Avow Hospice

Guiding an Improved Dementia Experience (GUIDE) Model Aims to Increase Care Coordination, Support for CaregiversNAPLES, FL (July 10, 2024) Today, Avow Care Services announced they have been selected by the Centers for Medicare & Medicaid Services (CMS) to participate in a new Medicare alternative payment model designed to support people living with dementia and their caregivers. Under CMS Guiding an Improved Dementia Experience (GUIDE) Model, Avow will be one of almost 400 participants building Dementia Care Programs (DCPs) across the country, working to increase care coordination and improve access to services and supports, including respite care, for people living with dementia and their caregivers.CMS is excited to partner with Avow under the GUIDE Model, said CMS Administrator Chiquita Brooks-LaSure. GUIDE is a new approach to how Medicare will pay for the care of people living with dementia. The GUIDE participants are envisioning new ways to support not only people living with dementia, but also to reduce strain on the people who care for them, so that more Americans can remain in their homes and communities, rather than in institutions.Launched on July 1, 2024, the GUIDE Model will test a new payment approach for key supportive services furnished to people living with dementia, including: comprehensive, person-centered assessments and care plans; care coordination; 24/7 access to an interdisciplinary care team member or help line; and certain respite services to support caregivers. People with dementia and their caregivers will have the assistance and support of a Care Navigator to help them access clinical and non-clinical services such as meals and transportation through community-based organizations."Our acceptance into the GUIDE Model emphasizes Avow's commitment to excellence in dementia care and our dedication to the communities we serve," said Jaysen Roa, President and CEO of Avow, Inc. "We are eager to implement this model, which aligns with our mission to offer support not only to our patients but also to their caregivers, enhancing both their well-being and quality of life."Avow participation in the GUIDE Model will help people living with dementia and their caregivers have access to education and support, such as training programs on best practices for caring for a loved one living with dementia. The GUIDE Model also provides respite services for certain people, enabling caregivers to take temporary breaks from their caregiving responsibilities. Respite is being tested under the GUIDE Model to assess its effect on helping caregivers continue to care for their loved ones at home, preventing or delaying the need for facility care.GUIDE Participants represent a wide range of health care providers, including large academic medical centers, small group practices, community-based organizations, health systems, hospice agencies, and other practices.This model delivers on a promise in the Biden Administrations Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers and aligns with the National Plan to Address Alzheimers DiseaseAbout Avow: Avow was founded in 1983 as Collier County's original, nonprofit hospice. Today, Avows nonprofit companies provide palliative care for adults and children facing chronic or serious illness and hospice care and bereavement support services for children and adults. To learn more about the scope of services provided by Avow, call 239-261-4404 or visit our website.  

Prescription opioids are sometimes used to treat moderate-to-severe pain. Because prescription opioids have a number of serious side effects, it is important for you to ask questions and learn more about the benefits and risks of opioids. Make sure youre getting care that is safe, effective, and right for you. This article provides information about nonopioid alternative treatments to manage pain. You and your healthcare practitioner can develop a course of treatment that uses multiple methods and modalities, including prescription medications such as opioids, and discuss the advantages and disadvantages of each approach. Pain management requires attention to biological, psychological, and environmental factors. Before deciding with your healthcare practitioner about how to treat your pain, you should consider options so that your treatment provides the greatest benefit with the lowest risk.Treatments provided by Licensed Healthcare ProvidersPhysical therapy (PT) and occupational therapy (OT). PT helps to increase flexibility and range of motion which can provide pain relief. PT can also restore or maintain your ability to move and walk. OT helps improve your ability to perform activities of daily living, such as dressing, bathing, and eating. Massage therapy. Therapeutic massage may relieve pain by relaxing painful muscles, tendons, and joints; relieving stress and anxiety; and possibly impeding pain messages to and from the brain. Acupuncture. Acupuncture is based on traditional Chinese medical concepts and modern medical techniques and provides pain relief with no side-effects by stimulating the bodys pain-relieving endorphins. Techniques may include inserting extremely fine needles into the skin at specific points on the body. Chiropractic care. Chiropractic physicians treat and rehabilitate pain, diseases and conditions using manual, mechanical, electrical, natural methods, physical therapy, nutrition and acupuncture.  Chiropractors practice a hands-on, prescription drug-free approach to health care that includes patient examination, diagnosis and treatment. Osteopathic Manipulative Treatment (OMT). Osteopathic physicians (DO) are educated, trained, and licensed physicians, but also receive additional training in OMT. OMT is a set of hands-on techniques used by osteopathic physicians to diagnose, treat, and prevent illness or injury. OMT is often used to treat pain but can also be used to promote healing, increase overall mobility, and treat other health problems. Behavioral interventions. Mental health professionals can offer many avenues for pain relief and management. For example, they can help you reframe negative thinking patterns about your pain that may be interfering with your ability to function well in life, work, and relationships. Behavioral interventions can allow you to better manage your pain by changing behavior patterns. Topical treatments and medications. Topical Agents, including Anesthetics, NSAIDs, Muscle Relaxers, and Neuropathic Agents, can be applied directly to the affected areas to provide needed pain relief and typically have a minimal risk of side-effects due to low absorption of the medication into the blood stream. Compounded topicals prepared by a pharmacist can be customized to the patients specific needs. Interventional pain management. Interventional procedures might include an injection of an anesthetic medicine or steroid around nerves, tendons, joints or muscles; spinal cord stimulation; insertion of a drug delivery system; or a procedure to stop a nerve from working for a long period of time. Non-opioid anesthesia. Non-opioid anesthesia. Non-opioid anesthesia refers to the anesthetic technique of using medications to provide anesthesia and post-operative pain relief in a way that does not require opioids. Anesthesiologists can replace opioids with other medications selected for their ability to block surgical and post-surgical pain. By replacing opioids and incorporating the variety of anesthetic and analgesic medications that block the process of pain, anesthesia providers can provide a safer anesthetic that avoids the adverse effects of opioids. Discuss these alternatives with your healthcare practitioner and talk about the advantages and disadvantages of the specific options being considered. Different approaches work better on different types of pain. Some treatments for pain can have undesirable side effects while others may provide benefits beyond pain relief. Depending on your insurance coverage, some options may not be covered, resulting in substantial out-of-pocket costs. Other options may require a significant time commitment due to the number of treatments or the time required for the treatment. Good communication between you and your healthcare practitioner is essential in building the best pain management plan for you. Information on Nonopioid Alternatives for the Treatment of Pain When you are selecting a healthcare practitioner, you can verify their license and find more information at: https://appsmqa.doh.state.fl.us/MQASearchServices/ Home You can find more information at these links. National Institutes of Health: https://nccih.nih.gov/health/pain/chronic.htm Centers for Disease Control and Prevention:  https://www.cdc.gov/drugoverdose/

Anxiety & Restlessness An inability to relax due to worry, or fear, about everyday situations. Experiencing anxiety & restlessness is common and treatable. However, if left unmanaged - these can interfere with you & your loved ones quality of life and create an unsafe situation. Two of the most common origins of anxiety & restlessness are: pain and trouble breathing. If you or your loved one is experiencing any symptoms of anxiety, it is important that you report this as soon as possible. Signs & Symptoms may include: Fatigue, or insomnia Trouble focusing Agitation Sadness or depression Increased heart rate, breathing, & sweating Nausea and/or vomiting Unpleasant sensations/cramps in extremities (arms & legs) What can be done to manage anxiety & restlessness? Always try calming relaxation techniques first: 1.Deep breathing, or the pursed lip exercise, 2.Listen to soothing music, or 3.Watch the Avow.tv Safe Place Guided Imagery video Express thoughts & feelings with an Avow Hospice Social Worker and/or Chaplain In combination with holistic treatments, an Avow Hospice nurse, or medical provider, is always available to discuss with you medication options, potential side effects, and frequency of when to give prescribed treatments. What should be reported to your Avow hospice team? Past history of anxiety and/or depression If your symptoms worsen or do not respond to your current interventions.Common Side Effects of Pain Medication Patients may receive help with pain, trouble breathing, or anxiety by their medical provider prescribing opioid (oh-pee-oyd) pain medications. These strong drugs help relieve discomfort and should always be taken as prescribed to avoid complications.  Tell your Avow team if the patient is experiencing these common and manageable side effects: Constipation: Pain medications can allow too much water to be absorbed, which can lead to hard or infrequent stools. Avow can prescribe medication (stool softener or laxative) to help manage constipation. Tell your Avow team if the patient has not had a bowel movement for three (3) days. Sleepiness: Feeling drowsy or sleepy only lasts a few days when starting, or increasing, a pain medication dose. This should go away as the body adjusts. Opioids are used to provide comfort, so this is normal. Patient caregivers: If you feel the patient is in their final weeks or days, tell the Avow team as soon as possible. Dizziness: When starting, or increasing, a pain medication dose, the patient may experience dizziness for the first couple of days. Dizziness typically decreases within that time. Be careful when changing positions (sitting to standing.) The patient may need assistance to prevent falls. Tell your Avow team about dizziness that does not go away after the first couple of days or if you or the patient has a fall. Ineffectiveness: If your loved one is still in pain after taking medication, he or she may need additional treatment. Tell your Avow team so we can make medicine or dosage changes that bring you relief. Nausea: Opioids can cause an upset stomach for the first few days, as the body adjusts to the medicine. Encourage the patient to eat a light snack (such as crackers) when taking opioid pain medication. Your Avow team may also treat the nausea with medication until it goes away. Tell your Avow team about nausea that does not go away, as it may be related to your condition. Remember: Do not skip or provide extra doses unless instructed by the Avow Hospice nurse.Constipation Hospice patients may experience constipation as a result of taking pain medication, moving less, eating and/or drinking less, or transitioning into a new phase of illness. They may suffer hard or infrequent stools that cause a great deal of anxiety, pain, and agitation. While bowel habits can vary from person to person, hospice patients should have a bowel movement at least once every three (3) days.  Signs and Symptoms: Dry, hard (pellet-like) stools Inability to pass stool Abdominal bloating Oozing, watery leakage Rectal pain or pressure If the patients constipation is left unmanaged, he or she may experience extreme pain, cramping, nausea, and vomiting. What can help with constipation? 1. If the patient is physically able to tolerate, or if his or her diet allows: Increase fluid intake to 6-8 glasses per day o Choose warm fluids such as water with lemon, tea, or prune juice Eat fibrous foods o Examples are bran, whole grains, fruits and vegetables Walk or do light Range of Motion (ROM) exercises Sit upright on the toilet, bedside commode, or bedpan Avoid fiber supplements (like Metamucil) as these can make symptoms worse 2. Keep a record of the patients bowel movements including date/time, consistency of stool (hard, soft, watery).  3. Talk to your Avow hospice nurse about prescribing a stool softener or laxative to help manage constipation.  What should you report to your Avow hospice team? The patient feels constipated or has not had a bowel movement in three (3) days Other symptoms such as nausea/vomiting, straining, diarrhea, pain, or rectal bleeding ,Dispelling the Myths of Opioids Opioids (oh-pee-oyd) is a class of drug that interacts with nerve cells in the body and brain to reduce feelings of pain and trouble breathing. Use of opioids in hospice care is common, necessary and a safe treatment option for pain and other symptom management. Your Avow Hospice nurse can address any questions or concerns you or the patient may have regarding the treatment plan and/or side effects of medications. Top 5 Myths of Opioid Use 1.Opioids are addicting Prescribed use of opioids to treat pain and other symptoms does not lead to addiction. This fearfulness to take pain medication can lead to suffering. Addiction is a chronic disease and only happens when a person misuses drugs despite physical or social harm. Addicts are not in control of their drug use. Opioids are strictly monitored and assessed on a routine basis. Always tell your care team if there is history of drug or alcohol abuse. 2.If a person takes large doses of opioids early in their disease process, the opioids will not be as effective later on when he/she needs higher doses. Tolerance is a reduced response to a drug used repeatedly. Hospice patients develop tolerance as their disease and symptom management needs increase. The right dose should give the same relief for quite a while. In many cases, the dose may increase when symptoms are worsening, then treatment could change to a lower dose once relief has been reached. If you are worried about this, talk to your care team about preferred options. 3.Giving opioids to a terminally ill patient will speed up death. Research shows that the use of opioids does not lead to a faster death. It is the disease that causes death, not the pain medicine. The small opioid dose for a hospice patient in their final weeks, days, or hours is to be used for comfort and relief of suffering and to allow the patient to experience a peaceful and dignified death. Withholding or withdrawing pain medication at the end of life is not appropriate or safe.Dyspnea (Trouble Breathing) Dyspnea (disp-nee-uh) is a medical term for troubled breathing. This symptom is closely related to heart and lung diseases. Experiencing difficulty breathing causes anxiety, agitation, fatigue and restlessness.  It may also interfere with daily activities such as eating, bathing, walking, talking and visiting with friends and family.  Signs and Symptoms Rapid breathing Tightness in the chest A feeling of being winded  Inability to speak in full sentences  Fear or panic about not getting enough air in or out of the lungs  What can be done to prevent and treat troubled breathing? Remain calm and reassuring for the patient o  Watch the Avow.TV Safe Place Imagery & Relaxation Music video Reposition the patient until his/her breathing improves o Raise the head of bed o Place pillows under the patients head, back and neck o Transfer the patient to a chair or recliner Increase air movement in the room by opening a window or using a fan  Apply a cool cloth to the patients head or neck Lead the patient in the pursed lip breathing exercise shown in the Avow.TV Caregiver Training video  Ask your Avow team about oxygen therapy for the patient . Your Avow Hospice nurse will train you how and when to safely administer oxygen  Medications (such as morphine or a nebulizer) may be needed to help o Your Avow Hospice nurse will discuss this with you and train on potential side effects  What should you report to your Avow hospice team? Breathing problems that continue or worsen   New or worsening cough  Need for additional oxygen or medication supplies for the patientEdema (Swelling)  Edema is unusual fluid buildup in the feet, ankles, legs, arms, hands or face. Congestive Heart Failure (CHF), liver, kidney or thyroid disease, and cancer can cause edema. Medications and diets with high salt can make the swelling worse.  Signs and Symptoms: Swollen joints, extremities or face  Trouble breathing Tightness in the skin or clothing  Indents or dimples left by accessories such as rings, watches or necklaces  Fluid oozing from the skin  What can be done to prevent and treat edema? Elevate the patients head, arms and/ or legs to a comfortable position o Your Avow Hospice nurse or aide will train you how to safely position and move the patient using pillows and assistive devices Avoid sitting, standing or crossing legs for long periods of time Limit consumption of high amounts of sodium (salt)  Examples are canned soups, processed foods and preserved meats  Wear compression stockings o Your Avow Hospice nurse can discuss this option with you and train you on their use Medications (such as diuretics) may be needed to treat edema  o Your Avow Hospice nurse can discuss this option with you and train you on potential side effects and dosage frequency  What should you report to your Avow hospice team? Any new or changed swollen areas Tenderness or pain in a reddened area  Changes in the color or temperature of the skin Trouble breathing or a persistent cough  Managing Fatigue Fatigue is defined as feeling tired, exhausted or generally lacking energy. This is a common symptom in both hospice patients and their primary caregivers. In hospice patients, fatigue may be caused by the persons illness, treatment, medications, emotions and other changes. For the caregivers, it is compassion fatigue and burnout. Education and support are essential with managing fatigue.   Signs and Symptoms: Increased agitation or restlessness Decreased motivation or lack of interest Emotional numbness Anxiety or sadness Sleep disruptions What can be done to prevent and treat fatigue in patients and their caregivers? Tell your Avow team about signs and symptoms you or the patient are experiencing Listen to your body and rest when you are feeling tired Establish a routine bedtime Take shorter naps earlier in the day Avoid caffeine before bedtime or patients: wear oxygen to sleep, if prescribed Prioritize and plan activities you enjoy .Allow time for self-care Utilize respite care Eat nutritious foods in small, easy-to-digest portions,  Protein, beans, fruits and vegetables Ensure or Boost What should you report to your Avow hospice team? Lifestyle or behavioral changes Treatments that are not working Medication side effects Avow is available 24 hours a day, 7 days a week (239)261-4404 National Suicide Prevention Lifeline is available 24 hours a day, 7 days a week 1-800-273-8255 Sadness & Depression Skin Care Tips Seriously ill patients may experience two common skin problems: pressure ulcers and chafed skin. Pressure Ulcer (Bedsore): is an area of the skin that loses its blood supply for extended periods of time. The skin reddens, breaks down, and becomes painful. If left untreated, wounds and infections could develop. Bedsores can be found on tailbones/ buttocks, joints (elbows, heels, ankles), back of the head, hips and spine.   Chafed Skin: is an irritation caused by heat, moisture or friction. Chafed skin occurs in areas of the body where there are skin folds. Examples are: groin, under breasts or in the abdomen. It is especially important to keep these areas clean and dry.  Even with the most attentive care, patients may still develop skin problems because of their declining condition. Heres what you can do: Make sure the patient changes position at least every 2 hours oIf the patient is unable to move safely by himself/herself, you may need to help Use warm water and gentle soap for baths Apply a lightweight lotion to the skin after bathing to increase moisture Keep bed linens clean, dry and free from wrinkles Change and apply clean absorbent pads and diapers often to keep skin dry of the patient uses a bedpan or bedside commode, move the patient off after a couple minutes to avoid pressure on the tailbone Never apply heat or further irritate reddened skin Your Avow team can order special supplies for the patient if needed, including:  Alternating pressure pad Special dressings What should you report to your Avow hospice care team? Irritated, itching or reddened areas of the skin Painful, burning or tingling of the skin Open wounds or new growths Do not attempt to lift or reposition anyone if you are unsure about your ability to do so safely. Use the push or rolling techniques that your hospice team members train you to use. 

Take Time to Grieve Avow provides guidance and support to families, relatives, friends and professional caregivers experiencing the loss through death of a significant relationship. Trained and experienced bereavement staff offer free programs to residents and visitors to the Collier County area. Understanding the ProcessUnderstanding the Process Loss through death can be one of lifes most difficult emotional challenges. Feelings may range from extreme loneliness and lack of energy to anxious activity, confusion and various physical symptoms. Few of us know what to expect and what to do. The grieving process may include some or all of the following: Shock and denial. Because of our own natural defense mechanisms, the announcement that a death has occurred is often shocking. It may take time for the reality of the tragedy to become clear. A sense of the unreality of death may recur throughout the grief process. Panic. When we lose a significant relationship, our emotional stability is disrupted and we may feel out of control. Preoccupation with the loss may cause us to question what our next actions will be or to feel panicky. Guilt. It is natural for us to have wanted everything done to save the person who has died. As we wonder what else might have been done, we may feel guilty. Anger. A need to find someone to blame for the loss is common. A feeling of hostility toward physicians, nurses, family members and God may develop. Loneliness. Bereavement can result in a feeling of emptiness and aloneness. When family and friends leave after the funeral, an even greater isolation may be experienced. Page 1Page Sleep, appetite and physical changes. Any combination of increased or decreased sleeping and eating may occur. A feeling of being tired, weak or hollow may also be experienced. Resistance to illness is low, making diet, rest, activity and expression very important. Readjustment. Eventually, the loss diminishes and reinvestment in life occurs. Allowing time to feel all normal feelings of grief and to express that grief helps the bereaved person become ready to live a new life and make plans for the future. Feelings    Sadness    Anger    Guilt    Anxiety    Loneliness    Fatigue    Helplessness    Shock    Yearning    Emancipation Physical    Relief    Numbness    Hollowness in stomach    Tightness in chest or throat    Sense of depersonalization (nothings seems real)    Breathlessness    Weakness    Lack of energy    Dry mouth 2 Symptoms of Grief Cognitive    Disbelief    Confusion    Preoccupation    Sense of presence    Visions/hallucinations Behavioral    Sleep disturbance    Appetite disturbance    Absent-mindedness    Social withdrawal    Dreams of the deceased    Avoidance of reminders    Searching, calling out    Restless over-activity    Crying    Visiting places or carrying     objects as reminders    Treasuring objects of the  deceased Page Things You Might Experience You can expect that your grief will probably:   Take much longer than most people think it will/should.   Take more energy than you ever would have imagined.   Involve many changes and be continually developing.   Show itself in all spheres of your life: psychological, social and physical.   Entail mourning not only for the actual person you have lost but also for all the hopes, dreams and unfulfilled expectations you held for that person, and for the needs that will go unmet because of the death.   Involve a wide variety of feelings and reactions, not solely those that are generally thought of as grief, such as depression and sadness. You may have some identity confusion as a result of this major loss and of the reactions you are experiencing that may be quite different for you. You may:   Grieve for many things both symbolic and tangible, not just the death alone.   Have a combination of anger and depression, such as irritability, frustration, annoyance, or intolerance.   Feel some anger and guilt, or at least some manifestation of these emotions.   Lack self esteem.   Experience grief spasms: acute upsurges of grief that occur suddenly with no warning.   Have trouble thinking and making decisions.   Feel as if you are going crazy.   Find yourself having a number of physical reactions.   Find that there are certain dates, events, stimuli or even experiences that bring upsurges of grief.   Begin a search for meaning and question your religion and/or philosophy of life. Society may:     Have unrealistic expectations about your mourning and may respond inappropriately to you. 3Page Is There a Right Way to Grieve? This is a normal question. Each person has his or her own way and pace, but there are common reactions people seem to have. The following are natural responses to grieving loss. 4    Am I doing this right?     How should I feel?    I seem to have no control.    Im so relieved its over.    I hurt so much I ache.    Its as if Im on the outside looking    on as the world goes by.    I cant concentrate and Im     absentminded.    This cant be real.    My throat feels tight.    My chest feels heavy.    What do I have to live for?    Sometimes I get so angry.    I cry at unexpected times.    I dont want to be around others.    I dont want people seeing me     when Im sad.    What am I going to do?    Im not hungry anymore.    I seem to be eating all of the time.    I sometimes feel or hear the     presence of him/her.    I feel so empty.    I dont like making decisions alone.    I feel numb.    Im so lonely. Page Keys to Grief Release Expression take the time to be purposeful    Writing    Drawing    Artistry    Talking    Rituals    Memory box    Shrine    Plant a tree in memory of    Donation in memory of    Memorial service on special date    Wear black, mourning jewelry, armband    Hang a wreath    Sobbing (use a towel)    Humor and laughter Reminiscing and relationship examination Redefinition    Of self    Of roles    Of terms    Strength as courage not stoicism     Sobbing as courageous not falling apart Reading Seeking others support Belief examination Meditation/Prayer/Affirmations Giving self permission Balancing    Wallowing with staying busy    Expression with withdrawal    Solitude with social    Relief with sorrow    Reminiscing with planning the futureSteps to Survival 1. Recognize the loss.  For awhile, you are numb. It has happened - try not to avoid it. 2. Be with the pain.  Youre hurting. Admit it. To feel pain after loss is normal. It is proof that you are alive; proof that you are able to respond. 3. You are not alone.  Loss is part of life. Everyone experiences it. 4. Youre a beautiful, worthwhile person.  You are much more than the emotional wound you are presently feeling. 5. You will survive.  Believe that you will heal. 6. Give yourself time to heal.  The greater the loss, the more time it will take. 7. Healing has progressions and regressions.  Healing and growth are not smooth upward progressions, but are full of ups and downs - dramatic leaps and depressing backslides. 8. Tomorrow will come.  Your life has been full of positive experiences. They will return. 9. Take good care of yourself.  Get plenty of rest. Stick to a schedule. Plan your days. Activity will give you a sense of order. 10. Keep decision-making to a minimum.  Expect your judgment to be clouded for awhile. You are going through change; dont make more decisions than you have to. 11. Seek comfort from others.  Its human and courageous. 12. Surround yourself with living things.  A new plant, a pet, a bowl of fresh fruit. Reaffirm your beliefs.  Use your faith right now. Explore it, lean on it, grow. 14. Recognize that weekends and holidays are the worst. Schedule activities you particularly enjoy. 15. Suicidal thoughts: these may arise - they are a symptom of pain. If you feel that they are getting out of control, seek professional help. 16. Do your mourning now. Allow yourself to be with your pain. It will pass sooner. Postponed grief can return to hound you. Grief feelings will be expressed one way or another. 17. Be gentle with yourself. You have suffered a disabling emotional wound. Treat yourself with care. 18. Let yourself heal completely. Give yourself time. You are a convalescent right now. Dont jump into new things too quickly. 19. If mementos are helpful to you, use them. If they bind you to a dead past, however, get rid of them. Before you say hello, you must say goodbye. 20. Anticipate a positive outcome. Pain is acceptable - it tells us we are hurting. But it is not a welcome long-term visitor. 21. It is OK to feel depressed. Crying is cleansing - a wonderful release. Be with these feelings for awhile. 22. Its OK to feel anger. Everyone acts angry at the loss of love. Channel it wisely and it will go away as you heal. Hit a pillow. Kick a bed. Yell and scream when youre alone. Run. Play hard games. Hit a punching bag. Play the piano. 23. Good eating habits help the healing process. Make sure you are nourished. 24. Youre vulnerable. Your resistance will be low. Invite help only from those who are trustworthy. Beware of the rebound. Theres a hole in your life. Be careful about rushing to fill it. 26. Beware of addictive activities. Alcohol, drugs, food, and diversions can all momentarily help us escape from pain. These never help us to heal. 27. Set a time limit on mourning. Remaining distraught for a long time is no proof that youre really loved. Real love is self-supporting. 28. Keep a journal. Putting your thoughts and feelings on paper is a good way to get them out. You can also refer back and see just how far you have come. 29. Heal at your own pace. Never compare yourself to another grieving person. Each of us has our own time clock. 30. You will grow. As you work through your sadness, you will grow. You may begin to understand that change and separation are a natural part of living. You are a better person for having loved. 31. Begin to look to the future. Begin to experiment with new lifestyles - new ways of filling the day. They might even turn out to be fun. 32. Give yourself praise. You are a richer, deeper, wiser person for having survived your grief. 33. Be open. Be open to new people, places, ideas, and experiences, but dont forget to build on the past. Dont throw out what has been worthwhile to you. Small changes are the best at first. 34. Begin to give of yourself. Giving can bring you the greatest joy. It is healing. 10 Grief Journal Today I felt so lonely. After allowing myself to cry, I called a friend. Now I feel less alone. Steps to Survival, continued...Page Grief Work Grief work begins when the honeymoon period is over, the friends have stopped calling, and everyone thinks you should be over it; things are supposed to be back to normal. Its at this point that real grieving begins. One common definition of grief work is summarized by the acronym T.E.A.R.: T =   To accept the reality of the loss. E  =   Experience the pain of the loss. A   =   Adjust to the new environment without your loved one. R   =   Reinvest in a new reality. Grief is Not an Enemy Grief is not an enemy it is a friend. It is a natural process of walking through hurt and growing because of the walk. Let it happen. Stand up tall to your friends and to yourself and say, Dont take my grief away from me. I deserve it, and I am going to have it. Doug Manning 11 35. Expect relapses. There will always be certain things that trigger sadness again. This is normal. 36. Alone does not mean lonely. Solitude can be creative, restful, and even fun. You can learn to enjoy it. 37. Enjoy your freedom. You are now in control. Make the most of your choices. You can even learn to take risks. 38. Celebrate your survival! LOSS = PAIN = GROWTH

Chances are you have heard that many older charitably minded people can benefit from making gifts directly from their individual retirement accounts (IRAs). Technically known as a qualified charitable distribution (QCD), this strategy is often informally referred to as an IRA charitable rollover.The primary benefits of an IRA charitable rollover are familiar to many. If a donor has reached the age of 70, he or she can make a gift from an IRA directly to a charitable organization without the amount of the distribution being treated as taxable income to the donoreffectively making the distribution a deductible gift. Furthermore, if the donor has reached the age at which he or she must take a required minimum distribution (RMD) from qualified retirement plans, a gift directly from an IRA reduces the amount of the RMD that otherwise would be taxable income on a dollar-for-dollar basis up to a maximum of $100,000 per taxpayer per year.These benefits have proved to be the headline grabbers, and rightfully so. There are, though, additional, often overlooked, benefits of IRA rollovers. Among those is the ability of a QCD to help many donors avoid additional tax on their Social Security benefits. Heres why: Up to 85% of Social Security benefits can be taxable, and the portion that is taxable is determined by the amount of other income the taxpayer has.A distribution from a retirement plan to a taxpayer is generally taxable and gets added to other income in determining how much of the taxpayers Social Security benefits gets taxed. Unless the recipient is already subject to the 85% maximum, more of the recipients Social Security benefits will be subject to taxeven if the recipient uses the distribution to make a charitable gift.A QCD, however, goes directly to the charitable organization without being considered distributed to the taxpayer and, therefore, does not increase the portion of Social Security benefits that are taxable. If you are intending to make charitable gifts and are old enough to make qualified charitable distributions, you will likely be well served by using QCDs to fund your philanthropic goals. Check with your financial advisor to determine your eligibility to make a QCD.

Avow Foundation, Inc. announces it has received a gift of $795,000 from the Nancy L. Weinig estate. The gift will be used to help seriously ill community residents who can benefit from hospice care.According to Mrs. Weinigs estate planning lawyer, Bradley G. Rigor of Quarles and Brady, LLP, Ms. Weinig was deeply touched by the loving care her close friends and family received through Avows hospice care services, and wanted to help Avow continue its wonderful work.Avow was founded on the belief that all people in our community who are at end of life deserve the special care that is hospice. We never turn away patients who cannot pay for services. Ms. Weinigs gift will help cover direct patient care costs and fund special therapies such as music, massage and Reiki energy treatments, which are funded 100% by donations.Donations to Avow Foundation, Inc. support Avows hospice services in Collier County, Florida and palliative care services in southwest Florida.To learn more about Avow Foundation, Inc. visit avowcares.org/donate-now or call 239-261-4404.About AvowAvow was founded in 1983 as Collier Countys original, nonprofit hospice. Today, Avows nonprofit companies provide palliative care consultations for people facing chronic or serious illness and hospice care and bereavement support services for children and adults.Avow Foundation develops and stewards resources that support Avows nonprofit, mission-driven services. The Foundation links people with opportunities that fuel their dreams, satisfy their desire to serve others, and ignite their benevolent spirit.About Quarles & Brady LLPQuarles & Brady is a full-service AmLaw 200 firm with more than 475 attorneys offering an array of legal services to corporate and individual clients that range from small entrepreneurial businesses to Fortune 100 companies, with practice focuses in health care and life sciences, business law, labor and employment, real estate, data privacy and security, and complex litigation. The firm has offices in Chicago; Indianapolis; Madison; Milwaukee; Naples, Florida; Phoenix; Scottsdale; Tampa; Tucson; and Washington, D.C. Additional information can be found online at Quarles.com, as well as on Twitter, and Facebook.

Did you know that 56% of Americans either do not have an estate plan or have one that needs to be updated to meet their current circumstances? This is an interesting statistic given that surveys show more than 75% of Americans believe it is important to have a competent estate plan.Each year, August is designated as National Make-A-Will Month. The purpose of this promotion is to encourage all Americans to have a will that adequately and accurately distributes their assets following their death to their loved ones and favorite charitable organizations.Taking the initial steps to create a will is difficult for many people even though they know the importance of having an up-to-date will. Here are some steps that you can take to get the momentum rolling no matter what category you are in.I do not have a will. Without a will, your assets will be distributed according to the rules established by your state of residence. Those rules likely do not follow your wishes, and, in some cases, they may even be the opposite of what you desire. Nor does your states distribution plan include charitable gifts. To avoid these disastrous results, consider the following simple steps:Make a list of all your assets including real estate, investments, retirement accounts, life insurance policies, and personal property such as cars, jewelry, boats, collections, etc.Make a list of the individuals whom you would like to remember with a gift from your estate.Make a list of the charitable organizations that have impacted your life that you would like to remember with a gift from your estate.You are well on your waythose three simple lists are the building blocks of every will! Your attorney will be grateful because this allows him or her to prepare your will quickly and efficiently.I have a very old will that needs to be updated. An outdated will can be nearly as disastrous as having no will at all. It is highly likely that many of your circumstances have changed, some of which you could not even fathom when you created your original will. To make sure you have a will that accurately reflects your current wishes, update the three lists above and consider these additional steps:Review the beneficiary designations of your retirement plans and life insurance policies to make sure they are aligned with the rest of your will.If you have a donor-advised fund, make sure you have completed a beneficiary-designation form so that those assets go to the charities you wish to support.Make sure your executor is still capable of handling that task. Name a contingent executor should your original executor not be able to fulfill those duties.My will is up to date! It is easy to be smug if you have an updated will. However, it is important to continually monitor your circumstances so that your currently accurate will does not quickly become outdated. For example, if you have children, what changes should you make when one or more of them are married, have children of their own, get divorced, or become incapacitated? And how quickly should you make those changes? Another example is when your favorite charity launches a new program that you think will set the course for its future. Should you modify your bequest to the charity to take that into account?We would be happy to assist you in exploring your options in a no-obligation discussion. Just contact our office via email or phone to meet with one of our gift planning experts.

Grief at the Holidays Tips for Coping01 November 2016 | webmasterGrieving the loss of someone is always challenging, but it can be increasingly so during holiday time. If you are dealing with loss or know someone who is, the following tips may be helpfulTips for those dealing with grief:Dont be afraid to change traditions. Old ones wont be the same so new ones may help. Keep the ones that are comforting.Show your emotions expression is healthy and positive.Rely on others.Remember children and encourage expression of their emotions.Dont block memories verbalize them.Trust your feelings. Dont say should to yourself.Seek out support from any belief systems you may have.Be patient with yourself.Shop early and avoid the added stress of holiday crowds.Seek out private time and options for fun.Help others.Tips for supporting someone who is grieving:Dont pretend that nothing has changed. Experiment with new traditions and acknowledge the difference from old ones.Encourage expressions of emotion and show your acceptance.Take initiative and dont wait for the bereaved to ask.Remember children and encourage expression of their emotions.Reminisce with the bereaved. Use the loved ones name, make a toast, acknowledge.Dont use should to the bereaved. Let them do their holidays their way.Accept decisions made by the bereaved. You dont have to approve.Encourage or offer to take them shopping early for presents.Provide time alone and fun time.Let the bereaved help you.Be patient.Avow bereavement professionals are available to take your calls at 239-261-4404 or join us at one of our open grief support group sessions.

Even for the wealthiest among us, the extent of our resources is finite. Many donors tell us one of the major factors they weigh in deciding whether or not to make a significant charitable gift is the impact the gift may have on their ability to fulfill other personal financial goals. Often, the goal they are most concerned about is leaving substantial assets to family members.Some donors have been able to allay those concerns to some degree by using a strategy that allows them to restore someor, in some cases, allof the value of a charitable gift to their assets. Simply stated, those donors use the tax savings they generate by making a significant charitable gift to purchase life insurance on themselves. Heres how that can work:Example: Faithful supporters Bill and Linda have decided to make a $250,000 contribution to fund a new program important to our mission even though they intend for their children, Marie and Jason, to ultimately receive the bulk of their estate. They are comfortable doing this because, in their 37% federal income-tax bracket, the gift will save them $92,500 in taxesand they plan to use those savings to purchase a life insurance policy. That policy will pay a death benefit of $200,000 to Marie and Jason when Bill and Linda have both passed, restoring most of the value of their gift to their estate.The degree to which this strategy works for a specific donor or donors depends on a number of variables. For example, the tax savings realized depend on the donors federal income-tax bracketand the amount of those savings determines how much insurance can be bought. And, of course, the younger the donor is, the more insurance that donor will be able to purchase with those savings. There are many different types of life insurance policies, and it is important to choose the one that best allows you to achieve your objectives.This so-called asset-replacement strategy may be extremely useful to you in your planning. But, before jumping in, we urge you to consult your financial advisors on whether this is appropriate for youand to direct you to the right insurance professional. We would be pleased to discuss the potential tax benefits of a gift with you and your advisors.