get better, CPR is important.

However, when a patient has an advanced life-threatening illness (such as cancer) and is dying, CPR may not be the option to choose. It's important for the patient, family members and doctor to talk about this issue before the need arises.

What happens during CPR?

During CPR, the chest is pressed on forcefully. Electric stimulation to the chest and special medicines are sometimes used. This is usually done for 15 to 30 minutes. A tube may also be put through the mouth or nose into the lung. This tube is then connected to a breathing machine.

What happens if CPR isn't done?

A person will become unconscious almost immediately and will die in 5 to 10 minutes.

What are the benefits of CPR?

For a patient with an advanced life-threatening illness who is dying, there are really no benefits.

CPR may prolong life for patients with a better health status or who are younger. CPR may also prolong life if it's done within 5 to 10 minutes of when the person's heart stopped beating or breathing stopped.

What are the risks of CPR?

Pressing on the chest can cause a sore chest, broken ribs or a collapsed lung. Patients with breathing tubes usually need medicine to keep them comfortable. Most patients who survive will need to be on a breathing machine in the intensive care unit to help them breathe for a while.

Few patients (less than 10 percent) in the hospital who have had CPR survive and are able to function the way they used to. Many patients live for a short time after CPR, but still die in the hospital. CPR may also prolong the dying process.

Patients who have more than one illness usually don't survive after CPR. Almost no one with advanced cancer survives CPR and lives long enough to leave the hospital. Of the few patients who do, many get weaker or have brain damage. Some patients may need to live on a breathing machine for the rest of their lives.

Cancer: End-of-Life Issues for the Caregiver

 
Not everyone who has cancer succumbs to the disease. In fact, there are nearly 9 million cancer survivors living in the United States today. However, if your loved one's cancer cannot be cured or controlled with treatment, then planning for how you and your loved one will handle the last stages of the disease can ease the burden for both of you. Ideally, you should make these decisions together, while your loved one is well enough to participate. Doing so can help give your loved one a sense of control over his or her future and relieve you from having to make difficult decisions on your own.
 

What kinds of things should we plan for?

Hospice care: Talk with your loved one about hospice care and advanced directives. Hospice care focuses on providing people whose illness can't be cured or controlled with treatment with the most dignified, pain-free existence possible in their last stage of life. Advance directives are instructions on what kind of care your loved one wishes to receive when he or she becomes unable to make medical decisions.

Financial and legal issues: You and your loved one may wish to have an accountant or lawyer help you sort through financial and legal issues. You can review things such as your loved one's insurance policy, finances and his or her will.

Funeral arrangements: Perhaps the most difficult part of this process is planning your loved one's funeral. Talk with your loved one about his or her preferences (for example, burial vs. cremation) in relation to your budget. Ask your loved one how he or she wants the service to be conducted. For example, you may want to discuss things such as what hymns or readings to include in the ceremony and whom your loved one wants to have as his or her pallbearers. Don't feel that any detail is too small to discuss. When selecting a funeral provider, be sure to compare prices, services and payment options. It will be easier to do this sooner rather than later.
 

Hospice Care

 

What is hospice care, and what are its purposes?

Hospice is the term for a special program of care for terminally ill (dying) patients and their families. Rather than trying to cure an illness, hospice efforts aim to make the patient comfortable, ease pain and other troublesome symptoms and support the family through a sad and difficult time.

A hospice care program tries to provide the best quality of life for dying patients by providing a holistic approach. That means giving spiritual, mental, emotional and physical comfort to the patients, their families and their other caregivers.

 

What is a hospice team?

A hospice team is a group of people who understand the special goals of hospice care. The team includes doctors, nurses, social workers, spiritual counselors, home health aides, bereavement counselors and volunteers. The hospice team helps patients live out their final days with dignity and with as much physical comfort as possible.
 

Is hospice care available to nursing home residents?

Yes. The services of hospice care programs are provided wherever patients are spending their final days. This includes their own home, a family member's home, a hospital, a nursing home or a hospice facility.

The members of the hospice team try to help nursing home patients be as free of pain as possible. They also try to help them be at peace with themselves and their illness. At the same time, the hospice team provides support, education and counseling to family members, nursing home staff and other nursing home residents who know the patient.

 

What specific services does a hospice program provide?

Hospice care programs can provide the following services:

 
  • Around-the-clock nursing care.
  • Training of family members in patient care, as appropriate.
  • Spiritual and emotional support for both the patient and the family.
  • Help with practical matters associated with terminal illness.
  • Speech, occupational and physical therapies (when these services are considered useful by the hospice team).
  • Coordination of services and care with the patient's family doctor.
  • Expert management of physical symptoms.
  • Bereavement and support groups for families.

What is bereavement support?

Bereavement support is help in coping with the loss of a loved one. Grieving is a normal psychological process that nursing home staff members, family members and friends go through when a person they love or take care of passes away.

Normal grief has no timetable or calendar. People experience grief in many different ways. Many people feel anger, loneliness, guilt, confusion and fear after a loved one dies. It helps to be able to talk about these feelings and about the person who has passed away.

Hospice is committed to helping people who are grieving. Hospice staff members and volunteers offer warm professional support to help family members with emotional healing and readjustment. Hospice respects the natural dying process. It provides patients and family members with an opportunity for spiritual growth during this final phase of life.
 

Pressure Sores

 

What are pressure sores?

Pressure sores are areas of injured skin and tissue. They are usually caused by sitting or lying in one position for too long. This puts pressure on certain areas of the body. The pressure can reduce the blood supply to the skin and the tissues under the skin. When a change in position doesn't occur often enough and the blood supply gets too low, a sore may form. Pressure sores are also called bedsores, pressure ulcers and decubitus ulcers.

 

Are pressure sores serious?

Pressure sores can be serious, depending on how much the skin and tissues have been damaged. You should call your doctor if you think a sore is forming.

Mild damage causes the skin to be discolored, but a sore doesn't form. In light-skinned people, the damaged skin may turn dark purple or red. In dark-skinned people, the area may become darker than normal. The area of damaged skin may also feel warmer than the surrounding skin.

Deep sores can go down into the muscle, or even to the bone. If pressure sores are not treated properly, they can become infected. An infection in a pressure sore can be serious. Pressure sores also hurt a lot and make it hard for a person to move around.

 

Who gets pressure sores?

Anyone who sits or lies in one position for a long time might get pressure sores. You are more likely to get pressure sores if you use a wheelchair or spend most of your time in bed. However, even people who are able to walk can get pressure sores when they must stay in bed because of an illness or injury. Some chronic diseases, such as diabetes and hardening of the arteries, make it hard for pressure sores to heal because of a poor blood supply to the area.

 

Where on the body can you get pressure sores?

Pressure sores usually develop over bony parts of the body that don't have much fat to pad them. Pressure sores are most common on the heels and on the hips. Other areas at risk for pressure sores include the base of the spine, the shoulder blades, the backs and sides of the knees, and the back of the head.

 

How are pressure sores treated?

Three things help pressure sores heal:

 
  • Relieving the pressure that caused the sore
  • Treating the sore itself
  • Improving nutrition and other conditions to help the sore heal

What can be done to reduce pressure on the sore?

Don't lie on pressure sores. Use foam pads or pillows to take pressure off the sore. Special mattresses, mattress covers, foam wedges or seat cushions can help support you in bed or in a chair to reduce or relieve pressure. Try to avoid resting directly on your hip bone when you're lying on your side. Use pillows under one side so that your weight rests on the fleshy part of your buttock instead of on your hip bone. Also, use pillows to keep your knees and ankles apart. When lying on your back, place a pillow under your lower calves to lift your ankles slightly off the bed. Change your position at least every 2 hours.

When sitting in a chair or wheelchair, sit upright and straight. An upright, straight position will allow you to move more easily and help prevent new sores. If you cannot move by yourself, have your caregiver shift your position at least every hour, or more often if possible.

 

How should the pressure sore be kept clean?

In order to heal, pressure sores must be kept clean and free of dead tissue. You can clean the sore by rinsing the area with a salt-water solution. The salt water removes extra fluid and loose material. Your doctor or nurse can show you how to clean your pressure sore.

Pressure sores should be kept covered with a bandage or dressing. Sometimes gauze is used. The gauze is kept moist and must be changed at least once a day. Newer kinds of dressings include a see-through film and a hydrocolloid dressing. A hydrocolloid dressing is a bandage made of a gel that molds to the pressure sore. These dressings can stay on for several days at a time.

Dead tissue (which may look like a scab) in the sore can interfere with healing and lead to infection. There are many ways to remove dead tissue from the pressure sore. Rinsing the sore every time you change the bandage is helpful. Special dressings that help your body dissolve the dead tissue can also be used. They are left in place for several days.

Another way to remove dead tissue is to put wet gauze bandages on the sore and allow them to dry. The dead tissue sticks to the gauze and is removed when the gauze is pulled off. Sometimes dead tissue must be removed surgically.

Removing dead tissue and cleaning the sore can hurt. Your doctor can suggest a pain reliever for you to take 30 to 60 minutes before your dressing is changed.

Why is good nutrition important for healing sores?
Good nutrition is important because it helps your body heal the sore. If you don't get enough calories, protein and other nutrients, your body won't be able to heal, no matter how well you care for the pressure sore. Your doctor or nurse or a dietitian can give you advice about a healthy diet. Be sure to tell your doctor if you have lost or gained weight recently.

 

What if the sore gets infected?

Pressure sores that become infected heal more slowly and can spread a dangerous infection to the rest of your body. If you notice any of the signs of infection listed below, call your doctor right away.

Signs of an infected pressure sore include the following:

 
  • Thick yellow or green pus
  • A bad smell from the sore
  • Redness or warmth around the sore
  • Swelling around the sore
  • Tenderness around the sore
 
Signs that the infection may have spread include the following:
  • Fever or chills
  • Mental confusion or difficulty concentrating
  • Rapid heartbeat
  • Weakness

How are infected pressure sores treated?

The treatment of an infected pressure sore depends on how bad the infection is. If only the sore itself is infected, an antibiotic ointment can be put on the sore. When bone or deeper tissue is infected, intravenous antibiotics (given through a needle put in a vein) are often required.

How can I tell if the sore is getting better?

As a pressure sore heals, it slowly gets smaller. Less fluid drains from it. New, healthy tissue starts growing at the bottom of the sore. This new tissue is light red or pink and looks lumpy and shiny. It may take 2 to 4 weeks of treatment before you see these signs of healing.

How can pressure sores be prevented?

The most important step to prevent pressure sores is to avoid prolonged pressure on one part of your body, especially the pressure points mentioned previously.

It's also important to keep your skin healthy. Keep your skin clean and dry. Use a mild soap (like Dove, Basis or Oil of Olay) and warm (not hot) water. Apply moisturizers so your skin doesn't get too dry. If you must spend a lot of time in bed or in a wheelchair, check your whole body every day for spots, color changes or other signs of sores. Pay special attention to the pressure points where sores are most likely to occur.

 

Autopsy

 

What is an autopsy?

An autopsy is a medical exam of the body of a person who has died. The purpose of an autopsy is to answer questions about the person's illness or the cause of death. In addition, autopsies provide valuable information that helps doctors save the lives of others. Autopsies are performed by specially trained doctors, called pathologists.
 

Who may request an autopsy?

You can request an autopsy if you are the person's next of kin or the legally responsible party. Your doctor will ask you to sign a consent form to give permission for the autopsy. You may limit the autopsy in any manner you wish.

However, if the cause of death is unclear, the pathologist may perform an autopsy without the family's permission.
 

What is the procedure for an autopsy?

First, the pathologist looks at the body for clues about the cause of death. Next, he or she examines the internal organs, taking samples as needed to look at under a microscope. The autopsy takes from 2 to 4 hours. The autopsy room looks similar to an operating room. An atmosphere of dignity and respect for the deceased is maintained at all times.

What does an autopsy cost?

If the autopsy is performed by family request, the cost is between $5000 & $8000 and is paid prior to the procedure.
 

Will an autopsy interfere with funeral arrangements?

No. Pathologists perform autopsies in a way that doesn't interfere with burial or cremation. Once the autopsy is completed, the hospital tells the funeral home. An autopsy won't delay funeral services.

 

When will the results of an autopsy be known?

The first findings from an autopsy are usually ready in 2 to 3 days. The doctor can review these results with you. A final report may take many weeks because of the detailed studies performed on tissue samples. The doctor will also review the final report with you.

Caregiver Stress

 

Who is a caregiver?

You're a caregiver if you give basic care to a person who has a chronic medical condition. A chronic condition is an illness that lasts for a long period of time or doesn't go away. Some examples of chronic conditions are cancer, stroke, multiple sclerosis, dementia, diabetes and Alzheimer's disease.

If you're a caregiver, you may be doing the following things for another person:
  • Lifting
  • Turning him or her in bed
  • Bathing
  • Dressing
  • Feeding
  • Cooking
  • Shopping
  • Paying bills
  • Running errands
  • Giving medicine
  • Keeping him or her company
  • Providing emotional support
 

Why is caregiving so hard?

The person you're caring for may not know you anymore. He or she may be too ill to talk or follow simple plans. This may make it hard for you to think of that person in the same way that you did before he or she became ill. This may be especially true if the person you're caring for suffers from dementia.

The person you're caring for may also have behavior problems, like yelling, hitting or wandering away from home. This behavior may make you feel angry and frustrated.

How can I tell if caregiving is putting too much stress on me?

Common signs of caregiver stress include the following:
  • Feeling sad or moody
  • Crying more often than you used to
  • Having low energy level
  • Feeling like you don't have any time to yourself
  • Having trouble sleeping, or not wanting to get out of bed in the morning
  • Having trouble eating, or eating too much
  • Seeing friends or relatives less often than you used to
  • Losing interest in your hobbies or the things you used to do with friends or family
  • Feeling angry at the person you are caring for or at other people or situations
 
In addition, you may not get any thanks from the person you are caring for. This may add to your feelings of stress and frustration.
 

What should I do if I'm feeling overwhelmed and stressed?

These feelings are not wrong or strange. Caregiving can be very stressful. Because being a caregiver is so hard, some doctors think of caregivers as "hidden patients." If you don't take care of yourself and stay well, you won't be able to help anyone else.

Talk with your family doctor about your feelings. Stay in touch with your friends and family members. Ask them for help in giving care. Asking for help doesn't make you a failure.

Look for help in your community. You may start by asking your church or synagogue if they have services or volunteers who can help you. You can also ask for help from support organizations (see "Other Organizations").

Grieving: Facing Illness, Death and Other Losses

 

What is grief?

Grief is a normal, healthy response to loss. One of the greatest losses that can occur is the death of someone you love. Other losses include the loss of your health or the health of someone you care about, or the end of an important relationship, such as a marriage. Healing from a loss involves coming to terms with the loss and the meaning of the loss in your life.

 

What are the normal feelings of grief?

 

Symptoms of grief

  • Anger
  • Blaming yourself
  • Crying spells
  • Diarrhea
  • Dizziness
  • Fast heartbeat
  • Feeling like there's a lump in your throat
  • Feeling like what's happening around you isn't real
  • Headaches
  • Hyperventilating -- sighing and yawning
  • Nausea
  • Not being able to get organized
  • Not feeling hungry or losing weight
  • Restlessness and irritability
  • Sadness or depression
  • Seeing images of the dead person
  • Shortness of breath
  • Tightness in your chest
  • Tiredness
  • Trouble concentrating
  • Trouble sleeping
As you face a loss, you may have different feelings at different times. These feelings include shock, denial, anger, guilt, sadness and acceptance. You may find yourself going back and forth from one feeling to another. For example, right when it seems that you're starting to accept your loss, you may find yourself feeling sad or guilty again. Your grief may never completely go away. But the pain you feel will lessen with time as you work through these feelings.

What usually happens first?

In the first hours or days after the loss, you may feel shocked, numb and confused. You may not remember what people have said to you. You may think and act as though the loss hasn't occurred. This is called denial.

As the shock wears off, reality will slowly break through. You'll begin to realize that the loss has happened. It's normal to feel abandoned and angry. You may direct your anger toward God, religion, doctors and nurses, the one who has died or other loved ones, or even yourself.

 

What happens after the anger wears off?

After you get through some of the anger and denial, it's normal to pretend things are like they used to be. If someone you love has died, you may play memories over and over in your mind. You may also feel the presence of your loved one, think you see him or her, or think you hear his or her voice.

You may also find yourself talking to your loved one as though he or she were in the room with you. As you begin to realize that your loved one is gone and won't be back, you'll begin to feel the full impact of your loss. These feelings may be scary because they're so strange and so strong. They may make you feel like you're losing control.

 
 

What happens then?

When you begin to realize the full impact of the loss on your life, you may feel depressed and hopeless. You may also feel guilty. You may find yourself thinking things like "if only" or "why me?" You may cry for no apparent reason. This is the most painful stage of healing, but it won't last forever. In normal grief, the depression will begin to lift with time.

What is the first sign of relief?

You may start to feel better in small ways. For example, you may find it's a little easier to get up in the morning, or you may have small bursts of energy. This is the time when you'll begin to reorganize your life around your loss or without your loved one.

 

What is the final stage?

 

Tips on dealing with a loss

  • Talk about how you're feeling with others.
  • Try to keep up with your daily tasks so you don't feel overwhelmed.
  • Get enough sleep, eat a well-balanced diet and exercise regularly.
  • Avoid alcohol. Alcohol can make you feel more depressed.
  • Get back into your normal routine as soon as you can.
  • Avoid making major decisions right away.
  • Allow yourself to grieve--to cry, to feel numb, to be angry or to feel however you're feeling.
  • Ask for help if you need it.
The last stage of accepting a loss is when you begin to reinvest in other relationships and activities. During this time, it's normal to feel guilty or disloyal to your loved one because you're moving on to new relationships. It's also normal to relive some of your feelings of grief on birthdays, anniversaries, holidays and during other special times.

 

How long does grief last?

You'll probably start to feel better in 6 to 8 weeks. The whole process can last anywhere from 6 months to 4 years.

If you feel like you're having trouble at any point, ask for help. People who can help include friends, family, clergy, a counselor or therapist, support groups and your family doctor.

Be sure to talk with your family doctor if you have a lot of trouble eating, sleeping or concentrating for more than the first couple of weeks. These can be signs of depression. Your family doctor can help you with depression so you can start to feel better.