TOUGH QUESTIONS, HONEST ANSWERS

Rev. Dr. Cherie Wallis Jackson, BCCC,CFHPCRev. Janet Ihne, M.Div.

TOUGH QUESTIONS, HONEST ANSWERS1Presentation PurposeTo examine Cultural and Faith Based Decisions at End of Life including:Religion/Spirituality: Facilitating and Complicating FactorsBreaking Bad News: When Family says, Dont Tell.Facility PlacementPerception of HospiceArtificial NutritionDNRDisposition of RemainsUse of Opiates and Withdrawal of Medication

PLEASE HOLD QUESTIONS UNTIL THE ENDIntroduction: End of Life Issues Regarding Religion/Spirituality/Cultural Define Religion and SpiritualityReligion- Embraces Several DimensionsExperiential

Ritualistic

Consequential

Intellectual

When were talking about experiential, were talking about the emotional ties to religion. Ritualistic is the participation in religious ceremonies, and consequential is the degree to which religion is integrated into the persons daily life. The Intellectual dimension is knowledge about the religions traditions, beliefs and practices. Any or all of these dimensions can have an impact on how a person faces death and copes with loss.3Religion/SpiritualitySpirituality:Has many definitionsSpirituality gives our lives context May or may not be connected to a specific belief system Connection with self/others, value system, meaningReligious observance, prayer, meditation or a belief in a higher power Nature, art, music, or a secular community

Spirituality has many definitions, but at its core, spirituality helps to give our lives context. Its not necessarily connected to a specific belief system or even religious worship.

Have you ever heard a patient or family member say, Im not religious. Im spiritual.?

Spirituality arises from ones connection with themselves and others, the development of ones personal value system, and ones search for meaning in life. Spirituality takes the form of religious observance, prayer, meditation or a belief in a higher power for many, while for others it can be found in nature, art, music, or a secular community. Spirituality is different for everyone.4

Facilitating Factors

Finding the Meaning in the IllnessA Sense of a Larger ConnectionFaith Practices Enhance HealthFaith Influences Sense of Control and Places in the Hands of Higher Power

According to a study by Siegel & Schrimshaw (2002) research has supported the fact that religion and spirituality can assist persons in finding a sense of meaning in the illness and death. The diagnosis of a life-threatening illness rocks our world and challenges all our assumptions as we struggle to make sense out of their illness. Later in the illness, individuals may seek to make sense of their suffering, their death, or their life. Throughout the this process, religious and spiritual perspectives can offer meaning and may offer reassurance that their illness is a part of a larger plan or that the illness itself may offer lessons to self or others. Even with death, there is evidence that religious and spiritual beliefs minimize fear and uncertainty by making sense of the illness. It also allows a sense of a larger connection. Even with the isolation of the illness, there may be a sense that God or some other higher power will sustain and protect. The more tangible evidence comes from the social support available through the ministries of a chaplain, clergy, spiritual advisor, ministry team, or even within the larger faith community. The sense that one is not alone because there are those who are caring, visiting, and praying, seems to provide benefits to the person dying, and their family members. Religious and spiritual practices and beliefs may even enhance health by reducing stress, depression, and anger, while offering emotional, physical, and spiritual support through prayer, companionship and rituals. Rituals may include the laying on of hands, anointing with oil, praying the Rosary, and meditation, to name a few. There is also evidence that spiritual and religious beliefs may have physiological benefits such as lowering blood pressure or enhancing immune function. These beliefs also may benefit an individuals sense of control. When someone has a life-threatening illness, they may feel that they have little or no control. Religious and spiritual beliefs may affirm a sense of personal control. Self-efficacy can be expressed in a number of ways, including the ability to find meaning or benefit from the experience. This control comes from leaving the illness in the hands of their higher power, perhaps believing that God will cure them or at least be present with them throughout the dying process.5Complicating FactorsFear of Gods judgmentConflicts with medical practiceMoral guilt as a penalty for sinLack of belief

Certain religious or spiritual beliefs may serve to increase rather than decrease death anxiety or complicate grief. For example, fears over divine judgment or uncertainty in an afterlife may not offer comfort to a dying person or their family. (Will I get into heaven? Was Mom saved before she died?) Also, some spiritual systems such as Christian Science may complicate medical treatments while others such as Jehovahs Witnesses may prohibit medical practices such as blood transfusions or blood-based therapies. Some may see their suffering as punishment for their sins, or they may be told by their pastor or church members that their illness is a result of sin. Such beliefs heap guilt upon the sick individual and further complicate their illness, spirituality and dying process. They may view their suffering as a comfort, believing they will receive purification that will appease God or better prepare them for the afterlife. Some may wear their illness like a badge, offering it as a way to gain a greater connection to God or others. And others will be taught or may believe that they could be healed if they only truly believed and that they themselves are hindering their own healing through their unbelief.6How to Break Bad News to the Patient

InformationLack of formal training Want to knowStrengthens patient/medical team relationshipsCollaborationPlan and cope

Formal training on how to break bad news to a patient is dismally low with only about 10 percent of clinicians possessing any formal training (Baile, Buckman, Lenzi et al, 1998). Most people want to know what they are facing, and with knowledge, the relationship between the physician, the RN Case Manager and the patient is strengthened. When the patient is informed, it also encourages collaboration, and permits the families and patients to plan for and cope with the illness.76-Step Protocol (Adapted from Robert Buckman)Getting startedWhat does the patient know?How much does the patient want to know?Sharing the informationResponding to patient, family feelingsPlanning and follow-up

8SPIKES- another way to define the 6 StepsResearch by Buckman adapted by Kathleen CicconeS= settingP= perceivesI = invitation K= knowledgeE= emphasizing/exploring emotionsS= Strategy and Summary.Another way to define the 6 steps is through the acronym of SPIKES. S is getting the setting right; P stands for what the patient perceives; I is an invitation to share the news; K is the giving of the knowledge; E is emphasizing and exploring the patients and familys emotions; and S stands for strategy and summary.9Step 1- SettingPhysical ContextPrivacyFamily membersBody languageListening skills

In getting the Setting right, youll want to plan what you will say; confirm the medical facts; do not delegate the responsibility to someone else; and create a conducive environment. How do we do this?

The setting must be private in a facility try to find a conference room. Next, identify the family members who are opposed to telling the patient that they are on hospice, and identify those who are willing to tell.Your body language talks. Make sure you are seated, and making good eye contact with each family member. Keep your body position neutral and open.Make sure you are hearing the family go into active or reflective listening, avoid interrupting them, and use silence and repetition to make sure you are accurately hearing what they have to say.

10Step 2-Perception- Before you tell, ask.Use different ways of asking what the family perceives.Ask open-ended questions, then correct misconceptions.Assess vocabulary and comprehension of medical terms.Note if denial is present. Reschedule if you are not prepared to answer tough questions.

Before you discuss the patients illness, ask them what they understand about their loved ones prognosis. Ask open-ended questions, then correct any misconceptions. These questions can be phrased as What have you been told about the medical diagnosis? What is your understanding of the reasons we are using morphine to treat pain?During your conversation, assess the family members vocabulary and comprehension of these medical terms, and also note if any denial is present. Are they engaging in wishful thinking or unrealistic expectations of the progression of the illness? Assess their ability to handle bad news. Please note, that if you are not prepared to answer tough questions, reschedule the conversation until you think it can be handled comfortably. What we often find, is that families underestimate the patients ability to cope.

11Step 3-InvitationThere are different ways of asking how much a patient or family member wants to know.Requesting information Denying information Choice of informationHandling informationThere are different ways of asking how much a patient or family member wants to know. When they do request information, the anxiety associated when delivering bad news will decrease. Denying information is a valid psychological coping mechanism, used by family members, and becomes more likely when the illness becomes more severe.Give the patient and family member the choice of how much information they want to hear.And remember, that people handle information differently.Be considerate of race, ethnicity, culture, socioeconomics, religion, as well as age and developmental level.

12Step 3-When the Family says Dont tell.What Happens When the Family Does Not Want to Inform the Patient they are on Hospice?Advance Preparation:Initial Assessment by admitting RN, RNCM, Social Worker, ChaplainWhat does the patient know?How does the patient handle information?Reasons to inform (right to know)Legal obligation to obtain Informed Consent from the patient.Foster family cooperationHonesty promotes trustProvides an opportunity to say goodbye

Ask the patient open-ended questions like, How do you want me to pray for you regarding your condition? to discern how much they know about their illness.

13Step 3-When the Family says Dont tell.Ask the Family:Why not tell?What fears do you have?What are your previous experiences when bad news was delivered?Is there a personal, cultural, or religious context?Talk to the Patient together.Again, most patients know that they are dyingMost patients handle the news better than expectedIra Byock, The Four Things That Matter Most.

In Ira Byocks book, The Four Things That Matter Most, he identifies the healing power in the words, Please forgive me. I forgive you. Thank you. and I love you. By not informing the patient that death is imminent, both the family and patient are missing out on one of the most precious and intimate moments in their lives. He explains that the word good bye- derives from God be with you which is a blessing usually said when one is departing. In leaving nothing unsaid, we are giving our loved one a blessing and in return, we are blessed.14Step 4- Giving the Knowledge

Say the information, then stop.Avoid monologue, promote dialogueAvoid medical jargonPause frequently, giving information in small piecesCheck for understandingUse silence, and body languageDont minimize the severityAvoid vagueness and confusionDiscuss the implications of Im sorryOne way to deliver bad news is to say something like: Unfortunately, Ive got some bad news to tell you .. Or Im sorry to tell you that .15Step 5- Acknowledging EmotionsEmotional ResponseTears, anger, sadness, love, anxiety, relief, otherCognitive ResponseDenial, blame, guilt, disbelief, fear, loss, shame, intellectualizationBasic psychophysiological responseFight-flight

In acknowledging their emotions, we are exploring and reflecting what we are seeing and hearing them say, and validating their emotional responses. Our natural instinct is to want to make things better. How can we change the bitter tears into better tears?16Step 5- Responding to FeelingsBe prepared for: Outburst of strong emotionA broad range of emotionsGive time to reactListen quietly and attentivelyEncourage descriptions of feelingsUse non-verbal communication

When I was a hospital chaplain working in the ER, I never knew what type of emotional response a traumatic event would trigger. From a Hispanic family grabbing my hands pulling me to my knees when I asked if they would like to pray, to a mother throwing up on me when the Dr. told her that her 16 year old daughter died from a gunshot wound, to telling an African American man that if he didnt stop yelling and throwing furniture, he would not be allowed to say goodbye to his Mother. Sometimes as Chaplains, we must use our pastoral authority to take control of the situation. 17Step 6- Strategy and SummaryPlan for the next stepsAdditional information: providing information of the dying processTreat symptomsDiscuss potential sources of supportBefore leaving, assess:The safety of the patientCaregiving support at home or facilityRepeat news at future visits as requested

18Step 6- When Language is a BarrierUse a skilled translatorSomeone who is familiar with medical terminologyComfortable translating bad newsConsider telephone translation servicesAvoid family as primary translatorsConfuses family membersMay not know how to translate medical conceptsRevise the news to protect the patientSupplement the translationSpeak directly to the patient

19Step 6- Communicating PrognosisInquire about reasons for asking:What are you expecting to happen?How specific do you want me to be?What experiences have you had with:Others with the same illness?Others who have died?20Placement in a Skilled Nursing FacilityBenefits of Placement24 hour careSafe environmentDaily nutritious mealsRehabilitation servicesMost homes are not designed to facilitate wheelchairs/walkersDescribe Pitfalls Based on Faith PracticesCaregivers may be unfamiliar with the patients faith tradition and how these beliefs inform decisions about treatment and care In many faiths and cultures, some families object to placing their loved one in a facility. This causes anxiety and disrupts care within the facility

CULTURES SUCH AS EAST ASIANS, ASIANS, AND HISPANIC TEND TO KEEP FAMILY MEMBERS AT HOME.21View of Hospice Based on Faith Tradition/ CultureAfrican Americans:A little over half are wary of health servicesThe younger generation understands they cant do it all and are more accepting of medical interventionIt is important to glorify the importance of their family connection. It all goes back to their faith. Faith doesnt have a culture.Education is the key to building trust and weighing the pros and cons of end-of-life decision making Native Americans:Approve of Hospice as long as spirituality needs are metAllowed to partake in traditional Native American rituals Hispanics:They want to stay alive as long as possible through the use of aggressive treatment, leading to revocations and readmissionsBlood HandsLow users of hospice- unfamiliar with the services. Culturally inappropriate as they like to care for their own For African Americans, this goes back to slavery. Satisfaction comes from education and by taking time to explain the progression of the disease process, and what to expect along the way. They do not like change, and traditionally want everything to be done to save their loved one.

For Hispanics, their religious beliefs tend to be more towards pro-life. Hispanics want everything medically to be done for their loved one. To make a decision that would deny treatment lends to the belief that they will have the blood of their loved one on their hands. This is where the term blood hands is used in this culture.22View of Hospice Based on Faith Tradition/ CultureAsians:Second fastest growing minority population in the U.S. with a lower utilization rate of hospice due to cultural barriers and inadequate health insuranceIn the Asian family, death is not discussed because there is a common superstition that talking about death will hasten ones death.East Indian:Palliative and hospice care are aligned with Hindu valuesHindus believe that death should not be prolonged or soughtHindus prefer to die at home surrounded by family

View of Hospice Based on Faith Tradition/CultureJudaism:Concerned whether the whole direction of the hospice care is legitimateUneasiness with regard to hospices perceived refusal to actively fight death and to surrender to fateAn observant Jewish family will consult with their rabbi

Islam: (means submission to the will of God)Duty of the mother and/or children to take care of the weak and disabled Important holidays and traditions, and diet and feedings may bring up issues in healthcareCaregivers must be the same gender as the patient

Buddhist:Concept of Right IntentionKarmic worldUse of painkillers are okay if they know this may cause death but the intention is to ease pain

The Jewish community are slowly jumping on board and accepting the idea behind hospice but is still not receptive to the DNR.

Islam- important holidays and the participation in fasting. Food restrictions is another issue- no pork, blood, carrion, and alcohol. Medication is another issue, if they consumed medication by mouth it breaks the fast.

Buddhist- right intention= good karma. Intentions are selflessly compassionate. No more suffering. Be sure to cultivate other clergy in your community, possibly through joining local ministerial alliances, and also cultivate relationships with the pastoral care directors or chaplains of your local hospitals. They are often a wonderful resource for diverse cultures and faith traditions. Develop a resource list for referrals so spiritual care needs can be met as quickly and efficiently as possible. If your local hospitals promote a clergy week or day where clergy are treated to various medical procedures, such as blood pressure checks, avail yourself of it to take the opportunity to meet other clergy and develop those resources.24Artificial NutritionExplain Benefits:Prolongs lifePromoting patient comfort by preventing skin breakdown, metabolic abnormalities and dehydrationFacilitates healing of woundsExplain Negative Impact:Aspiration, which can lead to pneumoniaWhen actively dying, does more harm than goodNeed to make decision to withdraw feeding

There are few treatment decisions more difficult for families and loved ones to make than those surrounding the use of artificial nutrition and hydration in the terminal patient. If family members are not given clear expectations regarding the effectiveness or lack thereof, myths and misconceptions will confuse and may cause undue emotional harm to the family and physical harm to the patient.25Artificial Nutrition and Hydration (ANH): Just the FactsThese facts come from the American Hospice Foundation:Like many medical interventions, all forms of ANH:Uncomfortable/painful procedures Side effects and potential complicationsIndications that ANH may be more beneficial than harmful (in patients who will likely recover from a serious illness)Contraindications that ANH is more harmful than beneficial (in patients with dementia)Like many medical procedures, all forms of ANH require the patient to undergo uncomfortable and painful procedures for the treatment to be started. ANH has known side effects and potential complications, including serious infections, fluid overload, nausea/vomiting and diarrhea, electrolyte and mineral imbalances, and even death. ANH may be more beneficial than harmful for the patient who will likely recover from a serious illness, but ANH is more harmful than beneficial for the patient not likely to recover from a serious illness, or in patients with dementia. At some point the body no longer needs water or nutrition the patient simply stops eating. Its part of the natural dying process. At that point, ANH only prolongs the inevitable and interferes with what the body is trying to do naturally.26Artificial Nutrition and HydrationDefined: ANH is a treatment intervention that delivers fluids and/or nutrition by means other than a person taking something by mouth and swallowing it Enteral: Nasogastric-Nutrition and/or fluids are delivered through a tube placed in the gastrointestinal tract. The tube may be passed through the nose and throat and ultimately to the stomachParenteral: Fluids are delivered via a catheter placed in a vein of the bodyGastrostomy: The tube is surgically placed directly into the stomach or small intestine (also known as a peg tube)

Initially, these treatments were intended to be temporary.

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28Artificial Nutrition and Hydration: MythsMyth: ANH prevents aspiration pneumoniaMyth: ANH speeds wound healingMyth: A dying person who has become dehydrated due to lack of fluids experiences extreme thirst, pain, and distressMyth: A person with advanced disease or terminal illness who stops eating will starve to death painfully

.In fact, ANH may increase the risk of aspiration pneumonia because the body cavity fills, then can come back up what could be referred to as gagging aspiration.ANH wont necessarily speed wound healing but it could help prevent wounds. However, there is good evidence that persons with advanced Alzheimers disease that there is more harm than good.3. In the dying person, studies have shown that the majority never experience thirst. Initially, thirst may occur but can be alleviated by small amounts of fluids, ice chips, or by lubricating the lips.Also, if a person is incontinent, they may suffer from increased skin breakdown due to constant moisture and irritation of urine/feces on skin. And for Cancer patients, the cancer actually feeds off the protein ingested by the patient, therefore the cancer will actually grow more quickly.Fact: When a person with advanced disease stops eating, it is because the disease process has progressed to the point where the body can no longer process food and fluids. Studies have shown that the majority of patients never experience hunger, and in those who do, small amounts of food and fluids relieves the hunger.

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Do Not Resuscitate (DNR)Benefits of a DNRNo chance of brain damage if CPR was not administeredMay allow patient to pass away peacefully

CITE THE SOURCE USED FOR THIS INFORMATION!!!

Medical researchers reviewed 113 studies on the use of CPR in hospitals conducted over a 33-year period. Out of 26, 095 patients who received CPR, 3,968 or 15.2% survived to be discharged from the hospital. Patients with the least chance for survival (less than 2%) are those who have more than two medical problems, who do not live independently, and those who have a terminal disease.

30Burdens of CPR

A frail patients ribs could be broken and a lung or spleen punctured because of the necessary force applied during CPRBrain injury can occur if the patient has been without oxygen. This can result in intellect and personality change or permanent unconsciousness (persistent vegetative state)Patient could be placed on a ventilator for a prolonged period of time, which creates an emotional and financial hardship on the familyThe family will be burdened with making the decision to withdraw the ventilator

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32Faith/Cultural Reasons for Refusal

Religious/Spiritual people have a strong belief that God will heal the sick. Patients and families do not want to lose HOPE. This is more realistic when there is a reasonable possibility of a good outcome.Hope is different than wishing Hope is future-oriented and directed at an objectHope is associated with uncertainty and therefore with possibility Ask, Can you tell me what you hope for now?Often, there is hope for a peaceful and pain free death

AT 3RD HOPE BULLET: How can we as healthcare professionals help family members reframe hope without giving false hope?

33Faith/Cultural Reasons for RefusalDo Not Resuscitate- implies refusing to take action.Again, people do not want to give up hopeAND- Allow Natural Death: removes the power from the clinicians and gives the power back to God. Now the hope can shift from curative to palliativeAmbivalence on the part of the patient or family is often communicated through religious language. Let God decideSometimes family members will use It is against our religion to slow down the decision making processAND Some hospices, hospitals, and medical centers have changed their terminology from DNR to AND.

This does not mean they wont change their mind when death is near.A chaplain visit is recommended to help educate and explore the nature of the religious objection.

34When I am dying, I am quite sure that the central issues for me will not be whether I am put on a ventilator, whether CPR is administered when my heart stops, or whether I receive artificial feeding. Although each of these could be important, each will almost certainly be peripheral. Rather, my central concerns will be how to face death, how to bring my life to a close, and how best to help my family go on without me. John Hardwig

35Use of Opiates and Withdrawal of MedicationUse of Opiates to Control Pain- Problem: Addiction versus ToleranceMyths:Patients are given opiates to hasten their death Fear of addictionOpiates are dangerous

Albert Schweitzer once said, Pain is a more terrible lord of mankind than even death itself. Pain is probably one of the most critical issues for the seriously ill. Problem: Even when the most stringent management of pain is followed, serious pain would be controlled acceptably 80-90% of the time, if were lucky. Research shows that approximately 50% of our patients are still not medicated enough to control pain. Studies do show that when pain is controlled, people tend to live longer, which contradicts the myth of hastening the patients death.Hospice patients on prescription opiates do not become addicted. They can increase their tolerance to the medication which will require adjustments. However, when they are prescribed opiates, they are prescribed in accordance to accepted guidelines and patients will not become addicts as feared by themselves or their family members.3. A common myth is that opiates are dangerous. Actually less so than aspirin! Aspirin can cause blood thinning, ulcers, bleeding, and kidney damage. It can even cause plaque to break loose and the patient to throw a blood clot. Also, aspirin doesnt provide any real pain control. Acetaminophen can cause liver damage.

36Medication: MYTHSFentanyl patches arrest breathingPatients will become tolerant to the pain medicationOpiates cause side effectsChoose pain control over grogginess or sleeping more

When people require an increase in their pain medication, it is because their disease is worsening and causing more pain. There is no need to save strong opiates for when the pain becomes worse.It is rare for Fentanyl patches to arrest the patients breathing. It is recommended and standard practice that the patient be started on a low dose before changing to a long-acting dose.As for patients becoming tolerant to the pain medication, many people stay on the same dosage for months, or even years. ***However, if the patient is no longer getting the same pain relief as before, then they have become tolerant. Pain puts off endorphins, and the endorphins burn off pain medication more rapidly so the meds may need to be increased to combat pain.All medications have some kind of side effect, however, most of the side effects of opiates, such as nausea, grogginess, itching and confusion, can be controlled with other medications, and usually go away within a few days. For example, itching is an expected outcome and not an adverse reaction to morphine. The patient is prescribed Benadryl for the itching brought on by morphine. The only side effect that does not go away is constipation. A proper bowel regimen must be put into place. And always encourage families to choose pain control over grogginess help them find a way to accept the grogginess, recognizing that their loved ones pain is controlled, making the dying process more peaceful.

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38Use of Opiates and Withdrawal of MedicationWithdrawal of MedicationMedications for End Stage Alzheimers patients.These medications can do more harm than goodMedications are routinely withdrawn when a patient is actively dyingFamily members inability to accept terminal diagnosis

Medications for Alzheimers, such as Namenda and Aricept, are supposed to be used for a short time only and are no longer effective in patients with end stage Alzheimers. And in fact, long-term use of Namenda and Aricept can cause cognitive long-term loss in patients with Alzheimer's a definite more harm than good.The types of medications that are withdrawn when a patient is actively dying are usually the preventive medications --- medications that preventing something rather than treating a symptom, such as statins for cholesterol, thyroid, vitamins, blood pressure, and anti-depressants. However, if the family insists on leaving the loved on blood pressure and antiarrithymia type meds, it wont hurt anything and the family will retain peace of mind.Often times family members are unable to accept the terminal diagnosis and harbor the hope, and belief, that Mom or Dad will bounce back like he or she did last time, and the time before, so they may refuse to discontinue most of those medications. To get them to that place will require the team gently educating the family on the needs of the patient and what will and will not benefit the patient. 39

Disposition of Remains:Cremation- Faith PracticesHindu-Cremation as soon as possibleBuddhist- Cremation is the most acceptedIslam- Strictly forbiddenJudaism- For most, cremation is strictly forbiddenMessianic Jews are the exceptionAfrican Americans- more accepted todayHispanic-Choose cremation for financial reasonsMost Catholics do not support cremation Caucasian- Very accepting of cremationNative Americans- Most are buried, not cremated

Hindu-instructs cremation as soon as possible, typically within 24 hours. Only men go to the crematorium, with the eldest son being the chief mourner. After the cremation, all bathe and share in cleaning the house and wear white clothes. 12 hours after the cremation, family members return to collect the ashes in what is called the bone gathering ceremony.

Buddhist-The Buddhist priest is allowed to accompany the deceased to the crematory and to witness the cremation.

Islam- Embalming and cremation are forbidden. The graves are dug on a southeast-northwest line. The head of the deceased is directed toward northwest in the US, toward the city of Mecca. Bodies are laid on the soil and dust.

Judaism-For most, embalming and cremation are forbidden, although some groups within the Reform movement permit cremation. The burial usually occurs within 24-48 hours of death. The body is placed in a simple wood box. It is encouraged to drill holes in the bottom of the casket to connect the body directly to the earth.

In the past, cremation was considered taboo to African Americans because in their faith tradition there would not be a body to be resurrected at the second coming of Christ. Cremation is more acceptable now, mostly because of the high cost associated with a traditional burial. It is helpful to remind the family that the body is a tent that houses us when we are alive and when we are absent from the body, we are present with the Lord.

Native Americans- Burials take place four days later, giving the departing spirit time to arrive in the spirit world. It is important to Navajos that the bodies be returned to and buried in their sacred land.

The Catholic Church dropped its prohibition of cremation in 1963. It now permits cremation only if that choice is not a reflection of doubt or disbelief about Catholic teachings about death, resurrection, and rebirth to eternal life. (Early Pagan cremations were seen as a denial of Christ's resurrection.) Despite that change in policy, however, one edict stands: The remains of one who has died must be treated with reverence. That means scattering cremated remains (the ashes) is forbidden. The cremated remains should be placed in a worthy container and then buried in a (preferably Catholic) cemetery or placed in crypt. It also means you can't keep the ashes on display at home on the mantle or put away in a bank vault.

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41Questions and Answers

42ResourcesLiving With Grief: Diversity and End-of-Life Care, Edited by Kenneth J. Doka and Amy S. Tucci, part of Living With Grief series, (Hospice Foundation of America: 2009) www.hospice foundation.org.Lynne Ann DeSpelder and Albert Lee Strickland, The Last Dance: Encountering Death and Dying, (New York, NY: McGraw-Hill, 2009)Handbook of Thanatology: The Essential body of Knowledge for the Study of Death, Dying, and Bereavement, Editor-in-Chief: David Balk, New York: Routledge, 2007) www.adec.orgJanice Harris Lord, Melissa Hook, Sharifa Alkhateeb, Sharon J. English, Spiritually Sensitive Caregiving: A Multi-Faith Handbook, (Burnsville NC: Compassion Books, 2008)Ira Byock, The Four Things That Matter Most, (New York, NY: Free Press, 2004)Walter F. Baile, Robert Buckman, Renato Lenzi, Gary Glober,Estela A. Beale, Andrzej P. Kudelka, SPIKESA Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer, The Oncologist, 2000, 5:302-311. doi: 10.1634/theoncologist.5-4-302. http://theoncologist.alphamedpres.org/content/5/4/302Kathleen Ciccone, Principal Investigator, Breaking Bad News, A Web-Based Educational Program for Physicians, Healthcare Association of the New York State Breast Cancer Demonstration Project, NY, 2003, www.hanys.org 43Resources continuedHank Dunn, Hard Choices for Loving People. (Landsdowne, VA: A&A Publishers, 2000) www.hankdunn.comLaVone V. Hazell, MS, FT, LFD. Cross-Cultural Funeral Service Rituals, Article retrieved 11/14/2013 http://www.funeralwise.comKathleen Dowling Singh, Taking a Spiritual Inventory, Article from On Our Own Terms: Moyers on Dying, Article retrieved 10/2/2013. http://www.pbs.org/wnet/onourownterms/articles/inventory2.htmlArtificial Nutrition and Hydration: Beneficial or Harmful? https://www.americanhospice.org/articles-mainmenu-8/caregiving-mainmenu-10/48-artific...Withholding or Withdrawal of Nutrition or Hydration http://www.livestrong.com/article/428169-withholding-or-withdrawal-of-nutrition-or-hydr...

44Resources continuedArtificial Nutrition in Older People with Dementia: Moral and Ethical Dilemmas http://web.ebscohost.com/ehost/delivery?sid=e113db9a-ff09-4098-a58d-5177dbf5e4c%4...Anticipatory Grief Work: What Is It and How Do You Do It? http://www.americanhospice.org/grief/working-through-grief/81-anticipatory-grief-work...Anticipatory Grief http://en.wikdipedia.org/wiki/Anticipatory_griefUse of Opiates to Manage Pain in the Seriously and Terminally Ill Patient http://www.americanhospice.org/articles-mainmenu-8/caregiving-mainmenu-10/233-use-of...45Resources continuedIdentifying and Addressing Pain in Cognitively Impaired Older Adults http://www.americanhospice.org/articles-mainmenu-8/caregiving-mainmenu-10/468-identifying...Pros and Cons of Do Not Resuscitate Orders in Nursing Homes:: California Nursing Home Abuse Lawyer Blog http://www.nursinghomeabuse lawyerblog.com/2013/03/pros_and_cons_of_do_not_resuscitateRoles of the Family and Health Professionals in the Care of the Seriously Ill Patient http://americanhospice.org/articles-mainmenu-8/caregiving-mainmenu-10/524-roles...46Resources continuedSelf-Assessment of Your Beliefs About Death and Dying http://www.pbs.org/wnet/onourownterms/articles/quiz.htmlWheres That Advance Care Directive http://newoldage.blogs.nytimes.com/2013/10/17/wheres-that-advance-directive/?_r=0Values Conflict at the End of Life http://newoldage.blogs.nytimes.com/2013/09/03/values-conflict-at-the-end-of-life/?smid=...Caregiver stress: Tips for taking care of yourself http://www.mayoclinic.com/health/caregiver-stress/MY01231/METHOD=print47Resources continuedSpirituality and stress relief: Make the connection http://www.mayoclinic.com/health/stress-relief/SR00035Caregiving at Lifes End: Facing the Challenges http://www.americanhospice.org/articles-mainmenu-8/caregiving-mainmenu-10/49-caregiving...Stress relief from laughter? Its no joke http://www.mayoclinic.com/health/stress-relief/SR00034Stress symptoms: Effects on your body and behavior http://www.mayoclinic.com/health/stress-symptomsw/SR00008_D 48Resources continuedHow to Cope With a Loved One in Nursing Home http://www.ehow.com/print/how_4478472_cope-loved-one-nursing-home.htmlComa and Persistent Vegetative State: An Exploration of Terms http://www.americanhospice.org/articles-mainmenu-8/caregiving-mainmenu-10/50-coma-...

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