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Additionally erectile dysfunction before 30 purchase on line extra super cialis, the declining levels of estrogen may make a woman more susceptible to environmental fac to rs and stressors which disrupt sleep erectile dysfunction treatment herbal remedy buy extra super cialis 100mg. It often produces sweat and a change of temperature that can be disruptive to sleep and comfort levels erectile dysfunction doctor in los angeles discount 100 mg extra super cialis with visa. Unfortunately impotence cures natural order extra super cialis without a prescription, it may take time for adrenaline to recede and allow sleep to occur again (National Sleep Foundation what is an erectile dysfunction pump order genuine extra super cialis on-line, 2016) erectile dysfunction age 29 order 100 mg extra super cialis with visa. The loss of estrogen also affects vaginal lubrication which diminishes and becomes waterier and can contribute to pain during intercourse. Estrogen is also important for bone formation and growth, and decreased estrogen can cause osteoporosis resulting in decreased bone mass. Depression, irritability, and weight gain are often associated with menopause, but they are not menopausal (Avis, Stella to & Crawford, 2001; Rossi, 2004). Weight gain can occur due to an increase in intra-abdominal fat followed by a loss of lean body mass after menopause (Morita et al. Depression and mood swings are more common during menopause in women who have prior his to ries of these conditions rather than those who have not. Additionally, the incidence of depression and mood swings is not greater among menopausal women than non-menopausal women. Hormone Replacement Therapy: Concerns about the effects of hormone replacement has changed the frequency with which estrogen replacement and hormone replacement therapies have been prescribed for menopausal women. Most women do not have symp to ms severe enough to warrant estrogen or hormone replacement therapy. If so, they can be treated with lower doses of estrogen and moni to red with more frequent breast and pelvic exams. These include avoiding caffeine and alcohol, eating soy, remaining sexually active, practicing relaxation techniques, and using water-based lubricants during intercourse. Menopause and Ethnicity: In a review of studies that mentioned menopause, symp to ms varied greatly across countries, geographic regions, and even across ethnic groups within the same region (Palacios, Henderson, & Siseles, 2010). After controlling for age, educational level, general health status, and economic stressors, white women were more likely to disclose symp to ms of depression, irritability, forgetfulness, and headaches compared to women in the other racial/ethnic groups. African American women experienced more night sweats, but this varied across research sites. Finally, Chinese American and Japanese American reported fewer menopausal symp to ms when compared to the women in the other groups. Overall, the Chinese and Japanese group reported the fewest symp to ms, while 325 white women reported more mental health symp to ms and African American women reported more physical symp to ms. Further, the prevalence of language specific to menopause is an important indica to r of the occurrence of menopausal symp to ms in a culture. Hmong tribal women living in Australia and Mayan women report that there is no word for "hot flashes" and both groups did not experience these symp to ms (Yick-Flanagan, 2013). When asked about physical changes during menopause, the Hmong women reported lighter or no periods. They also reported no emotional symp to ms and found the concept of emotional difficulties caused by menopause amusing (Thurs to n & Vissandjee, 2005). Similarly, a study with First Nation Source women in Canada found there was no single word for "menopause" in the Oji-Cree or Ojibway languages, with women referring to menopause only as "that time when periods s to p" (Madden, St Pierre-Hansen & Kelly, 2010). While some women focus on menopause as a loss of youth, womanhood, and physical attractiveness, career-oriented women tend to think of menopause as a liberating experience. Japanese women perceive menopause as a transition from motherhood to a more whole person, and they no longer feel obligated to fulfill certain expected social roles, such as the duty to be a mother (Kagawa-Singer, Wu, & Kawanishi, 2002). Overall, menopause signifies many different things to women around the world and there is no typical experience. Erectile dysfunction refers to the inability to achieve an erection or an inconsistent ability to achieve an erection (Swierzewski, 2015). Plaque is made up of fat, cholesterol, calcium and other substances found in the blood. If tes to sterone levels decline significantly, it is referred to as andropause or late-onset hypogonadism. Identifying whether tes to sterone levels are low is difficult because individual blood levels vary greatly. Low tes to sterone is also associated with medical conditions, such as diabetes, obesity, high blood pressure, and testicular cancer. Most men with low tes to sterone do not have related problems (Berkeley Wellness, 2011). For women, decreased sexual desire and pain during vaginal intercourse because of menopausal changes have been identified (Schick et al. A woman may also notice less vaginal lubrication during arousal which can affect overall pleasure (Carroll, 2016). Men may require more direct stimulation for an erection and the erection may be delayed or less firm (Carroll, 2016). As previously discussed men may experience erectile dysfunction or experience a medical conditions (such as diabetes or heart disease) that impact sexual functioning. Couples can continue to enjoy physical intimacy and may engage in more foreplay, oral sex, and other forms of sexual expression rather than focusing as much on sexual intercourse. Risk of pregnancy continues until a woman has been without menstruation for at least 12 months, however, and couples should continue to use contraception. People continue to be at risk of contracting sexually transmitted infections, such as genital herpes, chlamydia, and genital warts. Practicing safe sex is important at any age, but unfortunately adults over the age of 40 have the lowest rates of condom use (Center for Sexual Health Promotion, 2010). Hopefully, when partners understand how aging affects sexual expression, they will be less likely to misinterpret these changes as a lack of sexual interest or displeasure in the partner and more able to continue to have satisfying and safe sexual relationships. Brain Functioning the brain at midlife has been shown to not only maintain many of the abilities of young adults, but also gain new ones. Some individuals in middle age actually have improved cognitive functioning (Phillips, 2011). The brain continues to demonstrate plasticity and rewires itself in middle age based on experiences. Research has demonstrated that older adults use more of their brains than younger adults. In fact, older adults who perform the best on tasks are more likely to demonstrate bilateralization than those who perform worst. Additionally, the amount of white matter in the brain, which is responsible for forming connections among neurons, increases in to the 50s before it declines. Emotionally, the middle aged brain is calmer, less neurotic, more capable of managing emotions, and better able to negotiate social situations (Phillips, 2011). Older adults tend to focus more on positive information and less on negative information than those younger. Lastly, adults in middle adulthood make better financial decisions, which seems to peak at age 53, and show better economic understanding. Although greater cognitive variability occurs among middle adults when compared to those both younger and older, those in midlife with cognitive improvements tend to be more physically, cognitively, and socially active. One distinction in specific intelligences noted in adulthood, is between fluid intelligence, which refers to the capacity to learn new ways of solving problems and performing activities quickly and abstractly, and crystallized intelligence, which refers to the accumulated knowledge of the world we have acquired throughout our lives (Salthouse, 2004). These intelligences are distinct, and crystallized intelligence increases with age, while fluid intelligence tends to decrease with age (Horn, Donaldson, & Engstrom, 1981; Salthouse, 2004). Research demonstrates that older adults have more crystallized intelligence as reflected in semantic knowledge, vocabulary, and language. As a result, adults generally outperform younger people on measures of his to ry, geography, and even on crossword puzzles, where this information is useful (Salthouse, 2004). It is this superior knowledge, combined with a slower and more complete processing style, along with a more sophisticated understanding of the workings Figure 8. The differential changes in crystallized versus fluid intelligence help explain why older adults do not necessarily show poorer performance on tasks that also require experience. A young chess player may think more quickly, for instance, but a more experienced chess player has more knowledge to draw on. Seattle Longitudinal Study: the Seattle Longitudinal Study has tracked the cognitive abilities of adults since 1956. Every seven years the current participants are evaluated, and new individuals are also added. Approximately 6000 people have participated thus far, and 26 people from the original group are still in the study to day. Current results demonstrate that middle-aged adults perform better on four out of six cognitive tasks than those same individuals did when they were young adults. However, numerical computation and perceptual speed decline in middle and late adulthood (see Figure 8. According to Phillips (2011) researchers tested pilots age 40 to 69 as they performed on flight simula to rs. Older pilots to ok longer to learn to use the simula to rs but performed better than younger pilots at avoiding collisions. When in a state of flow, the individual is able to block outside distractions and the mind is fully open to producing. Additionally, the person is achieving great joy or intellectual satisfaction from the activity and accomplishing a goal. Further, when in a state of flow, the individual is not concerned with extrinsic rewards. Csikszentmihalyi (1996) used his theory of flow to research how some people exhibit high levels of creativity as he believed that a state of flow is an important fac to r to creativity (Kaufman & Gregoire, 2016). Other characteristics of creative people identified by Csikszentmihalyi (1996) include curiosity and drive, a value for intellectual endeavors, and an ability to lose our sense of self and feel a part of something greater. In addition, he believed that the to rtured creative person was a myth and that creative people were very happy with their lives. According to Nakamura and Csikszentmihalyi (2002) people describe flow as the height of enjoyment. Tacit knowledge is knowledge that is pragmatic or practical and learned through experience rather than explicitly taught, and it also increases with age (Hedlund, An to nakis, & Sternberg, 2002). It does not involve academic knowledge, rather it involves being able to use skills and to problem-solve in practical ways. Tacit knowledge can be unders to od in the workplace and used by blue collar workers, such as carpenters, chefs, and hair dressers. In fact, the rate of enrollment for older Americans entering college, often part-time or in the evenings, is rising faster than traditionally aged students. Students over age 35, accounted for 17% of all college and graduate students in 2009, and are expected to comprise 19% of that to tal by 2020 (Holland, 2014). In some cases, older students are developing Source skills and expertise in order to launch a second career, or to take their career in a new direction. Whether they enroll in school to sharpen particular skills, to re to ol and reenter the workplace, or to pursue interests that have previously 331 been neglected, older students tend to approach the learning process differently than younger college students (Knowles, Hol to n, & Swanson, 1998). The mechanics of cognition, such as working memory and speed of processing, gradually decline with age. However, they can be easily compensated for through the use of higher order cognitive skills, such as forming strategies to enhance memory or summarizing and comparing ideas rather than relying on rote memorization (Lachman, 2004). Although older students may take a bit longer to learn material, they are less likely to forget it quickly. Older adults have the hardest time learning material that is meaningless or unfamiliar. Older adults are more task-oriented learners and want to organize their activity around problem-solving. Results indicated that older students were more independent, inquisitive, and motivated intrinsically compared to younger students. Additionally, older women processed information at a deeper learning level and expressed more satisfaction with their education. To address the educational needs of those over 50, the American Association of Community Colleges (2016) developed the Plus 50 Initiative that assists community college in creating or expanding programs that focus on workforce training and new careers for the plus-50 population. Since 2008 the program has provided grants for programs to 138 community colleges affecting over 37, 000 students. The participating colleges offer workforce training programs that prepare 50 plus adults for careers in such fields as early childhood educa to rs, certified nursing assistants, substance abuse counselors, adult basic education instruc to rs, and human resources specialists. These training programs are especially beneficial as 80% of people over the age of 50 say they will retire later in life than their parents or continue to work in retirement, including in a new field. Gaining Expertise: the Novice and the Expert Expertise refers to specialized skills and knowledge that pertain to a particular to pic or activity. In contrast, a novice is someone who has limited experiences with a particular task. Expert thought is often characterized as intuitive, au to matic, strategic, and flexible. Novice cooks may slavishly follow the recipe step by step, while chefs may glance at recipes for ideas and then follow their own procedure. Their reactions appear instinctive over time, and this is because expertise allows us to process 332 information faster and more effectively (Crawford & Channon, 2002). This is because they are able to discount misleading symp to ms and other distrac to rs and hone in on the most likely problem the patient is experiencing (Norman, 2005).

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Development and validation of four-item version of Male Sexual Health Questionnaire to assess ejacula to ry dysfunction erectile dysfunction doctors in maine buy extra super cialis 100mg low price. Effects of alfuzosin 10 mg once daily on sexual function in men treated for symp to matic benign prostatic hyperplasia erectile dysfunction pump prescription order 100 mg extra super cialis fast delivery. A practical guide to the evaluation and treatment of male lower urinary tract symp to ms in the primary care setting erectile dysfunction after age 50 order extra super cialis 100 mg without prescription. Curvilinear transurethral ultrasound applica to r for selective prostate thermal therapy injections for erectile dysfunction side effects order extra super cialis 100 mg otc. Long term impact of superinfection by hepatitis G virus in hepatitis C virus-positive renal transplant patients erectile dysfunction at age 29 100mg extra super cialis overnight delivery. A study on the outcome of percutaneous transluminal renal angioplasty in patients with renal failure erectile dysfunction treatment with herbs discount 100 mg extra super cialis overnight delivery. Decision aids for benign prostatic hyperplasia: applicability across race and education. Immunoexpressions of p21, Rb, mcl-1 and bad gene products in normal, hyperplastic and carcinoma to us human prostates. Regulation of proliferation/apop to sis equilibrium by mi to gen-activated protein kinases in normal, hyperplastic, and carcinoma to us human prostate. Estrogen recep to rs alpha and beta in the normal, hyperplastic and carcinoma to us human prostate. Comparison in human normal prostate, benign prostatic hyperplasia, and prostatic carcinoma. Interferon-gamma and its functional recep to rs overexpression in benign prostatic hyperplasia and prostatic carcinoma: parallelism with c-myc and p53 expression. Effect of angiotensin converting enzyme inhibi to r or beta blocker on glomerular structural changes in young microalbuminuric patients with Type I (insulin-dependent) diabetes mellitus. Combined use of alpha-adrenergic and muscarinic antagonists for the treatment of voiding dysfunction. Activa to r protein 2alpha transcription fac to r expression is associated with luminal differentiation and is lost in prostate cancer. Neuroendocrine differentiation of human prostatic primary epithelial cells in vitro. Trans-differentiation of prostatic stromal cells leads to decreased glycoprotein hormone alpha production. The development of benign prostatic hyperplasia by trans-differentiation of prostatic stromal cells. Interdigitating dendritic cell sarcoma of urinary bladder mimicking large intravesical calculus. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Lower urinary tract symp to ms and erectile dysfunction: epidemiology and treatment in the aging man. Systemic stress responses in patients undergoing surgery for benign prostatic hyperplasia. Urtica dioica for treatment of benign prostatic hyperplasia: a prospective, randomized, double-blind, placebo-controlled, crossover study. Overexpression of E-cadherin and beta-catenin proteins in metastatic prostate cancer cells in bone. Ultrastructure of the secretion of prostasomes from benign and malignant epithelial cells in the prostate. Economic evaluation of treatment strategies for benign prostatic hyperplasia-is medical therapy more costly in the long runfi. Prostate specific antigen complexed to alpha-1-antichymotrypsin in patients with intermediate prostate specific antigen levels. Effectiveness of an anti-inflamma to ry drug, loxoprofen, for patients with nocturia. Limited usefulness of the free- to - to tal prostate-specific antigen ratio for the diagnosis and staging of prostate cancer in Japanese men. Are alpha-blockers involved in lower urinary tract dysfunction in multiple system atrophyfi Lower urinary tract dysfunction in Machado-Joseph disease: a study of 11 clinical-urodynamic observations. Urinary function in patients with corticobasal degeneration; comparison with normal subjects. Versican accumulation in human prostatic fibroblast cultures is enhanced by prostate cancer cell-derived transforming growth fac to r beta1. His to logical markers of risk and the role of high-grade prostatic intraepithelial neoplasia. Ultrasonography of urinary tract lesions caused by bilharziasis in Yemeni patients. Ultrasonographic urinary tract abnormalities in Schis to soma haema to bium infection. Estradiol/androgen recep to rs during aging: microsomal distribution in human benign prostatic hypertrophy. Two-dimensional ultrasound phased array design for tissue ablation for treatment of benign prostatic hyperplasia. Validity of cuff-uroflow as a diagnostic technique for bladder outlet obstruction in males. Quality of life of patients on the waiting list for benign prostatic hyperplasia surgery. Holmium laser enucleation versus open prostatec to my for benign prostatic hyperplasia: an inpatient cost analysis. Bladder neoplasms after nephroureterec to my: does the surgery of the lower ureter, transurethral resection or open surgery, influence the evolutionfi. Improved chemical synthesis and demonstration of the relaxin recep to r binding affinity and biological activity of mouse relaxin. Safety and efficacy of sustained-release alfuzosin on lower urinary tract symp to ms suggestive of benign prostatic hyperplasia in 3,095 Spanish patients evaluated during general practice. The clinical uroselectivity of alfuzosin is not significantly affected by the age of patients with lower urinary tract symp to ms suggestive of benign prostatic hyperplasia. Cardiovascular risk fac to rs correlate with prostate size in men with bladder outlet obstruction. High-power potassium-titanyl phosphate pho to selective laser vaporization of prostate for treatment of benign prostatic hyperplasia in men with large prostates. Combination therapy for the pharmacological management of benign prostatic hyperplasia: rationale and treatment options. Associated geni to urinary tract anomalies in anorectal malformations: a thirteen year review. Natriuretic and aquaretic effects of intravenously infused calcium in preascitic human cirrhosis: physiopathological and clinical implications. Stereologic estimation of the number of neuroendocrine cells in normal human prostate detected by immunohis to chemistry. Treatment of benign prostatic hyperplasia in patients with cardiovascular disease. Urethral reconstruction of strictures resulting from treatment of benign prostatic hypertrophy and prostate cancer. Urethroplasty in patients older than 65 years: indications, results, outcomes and suggested treatment modifications. Early assessment of renal resistance index after kidney transplant can help predict long-term renal function. Can a urinary tract symp to m score predict the development of pos to perative urinary retention in patients undergoing lower limb arthroplasty under spinal anaesthesiafi Concomitant longitudinal changes in frequency of and bother from lower urinary tract symp to ms in community dwelling men. A population based study of incidence and treatment of benign prostatic hyperplasia among residents of Olmsted County, Minnesota: 1987 to 1997. Insulin-like growth fac to r-1, insulin-like growth fac to r binding protein-3, and body mass index: clinical correlates of prostate volume among Black men. Ki-67 antigen and P53 protein expression in benign and malignant prostatic lesions. Age-related reference intervals for free and to tal prostate-specific antigen in a Singaporean population. Large benign prostatic hyperplasia means impossible ureteroscopy: myth or realityfi. Percent of free serum prostate-specific antigen and his to logical findings in patients undergoing open prostatec to my for benign prostatic hyperplasia. Longitudinal urethral sling with prepubic and retropubic fixation for male urinary incontinence. Correlation between lower urinary tract symp to ms and urethral function in benign prostatic hyperplasia. Molecular and cellular prostate biology: origin of prostate-specific antigen expression and implications for benign prostatic hyperplasia. Endocrine status in elderly men with lower urinary tract symp to ms: correlation of age, hormonal status, and lower urinary tract function. Association of vitamin D recep to r and 17 hydroxylase gene polymorphisms with benign prostatic hyperplasia and benign prostatic enlargement. Cross-sectional study of nocturia in both sexes: analysis of a voluntary health screening project. A comparative cross sectional study of lower urinary tract symp to ms in both sexes. Proteomic-based detection of urine proteins associated with acute renal allograft rejection. Predictive fac to rs for sacral neuromodulation in chronic lower urinary tract dysfunction. Mediating transurethral microwave thermotherapy by intraprostatic and periprostatic injections of mepivacaine epinephrine: effects on treatment time, energy consumption, and patient comfort. Diethylstilbesterol revisited: androgen deprivation, osteoporosis and prostate cancer. Vessels in benign prostatic hyperplasia contain more binding sites for endostatin than vessels in normal prostate tissue. Sensitivity analysis of the diagnostic value of endoscopies in cross-sectional studies in the absence of a gold standard. Kinetic fluorescence reverse transcriptase-polymerase chain reaction for alpha-methylacyl CoA racemase distinguishes prostate cancer from benign lesions. Complete upper and lower urinary tract obstruction caused by penetrating pellet injury of the kidney. Choice of urine collection methods for the diagnosis of urinary tract infection in young, febrile infants. Lower urinary tract symp to ms/benign prostatic hyperplasia: minimizing morbidity caused by treatment. Tamsulosin: 3-year long-term efficacy and safety in patients with lower urinary tract symp to ms suggestive of benign prostatic obstruction: analysis of a European, multinational, multicenter, open-label study. Long-term use of tamsulosin to treat lower urinary tract symp to ms/benign prostatic hyperplasia. Long-term therapy with the dual 5alpha-reductase inhibi to r dutasteride is well to lerated in men with symp to matic benign prostatic hyperplasia. A comparison of techniques for eliciting patient preferences in patients with benign prostatic hyperplasia. Anderson-Hynes pyeloplasty in horseshoe kidney in children: is it effective without symphysio to myfi. Lycopene inhibits disease progression in patients with benign prostate hyperplasia. Novel role for alpha1-adrenergic recep to r subtypes in lower urinary tract symp to ms. Molecular pharmacology of human alpha1-adrenergic recep to rs: unique features of the alpha 1a-subtype. Use of cyclooxygenase-2 inhibi to r for prevention of urethral strictures secondary to transurethral resection of the prostate. His to pathological aspects associated with the diagnosis of benign prostatic hyperplasia: clinical implications. Comparison of the percent free prostate-specific antigen levels in the serum of healthy men and in men with recurrent prostate cancer after radical prostatec to my. Three-dimensional grayscale ultrasound: evaluation of prostate cancer compared with benign prostatic hyperplasia. Serum levels of the adipokine vaspin in relation to metabolic and renal parameters. Alfuzosin 10 mg once daily improves sexual function in men with lower urinary tract symp to ms and concomitant sexual dysfunction. Repeated intensification of lower urinary tract symp to ms in the patient with benign prostatic hyperplasia during bisoprolol treatment. Morphological and biological predic to rs for treatment outcome of transurethral microwave thermotherapy. Predictives regarding outcome after transurethral resection for prostatic adenoma associated with detrusor underactivity. Holmium laser enucleation for prostatic adenoma: analysis of learning curve over the course of 70 consecutive cases. Analysis of prognostic fac to rs regarding the outcome after a transurethral resection for symp to matic benign prostatic enlargement. How many uncomplicated male and female overactive bladder patients reveal detrusor overactivity during urodynamic studyfi. Transurethral radiofrequency thermal ablation of prostatic tissue: a feasibility study in humans. The development and validation of a quality-of-life measure to assess partner morbidity in benign prostatic enlargement.

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In contrast erectile dysfunction what age cheap 100mg extra super cialis mastercard, medical orders are crafted by a medical professional on behalf of a seriously ill patient erectile dysfunction hormones buy cheap extra super cialis online. In some instances erectile dysfunction miracle shake purchase 100 mg extra super cialis free shipping, medical orders may be limited to the facility in which they were written erectile dysfunction beat discount 100mg extra super cialis free shipping. Cultural Differences in End-of-Life Decisions Cultural fac to rs strongly influence how doc to rs erectile dysfunction natural remedy order extra super cialis 100 mg amex, other health care providers does erectile dysfunction cause low sperm count order 100 mg extra super cialis with mastercard, and family members communicate bad news to patients, the expectations regarding who makes the health care decisions, and attitudes about end-of-life care (Ganz, 2019; Searight & Gafford, 2005a). In Western medicine, doc to rs take the approach that patients should be to ld the truth about their health. Thus, outside Western nations, and even among certain racial and ethnic groups within the those nations, doc to rs and family members may conceal the full nature of a terminal illness, as revealing such information is viewed as potentially harmful to the patient, or at the very least is seen as disrespectful and impolite. Family members also actively protect terminally ill patients from knowing about their illness in many Hispanic, Chinese, and Pakistani cultures (Kaufert & Putsch, 1997; Herndon & Joyce, 2004). However, in other nations the family or community plays the main role, or decisions are made primarily by medical professionals, or the doc to rs in concert with the family make the decisions for the patient. For instance, in comparison to European Americans and African Americans, Koreans and Mexican Americans are more likely to view family members as the decision makers rather than just Source the patient (Berger, 1998; Searight & Gafford, 2005a). Thus, there is an expectation that the family has a say in the health care decisions. As many cultures attribute high regard and respect for doc to rs, patients and families may defer some of the end-of-life decision making to the medical professionals (Searight & Gafford, 2005b). The notion of advanced directives hold little or no relevance in many cultures outside of western society (Blank, 2011). For instance, in India advanced directives are virtually non-existent, while in Germany they are regarded as a major part of health care (Chat to padhyay & Simon, 2008). In the United States, Canada, and most European countries artificial feeding is more commonly used once a patient has s to pped eating, while in many other nations lack of eating is seen as a sign, rather than a cause, of dying and do not consider using a feeding tube (Blank, 2011). Lipka (2014) also found that there were clear racial and ethnic differences in end-of-life wishes (see Figure 10. Whites are more likely than Blacks and Hispanics to prefer to have treatment s to pped if they have a terminal illness. While the majority of Blacks (61%) and Hispanics (55%) prefer that everything be done to keep them alive. Searight and Gafford (2005a) suggest that the low rate of completion of advanced directives among non-whites may reflect a distrust of the U. Euthanasia is further separated in to active euthanasia, which is intentionally causing death, usually through a lethal dose of medication, and passive euthanasia occurs when life-sustaining support is withdrawn. This can occur through the removal of a respira to r, feeding tube, or heart-lung machine. Physician-assisted dying is a form of active euthanasia whereby a physician Table 10. Allow Legal prescribes the means by which a person Physician-Assisted Dying can die. The United States federal State Date Passed government does not legislate physician Oregon Passed November 8, 1994, but assisted dying as laws are handled at the enacted Oc to ber 27, 1997 state level (ProCon. Vermont May 20, 2013 the person seeking physician-assisted California September 11, 2015 dying must be: (1) at least 18 years of age, D. Oc to ber 5, 2016 (2) have six or less months until expected Colorado November 8, 2016 death, and (3) obtain two oral (or least 15 Hawaii April 5, 2018 days apart) and one written request from a New Jersey March 25, 2019 physician (ProCon. Since 1997 in Oregon, 2,216 people had lethal prescriptions written and 1459 patients (65. As of 2014, Belgium is the only country that allows the right to die to those under the age of 18. According to a 2013 Pew Research Center survey, 47% of Americans approve and 49% disapprove of laws that would allow a physician to prescribe lethal doses of drugs that a terminally ill patient could use to commit suicide (Pew Research Center, 2013). Attitudes on physician-assisted dying were roughly the same in 2005, when 46% approved and 45% disapproved. Source Religious Practices after Death Funeral rites are expressions of loss that reflect personal and cultural beliefs about the meaning of death and the afterlife. These rites and ceremonies send the message that the death is real and allow friends and loved ones to express their love and duty to those who die. Under circumstances in which a person has been lost and presumed dead or when family members were unable to attend a funeral, there can continue to be a lack of closure that makes it difficult to grieve and to learn to live with loss. The following are some of the religious practices regarding death, however, individual religious interpretations and practices may occur (Dresser & Wasserman, 2010; Schechter, 2009). Hindu: the Hindu belief in reincarnation accelerates the funeral ritual, and deceased Hindus are cremated as soon as possible. After being washed, the body is anointed, dressed, and then placed on a stand decorated with flowers ready for cremation. The burial must occur as soon as possible after death, and a simple service consisting of prayers and a eulogy is given. After burial the family members typically gather in one home, often that of the deceased, and receive visi to rs. Muslim: In Islam the deceased are buried as soon as possible, and it is a requirement that the community be involved in the ritual. The individual is first washed and then wrapped in a plain white shroud called a kafan. The shrouded dead are placed directly in the earth without a casket and deep enough not to be disturbed. They are also positioned in the earth, on their right side, facing Mecca, Saudi Arabia. Roman Catholic: Before death an ill Catholic individual is anointed by a priest, Figure 10. The priest recites a prayer and applies consecrated oil to the forehead and hands of the ill person. The individual also takes a final communion consisting of consecrated bread and wine. The funeral mass is next which includes an opening prayer, bible readings, liturgy, communion, and a concluding rite. The funeral then moves to Source the cemetery where a blessing of the grave, scripture reading, and prayers conclude the funeral ritual. Green burials attempt to reduce the impact on the environment at every stage of the funeral. Grief, Bereavement, and Mourning the terms grief, bereavement, and mourning are often used interchangeably, however, they have different meanings. Grief can be in response to a physical loss, such as a death, or a social loss including a relationship or job. The time spent in bereavement for the loss of a loved one depends on the circumstances of the loss and the level of attachment to the person who died. Mourning is greatly influenced by cultural beliefs, practices, and rituals (Casarett, Kutner, & Abrahm,2001). Grief Reactions: Typical grief reactions involve mental, physical, social and/or emotional responses. These reactions can include feelings of numbness, anger, guilt, anxiety, sadness and despair. The individual can experience difficulty concentrating, sleep and eating problems, loss of interest in pleasurable activities, physical problems, and even illness. Research has demonstrated that the immune systems of individuals grieving is suppressed and their healthy cells behave more sluggishly, resulting in greater susceptibility to illnesses (Parkes & Prigerson, 2010). However, the intensity and duration of typical grief symp to ms do not match those usually seen in severe grief reactions, and symp to ms typically diminish within 6-10 weeks (Youdin, 2016). Additionally, these symp to ms may last six months or longer and mirror those seen in major depressive disorder (Youdin, 2016). Source th According to the Diagnostic and Statistical Manual of Mental Disorders (5 ed. Those who seek assistance for complicated grief usually have experienced traumatic forms of bereavement, such as unexpected, multiple and violent deaths, or those due to murders or suicides (Parkes & Prigerson, 2010). Disenfranchised Grief: Grief that is not socially recognized is referred to as disenfranchised grief (Doka, 1989). Due to the type of loss, there is no formal mourning practices or recognition by others that would comfort the grieving individual. Consequently, individuals experiencing disenfranchised grief may suffer intensified symp to ms due to the lack of social support (Parkes & Prigerson, 2010). Anticipa to ry Grief: Grief that occurs when a death is expected, and survivors have time to prepare to some extent before the loss is referred to as anticipa to ry grief. This expectation can make adjustment after a loss somewhat easier (Kubler-Ross & Kessler, 2005). A death after a long-term, painful illness may bring family members a sense of relief that the suffering is over, and the exhausting process of caring for someone who is ill is also completed. Models of Grief There are several theoretical models of grief, however, none is all encompassing (Youdin, 2016). These models are merely guidelines for what an individual may experience while grieving. It is important to remember that there is no one way to grieve, and people move through a variety of stages of grief in various ways. Five Stages of Grief: Kubler-Ross (1969, 1975) describes five stages of loss experienced by someone who faces the news of their impending death. These "stages" are not really stages that a person goes through in order or only once; nor are they stages that occur with the same intensity. Nevertheless, these stages help us to understand and recognize some of what a dying person experiences psychologically, and by understanding, we are more equipped to support that person as they die. Denial, or disbelief or shock, protects us by allowing such news to enter slowly and to give us time to come to grips with what is taking place. The person who receives positive test results for life-threatening conditions may question the results, seek second opinions, or may simply feel a sense of disbelief psychologically even though they know that the results are true. It helps us to temporarily 458 believe that we have a sense of control over our future and to feel that we have at least expressed our rage about how unfair life can be. Anger can be focused on a person, a health care provider, at God, or at the world in general. It can be expressed over issues that have nothing to do with our death; consequently, being in this stage of loss is not always obvious. Living better, devoting self to a cause, being a better friend, parent, or spouse, are all agreements one might willingly commit to if doing so would lengthen life. Asking to just live long enough to witness a family event or finish a task are examples of bargaining. Feeling the full weight of loss, crying, and losing interest in the outside world is an important part of the process of dying. This depression makes others feel very uncomfortable and family members may try to console their loved one. Sometimes hospice care may include the use of antidepressants to reduce depression during this stage. Reaching acceptance does not in any way imply that people who are dying are happy about it or content with it. It means that they are facing it and continuing to make arrangements and to say what they wish to say to others. Some terminally ill people find that they live life more fully than ever before after they come to this stage. According to Kubler-Ross (1969), behind these five stages focused on the identified emotions, there is a sense of hope. Kubler-Ross noted that in all the 200 plus patients she and her students interviewed, a little bit of hope that they might not die was always in the back of their minds.

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