Heart Valve Disorders

The heart has four chambers two small upper chambers (atria) and two larger lower chambers (ventricles). Each chamber is closed by a one-way valve. For various reasons these valves can malfunction, causing leakage (regurgitation) or failure to open properly (stenosis). The mitral valve, which allows blood to flow

from the left atrium to the left ventricle (the main pumping chamber of the heart), and the aortic valve, which allows blood to flow from the left ventricle to the aorta (the main artery of the body), are the most common sites for valve disease. These valves are under great strain from the powerful contractions of the left ventricle, which pumps blood throughout most of the body.

Mitral Valve Prolapse

Mitral valve prolapse is the most common valve disorder. Usually it is an inherited structural defect. The two parts, or leaflets, of the mitral valve thicken, preventing them from coming together properly. The leaflets bulge back into the left atrium as the ventricle contracts, allowing small amounts of blood to leak back

into the atrium. Prolapse is a term that means slippage out of position; in this case the valve leaflets have difficulty being in their correct position because they are too thick.

Most people with mitral valve prolapse experience no symptoms. Others may have a wide range of symptoms such as chest pain, palpitations (an awareness of one’s heartbeat), migraine headaches, dizziness, and fatigue that cannot be explained by the valve problem alone. Physicians diagnose mitral valve prolapse by using a stethoscope to listen to the characteristic clicking sound produced by the valves as they hit against one another. The condition also produces a heart murmur, or slight rushing sound, that the physician hears through the stethoscope when the heart contracts. Echocardiography (an ultrasound examination of the heart) allows a doctor to view the prolapse and determine its severity.

Most people with mitral valve prolapse do not need treatment. When symptoms such as extra heartbeats, a rapid heartbeat, or chest pain become bothersome, medications are prescribed to control them. In rare cases, when leakage becomes severe, surgical repair or valve replacement may be required. People with mitral valve prolapse are usually given antibiotics before dental or surgical procedures to decrease the risk that bloodborne bacteria will infect the heart valve.

Mitral Valve Regurgitation

Mitral valve regurgitation, also called mitral incompetence or mitral insufficiency, is leakage of blood back through the mitral valve into the left atrium each time the left ventricle contracts. This increases the volume and pressure in the left atrium, which, in turn, increases blood pressure in the vessels leading from the lungs to the heart. This results in lung congestion (fluid buildup). In the past, rheumatic fever was the most common cause of this condition. But with the advent of antibiotics, rheumatic fever is now rare in the United States, and the few cases that are seen are primarily in older people who had rheumatic fever in childhood. A more common cause of mitral valve regurgitation today is a heart attack, which can damage the supporting structures of the mitral valve. Mild cases of mitral valve regurgitation may not cause any symptoms. The condition may be recognized during a routine chest examination with a stethoscope, when a doctor hears a distinctive heart murmur caused by the blood leaking back into the left atrium when the left ventricle contracts. Diagnosis usually is confirmed by electrocardiography (ECG; an examination of the electrical activity of the heart) and chest X rays that indicate the left ventricle is enlarged. Echocardiography (an ultrasound examination of the heart) can produce an image of the faulty valve and indicate the severity of the problem. Since the left ventricle has to pump more blood to make up for the blood leaking back into the atrium, it gradually enlarges to increase the force of each heartbeat. The enlarged ventricle may cause palpitations (awareness of one’s heartbeat), which is particularly noticeable when the person lies on his left side. The left atrium also tends to enlarge to accommodate the extra blood leaking back from the ventricle. A very enlarged atrium often beats rapidly in an irregular fashion (atrial fibrillation). This reduces the heart’s pumping efficiency, and the lack of proper blood flow through the atrium allows blood clots to form. If a clot becomes detached, it may be pumped out of the heart and block a smaller artery elsewhere in the body, possibly causing a stroke or other damage. Finally, severe regurgitation reduces the forward flow of blood, causing heart failure, which may lead to coughing, swollen legs, or shortness of breath on exertion. Treatment for this condition can take several forms. Repairing the valve can either eliminate or reduce the regurgitation enough to make the symptoms tolerable and prevent heart damage. Atrial fibrillation accompanying mitral valve regurgitation is usually treated with medications that slow the heart rate and help control the fibrillation. In severe cases, the valve may be replaced surgically.

Mitral Valve Stenosis

Mitral valve stenosis is a narrowing of the mitral valve opening that increases resistance to blood flow from the left atrium to the left ventricle. This resistance causes pressure to build up in the atrium; the pressure then backs up through the veins of the lungs, causing increased pressure and congestion in the lungs. The increased stress on the lungs can lead to shortness of breath and eventually to congestive heart failure. Typically, the valve leaflets fuse together. Surgery is needed to widen or replace the valve. Mitral valve stenosis is almost always the result of rheumatic fever, which is rare today in the United States, where most cases occur in older people who had rheumatic fever during childhood. However, rheumatic fever can sometimes occur after an untreated “strep” throat infection (infection with streptococcal bacteria). Mitral valve stenosis also can be congenital (present from birth). Infants born with this condition rarely live beyond age 2 unless they have surgery to correct the condition.

If stenosis is severe, blood pressure increases in the left atrium and in the veins in the lungs, resulting in heart failure and an accumulation of fluid in the lungs (pulmonary edema). A person with heart failure easily becomes fatigued and short of breath. At first, shortness of breath may occur only during physical activity. Later the symptoms may occur even during rest. Some people find that they can breathe comfortably only when they are propped up with pillows or sitting upright.

Some people with mitral valve stenosis have a plum-colored flush in their cheeks. High blood pressure in the veins of the lungs may cause a small vein or tiny capillaries to burst and bleed slightly or massively into the lungs. Enlargement of the left atrium can result in atrial fibrillation (an abnormally fast heartbeat). To diagnose mitral valve stenosis, a physician uses a stethoscope to listen for a characteristic heart murmur as blood rushes through the narrowed valve from the left atrium. Unlike a normal valve, which opens silently, a valve

affected by mitral valve stenosis often makes a snapping sound as it opens to allow blood into the left ventricle. The diagnosis of mitral valve stenosis is usually confirmed by electrocardiography (ECG; an examination of the electrical activity of the heart), a chest X ray showing an enlarged atrium, or echocardiography (an ultrasound examination of the heart). Sometimes cardiac catheterization (a diagnostic test in which a thin, flexible tube is inserted into the heart through a blood vessel, to examine the heart) is performed to determine the extent and characteristics of the valve blockage. Treatment for mitral valve stenosis may include a variety of drugs. Betablockers, digoxin, and verapamil are used to slow the heart rate and control atrial fibrillation. Digoxin also strengthens the heartbeat if heart failure occurs. Diuretics are often prescribed to reduce the blood pressure in the lungs by reducing the volume of circulating blood. If medication does not reduce the symptoms adequately, surgical valve repair or replacement may be needed. People with mitral valve stenosis are given antibiotics before dental and surgical procedures to reduce the risk of a heart valve infection.

Aortic Stenosis

Aortic stenosis is an abnormal narrowing or stiffening of the aortic valve, which controls the flow of blood from the left ventricle to the aorta (the main artery of the body). As the valve narrows, the left ventricle has to beat harder to push the blood through the aorta and out into the body. The most common cause of aortic

stenosis is the gradual buildup of calcium deposits on the valve, a natural consequence of aging. Although this condition may appear at about age 60, it usually does not produce symptoms until age 70 or 80. Aortic stenosis also may result from childhood rheumatic fever. When rheumatic fever is the cause, aortic stenosis

usually is accompanied by mitral valve stenosis, mitral valve regurgitation, or both. In aortic stenosis, as the ventricle attempts to pump enough blood through the narrowed aortic valve, the left ventricle wall thickens, and the enlarged heart muscle requires an increasing blood supply from the coronary arteries. Eventually the blood supply to the heart becomes insufficient, causing angina (chest pain) on exertion. An insufficient blood supply can damage the heart muscle, reducing its ability to pump blood through the body. This reduced functioning can lead to congestive heart failure. A person with severe aortic stenosis may faint on exertion because the narrow valve prevents the ventricle from pumping enough blood out of the heart to the rest of the body. In diagnosing aortic stenosis, a physician will listen for the characteristic heart murmur through a stethoscope, note abnormalities in the pulse and electrical activity of the heart, and look for an enlarged heart as revealed by a chest X ray. Electrocardiography (ECG; an examination of the electrical activity of the heart), echocardiography (an ultrasound examination of the heart), and cardiac catheterization (a diagnostic test in which a thin, flexible tube is inserted into the heart through a blood vessel, to examine the heart) may be used to determine the severity of the stenosis. In adults with fainting, angina, and shortness of breath on exertion caused by aortic stenosis, the aortic valve is surgically replaced, preferably before the left ventricle is damaged beyond repair.

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Preventing High Blood Pressure

Anyone, regardless of age, sex, race, or heredity, can lower his or her risk of developing high blood pressure

or lower existing high blood pressure by taking the steps described here. Maintain a healthy weight. As your body weight increases, your blood pressure rises. In fact, being overweight can make you two to six times more likely to develop high blood pressure than if you maintain a desirable weight. It’s not just how much you weigh that is important; it also matters where your body stores excess fat. Your body shape is inherited from your parents, just like the color of your eyes and hair. Some people tend to store fat around their waists, while others store fat around the hips and thighs. “Apple-shaped” people who store extra fat at the waist appear to have higher health risks than “pear-shaped” people who store fat around the hips and thighs.

No matter where your extra weight is located, you can reduce your risk of developing high blood pressure by losing weight. Even a small weight loss can make a big difference. And if you are overweight and already have high blood pressure, losing weight can help you lower your blood pressure. To lose weight, you need to consume fewer calories than you burn. But don’t try to lose weight too quickly. The healthiest way to lose weight and keep it off is to do it gradually, by losing about a pound a week. By taking in 500 calories less per day and being more physically active, you should be able to lose about a pound (which equals 3,500 calories) a week. Losing weight and keeping it off involves making permanent lifestyle changes. Here’s how to eat healthfully and lose weight:

• Choose foods that are low in calories, sugar, and fat. Naturally, choosing lowcalorie foods cuts calories. But choosing foods low in fat also can cut calories. Fat is a concentrated source of calories, so eating fewer fatty foods will help reduce your calorie intake. Cutting back on butter, margarine, fatty salad dressings, fatty meats, skin on poultry, full-fat dairy products such as milk and cheese, fried foods, and sweets will also improve your cholesterol profile.

• Choose foods that are high in fiber. These include fruits; vegetables; wholegrain foods such as cereal, pasta, and bread; and dried peas and beans. Foods high in fiber are excellent substitutes for foods high in fat. The former are lower in calories and are a good source of essential vitamins and minerals.

• Limit serving sizes. When trying to lose weight, it’s not just the types of foods you eat, but how much you eat. To take in fewer calories, you need to limit your portion sizes. Try especially to take smaller helpings of high-calorie foods such as fatty meats and cheeses. And try not to go back for seconds. Today many restaurants take pride in serving large portions of food. This does not mean that you have to clean your plate. Choose the doggy-bag option; eat only half of what you are served and take the rest home for an excellent “free meal” the next day.

• Keep track of what you eat, when you eat, and why you eat. Write it down. Note whether you snack on high-calorie foods while watching television or if you skip breakfast and then eat a large lunch. Once you clearly see your eating habits, you can set goals for yourself—for example, cutting back on TV snacks or, when you do snack, having fresh fruit, low-fat or air-popped popcorn, or vegetables such as carrots and celery. If there’s no time to eat breakfast at home, take fruit, a bagel (skip the cream cheese), or whole-grain cereal with you to eat at work. Changing your eating habits will help you change your weight. Exercise regularly. Another way to lose weight and control blood pressure is through regular physical activity. Cutting down on fat and calories combined with regular exercise can help you lose more weight and keep it off longer than with either diet or exercise alone. Aerobic exercise provides added benefits. It helps improve the fitness of your heart, blood vessels, and lungs, which, in turn, protects you against heart disease. Activities such as stair climbing, bicycling, swimming, brisk walking, running, and jumping rope are called “aerobic,” which means that the body uses oxygen to make the energy it needs during the activity. Aerobic activities provide health benefits if done at the right intensity for at least 20 to 30 minutes, three to four times per week. If you think you don’t have time to exercise, try to exercise for two 15-minute periods or even three 10-minute periods during your day. You will still gain health benefits.

You need to see your doctor before starting an exercise program if you:

• have a health problem such as high blood pressure

• have angina (chest pain)

• tend to feel dizzy or faint

• have difficulty breathing after a mild workout

• are middle-aged or older and have not been active

• are planning a vigorous exercise program Otherwise, get up off the couch, get out, get active, and get fit.

Choose foods that are lower in salt. Most Americans take in more salt (sodium) than they need, which may help explain why the United States has higher rates of high blood pressure than countries where people eat less salt. Salt attracts water. Normally, if you have eaten too much salt, your kidneys eliminate the excess salt from your body along with a certain amount of water. But if your kidneys cannot get rid of the extra salt, your body retains the water that clings to the salt, which raises blood volume and, in some people, blood pressure. Certain people appear to be salt-sensitive, which means that their blood pressure goes up when they eat salt. Researchers think that about half of all people with high blood pressure are salt-sensitive and that as many as 70 to 80 percent of blacks are salt-sensitive. Other groups that seem to have a high incidence of salt sensitivity are older people, people who have diabetes, and people who are overweight. There is a good chance that if you are a member of one or more of these groups, decreasing your salt intake would be beneficial to your health. Research suggests that the average person needs only about 200 milligrams of sodium per day. Doctors recommend that people with high blood pressure take in no more than about 6 grams of salt per day, which equals about 2,400 milligrams of sodium, or about 1 teaspoon of table salt. A teaspoon of salt may seem like a lot to you, but remember that this refers to total salt intake for a day. This includes salt in processed and prepared foods, salt added during cooking, and salt sprinkled on food at the table. Americans eat an average of 4,000 to 6,000 milligrams of sodium each day, so many people could probably benefit from cutting back on their salt intake. The key to cutting back on salt is in teaching your taste buds to enjoy less salty foods. Here are a few tips for cutting back on salt:

• Check food labels for the amount of salt in the foods you buy. Choose foods that are low in sodium. Look for labels that say “sodium-free,” “very low in sodium,” “low sodium,” “light in sodium,” “reduced sodium,” “less sodium,” or “unsalted.” Then check the label for the amount of sodium per serving.

• Choose fresh or frozen vegetables, or canned vegetables labeled “no salt added.” Choose fresh poultry, fish, and lean meat rather than canned, cured, smoked, or processed varieties.

• Use herbs, spices, salt-free seasoning blends, and lemon juice instead of salt to add flavor to your food.

• Cook rice, pasta, and hot cereals without salt. Avoid using instant or flavored rice, pasta, and cereal mixes because they usually have added salt.

• Choose “convenience” foods that are low in sodium. Cut back on frozen dinners, packaged dinners such as macaroni and cheese, packaged mixes, canned soups or broths, and salad dressings, which often contain large amounts of sodium.

• Buy low-sodium, reduced-sodium, or no-salt-added versions of canned soups, dried soup mixes, or bouillon; canned vegetables and vegetable juices; low-fat cheeses; margarine; condiments such as ketchup or soy sauce; crackers and baked goods; processed lean meats; and snack foods such as chips, pretzels, and nuts.

• Rinse canned foods, such as tuna, to remove excess sodium. Drink alcoholic beverages only in moderation. Drinking too much alcohol can lead to the development of high blood pressure. To prevent high blood pressure, or if you already have high blood pressure, limit yourself to no more than two drinks per day. A drink is defined as 11⁄2 ounces of 80-proof distilled spirits, 5 ounces of wine, or 12 ounces of beer (regular or “lite”). Do not use tobacco. Although it is not a direct cause of high blood pressure, smoking puts you at risk of developing the disease. The chemicals in tobacco smoke can damage the artery walls, making them more susceptible to plaque formation. Plaques narrow the arteries and interfere with blood flow to the heart,

brain, and other organs and tissues. Blood clots can form on the rough surface of a plaque. A blood clot or plaque can block an artery, causing a heart attack or a stroke. The nicotine in tobacco is a powerful stimulant that causes the heart rate to increase, the arteries to constrict, and blood pressure to rise. Smoking also affects cholesterol levels in the blood: it can increase LDL (“bad” cholesterol) levels and decrease HDL (“good” cholesterol) levels. All of these tobacco induced effects can contribute to the development of high blood pressure. Although it is sometimes promoted as a smoke-free alternative to cigarettes and cigars, smokeless tobacco also puts you at risk of developing high blood pressure. The nicotine, sodium, and licorice contained in smokeless tobacco products all can raise blood pressure. Considering these health risks, it makes sense to give up your tobacco habit now. Here are some other factors that may help prevent high blood pressure:

• Potassium. A certain amount of potassium is essential for proper body function. Eating foods rich in potassium may help protect some people from developing high blood pressure. Many people get enough potassium from eating fruits, vegetables, dairy products, and fish, so potassium supplements are rarely needed. Too much potassium can disturb your heart rhythm.

• Calcium. People with low calcium intake have higher rates of high blood pressure. It is best to get the calcium you need 1,000 to 1,500 milligrams per day for adult men from the foods you eat. Low-fat and nonfat dairy products such as milk, yogurt, and cheese are excellent sources of calcium. It has not been proven that taking calcium supplements helps prevent high blood pressure.

• Magnesium. A diet low in magnesium may make your blood pressure rise. However, doctors do not recommend taking magnesium supplements to help prevent high blood pressure. The amount of magnesium you get in a healthy diet is enough. Magnesium is found in whole grains; green, leafy vegetables; nuts; seeds; and dried peas and beans.

• Fish oils. A type of fat called omega-3 fatty acids is found in fatty fish such as mackerel and salmon. Evidence suggests that eating fish at least twice a week can help reduce high blood pressure. Talk to your doctor if you are considering taking fish oil supplements. Most fish, if not fried or prepared with added

fat, are low in saturated fat and calories and are a good source of essential nutrients.

• Fats, carbohydrates, and protein. Varying the amount and type of fats, carbohydrates, and protein in the diet has little if any effect on blood pressure. But for overall heart health, it is crucial to limit the amount of fat in your diet, especially the saturated fat found in foods such as fatty meats and full-fat dairy products. Saturated fats raise your blood cholesterol level, and a high cholesterol level is another risk factor for heart disease. Foods high in fat are usually also high in calories. Foods high in complex carbohydrates (starch and fiber) are often low in fat and calories so eat these foods in moderate amounts instead of eating high-fat foods. Always check food labels.

• Caffeine. The caffeine found in coffee, tea, and colas may cause blood pressure to rise, but only temporarily. In a short time your blood pressure will return to its previous level. Unless you are sensitive to caffeine, you do not have to limit caffeine intake to prevent high blood pressure.

• Garlic and onions. Increased amounts of garlic and onions have not been found to affect blood pressure. Of course, they are rich in antioxidants and are tasty substitutes for salty seasonings.

• Stress management. Stress can make blood pressure go up for a while and over time may contribute to high blood pressure. Stress management techniques such as biofeedback, meditation, and relaxation can help you to deal positively with the stress-producing events in your life, and may help you control your blood pressure.

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High Blood Pressure

High blood pressure, or hypertension, increases your chances of developing heart disease or kidney disease and of having a stroke. About one in every four American adults has high blood pressure but may not be aware of it. It is often called “the silent killer” because it usually causes no symptoms. However, high blood pressure is easy to diagnose, and there are practical steps you can take to bring your blood pressure under control. Blood pressure is the force of blood pushing against the walls of the arteries that carry blood throughout your body. It is measured in millimeters of mercury, or mm Hg, using an instrument called a sphygmomanometer (pronounced sfig'mo-mah-nom'e-ter). Blood pressure is highest when the heart contracts (beats) and pumps blood into the arteries. This is called the systolic pressure. Between beats, when the heart is resting, the pressure falls. This is called the diastolic pressure. A blood pressure reading is always given as a combination of these two pressures; the high (systolic) pressure is written above or before the low (diastolic) pressure. For example, if your blood pressure reading is 120 over 70, it is written as 120/70 mm Hg; 120 is the systolic pressure, and 70 is the diastolic pressure. 

Different activities make your blood pressure rise or fall. For example, normally, blood pressure rises when you are exercising and falls when you are resting. A blood pressure reading of 140/90 mm Hg or lower is generally considered normal. High blood pressure is classified according to guidelines that reflect the levels at which blood pressure begins to pose significant health risks. The guidelines for classifying blood pressure are shown in the following table:

A diagnosis of high blood pressure is based on two or more blood pressure readings taken at separate visits to the doctor’s office. If your systolic pressure falls into one category and your diastolic pressure into another, the higher reading will be used to classify your blood pressure. For example, a blood pressure of 160/90 mm Hg would be classified as stage II. A reading of 170/120 mm Hg would be classified as stage III. Because diastolic pressure represents the lower and more constant level of pressure in the arteries, physicians may emphasize it more, especially in younger people. However, the systolic blood pressure is more important for determining the risk of heart attack or stroke. People with high blood pressure have elevated blood pressure most of the time. Their blood is pushing against the walls of their arteries with higher than normal force. If left untreated, high blood pressure can lead to:

• Atherosclerosis. Uncontrolled high blood pressure causes the artery walls to thicken and lose elasticity. This encourages formation of fatty deposits on the artery wall, which narrow the channel and interfere with blood flow throughout

the body. In time, atherosclerosis can lead to a heart attack or a stroke.

• Enlarged heart. High blood pressure causes the heart to work harder. Over time this causes the heart muscle to thicken and stretch. The heart becomes less efficient and has to work harder and harder to pump blood throughout the body. Eventually this can result in heart failure.

• Kidney damage. The kidneys act as filters to rid the body of wastes. Over a number of years, high blood pressure can narrow and thicken the blood vessels of the kidneys. The kidneys then filter less blood, and waste builds up in the bloodstream. This could lead to kidney failure. When kidney failure occurs, dialysis (a technique to remove waste products from the blood and excess fluids from the body) or a kidney transplant may be necessary.

• Stroke. High blood pressure can weaken the walls of the arteries or cause them to thicken. A weakened artery wall in the brain could break, causing a hemorrhage. If a blood clot blocks one of the narrowed arteries, a stroke may occur. In most cases, the cause or causes of high blood pressure are unknown. This type is known as primary or essential hypertension. Primary hypertension cannot be cured, but it can be controlled. Secondary hypertension is caused by, or is “secondary” to, another disease. For example, some cases of high blood pressure can be traced to tumors of the adrenal gland, chronic kidney disease, or hormone abnormalities. Secondary hypertension can be cured by treating its underlying cause.

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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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