NHPCO Urges Congressional Intervention as CMS Finalizes Rate Cuts
Labels: hospice and palliative care, providers
Labels: hospice and palliative care, providers
Older patients with chronic conditions can, over time, lose the ability to care for their own basic needs and safety. But how can physicians maintain respect for a patient's autonomy while assessing self-neglect?
. . .physicians who see older patients -- or even patients living alone without family members or social support -- have an obligation to recognize and pursue explanations for signs and behavior that may signal self-neglect. Acting on these signals is not always comfortable -- particularly if patients' spouses or other family members are in the picture. But self-neglect exposes patients to greater risk for morbidity and mortality that can be avoided once it is recognized and managed. The physician's role is clear.
Hospices serving Medicare beneficiaries will see a 2.5 percent increase in their payments for 2009 according to a final regulation published today by CMS.
The increase in the hospice wage index is the net result of a 3.6 percent increase in the so-called “market basket” indicator of cost, offset by a 1.1 percent decrease in payments to hospices as CMS phases out a transitional payment to these providers.
As published in the Federal Register on July 31, CMS is phasing-out an adjustment to the hospice wage index that was put into place over 10 years ago to help hospices through a transition to the new wage index. Phasing-out this special adjustment will save Medicare $2.18 billion over five years. It is estimated that payments to hospices would decrease by approximately 1.1 percent for FY 2009, the first year of the three-year phase-out of the adjustment.
This final rule reflects the ongoing efforts of CMS to support beneficiary access to hospice services while maintaining responsible financial stewardship of the Medicare Trust Fund.
Labels: hospice and palliative care, providers
You have excised a pancreatic adenocarcinoma from your respected college biology professor, who is now retired and widowed at age 85. He returns for follow-up examination after 9 months. Laboratory tests and imaging confirm recurrence of the tumor, with widespread metastases. He is being treated by a psychiatrist for depression and mild dementia, but remains legally competent and maintains his own home. His three adult children, two sons and a daughter, are ardent in their request that you withhold the bad news from the patient. Radiation and chemotherapy are marginally indicated for palliation, but he will probably consent to the therapy if you refer him. The patient hasn’t asked you for results of the diagnostic tests. What should you do?
(A) Respect the family’s request. Don’t volunteer the information about prognosis, and refer for palliation.
(B) Ignore the family’s request. Tactfully tell the patient that his cancer has recurred, and seek his consent for aggressive treatment.
(C) Tell the patient only if he specifically asks about his prognosis and recommend palliative therapy.
(D) Dissemble and minimize the seriousness, even if he asks. Tell him that
some other doctors are going to mop up the remaining cancer cells.
(E) Tell the patient the truth. Provide him with appropriate referrals.
Labels: providers
For physicians who practice in the hospice and palliative care setting, the changes likely will not drastically change the way they go about treating patients, said Porter S. Storey, MD. He's a hospital-based palliative care specialist in Boulder, Colo., and the American Academy of Hospice and Palliative Medicine's executive vice president. CMS acknowledged, for instance, that many hospice patients are already very involved in their treatment plans.
Although the changes are not revolutionary, they are evolutionary for the physicians involved in end-of-life care, and this evolution has already started, Dr. Storey said.
"They clearly intend for hospice physicians to be much more involved in the care of patients," he said. "In the past it was possible for a small hospice to just employ a doctor to come by once a week and sign papers. Those days are really over."
For example, Medicare will require, for the first time, that hospices develop quality-assessment and performance-improvement programs and that their physicians participate in the process. Most physicians will welcome this opportunity to become more involved in improving outcomes, Dr. Storey said.
Labels: providers
DR. DIANE MEIER: When I asked him about her treatment options and the pros and cons of the different treatment options, one of the treatments that he had suggested to her when I asked him about it, he said he didn't really think it would help her.
And I said, "You know, do we still want to offer her something that isn't really going to help her and might carry consequences or side effects?" And he said, "I don't want Judy to think I'm giving up on her."
And I thought that captured it perfectly, that here was a physician who cared so deeply about his patient that he wanted to convey to her his commitment to her, that he was not going to abandon her no matter what. The way he thought he had to do that was by offering treatments, regardless of how likely they were to benefit, in a way.
DR. BARRON LERNER: They feel that it's almost wrong to have that sort of discussion, that giving up is equivalent to doing something bad. And we're really not giving up here.
We're just shifting from aggressive treatment to try to kill sick cancer cells to aggressive palliation, where we're going to do as much as we can to prolong life for as long as possible and to keep the person as comfortable as possible.
Labels: disease and disability, end-of-life, providers
"Our survey reveals that perinatal death has a profound effect on obstetricians, and 8 percent had considered giving up obstetrics because of the emotional difficulty of caring for patients with perinatal death," says lead author Katherine Gold, M.D., MSW, of U-M's Department of Family Medicine and Department of Obstetrics and Gynecology.
"We know that stillbirth and infant death are traumatic events for families; this study suggests that they are also traumatic for the physician."
. . .
Two-thirds of physicians supported training by formal presentations or seminars, and nearly half recommended informal gatherings for physicians to discuss difficult experiences. Many respondents suggested that a meeting with bereaved parents could serve as a useful training strategy as well as a way of helping physicians cope with their own feelings about the loss.
Even though death is an inevitable part of the human condition, it's not something that most doctors, including me, ever get too comfortable with. We get used to pushing it off until another day.
When death is approaching, the natural tendency is to avoid situations that are uncomfortable, emotionally detach, visit less often, fill our time with something that seems more productive.
It's during those times when I remind myself to slow down, sit down and listen. What I have to offer when there is nothing more that medicine can do is some comfort and companionship.
Labels: hospice and palliative care, providers
Pallimed: What are the important lessons learned from the flooding to share with other hospice agencies as they look at their own disaster planning?
Dr. Wensel: The greatest lesson learned is to plan for the worse case scenario. As a hospice think about if you lost half your staff, some of your patients had to be evacuated, and you had no safe water. You can never plan for every possible problem that might come up, but it would be very helpful to talk through different disaster plans with your staff. You never realize how wonderful it is to wash your hands, brush your teeth or take a bath until you can't. I had never thought about all the things we do to care for patents that require water.
Labels: caregiving, hospice and palliative care, providers
In our day-to-day work, most ethical questions we face turn on issues of patient choice. One fairly common example can arise in home care. Most of our patients live at home and have sufficient day-to-day care from family and friends. Sometimes, though, we will have a patient who lives alone or has a frail caregiver. Staying at home might be incredibly important to that patient, but because of growing weakness, the patient's self-care capacity may diminish and the whole situation may become riskier. Sometimes, insurance pays for the kind of custodial care that the patient needs, but that is rare. The hospice staff wants the best and safest care for the patient and starts to think of a transfer to a nursing home or the hospice residence. But the patient wants to be home and often sees a fall or even death as far less of a concern than leaving home. This sort of situation can create a great deal of dynamic tension. How much risk is too much risk, and who has the right to say that the risk is too much? What leverage do we have to impel changes, especially with a rational patient? Do we need to call Adult Protective Services? We live with this tension and explore the situation among ourselves and with the patient and family. Things usually turn out OK, in no small part because of that dynamic tension.
Labels: end-of-life, hospice and palliative care, providers
Labels: hospice and palliative care, providers
Labels: caregiving, end-of-life, grief, providers
A major implication of the new perspective is that bereavement professionals can enjoy a more realistic and positive view of their helping efforts. For the past 6 years, the possibility of harming clients has troubled counselors who accepted the TIDE [treatment-induced deterioration effects] findings. If 38% of grief-counseling clients and nearly 50% of normally bereaved clients are worse off at the end of treatment than they would have been without treatment, grief counseling is ethically problematic. The perspective offered here should provide relief for these counselors.
Hospice administrators and other nonclinicians who assist the bereaved can also approach their work with greater confidence. Many of these professionals were strongly influenced by the new pessimism. Patti Homan, the Bereavement Professional Section leader for the National Council of Hospice and Palliative Professionals of the National Hospice and Palliative Care Organization, received inquiries from hospice bereavement coordinators in different parts of the country who were concerned because their administrators, as a result of the publicity that attended the CFAH report, were questioning the value of their bereavement programs (personal communication, March 1, 2006).
Correcting these negative views of grief counseling and bereavement services will be difficult; replacing them with the cautious optimism that seems warranted in light of research findings to date will require systematic efforts.
But there's a problem: 11 years ago, Congress mandated that terminally-ill patients are entitled to unlimited hospice care - but Medicare only pays the hospices for six months' worth, CBS News correspondent Thalia Assuras reports.
Labels: hospice and palliative care, providers
Labels: providers
Labels: providers
The programme encourages and enables local teams to work in partnership with service users to improve the environment in which they deliver care. The programme consists of two elements: a development programme for a nurse-led, multidisciplinary team and a grant for the team to undertake a project to improve their patient environment. Throughout our work on the environment of care, one theme has remained constant– the need for health care settings that make patients feel cared for and staff feel valued.
. . .
As a result of our practical experience we recommend that all the settings with which end-of-life care occurs provide:
- a room where patient and family can be taken for confidential discussions.
- the option of single room accommodation designed to engender a feeling of homeliness where patients retain control over their environment
- informal gathering spaces and places where families can meet, confer andtalk with care staff
- guest rooms where close family or friends can stay overnight with facilities for catering and internet access
- appropriate places for 'viewing' the deceased.
Our practical experience also leads us to recommend that all health service providers include care of the dying, bereaved and deceased in corporate induction programmes for all staff and that professional training for all staff groups should include material on the impact of the environment in end-of-life care.
As a result of our consultative conference, considering the issues raised by the work, we recommend the Department of Health should develop national standards for the environment for end-of-life care, significantly increase investment in these environments and ensure that policy and practice development enables everybody to make choices about where they would prefer to die and to revisit that choice as their condition changes.
Labels: end-of-life, hospice and palliative care, providers
Increasing access to palliative care in the home or other residential settings. Many hospice experts argue that removing the typical eligibility requirement of a six-month prognosis would meet many more patients' needs for palliative care and create access for patients with chronic illnesses.
Because payment for hospice is largely government-funded through Medicare and state Medicaid programs, however, myriad economic and public relations questions must be addressed.
Hospice Rule Changes. Two issues are driving increased CMS scrutiny of the hospice industry: First, the dramatic growth in CMS payments to hospice and second, suspected fraud and abuse in the hospice industry.
Most significant among the imminent changes to the Medicare hospice benefit are a new emphasis on quality assessment and performance improvement, a first step toward what experts agree will be a public reporting initiative and, eventually, a pay-for-performance design for hospice reimbursement, and a new emphasis on leadership at the board level.
Compression of Reimbursement. Noting the hospice industry's exponential rate of growth, CMS has signaled that reimbursement reforms including across-the-board per diem rate cuts and greater scrutiny of claims are on the horizon. And it's unlikely that there will be any help for those hospices that exceed the annual, aggregate per-beneficiary cap on reimbursement -- an increasing problem with growing enrollment of longer-stay patients.
General Inpatient Care and Hospice-managed Inpatient Units. Many hospices now own and operate small, freestanding or co-located facilities where they provide residential and acute-level care to hospice patients. As development of these units has accelerated, utilization of the general inpatient (GIP) level of the Medicare hospice benefit has increased.
CMS is tracking this trend, and has noted a growth in hospice-related expenditures for GIP between 2001 and 2005. Hospices should expect to see greater regulatory scrutiny of utilization.
Hospice in Nursing Homes. Hospices routinely bring the hospice model and service package to residents of nursing homes, providing support to the residents' families and nursing home staff in addition to the resident himself.
Labels: hospice and palliative care, providers
To those of us helping our loved one through difficult times, a caregiver is someone you hire to help if don’t have the time or skills to care for your loved one. I remember early on my aunt said, “have you seen or read the caregiver book I got during Bill’s illness?” Why would I need to read such a book, I was her niece helping her because I had the time and I loved her. I was not her caregiver. It really did not hit me until about 6 months in that I realized, but never verbalized, that I was her primary caregiver.
When the medical home was first conceived by pediatricians about four decades ago, doctors thought it would most help patients with complex or chronic problems. Tests in several practices nationwide found that these patients treated in medical homes more often got needed care promptly, hospitalization rates dropped and patient satisfaction rose.
Still, the concept didn't gain much traction until the last four years, when organizations representing 333,000 doctors, including many of the nation's primary care physicians, endorsed the medical home for all patients.
Labels: caregiving, grief, providers
"Patient satisfaction data collected by NHPCO shows the 98.5 percent of families would recommend hospice to others, reflecting the high level of family satisfaction with care. Coupled with the fact that hospice can be cost effective to Medicare, it seems illogical to put rules in place that would cut down on the care hospice providers could offer," Schumacher noted.
The result of this proposed rule would potentially mean less care to patients and family caregivers during the end of life.
"NHPCO and its affiliate, The Alliance for Care at the End of Life, recently supported bipartisan, bicameral letters from 87 Members of Congress sent to Secretary Leavitt in opposition to the proposed rule and subsequent rate cuts to hospice care. The rule release merely marks the beginning of an arduous regulatory process -- one that we will engage in to the very end to ensure that this valuable benefit to the dying is not sacrificed to short-sighted cost cutting whims," concluded Schumacher.
Labels: hospice and palliative care, providers
Labels: caregiving, end-of-life, providers
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| Pamela Gabbay |
Through a contact at school, she heard about a children’s grief center, the Mourning Star Center, that was opening in her community. Not only was she struck by the proximity of the center to her home, but even the name held meaning for her. “My mother had always talked fondly about a boat she had worked on—the Morning Star!” Gabbay said. “I signed on as the first volunteer at the center, and on that first day I knew I was home.”
One of the most wonderful and surprising elements of Gabbay’s work is witnessing the level of compassion and support that the children and teenagers offer to each other. She remembers the conversation between two boys, both of whom had 14-year-old brothers who had died, sharing what their families had each done with their brothers’ belongings. “Watching how the teens make new friends, how they lean on each other and show true compassion for one another, is a true gift,” and is an ongoing reminder of the importance of peer support, Gabbay said.
Of course, supporting grieving children takes much more than peer support. Gabbay and the others on staff at Mourning Star provide a wide range of activities and programming, much of it focusing on how to deal with “special days,” like holidays or birthdays. And as kids grow and change, their needs change as well. As Gabbay points out, the transition is “huge for that 8th-grader who is becoming a high-school freshman without Mom around,” and that same student may need renewed support when facing graduation four years later.
The Mourning Star Center runs concurrent parent groups and Gabbay strongly encourages parents to learn as much about what kids may be facing in grief and loss. Parents of grieving children and teens, of course, often worry that their grieving child may not be doing well in school. Gabbay often uses the analogy of an Etch-a-Sketch, the children’s toy that one draws on and then shakes up to erase the picture. “A kid may be drawing a picture, having fun,” she says, and then when a parent dies, it’s as if “someone comes along and shakes it all up, and all of the pictures and information is gone.” These stories, she says, can often be a way to help adults find a better understanding of what kids may be going through.
These examples can also be very useful when educating teachers and school administrators about grief and loss, Gabbay has found. Just as grief may affect adults cognitively, the same can be true for young people. So a grieving teenager may not be grasping algebra concepts cognitively, and at the same time may be asking the question, “Why does algebra matter right now, anyway?” Gabbay is enthusiastic about the “fabulous, caring individuals” in her local school system and has found the schools to be open about setting up grief groups and accessing the resources that her grief center provides. And she has found that the importance of this not only helps children cope, but that young people will remember those teachers who reacted to their loss in a supportive and helpful way.
When Gabbay speaks to teachers or other adults who want to help children and adolescents cope with loss, one point she always makes is that young people experiencing loss often feel “invisible;” that they feel they are not seen or heard in the same way. Yet she also finds that, while younger children need to be “seen and heard,” teens may prefer that others do not directly address their loss. Gabbay’s advice is to always ask the young person what he or she feels would be most helpful.
One experience that Gabbay has found particularly “amazing—one of the best weekends of my life,” was when she directed Camp Erin, an overnight grief camp funded by the Moyer Foundation. Forty-six kids attended the two –day camp in the mountains, as well as 50 volunteers—“all of whom expressed enthusiasm and interest in attending next year’s summer session the day we ended!” Gabbay recounts. Gabbay describes the arc that she witnessed in the kids who attended. “When they arrived on Friday, they were somewhat trepidatious—they were getting to know each other, asking questions. By mid-day Saturday you could already see a change—they weren’t just bonding with each other, but were actively working on processing their individual grief experiences. You could see a real awareness of the concept that they weren’t ‘alone’—the realization that others understood. For many, it literally added a spring in their step!” By Saturday night’s ceremony, in which each child lit a luminary for the person who had died and placed it in a boat which was then set afloat on the lake, Gabbay said that the adults could see that, “it was as though a burden had been lifted, if even just for that one night.” Many parents made similar observations when reunited with their children on Sunday. Gabbay already has plans to expand participation in this summer’s camp, and the kids at Mourning Star are still talking about it as well.
While Gabbay clearly has found her calling in her work of helping young people cope with loss, she is quick to acknowledge that the work can be difficult. She feels fortunate to work with a strong team at the Mourning Star Center, a team that can “lean on each other in a meaningful way.” She emphasizes how important it is that they can stop for a hug or to talk, recognizing that “it’s okay to be honest and real about how hard it can be to hear these stories every day.” Gabbay also began an ADEC (Association for Death Education and Counseling) chapter in her area. She did this partly out of the need to have a forum for local professionals to network and share ideas, she says, but also because of the need to be with others who, even with “just a look,” can offer understanding and support.
Gabbay recognizes the importance of self-care. A self-professed “huge music fan,” she is sure to attend at least ten concerts every year, and even books passage on a rock-and-roll cruise. One of her favorite activities each week is to “turn up the music, hop into the pool” with her two teenagers, and just “act silly.” These moments help sustain Gabbay, someone who truly feels that “once you find your calling, you can’t stop!
Pamela Gabbay, M.A., FT, was awarded the Fellow in Thanatology by the Association for Death Education and Counseling and is a Certified Bereavement Counselor. She earned her B.A. in Psychology from California State University, San Bernardino and her M.A. in Psychology from Claremont Graduate University. Pamela is the Program Director of The Mourning Star Center for grieving children in Palm Desert, California. The Mourning Star Center is a community service program of The Visiting Nurse Association of the Inland Counties - Hospice.
Pamela is the Camp Coordinator for Camp Erin - Palm Springs, the first Camp Erin in California. This camp is a free camp for grieving children created in partnership with The Mourning Star Center and The Moyer Foundation. Pamela is also President of the California Chapter of the Association for Death Education and Counseling (ADEC So Cal). ADEC So Cal is an organization dedicated to promoting excellence in death education. Additionally, Pamela is co-owner of Grief Posters.com, a poster company that produces sensitive and educational grief-related posters.Labels: disease and disability, end-of-life, hospice and palliative care, providers
"There's room for improved understanding between doctors and lawyers generally," said (Ned)Spurgeon, who teaches health law and elder law and policy at McGeorge. ". . . Hopefully, this will mean better-educated doctors and lawyers with respect to enabling patients to have their surrogates make better decisions."
Labels: end-of-life, providers
Labels: disease and disability, providers
We both wanted to be standing next to Dr Campbell in this scenario,to help with some possible responses. After the patient asked how he would die, Dr Campbell gently described how patients usually die, yet there was a missed opportunity. One of us might have said, "Tell us what you are most afraid of." Most junior faculty can’t imagine asking something like this, which seems to invite more anxiety and discomfort for both the patient and the doctor. In contrast, it is usually therapeutic because no one can reassure the patient until he knows what is really frightening him.
We expect the patient might have responded, "I don’t want to suffocate to death!" Or, "I don’t want to bleed to death!" "I don’t want my family to witness this." He might also have cried.
We would model being silent in the presence of the patient's distress, which conveys the message that we won’t run away even if the going gets tough. We would reach out, silently, to touch his arm. We would both be seated. When the patient stopped crying we would then say, "Many patients feel just like you do. Fortunately, it doesn’t have to be that way. Would it help to talk about what might happen, and what we’d do so you won’t suffer? Some patients just want to be reassured that the doctor will manage things, but most are reassured by talking about their worst nightmares, and making a plan. How is it for you?"
If the patient wanted, we would discuss aggressive comfort measures, including aggressive sedation if something overwhelming happens. We would firmly tell him he won’t die feeling like he is suffocating. While we can’t control the cancer, we CAN control how he feels. We can also control the environment so his family and the nursing staff won’t be traumatized.
After the interaction, we’d join Dr Campbell in the hall with his colleagues and the nurses, and debrief the interaction in order to meet the team's personal self-care needs. We’d listen while they told us how uncomfortable they felt. We’d tell stories about similar situations when we felt helpless, and how we got to the place where we don’t feel that way anymore. We’d rehearse what to do in the case of worst scenarios, supervise the writing of the orders, and make sure the nurses knew what to do and whom to call . . .
Labels: end-of-life, hospice and palliative care, providers
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"As the racial, ethnic and cultural diversity of the U.S. population continues to increase, there is an ever-growing need for the health care profession to become culturally competent in all aspects of care delivery—and this includes the care we provide to grieving patients and their families. A recently published article on cultural diversity and grief states that the need for culturally sensitive grief/bereavement educators and counselors is on the rise and that health care providers must continue to expand their knowledge of the many ways that people grieve."
"Dr. Horn, of the Institute for Clinical Outcomes Research, praised the collaborative as 'the first major national effort driven by Medicare to reduce pressure ulcers.' But she said that better outcomes could be achieved if more nursing homes improved their documentation, so that all of the information on a given resident, including details on eating, urinary and bowel function, appeared on a single sheet, with key reminders to nursing assistants and other staff members about best practices.
Institutional change and work-flow redesign are critical, she added, given the high rates of turnover in nursing home staff across the country."
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| Vince Chiles |
“You’re such an angel. . . You were sent by God. . . You’re so special, thank you so much.” These are the kinds of comments that hospice nurses, social workers, home health aides, chaplains, and volunteers hear everyday from their patients and patients’ families. Hospice staff have been compared to angels, but unlike their heavenly comparisons are mortal, and as a result are affected by the work they do daily..
Being in close proximity to the terminally ill and dying affects the hospice professional in profound emotional, social, spiritual and psychological ways. It is next to impossible not to form some type of emotional bond to hospice patients, and when they die, the professional and volunteer grieves. The hospice professional and volunteer must temper social interactions with family and friends who aren’t as comfortable talking about death and dying, and might feel as if they, as hospice workers, don’t have people who understand their needs. By working so closely to death, one will naturally question his or her own religious and/or spiritual beliefs, and sometimes wrestle with doubt and uncertainty. As the hospice professional searches for good answers for all the suffering and pain she witnesses, she may also experience psychological stress from this work.
It is important that the seasoned hospice professional develop an arsenal of self-care techniques to combat the potential occupational hazards. I feel the best self-care techniques are those that are natural, effortless and produce instant benefit. By natural I mean that these are skills you already possess. (You may be unaware of their self-care power.) By effortless I mean that these skills require little or no physical effort to perform. Finally, by instant I mean that they only require a few seconds or minutes to perform. Self-care skills that combine these three elements are easy to use and to benefit from. Some examples:
Breathe Deeply: Deep breathing is a great example of a self-care technique that meets the above criteria. Breathing is natural; we all do it, and it is often effortless. When feeling stressed or burdened by the emotional pressures of hospice work, this technique can be used for short periods of time, in a few seconds to minutes, and it produces quick benefits. You perform this exercise by focusing your attention on inhaling and exhaling, and then comfortably allowing each exchange to last three to four seconds. Deep breathing helps to increase oxygen flow to your brain, which allows you to clear your mind and feel refreshed. As a result, deep breathing is a natural, effortless, and instant self-care technique.
Laugh Out Loud: Another easy and fun self-care technique is to laugh longer and harder each time someone tells a joke or a funny story. Laughing has many benefits, from stimulating the immune system to improving one’s mood. Laughing at someone else’s joke improves inter-personal relations, and also helps to promote the other person’s mood. Laughing is natural, it’s simple, and it’s instant. It may feel a little awkward at first, but after you experience its benefits, it will be contagious.
Practice Kindness: We’ve all seen the bumper sticker “Practice Random Acts of Kindness.” Being kind by holding a door open, or by complimenting a store clerk on good service, takes only seconds to do, but kindness can go a long way to promote one’s well-being. We may not think kindness is natural, but it is - our survival depends on it. Kind deeds can be effortless, and the benefits are instant in improving the outlooks of the giver and receiver.
Feel Grateful: Remind yourself to feel grateful everyday. Feel gratitude for the air you breathe, your home, your loved ones, and your life. Gratitude is effortless. It requires only a momentary reflection on what you appreciate in your life. Feeling gratitude is a great self-care technique because it can be done by reflecting on five to 10 things you appreciate today. The rewards of practicing gratitude include a better outlook and increased sense of satisfaction with oneself.
Do you have a self-care technique that you have found especially helpful and easy to do? If so, please share it with us here.
Labels: providers
Labels: hospice and palliative care, providers
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| Dr. Kenneth J. Doka |
Labels: end-of-life, providers
Labels: end-of-life, providers
Labels: caregiver story, disease and disability, providers
Labels: end-of-life, providers
Labels: caregiving, providers
Labels: disease and disability, end-of-life, providers