An Examination of Interdisciplinary Perspectives Regarding Death and End of Life Care

1. An Examination of Interdisciplinary Perspectives Regarding Death and End of Life Care By: ShanielleBlack R.N. Kelsey Bureau R.N. Krista Keehn R.N., CMSRN YuririaLemus, R.T. (R) (AART) Jessica Nebeker, R.N. Boise State University

2. “In recognition of the universal need for humane end of life care, the American Association of Colleges of Nursing, supported by the Robert Wood Johnson Foundation, convened a roundtable of expert nurses and other health care professionals to stimulate scholarly discourse and initiate change on this important reality. This is in accord with the International Council of Nurses' 1997 mandate that nurses have a unique and primary responsibility for ensuring that individuals at the end of life experience a peaceful death.” (Robert Wood Johnson Foundation End-of Life-Care Roundtable) • GOALS SHOULD INCLUDE: • To improve the quality of life for individuals facing a terminal illness. • Promote a peaceful and respectful death. • Work as a collaborative team with clearly defined roles. • Involve the palliative care team. • Care should be patient-centered. • Care should involve family. • Care should be culturally sensitive. • Spiritual and religious beliefs need to be addressed. • “Persons are living until the moment of death.” • “Coordinated care should be offered by a variety of professionals, with attention to the physical, psychological, social, and spiritual needs of patients and their families.” • (Kay Kittrell Chitty, and Beth Perry Black, 2011, p. 17)

3. The Following Questions Were Asked to Numerous Health Care Workers: • Describe the role you / your discipline play in end of life patient care. • At what stage of the dying process do you care for patients? • Describe any personal experience you have had with death and dying. • How comfortable are you dealing with terminally ill patients or death? • Do you feel you communicate openly and effectively with patients and their families about end of life issues? • How do you cope with death, or loss of a patient? • In reference to end of life issues, what is the most difficult part of your job? • In reference to end of life issues, what is the most fulfilling part of your job? • Do you think your educational training program adequately prepared you to deal with end of life care? • When caring for a dying patient and their family do you feel that taking care of both their physical and spiritual health is a priority? • How do you feel about physician assisted suicide? • What advice or insight would you give to a person entering healthcare , or another discipline of health care?

4. Dan Merkes B.S.N.Emergency Nursing Dan is the designated charge Nurse at St. Luke’s Meridian In the emergency department. For the past 18 years he has worked in emergency departments across the United States including trauma services in Chicago. Describe the role you/your discipline play in end of life patient care? I coordinate the personnel within my department to respond to those dying. This includes mobilizing medical staff to respond with medical interventions, social workers and chaplains to provide spiritual care and support services, notifying coroner of death and to investigate any wrongful death scenarios, notifying STATLINE for potential organ donation and coordinate the recovery of any eligible organs, amongst other duties. At what stage of the dying process do you care for patients? From the acute state of arrival until they are released from our department. Describe any personal experience you have had with death and dying? I have been in the ED for 18 years and deal with death and dying on a daily basis. I have had Several close family members and friends die beginning at an early age and have unfortunately had a lot of exposure. How comfortably are you dealing with terminally ill patients or death? I am quite comfortable with these patients and recognize it an opportunity to provide compassion and care to someone in there final moments on earth. I recognize this as a privilege and enormous responsibility. Do you feel you can communicate openly and effectively with patient and their families about end of life issues? Yes, I take every opportunity to make a difference to the family members and display compassion and understating to their loss. How do you cope with death, or the loss of a patient? Event debriefings and discussions with colleagues to discuss feelings surrounding the event.

5. Dr. Jeff SymmondsVascular Surgeon Jeff Symmonds is a successful vascular surgeon of over 25 years, practicing at the Saint Alphonsus Medical Group, Vascular Services in Boise, Idaho. He attended Duke University Medical School followed by his residency at University of California (San Francisco) Medical Center. He also did a fellowship at the Mayo Medical Center (Rochester) and is a member of the American Board of General Surgery (1985, 1995); Vascular Surgery (1990, 2000, 2010). His special practice interests include: Lung Cancer, Endovascular Surgery - Balloon Angioplasty, Stents, Atherectomy; Carotid, Aortic, Lower Extremity Arterial Repairs. Describe the role you/your discipline play in end of life patient care? As a vascular and thoracic surgeon, my patients typically are geriatric, ages 60 -90, with the usual elderly diseases of atherosclerosis, COPD, diabetes.  I operate on them to resolve problems with carotid occlusive disease to prevent strokes, repair abdominal aortic aneurysms, and repair blocked arteries to the legs to improve walking ability or avoid amputation.  I also remove lung cancers in hopes of curing people of cancer. As a vascular and thoracic surgeon, my patients typically are geriatric, ages 60 -90, with the usual elderly diseases of atherosclerosis, COPD, diabetes.  I operate on them to resolve problems with carotid occlusive disease to prevent strokes, repair abdominal aortic aneurysms, and repair blocked arteries to the legs to improve walking ability or avoid amputation.  I also remove lung cancers in hopes of curing people of cancer.  My goal always is to keep people alive and have them survive their surgery, but occasionally they don't make it.  Mortality rates with the various procedures I do run less than 5%, depending on the severity of illness.  Lung cancer patients will occasionally die from pulmonary insufficiency or pneumonia post lung cancer resection; AAA patients sometimes die on the operating table from ruptured aneurysm bleeding, or after surgery from MI, renal failure, respiratory failure, stroke etc.  Advanced heart disease runs hand in hand with peripheral vascular disease and diabetes so all my patients are at risk for MI, arrhythmias, stroke, etc.  All my patients have personal physicians they see routinely who have referred them to me and most have Cardiologists associated as well. My goal always is to keep people alive and have them survive their surgery, but occasionally they don't make it.  Mortality rates with the various procedures I do run less than 5%, depending on the severity of illness.  Lung cancer patients will occasionally die from pulmonary insufficiency or pneumonia post lung cancer resection; AAA patients sometimes die on the operating table from ruptured aneurysm bleeding, or after surgery from MI, renal failure, respiratory failure, stroke etc.  Advanced heart disease runs hand in hand with peripheral vascular disease and diabetes so all my patients are at risk for MI, arrhythmias, stroke, etc.  All my patients have personal physicians they see routinely who have referred them to me and most have Cardiologists associated as well. CONT’…

6. Dr. Jeff SymmondsVascular Surgeon CONT’ Whenever I admit patients for surgery I keep their other physicians involved in their medical management while in they are in the hospital, to keep the other physicians informed and to use their expertise in managing complex medical issues.  Sick patients are managed in the ICU or CCU and there are Intensivists and Hospitalists I utilize to help with post-operative care.   As I am often in the O.R. the Intensivists (who are all Pulmonologists as well) assume primary care of the sick patients as they are always in the ICU and are available for acute problems and questions when I am tied up.  If patients are critically or terminally ill post op, the Intensivists do a lot of the communication with the patient's families during the day.  We both will hold meetings with the families routinely to inform them of the patient's condition and prognosis and options.  I routinely have a discussion with my patients pre-operatively about risks of dying related to their upcoming surgery and discuss DNR/DNI options and discuss their wishes to those regards. However, I and my patients go into surgery assuming they will do fine and make it through surgery safely.  It is not uncommon that DNR/DNI decisions are not specified by the patient preoperatively (emergencies) and most often they don't have living wills documenting their desires.  In the event things turn out badly and they develop complications that lead to their death, the patients are severely ill, usually intubated and ventilated and sedated, so that they no longer can adequately communicate about their wishes, so end of life management and decisions are usually shifted to the families, who often don't know and haven't discussed these issues with their parent/family member.  Once end of life decisions are needed, my patients usually have been in the ICU for extended periods and all hopes of improvement are waning.  The involved physicians and the family members, plus the nurses, Chaplain, Case Manager and a Palliative Care/Medical Ethics Specialist get together to work out options and plans for withdrawal of support and terminal care for the patient. Do you feel you can communicate openly and effectively with patient and their families about end of life issues? I try to communicate openly and frankly about risks, options, prognosis with the patients and their families. I am not eager to have these difficult discussions, but they are necessary to help them through these transitions. Some family members are very understanding, especially if the patient has been chronically ill and deteriorating pre-operatively; whereas if impending death is unexpected the family may be angry, despondent, litigious, belligerent, etc. which makes the discussion tough.

7. Dr. Jeff SymmondsVascular Surgeon CONT’ How do you cope with death, or the loss of a patient? I always find having patients die quite stressful, usually because it is unexpected with the planned surgery.  Reducing the frequency of patients dying is related to patient selection for surgery, which comes with practice experience, having better appreciation for appropriate candidates for surgery.  Certainly, I have gotten better at this over the last 25 years, so deaths are less frequent.  I am quite realistic about the risks of each operation and understand that occasionally complications occur that are unavoidable that can lead to a patient's death.  As long as I can attest to myself that I have done everything I can pre-operatively to prepare the patient well to get through their surgery safely, have performed their operation to the best of my abilities (to the best of any surgeon's abilities - if I think there are better surgical options than I can offer in Boise, then I will refer the patient to a university medical center), and have managed their post-op care well, utilizing the support of the appropriate specialists for the problems that arise, then I have to be accepting that the death is unavoidable and inevitable.  Vascular surgery is always quite humbling in that I can perform a great operation, do very complex arterial repairs, have the patient stable in the ICU post op, then have some unexpected complication arise that will lead to their death, nevertheless.  It is an insult to one's ego, and part of the difficulty of the profession.  It leads to constant self-assessment to look for ways to improve on preparation, operative technique and performance and on post op care.  That is all part of the "practice" of surgery, it is a perpetual state of learning. In reference to end of life issues what is the most difficult part of your job? Usually dealing with the stricken family members, as alluded to above; one must ascertain how the death is affecting various individuals and deal with each reaction.  Having the support personnel, (nursing staff, palliative care consultant, minister, etc.), along often helps with this. In reference to end of life issues what is the most rewarding part of your job? Hopefully, that I have helped the patient to a comfortable and relatively stress free demise, and the family to a point of understanding and acceptance of the passing of their family member.

8. Erin Goodfellow A.S.N.Hospice Nursing Erin has been a nurse for six years after graduating from the Collage of Southern Idaho with her Associates of Nursing degree. She is currently enrolled at Boise State University to complete her bachelors degree. She has been working as a hospice nurse for the past year a half, and finds it very rewarding. At what stage of the dying process do you care for patients? We care for the patient through all stages, but in the dying process the nurse helps direct the care to the primary caregiver and gives resources and information about the end-of-life process. Describe any personal experience you have had with death and dying? • I have had many different death experiences. Some aren’t “pretty” and sometimes they are so beautiful laying there. I usually have become very close to patient and family and I will sometimes cry with them and know that that is okay. How comfortably are you dealing with terminally ill patients or death? I am quite comfortable with these patients and recognize it an opportunity to provide compassion and care to someone in there final moments on earth. I recognize this as a privilege and enormous responsibility. Do you feel you can communicate openly and effectively with patient and their families about end of life issues? At first it was hard, but over time I have become able to communicate easily with patients and families. I always invite questions when they haven’t directly asked about what will happen so they feel more comfortable about the dying process. Do you think your educational or training program adequately prepared you to deal with end of life care? Absolutely not! There is no training for this within the academic world. It is all experience and the help of others that have experienced it to help you through it and that is what makes you a better caregiver.

9. Alex Chamberlin Spiritual Services St. Luke’s Describe the role you/your discipline play in end of life patient care? At St. Luke’s Chaplains are called for every Code Blue and every death. We are often included in care conferences, where limiting treatment or changing the medical goals are discussed with family. We assist with communication between caregivers and family, help patients/family reflect on what values and priorities propel them toward certain treatment options, assist them with understanding hospital processes regarding funeral homes, offer prayer, sacraments, and other rituals that impart meaning, facilitate reminiscence, and offer a physical presenceof compassionate support. Describe any personal experience you have had with death and dying? How much time do you have? One story…I was asked by an OB/GYN to see his patient after a scan revealed that her 20 week fetus had no arms or legs. I sat with her as she sobbed, expressed a deep sadness, and a willingness to raise the girl if lack of limbs proved to be her only disability. A subsequent scan revealed an omphalocele and facial deformities. She decided to induce labor (22 weeks) so she could hold her baby before she succumbed to her deformities, and asked me to be present to bless the baby when born. I was there for the delivery and was in awe of this woman as she sang to her little girl, completely oblivious to the multiple deformities as her little girl’s heart beat for almost an hour. I then officiated at the graveside service. I was amazed at how they loved each other, made decisions with ambivalence as well as resolve that they were doing something loving. I wept at the graveside with them and then enjoyed a meal at their home with family. She had a subsequent, healthy, child. In reference to end of life issues what is the most fulfilling part of your job? I am an organ/tissue requestor and I am finding that approaching a family to see if their loved one would approve of making such a gift can be very rewarding. It gives them something positive to do amid sadness. They often start out saying, “I can’t believe this is happening…what do we do now?” After agreeing to organ or tissue donation I hear them saying to others, “He/she is going to help others; that is how she would have wanted it.”

10. Alex Chamberlin Spiritual Services St. Luke’s CONT’ When carrying for a dying patient and their family do feel that taking care of both their physical and spiritual health is a priority? • Duh. Of course, my scope of practice is focused upon the emotional and spiritual aspects. I attempt to make sure their physical comfort is being addressed, even if I am not the one providing that particular care. Likewise, I don’t expect clinical personnel to be fully trained/comfortable in responding to questions of faith, meaning, purpose, or ultimate matters…that is why we are on call 24/7. What advice or insight would you give to a person entering healthcare? • Learn what you love to do, and then find someone who will pay you to do that. Life is too short to go to a job you hate, or which drains you because your gifts lie elsewhere. Healthcare is a job filled with meaning as you provide treatment, care, and your very soul for people who are at turning points in their lives. And to avoid burnout, remember that the first priority of a nurse is the care of said nurse (or doctor, chaplain, etc.) If you don’t know how to play and how to “leave work at work” you might as well get the orange marmalade (for you are toast!)

11. Alexander J. Black, L.C.S.W. Corrections Social Worker Describe the role you/your discipline play in end of life patient care? As a prison clinician, my role is to help individuals process through feelings of grief for themselves if they are terminally ill, or for family members who are terminal or passed away. As a social worker, I focus on helping people problem solve and prepare for death. At what stage of the dying process do you care for patients? I mainly deal with the family members of the dying person. I have worked with several inmates at various stages of their terminal illness. In reference to end of life issues what is the most difficult part of your job? The distance and barriers preventing contact between my clients and family of loved ones. This is the same issue if my client has a terminal illness or has a family member who is terminal. I also face the idea that emotions are a sign of weakness. In reference to end of life issues what is the most rewarding part of your job? When my clients can use death as a motivation for change. How do you feel about physician assisted suicide? I feel that it is unethical for a physician, or other professional to assist in suicide. However after the patient has been educated about alternatives, the patient’s right to self determination should be impeded.

12. Bob Condon, L.C.S.W. Hospice Social Worker Describe the role you/your discipline play in end of life patient care? As a social worker for a small, private hospital I am involved in all aspects of end of life care within the scope of practice. Tasks include: help with a living will/post-form changes, determining Power of Attorney for medical care, funeral arrangements, contact organ and donor line, issues of grief and sitting with patients who have no family to ensure they do not die alone. At what stage of the dying process do you care for patients? • My interactions start at admission and end with discharge, irrespective of the type of discharge, heaven, home or a facility. I am frequently called upon to help families and patient work through the Kubler-Ross stages of death as they do not have a great deal of time, in some cases. Getting the family to move in a direction where decisions are being made and the family can support the members of the family. Describe any personal experience you have had with death and dying? Watching my grandmothers die, one from cancer, the other from COPD, were my first interaction with the grief process, however, it has been my professional experience that has shaped my way of coping with this process. As a social worker in the child protection arena, I was asked to manage a very difficult case. The child, at the time I became the case manager was six years of age and had problematic secretion and was constantly dealing with an infection of some sort. At age three months, the child was shaken by his father. The child at six had no cognitive function and limited response to any external stimuli. However, due to the infection and poor immune response, he was always sick and was being placed on antibiotics, which were ultimately more harm to the child then good. Due to the position of the state, the child continued to receive care, even when it was harmful as the state of Idaho would not allow for a death. I assisted the child’s mother, whose only fault was she was young and naive, appeal to the court, suggesting that the residual rights of the mother included determining continued medical care. The Court agreed and the mother made the decision to with-hold care from the child. He died five days after the court hearing. After one argues with the state and wins, knowing the outcome is the death of a child, anything else is frosting on the cake.

13. Jessica Kowitz, R.T. (R)(ARRT) Jessica graduated from Idaho State University in 2012 with a B.S in Radiologic Sciences. She has worked in the radiology field for 2 years and has decided to further her education in radiology by attending BSU to obtain her second Bachelors degree with an emphasis in magnetic resonance imaging. Describe the role you/your discipline play in end of life patient care? X-Ray may play a large role in the end of a patients life. Chest x-rays are most often what I do and many of my patients are on vents so it’s hard to say if the patient will recover. At what stage of the dying process do you care for patients? • In a perfect world hopefully my patients are not going to die while in our care. Ideally we want them back to their normal. Describe any personal experience you have had with death and dying? • I’ve seen patients come into the ER then to ICU then surgery for organ donation that we have had to x-ray. On the other hand I’ve had what were thought to be well recovering pts who get a CXR one day and are gone the next. How comfortably are you dealing with terminally ill patients or death? Very, it’s a part of life/living process. How do you cope with death, or the loss of a patient? • Fine, it’s sad a life is lost by hopefully it was appreciated. In reference to end of life issues what is the most rewarding part of your job? • Knowing that I tried making a positive experience in an individuals last days.

14. Brandon Lindberg, R.T. (R)(MR)(ARRT) Brandon graduated from ISU with his B.S in Radiologic Sciences. After graduation Brandon decided to take on a job at St. Luke's in Meredian and till this day he is still employed and is enjoying his job as a Magnetic Resonance Imaging Technologist. Describe the role you/your discipline play in end of life patient care? The role I play in end of life patient care is performing MRI scans to evaluate quality of life with images. At what stage of the dying process do you care for patients? • I care for patients at all levels of life. MRI covers healthy patients as well as terminally ill patients. Describe any personal experience you have had with death and dying? • I have been part of multiple experiences with death and dying. The most common is patients that have stopped breathing (coded) while performing MRI scans. How comfortably are you dealing with terminally ill patients or death? I have grown comfortable with death and dying, however, it is never easy to be part of a study in which I know the patient is going to die. In reference to end of life issues what is the most difficult part of your job? • Performing MRI scans on babies that are terminal do to trauma or birth defect. When caring for a dying patient and their family do you feel that taking care of both their physical and spiritual health is a priority ? • When I am caring for a dying patient they are usually not able to communicate with me. I do always treat all my patients with respect. I would like to think if they where able to talk to me they would say they were treated physically and spiritually well. When I am caring for a dying patient they are usually not able to communicate with me. I do always treat all my patients with respect. I would like to think if they where able to talk to me they would say they were treated physically and spiritually well.

15. Dave Kenat Jr. Deputy Sheriff and Chaplain for Yellowstone County, Montana At what stage of the dying process do you care for patients? I have been present with those who have died in car accidents. I have been present with those who have died of heart attacks. I have been present with those who have committed suicide. I have been present at scenes of homicide and natural deaths. Describe the role you/your discipline play in end of life patient care? There are nine Christian disciplines that each individual practices. Amongst them is the practice of prayer and study of the Word of God. As a chaplain, it is my duty to bring comfort to those who suffer. To comfort means to comes along side to help, to support, to strengthen. It also means one who intercedes, an advisor, advocate, or an encourager. Meaning, one who puts courage into them. Many believe that comforting is when one protects them from difficulties, to sympathize, or pamper. But, this is not true comfort. Comfort is to come along side one who suffers and provide strength and courage to them when they face the trials of life. True comfort helps an individual face life honestly and faithfully. Amongst those trials is the appointment of death. It is an appointment we all meet. As a chaplain, as well as an officer, it has been my honor to be present when the appointment to meet one's maker is present. My job would be to provide comfort and help them embrace death, should the situation be dire. Or, to provide them courage to endure if the injury is great, but the appointment of death has not truly arrived. As a chaplain, the first ministry is the ministry of presence. As St. Francis of Assisi said; "At all times teach the Gospel. And, when absolutely necessary, use words." The ministry of presence is just being there for them, saying nothing, and providing God's love. If they want, I can pray with them. If they want, I can even provide scripture that will provide them the hope that Jesus provided for us all. How comfortable are you dealing with terminally ill patients or death? Having nearly died due to a misdiagnosed MRSA infection which resulted in a six week stay in the hospital, including two weeks in ICU, I have found that terminally ill patients tend to bond with me because I understand many of the feelings they are experiencing. However, I never tell them that I UNDERSTAND there feelings. I tell them I was diagnosed as being terminal in 2006. I also tell them that I was spared by the grace of God. I tell them how I felt when I was first told that I had approximately one week to live. This tends to open the door of conversation.

16. Dave Kenat Jr. Deputy Sheriff and Chaplain for Yellowstone County, Montana CONT’ How do you cope with death, or loss of a patient? I cope with the deaths of friends, victims, patients, and strangers through tears. I do not hide from the feeling of loss. When Jesus' friend Lazerus died, Jesus wept. We are meant to feel love and loss. It is a part of life. When we distance ourselves from that, we become hard and cold. We stop seeing people as human beings and begin to see them as objects, easily able to discard. I also rely on the love and support of my wife. I like to go home and cuddle with her. I also spend time talking to God about how I feel. Some deaths move me more than others. I do not force myself to cry. If I cry, I cry. If I am moved by the death, I allow myself to embrace the feelings. I know that God has a Divine plan for all of us. I also know that this is not the end of our existence. Jesus came to earth and saved us all from the wage of sin, which is death. I know that when we die, we are given the opportunity to spend eternity with God, Jesus, and all those whom we have loved and were loved by. When I mourn it is because I miss the presence of that individual in my life. It is a selfish act, in many ways. Because, as the book of Genesis points out in the Noahiccovenant, God promises the decedents of Noah and all living creatures that there will come a time when there will be no more suffering and we will live in the eternal bliss of Heaven. When we die, we have the choice to go and live forever with God. However, as Jesus demonstrated, we were given the gift of love. It is okay to feel. I also like to speak with other believers. I have found there are times when the death is especially tragic. There are times that speaking to a brother or sister has provided me with the voice and word of God. In other words, God worked through someone to provide me with something I needed to hear to get me through this. In reference to end of life issues, what is the most difficult part of your job? The most difficult part of my job is having to tell a husband, wife, or child that there mother, father, or child is dead. In reference to end of life issues, what is the most fulfilling part of your job? The Most fulfilling part of my job is being able to be present when tragedy has struck and I can demonstrate the love that God has for them merely by being there and bearing witness. As a chaplain, the greatest thing a person can do for a grieving family, is just be there.

17. Kristi Petersen Deckard NREMT Emergency Medical Technician ACLS, PALS, BLS/ First Aid, Wilderness First Aid Instructor, Assistant Fire Chief of Blue Creek Fire Department Describe the role you / your discipline play in end of life? My role is to assess the scene that I am responding to and determine plan of care. Starting CPR or not? Dealing with the family that is around and assisting with the code that usually lasts about 20-40 minutes. I have never had a save on the job so dealing with the family again and calling the coroner are the main points. Locking the house up once we leave and dealing with animals as well. At what stage of the dying process do you care for patients? The last two stages are the most I've been exposed to with responding to 911 calls. Either they are in the process of expiration or they are very close to being in that situation. Describe any personal experience you have had with death and dying. My personal experience would have to be the fear of dying form cancer. I am a survivor but have mixed in the thoughts of not making it before. A very frightening process none the less and recently having a save with a 3 year old boy on my x-mas vacation was one for the books. How comfortable are you dealing with terminally ill patients or death? Honestly since I lost my grandfather this last spring not so great. I lost a dog just after mothers day to a horrible accident in my backyard and the neighbors dog who is fed blood. My little mini schnauzer didn't have a chance. I did rush him to the vet and care for him 48 hours before he passed away. This was one of the hardest things I have ever gone through to date. I also cared for my grandfather who was in a nursing home on hospice for a week straight. Watching him go down hill every so many hours was ok for me. I knew he was going to die and every minute I had with him in the meantime was healing for me. In reference to end of life issues, what is the most difficult part of your job? Announcing to the family that we did everything we could because I feel their pain and watched their love one expire with my own hands.

18. Jessica Nebeker, R.N.

19. References:Robert Wood Johnson Foundation End-of Life-Care Roundtable (Comp.). (2000, March 3). Peacful death: Recommended competencies and curriciular guidelines for end-of-life nursing care. Retrieved from http://www.aacn.nche.edu/elnec/publications/peaceful-deathKay Kittrell Chitty, and Beth Perry Black. (2011). Professional nursing (p. 17). Missouri: Saunders Elsevier.Kubler-Ross, E., & Kessler, D. (2012). The five stages of grief. Retrieved from http://grief.com/the-five-stages-of-grief/ A Special Thank You: Dan Merkes B.S.N., Dr. Jeff Symmonds, Shauna Ellefson, B.S.N., N.P., Erin Goodfellow A.S.N., Bryan M. Shiflett, M.D., Alex Chamberlin, Alexander J. Black, L.C.S.W., Bob Condon, L.C.S.W., Jessica Kowitz, R.T., Brandon Lindberg, R.T., Dave Kenat Jr.