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Sustaining Our Ability to Provide Palliative Care. Palliative Care Update 2009 David F. Giansiracusa, MD Director, Palliative Care Program Maine Medical Center Portland, Maine. I have no relevant financial relationships to disclose.

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sustaining our ability to provide palliative care
Sustaining Our Ability to Provide Palliative Care

Palliative Care Update 2009

David F. Giansiracusa, MD

Director, Palliative Care Program

Maine Medical Center

Portland, Maine

Why discuss compassion

fatigue, burnout, and

self-care at a Palliative

Care symposium ?

“Physicians (clinicians) working with patients at the end of life frequently have to respond to overwhelming human suffering….Self care is an essential part of the therapeutic mandate. Self care enables physicians (clinicians) to care for their patients in a sustainable way with greater compassion, sensitivity, effectiveness, and empathy.”

“The heart must first pump blood to itself.”

(Kearney M. JAMA. 2009;301(11):1157)

Lack of self-care may

have serious professional

& personal consequences

  • Define compassion fatigue and burnout and their causes and consequences.
  • Address risk factors.
  • Recognize burnout and compassion fatigue in oneself.
  • Become familiar with what individuals and organizations may do to prevent and alleviate burnout and compassion fatigue.
compassion fatigue
Compassion Fatigue
  • Experience of emotional depletion due to the suffering of another
  • Secondary or vicarious traumatization
  • Evolves from the relationship of the clinician with the patient in the setting of an imbalance of self-care and care of others

(Figley CR. Compassion Fatigue, 1995.)

symptoms of compassion fatigue like those of post traumatic stress disorder
Symptoms of Compassion Fatigue: Like Those of Post-Traumatic Stress Disorder
  • Hyper-arousal: irritability, disturbed sleep, hyper-vigilance
  • Avoidance:“not wanting to go there”
  • Re-experiencing: intrusive thoughts or dreams, psychological or physiological distress of reminders of work with dying or suffering

(Figley CR. Compassion Fatigue, 1995)

what characterizes burnout
  • Overwhelming emotional and interpersonal job stresses that create an imbalance of professional demands and rewards
  • Arises from stresses of the clinician’s interaction with the work environment
  • Results in frustration, powerlessness, and inability to achieve work goals
manifestations of burnout
Manifestations of Burnout
  • Emotional Exhaustion:

- Depletion

- Irritability/anger

- Depression/guilt

  • Depersonalization:

- Cynicism

- Feelings of resentment

- Withdrawal

  • Reduced sense of personal accomplishment:

- Negative self-concept

- Complaining without offering a solution

(Maslach, Schaufeli, Leiter, Annual Reviews Psychology 2001)

distinction between burnout and depression
Distinction Between Burnout and Depression
  • Burnout only involves a person’s relationship to his or her work
  • Depression globally affects a person’s life

(Maslach C, Jackson SE, Leiter MP. Burnout Inventory Manual. 3rd ed. Palo Alto, California: Consulting Psychologists Press, 1996)

  • Experienced, but also 
  • Prompts action to distance oneself emotionally and cognitively from one’s work as a way to cope
  • Coping mechanism of distancing oneself from those one cares for-
  • Results in failing to appreciate the qualities which make recipients unique and engaging people
reduced sense of personal accomplishment
Reduced Sense of Personal Accomplishment
  • May develop in parallel, rather than sequentially with exhaustion and depersonalization
  • Contributor: Lack of relevant resources rather than work overload and social conflict
the six areas of work life
The Six Areas of Work Life
  • Workload
  • Control
  • Reward
  • Community
  • Fairness
  • Values

(Maslach D, Leiter MP. 1997 The Truth about Burnout. San Francisco: Jossey-Bass)

the match mismatch theoretical framework of burnout
The “Match/Mismatch” Theoretical Framework of Burnout:
  • Of six domains of job:
  • Greater the gap or mismatch, greater the likelihood of burnout
  • Greater the fit, the greater the likelihood of engagement with work

(Maslach and Leiter. The Truth About Burnout.)

varying importance of the six components of work
Varying Importance of the Six Components of Work
  • Not clear how much of a mismatch people are able to tolerate:

May depend on:

-Particular area

-Pattern of other areas

For example, with meaningful rewards, enjoyable working relationship with colleagues, feeling that work is appreciated, people may tolerate much greater workload

(Maslach and Leiter. The Truth About Burnout)

personal consequences of burnout
Personal Consequences of Burnout
  • Stress, Anxiety, Anger, Depression
  • Substance abuse
  • Family disruption
  • Stress-related health problems

(Maslach, Schaufeli, Leiter. Job burnout. Annual Reviews Psychology. 2001)

pathologic associations with burnout
Pathologic Associations with Burnout
  • Increased incidence of cardiovascular disease, Type 2 diabetes, impaired fertility, poor self-rating of health
  • Psychoneuroimmunological mechanisms  inflammation
  • In women, burnout associated with higher CRP and fibrinogen levels
  • In men, CRP and fibrinogen levels associated with depression

(Mayer and Watkins, 1998; Toker el al. 2005)

self care not so soft after all
Self-Care Not So Soft After All
  • Depression in: 12% of male physicians, 18% of female physicians; 15-30% of medical students and residents
  • After accidents, suicide is the most common cause of death among medical students
  • Doctors and nurses at higher risk for suicide
  • Doctors 70% higher mortality rates from self-inflicted injury (Frank et al. 2000)
  • As many as 400 physicians commit suicide each year in the United States.

(Alessandra Strada, PhD. AAHPM meeting, 2009)

“Physicians (clinicians) are not merely bearers of knowledge and skills, vitally important as those are, but are themselves the instruments of care.”

__Eric Cassell, The Nature of Suffering and the Goals of Medicine, New York: Oxford, 2004

job related consequences of burnout
Job-Related Consequencesof Burnout
  • Decreased job performance

(Parker, Kulik, J Behav Med 1995)

  • Reduced commitment to work

(Leiter, Harvie, Frizzell. Soc Sci Med 1998)

  • Low career satisfaction

(Goldberg et al. Acad Emerg Med 1996)

(Lemkau, Rafferty, Gordon. Fam Pract Res J 1994)

clinical consequences of burnout may lead to poor patient care
Clinical Consequences of Burnout-May Lead to Poor Patient Care
  • Prolonged hospital stays
  • Lack of discussion of patients’ and family members’ preferences and goals of care
  • Patient and family feeling a sense of abandonment
  • Excessive use of technological interventions
who is at risk of burnout professions with intense involvement with people
Who Is At Risk of Burnout?Professions with Intense Involvement with People
  • Physicians (rates ranging 25% to 60%)

(Gunderson. Ann Intern Med 2001)

(Ramirez et al. “Burnout and psychiatric disorder among

cancer clinicians” Br J Cancer 1995)

  • Nurses

(Kilfedder, Power, Wells. Soc Sci Med 1998)

  • Educators

(Chernis. Beyond Burnout. NY:Routledge, 1995)

  • Clergy

(Kirk Byron Jones. Rest in the Storm)

risk factors for burnout
Risk Factors for Burnout
  • Being a younger caregivers
  • Having responsibility for dependents: children or parents
  • Being single
  • Being highly motivated with intense investment in one’s profession
  • Lacking awareness of one’s own physical and emotional needs
risk factors for burnout in medical residents
Risk Factors for Burnout in Medical Residents
  • Caring for patients with severe illness and suffering
  • Having limited relationships with patients and families---time, role on health care team
  • Feeling a need to rescue, fix-it
  • Facing difficult communication challenges (“get the DNR”)
burnout in medical residents
Burnout in Medical Residents
  • 87 (76%) of internal medicine residents (115 or 76% responding to survey) met criteria for burnout:

-More likely to self-report suboptimal patient care which was associated with cynicism and depersonalization

(Shanafelt, Bradley, Wipf, Back. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358-367)

residents self reports of providing suboptimal care
Residents’ Self-Reports of Providing Suboptimal Care

“I discharged patients to make the service ‘manageable’ because the team was so busy.”

“I did not fully discuss treatment options or answer a patient’s questions.”

“I ordered restraints or medications for an agitated patient without evaluating.”

“I did not perform a diagnostic test because of desire to discharge a patient.”

(Shanafelt, AIM, 2002)

self reports of residents who experienced burnout
Self-Reports of Residents Who Experienced Burnout

“I paid little attention to the social or personal impact of an illness on a patient.”

“I had little emotional reaction to the death of one of my patients.”

“I felt guilty about how I treated a patient from a humanitarian standpoint.”

(Shanafelt. AIM, 2002)

even experienced clinicians may feel
Even Experienced Clinicians May Feel:

“a sense of failure and frustration when the patient’s illness progresses, a sense of powerlessness against illness and its associated losses, (unrecognized) grief, a fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings.”

(Meier et al. JAMA 2001)

“The worst loneliness is to not

be comfortable with one’s self.”

__Mark Twain

health care professionals vulnerability to burnout
Health Care Professionals’ Vulnerability to Burnout
  • Work closely with patients and families who are intensely suffering,

In crisis, and often in conflict

The “Lightening Rod Effect”

  • Conversations require time, focus, and emotional and intellectual energy

(Meier and Beresford, J Pall Med, October 2006)

clinicians experience
Clinicians Experience
  • Constant exposure to death
  • Inadequate time with dying patients
  • Growing workload and increasing deaths
  • Inadequate coping with one’s own emotional response to dying patients
  • Need to carry on in wake of patient deaths
  • Communication challenges with dying patients and relatives
  • Inability to live up to one’s own standards
  • Feeling of depression, grief, guilt in response to loss

(Kearney MK et al. Self-care of physicians caring for patients at the end of life. JAMA; 2009; 301 (11):1155-1164)

our challenges
Our Challenges

We work under pressures of:

  • Workload
  • Bureaucratic frustrations (conflict with individualist spirit and values)
  • Interpersonal conflicts
  • “Culture of Medicine”

(Meier D, Beresford L. J Pall Med, 10/2006)

our vulnerability
  • Experience feelings of guilt, insecurity, frustration, inadequacy.

(A sense of “not being enough”)

  • Identify with patient or family members may heighten our own sense of grief (Tim)
  • Be involved in conflicts over goals of care or “agendas”

(Meier, Back, Morrison.The inner life of physicians.JAMA, 2001)

recognizing burnout compassion fatigue in oneself
Recognizing Burnout/Compassion Fatigue in Oneself
  • Wish to avoid work
  • Avoidance-rounding when family are not present, when patient not fully awake
  • Feeling sense of anger and frustration towards patients, families, colleagues
  • Resisting evaluation for disease progression
  • Not communicating serious prognoses
  • Over-dependence on technological life-prolonging interventions
self care non work related activities
Self-Care: Non-Work Related Activities
  • Enrich ourselves through relationships:

∙ Family

∙ Friends

∙ Patients and their Families

. Experience of others

self care activities
Self-Care Activities
  • Regular exercise, proper nutrition, adequate rest
  • Take/make time to laugh and relax with friends
  • Enjoy meaningful solitude-walks, reading, writing, other hobbies
benefits of maintaining professional boundaries
Benefits of Maintaining Professional Boundaries
  • May offer protection from occupational stressors
  • May foster renewal outside of work

(Jackson VA, Mack J, Matsuyama R, et al. J Palliat Med. A qualitative study of oncologists’ approach to end-of-life care. 2008;11(6):893-906)

limitations of maintaining professional boundaries
Limitations of Maintaining Professional Boundaries
  • Clinician may be less emotionally available to patients
  • Clinician may experience work as less rewarding

“may feel as though they are drowning and barely able to come up for air, whereas self-care with self-awareness is like learning to breathe underwater.”

(Jackson VA, Mack J, Matsuyama R, et al. J Palliat Med. 2008;11(6):893-906)

enhancing self care through self awareness and
Enhancing Self-Care Through Self-Awareness and
  • Involves self-knowledge and dual-awareness of:

- patient and work environment with one’s own subjective experience

  • Fosters:

- job engagement and

- less stress with work interactions

- empathy as a mutually healing connection with patients

- compassion satisfaction and sense of enrichment and growth in witnessing how patients have found meaning and peace as they approach their deaths (vicarious posttraumatic growth)

-improved patient care and satisfaction

(Kearney M. JAMA, 2009;301(11):1161)


“Everything that happens to you is your teacher. The secret is to sit at the feet of your own life and be taught by it.”Polly E. Berends(c/o Alessandra Strada)

caring for yourself
Caring for Yourself
  • Identify ways to process intense emotions (share with another, meditate, exercise)
  • Attend to your own emotional and spiritual needs including grieving your losses
  • Monitor your emotional reactions, assess self for depression—if so, get help!
self awareness
  • What are our sources of meaning?
  • Where are we most vulnerable?
  • How do we grieve?
  • How is the mind-body connection occurring within us as we work?
self awareness53
  • What aspects of work are most gratifying?

Relationships with patients



Program development

  • How do professional demands affect us?
  • How do we view the rewards of our work?
potential pitfalls
Potential Pitfalls
  • “It is my nature.”

- Danger: assume that problems cannot occur

  • Professionally trained to deal with emotions

- Or trained to suppress/repress/disconnect from

  • “It must be so depressing.”

- Danger: only focus on rewards, minimize risks

  • “I don’t know how you do it. I could never do what you do.”

- Danger: pride, power, ego, idealization

(Alessandra Strada, PhD, AAHPM, 2009)

self care measures that may prevent burnout
Self-Care Measures That May Prevent Burnout
  • Mindful meditation*
  • Reflective Writing*
  • Training in communication skills
  • Development of self-awareness skills
  • Practice of self-care activities
  • Continued educational activities
  • Participation in research
  • Mindfulness-based stress reduction and meaning-centered interventions for team

*evidence for enhancing self-awareness

(Kearney M et al. Self-care of physicians caring for patients at the end of life. JAMA, 2009;301(11):1155-64)

mindfulness meditation
Mindfulness Meditation
  • The practice of careful attention to minute shifts in body, mind, emotions, and environment while holding a kind, non- judgmental attitude toward self & others
  • Fosters development of:

- a kind, objective witnessing attitude

- empathy for others

- compassion for self

  • Reduces anxiety and enhances sense of well-being

(Kabat-Zinn J. Clin Psychol Sci Proc. 2003;10(2):144-155;

Grossman P. et al.J Pyschosom Res. 2004;57(1):35-43

reflective writing
Reflective Writing
  • Writing in a reflective and emotionally expressive way
  • Promotes reflection and empathetic engagement

(Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902;

Pennebaker JW. Opening Up: The Healing Power of Expressive Emotions. New York, NY: Guilford Press, 1997.)

self care and self awareness practices in the workplace kearney m et al jama 2009 301 11 1155 1164
Walking meditation

At scheduled times:

-4 cleansing breaths,

-think of a loved-one,

-recite a poem/prayer

Reward yourself after a task: coffee break

Attend to nature out of a window

Half minute of silence or read a poem before meeting

Cleansing breaths, “acknowledge patient as a fellow traveler”, ask to “make me an instrument of thy peace” before patient visit

Keep field book/journal to write about meaningful or traumatic encounters, and share them

Develop end of the workday ritual

Always figure out a way to touch the patient

Self-Care and Self-Awareness Practices in the Workplace(Kearney M et al. JAMA. 2009;301(11):1155-1164
caring for yourself59
Caring for Yourself
  • Acknowledge:

Medicine’s limitations and your own limitations

“Be appreciative of your limited successes, more tolerant of your limited failures…..

I strive to do the very best, but I am pleased with

‘good enough’”.

__J. Andrew Billings

caring for yourself61
Caring for Yourself

Bring a colleague

sharing with colleagues
Sharing with Colleagues

Address “the affect” and share on team rounds:

  • death of a patient
  • particular identification with a patient (you, one of your loved-ones: spouse, child)
  • particularly challenging patient/family
  • being “fired” by patient or family
caring for yourself63
Caring for Yourself
  • Formal, scheduled support groups
  • Mentoring from more experienced practitioner(s)
  • Participation in team processes/rituals to acknowledge losses and patients who have died-Memorial Services, patient recognition rounds, de-briefings
  • Personal support system

(Meier and Beresford, J Pall Med, October, 2006)

renewal enhance our skill
Renewal: Enhance Our Skill
  • Growth experiences in skill and self-discovery as well as linkages with others:

∙ Practical Aspects of Palliative Care


∙ Palliative Care Education and Practice

(PCEP) program

∙ Educating Physicians in End-of-Life Care (EPEC)

Institute for the Study of Health and Illness (ISHI), Commonweal: retreats with Rachel Naomi Remen
  • “Spirituality and Meaning in Medicine” Conference
  • Other organizations offering group discussions, conferences, retreats:

∙ “Renew”

∙ “Doctor to Heal”

renew our values and refresh our goals and skills
Renew Our Values and Refresh Our Goals and Skills

“Looking through new eyes” at the work we do and the people we care for.


Making the problem go away.


Giving people the resources to enjoy life when they cannot make the problem go away.”

__Rabbi Harold Kushner

“There are two ways of

of spreading light;

To be the candle

Or the mirror that

reflects it.”

__Edith Wharton

experience the wonder of patients their families and our colleagues
Experience the Wonder of Patients, Their Families, and our Colleagues
  • Love in a family
  • Resilience
  • Courage
  • Values
  • Way patient views his own life and death
“Man is not destroyed by

suffering alone,

But by suffering without meaning.”

__Viktor Frankl, Man’s Search For Meaning

Look within yourself:

“What is hardest for me in doing my work?”

“What brings me the most joy and meaning in doing my work?”

Pursue a personal quest to find meaning and purpose in life and a relationship to something greater than oneself....

The shift from ourselves to caring for others.

__Michael Kearney, Mortally Wounded

“Those who give from the source are nourished in the giving.”

__Stephen Levine, Who Dies

“Healing requires recognition of the human face of each person one sets to heal and of the message that both the healer and the healed share a bond that ties them to each other through their humanity, their mortality, and the God-given spark of grace that lives in each of them.”

__Daniel P. Sulmasy, The Healer’s Calling

so what have i learned
So What Have I Learned?
  • Self care is extraordinarily important, but may not be sufficient to prevent burnout
  • Organizational interventions are likely also necessary: a focus on workload, control, rewards, community, fairness, and values of work environment
personal reflection on self care
Personal Reflection on Self Care

“I learned this, at least, by my experiment;

that if one advances confidently in the direction of his dreams, and endeavors to live the life which he has imagined,

he will meet a success unexpected in common hours”

__Henry David Thoreau, Walden

reflection on institutional factors and burnout
Reflection on Institutional Factors and Burnout

“You’re lucky you work at a place where the coffee is not so bad”

Family member/visitor comment:

  • Kearney MK, Weininger RB, Vachon MLS, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life…”Being connected…a key to my survival”. JAMA. 2009;30(11):1154-1164.
  • Maslach C, Goldberg J. Prevention of burnout: New perspectives. Applied and Preventive Psychology, 7:63-74, 1998
  • Zapf D, Seifert C, Schmutte B, Mertini H, Holz M. Emotion work and job stressors and their effects on burnout. Psychology and Health,16:527-545, 2001
  • Zapf D, Holz M. On the positive and negative effects of emotion work in organizations. European Journal of Work and Organizational Psychology, 15:1-28, 2006
  • Maslach C, Schaufeli WB, Leiter MP. “Job burnout”. Annual Reviews of Psychology. 52:397-422, 2001.
  • Maslach C, Leiter MP. The Truth about Burnout, San Francisco: Jossey-Bass, 1997.
  • Leiter MP, Maslach C. Preventing Burnout and Building Engagement: A Complete Program for Organizational Renewal, San Francisco: Jossey-Bass, 2000.
  • Maslach C, Goldberg J. “Prevention of burnout: new prespectives. Appl. Prev. Psychol. 7:63-74, 1998.
  • Meier DE, Beresford L. “Preventing burnout”, Journal of Palliative Medicine. 9(5):1045-1048, 2006 (October).
  • Zalenski RJ, Raspa R. “Maslow’s hierarchy of needs: A framework for achieving human potential in hospice. Journal of Palliative Medicine.9(5):1120-1127, 2006 (October)
  • Schapira L. “Stress, burnout, and renewal”, Chapter 4. Conversations in Care (
  • Blust L. “Health Professional Burnout: Parts I-IV. Fast Fact and Concept #167-170. 2007,
  • Gundersen L. Physician burnout. Ann Intern Med. 135:145-148, 2001.
  • Rabow MW, McPhee SJ. Doctoring to heal. West J Med. 174:66-69, 2001.
  • Freudenberger H. Staff burn-out. J Soc Issues 30:159-165, 1974.
  • Mount BM. Dealing with our losses. J Clin Oncology. 4(7):1127-1134, 1986.
  • Remen RN. Recapturing the soul of medicine. West J Med. 174:4-5, 2001.
  • Meier DE, Back AL, Morrison S. The inner life of physicians and care of the seriously ill. JAMA. 286(23):3007-3014, 2001.
  • Jenkins V, Fallowfield L. Can communication skills training alter physicians’ beliefs and behaviors in the clinics? J Clin Onc. 20(3):765-769, 2002.
  • Block SD. Psychological considerations, growth, transcendence at the end of life: The art of the possible. JAMA 285:2898-2905, 2001.
  • Cassell E. The nature of suffering and the goals of medicine. N Engl J Med.306:639-645, 1982
  • Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 136:358-367, 2002.
  • Ramirez AJ, Graham J, Richards MA, et. al. Burnout and psychiatric disorders among cancer clinicians. Br J Cancer 71:1263-9, 1995
  • Kilfedder CJ, Power KG, Wells TJ. Burnout in psychiatric nursing. J Adv Nurs 34:383-96, 2001
  • Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med 47:1611-7, 1998
  • Cherniss C. Beyond Burnout: Helping Teachers, Nurses, Therapists, and Lawyers Recover from Stress and Disillusionment, New York: Routledge, 1995
  • Goldberg R, Boss RW, Chan L. et al. Burnout and its correlates in emergency physicians. Acad Emerg Med 3:1156-64, 1996
  • Lemkau J, Rafferty J, Gordon R Jr. Burnout and career-choice regret among family practice physicians in early practice. Fam Pract Res J 14:213-22, 1994
  • Smith AK, Buss MK, Giansiracusa DF, Block SD. On being fired: Experiences of patient-initiated termination of the patient-physician relationship in palliative medicine. J Palliat Med. 10(4):938-947, 2007
  • Sherman DW. Nurses’ stress and burnout. Amer. J Nursing. 104: 48-56, 2004.
  • Redinbaugh EM, Sullivan AM, Block SD et al. Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital doctors. British Medical Journal 327:1-6, 26 July 2003.
  • Rando T. Grief, Dying and Death: Clinical Interventions for Caregivers. Campaign, IL: Research Press, 1984.
  • Figley CR ed. Compassion Fatigue: Coping with Secondary Traumatic Stress in Those Who Treat the Traumatized. London: Brunner-Routledge, 1995
  • Groves JE. Taking care of the hateful patient. N Engl J Med. 298:883-887, 1978
  • Novack DH, Suchman AL, Clark W, et al. Calibrating the physician: personal awareness and effective patient care. JAMA.278:502-509, 1997.
  • Zuker A. Dissatisfaction with medical practice. N Engl J Med. 350:69-75, 2004.
  • Eric Cassell. The Nature of Suffering and Goals of Medicine. New York: Oxford Press. 2004.
  • James Hallenbeck. Palliative Care Perspectives. New York: Oxford University Presss, 2003.
  • Nouwen H. The Wounded Healer, Garden City, NY. Doubleday, 1972.
  • Ferrell BR, Coyle N. The Nature of Suffering and the Goals of Nursing. Oxford University Press, 2008.
suggested readings
Suggested Readings
  • Ken Wilber, Grace and Grit: Spirituality and Healing in the Life and Death of Treya Killam Wilber, Boston, Shambhala, 2000.
  • Wallace Stegner, Crossing to Safety, 1987, Modern Library, 2002.
  • Wallace Stegner, All the Little Live Things, Penguin Books, 1967
  • Jean Vanier, Becoming Human, Paulist Press, 1999.
  • Michael Kearney, Mortally Wounded. New York: Simon and Schuster, 1996
suggested readings99
Suggested Readings
  • Michael J Fox, Lucky Man: A Memoir, Hyperion, 2003.
  • Michael J Fox, Always Looking Up: The Adventures of an Incurable Optimist, Hyperion, 2009.
  • Jean Shinoda Bolen, Close to the Bone, New York: Touchstone, 1996.
  • Christine Longaker, Facing Death and Finding Hope: A Guide to the Emotional and Spiritual Care of the Dying, New York: Doubleday, 1997
  • David Kuhl, What Dying People Want, New York: PublicAffairs, 2002.
suggested reading
Suggested Reading
  • Reynolds Price, A Whole New Life: An Illness and a Healing, Schribner, 2003.
  • Christopher Reeves, Still Me, Ballantine Books, 1999.
  • Christopher Reeves, Nothing Is Impossible, Ballantine Books, 2004.
  • Martha Weinman Lear, Heartsounds, New York: Simon and Schuster, 1980.
suggested reading101
Suggested Reading
  • Morton Kondrake. Saving Milly, New York: Ballantine Books, 2001.
  • Reeve Lindbergh. No More Words: A Journal of My Mother, Anne Morrow Lindbergh, New York: Simon and Schuster, 2001.
  • William Bridges. The Way of Transition: Embracing Life’s Most Difficult Moments. Cambridge, MA, Perseus Publishing, 2001.
suggested reading102
Suggested Reading
  • Ram Dass, Still Here: Embracing Aging, Changing, and Dying, Riverhead Trade, 2001.
  • Viktor Frankl, Man’s Search for Meaning, Pocket Publishers, 1971
  • Ira Byock. Dying Well: Peace and Possibilities at the End of Life. New York: Riverhead Books, 1997.
  • Kotter J. Leading Change, Harvard Business School Press, 1996
suggested reading103
Suggested Reading
  • Bill Bazan. Medicine In Search of Meaning: A Spiritual Journey for Physicians, Caritas Communications, 1999.
  • Kirk Byron Jones. Rest in the Storm: Self-care Strategies for Clergy and Other Caregivers Judson Press, 2001
  • The Dalai Lama. The Art of Happiness, Riverhead Books, 1998.
  • William Bridges. The Way of Transitions: Embracing Life’s Most Difficult Moments, Perseus Publishing, 2001.
suggested reading104
Suggested Reading
  • Kubler-Ross E. Death: The Final Stage of Growth, New York: Touchstone, 1975.
  • Kabat-Zinn J. Wherever You Go, There You Are. New York: Hyperion, 1994.
  • Santorelli S. Heal Thy Self: Lessons on Mindfulness in Medicine, New York: Bell Tower, 1999.
  • Arthur W. Frank. The Wounded Storyteller: Body, Illness, and Ethics. University of Chicago Press, 1997.
suggested reading105
Suggested Reading
  • Brian Sibley. C.S. Lewis through the Shadowlands: The Story of His Life with Joy Davidman, Grand Rapids: Spire, 1999.
  • Henri J.M. Nouwen. Our Greatest Gift: A Meditation on Dying and Caring, San Francisco: HarperCollins, 1994.
  • Harold S. Kushner. The Lord is My Shepherd: Healing Wisdom of the Twenty-Third Psalm, New York: Anchor Books, 2003.
suggested reading106
Suggested Reading
  • Daniel Sulmasy. The Healer’s Calling: A Spirituality for Physicians and Other Health Care Professionals. Paulist Press, New York, 1997
  • Daniel Sulmasy. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care, Georgetown University Press, 2006
  • Arthur W. Frank. The Wounded Storyteller: Body, Illness, and Ethics. Chicago, University of Chicago Press, 1995.
  • Milton Lewis. Medicine and Care of the Dying: A Modern History. Oxford University Press. 2006
suggested readings107
Suggested Readings
  • {Risking Everything}, Roger Housden (ed), New York, Harmony Books, 2003
  • Jane Kenyon. Let Evening Come (Poems), Saint Paul: Graywolf Press, 1990.
  • Jane Kenyon. Otherwise: New and Selected Poems. Saint Paul: Graywolf Press, 1996.
  • Donald Hall. Without. (Poems), New York: Mariner Books, 1998.
  • Mary Oliver. West Wind (Poems and Prose Poems), New York: Mariner Books, 1997.