But, as is true for a number of other alternative therapies, much of the evidence to support meditation’s effectiveness in promoting mental or physical health isn’t quite up to snuff. Why? First, many studies don’t include a good control treatment to compare with mindful meditation. Second, the people most likely to volunteer for a meditation study are often already sold on meditation’s benefits and so are more likely to report positive effects.
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But when researchers from Johns Hopkins University in Baltimore, MD sifted through nearly 19,000 meditation studies, they found 47 trials that addressed those issues and met their criteria for well-designed studies. Their findings, published in JAMA Internal Medicine, suggest that mindful meditation can help ease psychological stresses like anxiety, depression, and pain.

Dr. Elizabeth Hoge, a psychiatrist at the Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School, says that mindfulness meditation makes perfect sense for treating anxiety. “People with anxiety have a problem dealing with distracting thoughts that have too much power,” she explains. “They can’t distinguish between a problem-solving thought and a nagging worry that has no benefit.”
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“If you have unproductive worries,” says Dr. Hoge, you can train yourself to experience those thoughts completely differently. “You might think ‘I’m late, I might lose my job if I don’t get there on time, and it will be a disaster!’ Mindfulness teaches you to recognize, ‘Oh, there’s that thought again. I’ve been here before. But it’s just that—a thought, and not a part of my core self,’” says Dr. Hoge.

One of her studies (which was included in the JAMA Internal Medicine review) found that a mindfulness-based stress reduction program helped quell anxiety symptoms in people with generalized anxiety disorder, a condition marked by hard-to-control worries, poor sleep, and irritability. People in the control group—who also improved, but not as much as those in the meditation group—were taught general stress management techniques. All the participants received similar amounts of time, attention, and group interaction.

To get a sense of mindfulness meditation, you can try one of the guided recordings by Dr. Ronald Siegel, an assistant clinical professor of psychology at Harvard Medical School. They are available for free at www.mindfulness-solution.com.

Some people find that learning mindfulness meditation techniques and practicing them with a group is especially helpful, says Dr. Hoge. Mindfulness-based stress reduction training, developed by Dr. Jon Kabat-Zinn at the University of Massachusetts Medical School in Worcester, MA, is now widely available in cities throughout the United States.
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Thich Nhat Hahn offers this short mindful meditation in his book Being Peace: “Breathing in, I calm my body. Breathing out, I smile. Dwelling in the present moment, I know this is a wonderful moment.”

Related Information: Positive Psychology: Harnessing the power of happiness,…

What do they do?
A living will and a health care power of attorney are related but work in different ways. In a living will, you describe your goals for medical treatment, your religious or spiritual beliefs, and any guidance you wish to give regarding your medical treatment in various circumstances. A health care power of attorney permits you to name a health care proxy, or agent — a person who will make medical decisions on your behalf if you are unable to make them yourself.

People sometimes worry that by signing one of these documents they give up control over their medical treatment. But it doesn't work that way. As long as you're able to make and communicate your decisions, your word supersedes anything you've written or said to others. An advance care directive goes into effect only when you're unconscious or too ill to make your wishes known — and once you recover from the incapacity, what you say takes precedence over any document.

Advance care directives are not difficult to create. You can write one up on your own, without a lawyer's help (see "Selected resource"). Some experts suggest that you either make a living will or assign a health care proxy. If you choose to have both, naming a health care proxy should be a priority, to ensure that someone can act in situations not covered in a living will.

Your health care proxy
If you can't make health care choices for yourself and don't have a health care proxy, the job of making them will likely fall to one or more of your relatives. For many people, this isn't a problem. But if you don't feel close to your legal next of kin, you may not want these decisions to be in his or her hands. Also, if two or more relatives are involved, your clinicians may feel they need to get a consensus before proceeding. This can cause conflict and delay treatment.

Most people pick a spouse, partner, adult child, or close friend as their health care proxy. It's best not to appoint more than one (and in many states it's illegal to do so) because all of them would need to agree on every decision. But do appoint an alternate proxy in the event your proxy is unavailable when needed. You can also instruct your proxy to consult others.

Your health care proxy is obliged by law to make decisions that she or he thinks you would have made. Talk to your proxy about medical treatments you may or may not want and about how your religious or spiritual beliefs and personal concerns shape your treatment preferences in various situations. If you have a living will, go over it with your proxy. You can't anticipate everything, so make sure you feel absolutely comfortable allowing the proxy to make decisions about matters you haven't specifically discussed.

What's in a living will?
A living will provides a written record that can guide your doctors and loved ones in caring for you. Often, it's used to determine how aggressive you would like your health care to be near the end of life. Be careful in describing your wishes, because it's impossible to know all the variables that might affect a future decision. For example, if you say you don't want to be tube-fed under any circumstances, you might be lowering your chance of recovery from a temporary health setback.

Your physician can explain medical terms and discuss what's possible and what's unlikely to work given your situation and goals. It's a good idea to talk to her or him before you finalize your wishes, whether you do that in a document or in conversations with your health care proxy, family, and friends.

The information that's required for a living will or other advance care directive differs from state to state. To download the correct forms for your state, go to Caring Connections, a Web site of the National Hospice and Palliative Care Organization, at www.caringinfo.org.

Living wills generally cover certain procedures that might be performed when a person is incapacitated or at the end of life, including these:

Artificial nutrition (tube feeding). If you can't swallow anything, this procedure supplies nutrients and fluids through a tube inserted through your nose into your stomach (short-term), through the abdominal wall into the stomach (long-term), or into a vein if your gut isn't working properly. Tube feeding may be used as a bridge when the underlying problem is thought to be temporary and the person is likely to recover. More controversially, it has also been used long-term to help keep a person with an irreversible condition alive. Hydration (giving a solution of water, sugar, and minerals through the vein) can also be used short-term or long-term.

Cardiopulmonary resuscitation (CPR). If your heart or breathing stop and you become unconscious, you may be resuscitated by CPR. This technique involves artificial circulation (chest compressions), artificial respiration (mouth-to-mouth breathing), and defibrillation (to shock the heart back into a steady rhythm). If CPR fails, the next step is advanced cardiac life support: intubation and mechanical ventilation plus medications to control heart rate, raise or lower blood pressure, or improve kidney function. CPR can cause injury, and the revival rate with CPR is low — no more than 22% in general, and as low as zero for older, frail people. Some people with terminal illnesses who have been resuscitated this way say they wish they hadn't been. Think about whether there are situations in which you wouldn't want CPR.

Mechanical ventilation. A ventilator or respirator (sometimes called a breathing machine) forces air into the lungs when you can't breathe on your own. A tube attached to the machine is inserted into the nose, mouth, or throat and passed into the trachea (windpipe). Because this is extremely uncomfortable, people on ventilators require high doses of sedatives and therefore are not fully conscious. Like tube feeding, mechanical ventilation can be used for a short period of time, as a bridge to recovery, or long-term. You should decide whether you want to be kept on mechanical ventilation if physicians determine you will never be able to breathe again on your own.


A doctor talks about: Advance care directives
Celeste Robb-Nicholson, M.D.
In my own medical practice, I find advance care directives invaluable. They help me open a dialogue with my patients about their deepest concerns, especially about being critically ill or incapacitated — whether they fear pain, loneliness, lack of control, or becoming a burden. These documents also give family members or friends the guidance they need to make difficult choices for an incapacitated loved one.

But no document can anticipate everything. Early on in many critical situations, it's impossible to predict a patient's outcome. The advance care directive doesn't lessen my responsibility to bring my medical insights to bear on my patient's predicament. She may need a respirator, feeding tube, catheters, or more, to get through a difficult part of her illness. All doctors have seen critically ill patients — burn victims are a good example — who recover a very good quality of life after terrible ordeals. Unless a patient has a known terminal illness, we do what we believe will support her life.

Sometimes the patient doesn't respond, and the medical technology we called upon ends up supporting a kind of life she doesn't want. In these circumstances, patients, families, and doctors may find themselves second-guessing their original decisions. All parties may have to consider withholding or withdrawing medical support. A living will or health care proxy can help in those situations.

Even with a living will, the issues surrounding end-of-life care are rarely simple or clear-cut. A doctor's notion of "quality of life" may differ from her patient's, and she may not feel completely confident of her patient's wishes in the immediate circumstances. Family members may have strong and conflicting views.

We physicians want to help our patients live while honoring their choices about dying and acknowledging their fears about living with a poor quality of life. Advance care directives are important guidelines, but there's no substitute for frank conversations with your physician, your health care proxy (should you choose one), and anyone else who is close to you. Such dialogues help foster trust and confidence that all those involved will work together in your best interest.

Sharing your health care preferences
After your health care proxy, your primary care physician is the most important person to talk to about your advance care directives. A physician who disagrees with your wishes doesn't have to carry them out, but she or he is obligated to find another clinician who will. Make sure your physician knows the contents of your advance care directives and agrees to find a clinician to comply with any requests that she or he finds problematic.

It's important to define any terms in your health care proxy form or living will that could be open to various interpretations. One study found that a group of doctors given a hypothetical living will and patient story came to very different conclusions about what should be done. Terms like "life-threatening," "short period of time," "severe disease," "end-stage condition," and, especially, "quality of life" may require clarification or specification.

Once you've completed your living will and health care proxy form, keep the originals at home in a safe place, and give copies to your proxy, alternate proxy, and physician (she or he should keep the copies in your medical file along with notes about any conversations you've had and the health care proxy's current contact information).

Advance planning for end-of-life care
In 1990, Congress passed the Patient Self-Determination Act guaranteeing patients the right to accept or refuse treatment and to complete advance care directives. Since then, an increasing number of people have made living wills and assigned health care proxies, but the effectiveness of such measures has been the subject of debate. The directives aren't always available when needed; the clinician may not even know a directive exists; the proxy may be unavailable or emotionally unable to provide guidance; or the patient's stated preferences with respect to medical interventions may be outdated or inapplicable to the specific circumstances.

To counter these problems, some experts have proposed an additional form for people with terminal or advanced illnesses, called Physician Orders for Life-Sustaining Treatment (POLST). POLST doesn't supplant a living will or health care proxy form, although it could function in the absence of one.
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The first step is a discussion about end-of-life treatment options between the physician and patient (or an authorized health care decision-maker). The patient decides on a treatment plan, and her wishes are then translated into medical orders, which are recorded on a brightly colored form signed by the physician and kept in the front of the patient's medical record, to guide health providers during an emergency. The POLST form focuses on potentially imminent decisions rather than long-term planning. It covers interventions such as CPR, intubation, and tube feeding, and it goes with the patient if she or he moves to another facility.

So far, POLST programs have been endorsed or are in development in more than 30 states. For more information, go to www.ohsu.edu/polst.

Living longer with heart failure
We tend to think about these discussions as being appropriate for people who are either very old or who have an advanced stage of cancer. In fact, cardiovascular disease is the most common cause of death. Yet over the past few decades, treatment advances have changed the arc of this disease. More people are surviving heart attacks, which means there are more people who eventually develop heart failure—when the weakened heart can't pump enough blood to meet the body's needs. But improved therapies have also greatly extended the lives of people with heart failure.

"Thirty years ago, people with advanced heart disease who didn't get a heart transplant were dead within two years. Today, I follow many patients who have survived more than a decade with their own hearts despite heart failure, thanks to better medications and special pacemakers," explains Dr. Stevenson. These days, many people with heart failure survive into old age and end up dying of something else—an illustration of the uncertainty we all live with.

None of us knows what's going to happen in five years, in 10 years, or even tomorrow. Perhaps the most feared outcome is a stroke. So that old adage—to plan for the worst and hope for the best—makes sense. But this uncertainty is a fundamental aspect of the value and meaning of the human journey, says Dr. Stevenson.

Accepting uncertainty
​For people with a serious, chronic illness like advanced heart disease, one question invariably comes up: "Doctor, how long do I have?" But no doctor can answer that question for any disease, says Dr. Stevenson, noting that heart disease is particularly fraught with uncertainty. People with advanced heart failure can have bad days when they struggle to breathe and feel weak and exhausted, followed by some good days where they are able to enjoy their activities and interactions. However, many cardiac conditions increase your risk for dying unexpectedly from a sudden rhythm disturbance, even when things are going well, she explains.

Only about a quarter of adult Americans have an advance directive, a document that helps guide your future care. The first step is to choose a health care proxy—someone who will have the knowledge and strength to carry out your wishes regarding the health care you receive. Many people have heard of a living will. However, this document may not address the range of possible situations beyond whether you want to be resuscitated or receive artificial life support. The numerous possible decisions are hard to anticipate unless you already have a potentially terminal disease.

A health decision worksheet may be a better way to help you consider and explain your goals for care in more detail. It includes questions about your fears about your final stages of life, what aspects of your life are most crucial to you, and what will bring you joy, as well as detailed questions about medical care, such as artificial nutrition, hemodialysis, and comfort care that is focused on symptoms rather than survival.

For a free copy of this worksheet and a health care proxy form, see www.health.harvard.edu/ADforms. To order Harvard Health Publishing' detailed report on this topic, Advance Care Planning: A guide to advance directives, living wills, and other strategies for communicating health care preferences, see www.health.harvard.edu/lw.

Simplify future decisions
Your wishes and priorities will likely change as you age and develop new or progressive medical conditions. So it's a good idea to review any health care documents every few years while you're healthy, or more urgently if you have any new diagnoses or other major changes in your life.
Dr. Stevenson, a co-author of the American Heart Association's statement on shared decision making in advanced heart failure, points out one of the most important take-home messages from that document: "Difficult discussions now will simplify difficult decisions in the future." In other words: give your family and friends a gift for the future—the comfort of knowing how you want to be treated during what could be a challenging time for everyone.

Even if these conversations may feel awkward and emotional, they are often followed by a profound sense of relief. "Unspoken fears about what might happen can isolate us from those we care about," says Dr. Stevenson. "Sharing them can reinforce the vital connections to each other, both now and in the times ahead."

End-of-life care for heart failure
People with advanced heart failure may eventually reach a point where their symptoms become hard to manage. They have may have difficulty breathing, which makes everything—even sleeping—an effort, and their bodies may swell with excess fluid because of poor kidney function. When bouts of hospitalization become more frequent, they may want to arrange a consultation with a palliative care specialist. Palliative care aims to keep a person with a serious, advanced illness comfortable and pain-free with a combination of measures to treat distressing symptoms.
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For example, small doses of narcotics can help people feel more comfortable and breathe more easily yet still remain alert and able to interact with their families, says Dr. Stevenson. People who have a device that corrects abnormal rhythms (an implantable cardioverter-defibrillator, or ICD) may want to have a discussion with their physician about when to disable the feature that delivers a shock to restore a normal heart rhythm. Keeping an ICD functioning can interfere with what might be considered a more natural death, says Dr. Stevenson.

The term "positive psychology" is a broad one, encompassing a variety of techniques that encourage people to identify and further develop their own positive emotions, experiences, and character traits. In many ways, positive psychology builds on key tenets of humanistic psychology. Carl Rogers' client-centered therapy, for example, was based on the theory that people could improve their lives by expressing their authentic selves. And Abraham Maslow identified traits of self-actualized people that are similar to the character strengths identified and used in some positive psychology interventions.

Although initially developed as a way to advance well-being and optimal functioning in healthy people, positive psychology techniques are now being promoted as a complement to more traditional forms of therapy. For example, University of Pennsylvania psychologist Martin E.P. Seligman, a well-known advocate of positive psychology, has described its core philosophy as a "build what's strong" approach that can augment the "fix what's wrong" approach of more traditional psychotherapy.

Another pioneer in the field, Harvard psychiatrist George E. Vaillant, sees positive psychology as a way to encourage patients to focus on positive emotions and build strengths, supplementing psychotherapy that focuses on negative emotions, like anger and sorrow. In a talk about positive psychology, Dr. Vaillant cited the example of a standard psychiatric textbook used by psychiatrists and clinical psychologists. The textbook, he says, contains roughly a million lines of text, with thousands of lines devoted to anxiety and depression, and hundreds discussing terror, shame, guilt, anger, and fear. But only five lines in the textbook discuss hope, only one mentions joy, and not a single line mentions compassion or love.

To counter the traditional focus on pathology, Seligman and another psychologist, Christopher Peterson, have formalized the tenets of positive psychology in a book, Character Strengths and Virtues: A Handbook and Classification (CSV), which they created as a counterpoint to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV). Just as the DSM-IV classifies a range of psychiatric disorders, the CSV provides details and classifications for various strengths that enable people to thrive. The book identifies 24 character strengths, like curiosity and zest, organized according to six overarching virtues, such as wisdom and courage.
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A number of different counseling and coaching strategies rely on aspects of positive psychology. Although it's impossible to review all of them in a single article, a few examples can help to provide a taste of how they may complement more traditional therapies.

Summary points

• Positive psychology focuses on positive emotions and personal strengths.
• It can complement rather than replace traditional psychotherapy.
• Studies evaluating outcomes of interventions using positive psychology have mostly been small and short term.

Well-being therapy
As its name implies, well-being therapy tries to promote recovery from depression and other affective disorders by having a patient focus on and promote the positive, as well as alleviating negative aspects of life. Developed by Giovanni Fava at the University of Bologna in Italy, well-being therapy is based in large part on the work of psychologist Carol Ryff and her multidimensional model of subjective well-being. Ryff's model consists of six tenets: mastery of the environment, personal growth, purpose in life, autonomy, self-acceptance, and positive relationships.

In practical terms, well-being therapy is much like cognitive behavioral therapy. A patient keeps a journal to keep track of and recognize the positive events that occur each day. Next the patient starts recognizing negative thoughts and beliefs that distract from or disrupt positive events. The ultimate goal is to challenge and eventually change negative ways of thinking, to enable positive events to have more of an impact on the patient's life.

Positive psychotherapy
Seligman and colleagues at the University of Pennsylvania developed positive psychotherapy as a way to treat depression by building positive emotions, character strengths, and sense of meaning, not just by reducing negative symptoms such as sadness. This therapy uses a combination of 12 exercises (such as the following) that can be practiced individually or in groups.

Using your signature strengths. Identify your top five strengths (see "Resources" for a free online questionnaire) and try to use them in some new way daily.

Three good things. Every evening, write down three good things that happened that day and think about why they happened.

Gratitude visit. Write a letter to someone explaining why you feel grateful for something they've done or said. Read the letter to the recipient, either in person or over the phone.

This is one of the few forms of positive psychotherapy that has been tested in a randomized controlled trial. The study found that some exercises are more beneficial than others (see "Does positive psychology work?" for details).

Integrating positive psychology in practice
Psychologist Carol Kauffman, director of the Coaching and Positive Psychology Initiative at Harvard's McLean Hospital, discussed four techniques for integrating the principles of positive psychology into more traditional types of individual or group therapy.

Reverse the focus from negative to positive. Most people tend to dwell on negative events or emotions and ignore the positive ones — and therapy can encourage this. One way to reverse the focus is to use techniques aimed at shifting attention to more positive aspects of life. For example, take a mental spotlight each night and scan over the events of the day, thinking about what went right. Another tip is to compile "I did it" lists instead of only writing down what needs to be done.

Develop a language of strength. Therapists and patients often talk about pain, conflict, and anger. Although these are all aspects of life, it may be harder for people to talk about or even identify more positive qualities and personal strengths.

Kauffman and other positive psychology practitioners often use strength coaching while advising patients. Just as an athlete exercises certain muscles to become stronger, the theory is that people who use their strengths regularly will function better in life. To boost mental facility, Kauffman recommends that people identify one top strength and then use it at least once a day.

Balance the positive and negative. It's also important for people to identify and foster the positive for themselves and others in order to provide a balance to the negative. For example, business executives may mix praise with criticism when evaluating employees to nurture their growth.

Build strategies that foster hope. Finding ways to foster hope in someone may increase that person's ability to deal with adversity and overcome a challenge. One way to cultivate hope is to reduce the scope of the problem — perhaps by breaking it down into components that can be tackled one at a time. Another way is to identify skills and coping mechanisms that would enable someone to overcome a particular challenge, and then provide a way to build them.

Does positive psychology work?
Proponents of positive psychology tend to cite studies showing that optimistic or happy people are healthier, more successful, and live longer than other people. Critics counter that people may have inborn temperaments that function a bit like set-points, and that interventions aimed at making them happier will only work for a limited time. Eventually, the critics claim, people return to their baseline level of happiness.

A 2005 review of the studies published about positive psychology interventions found that only one involved people with clinical depression — and that study was small, and the intervention was not tested against a control. The study enrolled 16 people who met the criteria for clinical depression according to their scores on the Beck Depression Inventory and the Hamilton Rating Scale of Depression. Participants met weekly for 15 weeks to discuss readings about topics such as how to increase satisfaction with health and improve self-esteem. All 13 people who completed the study were reassessed at the end of the intervention; none of them met the criteria for clinical depression.

​Since then, only one large randomized controlled trial of a positive psychology intervention for people with clinical depression has been published. After two preliminary studies found positive psychotherapy (PPT) to be promising, Seligman and colleagues conducted a randomized controlled trial involving 411 participants that compared five different PPT exercises with a control exercise, all of which were administered over the Internet and could be completed in one week. Participants were assessed before the intervention and then periodically afterward for six months.

At the six-month mark, participants were rated by the Steen Happiness Index and the Center for Epidemiologic Studies Depression Scale. Those completing the "using your signature strengths" and "three good things" exercises rated significantly happier and less depressed than the control group. The "gratitude visit" exercise also created positive changes, but only for one month. The two other exercises and the control exercise created briefer and transient effects.

Most other studies have been short-term in nature (several lasted six to 10 weeks, and one lasted three days) and have involved people who did not have psychiatric diagnoses. This means it remains unclear whether positive psychology techniques will help people suffering from depression and other psychiatric disorders.

Another limitation in the research so far is that investigators have evaluated mostly individual strategies, but positive psychology interventions usually combine several techniques at once. It's also unclear how best to combine positive psychology interventions with more traditional types of therapy, such as cognitive behavioral therapy, or with medication.

Although the jury is still out on the clinical impact of positive psychology, leaders in the field are encouraging patients and clinicians to give positive techniques a try. After all, there are few risks involved when someone discovers his or her strengths or focuses on the positive side of life — and there may be valuable benefits.

Advance care planning is not just about old age. At any age, a medical crisis could leave you too ill to make your own healthcare decisions. Even if you are not sick now, planning for health care in the future is an important step toward making sure you get the medical care you would want, if you are unable to speak for yourself and doctors and family members are making the decisions for you.

Many Americans face questions about medical treatment but may not be capable of making those decisions, for example, in an emergency or at the end of life. This article will explain the types of decisions that may need to be made in such cases and questions you can think about now so you're prepared later. It can help you think about who you would want to make decisions for you if you can't make them yourself. It will also discuss ways you can share your wishes with others. Knowing who you want to make decisions on your behalf and how you would decide might take some of the burden off family and friends.

Start by thinking about what kind of treatment you do or do not want in a medical emergency. It might help to talk with your doctor about how your current health conditions might influence your health in the future. For example, what decisions would you or your family face if your high blood pressure leads to a stroke? You can ask your doctor to help you understand and think through your choices before you put them in writing. Discussing advance care planning decisions with your doctor is free through Medicare during your annual wellness visit. Private health insurance may also cover these discussions.

If you don't have any medical issues now, your family medical history might be a clue to help you think about the future. Talk with your doctor about decisions that might come up if you develop health problems similar to those of other family members.

In considering treatment decisions, your personal values are key. Is your main desire to have the most days of life? Or, would your focus be on quality of life, as you see it? What if an illness leaves you paralyzed or in a permanent coma and you need to be on a ventilator? Would you want that?
What makes life meaningful to you? If your heart stops or you have trouble breathing, would you want to undergo life-saving measures if it meant that, in the future, you could be well enough to spend time with your family? Would you be content if the emergency leaves you simply able to spend your days listening to books on tape or gazing out the window?

But, there are many other scenarios. Here are a few. What would you decide?

• If a stroke leaves you unable to move and then your heart stops, would you want CPR? What if you were also mentally impaired by a stroke—does your decision change?
• What if you are in pain at the end of life? Do you want medication to treat the pain, even if it will make you more drowsy and lethargic?
• What if you are permanently unconscious and then develop pneumonia? Would you want antibiotics and to be placed on a ventilator?

For some people, staying alive as long as medically possible, or long enough to see an important event like a grandchild's wedding, is the most important thing. An advance directive can help to make that possible. Others have a clear idea about when they would no longer want to prolong their life. An advance directive can help with that, too.
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Your decisions about how to handle any of these situations could be different at age 40 than at age 85. Or, they could be different if you have an incurable condition as opposed to being generally healthy. An advance directive allows you to provide instructions for these types of situations and then to change the instructions as you get older or if your viewpoint changes.

What happens if you have no advance directive or have made no plans and you become unable to speak for yourself? In such cases, the state where you live will assign someone to make medical decisions on your behalf. This will probably be your spouse, your parents if they are available, or your children if they are adults. If you have no family members, the state will choose someone to represent your best interests.
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Always remember: an advance directive is only used if you are in danger of dying and need certain emergency or special measures to keep you alive, but you are not able to make those decisions on your own. An advance directive allows you to make your wishes about medical treatment known.
It is difficult to predict the future with certainty. You may never face a medical situation where you are unable to speak for yourself and make your wishes known. But having an advance directive may give you and those close to you some peace of mind.

CaringInfo
National Hospice and Palliative Care Organization
1-800-658-8898 (toll-free)
caringinfo@nhpco.org
www.caringinfo.org

Center for Practical Bioethics
1-800-344-3829 (toll-free)
center@centerforbioethics.org
www.practicalbioethics.org
OrganDonor.gov

Health Resources & Services Administration
www.organdonor.gov

National POLST Paradigm
1-202-780-8352
info@polst.org
www.polst.org
Put It In Writing 
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American Hospital Association 
1-800-424-4301 
https://www.aha.org/2017-12-11-put-it-writing

Plan for the Future 
No one ever plans to be sick or disabled. Yet, it’s this kind of planning that can make all the difference in an emergency. Long before she fell, Louise put all her important papers in one place and told her  
son where to find them. She gave him the name of her lawyer, as well as a list of people he could contact at her bank, doctor’s office, insurance company, and investment firm. She made sure he had copies of her Medicare and other health insurance cards. She added her son’s name to her checking account and safe deposit box at the bank. Louise made sure Medicare and her doctor had written permission to talk with her son about her health and insurance claims. 
On the other hand, Ben always took care of family money matters, and he never talked about the details with Shirley. No one but Ben knew that his life insurance policy was in a box in the closet or that the car title and deed to the house were filed in his desk drawer. Ben never expected that his wife would have to take over. His lack of planning has made a tough job even tougher for Shirley. 

What Exactly Is an “Important Paper”? 
The answer to this question may be different for every family. Remember, this is a starting place. You may have other information to add. For example, if you have a pet, you will want to include the name and address of your veterinarian. Include complete information about: 

Personal Records 

• Full legal name 
• Social Security number 
• Legal residence 
• Date and place of birth 
• Names and addresses of spouse and children 
• Location of birth and death certificates and certificates of marriage, divorce, citizenship, and adoption 
• Employers and dates of employment 
• Education and military records 
• Names and phone numbers of religious contacts 
• Memberships in groups and awards received
• Names and phone numbers of close friends, relatives, doctors, lawyers, and financial advisors 
• Medications taken regularly (be sure to update this regularly)
• Location of living will and other legal documents 

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Steps for Getting Your Affairs in Order 

• Put your important papers and copies of legal documents in one place. You can set up a file, put everything in a desk or dresser drawer, or list the information and location of papers in a notebook. If your papers are in a bank safe deposit box, keep copies in a file at home. Check each year to see if there’s anything new to add. 
• Tell a trusted family member or friend where you put all your important papers. You don’t need to tell this friend or family member about your personal affairs, but someone should know where you keep your papers in case of an emergency. If you don’t have a relative or friend you trust, ask a lawyer to help. 
• Discuss your end-of-life preferences with your doctor. He or she can explain what health decisions you may have to make in the future and what treatment options are available. Talking with your doctor can help ensure your wishes are honored, and the visit may be covered by insurance. 
• Give permission in advance for your doctor or lawyer to talk with your caregiver as needed. There may be questions about your care, a bill, or a health insurance claim. Without your consent, your caregiver may not be able to get needed information. You can give your okay in advance to Medicare, a credit card company, your bank, or your doctor. You may need to sign and return a form. 

Financial Records 

• Sources of income and assets (pension from your employer, IRAs, 401(k)s, interest, etc.)
• Social Security and Medicare/Medicaid information 
• Insurance information (life, health, long- term care, home, car) with policy numbers and agents’ names and phone numbers
• Names of your banks and account numbers (checking, savings, credit union) ■ Investment income (stocks, bonds, property) and stockbrokers’ names and phone numbers 
• Copy of most recent income tax return 
• Location of most up-to-date will with an original signature 
• Liabilities, including property tax— what is owed, to whom, and when payments are due 
• Mortgages and debts—how and when they are paid
• Location of original deed of trust for home 
• Car title and registration 
• Credit and debit card names and numbers 
• Location of safe deposit box and key 

Legal Documents 
There are many different types of legal documents that can help you plan how your affairs will be handled in the future. Many of these documents have names that sound 
alike, so make sure you are getting the documents you want. Also, State laws vary, so find out about the rules, requirements, and forms used in your State. 
Wills and trusts let you name the person you want your money and property to go to after you die. 
Advance directives let you make arrangements for your care if you become sick. Two common types of advance directives are: 

• A living will gives you a say in your health care if you become too sick to make your wishes known. In a living will, you can state what kind of care you do or don’t want. This can make it easier for family members to make tough healthcare decisions for you. 
• A durable power of attorney for health care lets you name the person you want to make medical decisions for you if you can’t make them yourself. Make sure the person you name is willing to make those decisions for you. 
• For legal matters, there are ways to give someone you trust the power to act in your place. 
• A general power of attorney lets you give someone else the authority to act on your behalf, but this power will end if you are unable to make your own decisions. 
• A durable power of attorney allows you to name someone to act on your behalf for any legal task, but it stays in place if you become unable to make your own decisions. 

Help for Getting Your Papers in Order 
You may want to talk with a lawyer about setting up a general power of attorney, durable power of attorney, joint account, trust, or advance directive. Be sure to ask about the lawyer’s fees before you make an appointment. 
You should be able to find a directory of local lawyers on the internet or at your local library, or you can contact your local bar association for lawyers in your area. Your local bar association can also help you find what free legal aid options your State has to offer. An informed family member may be able to help you manage some of these issues. 
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The science of super brains

What makes super-agers’ brains so super? A small study published in The Journal of Neuroscience looked at this question. Researchers enrolled 44 adults ages 60 to 80 and found that those who performed well on memory tests had brains with youthful characteristics. Specifically, the cortexes of their brains — the outermost layer of brain cells essential to many thinking abilities — were comparable in size to those of the younger adults in a control group. Scans found that the brain regions associated with the ability to learn and remember new information — which include the hippocampus and medial prefrontal cortex — were larger in super-agers than in normal older adults.
Lead researcher Dr. Bradford Dickerson, associate professor of neurology at Harvard-affiliated Massachusetts General Hospital, said that one of the most surprising findings was that the size of the super-agers’ brains did not fall somewhere between the younger people and the other older adults. “Their brain size was close to equal to that of the younger subjects, which suggests that the brain size was preserved,” he says.

Wouldn’t you like to be a super-ager too?

Are super-agers born or made? Probably a little of both, says Dr. Dickerson. “There may be a genetic component that makes them more resilient to natural aging, but it also may be associated with lifestyle habits,” he says.
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So, can you become a super-ager? While you may not be able to transport your brain back to your 20s, it may be possible to maintain and even improve some cognitive function with a combined approach to treatment, says Dr. Dickerson. For example:

• Do regular aerobic exercise. Research has suggested that aerobic exercise can improve cognitive function, even if you begin later in life or have shown signs of mental decline. A study presented at the 2016 annual meeting of the Radiological Society of North America found that older adults (average age 67) with mild cognitive impairment who exercised four times a week over a six-month period (using either a treadmill, a stationary bike, or an elliptical trainer) experienced an increase in brain volume and better executive function.
• Get plenty of sleep. Using MRI scans, a study in NeuroImage looked at the brains of 41 healthy men who were deprived of sleep for one night. The researchers found that compared with those who’d had a regular night’s sleep, they showed a decline in memory and attention. Older adults often have trouble falling asleep or staying asleep, problems that may reflect drug side effects or health conditions. See your doctor if you have sleep issues.
• Lower anxiety with meditation. Chronic levels of anxiety may speed up the conversion to Alzheimer’s disease in people with mild cognitive impairment (MCI). In fact, a 2014 study in The American Journal of Geriatric Psychiatry found that in MCI patients with mild, moderate, or severe anxiety, Alzheimer’s risk increased by 33%, 78%, and 135%, respectively. Mindfulness meditation can help lower anxiety levels, according to findings published online earlier this year by Psychiatry Research. Meditation programs for beginners are offered at many yoga studios and senior centers. You can try a free online guided meditation exercise from Ronald Siegel, an assistant clinical professor of psychology at Harvard Medical School.

Falls are particularly hard to study — and prevent — because no two falls are the same

Over the years I have interviewed hundreds of older adults who had recently suffered a fall, and one thing is clear: each fall occurs from the unique interaction of the person’s balance, the task they were performing just prior to the fall, and the ever-changing environment in which they were moving. All these things make it difficult to pinpoint the exact cause of a particular fall, and nearly impossible to uncover commonalities across all falls suffered by older adults.

The complexity of falls may be the key to their prevention

It is now quite clear that fall-prevention strategies that target just one factor with a well-known link to fall risk, such as muscle weakness, do not effectively reduce falls in older adults. Instead, researchers now believe that in order to keep older adults safe and free from falls over the years, interventions must continuously target multiple individual and environmental factors.

This current viewpoint is perhaps best highlighted by the ongoing STRIDE clinical trial. This pragmatic trial has enrolled 86 primary care practice sites across the country and over 5,400 older adults who are at risk for falls. The aim of this study is to compare the effectiveness of the current standard of care (which is primarily education about fall prevention) with individualized interventions developed by nurse “falls care managers” working in collaboration with primary care physicians. The falls care manager first assesses the older adult for eight key modifiable risk factors for falls and fall-related injuries: strength and balance, medications, vitamin D deficiency, home safety, orthostatic hypotension, visual impairment, foot problems and footwear, and osteoporosis. They use this information, together with personal preferences from each participant, to devise and implement an individually-tailored intervention that combines strategies for the older adult, recommendations for their doctor, and even referrals to health providers and local community-based organizations to support certain aspects of the intervention.

The STRIDE trial is closed to enrollment; however, data collection and analyses of its effectiveness are still underway. In the meantime, here are five specific actions you can take to minimize risk factors for falling.

• Make exercise part of your daily routine. According to the Harvard Medical School Special Health Report Better Balance, tight, inflexible, or weak muscles together with poor posture and endurance impinge on balance and can lead to falls. Regular, clinician-approved exercise can help counteract each of these factors. A recent analysis in the Cochrane Database of Systematic Reviews concluded that regular exercise may reduce the rate of falls by 23%, and the number of people who fall by 15%.
• Stay mentally active. Researchers have recently identified cognition as a key player in balance and fall risk. This is because we must pay attention to the world around us, avoid distraction, “remember” where our body is in space, and make the right decisions to modify our movements when our environment changes unexpectedly. It is for these reasons that staying mentally active, and participating in mind-body exercises such as tai chi, yoga, or dance, have been shown to be particularly effective fall-prevention strategies for older adults.
• Review your medications. Discuss all of your medications with your doctor and use them strictly as prescribed. Be aware that some medications have side effects (drowsiness, dizziness, muscle weakness, etc.) that may alter your balance and lead to a fall.
• Have your vision and hearing checked regularly. We depend on our vision and hearing to maintain our balance as we move through each day. Wearing glasses and hearing aids when prescribed can reduce the likelihood of balance issues and falls.
• Conduct an annual home inventory. Reorganizing the bedroom, kitchen, living room, and other common areas according to your needs is also important to reduce falls and/or prevent them from recurring over time. For example, keep medicines, clothing, food, dishes, and other necessities for day-to-day living within easy reach. Avoid scatter rugs and remove low-rise furniture, such as coffee tables and bookcases, that may clutter direct access to doors, hallways, and windows. Light the way day and night with lamps by the bed and nightlights in each room, and install light switches by all doors. Handrails on both sides of the stairs and grab bars for the shower and toilet are essential.

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It is also important to remember that falls have a significant impact on your quality of life, whether they cause injury or not. Just the fear of falling can cause loss of confidence and depression, which can lead to isolation and anxiety as older adults withdraw from outside activities or social engagements. Implementing multiple preventive measures early and evaluating them often can facilitate your mobility, reduce your chances of losing balance, and help maintain your quality of life for years to come.

Lesson 1: Happy childhoods matter

Having warm relationships with parents in childhood predicts that you will have warmer and more secure relationships with those closest to you in adulthood. We found that warm childhoods reached across decades to predict more secure relationships with spouses at age 80. A close relationship with at least one sibling in childhood predicts that people are less likely to become depressed by age 50. And warmer childhood relationships predict better physical health in adulthood all the way into old age.

Lesson 2: Fostering the welfare of the next generation can ease the sting of difficult childhoods

People who grow up in difficult childhood environments (chaotic families, economic uncertainty) grow old less happily than those who have more fortunate childhoods. But by the time these people reach middle age (ages 50 to 65), those who mentor the next generation — guiding younger adults at home or at work — are happier and better adjusted than those who do not. The kind of maturation needed to nurture younger people also seems to reduce some of the sting of growing up disadvantaged.

Lesson 3: Coping effectively with stress has lifelong benefits

We all have habitual ways of managing stress and relieving anxiety. Some people tend to ignore uncomfortable facts, while others tend to face difficult issues and deal with what is unpleasant. For example, someone who is angry at his boss might “forget about it” but start missing important work deadlines. Alternatively, he might find a way to take up his concerns directly with that boss. We found that the people who cope with stress by engaging more directly with reality rather than pushing it away have better relationships with others. This coping style makes it easier for others to deal with them, which in turn makes people want to help them. They end up having better relationships and more social support, and this predicts healthier aging in your 60s and 70s. People who use these more adaptive coping mechanisms in middle age also end up with brains that stay sharper longer.

Lesson 4: Breaking bad habits earlier in life makes a difference

Watching people’s smoking habits across adulthood, those who quit earlier are less likely to develop lung disease as they grow old. They are also more likely to live longer than people who do not quit smoking or who quit later in life. Our findings differ from some studies that find no change in risk of disease and death once you’re tobacco-free for 15 years or more. Getting off the couch and starting to exercise earlier in life predicts that you’ll stay healthy longer in life, that your brain will stay sharper, and even that your immune system will be stronger.

Lesson 5: Time with others makes us happier

Looking back on their lives, people most often report their time with others as the most meaningful part of life, and what they’re proudest of. Time with other people makes us happier on a day-to-day basis, and time with a close partner buffers us against the mood dips that come with increased physical pain.

You can learn more about the study and our research at www.robertwaldinger.com and www.adultdevelopmentstudy.org. We are now studying the children of these men. Almost 1,300 of these second-generation baby boomers are participating in our study, and we hope to know more about what helps people thrive across generations.
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Stay tuned.

Exactly how should you improve your diet?

Just what does “improving your diet” mean? Limiting unhealthy foods is a good start. Fewer French fries, less salt, and a little less ice cream are all good ideas and make sense. But this new report, and several expert guidelines, suggest that it’s not only what you don’t eat. What you do eat matters, too. It’s also important to eat more healthy foods.

In this study, researchers analyzed patient surveys between 1990 and 2012, food availability data from the Food and Agriculture Organization of the United Nations, and data on cardiovascular deaths in 2015. They estimated that the biggest contributors to the premature cardiovascular deaths of more than 220,000 men and about 190,000 women were due to

• high consumption of salt and trans fat (a particularly unhealthy form of unsaturated fat commonly found in processed foods as “partially hydrogenated oils”)
• low consumption of nuts, seeds, vegetables, and whole grains.

And here’s why it matters:
Cardiovascular disease is the #1 cause of death in the U. S.Cardiovascular disease accounts for an estimated 787,000 deaths each year. And dietary factors can affect one’s risk of cardiovascular disease because:

• obesity increases the risk of type 2 diabetes, and both obesity and diabetes are risk factors for cardiovascular disease

 

• high blood pressure (hypertension) is more common among those with high salt intake and obesity
• diet affects cholesterol levels
• research suggests that not eating enough fruits, vegetables, and fiber may increase risk.

Ever started a new diet?

It’s easy to make recommendations about improving dietary choices. Making long-lasting change is hard. Willpower and commitment is often not enough. Just ask anyone who has been frustrated by repeated and unsuccessful efforts to lose weight, lower blood pressure, or lower cholesterol by starting a new diet.

The pervasiveness of unhealthy diets and the epidemic of obesity in this country have led to the suggestion that we should approach this as a public health problem that might be improved by taxing unhealthy foods and subsidizing healthier options. Another new studylooked at the impact of this approach. In fact, in places where unhealthy foods were taxed or where healthy foods became less expensive through subsidies, diets tended to improve. Of course, that raises the question of how much government agencies or others should be involved in swaying consumers’ dietary choices. But from a public health perspective, the data seem clear: if you want to encourage healthier eating, one approach is through the pocketbook.

And, finally…

If you’re not sure what constitutes a healthy diet, it might be because there is no one diet that’s best for everyone. However, there a number of dietary guidelines worth considering, including:

• The Mediterranean Diet
• Choose My Plate from the USDA
• the Healthy Eating Plate from the Harvard School of Public Health and Harvard Medical School.

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Talk to your doctor about your diet. Depending on your overall health and current diet, it might be a good idea to meet with a nutritionist. The goal is to come up with a healthy diet you can stick with. It may not be easy, but a change that could prevent more than 400,000 deaths per year is a change worth making. After all, one of those prevented deaths could be yours.