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EEPPEECC

EEPPEECC

Last Hours of LivingLast Hours of Living

Module 12Module 12Module 12Module 12

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

Last hours of livingLast hours of living

Everyone will dieEveryone will die

< 10% suddenly< 10% suddenly

> 90% prolonged illness> 90% prolonged illness

Last opportunity for life closureLast opportunity for life closure

Little experience with deathLittle experience with death

exaggerated sense of dying processexaggerated sense of dying process

Everyone will dieEveryone will die

< 10% suddenly< 10% suddenly

> 90% prolonged illness> 90% prolonged illness

Last opportunity for life closureLast opportunity for life closure

Little experience with deathLittle experience with death

exaggerated sense of dying processexaggerated sense of dying process

Preparing for the last hours of life . . .Preparing for the last hours of life . . . Time course unpredictableTime course unpredictable

Any setting that permits privacy, Any setting that permits privacy, intimacyintimacy

Anticipate need for medications, Anticipate need for medications, equipment, suppliesequipment, supplies

Regularly review the plan of care Regularly review the plan of care

Time course unpredictableTime course unpredictable

Any setting that permits privacy, Any setting that permits privacy, intimacyintimacy

Anticipate need for medications, Anticipate need for medications, equipment, suppliesequipment, supplies

Regularly review the plan of care Regularly review the plan of care

. . . Preparing for the last hours of life. . . Preparing for the last hours of life CaregiversCaregivers

awareness of patient choicesawareness of patient choices

knowledgeable, skilled, confidentknowledgeable, skilled, confident

rapid responserapid response

Likely events, signs, symptoms of Likely events, signs, symptoms of the dying processthe dying process

CaregiversCaregivers

awareness of patient choicesawareness of patient choices

knowledgeable, skilled, confidentknowledgeable, skilled, confident

rapid responserapid response

Likely events, signs, symptoms of Likely events, signs, symptoms of the dying processthe dying process

EEPPEECC

EEPPEECC Module 12, Part 1

Physiologic Changes, Symptom Management

Module 12, Part 1 Physiologic Changes, Symptom Management

ObjectivesObjectives

Assess, manage the Assess, manage the pathophysiologic changes of dyingpathophysiologic changes of dying

Assess, manage the Assess, manage the pathophysiologic changes of dyingpathophysiologic changes of dying

Physiologic changes during the dying processPhysiologic changes during the dying process Increasing weakness, fatigueIncreasing weakness, fatigue

Decreasing appetite / fluid intakeDecreasing appetite / fluid intake

Decreasing blood perfusionDecreasing blood perfusion

Neurologic dysfunctionNeurologic dysfunction

PainPain

Loss of ability to close eyesLoss of ability to close eyes

Increasing weakness, fatigueIncreasing weakness, fatigue

Decreasing appetite / fluid intakeDecreasing appetite / fluid intake

Decreasing blood perfusionDecreasing blood perfusion

Neurologic dysfunctionNeurologic dysfunction

PainPain

Loss of ability to close eyesLoss of ability to close eyes

Weakness / fatigueWeakness / fatigue

Decreased ability to moveDecreased ability to move

Joint position fatigueJoint position fatigue

Increased risk of pressure ulcersIncreased risk of pressure ulcers

Increased need for careIncreased need for care

activities of daily livingactivities of daily living

turning, movement, massageturning, movement, massage

Decreased ability to moveDecreased ability to move

Joint position fatigueJoint position fatigue

Increased risk of pressure ulcersIncreased risk of pressure ulcers

Increased need for careIncreased need for care

activities of daily livingactivities of daily living

turning, movement, massageturning, movement, massage

Decreasing appetite / food intakeDecreasing appetite / food intake Fears: “giving in,” starvationFears: “giving in,” starvation

RemindersReminders

food may be nauseatingfood may be nauseating

anorexia may be protectiveanorexia may be protective

risk of aspirationrisk of aspiration

clenched teeth express desires, controlclenched teeth express desires, control

Help family find alternative ways to Help family find alternative ways to carecare

Fears: “giving in,” starvationFears: “giving in,” starvation

RemindersReminders

food may be nauseatingfood may be nauseating

anorexia may be protectiveanorexia may be protective

risk of aspirationrisk of aspiration

clenched teeth express desires, controlclenched teeth express desires, control

Help family find alternative ways to Help family find alternative ways to carecare

Decreasing fluid intake . . .Decreasing fluid intake . . .

Oral rehydrating fluidsOral rehydrating fluids

Fears: dehydration, thirstFears: dehydration, thirst

Remind families, caregiversRemind families, caregivers

dehydration does not cause distressdehydration does not cause distress

dehydration may be protectivedehydration may be protective

Oral rehydrating fluidsOral rehydrating fluids

Fears: dehydration, thirstFears: dehydration, thirst

Remind families, caregiversRemind families, caregivers

dehydration does not cause distressdehydration does not cause distress

dehydration may be protectivedehydration may be protective

. . . Decreasing fluid intake. . . Decreasing fluid intake

Parenteral fluids may be harmfulParenteral fluids may be harmful

fluid overload, breathlessness, cough, fluid overload, breathlessness, cough, secretionssecretions

Mucosa / conjunctiva careMucosa / conjunctiva care

Parenteral fluids may be harmfulParenteral fluids may be harmful

fluid overload, breathlessness, cough, fluid overload, breathlessness, cough, secretionssecretions

Mucosa / conjunctiva careMucosa / conjunctiva care

Decreasing blood perfusionDecreasing blood perfusion Tachycardia, hypotensionTachycardia, hypotension

Peripheral cooling, cyanosisPeripheral cooling, cyanosis

Mottling of skinMottling of skin

Diminished urine outputDiminished urine output

Parenteral fluids will not reverseParenteral fluids will not reverse

Tachycardia, hypotensionTachycardia, hypotension

Peripheral cooling, cyanosisPeripheral cooling, cyanosis

Mottling of skinMottling of skin

Diminished urine outputDiminished urine output

Parenteral fluids will not reverseParenteral fluids will not reverse

Neurologic dysfunctionNeurologic dysfunction

Decreasing level of consciousnessDecreasing level of consciousness

Communication with the Communication with the unconscious patientunconscious patient

Terminal deliriumTerminal delirium

Changes in respirationChanges in respiration

Loss of ability to swallow, sphincter Loss of ability to swallow, sphincter controlcontrol

Decreasing level of consciousnessDecreasing level of consciousness

Communication with the Communication with the unconscious patientunconscious patient

Terminal deliriumTerminal delirium

Changes in respirationChanges in respiration

Loss of ability to swallow, sphincter Loss of ability to swallow, sphincter controlcontrol

2 roads to death2 roads to death

RestlessRestless

ConfusedConfused TremulousTremulous

HallucinationsHallucinations

Mumbling DeliriumMumbling Delirium

Myoclonic JerksMyoclonic JerksSleepySleepy

LethargicLethargic

ObtundedObtunded

SemicomatoseSemicomatose

ComatoseComatose

SeizuresSeizures

THE USUAL ROAD

THE USUAL ROAD

THE DIFFICULT ROAD

THE DIFFICULT ROAD

NormalNormal

DeadDead

Decreasing level of consciousnessDecreasing level of consciousness ““The usual road to death”The usual road to death”

ProgressionProgression

Eyelash reflexEyelash reflex

““The usual road to death”The usual road to death”

ProgressionProgression

Eyelash reflexEyelash reflex

Communication with the unconscious patient . . .Communication with the unconscious patient . . .

Distressing to familyDistressing to family

Awareness > ability to respondAwareness > ability to respond

Assume patient hears everythingAssume patient hears everything

Distressing to familyDistressing to family

Awareness > ability to respondAwareness > ability to respond

Assume patient hears everythingAssume patient hears everything

. . . Communication with the unconscious patient. . . Communication with the unconscious patient

Create familiar environmentCreate familiar environment

Include in conversationsInclude in conversations

assure of presence, safetyassure of presence, safety

Give permission to dieGive permission to die

Touch Touch

Create familiar environmentCreate familiar environment

Include in conversationsInclude in conversations

assure of presence, safetyassure of presence, safety

Give permission to dieGive permission to die

Touch Touch

Terminal deliriumTerminal delirium ““The difficult road to death”The difficult road to death” Medical managementMedical management

benzodiazepinesbenzodiazepineslorazepam, midazolam lorazepam, midazolam

neurolepticsneurolepticshaloperidol, chlorpromazinehaloperidol, chlorpromazine

SeizuresSeizures Family needs support, educationFamily needs support, education

““The difficult road to death”The difficult road to death” Medical managementMedical management

benzodiazepinesbenzodiazepineslorazepam, midazolam lorazepam, midazolam

neurolepticsneurolepticshaloperidol, chlorpromazinehaloperidol, chlorpromazine

SeizuresSeizures Family needs support, educationFamily needs support, education

Changes in respiration . . .Changes in respiration . . . Altered breathing patternsAltered breathing patterns

diminishing tidal volumediminishing tidal volume

apneaapnea

Cheyne-Stokes respirationsCheyne-Stokes respirations

accessory muscle useaccessory muscle use

last reflex breathslast reflex breaths

Altered breathing patternsAltered breathing patterns

diminishing tidal volumediminishing tidal volume

apneaapnea

Cheyne-Stokes respirationsCheyne-Stokes respirations

accessory muscle useaccessory muscle use

last reflex breathslast reflex breaths

. . . Changes in respiration . . . Changes in respiration FearsFears

suffocationsuffocation

ManagementManagement

family supportfamily support

oxygen may prolong dying processoxygen may prolong dying process

breathlessnessbreathlessness

FearsFears

suffocationsuffocation

ManagementManagement

family supportfamily support

oxygen may prolong dying processoxygen may prolong dying process

breathlessnessbreathlessness

Loss of ability to swallowLoss of ability to swallow

Loss of gag reflexLoss of gag reflex

Buildup of saliva, secretionsBuildup of saliva, secretions

scopolamine to dry secretionsscopolamine to dry secretions

postural drainagepostural drainage

positioningpositioning

suctioningsuctioning

Loss of gag reflexLoss of gag reflex

Buildup of saliva, secretionsBuildup of saliva, secretions

scopolamine to dry secretionsscopolamine to dry secretions

postural drainagepostural drainage

positioningpositioning

suctioningsuctioning

Loss of sphincter controlLoss of sphincter control

Incontinence of urine, stoolIncontinence of urine, stool

Family needs knowledge, supportFamily needs knowledge, support

Cleaning, skin careCleaning, skin care

Urinary cathetersUrinary catheters

Absorbent pads, surfacesAbsorbent pads, surfaces

Incontinence of urine, stoolIncontinence of urine, stool

Family needs knowledge, supportFamily needs knowledge, support

Cleaning, skin careCleaning, skin care

Urinary cathetersUrinary catheters

Absorbent pads, surfacesAbsorbent pads, surfaces

Pain . . .Pain . . . Fear of increased painFear of increased pain

Assessment of the unconscious Assessment of the unconscious patientpatient

persistent vs fleeting expressionpersistent vs fleeting expression

grimace or physiologic signsgrimace or physiologic signs

incident vs rest painincident vs rest pain

distinction from terminal deliriumdistinction from terminal delirium

Fear of increased painFear of increased pain

Assessment of the unconscious Assessment of the unconscious patientpatient

persistent vs fleeting expressionpersistent vs fleeting expression

grimace or physiologic signsgrimace or physiologic signs

incident vs rest painincident vs rest pain

distinction from terminal deliriumdistinction from terminal delirium

. . . Pain. . . Pain Management when no urine outputManagement when no urine output

stop routine dosing, infusions of stop routine dosing, infusions of morphinemorphine

breakthrough dosing as needed (prn)breakthrough dosing as needed (prn)

least invasive route of administrationleast invasive route of administration

Management when no urine outputManagement when no urine output

stop routine dosing, infusions of stop routine dosing, infusions of morphinemorphine

breakthrough dosing as needed (prn)breakthrough dosing as needed (prn)

least invasive route of administrationleast invasive route of administration

Loss of ability to close eyesLoss of ability to close eyes Loss of retro-orbital fat padLoss of retro-orbital fat pad

Insufficient eyelid lengthInsufficient eyelid length

Conjunctival exposureConjunctival exposure

increased risk of dryness, painincreased risk of dryness, pain

maintain moisturemaintain moisture

Loss of retro-orbital fat padLoss of retro-orbital fat pad

Insufficient eyelid lengthInsufficient eyelid length

Conjunctival exposureConjunctival exposure

increased risk of dryness, painincreased risk of dryness, pain

maintain moisturemaintain moisture

MedicationsMedications

Limit to essential medicationsLimit to essential medications

Choose less invasive route of Choose less invasive route of administrationadministration

buccal mucosal or oral first, then buccal mucosal or oral first, then consider rectalconsider rectal

subcutaneous, intravenous rarelysubcutaneous, intravenous rarely

intramuscular almost neverintramuscular almost never

Limit to essential medicationsLimit to essential medications

Choose less invasive route of Choose less invasive route of administrationadministration

buccal mucosal or oral first, then buccal mucosal or oral first, then consider rectalconsider rectal

subcutaneous, intravenous rarelysubcutaneous, intravenous rarely

intramuscular almost neverintramuscular almost never

EEPPEECC

EEPPEECC Physiologic Physiologic

Changes, Symptom Changes, Symptom Management Management

SummarySummary

Physiologic Physiologic Changes, Symptom Changes, Symptom Management Management

SummarySummary

EEPPEECC

EEPPEECC Module 12, Part 2

Expected DeathModule 12, Part 2 Expected Death

ObjectivesObjectives

Prepare, support the patient, family, Prepare, support the patient, family, caregivers caregivers

Prepare, support the patient, family, Prepare, support the patient, family, caregivers caregivers

As expected death approaches . . .As expected death approaches . . . DiscussDiscuss

status of patient, realistic care goalsstatus of patient, realistic care goals

role of physician, interdisciplinary teamrole of physician, interdisciplinary team

What patient experiences What patient experiences what what onlookers seeonlookers see

DiscussDiscuss

status of patient, realistic care goalsstatus of patient, realistic care goals

role of physician, interdisciplinary teamrole of physician, interdisciplinary team

What patient experiences What patient experiences what what onlookers seeonlookers see

. . . As expected death approaches. . . As expected death approaches Reinforce signs, events of dying Reinforce signs, events of dying

processprocess

Personal, cultural, religious, rituals, Personal, cultural, religious, rituals, funeral planningfuneral planning

Family support throughout the Family support throughout the processprocess

Reinforce signs, events of dying Reinforce signs, events of dying processprocess

Personal, cultural, religious, rituals, Personal, cultural, religious, rituals, funeral planningfuneral planning

Family support throughout the Family support throughout the processprocess

Signs that death has occurred . . .Signs that death has occurred . . . Absence of heartbeat, respirationsAbsence of heartbeat, respirations

Pupils fixedPupils fixed

Color turns to a waxen pallor as Color turns to a waxen pallor as blood settlesblood settles

Body temperature dropsBody temperature drops

Absence of heartbeat, respirationsAbsence of heartbeat, respirations

Pupils fixedPupils fixed

Color turns to a waxen pallor as Color turns to a waxen pallor as blood settlesblood settles

Body temperature dropsBody temperature drops

. . . Signs that death has occurred. . . Signs that death has occurred Muscles, sphincters relaxMuscles, sphincters relax

release of stool, urinerelease of stool, urine

eyes can remain openeyes can remain open

jaw falls openjaw falls open

body fluids may trickle internallybody fluids may trickle internally

Muscles, sphincters relaxMuscles, sphincters relax

release of stool, urinerelease of stool, urine

eyes can remain openeyes can remain open

jaw falls openjaw falls open

body fluids may trickle internallybody fluids may trickle internally

What to do when death occursWhat to do when death occurs Don’t call 911Don’t call 911

Whom to callWhom to call

No specific “rules”No specific “rules”

Rarely any need for coronerRarely any need for coroner

Organ donationOrgan donation

Traditions, rites, ritualsTraditions, rites, rituals

Don’t call 911Don’t call 911

Whom to callWhom to call

No specific “rules”No specific “rules”

Rarely any need for coronerRarely any need for coroner

Organ donationOrgan donation

Traditions, rites, ritualsTraditions, rites, rituals

After expected death occurs . . .After expected death occurs . . . Care shifts from patient to family / Care shifts from patient to family /

caregiverscaregivers

Different loss for everyoneDifferent loss for everyone

Invite those not present to bedsideInvite those not present to bedside

Care shifts from patient to family / Care shifts from patient to family / caregiverscaregivers

Different loss for everyoneDifferent loss for everyone

Invite those not present to bedsideInvite those not present to bedside

. . . After expected death occurs. . . After expected death occurs Take time to witness what has Take time to witness what has

happenedhappened

Create a peaceful, accessible Create a peaceful, accessible environmentenvironment

When rigor mortis sets inWhen rigor mortis sets in

Assess acute grief reactionsAssess acute grief reactions

Take time to witness what has Take time to witness what has happenedhappened

Create a peaceful, accessible Create a peaceful, accessible environmentenvironment

When rigor mortis sets inWhen rigor mortis sets in

Assess acute grief reactionsAssess acute grief reactions

Moving the bodyMoving the body

Prepare the bodyPrepare the body

Choice of funeral service providersChoice of funeral service providers

Wrapping, moving the bodyWrapping, moving the body

family presencefamily presence

intolerance of closed body bagsintolerance of closed body bags

Prepare the bodyPrepare the body

Choice of funeral service providersChoice of funeral service providers

Wrapping, moving the bodyWrapping, moving the body

family presencefamily presence

intolerance of closed body bagsintolerance of closed body bags

Other tasksOther tasks

Notify other physicians, caregivers of Notify other physicians, caregivers of the deaththe death

stop servicesstop services

arrange to remove equipment / suppliesarrange to remove equipment / supplies

Secure valuables with executorSecure valuables with executor

Dispose of medications, biologic Dispose of medications, biologic wasteswastes

Notify other physicians, caregivers of Notify other physicians, caregivers of the deaththe death

stop servicesstop services

arrange to remove equipment / suppliesarrange to remove equipment / supplies

Secure valuables with executorSecure valuables with executor

Dispose of medications, biologic Dispose of medications, biologic wasteswastes

Bereavement careBereavement care

Bereavement careBereavement care

Attendance at funeralAttendance at funeral

Follow up to assess grief reactions, Follow up to assess grief reactions, provide supportprovide support

Assistance with practical mattersAssistance with practical matters

redeem insuranceredeem insurance

will, financial obligations, estate closurewill, financial obligations, estate closure

Bereavement careBereavement care

Attendance at funeralAttendance at funeral

Follow up to assess grief reactions, Follow up to assess grief reactions, provide supportprovide support

Assistance with practical mattersAssistance with practical matters

redeem insuranceredeem insurance

will, financial obligations, estate closurewill, financial obligations, estate closure

Dying in institutionsDying in institutions

Home-like environmentHome-like environment

permit privacy, intimacypermit privacy, intimacy

personal things, photospersonal things, photos

Continuity of care plansContinuity of care plans

Avoid abrupt changes of settings Avoid abrupt changes of settings

Consider a specialized unitConsider a specialized unit

Home-like environmentHome-like environment

permit privacy, intimacypermit privacy, intimacy

personal things, photospersonal things, photos

Continuity of care plansContinuity of care plans

Avoid abrupt changes of settings Avoid abrupt changes of settings

Consider a specialized unitConsider a specialized unit

EEPPEECC

EEPPEECC Expected Death Expected Death

SummarySummaryExpected Death Expected Death

SummarySummary

EEPPEECC

EEPPEECC Module 12, Part 3

Loss, Grief, Bereavement

Module 12, Part 3 Loss, Grief, Bereavement

ObjectivesObjectives

Identify, manage initial grief Identify, manage initial grief reactionsreactions

Identify, manage initial grief Identify, manage initial grief reactionsreactions

Loss, grief with life-threatening illness . . .Loss, grief with life-threatening illness . . . Highly vulnerableHighly vulnerable

Frequent lossesFrequent losses

function / control / independencefunction / control / independence

image of self / sense of dignityimage of self / sense of dignity

relationshipsrelationships

sense of futuresense of future

Highly vulnerableHighly vulnerable

Frequent lossesFrequent losses

function / control / independencefunction / control / independence

image of self / sense of dignityimage of self / sense of dignity

relationshipsrelationships

sense of futuresense of future

. . . Loss, grief with life-threatening illness. . . Loss, grief with life-threatening illness Confront end of lifeConfront end of life

high emotionshigh emotions

multiple coping responsesmultiple coping responses

Confront end of lifeConfront end of life

high emotionshigh emotions

multiple coping responsesmultiple coping responses

Loss, grief, coping Loss, grief, coping

Grief = emotional response to lossGrief = emotional response to loss

Coping strategiesCoping strategies

conscious, unconsciousconscious, unconscious

avoidanceavoidance

destructivedestructive

suicidal ideationsuicidal ideation

Grief = emotional response to lossGrief = emotional response to loss

Coping strategiesCoping strategies

conscious, unconsciousconscious, unconscious

avoidanceavoidance

destructivedestructive

suicidal ideationsuicidal ideation

Normal griefNormal grief PhysicalPhysical

hollowness in stomach, tightness in hollowness in stomach, tightness in chest, heart palpitationschest, heart palpitations

EmotionalEmotionalnumbness, relief, sadness, fear, anger, numbness, relief, sadness, fear, anger,

guiltguilt

CognitiveCognitivedisbelief, confusion, inability to disbelief, confusion, inability to

concentrateconcentrate

PhysicalPhysicalhollowness in stomach, tightness in hollowness in stomach, tightness in

chest, heart palpitationschest, heart palpitations

EmotionalEmotionalnumbness, relief, sadness, fear, anger, numbness, relief, sadness, fear, anger,

guiltguilt

CognitiveCognitivedisbelief, confusion, inability to disbelief, confusion, inability to

concentrateconcentrate

Complicated grief . . .Complicated grief . . .

Chronic griefChronic grief

normal grief reactions over very long normal grief reactions over very long periods of timeperiods of time

Delayed griefDelayed grief

normal grief reactions are suppressed normal grief reactions are suppressed or postponedor postponed

Chronic griefChronic grief

normal grief reactions over very long normal grief reactions over very long periods of timeperiods of time

Delayed griefDelayed grief

normal grief reactions are suppressed normal grief reactions are suppressed or postponedor postponed

. . . Complicated grief. . . Complicated grief

Exaggerated griefExaggerated grief

self-destructive behaviors eg, suicideself-destructive behaviors eg, suicide

Masked griefMasked grief

unaware that behaviors are a result of unaware that behaviors are a result of the lossthe loss

Exaggerated griefExaggerated grief

self-destructive behaviors eg, suicideself-destructive behaviors eg, suicide

Masked griefMasked grief

unaware that behaviors are a result of unaware that behaviors are a result of the lossthe loss

Tasks of the grievingTasks of the grieving

1.1. Accept the reality of the loss Accept the reality of the loss

2.2. Experience the pain caused by the Experience the pain caused by the lossloss

3.3. Adjust to the new environment after Adjust to the new environment after the lossthe loss

4.4. Rebuild a new life Rebuild a new life

1.1. Accept the reality of the loss Accept the reality of the loss

2.2. Experience the pain caused by the Experience the pain caused by the lossloss

3.3. Adjust to the new environment after Adjust to the new environment after the lossthe loss

4.4. Rebuild a new life Rebuild a new life

Assessment of griefAssessment of grief

Repeated assessmentsRepeated assessments

anticipated, actual lossesanticipated, actual losses

emotional responsesemotional responses

coping strategiescoping strategies

role of religionrole of religion

Interdisciplinary team assessment, Interdisciplinary team assessment, monitoringmonitoring

Repeated assessmentsRepeated assessments

anticipated, actual lossesanticipated, actual losses

emotional responsesemotional responses

coping strategiescoping strategies

role of religionrole of religion

Interdisciplinary team assessment, Interdisciplinary team assessment, monitoringmonitoring

Grief managementGrief management

If reactions, coping strategies If reactions, coping strategies appropriateappropriate

monitormonitor

supportsupport

counselingcounseling

ritualsrituals

If inappropriate, potentially harmfulIf inappropriate, potentially harmful

rapid, skilled assessment, interventionrapid, skilled assessment, intervention

If reactions, coping strategies If reactions, coping strategies appropriateappropriate

monitormonitor

supportsupport

counselingcounseling

ritualsrituals

If inappropriate, potentially harmfulIf inappropriate, potentially harmful

rapid, skilled assessment, interventionrapid, skilled assessment, intervention

EEPPEECC

EEPPEECC Loss, Grief, Loss, Grief,

BereavementBereavement

SummarySummary

Loss, Grief, Loss, Grief, BereavementBereavement

SummarySummary