■ Bargaining

■ Depression or sadness

■ Acceptance

These stages may occur sequentially or overlap in different combinations. At each stage, follow the same approach. Be alert to patients' feelings and to cues that they want to talk about them. Use facilitative techniques to help them to bring out their concerns. Make openings for them to ask questions: "I wonder if you have any concerns about the procedure?" . . . "Your illness?" . . . "What it will be like when you go home?" Explore these concerns and provide whatever information the patient requests. Be wary of inappropriate reassurance. If you can explore and accept patients' feelings, answer their questions, and demonstrate your commitment to staying with them throughout their illness, reassurance will grow where it really matters—within the patients themselves.

Dying patients rarely want to talk about their illnesses all the time, nor do they wish to confide in everyone they meet. Give them opportunities to talk and then listen receptively, but if they prefer to stay at a social level, you need not feel like a failure. Remember that illness—even a terminal one—is only one small part of the total person. A smile, a touch, an inquiry after a family member, a comment on the day's events, or even some gentle humor all recognize and affirm other areas of the patient's individuality and help sustain the living person. To communicate appropriately, you have to get to know the patient; that is part of the helping process.

Understanding the patient's wishes about treatment at the end of life is an important part of a clinician's role. Failing to establish this communication is widely viewed as a flaw in clinical care. Even if discussions of death and dying are difficult for you, you must learn to ask specific questions. The condition of the patient and the health care setting often determine what needs to be discussed. For patients who are acutely ill and in the hospital, discussing what the patient wants to have done in the event of a cardiac or {respiratory arrest is usually mandatory. Asking about "DNR status" (Do Not Resuscitate) is often difficult when the clinician has no previous relationship with the patient and lacks knowledge of the patient's values or life ^experience. Patients may also be unrealistic about the effectiveness of resuscitation based on information in the media. Find out about the patient's frame of reference. "What experiences have you had with the death of a lose friend or relative?" "What do you know about cardiopulmonary re-iscitation (CPR)?" Educate patients about the likely success of CPR, es-ecially if they are chronically ill or advanced in age. Assure them that reeving pain and taking care of their other spiritual and physical needs will a priority.

In general, it is important to encourage any adult, but especially the elderly or chronically ill, to establish a health proxy, an individual who can act for the patient in life-threatening situations. This can be part of the interview aimed at a "values history" that identifies what is important to the patient and makes life worth living, and the point when living would no longer be worthwhile. Ask about how patients spend their time every day, what brings them joy, and what they look forward to. Make sure to clarify the meaning of statements like "You said that you don't want to be a burden to your family. What exactly do you mean by that?" In addition, explore the patient's religious or spiritual frame of reference so you and the patient can make the most appropriate decisions about health care.

Sexuality in the Clinician-Patient Relationship. Clinicians occasionally find themselves physically attracted to their patients. The emotional and physical intimacy of the clinician-patient relationship may lead to sexual feelings. If you become aware of such feelings, accept them as a normal human response and bring them to the conscious level so they will not affect your behavior. Denying these feelings makes it more likely for you to act inappropriately. Any sexual contact or romantic relationship with patients is unethical; keep your relationship with the patient within professional bounds and seek help if you need it.

Occasionally, clinicians meet patients who are frankly seductive or make sexual advances. Calmly but firmly make it clear that your relationship is professional, not personal. You may also wish to reflect on your image. Have you been overly warm with the patient? Expressed your affection physically? Sought his or her emotional support? Has your clothing or demeanor been unconsciously seductive? It is your responsibility to avoid these problems.

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