Dealing with End-of-Life Decisions

Over the course of a lifetime, men face a variety of inevitable stresses that create emotional responses. Dealing with death and dying presents some of life’s greatest emotional stress. There are two ways in which a man finds himself confronting the issues surrounding death and dying: as someone caring for a dying person, most often a parent, and as someone who is facing his own death. In both roles he must find ways to deal with his grief. Grief affects each person differently but typically involves four stages shock, denial, depression and withdrawal, and acceptance. If you are grieving, it is important for your emotional health to talk about your feelings to a family member or a close friend, to others in a support group, or to a counselor. “Bottled up” emotions can lead to depression, withdrawal from friends and society, sudden irrational outbursts, feelings of anger and resentment, insomnia, and even physical illness. Here are some positive steps you can take to deal with grief:

• Rest, eat a healthy diet (see page 43), and keep warm (emotional stress will make your body temperature drop). Avoid caffeine and alcohol because they can add to your stress.

• Use relaxation techniques. Try deep breathing. People who are under stress tend to hold their breath or to breathe shallowly, which can cause fatigue and anxiety.

• Express your feelings. Talk to family, friends, members of a support group, or clergy.

• Accept help. Let others care for you. Let your friends and family make a meal for you, do some housework, or just listen to you. Such support can be healing for them as well as for you.

• Take as much time as you need. Grieving has no time frame.

• Think about how your life has changed and what that means for the future.

Family Caregiving

A large part of the stress related to the dying of family members has to do with the challenges of providing care. People who have a terminal illness usually have important and wide-ranging needs for assistance in addition to the medical care they receive from physicians and other healthcare workers. A majority of people

who are dying require home nursing care, help with transportation, homemaking services, and personal care. In many cases their families must take on the substantial burden of caring for them. In some cases, home healthcare programs may help. Traditionally, women have provided most of the home care, even when the family member is the man’s parent or grandparent. But today, with most women working outside the home, men and members of religious or civic organizations have an opportunity to be more actively engaged in caring for the dying. People are relying increasingly on paid workers to provide the nonmedical care needed by family members who are dying.

Hospice Care

Hospice care is a life-affirming approach to caring for people who are in the final phase of a terminal illness. Hospice regards death as a natural part of life, and emphasizes the comfort and quality of life of a dying person. The focus is on relieving pain and controlling other symptoms. With hospice care, a dying person is allowed to live his or her last days with dignity, pain-free and alert, surrounded by loved ones at home or in a homelike setting. In general, a person becomes eligible to enter a hospice program when a doctor has determined that he or she has 6 months or less to live and refers him or her to a hospice program. Family members, friends, clergy, or healthcare professionals also can make referrals. Under the supervision of a doctor, an interdisciplinary team doctors, nurses, therapists, counselors, social workers, clergy, healthcare aides, and volunteers works closely with the dying person to provide medical care and support. The team deals with the person’s medical, emotional, and spiritual needs. And because the entire family is regarded as the “unit of care,” the hospice team also provides support and assistance to the person’s loved ones. Members of the hospice team are available to assist the person and his or her loved ones 24 hours a

day, 7 days a week. After the person has died, the hospice program also provides grief counseling to the survivors.

Advance Directives

When a person becomes seriously ill and is no longer able to make decisions about his or her healthcare, those decisions are usually made by a close family member or by the person’s doctor. Advance directives are legal documents designed to help ensure that healthcare decisions made on a person’s behalf are consistent with his or her preferences. Advance directives may provide either general guidelines or specific instructions. Although advance directives do not go into effect until the person is unable to make his or her own healthcare decisions, the forms should be prepared and signed long before they are needed. When the person is in a hospital or a nursing home, emotional factors may make it challenging to talk about the forms (and the issues involved). These documents should be reviewed and updated regularly. The person can revise or withdraw his or her advance directives at any time. Advance directive forms are available through hospital social service departments and from state or local medical societies and bar associations, or you can consult a lawyer to produce your own living will and durable power of attorney for healthcare. Because requirements for advance directives vary from state to state, you should consider talking to a lawyer when preparing or filling out these documents. Be sure to tell the doctor and the person you have chosen to make your healthcare decisions about your advance directives. Give each of them a copy, and keep a copy for yourself. The most common types of advance directives are living wills, durable powers of attorney, do-not-resuscitate orders, and organ and tissue donor cards:

• A living will is a document that indicates a person’s wishes regarding lifesustaining medical treatments. It is prepared by a competent person and goes into effect only when the person is unable to speak for himself or herself. A living will guides medical professionals and family members so they can make healthcare decisions that are consistent with the person’s beliefs. A living will can be revised or withdrawn by the person at any time. You should consult a lawyer when preparing a living will because legal requirements vary from state to state.

• A durable power of attorney for healthcare is a document in which a competent person gives another person (called a healthcare proxy) the power to make healthcare decisions for him or her. It goes into effect only in the event that the person is unable to make such decisions. The durable power of attorney can be withdrawn by the person who initiated it at any time.

• A do-not-resuscitate (DNR) order states that no one should perform heroic measures, including CPR and the use of mechanical life support equipment, to restart a person’s heart should it stop. The document must be signed by the person if he or she is competent (or by his or her healthcare proxy if he or she is not competent) and by his or her doctor. In some cases, doctors recommend that people wear a special bracelet or necklace that communicates their DNR status to emergency responders. The person should keep a copy of the document in his or her home in a prominent place where it will be noticed by emergency medical personnel called to the home; the doctor should keep a copy in the person’s medical records at all times to make sure that the person’s wishes are respected. DNR orders can be withdrawn at any time by the patient, as long as he or she is competent.

• Anorgan and tissue donor card informs medical personnel that your organs and tissues may be used for transplant in the event of your death. Many states provide an opportunity to register as an organ and tissue donor when you apply for a driver’s license or state identification card. Your donor status is then indicated on the license or identification card. Be sure to tell your loved ones that you are a registered donor.

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Relationships

People have a strong need to connect with others, and the central task of adulthood involves the ability to master relationships. Both men and women have a similar need to be close. But the way in which many boys are raised and socialized in our society sometimes makes it difficult for them to recognize and acknowledge this. Boys want to be like their fathers and loved by them. Similarly, boys have normal and natural wishes to be close to and to feel loved by their mothers. Many men grow up wanting to be closer to their mother and father, yet some may feel they have to hold back to feel manly. Unfulfilled attachment needs can create a great deal of inner sadness or anger, which can continue into adulthood. For many males, a struggle with competence, independence, stoicism, and public performance can evolve, obscuring their ability to be responsive to those they love. They may have a strong drive to prove their competence. But even as they achieve competence, the urge to connect does not disappear.

The Changing Male Image

Attempts to describe behavior associated with male expectations often result in a series of negatives, such as men don’t cry, men don’t show their feelings, or men are never scared. Positive ways of describing masculine behavior have traditionally focused on characteristics such as physical strength, aggressiveness,
and independence. Cultural or ethnic expectations, socioeconomic success, individual achievement, and education level heavily influence the perception of male characteristics. Men who are married tend to live longer than men who are single. Does this mean that marriage is the healthiest form of relationship for men? Not necessarily. But it does mean that a stable, long-term relationship includes features that positively affect many men’s emotional and physical health. Role expectations for men in Western societies traditionally have emphasized protection and provision. In colonial times, physical strength was essential to survival. Along with these expectations was the premise that a man should hold a leadership position in the family and should be in charge of both household and community affairs. Many of these male role expectations remain today;
many men see themselves as the primary provider for their families. This view is often reinforced by their partners. However, cultural role expectations for men are changing. This has become a potential source of anxiety for both men and women. Some men may learn that providing financial support is not enough to satisfy their partner, although their ability to provide may still be used as a measure of both their worth and their suitability as a partner. Most women also expect to have emotional support, mutual respect, stability,
and a satisfying sexual life as part of their relationship. Working women expect greater participation by their partner in household chores and child rearing. Tension in marriage is often the result of different role expectations and unfulfilled needs. The role behaviors and values you learned during childhood may not
work in your relationship today. Men who remain well adjusted and healthy throughout life seem to have mastered the following values:
• intimacy achieving an interdependent, mutually responsible, committed relationship
• satisfying work—engaging in work that is valued and rewarding
• parenting accepting responsibility for the physical and emotional health and well-being of children
• leadership—taking responsibility for being a positive role model and inspiration to others

• integrity—following a code of moral values

Being a Father

In the past, fathers were expected to play a limited role in their childrens’ lives. Once a child was conceived, the father’s role was often defined primarily in terms of supporting the mother, both financially and emotionally. Often he was the major disciplinarian. Childcare was considered women’s work. The father’s
responsibility was to be a role model for his sons, to impart sexual knowledge to them at the appropriate time, and to be a good provider. He often represented the disciplined, serious side of life. Today, a new awareness of the importance of fathers is having a beneficial effect on the lives of children. Fathers are crucial to the emotional and intellectual growth of their children. Fathers contribute to the welfare of their families in
many different ways—providing financial support or assistance; providing emotional support for their partner; performing household and childcare tasks; nurturing a caring, committed relationship with their partner; and having frequent and positive personal contact with their children.

Bonding with Your Child

In the past, many fathers of newborns sometimes found it difficult to bond with their infants and to express their feelings. Today, however, most fathers are bonding with their children and playing a nurturing role in their lives. Most fathers want to be involved, even occasionally volunteering to stay home from work to spend more time with their baby. When fathers become involved during the pregnancy, delivery, and postpartum period, their involvement with and attachment to their infants are strong. The period immediately after delivery is especially conducive to the development of psychological ties between parents and their newborns. Fathers experience the same feelings of warmth, devotion, protectiveness, and pleasure at
physical contact with their children that mothers do.

Divorce

If your marriage fails, it does not mean that you are a failure or that your role as a father is diminished. Try not to let your contact with your children drop off after your divorce. Children are at risk when they grow up without their father. They are more likely than children who have regular contact with their fathers to have psychological problems, abuse drugs and alcohol, live in poverty, and fail in school. Almost half of all divorced fathers have not seen their children in the past year. Keep in mind that your child needs and wants your continued love and emotional support even if you are no longer living together as a family.


Blended Families 

A blended family, or stepfamily, includes a couple with one or more children from a previous relationship. Half of all people in the United States will experience a stepfamily relationship at some time in their lives as a stepparent, remarried parent, or stepchild. Children in blended families have strong emotional connections to a parent who lives in another household or to a parent who has died. In many cases, a child moves back and forth between two households that often have very different rules and expectations. This adjustment period can be even more stressful than a divorce or living in a single-parent home. Children may feel angry, anxious,
or depressed and worry that they won’t be able to have as much contact with either parent. Blended families in which both adults have children from previous relationships have the biggest problems to overcome. Children in these families may worry that their own parent will have less time to spend with them, that they will have to share their bedroom or possessions with a stepsibling they hardly know, or that their place in the family hierarchy will change. Rules and family routines may be different. All these new experiences can put stress on a child. He or she may display his or her feelings through disruptive behavior, or perform poorly in school. Give your child time to adjust to the situation, to become familiar with the new family members, and to get used to the working structure of the household. Stepfamilies who work together to solve problems eventually find a living arrangement they can all be happy with. Once you make it through the difficult early
years, you will probably find that being part of a stepfamily is an enriching, fulfilling experience. Here are some tips for helping to make living in a stepfamily rewarding for everyone involved:
• Put a priority on the couple relationship; a secure relationship between the two adults is essential for a successful blended family. In many stepfamilies, couples spend so much time dealing with child issues that they don’t nurture their own relationship.
• Agree with your partner on a few important rules and spell them out to the children. Always support each other in front of the children.
• Be patient in establishing a relationship with a stepchild—it takes time. And be cautious when taking on a parenting role, especially with a teenager, who may never accept you as a parent. Your stepchildren are more likely to treat you with respect and courtesy if you treat them the same way.
• Supervision of children is especially important in a blended family, especially when their ages vary. It can be tempting for an older child to stretch the rules with a younger or smaller stepsibling when the two are left alone.
• Have regular family meetings to discuss the week’s activities or any problems that might come up. Open communication helps establish healthy relationships among all family members.
• Take most of the responsibility for disciplining your own child. Give the stepparent time to establish a trusting relationship with your child before beginning to set rules for him or her. Discipline all children in the household equally and fairly.
• Resolve any personal differences between a stepparent and a stepchild or between stepsiblings promptly and directly; unresolved problems tend to get worse over time.
• Set aside time for one-on-one activities between family members. Stepchildren need to spend time alone with their parent; stepparents should do things alone with stepchildren; and the two adults should spend time alone with each other.
• Participate in a support group for stepfamilies. You’ll see that you are not alone and can learn a lot from the experiences of other stepfamilies.
• If your children are part of their other parent’s stepfamily, support that family and cooperate with both of the adults involved. Competition and tension between two households can cause the children to suffer emotionally.

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Stress Management

Doctors don’t know all of the ways that stress and illness are connected, but they do know that the central nervous system (the brain and the spinal cord) and the immune system can influence one another during stress. Short-term positive stress can be invigorating, stimulating us to respond positively to meaningful challenges and opportunities. Short-term negative stress can be life-saving, causing us to flee dangerous situations. The brain releases hormones into the bloodstream, causing the heart to beat faster, the face to flush, and the arm and leg muscles to tighten, allowing the person to run away or escape. Once the danger is over, the body repairs damaged areas and returns to its prestressed state. In long-term stress, the hormones continue to be released but the body does not have time to make repairs or to rest and recuperate. This is the type of stress that creates health problems. Under constant stress, a person becomes so conditioned to expect potential problems that his or her body tightens and remains in that state until the stress stops. Under this long-term stress state, the body can develop stress-related problems. Many connections between stress and chronic conditions are known. Stress increases blood levels of adrenaline and cortisol, two so-called stress hormones. Cortisol can suppress the immune system, making people more susceptible to infectious diseases such as colds and flu. The effects of stress on the circulatory system (a quicker pulse, narrowed blood vessels, and thickened blood) can make people more susceptible to heart rhythm irregularities, angina (chest pain), high blood pressure, and stroke. Muscles tighten as stress starts, often causing intense headaches, backaches, and gastrointestinal problems. Stress also can cause testosterone levels to decrease and blood vessels in the penis to constrict, often resulting in erection problems. The rush of hormones caused by a stressful situation can bring on an asthma attack in a person with a history of asthma. Stress also draws the blood supply away from the abdominal area and encourages overproduction of acids in the digestive system, often leading to indigestion and other gastrointestinal problems. Other problems related to stress include insomnia and irritability. The number of hours worked does not seem to cause as much stress as do two other occupational factors: lack of control and inadequate social support. Men who have little control over the demands of their jobs feel more stress than those who have more control. Men who also experience a low level of social support from coworkers have even more problems. What is stressful to one person may be relaxing to another. Some people, for example, like to keep busy all the time, while others need to take frequent breaks. Some people can keep track of multiple tasks, while others prefer to do tasks in sequence. If you are under stress, it is important to recognize it and deal with it in a positive way. Here are some tips to help you relieve stress:

• Exercise regularly. You can decrease stress and release tension through regular exercise or other physical activity. Running, walking, swimming, dancing, playing tennis, or working in your garden are some activities you may want to try.

• Talk about your stress. For example, talk to a friend, family member, teacher, or boss about what is bothering you. If that does not help to resolve the problem, consider seeking help from a professional therapist or counselor. Ask your doctor for a referral, or contact the employee assistance program at work.

• Know your limits. If a stressful situation gets beyond control, walk away. Return to deal with the situation when you have calmed down.

• Take care of yourself. Get plenty of rest and eat a healthy diet. If you feel irritable and tense from lack of sleep or if you are not eating properly, you will be less able to deal with stressful situations.

• Take time for yourself. Take a break from regular work and do something you enjoy. Just relax.

• Be a participant in life. Help yourself by helping others. Share your abilities with other members of your community by volunteering.

• Prioritize your tasks. To keep your schedule from overwhelming you, make a list of your tasks and check them off as you complete them.

• Be cooperative. If things do not go your way, try compromise rather than confrontation. A little give and take on both sides can help you meet your goals and make everyone feel better.

• Cry if you need to. Crying can be a healthy way to bring relief to your tension or anxiety.

• Create a quiet scene in your mind. You can’t always get away, but you can try closing your eyes and letting

your mind wander. A quiet country scene painted mentally can temporarily take you out of the turmoil of a stressful situation and help you to relax. Listening to beautiful music or reading a good book may help you achieve the same results.

• Avoid self-medication. When you need them, you can use prescription or over-the-counter medications to

relieve stress temporarily, but realize that they don’t remove the conditions that caused the stress in the first place. Becoming overly reliant on drugs or alcohol can only complicate matters in the long run. They may be habit forming, or they may interfere with your body’s ability to function normally.

• Learn to relax by using a specific relaxation strategy, such as meditation or deep-breathing exercises. Participate in activities you can enjoy without competing. Cycle, swim, or walk the dog. Forget about always

winning. Relaxation can stimulate the release of endorphin's brain chemicals that promote feelings of well-being. Relaxation strategies work by blocking conscious thoughts, resulting in decreased tension, lower heart and breathing rates, and slower metabolism. Several relaxation techniques, such as meditation, guided imagery, muscle relaxation, and deep breathing, can be used to relieve stress and bring on the relaxation response. If you feel that you are under severe or long-term stress, seek help immediately. Talk about your problems with your doctor. He or she can treat any stress related disorders you may have developed and will refer you to the appropriate mental health professional.

How to Get a Good Night’s Sleep

Sleep is a basic requirement for good health. The mind and the body need sleep to perform maintenance and repair. Even one night of disrupted or missed sleep can drastically alter a person’s chemical balance and cause daytime sleepiness and fatigue. The results of such sleep deprivation can reduce productivity as well as increase the chances of accidents at home or at work. Most adults need 7 to 8 hours of sleep each night, although sleep requirements may differ from one person to the next. For example, some people may feel rested after 5 or 6 hours of sleep, whereas others may still feel sleepy after 9 or more hours of sleep. In general, people tend to sleep less soundly as they age. They may wake up more frequently and have a harder time getting back to sleep. Many older men may find that they simply don’t need as much sleep as they did when they were younger. Overweight men may have problems getting a good night’s sleep. Snoring also may contribute to a loss of sleep. Sleep apnea (a condition characterized by brief episodes of interrupted breathing during sleep) is another common reason for losing sleep. Many people who have sleep apnea find it difficult to stay awake during the day. However, the most common reason for an occasional night of lost sleep is worry or anxiety. Here are some helpful tips for getting a good night’s sleep:

• Stick to a regular schedule for going to bed and getting up. Going to bed and getting up at the same time help set your biological clock.

• Do not sleep late on weekends, and avoid napping during the day.

• Make your bedroom exclusively a place for sleep and sex. This means no TV, work, or serious discussions while in bed. Keep your bedroom comfortable, dark, quiet, and not too warm (about 60 to 65 degrees Fahrenheit).

• Exercise during the day so your metabolism has slowed by bedtime and you are ready for sleep.

• Avoid stimulants such as caffeine, nicotine, and alcohol, and rich, heavy meals before bedtime.

• If you are not lactose intolerant, drink a warm glass of milk just before bedtime. But don’t drink so much that a full bladder disturbs your sleep.

• Have sex before bedtime; it may have a relaxing effect.

• Take a warm bath just before bedtime to help you relax.

• Set aside some quiet time about an hour or so before bedtime.

• If you still can’t fall asleep, get up and read or do a simple chore until you become tired.

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Physical and Emotional Health: How They Interact

Doctors are not sure exactly how physical and mental health influence each other, but growing scientific evidence suggests that the mind/body connection is real. For example, the so-called fight or flight response, in which the nervous system and the adrenal glands flood the body with the hormone adrenaline when you are frightened, increases both heart rate and blood flow to the muscles. This response prepares the body to deal with apparent danger. In this case, the survival response is helpful. However, when a person is under constant stress, the body steadily releases a hormone called cortisol, which can cause long-term damage to the brain and other organs. The harmful effects of this hormone include an increased tendency for blood to clot, a surge in the pressure on coronary arteries, increased blood pressure, and other demands on the heart and blood vessels. There has been a recent surge of interest in the mind/body connection by physicians to see if positive health effects can be obtained from relaxation techniques such as meditation. The increasing complexity and pace of life and the awareness that long-term stress has a negative physiological effect on the body have triggered the exploration of relaxation techniques. By combining knowledge of meditative techniques from Eastern cultures with Western scientific techniques, doctors have developed a form of meditation that may have positive effects on blood pressure and heart disease. Meditation appears to lower metabolism decreasing breathing rate, heart rate, and blood pressure. An understanding of the connection between the mind and the body becomes clearer as new techniques are found to examine and to measure the

nervous system’s subtle control over changes in the circulatory system. The positive response of the circulatory system to a variety of relaxation techniques, such as meditation and biofeedback, can now be explained partly in physiological terms. In addition to high blood pressure, meditation has been shown to benefit people who have chronic pain, tension headaches, asthma, insomnia, and other stress-related problems. Interest in the mind/body connection has now expanded into studying the possibility of using mental techniques to strengthen the immune system. The immune system fights germs such as viruses and eliminates cells that are damaged, are turning cancerous, or have become cancerous. Researchers are trying

to determine whether stress that accompanies major, life-changing events such as divorce or moving into a nursing home can lead to changes in the immune system that make people more vulnerable to infection, heart disease, or other illnesses. Factors that can contribute to a negative response of the immune system include whether a person feels in control of a given situation and whether a person feels lonely. One technique being tested to teach the immune system to work better is biofeedback, in which special instruments that measure the body’s vital signs amplify the signs that represent relaxation, in order to train the person to recognize and replicate them. Biofeedback is being used in studies of people with diabetes who are under stress; the aim is to substitute relaxation exercises for additional insulin injections needed to deal with the stress. Other research is focused on relieving chronic lower back pain and muscle pain. Guided imagery is a system that uses symbols to imagine the desired physical changes occurring in the body during the treatment of asthma and cancer. Some people who repeatedly imagine a healing process may be able to boost their immune system. For example, a person might imagine his or her healthy white blood cells as white knights on horses subduing a source of infection. Or a patient with cancer might see his or her white blood cells as a computer game, gobbling up the cancer cells. Some people with AIDS (acquired immunodeficiency syndrome) or with cancer use complementary therapies such as meditation and massage to supplement their medical and surgical treatments. Keep in mind, however, that few alternative and complementary therapies have been proven safe and effective through rigorous scientific testing, and some can be very expensive. If you are thinking about trying an alternative treatment, talk to your doctor. Some therapies can be harmful, especially if you forgo conventional medical treatment for a serious illness. Never stop taking a prescription medication unless your doctor tells you to.

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Emotional Health and Well-being

As a boy, you were probably taught not to cry, but to act tough and “be a man.” Although attitudes are changing in our society, many males are still brought up not to express their emotions, learning that any display of feeling (other than anger) is a sign of weakness. While living up to the traditional, aggressive masculine identity may give a man certain advantages in a competitive society, it also can explain why the rates of substance abuse, domestic violence, homicide, suicide, sexual abuse, automobile accidents, and stress-related chronic illness are higher in men than in women. If a man has not learned to properly deal with

and express his emotions, then stressful situations may lead to inappropriate responses such as anger or violence. If you have a son, it’s important to teach him not to shut down his feelings, because such an emotional disconnection can lead to a lack of empathy, sympathy, and the ability to express himself productively. This stereotypical male image, combined with exposure to violent television programs, movies, and video games, may promote violent and remorseless behavior in boys. It also can lead to an emotional disorder such as depression. Remember that your son needs your time and understanding. Spend as much time with him as you can and encourage him to be caring rather than tough. Don’t force him to suppress his

emotions. Instead, tell him it’s okay to cry and teach him by example to feel empathy for other people. Fortunately, there are many hopeful signs for men with an emotional disorder, including new ways of diagnosing emotional problems and more effective methods of treating them. The social stigma once linked to emotional problems has lessened considerably as medical science has come to understand the biological basis of these disorders. Of course, not all emotional problems can be classified as a disorder. We all feel stress to varying degrees in a variety of situations. In terms of major stresses, men are just as likely as women to undergo an emotional upheaval during a time of divorce or from the loss of a job. The death of a spouse or parent will trigger a natural and extended period of bereavement as a man comes to grips with the loss of his life partner or family member. The best way to ensure your own emotional health is to find practical ways to handle stress and restrain your feelings of anger. This section will give you important information about stress management and the control of anger. In the final analysis, your emotional health is more under your own control than you think. The key is learning effective ways to exercise this control.

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