Becoming helpless and dependent is one of the most common fears among people with a potentially disabling health problem. This fear usually has physical as well as financial, social and emotional components.

As your health condition changes over time, you may need to consider changing your living situation. These changes may involve hiring someone to help you in your home, or moving to a living situation where help is provided. The decision about which alternative is best will be related to your needs and how best these can be met.

The first thing you will need to do is carefully evaluate what you can do for yourself, and what activities of daily living (ADLs) will require some kind of help. ADLs are the everyday things like getting out of bed, bathing, dressing, preparing and eating your meals, cleaning house, shopping, paying bills, etc. Most people can do all of these, even though they may have to do them slowly, with some modification, or with some help from gadgets.

Some people, though, may eventually find one or more of these no longer possible without help from somebody else. For example, you may still be able to fix meals, but your mobility may be impaired to the degree that shopping is no longer possible. Or, if you have problems with fainting or sudden bouts of unconsciousness, you might need to have somebody around at all times. When you have analyzed your situation, you should make a list, with one column for those activities that you need help with, and the other column for some ideas on what kind of help you might look for.

Example:

Can't go shopping:

• Get daughter to shop for me
• Find a volunteer shopping service
• Shop at a store that delivers
• Ask neighbor to shop for me when she does her own shopping
• Get home delivered meals

Can't be by myself:

• Hire an around-the-clock attendant
• Move in with a relative
• Get a "Life-Line" emergency response system
• Move to a board and care home
• Move to a retirement community

When you have listed your problems, and the possible solutions to the problems, select the solution that seems the most workable, acceptable and least expensive for your needs.

The selection will depend upon your finances, the family or other resources you can call on, and how well any of the potential solutions will in fact solve your problem. Sometimes, one solution will be the answer for several problems. For instance, if you can't shop, can't be alone, and maybe household chores are reaching the point of a foreseeable need for help, you might consider that a retirement home will solve all these problems, since it offers meals, regular house cleaning, and transportation for errands and medical appointments.

Even if you are not of "retirement" age, many facilities accept younger people, depending on the facility's particular policies. Most facilities for the "retired" take residents as young as 50, or younger if one of a couple is the minimum age. If you are a young person, the local center for the disabled or "independent living center" should be able to direct you to an out-of-home care facility appropriate for you.

Your appraisal of your situation and needs may well be aided by sitting down with a trusted friend or relative and discussing your abilities and limitations with him or her. Sometimes another person can spot things we ourselves overlook, or would like to ignore.

Make changes in your life slowly, incrementally. You don't need to change your whole life around to solve one problem. Remember, too, that you can always change your mind, if you don't burn your bridges behind you. If you think that moving out of your own place to another living arrangement (relatives, care home, etc.) would be the thing to do, don't give up your present home until you are settled in to your new home, and are sure you want to stay there.

If you think you need help with some activities, hiring help at home is less drastic than moving out, and may be enough for quite a while. If you can't be alone, and you live with a family member who is away from home during the day, maybe going to an adult or senior day care center will be enough to keep you safe and comfortable while your family is away. In fact, adult day care centers are ideal places to find new friends and activities geared to your abilities.

A social worker at your local senior center, center for the disabled, or your hospital social services department can be very helpful in providing information about resources in your community, and also in giving you ideas about how to deal with your care needs. There are several kinds of professionals who can be of great help. As previously mentioned, social workers are good for helping you decide how to solve financial and living arrangement problems and locating appropriate community resources. Some social workers are also trained in counseling the disabled and/or the elderly in relation to emotional and relationship problems that may be associated with your health problem.

A licensed occupational therapist can assess your daily living needs, and suggest assistive devices or rearrangements in your environment to make life easier.

An attorney specializing in elder law should be on your list for helping you set your financial affairs in order to preserve your assets, to prepare a proper will, and perhaps to execute a durable power of attorney for both health care and financial management. If finances are a concern, ask your local senior center for the names of attorneys who offer free or low cost services to seniors. Your local Bar Association can also refer you to a list of attorneys who are competent in this area. These attorneys are generally familiar with the laws applying to younger disabled persons as well. Even if you are not a "senior," your legal needs are much the same as those of the older person.

If you find that you cannot manage your ADLs alone, the first option is usually to hire somebody to help. Most people just need a person called a home aide, or some similar title. These are people who provide no medically related services needing special licensing, but do help with bathing, dressing, meal preparation, and household chores.

There are a number of ways to find somebody. The easiest, but most expensive, is to hire someone through one of the home care agencies, usually listed under "home care" or "home nursing" in the telephone yellow pages. These are usually (but not always) private, for-profit businesses that supply caregiver staff to private individuals at home. The fees charged vary with the skill and license of the caregiver, and will include an amount for social security, insurance, bonding, and profit for the agency.

The fees are usually about double what you would expect to pay for someone you hire directly. The advantage, if you can afford it, is that the agency assumes all payroll responsibilities, including social security and federal and state taxes, responsibility for the skill and integrity of the attendant, and can replace an ill or no-show attendant right away. The agency pays the staff directly. The client has no involvement with paying the attendant, but pays the agency.

Registered nurses (R.N.) hired this way are very expensive, but it is rare that home care for a chronically ill person requires a registered nurse. Licensed vocational nurses (L.V.N.) will cost somewhat less, but are still expensive, and are usually not needed unless there are nursing services required (such as dressing changes, injections, ventilator management, etc.). Certified nursing assistants (C.N.A.) have some basic training in nursing, are much less expensive, and can provide satisfactory care for all but the most critically ill person at home.

Most of these agencies also supply home aides as well as licensed staff. Unless you are bed-ridden, or require some procedure that must be done by someone with a certain category of license, a home aide will most likely be the most appropriate for your needs.

There are registries that supply pre-screened lists of attendants or caregivers, from which you select the one you wish to hire. The agency will charge a "placement fee," usually equal to one month's pay of the person hired. The agency will assume no liability for the skill or honesty of these people, and it will be necessary to check references and interview carefully, just as you would someone who comes from any other source. This type of resource can be found in the yellow pages under the same listing as "home nursing agencies" or "registries." Some agencies provide both their own staff and registries of staff for you to select from.

Other resources that may provide help at home include senior centers and centers serving the disabled population. They often have listings of people who have called them to say they want work as a home attendant, or have put a notice up on a bulletin board there. These job seekers are not screened, and need to be interviewed carefully and have references checked before they start on the job.

Many experienced home care attendants use the local newspaper's classified "employment wanted" section to find new jobs. Home attendant jobs tend to be temporary, since one's patient usually progresses to a need for more or sometimes less care than they provide, so the attendant must then look for a new job. Again, one can find a competent helper through the newspaper, but the advice to interview carefully is valid here, too.

Probably the best source of help is word of mouth, from somebody who has employed a person, or knows of somebody who has worked for someone they know. Putting the word out through your family and social network may result in a jewel.

Home sharing may be a solution for the person who has space, and could offer a home to someone in exchange for help. This works best if the help needed consists mainly of household and garden chores. Some people may be willing to provide personal care, such as help with dressing and bathing and meal preparation. Some communities have agencies or government bureaus that help home-sharers and home-sharers locate each other.

The person who needs very little personal care, but recognizes the need to live in a more protected setting, with security, emergency response services, etc., and who is older (usually over 50) may wish to consider a retirement community. These may be owned units, rental units, or so-called "life care" facilities. The "life care" facility requires a substantial advance payment (called an endowment, accommodation fee, or similar label), plus a monthly charge that covers space, services and, in some cases, personal and/or nursing care when or if the need for that comes. Other such facilities are subsidized (as of this writing) by the federal government for low-income applicants. The criteria for what constitutes low-income is set by the rules governing the federal subsidy that finances the organization.

There are almost always waiting lists for retirement communities, even before they are built and ready for occupancy. If you think such a place would be right for you, you should get on the waiting list right away. You can always change your mind or decline if you are not ready when a space is offered. To locate a facility in your community, call the Senior Center or go to the library and consult the directory of the Association of Homes for the Aged. Your reference librarian should be able to help you find this publication.

Residential care homes, or board and care homes, are licensed by the state or county social services agency. They provide non-medical care and supervision for those who cannot live alone. These homes fall into two categories, large and small. The small ones have about six residents, who live in a family-like setting in a neighborhood residence. The large ones have more residents, sometimes hundreds, who live in a boarding house or hotel-like setting. They take meals in a central dining room, and have individual or shared rooms, with activities in large common rooms.

In either type facility the services to the residents are the same -- all meals, assistance with bathing and dressing as needed, laundry, housekeeping, transportation to medical appointments, supervision and assistance with taking medications. In the larger facilities, there are usually professional activities directors. Residents of the larger facilities usually need to be more independent, since there tends not to be as much personal attention as in the smaller homes.

These homes are licensed in most states for either "elderly" (over 62) or "adult" (under 62). The adult category is further divided into facilities for mentally ill, mentally retarded, or physically disabled.

It is important when considering a residential care home to evaluate the type of residents already living there to make sure that you will fit in. For example, some of these facilities may cater to individuals who are mentally confused. If you are mentally clear, you would not find much companionship there. If everybody is hard of hearing, you might have trouble finding anybody to talk to.

Although all homes are by law required to provide wholesome meals, you should make sure the cuisine is to your liking, and can meet your dietary needs. If you need a salt-free or diabetic diet for instance, be sure the operator is willing to prepare your special diet.

The monthly fees for residential care homes vary, depending upon whether they are spartan or luxurious. The most spartan facilities cost about the same as the SSI (Supplemental Security Income) benefit, and will take SSI beneficiaries, billing the government directly. The more luxurious the home is with respect to furnishings, neighborhood, services, etc., the greater the cost. However, even the nicest of these will probably cost less than full-time, 24 hour, seven day at home care.

Sometimes called "nursing homes" or "convalescent hospitals," the skilled nursing facility provides the most comprehensive care for severely ill or disabled people. Some of you may have already spent some time in a nursing home. Typically, a person who has had a stroke or a hip or knee replacement will be transferred from the acute hospital to a skilled nursing facility for a period of rehabilitation before going home. Recent studies have shown that almost half of all people over 65 will spend some time in a nursing home, many of them only for a short time.

No care situation seems to inspire more fear than the prospect of having to go to a nursing home. "Horror stories" in the news media help to foster anxiety about what awful fate will befall anyone who has the misfortune to have to go there.

Public scrutiny is valuable in helping assure that standards of care and humane and competent treatment are provided. It must be remembered that nursing homes serve a critical need. When one really needs a nursing home, usually no other care situation will meet this need.

Skilled nursing facilities provide medically related care for people who are no longer able to be in a non-medical care situation. This means that there may be medications to be administered, either by injection or intravenously, or monitored by professional nursing staff. A nursing home patient is usually very physically limited, needing to have help getting in and out of bed, eating, bathing, or dealing with bladder and/or bowel control. Skilled nursing facilities can also manage care of feeding tubes, respirators, and other "hi-tech" care equipment.

For those who are partially or temporarily disabled, the skilled nursing facility also provides physical, occupational and speech therapy, wound care, and other therapies.

Not all nursing homes provide all types of care. Some specialize in rehabilitation and therapies and some specialize in long-term, custodial care. Some are able to provide high-tech nursing services, others do not.

In selecting a nursing home, you should seek out the help of the hospital discharge planner or social worker, or a similar professional from a home care agency or center for seniors or the disabled. There are organizations to monitor local nursing homes. Each nursing home is required by law to post in a prominent place the name and phone number of the "ombudsman," a person assigned by the state licensing agency to assist patients and their families with problems in relation to their nursing home care. The agencies that can help you with this are listed in the yellow pages under "social service organizations."

Next to the basic fear of physical dependency, the greatest fear most people experience is the fear of not having enough money to pay for one's needs. Being sick often requires expensive care and treatment. If you are too ill or disabled to work, the loss of income, and especially your health insurance coverage, may present an overwhelming financial problem. You can, however, avoid some of the risks by planning ahead and knowing your resources.

Health insurance and Medicare may meet only a part of the ultimate total cost of your care. There are many needs that Medicare does not meet at all. Most private "Medi-gap" insurance policies cover only the 20% "co-payment" of what Medicare does cover.

However, supplemental insurance policies are becoming more available. Due to increasing concern and pressure on the part of public interest groups and governmental bodies, these policies are beginning to offer the kind of coverage that provides for care needs that Medicare and "Medi-gap" insurance do not pay for. If you plan to buy such insurance for yourself, carefully read the sections on limitations and exclusions. Be sure the policy covers nursing home care at a daily rate level that is realistic for your community. Check that it will cover treatments or care for "pre-existing conditions." Some policies have a waiting period for such pre-existing conditions, usually three to six months. Others won't cover you at all for any condition that was diagnosed before the start date of the policy.

If you are too sick to work, either permanently, or for some extended period, you may be entitled to draw your Social Security on the basis of your disability. If you have dependent children, they would also receive benefits. If you have been disabled for a specified period (as of this writing it is two years), you may be entitled to Medicare coverage for your medical treatment needs.

If you have only minimal savings and little or no income, the federal Medicaid program can pay for medical treatment and long term skilled or custodial care. The eligibility rules on assets and income differ from state to state. If you have savings of less than the U.S. median of one month's wages, and income at or slightly above the official federal "poverty line" (this changes from year to year), you should consult your local social services department to see if you are entitled to benefits.

If Social Security benefits are unavailable or insufficient, the Supplemental Security Income (SSI) program is available to those who meet the eligibility criteria outlined above for Medicaid.

The SSI and the Medicaid programs are available to those who have little or no income or savings. If you have some savings, you will have to pay for your care until you have "spent down" to meet the asset limitation criteria. If you have income above a certain level, you will have what is termed a "co-payment," or "share-of-cost," which you will pay before Medicaid would begin to supplement.

The social work department in the hospital where you have obtained treatment can advise you about your own situation and the probability of your being eligible for these programs. The local agency serving the disabled usually has advisors who can refer you to programs and resources for which you may be eligible. Senior centers often have counselors knowledgeable about the ins-and-outs of health care insurance.

Let's talk about the emotional aspects of becoming dependent. Every human being emerges from childhood reaching for and cherishing every possible sign of independence -- the driver's license, the first job, the first checking account, the first time we go out and don't have to tell anybody where we are going or when we will be back, and so on. In these, and many other ways, we demonstrate to ourselves as well as to others that we are "grown up" -- in charge of our lives and able to take care of ourselves without any help from parents.

If a time comes when we must face the realization that we need help, that we can no longer manage completely on our own, it may seem like a return to childhood, and having to let somebody else be in charge of our lives. This can be very painful and embarrassing.

Some people in this situation become extremely depressed, and can no longer find any joy in life. Others fight off the recognition of their need for help, thus placing themselves in possible danger, and making life difficult and frustrating for those who would like to be helpful. Still others give up completely, and expect others to take total responsibility for their lives, demanding attention and services from their children or other family members. If you are having one or more of these reactions, you can help yourself to feel better, and develop a more positive response.

The concept, "...change the things I can change, and accept the things I cannot change, and have the wisdom to know the difference," is really fundamental to being able to stay in charge of our lives. You must be able to correctly evaluate your situation. You must identify those activities requiring the help of somebody else (going shopping, cleaning house, for instance) and those activities you can still do on your own (getting dressed, paying bills, writing letters).

This means making decisions, and as long as you keep the decision-making prerogative, you are in charge. It is important to make a decision and take action while you are still able to do so, before circumstances intervene and the decision gets made for you. That means being realistic and honest with yourself.

Some people find that talking with a sympathetic listener, either a professional counselor or a sensible close friend or family member, is very comforting and helpful. An objective listener often helps by pointing out alternatives and options you may have overlooked or were not aware of. They can provide information, or another point of view or interpretation of a situation that you would not have come upon yourself. This is part of the self-management process.

Be very careful, however, in evaluating advice from somebody who has something to sell you. There are many people whose solution to your problem just happens to be whatever it is they happen to be selling-health or burial insurance policies, special and expensive furniture, Sunshine Cruises, special magazines or health foods with magical curative properties.

In talking with family members or friends who offer to be helpful, be as open and reasonable as you can be, and at the same time, try to make them understand that you will reserve for yourself the right to decide how much and what kind of help you will accept. They will probably be more cooperative and understanding if you can say, "yes, I do need some help with..., but I still want to do...myself."

Insist on being consulted. Lay the ground rules with your helpers early on. Ask to be presented with choices, so you can decide what is best for you as you see it. If you try to objectively weigh the suggestions made to you, and don't dismiss every option out of hand, people will consider you able to make reasonable decisions, and continue to provide you the opportunity to do so.

Be appreciative. Recognize the good will and the efforts of those who want to help. Even though you may be embarrassed, you will maintain your dignity by accepting with grace the help that is offered, if you need it. If you are truly convinced that you are being offered help you don't need, you can decline it with tact and appreciation. For example, you can say, "I appreciate your offer to have Thanksgiving at your house, but I'd like to continue having it here. I could really use some help, though -- maybe with the clean-up after dinner."

If you are at length unable to come to terms with your increasing need to be dependent upon others for help in managing your living situation, you should consult a professional counselor. This should be someone who has experience with the emotional and social issues of people with disabling health problems.

Your local agency providing services to the disabled should be able to refer you to the right kind of counselor. The local or national organization dedicated to serving people with your specific health condition (American Lung Association, American Heart Association, etc.) can also refer you to support groups and classes to help you in dealing with your condition. You should be able to locate the agency you need through the telephone book yellow pages under the listing "social service organizations."

Akin to the fear and embarrassment of becoming physically dependent is the fear of being abandoned by family members who would be expected to provide needed help. Tales of being "dumped" in a nursing home by children who never come to visit haunt many who worry that may happen to them.

We need to be sure that we do reach out to family and friends and ask for the help we need when we recognize that we can't go on alone. It sometimes happens that in the expectation of rejection people fail to ask for help. Some people try to hide their need in fear that their need will cause loved ones to withdraw. Families often complain, "if we'd only known...," when it is revealed that a loved one had needs for help that were unmet.

If you really cannot turn to close family or friends because they are unable or unwilling to become involved in your care, there are agencies dedicated to providing for such situations. Through your local social service department's "adult protective services" program or Family Services Association you should be able to locate a "case manager" who will be able to organize the resources in your community to provide the help you need. The social services department in your local hospital can also put you in touch with the right agency.

A chronic, disabling health problem should not re-define a person as an asexual being who's lost interest in sex. If anything, a person who has to face and adapt to changes caused by a chronic disease needs the love and comfort of a close, intimate relationship perhaps more than ever.

However, this aspect of life is often ignored, denied or feared. The heart attack patient or his or her partner is often concerned that sexual activity will bring on another heart attack. The stroke patient is worried that another stroke will occur during sexual activity, or that the residual functional limitations will make it physically impossible to engage in sexual intercourse. People with breathing difficulties worry that sex is too strenuous and will bring on an attack of coughing and wheezing, or worse.

One of the most subtle, and devastating barriers to fulfilling sexuality is the damage that has been caused to a person's self-image and self-esteem. Many patients report that they believe they are physically unattractive as a result of their disease -- their paralysis, their shortness of breath, or weight gain from medication, a sense of not being really a whole, functioning being. This causes them to avoid sexual situations, and they "try not to think about it."

Attitude and communication are the keys to resuming the sexual aspect of your relationships. You must believe that sex is a necessary and rewarding part of your life, and you must communicate that to your partner.

As of this writing there are few instructional materials on sexuality specifically written for physically disabled people. There are, however, a number of very useful general "how-to" guides in the bookstores for those wanting to enhance their sexual relationships. If you understand and appreciate your own needs and preferences, and those of your partner, you can use creativity in adapting the activities described in these guides to your own relationship.

It is important to avoid any assumptions that there is only one "right way" to be sexually fulfilled. Here are some ways to help you enhance sexual fulfillment:

• Try to establish a calm and relaxed atmosphere. Stressful or highly emotional conversations tend to cause anxiety and are not conducive to satisfying sexual activities.
• Find positions that are comfortable for both of you. There is no "right" way to have sex. Try to achieve open communication with your partner about what you like and want in the course of sexual activities.
• Avoid sexual activity when you feel really tired.
• Avoid sexual activity right after a big meal.
• Avoid drinking alcohol before sex. If you have trouble with sexual performance, check with your doctor to see if you are taking medication which may be causing this. Adjustments in dosage or switching to another medication may help.
• Good physical fitness enhances sexual performance.
• If you are having problems with arousal, or loss of interest in sex, it may be due to depression. This is usually temporary. If time and patience do not resolve the problem, you might consider consulting a professional experienced in sexual counseling.
• Enjoy a "romantic weekend." Special "Marriage Encounter" weekends are available through some churches for people who want to enhance their marriages in general.

When we experience any kind of a loss -- small ones (such as losing one's car keys), or big ones (such as losing a life partner or facing a disabling or terminal illness) -- we go through an emotional process of grieving and coming to terms with the loss.

A person with a chronic, disabling health problem experiences a variety of losses. These include loss of confidence, loss of self-esteem, loss of independence, loss of the lifestyle we knew and cherished, and perhaps the most painful of all, the loss of a positive self-image if our condition has an effect on appearance (such as stroke or rheumatoid arthritis, or the residual paralysis from a stroke).

Elizabeth Kubler-Ross, who has written extensively about this process, describes the stages of grief:

• Shock, when one feels both a mental and a physical reaction to the initial recognition of the loss.
• Denial, when the person tells himself "No, it can't be true," and proceeds to act for a time as if it were not true.
• Anger, the "why me" feelings, and searching for someone or something to blame (if the doctor had diagnosed it early enough I'd have been cured, or the job caused me too much stress, etc.)
• Bargaining, when we say to ourselves, to someone else, to God "I'll never smoke again," or "I'll follow my treatment regimen absolutely to the letter," or "I'll go to church every Sunday," "if only I can get over this."
• Depression, when the real awareness sets in, we confront the truth about the situation, and experience deep feelings of sadness and hopelessness.
• Acceptance, when we eventually recognize that we must deal with what has happened, and make up our minds to do what we have to do.

We do not pass through these stages in a linear out-of-one-into-the-next fashion. We are more apt to have several, or even many flip-flops back and forth between them. Don't be discouraged if you find yourself angry or depressed again, when you thought you had reached acceptance.

Let's talk more about the depression stage of the grief process, since this is the stage where many people get stuck, and there are several ways to move out of this stage toward acceptance.

The most consistent and significant core element in depression is a sense of powerlessness. This is perceived in feelings of helplessness, inability to restore one's losses, to have any effect on events or their outcome.

People may sometimes hide their depression from themselves because they cannot bring themselves to face and deal with their unhappy situation and the implications for their future. Instead, they express depression in behavioral ways. It is not uncommon for people who are experiencing a reactive depression to find themselves sleeping a lot or unable to sleep well, overeating or not hungry at all, avoiding people and places they used to find interesting, or finding that they cannot stand to be alone, even for a little while.

Increased irritability or impatience are typical ways to express depression, though these outbursts are often unrelated to real events, often mystifying the person who is the target of our irascibility. Sudden neglect of personal appearance or business or personal concerns is not uncommon with a depressed person. Depressed people often find themselves unable to enjoy activities, experiences or relationships that were previously satisfying.

Not all depression behavior is negative. Sometimes unrealistic "cheeriness" will mask what the person is really feeling, and the wise observer will recognize the brittleness or "phoniness" of the mood. Refusal to accept offers of help, even in the face of obvious need for it, is a frequent symptom of unrecognized depression.

Depression behavior tends to be excessive in one direction or another from what would be considered normal for that individual.

The paradox of depression-related behavior is that the more one engages in the behavior, the more likely it is that one will ultimately drive away the people who are most able to provide the comfort and support that the depressed person needs in their time of sorrow. Most of our friends and family want to help us feel better, but often they don't really know what to do to help. As their efforts to comfort and reassure us are frustrated, they may at some point throw up their hands and quit trying. Then the depressed person winds up saying "see, nobody cares," thus reinforcing the feelings of loss and loneliness.

The first thing to do is to recognize that you may be depressed, and take actions aimed at reversing the feelings. If you perceive in yourself, or hear associates complaining that you are exhibiting behaviors like those described above, stop and take stock. Consider that your nearest and dearest may be telling you the truth.

There are several different ways to manage depression. Probably the most direct and effective approach is to take steps to restore your sense of self-worth and autonomy. If you can begin to take charge of your situation, you will begin to feel stronger, more effective, and develop a sense of personal power. This means that you must be willing to make the decisions you can make, do for yourself what you can actually do, and engage in the problem-solving self-management process.

It is important that you develop the ability to communicate your needs and thoughts effectively. If your loved ones want to help you, tell them how they can best do so. A candid assessment of your needs, and the simple and direct statement to another person of what they can do to help will keep you in the autonomous position. If you can say, "could you pick up some groceries for me while you are at the store," it will keep another from having to guess (often wrongly) about what you need, and give them a sense of importance in being able to help you.

Most people love to feel important to another person, and are grateful for the opportunity. The only catch is that it not be overdone to the point of becoming a burden. "Please, could you open the door for me?" is more dignified than struggling with the door; while an onlooker stands by, feeling uncomfortable and not knowing whether or not to offer help.

As you become aware of your needs for help and as these needs increase, it will be important to sit down with those closest to you and share with them what is happening to you, and the implications with respect to your abilities and limitations. You will need to provide them with an honest representation of how your condition will affect them, and evaluate realistically what kind of help you will be needing and how that help might be best provided.

If you will soon be unable to pursue an activity, such as square dancing or tennis, or perform some task, such as driving the car, those who will be affected need to know about this. They will also need to be reassured that you will still be able to do many things, and even though you no longer play golf, for instance, you would love to play cards, or go to concerts instead.

Your loved ones also need to know that you intend to remain as functional as possible, both physically and mentally, and that you don't want to be considered totally helpless, even though you do have limitations.

As you can see, communication with others is a key part of dealing with your depressed state of mind.

Many depressed people isolate themselves at home and endure their misery alone. Though the idea may at first seem unappealing, if you have been avoiding company, do make opportunities to be among people, even if only by a telephone call to a friend, or having somebody come over for coffee or a meal. When you are with somebody, resist the inclination to discuss your medical condition and how you feel about it, and instead focus on what is going on in the life of the person you are with.

Distraction and intellectual stimulation will help you feel better, and divert your focus from yourself and your problems to things outside yourself. Your favorite music or other entertainment, enjoyed in the company of a friend or family member, can raise your spirits.

Joining a group or class to learn a new skill will feed your need to feel more capable. Research about your condition and treatments will make you a better treatment team partner with your doctor, and better prepared to take charge of your treatment decisions.

Practice positive "self-talk." Scientific research has proven that positive thinking is very highly associated with positive outcomes. The human mind's ability to affect the body is truly miraculous. It is almost impossible to feel sad when we say something happy. The power of "I think I can do it" to enable us to accomplish is enormous. This phenomenon is called "self efficacy." Self-talk can be a very effective way to gain control of your emotions and attitudes. When you feel depressed, practicing positive, optimistic thoughts, in the form of the internal conversations that you hold with yourself will help you feel better emotionally and physically.

"Feelings are facts" is a way of saying that what we feel is real to us, regardless of whether or not the feelings are realistic. What we do about these feelings depends upon our attitude about ourselves, about our ability to solve our problems, about the prospects of a satisfying life. If our attitude is positive and goal-oriented, if we believe that we can still make some good things happen in our lives, then we will be able to do that. There is magic in believing.

Fear of death is something most of us only begin to experience when something happens to bring us face to face with the possibility of our own death. Losing someone close, an accident that might have been fatal, or learning we have a health condition that may shorten our lives usually causes us to consider the inevitability of our own eventual passing. Many people, even then, try to avoid facing the future because they are afraid to think about it.

Our attitudes about death are shaped by our own central attitudes about life. This is the product of our culture, our family's influences, perhaps by our religion, and certainly by our life experiences.

If you are ready to think about your own future -- about the near or distant prospect that your life will most certainly end at some time -- then the ideas that follow will be useful to you. If you are not ready to think about it just yet, put this aside, and come back to it later.

As with depression, the most useful way to come to terms with your eventual death is to take positive steps to prepare for it. This means to get your house in order by attending to all the necessary small and large details. If you continue to avoid dealing with these details, you will create problems for yourself and for those involved with your situation in a significant way.

The are several components to getting your house in order:

• Decide, and then convey to others your wishes about how and where you want to be during your last days and hours. Do you want to be in a hospital or at home? When do you want procedures to prolong your life stopped? At what point do you want to let nature take its course when it is determined that death is inevitable? Who should be with you; only the few people who are nearest and dearest, or all the people you care about and want to see one last time?
• Make a will. Even if your estate is a small one, you may have definite preferences about who should have what. If you have a large estate, the tax implications of a proper will may be very significant.
• Make arrangements, or at least plans for your funeral. Your grieving family would be very relieved not to have to decide what you would want, and how much to spend. There are prepaid "future need" funeral plans available, and you can purchase burial space where and of the type you prefer.
• Make a Durable Power of Attorney for Health Care, and also one that will let someone manage your financial affairs. You should also discuss your wishes with your personal physician, even if he or she doesn't seem to be very interested. (Your physician may also have trouble facing the prospect of losing you.)

Be sure that some kind of document or notation is included in your medical records that indicates your wishes in case you can't communicate them when the time comes.

Be sure that the persons you want to handle things after your death are aware of all that they need to know about your wishes, your plans and arrangements, and the location of necessary documents. You will need to talk to them, or at least prepare a detailed letter of instructions, and give it to someone who can be counted on to deliver it to the proper person when needed. This should be a person close enough to you to know when that time is at hand. You may not want your spouse to have to take on these responsibilities, for example, but your spouse may be the best person to keep your letter, and know when to give it to your designated agent.

You can purchase at any well-stocked stationery store a pre-organized kit, in which you place a copy of your will, your Durable Power of Attorney, important papers and information about your financial and personal affairs. There are forms that you fill out about bank and charge accounts, insurance policies, the location of important documents, your safe deposit box and where the key is kept, etc. This is a handy, concise way of getting everything together that anyone might need to know about.

• Finish "business" with the world around you. Mend your relationships. Pay your debts, both financial and personal. Say what needs to be said to those who need to hear it. Do what needs to be done. Forgive yourself. Forgive others.
• Talk about your feelings about your death. Most family and close friends are reluctant to initiate such a conversation, but appreciate it if you bring it up. You may find that there is much to say and to hear from your loved ones. If you find that they are unwilling to listen to you talk about your death and the feelings that you are perceiving, find someone who will be comfortable and empathetic in listening to you. Your family and friends may be able to listen to you later on. Remember, those who love you will also go through the stages of grieving when they have to think about the prospect of losing you.

A large component in fear of death is the fear of the unknown. "What will it be like?" "Will it be painful?" "What will happen to me (after I die)?"

Most people who die of a disease are ready to die when the time comes. Pain killers and the disease process itself weaken body and mind and the awareness of self diminishes without the realization that this is happening. Most people just "slip away," with the transition between the state of living and that of no longer living hardly identifiable. Reports from people who have been brought back to life after being in a state of clinical death indicate they experienced a sense of peacefulness and clarity, and were not frightened.

A dying person may sometimes feel very lonely and abandoned. Regrettably, many people cannot deal with their own emotions when they are around a person they know to be dying, and so deliberately avoid their company, or they may engage in superficial chit-chat, broken by long awkward silences. This is often puzzling and hurtful to those who are dying, who need companionship and solace from those they counted on.

You can sometimes help by telling your family and friends what you want and need from them -- attention, entertainment, comfort, practical help, etc. Again, when a person has something positive to do, they are more able to cope with their emotions. If you can engage your family and loved ones in specific activities, they can feel needed, and can relate to you around the activity. This will give you something to talk about, to occupy time, or at least provide a definition of the situation for them and for you.

If you choose to die at home, a hospice can be very helpful. These organizations provide both physical and emotional care to people who are dying, as well as for their families.

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