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Thank You Holly well I'm I'm honored and.glad to be here and it's probably.relieving some of my anxiety that I.can't find out what the election reports.are for an hour and a half or so so but.living with uncertainty is something.that cancer patients live with all the.time and their families and we're all.living with at the moment so hopefully.we'll all have a good outcome I'm.pleased to be here on behalf of the.survivorship program at Stanford then.Holly has been doing some wonderful work.in running that program it's great to.have a place where people can live with.cancer you know the it used to be cancer.was considered a terminal illness and.people didn't want to mention the C word.or the D word and can you hear by the.way all right let speak up a little okay.I will speak up a little I hope you.enjoyed my lecture it used to be.considered a terminal illness now we're.thinking of it more as a chronic illness.you know something more like diabetes.half of all people diagnosed with cancer.will live to die of something else which.is a good thing but it means that.there's more and more importance to the.notion of survivorship and in helping.people live as well as they can as long.as they can with cancer and there's a.lot of stress involved with that so what.I hope to do is share with you some of.what we've learned over three and a half.decades here at Stanford trying to help.people with cancer live better with the.disease and learning from them and I'm.very grateful to them they've given.generously of their time and their.experience to help us understand better.how to be of help with cancer so I want.to dedicate this lecture to the memory.of Ernie and Izzy Rosenbaum Ernie was an.irrepressible wonderful man who started.supportive care for cancer patients like.30 years ago at Mount Zion hospital.before anybody even thought about doing.it and he worked tirelessly he brought.as holly mentioned the program here to.Stanford just out of the goodness of his.heart you know normally people call you.up and they say.oh I've got something for you you know.it's gonna be wonderful and then you.then you pay the piper later on it was.never the case with Ernie he was just.giving and giving and giving and he.brought the program down here and the.reason it's here is because he did that.whenever you'd call him up on the phone.he'd say just a good news David just a.good news that's all I want to hear but.he was really good at dealing with bad.news and helping his patients deal with.bad news and he was with him anytime.anywhere he was also the doctor to the.Opera and Pavarotti used to call him my.friend Ernesto and he was so he he was a.real fixture in San Francisco in the art.scene as well as medicine and just gave.throughout his life and he was a.wonderful supportive guy and I miss him.and his his the love of his life is he.who kept him on track for some 45 years.or something like that they were deeply.in love with one another and it was a.real pleasure to to be with both of them.and he carried on for several years.after his death I was frankly worried.about him but he was so busy given to.people that it really helped him with.his own grief about Izzy's death and so.he's he's just a terrific guy so this.lecture is dedicated to him these are.some of the books that he wrote he wrote.a number of them cancer supportive care.cancer survivorship you're not alone and.there's still wonderful reading and.we're actually in the process of putting.together a website that will provide.access to these and many other books as.well and we're working on a final book.that he was writing I just ran into one.of the colleagues who said you know I.had a wonderful but strange experience.he said two days after Ernie died I got.a letter in the mail asking me to update.the chapter I had written for his book.so you know right until the day he died.Ernie was working on it and we will get.that done too so what I hope to review.with you is issues of stress and.depression related to cancer some psycho.psycho therapeutic treatments that we.have to help people deal with cancer.what the results are and examining the.rather interesting question of whether.helping people excuse me to live better.and they also help them to live longer.and what we think some of the pathways.are and I hope to leave you with some.points about how one can deal more.effectively with the inevitable.stressors of cancer we were running a.support group one day and in marched one.of my metastatic breast cancer patients.with this life-size dressmakers maquette.that she had redone to show the effects.of cancer on her body and so she had had.a left Radek modified radical mastectomy.with a tram flap reconstruction she had.radiation burns she had an open biopsy.there now I'm glad to say that since the.time that she did this the treatments.have become less invasive and less.damaging but it still happens and this.was her way of reminding us that you.live with these things all of your life.you can't forget them every day you.confront the effects of the cancer and.its treatment and so there are it's not.just one big stress it's a series of.stressors that people inhabit in their.own bodies and part of the stress of.dealing with cancer is in a way.reconstituting your relationship to your.own body because unlike other illnesses.where you know your heart or your.kidneys or your liver lets you down.cancer is different in that that cancer.the part of your body becomes the enemy.and so you have to kind of come to terms.with the fact that if one part of your.body is doing damage to the rest and.that's a difficult thing to live with.she gave me permission to use her name.so this is not a HIPAA violation her.name was Maurice Jaffe she was a Silicon.Valley engineer when she started doing.this and by the time she died she when.she got metastatic disease she said to.me you know I've always wanted to be an.artist I've been a good engineer I'm.tired of it I want to be an artist so.she went back to school studied and was.teaching art and it produced a very.beautiful body of art by the time she.died so she had used cancer as an.occasion to change her priorities in.life which is one very good way to.handle the stress of cancer as I had.mentioned the number of cancer survivors.is growing this is a good problem to.have medical care is getting better.people are living.longer with cancer so in the 1970s there.were three million cancer survivors in.the United States right now there are.more than 12 million so the number is.quadrupled that's a very good thing and.some of you are right here in the room.and so people are living better and.longer with cancer and that means that.the issue of survivorship and helping.people deal with the stress of cancer is.a growing and important issue for us to.deal with the Institute of Medicine of.the National Academies has issued a.report on called cancer care for the.whole patient and what they noted is.that addressing psychosocial needs.should be an integral part of quality.cancer care and that evidence supports.the effectiveness of services aimed at.relieving the emotional distress that.accompanies many chronic illnesses we're.leaving it now we're living in including.cancer even in the case of debilitating.depression and anxiety so there are good.treatments for the emotional problems.that go along with the physical problems.and we need to think of them as.coexisting issues that we can deal with.effectively this was a done by a French.cancer patient I knew who depicted.cancer which is you know the word cancer.was the greek for crab crab like growth.was the idea and so her she lost her.hair in chemotherapy and she decided.that she would image that by replacing.it with the crab and I'll show you some.more of her drawings but she had a sense.of humor and you know it's a wonderful.thing you know laughter can be a great.thing even in very difficult situations.one of our support groups one of the.women said you know my husband is.hopeless at organizing anything and so.I'm gonna have to organize my own burial.actually so she called skyline Park and.she asked what it would cost her to be.buried there and they quoted her an.astronomical amount of money we all know.what real estate costs in Northern.California and she said well you know.actually I represent a group of women.who are looking for a place to be buried.and it was a very long pause and the.woman at Skyline Park say Skylon Park.does not offer group discounts.and and the the wonderful thing is that.all of these women with metastatic.breast cancer got a good laugh out of.trying to get a group discount at a.cemetery so you can face anything if you.do it together and sometimes with humor.and that's one of the lessons that we.learn here so there are many stressors.in dealing with cancer.there's the existential issues and.everybody thinks cancer is going to kill.them even though in at least half the.cases it won't there are problems.related to pain the meaning of the.diagnosis fear about recurrence very.important treatment decisions early on a.treatment changes in social environment.I tell the students you know what if you.had to live the life of a cancer patient.for a month without having cancer you.wouldn't be feeling so good by the end.of it because instead of doing the.things that you like to do or they make.you feel productive you spend your time.sitting around waiting rooms reading.stale magazines surrounded by mostly.strangers people who don't know you and.don't know who you are and that in and.of itself can get demoralizing and.depressing on top of also feeling sick.and having side effects of chemotherapy.and other things so the social changes.related to cancer can be powerful the.treatments are very hard to go through.and people often find themselves feeling.depressed sad fatigued for months after.their chemotherapy or their radiotherapy.is over and they often blame themselves.for it they think you know if I were.really tough I'd be out there you know.jogging the next day actually exercise.is a good thing to do even during.chemotherapy and one of my tips about.living with cancer is do what your.grandmother told you to do eat well.sleep well and get plenty of exercise.and that is especially true during.cancer because you need to think of your.body as being in training to cope with.the disease and with the treatments.related to the disease we tend to think.you know I can forget about cholesterol.and all those other things because I've.got cancer that's what's going to get me.well you know what more women die of.heart disease who have breast cancer.than die of breast cancer so it's very.important to take care.your total health and think of your body.as being in training and treat it the.way you would if you were in training.for anything else this is my French.patient who said the villain crab goes.on the attack here and so this is her.sense of a part of her body being the.enemy so my summary of and I will go.through this in some detail of how I.think it's best to face cancer it is.summarized by the acronym faces whoops.wrong way there we go the acronym faces.hmm.so the first thing is face it rather.than flee it many people would rather.avoid or pretend they don't have a.problem when they do and that just makes.the problem worse because it pursues you.if you face it head-on you can figure.what to do about it and the second the.it is very important to cope actively.with the disease feeling feeling.helpless is something that only adds to.stress life always has stress in it if.we weren't stressed we'd be dead it's.just a part of life but if you don't.feel you can formulate a plan for how to.deal with the stress you feel more.helpless and more stressed so the idea.here is face the problem excuse me sorry.hey Holly which might get me some water.please thank you learn to alter your.perception of what the situation is see.it from a new point of view and I'll.show you some techniques that we use to.help people do that to alter their.perception of the situation cope.actively with it find some aspect of the.problem you can do something about.express rather than suppress emotion.emotion is your friend not your enemy.many cancer patients and their families.feel that if they somehow suppress how.they feel about cancer that they can.actually control the disease and it.doesn't work that way emotion is our.signal system telling us that something.is important we better pay attention to.it and using those emotions.to help face and deal with what you're.dealing with help build social support.can be a very helpful way of coping in.this disease and the final letter is.social support it is.yeah I'm sorry well Hollywood get some.more social support is an absolutely.critical aspect of coping with any kind.of stress we are social creatures we're.not just splendid individuals and for.human beings social support is a.survival mechanism from the time that we.were running around in caves and so it.is tremendously important to gather.social support and use it what's the oh.thank you aren't you nice thank you.medication here this is really good all.right thank you this is my French.patients depiction of how the treatments.are long and hard to undergo and one of.the paradoxes you know I tell them I.tell my medical students that it's much.harder to be an oncologist than a.cardiologist and anybody know why any.thoughts about why that might be well.you know if you are brought into the.emergency room with crushing substernal.chest pain you think you're gonna die.your cardiologist is with you for a.couple of minutes and suddenly you think.you're gonna live and the pain goes away.so you instantly love your cardiologist.right but what's the deal with oncology.it's exactly the opposite you think.you're fine.you got a lump or a little bleeding or.something and the doctors words.transform that into a life threat and.then the treatments feel much worse than.the disease you know Susan love calls it./ poison and burn and and so very often.oncologists have to work around the.natural feeling patients have Thank You.Molly that they're being punished that.they're being punished by their doctors.so it's one of the ironies that cancer.treatment is such an ordeal.she also noted that there's a great.sadness that often comes with a disease.and sadness is a natural part of human.life it comes along with having cancer.at times but it can sometimes morph into.something worse depression and the.difference is you feel sad about.something that would plausibly make you.sad depression is feeling hopeless.helpless and worthless.it's feeling that there's nothing good.is ever going to come that there's.nothing you can do about it and that.there must be something wrong with you.that got you into this situation and so.when it extends beyond just what it is.you're feeling sad about to those senses.of hopelessness helplessness and.worthlessness that's when you're getting.depressed and depressed people are.fatigued they don't sleep well they.don't eat well they don't do things that.will help them cooperate with their.treatment and depression is not a.natural concomitant of cancer it's a.comorbid illness it's another disease.that we know how to treat and that.requires attention and treatment about.3% of the general population are.depressed and I suspect the numbers will.shift and it'll be higher than 3% in.either red or blue states and lower than.3% in others later on this evening but.the overall average is about 3% and at.the moment I'd say they're all anxious.rather than depressed but we'll see what.happened among medical outpatients the.rate is twice as high as 6% among.medical inpatients I'm sorry.yeah depression is a feeling a pervasive.sadness that involves hopelessness.helplessness and worthlessness so you in.general feel not just that a bad thing.that has happened or that you've.something you should feel sad about but.there's something wrong with you you.don't deserve anything better you have.fatigue you don't sleep well.particularly waking up early in the.morning and you have this pervasive.sense of misery and sadness throughout.your life it isn't just some time but.all the time for its protracted period.of time you feel sad.these numbers are us but they're they're.not so different from the rest of the.world but this is us prevalence.six percent among outpatients twelve.percent among medical inpatients one out.of nine medical inpatients are.clinically depressed and unfortunately.it's often overlooked with cancer for.example people say well of course she.said she's got a bad prognosis of course.she's an eating she's got nausea from.chemotherapy of course she hasn't.sleeping she's worried about the disease.but in fact that may not be the.situation this situation may be that.they're depressed about a quarter of all.cancer patients have clinically.significant depression about 20% of the.terminally ill and interestingly there's.a vote I think in Massachusetts about.assisted suicide which I am not in favor.of two-thirds of people who request.assisted suicide are depressed and.depressed people get suicidal and it's a.psychiatric problem it's not a medical.problem in that sense it should be.treated and I think that any doctor who.seriously considers deliberately killing.a patient ought to sit down take a deep.breath reread the Hippocratic oath and.help the patient with their depression.their pain and other problems relating.to the disease most patients who request.assisted suicide if you don't do it and.wait a couple weeks will change their.mind but you can't change your mind if.you're already done it so depression is.an unrecognized and very serious problem.it's a serious problem in another way.our group published this in the Journal.of Clinical Oncology last year and what.this is showing and I'll show you a.number of slides like this what this.these are called survival curves and.basically what they show you is the odds.of being alive at a given point after.the time you initiated the study so.everybody was alive up here and the more.sharply the the curve drops the more.rapidly members of that particular group.die and what you see here is the the.yellow line are people whose depression.in this baseline period was getting.worse and the blue line are people whose.depression was getting better and the.ones whose depression was getting better.as you see lives significantly longer.than the ones whose depression was.getting worse and we in this analysis.controlled for all the usual.factors for breast cancer estrogen.receptor status progesterone receptor.status Herceptin hurt two new receptor.status age at diagnosis time from.initial diagnosis to relapse an.independent of all those risk factors.being depressed predicted shorter.survival so treating depression in.theory could help you live longer as.well as better yes yeah we are and stay.tuned a little bit later in the talk.that's exactly where I'm heading.thank you so the average difference.between those whose depression was.getting better in those days getting.worse was about two years actually so.it's not a trivial amount of time so it.suggests that we really ought to be.thinking about treating depression and.stress and additional the other things.we need to be doing to treat cancer so.how do we do that how do we treat it.this by the way it was done by a Dutch.breast cancer patient to depict her own.despair about the disease and one thing.that continues to astound me is it's the.only work of art she did in her life was.that sculpture which is really a.remarkable sculpture so there are.medications that are helpful for cancer.many of them work on the serotonin.pathway which is a major.neurotransmitter that is related to mood.and impulse control in the brain.norepinephrine is another major.transmitter and some of the.antidepressants work on that as well.there is now some interesting research.on brain stimulation what's called.transcranial magnetic stimulation that.may stimulate certain parts of the brain.as I was saying there are these various.somatic ways of treating treating.depression and they're also.psychotherapeutic ways that are very.effective some people respond to one of.the other some respond to both but we.have an array of effective treatments.that should be used in treating.depression yeah.you're on these strong medications have.they studied the interaction well.certain some of the in this study that I.showed you here some of these people.were on medication and so the course of.the depression was related to the.medications in part in part to.psychotherapy in part some people just.naturally getting better or worse it's.important one one thing that is worth.keeping in mind if you have breast.cancer and or on these medications is.some antidepressants actually compete.with it for the metabolism of tamoxifen.so if you're on if you're on tamoxifen.as an estrogen response modulator for.breast cancer some antidepressants may.be a problem some of them are not but.it's very important to talk to your.doctors if you're on it because they can.make the tamoxifen less effective.because the active form of tamoxifen is.a drug called endoxifen it has to be.metabolized by the body and some.antidepressants will impair that so it's.very important to have that clarified.yes no no the remedy X is not.metabolized by the same system so it's.not a problem.it's just tamoxifen that is an issue.so here is one depiction of the.antidepressant pathway but there there.are others this was the New Jersey.Turnpike I think shortly shortly after.the storm actually there yeah so I'm.going to not focus much now on.pharmacology but on psychotherapy and.this is by way of saying that there is.tremendous power and social connection.and this is a review of studies.published in the journal Science some.years ago and which showed us a very.simple thing the relationship between.social connection and mortality that.people who were low in social.integration had higher rates of.all-cause mortality and cancer mortality.than those who were high in social.integration so loneliness is bad for.your health in fact.it's as bad for your health as smoking.or having high serum cholesterol levels.we are really social creatures and the.way this study got started was Leonard.Syme who was a sociologist at Berkeley.which is a small University on the other.side of the bay had some friends over.from Japan and he was showing him around.San Francisco and they looked they did.they weren't enjoying the beauty of the.city and they said what a sad place and.he said what are you talking about.they said you Americans are so alone.everybody walks around here by.themselves you never see that in Japan.people girls work arm in arm and arm and.everybody's talking with somebody and.this is a very isolated culture which it.is actually and it gets worse when you.get cancer because people don't want to.mention the c-word or even worse to D.word they don't know what to say and so.many social relations some get better.but many get worse and it's harder to.start new ones so social isolation is.part of the problem and the stress of.dealing with cancer so what we started.doing in the 1970s here was putting.together support groups of women with.breast cancer and at the time we were.told that that was a terrible idea that.you would demoralize women by putting.them and these were women with.metastatic disease so they had advanced.breast cancer but we were told that you.would make them worse because they would.see one another die and you demoralize.them and we were very worried about that.and we actually followed them week by.week word by word we're worried.demoralizing them or not after a while.it began to dawn on me that death is not.a novel concept to a cancer patient that.watching somebody else die of it is not.the first time you thought of it and.that we should deprive them of is the.opportunity to see what it felt like to.see how to deal with it and that's what.we did in the groups and I'll show you.some examples of that there are seven.issues that we dealt with in the groups.and these are themes that I think are.helpful for anybody dealing with cancer.and other life-threatening illness build.new bonds of social support and it is.amazing how fast people form intense.connections with one another when.they're coping with the same illness.because you know what it's like you've.been there and there are other things.too there's nothing good about getting.cancer but you can use your experience.to help other people cope with the same.illness and so something genuinely good.comes out of a bad situation you start.to feel like an expert in life you know.something about coping that you can use.to help other people and that makes you.feel better about yourself.you can also see the illness from the.perspective of your own loved ones of.how what it's like to deal with someone.who has cancer rather than be the one.who has cancer so you learn a deeper.level of understanding for what other.people are dealing with and going.through we had one woman who a new woman.joined the group who was very ill lovely.woman very ill and another member said.you know I'm gonna stop doing this now.but I realized what I've been doing I've.been keeping my distance from you.because I'm protecting myself I can see.how sick you are and I'm sort of.protecting myself against loss and she.said I'm gonna not do that but I now.understand how my family have been.dealing with me that they've been.protecting themselves in the same way so.you see it from the other point of view.it changes your perspective we encourage.the expression about emotion let people.talk about anger fear and sadness.emotion can be your friend not your.enemy it can bring you closer to people.if you talk openly about how you feel.you can detoxify fears of dying in death.you can you know there's nothing we can.do about being dead but there's a lot we.can do about how we die and many cancer.patients are much more worried about the.process of dying than death itself.that's a big stressor we all have to.deal with it but there are even aspects.of that that we can take control over.and patients find that they are less.overwhelmed by their fears of dying in.death when they can face it together.another way to think of that is that we.don't talk about death much in our.culture we don't deal with it very well.but one way in which we comprehend it is.being alone.you know there's an old spiritual goes.you got to walk that lonesome Valley by.yourself well what we tend to do is.isolate people who are worried about.deine and that makes them feel already a.little bit dead it's very different to.talk about death at 2:00 in the.afternoon in a group and to worry about.death alone at 2:00 o'clock in the.morning and patients find that it is.reassuring it is not damaging to them to.deal with it we encourage them to.reorder life priorities like Maurice who.decided to become an artist if you're.not going to live forever you may want.to live differently and many of my.patients say life has never been the.same since I got cancer but in many ways.it's better so they feel that they can.understand and deal better with the.illness by changing their own priorities.in life and taking it seriously we.improve try to improve communication.with families and friends help them.understand one another and what they.need and and deal with things in a more.direct and forthright way exchanging.roles you know helping if the patient.can't you know there was one patient of.mine who was very upset she was in bed.she felt very weak she'd just gotten a.lot of radiotherapy and her husband was.cooking dinner and trying to keep up.with things and she had a kind of.meltdown when he said to their child who.wanted help with homework wait till.after dinner and I'll help you with your.homework and she screamed at him I can't.cook dinner I can't stand over the sink.but I can help our kid with his homework.so send him in here so you know just a.sense of being able to do what you can.do in exchange roles can be very helpful.improve communication with doctors it it.sometimes patients don't get the.opportunity or don't avail themselves.the opportunity to communicate clearly.what they want or get their questions.answered and it's very important and.then we do symptom management exercises.nothing a little bit about that as well.we've written a book called group.therapy for cancer patients that.summarizes this intervention program for.patients with cancer so one of our goals.in terms of managing distress stress and.distress related to cancer is to convert.anxiety into fear and depression into.sadness try and find something that is.triggering this feeling of discomfort.you have in your chest or this.overwhelming sense of sadness and you.can then begin to deal with.and begin to think about how to approach.and what to do about it.it's the sense of overwhelming misery.that's a problem and if you keep.avoiding the things that make you sad.you are less and less clear about what.it is that's troubling you.so use it as a trigger and a signal that.it's time to do something and focus your.distress in ways that help you clarify.what it is that's troubling you.Shakespeare of course said it Beth he.said give sorrow words the grief that.does not speak whispers the or fraud.heart and bids it break we found in.these studies that we actually succeeded.in reducing our patients tendency to.suppress their emotions you know many.cancer patients feel like you know.crying it's like opening Pandora's box.you know if I start I'll never stop well.I've never lost a patient in terminal.crying you know they start and then they.stop and they usually feel better.afterwards and we found that we could.actually reduce their tendency to.suppress emotion compared to the control.group that were comparable that didn't.have the opportunity to come to these.groups every week and that that actually.improved their mood so the more open.they were about their feelings the less.anxious and depressed they were over.time so it's sort of short-term pain.long-term gain dealing with your.feelings is helpful not hurtful and this.was their sense of being competent in.dealing with their emotions and the ones.who were in our groups felt that they.were handling their emotions better than.the control group even though they were.suppressing them less we dealt with very.serious and difficult issues so when one.of our patients died another one who was.a poet that made these little cards that.she handed out dear Eva whenever the.wind is from the sea salty and strong.you are here remembering your zest for.hilltops and the sturdy surf of your.laughter.gentles my grief at your going and.tempers the thought of my own and you.know there's something healing in that.she was facing it they were dealing with.it but in a way that led them to feel.better about themselves I don't know if.I have yes another patient said that.what I found in the beginning of the.group is like that fear you have.standing at the top of a tall building.or at the edge of the grand can.at first you're afraid to look down I.don't look like Heights.but gradually learn to do it and you can.see that falling down would be a.disaster.nonetheless you feel better about.yourself because you're able to look at.it I can't say I feel serene but I can.look at it so just being able to face.whatever it is you have to face gives.you a sense of handling it better.avoiding it is damaging dealing whether.it makes you feel better we encourage.people to face the limitations of time.and decide how you want to spend the.precious resources that you have left.and many of us live with the the fantasy.that we're going to live on forever and.die in our sleep when we're 140 life.isn't like that and so taking hold of.life and taking advantage of whatever.opportunities you have is the kind of.gift that cancer gives people because it.you know it's not like having a heart.attack where you're fine one minute and.dead the next.there's warning and you can give some.serious thought to how you want to spend.the time that you have that's both the.stress but also an opportunity to live.differently and live better not.everybody gets it however he's saying.I'm sorry mr. Rainey are Tesh you have.two weeks to live and he says can I take.them in August I don't don't think he.quite was clear on the concept yeah oh.yes the orpheus exercise so there was an.existential psychologist named James.Bugan Thal who developed an exercise.called the Orpheus exercise and what.this involved was we had people in the.group sit around close their eyes and.say make a list of attributes about.yourself things that you are you know.teacher loved or ski or whatever it is.and rank order them in importance and.now imagine that you can no longer be.the least important one and ask yourself.the question Who am I so how do you kind.of redefine yourself when you have to.start giving up things that are really.precious to you and that's what this.exercise is so it's a way of facing in a.very concrete and personal way how you.redefine who you are when you can't be.the things you used to be as I mentioned.this is my French patient patients often.feel punished by their doctors and their.treatment and we don't always respond.he's saying I'm sorry mr. McConnell your.insurance plan only provides for.empathetic nodding and has said and.downward glance there's a 200 dollar.copay for any additional words of.compassion not to exceed 40 words or.three expressions of sympathy or.condolence and all I can tell you is I.wish this were funny unfortunately it's.not you know something I wish President.Obama had said when he was talking about.the Medicare system and you know a we.our health care system is a catastrophe.and has been colonized by predatory.insurance companies who want nothing but.to make money and who care less about.health care and one of the things that.President Obama could have pointed out.is that the the bloated inefficient.hateful government behemoth health care.insurance system Medicare you know what.the rate of overhead for providing care.is in Medicare anybody know the number.it's 2.7 percent now what that means is.that ninety seven point three percent of.every dollar going through the Medicare.system actually goes to pay for medical.care now in the lean efficient corporate.private insurance system you know what.the overhead rate is anybody want to.guess it's 27 percent twenty seven ten.times more than government insurance and.Medicare has to take care of the sickest.people because it gets everybody 65 and.older so the insurance industry has.spent the infinite amount of money it.has sucked out of the health care system.to make sure that there was no public.option in Obamacare they would say we.can't compete because it's government we.can't they can't compete because.government does it so much better than.they do and so it's a real tragedy that.we're still having to debate whether we.should have any motion towards.single-payer health care system in.Canada with a private fever with a.publicly funded fee-for-service system.the overhead rates 11% which is still a.whole lot better than 27% so and you.know one of the other things that just.drives me wild is that the leading cause.of bankruptcy in the United States is.guess what health care in Europe that.never happens nobody ever goes bankrupt.because of health care so we really have.a problem and we'll know more about.what's gonna happen to that.a few hours later on tonight but it's.very sad actually that medicine has been.colonised by health care and I have to.tell you as a physician that one word.that makes my skin crawl is the word.provider you know did you ever hear her.mother proudly say there he goes my son.the provider you know I don't think so.it's when when European countries.colonized Africa and Asia they came up.with demeaning terms for the natives to.justify the occupation and that's.exactly what the insurance industry has.done with medicine that you know I'm not.a provider I'm a physician there are.nurses psychologists social workers.other professionals who care for.patients and to call us providers is a.way of saying one of yous as good as.another.and we're the ones who were running the.show and it's a very bad thing for.healthcare and I'm sure you've all dealt.with this in dealing with your health.care decisions.it isn't government that's interfering.with your healthcare choices it's.private insurance they tell you who you.can see and who you can't because they.tell you what you pay for and what you.don't so we've got a real problem here.because we want to offer these kinds of.things to people and we have private.insurers who are making it very.difficult or impossible to do it it's a.real tragedy so what can patients do to.deal with physicians in a more.constructive way and what can physicians.do to help patients feel better if.they've got the time to do it.communication Control and caring.communicate clearly with Doc's so.another way to handle the stress of.being ill is to communicate your.situation clearly where physicians we're.not mind reader's we don't always know.what it is that is troubling you the.most and I advise patients if you've got.your you know your typical list of.questions that you always have here's.the trick give it to the doctor at the.beginning not the end of the interview.you know usually you let the doctor do.his or her thing and then you do it by.which time he or she has 15 people out.there waiting and they've already.allotted the amount of time they have so.you just say whatever amount of time you.have with me I hope some of it will be.devoted to dealing with these questions.it works a whole lot better so you have.a right to get your questions answered.but do it in a way that's respectful to.the doctors time and need to care for.other patients as well control their.patients feel better about the care.they're getting if they feel in control.of those aspects of it they can control.so participate in decisions where there.are choices to be made you have a right.it's your body you have a right to be.involved in those decisions there are.some decisions that just have to be made.medically that patients can't make them.but there are a lot where there really.are trade-offs and it's a good idea to.participate in those decisions studies.have shown like in in where there's a.trade-off between lumpectomy and.mastectomy for example that patients who.felt that they participated in the.choice were happy or afterwards.regardless of which choice they made so.participating really makes a difference.and finally the sense of caring you know.in medicine the oldest adage in medicine.is that our job is to cure rarely.release suffering often in comfort.always and when medicine got scientific.and interventional we changed our job.description to be that our job is to.cure always relieve suffering if you.have the time and let someone else do.the comforting and that's a bad mistake.we've painted ourselves into a corner.because no matter how good medicine gets.the death rate will always be one per.person you know sooner or later we're.all going to die of something we're.going to need well-trained professionals.to help us do it and so the idea that.we're there to cure all the time is just.wrong that's not what we do when we can.by all means go for it we do it but.there's a lot of other things that are.involved in healthcare that we tend to.overlook so did these groups help people.and he's saying do you remember what you.were feeling before the we you ate the.other members of the group it's a it's a.rare side effect of treatment yes these.groups help people so we had these women.with advanced breast cancer 90 minutes.once a week sit there and talk about.these themes that we've mentioned and.what you see is that the women in the.support groups in the support groups got.less anxious and depressed over the year.the women in the control condition who.didn't get the support groups got more.anxious and depressed so talking about.these problems relieves them it doesn't.make them worse and we were able to.repeat this finding in a new study 15.years later showing greater reduction in.distress in the treatment group than the.control group.so we have solid evidence and other.groups around the world have evidence to.that helping people face these problems.reduces their distress that doesn't add.to it this is uh I don't have any of you.heard of Cochrane Database reviews.anybody there's a Cochrane collaborative.it was funded by a very wealthy.businessman named Cochrane who felt that.a lot of medical practice was not based.on the best review of evidence so he.paid for people to go through and review.evidence about all kinds of treatments.and in fact when Cochrane himself had a.heart attack he decided to forego one of.the common treatments at the time.because his own database review said.doesn't help you know and he's still.alive so I guess he was right this is a.review of the effects of group.psychotherapy and treating depression.among cancer patients even advanced.cancer patients and what it shows is.that the treatments are effective that.they help people so the summary is from.a very dispassionate and tough-minded.review that these things actually help.they don't hurt patients so that was our.concern early on if I'm convinced of.anything from 35 years of doing this.it's that it helps people to bring them.together to deal with these kinds of.stressors including the worst kinds of.stressors now one of the other things we.do is we teach patients techniques like.self-hypnosis to control symptoms like.anxiety and depression my daughter Julia.did this drawing my dad hypnotizes.people and makes them want to live.longer and you see a particularly.successful clinical example here.now just julia is now a senior law.student but she says to me dead.are you still showing that drawing your.money so I do have to tell you that it.doesn't represent her current level of.artistic or intellectual ability but.hypnosis is just a form of highly.focused attention like how many of you.have had the experience of getting so.caught up in a good movie that you.forget you're watching the movie and you.enter the imagined world any of you.never had an experience like that or.some it's depends on the movie yes um.but hypnosis is just a form of focused.attention it's like looking through the.telephoto lens of a camera which you see.you see with great detail but you're.less aware of the surroundings now we.all do this naturally so these you know.you probably are having sensations by.now in your bottoms touching these.wonderful soft chairs that Stanford has.provided you hopefully that was not.foremost in your mind until I brought it.to your attention so our brains are very.good at paying attention to some things.and putting outside of awareness others.hypnosis is a more disciplined way of.doing that and you can actually reduce.or even eliminate pain in doing it and I.actually I had the opportunity a couple.of weeks ago in New York to give a.presentation to His Holiness the Dalai.Lama we were interested in mindfulness.compassion and health and what how they.were related so he said to me I was.talking about if noses he said well.doctor it doesn't actually change the.pain does it it just changes how you act.and I say no we actually have brain.imaging studies that show you literally.reduce how much pain people feel and he.said well can you help me with my right.knee he said it kind of hurts so I said.I'd be honored to do it he said well I'm.too skeptical I wouldn't be a good.subject and I told him we have ways of.dealing with that so so I may have an.opportunity to do it but what this shows.is that while pain signals travel up to.the brain through the part of the spinal.cord called the spinothalamic tract and.a processed in the brain there is.top-down modulation of pain - so the.meaning of pain how surprising it is.whether you think it means something is.getting worse are all factors that can.literally change how much pain you feel.as you see here I think you can see it.see the baby's getting the shot here and.the father is the one who's in pain so.the meaning of the pain has a lot to do.with it and we can use that to help.people even with very serious pain do.better this is an EEG time lock to.presenting a series of shocks to some.Stanford students who volunteered in a.study and the red line is that brains.normal electrical reaction to these.shocks here the yellow line is the.brains response to the same shocks but.delivered while they were hypnotized and.told your hand is an ice-water it's cool.and numb and you see that these early.components just about disappeared and.the later ones were only half as big so.we literally change the way their brains.responded as rapidly as it whoops.sorry as rapidly as a tenth of a second.after the shocks were administered so.you can literally change transform what.pain you feel and these are studies done.by a researcher named Pierre Rainville.in Montreal showing parts of the brain.that are involved in analgesia using.hypnosis and the main point here is that.the words you use change the part of the.brain that is involved so if you say to.people your hand is cool and numb the.way we did in this other experiment.it's the somatosensory cortex the part.of the brain that processes sensation.here that turns itself down if instead.you say well the pains there but it.won't bother you which many people feel.when they take opiates it's there but.who cares it's a different part of the.brain called the anterior cingulate.cortex and this part is a kind of worry.center in the brain it tells us what to.worry about what to pay attention to and.what not and that part of the brain is.also involved in have not account of.Jesus so we know specific parts of the.brain so this is not a matter of fixing.your brain it's a matter of using your.brain to actually alter the way you.perceive pain and we teach patients to.do that as a self hypnosis exercise so.they don't need me with them at 2:00 in.the morning they need to know how to do.self-hypnosis to alter transform their.pain experience and this is what we get.at the end of a year of teaching.patients self-hypnosis the women in our.support groups had half the pain the.control group did on the same in very.low amounts of medication.so it's highly effective in helping.people to control even chronic and.severe cancer pain and this is a.replication of that study again in a new.sample 15 years later so we can help.people live more comfortably and reduce.their pain so the next question is well.what effect is this better coping this.better stress management this better.pain management have on the course of.disease and I initially thought not much.I thought it was an interesting idea.there was a guy any of you know Karl.Simonton have you heard of this he wrote.a book called getting well again and the.idea is you just visualize your white.cells killing your cancer cells and lo.and behold it will happen and I thought.it was an interesting idea but there was.no evidence that it was true and there.still isn't but I decided to follow up.on these early studies we did because we.knew we'd help these women emotionally.and see what happened to them physically.and much to my surprise we found in.effect on survival so the women who were.randomly assigned random assignment.simply means you can't choose whether.you're in the treatment or the control.group the computer chooses for you.because if you let people choose the.problem is if you see a difference you.don't know if the difference is due to.the fact that certain kinds of people.will choose one thing versus another so.this is a fundamental basis of clinical.trials is that you randomly assign.people to different treatments whoops.and what you see here is that by the end.of 48 months four years all the controls.had died but a third of the treatment.group was still alive and this wasn't.doing any differences in the medical.treatment they got the average.difference in survival was 18 months so.we published this in The Lancet in 1989.and we got a fair amount of attention.for this and I was surprised by him you.know I was pleased but I didn't expect.that we would see what amounts to a.pretty hefty effect on survival so a.number of people tried to replicate this.study we did and when we did another.study that we published about a decade.ago less than that half a decade ago we.found that we didn't get an overall.survival effect but we got an.interaction with whether the patients.were er negative or er positive so.estrogen receptor positive breast can.sir is better in some ways because it.responds to hormonal treatments which we.didn't have thirty years ago but the ER.negative tumors do not and what we found.was that the ER positive patients didn't.get a survival advantage but they were.doing better anyway because the hormonal.treatments were better the ER negative.patients had the same kind of difference.in survival that we had whoops that we.had seen in the earlier study so the.ones who weren't benefiting from newer.treatments did survive longer if they.were in our support groups compared to.controls and in fact overall survival.had mortality from breast cancer has.been going down in the period between.our first and our second study largely.because of better hormonal and.chemotherapy treatments so the.treatments have improved that's great.and I'm always pleased whatever it is.that works but we think that may account.for some of the differences this is a.study published by Barbara Anderson at.The Ohio State University she did a.similar kind of group therapy but more.educational in nature for women with.primary breast cancer so earlier stage.disease and she found sorry she found an.effect on survival as well so the ones.who got the psychotherapy lives.significantly longer than the ones who.were in the control condition there's.another study that was published just a.year ago in the New England Journal of.Medicine for people with end-stage lung.cancer non-small cell lung cancer very.serious disease they were treated with.palliative care so treating their pain.their depression right at the end of.life and they were able to significantly.reduce their depression to some extent.their anxiety as well and they live.two-and-a-half months longer.significantly longer if they got the.palliative care compared to standard.care so there are now eight studies.eight randomized trials that show that.emotional support for cancer patients.not only improves quality of life it.actually improves quantity of life.however there are seven other studies.that show no difference I'm glad to say.there are no studies that show that.psychotherapy kills patients that.doesn't happen so the studies are not.randomly distributed.the studies if anything show that.psychotherapy helpful not all of them do.so others are still doing this research.I'm still doing this research I think.it's still an open question but by now I.think it's a pretty interesting question.about whether handling the stress better.facing it directly altering your.perception of your situation and your.perception of pain coping actively.expressing emotion getting social.support doesn't help you not just.improve the quality of life but improve.the quantity of life as well another.picture of my for my French patients.showing how punished she felt and sort.of wistfully seeing an image of herself.before her treatment so you had asked a.question earlier on so what are the.mechanisms well that's a complex area.we're still working on it but I'll.before I stop and take questions I'll.give you some ideas that we haven't some.data that we have that's right.and so the follow-on from that is the.different parts of the body can be.accessed too so one air at one system.we're very interested in is the.hypothalamic-pituitary-adrenal axis this.basically it's a long word for a stress.hormone called cortisol cortisol it's a.it mobilizes glucose in the blood it.prepares you to fight or flee it's.secreted by the adrenal glands here on.top of the kidneys and there's a complex.system that allows the brain to trigger.a hormone called CR h that goes to the.pituitary that secretes ACTH that goes.around on the blood and tells the.adrenals okay pump out cortisol you need.to raise your blood sugar but it.wouldn't be good for if you did that all.the time so the system has this very.delicate feedback regulation so that.once the stress is over you turn the.system off and you go back to normal.however and that doesn't always work.particularly with depression so this is.a nice normal daily pattern of cortisol.our cortisol levels are highest in the.morning and by now your cortisol levels.should all be quite low we're down here.except with the election they may.start to go up again very quickly.depending on the results people with.depression tend to not have this nice.daily variation of cortisol tends to be.high in flat PTSD low in flat so the.daily variation is part of a normal body.response to the stress of waking up in.the morning among other things we found.him on our breast cancer patients that a.lot of them had abnormal cortisol.patterns they didn't have this nice high.level in the morning going down late in.the day they had either flat or even.increasing patterns throughout the day.yeah yes oh here yeah here's what yeah.well it seems that people with.fibromyalgia have a number of hormonal.and also immune function problems and.that people with fibromyalgia tend not.to have this nice normal daily variation.in cortisol and it may be something that.contributes to the fibromyalgia it's a.complicated thing there's a mood.disorder associated with it as well but.yes there is evidence of people with.chronic pain in fibromyalgia have this.abnormal cord pattern and what we think.happens is that they kind of burn out.the system I don't know if I don't think.I have the slide here but basically the.this court system can be something like.an overuse light switch that if you keep.turning it on all the time sometimes it.just stays on you know so you don't have.you lose that ability to shut the system.down when you need to or at other times.it stays off which is more like what you.see in this fiber of my ALJ and PTSD.pattern so the system does not correct.itself and you either don't have.cortisol when you need it or you have it.around all the time when you don't need.it that's been called a low static load.it's it it's how chronic stressors can.degrade the body's response system to.stress and we found that that isn't a.good thing for breast cancer patients so.the ones that had these abnormal.patterns.where they tend to stay high actually.also had shorter survival than the ones.who had the normal cortisol patterns and.again this is a prediction independent.of all the other risk factors so it.suggests that having a normal stress.response system is an important factor.and and this has recently been seen with.lung cancer patients as well sandy.Sefton who did the original work on the.diurnal cortisol pattern in breast.cancer found the same thing with lung.cancer patients as well so it seems that.an abnormal stress response system may.increase risk for shorter survival with.cancer one of the factors that's.associated with it is poor sleep so the.ones who have these abnormal patterns.don't sleep as well they wake up more.during the night and sleep disruption.now I mentioned the grandmother effect.earlier can be a real risk factor as.well so we're looking now we're actively.studying we've had a number of wonderful.people with cancer come in and help us.study their sleep wakefulness patterns.and their hormonal patterns and we're.actively investigating that now and some.of our early works suggest that people.who are having the most trouble sleep.sleeping do not live as long and this is.not like two weeks before you die this.is years before so a good stable pattern.of sleep actually is a good predictor of.better survival yeah well that can.certainly it can contribute to the.aberrant patterns that if you're waking.at night you're probably triggering an.acute cortisol response the more.frustrated you are the more you're doing.it.menopause of course has its own or.mental factors and women getting breast.cancer treatment if they haven't been.menopausal become menopausal due to the.treatment so that can complicate the.situation and what we want to do is help.them re-establish normal sleep-wake.patterns as best we can and there are.good therapeutic treatments some.medications but they tend to be over.utilized and other kinds of sleep.hygiene and sleep training treatments.can be very helpful and I'll give you.one tip that it's a more complex thing.but if you can see your clock from your.bed.turn it around because seeing what time.it is when you wake up in the middle of.the night is an arousal cue and what.you're doing is waking yourself up more.so it doesn't matter what time it is.you set the alarm if you need to but you.don't want to know in the middle of the.night what time it is when you're waking.up so things like that can help you.actually sleep better even if you're.having difficulty sleeping one of the.other reasons that Oksana polish in our.group found is that people who sleep.better at night have better abilities to.control their nervous system arousal.during the day we call it vagal tone.it's the positive the ability of the.parasympathetic nervous system to slow.heart rate and lower blood pressure and.we all know this if you've not had a.good night's sleep and even minor things.happen the next day you know you're not.at your best you know you're angry and.fussy and you just don't handle the.stresses as well as you do if you've had.a good night's sleep and so we have.better vagal tone among our cancer.patients who sleep better at night so.it's another reason to eat well sleep.well and get plenty of exercise and.exercise during the day will help you.sleep better at night and this was an.article back when there was a Time.magazine of talking about sleep and the.fact that losing sleep cancer might be.something to lose sleep over but we'd.rather regain the sleep and lose the.cancer and there's some evidence that.sleeping better may help you with that.as well so some of the factors that we.think can translate from stress.management into differential rates of.tumor progression include these.circadian rhythms of sleep and.wakefulness these stress hormones and.effects on the immune system as well and.that's another complex but an.interesting area where we think these.stress hormones can inhibit functions of.the immune system that have to do with.cancer surveillance as well women with.these abnormal cortisol patterns had.lower numbers of natural killer cells.and these are cells in natural cells in.the immune system that actually kill.transformed and dying cells they don't.recognize the external antigens like.viruses and bacteria they recognize.transform cells in the body and they are.involved in tumors severe.so the women who had these abnormal.cortisol patterns actually had fewer.natural killer cells in their blood so.that's another possible connection we.found that high depression was.associated with poor natural immunity so.you know when you've got a TB test you.have an antigen stuck under your skin.and 48 hours later you see if you have.an immune response to it that so it's a.net it's a low-tech but natural way of.measuring the body's immune system and.those of our patients who had higher.depression scores had poor natural.immunity so depression and high cortisol.levels can actually interfere with the.body's natural immune system this is.work from a group at Texas MD Anderson.Medical Center in University of Iowa.showing that another stress hormone.epinephrine which increases heart rate.and as is secreted by the adrenal.medulla is actually associated with more.rapid tumor growth in animals and I.think you may be able to see here that.there's more growth here than here and.the epinephrine among other things.stimulates blood supply to support the.tumor there's a there's a substance.called vascular endothelial growth.factor that is higher in these animals.when they're stressed so there are a.number of hormone systems that seem to.have an effect on tumor growth and this.is just a sort of a little diagram here.that they provide showing how the stress.and the norepinephrine production can.trigger vascular support and allow.tumors to take hold more so there's.reason to think and we should handle.stress better just because your life.will feel better if you do but it's also.possible that it may help your bodies.cope better with the illness as well and.in fact there's a clinical outcome of.this now there's a drug called.propranolol or inderal you may have.heard of it it's a beta blocker it.blocks sympathetic arousal and somebody.got the idea I want to I wonder if.breast cancer patients who happen to get.into all because they're hypertensive.have a different outcome with their.breast cancer if this was right that it.may have an effect on on tumor blood.supply and growth and sure enough the.answer is yes that the ones who happen.to be.inderal actually live longer than those.who are not so it suggests a whole new.way of treating cancer that may have.more to do with stress management and.even medications that help with stress.management than controls and this is.just another studies showing the same.thing even with triple negative that is.er PR negative breast cancers do better.if they get into all so it's a whole new.way of thinking that stress management.may help us better manage overall people.with cancer a couple of other mechanisms.one of them involves telomeres and you.may have heard about telomeres which are.the capsid ends of chromosomes they get.shorter as we age and so mine are still.pretty long but yours I'm shorter very.young and Elizabeth Blackburn who's a.faculty member at UCSF won the Nobel.Prize for this a couple years ago she's.delightful person and she's also shown.that stress is associated with shorter.telomeres so caregivers are who have.high stress actually have shorter.telomeres and less telomerase less.active telomerase which helps to repair.the length of telomeres so we're now.studying this in collaboration with her.to see what the effect of cancer related.stress is to telomere length there is.evidence that cortisol actually inhibits.the activity the expression of genes.that are tumor suppressor genes like.brca1 you've heard of that if there's a.mutation in that gene the the rate of.breast cancer goes from like 7 or 8% to.85% cortisol applied to this gene can.inhibit its activity and there's another.gene like that called p53 which is a.major tumor suppressor gene what these.genes do is they basically when cells.start to transform and don't function.right they send it a drop-dead signal so.the cell dies rather than continuing to.proliferate but stress can inhibit the.activity of that gene as well so we're.learning more and more that stressors in.various ways through hormones through.immune function and through effects on.gene expression may actually affect.how well people live and how long they.may live with cancer and this is just.another example of the data is showing.that stress and cortisol inhibit p53.gene expression so in summary we think.that stress and the way people handle it.their emotional and social support their.cognitive adaptation to the illness can.affect hormones that involve stress can.affect immune function can affect the.expression of genes that have an effect.on the body's ability to fight cancer.our goal is to transform people from.feeling damaged by the disease to.transcending it when you see the winged.victory of samothrace at the Louvre it's.a stunning piece of art you don't say oh.my there's a woman who's missing her.arms in her head do you see it as an.image of transcendence so our bodies can.be damaged and we can still transcend.and that's what we try to teach people.in dealing with the stresses of cancer.so again we think cancer is best handled.by facing rather than fleeing altering.your perception of the situation.coping actively expressing emotion and.seeking social support and that sense.feeling may lead to healing.so my French cancer patient said you.know you have some calm days you have.some better days oh my goodness okay.we'll turn that off you have some calm.days and she did the typical French.thing she made a meal of the crab she.barbecued it and she says Elora Kosh.so in summary psychotherapy works.depression in psychotherapy may affect.disease progression as well as quality.of life feeling better may lead to.healing better it isn't just mind over.matter but mine matters this is some of.the wonderful people in our Center on.stress and health who have helped us.study this and again I'm grateful to our.patients as well who have given a great.deal of their time and energy I also.want to thank our support and one of the.great things our federal government does.as a National Institutes of Health which.provides world-leading support for all.kinds of research that help us improve.the quality and quantity of life the.National Cancer Institute the National.Institute of Mental Health.the California breast cancer.search program a wonderful program the.Dana Foundation and MacArthur Foundation.and others and without their help we.couldn't be doing when I have been.presenting to you here Shakespeare said.when we are better see bearing our woes.we scarcely think our miseries our foes.the mind much sufferings death or skip.when grief hath mates and bearing.fellowship but the mind-body.relationship is nothing to fool around.with he's saying what happened here.Sargent he said it's a placebo overdose.we're pretty sure he only thinks he's.dead.so thank you for your attention.

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  3. Now, sign in to your registered Google account.
  4. Open the link of the document and choose the option 'Open in e-sign'.
  5. Choose the option of 'My Signature'.
  6. Generate your signature and put it in the document where you choose.

After placing your e-sign, send your document or share with your team members. What's more, CocoSign give its users the options to merge PDFs and add more than one signee.

How to create an electronic signature for the Ohio Survivorship Example Form in Gmail?

in Today's era, businesses have remodeled their workflow and evolved to being paperless. This involves the signing document through emails. You can easily e-sign the Ohio Survivorship Example Form without logging out of your Gmail account.

Follow the key elements below:

  1. Get the CocoSign extension from Google Chrome Web store.
  2. Open the document that needs to be e-signed.
  3. Choose the "Sign” option and write your signature.
  4. Choose 'Done' and your signed document will be attached to your draft mail produced by the e-signature app of CocoSign.

The extension of CocoSign has taken care of your problem. Try it today!

How to create an e-signature for the Ohio Survivorship Example Form straight from your smartphone?

Smartphones have substantially replaced the PCs and laptops in the past 10 years. In order to taken care of your problem, CocoSign aids to sign the document via your personal cell phone.

A high quality internet connection is all you need on your cell phone and you can e-sign your Ohio Survivorship Example Form using the tap of your finger. Follow the key elements below:

  1. Click the website of CocoSign and create an account.
  2. Next, choose and upload the document that you need to get e-signed.
  3. Choose the "My signature" option.
  4. Write down and apply your signature to the document.
  5. Check the document and tap 'Done'.

It takes you shortly to place an e-signature to the Ohio Survivorship Example Form from your cell phone. Print or share your form whatever you like.

How to create an e-signature for the Ohio Survivorship Example Form on iOS?

The iOS users would be satisfied to know that CocoSign give an iOS app to assist them. If an iOS user needs to e-sign the Ohio Survivorship Example Form , work with the CocoSign app wthout doubt.

Here's instruction place an electronic signature for the Ohio Survivorship Example Form on iOS:

  1. Add the application from Apple Store.
  2. Register for an account either by your email address or via social account of Facebook or Google.
  3. Upload the document that needs to be signed.
  4. Choose the space where you want to sign and choose the option 'Insert Signature'.
  5. Draw your signature as you prefer and place it in the document.
  6. You can send it or upload the document on the Cloud.

How to create an electronic signature for the Ohio Survivorship Example Form on Android?

The great popularity of Android phones users has given rise to the development of CocoSign for Android. You can insert the app for your Android phone from Google Play Store.

You can place an e-signature for Ohio Survivorship Example Form on Android following these key elements:

  1. Login to the CocoSign account through email address, Facebook or Google account.
  2. Upload your PDF file that needs to be signed electronically by choosing on the "+” icon.
  3. Click the space where you need to place your signature and write it in a pop up window.
  4. Finalize and adjust it by choosing the '✓' symbol.
  5. Save the changes.
  6. Print and share your document, as desired.

Get CocoSign today to assist your business operation and save yourself a large amount of time and energy by signing your Ohio Survivorship Example Form on the Android phone.

Ohio Survivorship Example Form FAQs

Some of the confused FAQs related to the Ohio Survivorship Example Form are:

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How do you get a survivorship deed?

Generically, speaking, if the Deed of the property was held as Joint Tenants, then NO. Two surviving owners get the Decedent's share. That is, previoysly-1/3-each owners are now 50-50 owners. However, if the Deed was held as Tenants in Common, nothing changes for the syrviving siblings. The Decedent's spouse gets his/her share. All three remain 1/3-each-owners.

When do I have to learn how to fill out a W-2 form?

While I did not study physics this is something that relates to my field as well. One thing to remember is the scope of the field which you are talking about. With physics it might seem narrower than History or Archaeology but I suspect that when you boil it down it isn’t. It would be impossible to cover everything in a subject even going all the way through to gaining a doctorate. The answer you got and posted up is very accurate and extremely good advice. What a lot of it boils down to in education (especially nowadays) is not so much teaching specific facts but teaching themes and how to find Continue Reading

Can a survivorship deed be changed?

Logically its difficult with the existing laws - post sale how will you maintain - what will be the co-ownership agreement and if anything happens to that property, how the process would be? hence, as it was approved in quite a few lower courts, a split-house’ method is best - i.e., please split the property into two - with a small correction in door number as well (with proper approval from local punchayat / municipality) - then that will work fine with all

How do you know if you need to fill out a 1099 form?

It can also be that he used the wrong form and will still be deducting taxes as he should be. Using the wrong form and doing the right thing isnt exactly a federal offense

How can I fill out Google's intern host matching form to optimize my chances of receiving a match?

I was selected for a summer internship 2016. I tried to be very open while filling the preference form: I choose many products as my favorite products and I said I'm open about the team I want to join. I even was very open in the location and start date to get host matching interviews (I negotiated the start date in the interview until both me and my host were happy.) You could ask your recruiter to review your form (there are very cool and could help you a lot since they have a bigger experience). Do a search on the potential team. Before the interviews, try to find smart question that you are Continue Reading

How can I make it easier for users to fill out a form on mobile apps?

Make it fast. Ask them as few questions as possible (don't collect unnecessary information) and pre-populate as many fields as possible. Don't ask offputting questions where the respondent might have to enter sensitive personal information. If some users see you collecting sensitive information, they might not be ready to share that with you yet based on what you are offering, and they will think twice about completing the form.

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