sibling grief: a case report

7
Sibling Grief= A Case Report Sue P. Heiney The intensity of sibling grief and the significance of sibling mourning are de- scribed in research studies. Yet, nurses caring for dying children may be unaware of these findings and may not offer adequate support to assist siblings in work- ing through grief. Thii article detaii one child’s perceptions of the loss of a brother and provides rich clinical material for understanding typical sibting re- sponses. The description of the therapy sessions provides a model for working with siblings and demonstrates the value of art as a therapeutic medium. These strategies are useful for nurses working with grieving siblings and may be ap- plicable to other situations in which children experience a significant loss. Copyright 0 1991 by W.B. Saunders Company Humpty-Dumpty sat on a wall. Humpty-Dumpty had a great fall, All the King’s horses and all the King’s men, Couldn’t put Humpty together again. T HE NURSERY rhyme, Humpty-Dumpty, re- flects both lay and professional beliefs about sibling grief. Caregivers and families alike have avoided discussing the death of a child’s sibling, fearing that the child would be devastated by the discussion and would fall apart and and be incon- solable. Harboring such misconceptions about children and grief has led to a poor understanding of sibling grief and to its being largely ignored by nurses and other practitioners (Demi, 1987). The purpose of this article is to describe the content of eight counseling sessions with a 9- year-old boy whose baby brother had recently died of cancer. The sessions evolved from a support group project and was part of an overall program of bereavement support developed by the author, whose nursing practice focuses on providing psy- chosocial support to children with cancer and their families. Additionally, a framework for the ses- sions and specific therapeutic interventions used will be detailed. LITERATURE REVIEW AND THEORETICAL FRAMEWORK A review of the literature uncovers a wealth of information concerning healthy children’s under- standing of death. Since the child in this case study was 9 years old, a summary of these findings is given. Additionally, specific research data and an- ecdotal reports related to sibling grief are summa- rized. This information was the basis for the theo- retical framework that guided the therapeutic interventions. Children’s Understanding of Death Jean Piaget was the first to present a theory that described children’s cognitive development as oc- curring in stages from sensorimotor to formal op- erations (Piaget, 1960). Researchers since have ap- plied Piaget’s theory to children’s understanding of death and have found that three of the stages that Piaget posited-preoperational, concrete-opera- tional, and formal operational-parallel the child’s changing cognitions about death. For example, Nagy’s landmark study (1948) found that children younger than 5 years old (preoperational) perceive death as reversible; children between the ages of 5 and 9 years perceive death in terms of magical thinking; children older than the age of 9 years see death as the end of corporal activities. Addition- ally, the 9.year-old child recognizes that death is From the Children j Hospital Center for Cancer and Blood Disorders at Richland Memorial, Columbia, South Carolina. Address reprint requests to Sue P. Heiney, M.N., R.N., C.S., Mental Health Clinical Nurse Specialist, Children’s Hospital Center for Cancer and Blood Disorders at Rich- land Memorial, Five Richland Medical Park, Columbia, SC 29203. Copyright 0 1991 by W.B. Saunders Company 0883-9417l91/0503-0002$3.00/0 Archives of Psychiatric Nursing, Vol. V, No. 3 (June), 1991: pp. 121-127 121

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Sibling Grief= A Case Report Sue P. Heiney

The intensity of sibling grief and the significance of sibling mourning are de- scribed in research studies. Yet, nurses caring for dying children may be unaware of these findings and may not offer adequate support to assist siblings in work- ing through grief. Thii article detaii one child’s perceptions of the loss of a brother and provides rich clinical material for understanding typical sibting re- sponses. The description of the therapy sessions provides a model for working with siblings and demonstrates the value of art as a therapeutic medium. These strategies are useful for nurses working with grieving siblings and may be ap- plicable to other situations in which children experience a significant loss. Copyright 0 1991 by W.B. Saunders Company

Humpty-Dumpty sat on a wall.

Humpty-Dumpty had a great fall,

All the King’s horses and all the King’s men,

Couldn’t put Humpty together again.

T HE NURSERY rhyme, Humpty-Dumpty, re-

flects both lay and professional beliefs about

sibling grief. Caregivers and families alike have

avoided discussing the death of a child’s sibling,

fearing that the child would be devastated by the

discussion and would fall apart and and be incon- solable. Harboring such misconceptions about

children and grief has led to a poor understanding

of sibling grief and to its being largely ignored by nurses and other practitioners (Demi, 1987).

The purpose of this article is to describe the content of eight counseling sessions with a 9-

year-old boy whose baby brother had recently died

of cancer. The sessions evolved from a support

group project and was part of an overall program of bereavement support developed by the author,

whose nursing practice focuses on providing psy-

chosocial support to children with cancer and their

families. Additionally, a framework for the ses- sions and specific therapeutic interventions used will be detailed.

LITERATURE REVIEW AND

THEORETICAL FRAMEWORK

A review of the literature uncovers a wealth of information concerning healthy children’s under- standing of death. Since the child in this case study was 9 years old, a summary of these findings is

given. Additionally, specific research data and an-

ecdotal reports related to sibling grief are summa- rized. This information was the basis for the theo-

retical framework that guided the therapeutic

interventions.

Children’s Understanding of Death

Jean Piaget was the first to present a theory that

described children’s cognitive development as oc-

curring in stages from sensorimotor to formal op-

erations (Piaget, 1960). Researchers since have ap-

plied Piaget’s theory to children’s understanding of

death and have found that three of the stages that

Piaget posited-preoperational, concrete-opera-

tional, and formal operational-parallel the child’s changing cognitions about death. For example,

Nagy’s landmark study (1948) found that children

younger than 5 years old (preoperational) perceive death as reversible; children between the ages of 5

and 9 years perceive death in terms of magical

thinking; children older than the age of 9 years see

death as the end of corporal activities. Addition-

ally, the 9.year-old child recognizes that death is

From the Children j Hospital Center for Cancer and Blood Disorders at Richland Memorial, Columbia, South Carolina.

Address reprint requests to Sue P. Heiney, M.N., R.N., C.S., Mental Health Clinical Nurse Specialist, Children’s Hospital Center for Cancer and Blood Disorders at Rich- land Memorial, Five Richland Medical Park, Columbia, SC 29203.

Copyright 0 1991 by W.B. Saunders Company 0883-9417l91/0503-0002$3.00/0

Archives of Psychiatric Nursing, Vol. V, No. 3 (June), 1991: pp. 121-127 121

122 SUE P. HEINEY

universal, that it happens to all living creatures. Later researchers have substantiated healthy chil- dren’s conceptions of death as coinciding with their developmental stage. Three death-related concepts were studied: irreversibility, universality, and inevitability. Therefore, between birth and the age of 9 years children gradually come to under- stand that a dead person is gone forever and death eventually will happen to everyone (Childers & Wimmer, 1971; Gartley & Bemasconi, 1967; Koocher, 1973; Nagy, 1948). A partial under- standing of sibling grief comes from children’s concept of death. Additional understanding is gained by reviewing the literature on children’s grief.

Children’s Grief

Mental health specialists, depending upon their theoretical orientation, have differing opinions about whether children grieve or mourn. Psycho- analysts contend that children are not emotionally capable of detaching from the inner representation of the person who died (Fox, 1988). In contrast, other theorists believe that grief is a process of reactions to loss, and includes the mental work that a child completes following the loss of a loved one (Fox, 1988; Furman, 1974; Rando, 1984). Ele- ments that must be present for grief to occur are the understanding of death described above, an under- standing of time (past, present, future), a concept of self, and some ego mastery (Furman, 1973). Normal grieving involves realizing and feeling the pain of the loss, adjusting to life without the miss- ing person, and withdrawing emotional energy from the loved one and reinvesting it in another (Worden, 1982).

Sibling Grief

The death of a brother or sister during childhood is a loss that may precipitate grief. Recently, re- searchers have begun to study sibling grief as a subset of childhood grief (Balk, 1983; Michael & Lansdown, 1986). As early as 1963, a review by Cain, Fast, and Erickson of children’s disturbed reactions to the death of a sibling found guilt and blame; distorted concepts of illness and death; dis- turbed attitudes toward doctors, hospitals, and re- ligion; death phobias; comparisons and identifica- tions and misidentification with the dead child; and disturbances in cognitive functioning. No effort was made to determine if these were healthy or

unhealthy indications of grief and mourning. No- table work also has been done by Rosen, who found that the most striking feature of sibling loss is a prohibition against mourning. The prohibitions came from parental, personal, and societal influ- ences. The surviving child tries to protect the par- ents from further distress by avoiding discussions about the deceased. Additionally, the child’s sup- port network lacks the understanding that the grief is valid (Fox, 1988; Rosen, 1984, 1986). There- fore, the child is encouraged not to reminisce or express feelings, but rather, to be strong and silent. Consequently, the child does not mourn the loss openly. Rosen’s and other researchers’ findings further suggest that sibling grief is similar to grief experienced by adults, may cause long-term dis- tress, and has life-long significance to the survi- vors (Michael & Lansdown, 1986; Rosen, 1984, 1986).

The literature documents a myriad of normal reactions that grieving adults experience: Chil- dren’s and siblings’ responses to loss encompass both the same reactions and different ones. Sib- lings may deny the event or experience sadness, anger, guilt, and fear. Also, the child may com- plain of bodily discomfort or act out by refusing to obey rules. On a more serious level, the sibling may become depressed, misbehave excessively, or withdraw and be indifferent. The child may have many questions about the death and may respond in an egocentric manner, e.g., ask if he can move into the dead child’s room (Fox, 1988; Scherago, 1987). Grieving parents may react severely to this behavior, leading to further suppression of the grief reaction.

In addition to research findings and professional reports about sibling grief, the lay literature has recently addressed this problem. True accounts of sibling grief are described in Losing Someone You Love (Richter, 1986) and For Those Who Live (La- Tour, 1983). These books relate personal experi- ences with loss of a sibling. They reinforce the research finding that sibling loss is a significant loss, attended by grief and mourning. A third source for a perspective on sibling loss is chil- dren’s books that give fictional accounts of sibling loss. Some of these accounts seem to be based on the author’s personal experience with loss. Nota- bly, Nadia the Willful (Alexander, 1983), which is a story about a powerful sultan who will not allow his beloved deceased son’s name to be spo-

SIBLING GRIEF 123

ken, gives powerful credence to the prohibition

against mourning. Several sources have docu- mented sibling grief and provided an insight into bereavement issues that may emerge during grief counseling sessions.

CASE HISTORY

Johnny (all names used in describing the case

study are fictionalized) is a 9-year-old boy whose

younger brother had been dead less than 3 months

when he participated in the sessions described be-

low. Johnny is a bright student in a local elemen-

tary school who earns average grades. Other than

the loss of his brother, his most recent stress was a

move to a new neighborhood that necessitated a change in schools. He seemed to make friends eas-

ily and to have a good relationship with his par-

ents. His parents seemed to be loving and caring, but

were deeply grieving the death of their younger

child. The parents seemed psychologically healthy: the mother is a school teacher and the

father is a retail salesman. The parents had exhib-

ited minimal denial of the impending death of their

child, had encouraged Johnny to be in the hospital with them, and had supported him. The entire fam-

ily seemed to have an extensive support network.

Both parents completed the parent bereavement group sessions held concurrently with the sibling

sessions.

CONTENT DESCRIPTION OF EACH SESSION

Originally, the therapists planned to have a sib-

ling support group that met concurrently with a

parent bereavement group. However, due to a

number of bereaved parents who dropped out of this group and the large number of families whose

only child had died, Johnny was the only child

who attended more than two sessions. Although no

psychological testing was planned, informed con- sent was obtained from the parents for Johnny to

participate in the sessions. At the conclusion of the

sessions, written consent was obtained from the

parents and from Johnny to make slides and black- and-white pictures of the drawings described in

this paper.

A detailed account of the session’s content, based on the process log kept by the author, is described below. The sessions were structured around topics critical to the resolution of grief and included positive and negative feelings, memories

about treatment, memories about the funeral, the

meaning and causality of the death, and saying good-bye. The general format of each of the eight sessions was introduction of the topic for the ses-

sion, asking the child to draw a picture about the

topic, and encouraging the child talk about and

explain the picture. Additionally, the sessions

were structured around the child’s developmental

stage (concrete-operational), which indicated that

Johnny understood that death is irreversible and is

the cessation of life. He seemed to understand that

his brother was gone forever.

Session I

This session began with the cotherapists descrip-

tion of the purpose of the sessions and the group’s contract. Confidentiality of the sessions was not a

contract item because the therapists believed that

the parents and children needed to be connected in

their grief and that the parents should receive a

summary of the sessions and of their child’s par-

ticipation. The leaders then explained that the chil-

dren needed to get to know each other. Each child

was asked to list several things about themselves

and then to tell the group about these items. For

example, the children were asked to tell about their favorite color and class in school, a favorite time

of the year, and a place they liked to go. Next,

each child was asked to share a positive memory of

their deceased sibling. Johnny remembered that

his brother “laughed a lot. ” Next, the leaders

discussed the purpose of the group, which was to

be a special time for sharing thoughts and feelings

about the brother or sister that had died. Only one

child (Johnny) was able afterward to state the pur-

pose of the group. Lastly, a brief overview of the

next sessions was given.

Session 2

In session 2, the idea of drawing pictures about

the topics was introduced. The child was encour-

aged to draw during this and each subsequent ses-

sion. Johnny was told that he could make a mem-

ory book about the sessions that he could take home when the sessions were over. The focus of

this session was memories about diagnosis/

treatment. Johnny drew two pictures: one depicts an angry child hitting a figure wearing a nurse’s cap; the second shows a doctor helping another patient. The therapists acknowledged that he could have both good and bad memories about his broth-

124 SUE P. HEINEY

er’s treatment. When discussing the child hitting the nurse, Johnny made veiled references to the baby but would not directly admit that the drawing represented his brother. He certainly could not ver- balize that it may have represented his own feel- ings of anger toward the doctors and nurses. In- stead, he said, “They want to do good.”

Session 3

The focus of this session was remembering the last few days before Johnny’s brother died. His baby brother was in the hospital and Johnny visited but only stayed in the room a short time. He would often go to the playroom and interact with the child life specialists. Johnny’s best memory of this time was going to a carnival and getting his face painted like a clown. He remembered making his brother laugh. His picture shows a child standing beside a crib with his arms raised and a baby in the crib smiling. He entitled this picture, “The clown that made Bobby laugh. ” As he talked about his pic- ture he began to express intense feelings of sadness at his loss. He graphically described his plan to commit suicide, to swing out on a rope over a lake, jump in, and not come back up. The therapists gently asked Johnny whether he intended to follow through with his plan and whether he was feeling that he might hurt himself now. He responded that he was not as sad at this time as he had been and did not want to carry out the plan. The therapists supported him in feeling very sad and not knowing what to do to get rid of the pain. The therapists contracted with him to talk to them or another adult if he felt that bad again in the future.

Session 4

Especially because of the intense feelings of sadness expressed in the last session, the therapists felt strongly that they should continue to explore Johnny’s memories of his brother and significant information about the funeral. Therefore, Johnny was asked to draw his memories of the funeral. He drew a picture of a baby in a casket holding a toy and a pacifier. Two adults stand on one side of the casket, the mother has a tear falling from her eye; the father is expressionless. Johnny stands with tears falling from his eyes on the other side of the casket. He entitled this drawing, “The family is feeling sad.” During this session, Johnny was able to more openly discuss his feelings of sadness and how much he missed his brother. He expressed

fears and concerns that sharing his feelings would make his family, especially his mother, feel greater sadness and increase her episodes of cry- ing. The therapists explained that being sad is nor- mal and that parents may feel better after they cry. He was encouraged to talk with his parents and tell them his feelings.

Session 5

Session 5 was structured to explore existential issues surrounding the death, the meaning of the loss, and explanations of the cause of the death. Johnny was asked to draw a picture about why his brother became sick and died. He drew a refriger- ator and stove with a pot sitting on top holding an object. A child is standing to the side and a caption above his heads read, “Oh, no!!!” The title of Johnny’s picture was, “I’m afraid I made Bobby die.” Johnny explained that he thought his brother got sick from cancer because he had not boiled the bottle nipples long enough. After listening to his explanation, the therapists explained that no one knows why children get cancer, but that scientists do know that it’s not anyone’s fault. After further discussion, Johnny drew another picture to explain why bad things sometimes happen. He drew two children with bicycles, one riding and the second one falling down and bleeding. Across the top of the picture are two figures, separated from the rest of the picture by a wavy line, which may have represented heaven or clouds. He explained his drawing by stating that the guardian angel was not watching and consequently, the child fell down. The second figure was never explained but was smaller than the angel. Johnny entitled this picture, “Good days and bad days.”

Session 6

The purpose of this session was to assess Johnny’s current functioning and encourage him to interact with friends. He drew a picture of himself and his friend playing outside his house. His par- ents are watching through the windows.

Session 7

This session focuses on further exploring Johnny’s feelings, especially his guilt and current functioning. The therapists asked him to draw a picture showing how things were now. He drew a picture of himself playing football with his father. He entitled this picture, “I feel better now because

SIBLING GRIEF 125

I talked and found out it wasn’t my fault. ” Toward the end of this session, Johnny stated, “I didn’t

kill Bobby.” However, he did not yet feel com-

fortable talking with his parents about these feel-

ings. The therapists did see Johnny tell a friend

whom he saw after the sessions that he was attend-

ing a group for children who had lost a brother or sister.

Session 8

Session 8 was a termination session and focused

on the therapists’ telling Johnny good-bye as well

as facilitating Johnny’s saying good-bye to his de-

ceased brother. This was very hard for Johnny,

who wanted the sessions to continue. The thera-

pists shared their feelings of sadness and how

much the sessions had meant to them. Johnny be-

came teary and expressed much sadness. The ther-

apists suggested that maybe Johnny did not get a chance to say good-bye to his brother as he may

have wished. Johnny agreed. He was offered a

chance to say good-bye in a drawing by showing

what he might have wanted to do before his brother

died. He drew two figures, one large and one

small; the large figure appears to be holding the smaller figure in his arms. Johnny entitled this pic-

ture, “Good-bye, I will miss you for a long time

and I love you. ’ ’

Parent Conference

After the sessions were over, both parents were

invited to discuss the results of the sessions. They

were aware of some of Johnny’s sadness but were

totally unaware of his intense guilt and suicidal

thoughts. They were visibly disturbed by this in-

formation. This information was not shared earlier

with the parents because the therapists’ assessment

during the session in which the thoughts were re-

vealed indicated that the suicidal ideation had passed and the child was not in danger of hurting himself. However, the therapists were able to help them see that Johnny’s concern for their feelings

had motivated him to keep these thoughts to him- self. They were encouraged to talk to Johnny and

share their feelings while showing him that they could tolerate their sadness and distress. This ap- proach provided an ongoing model for Johnny and further promoted sharing and supporting each other as a family to resolve their grief.

Current Status

Three years have passed since Johnny partici-

pated in these sessions. In ongoing, informal con-

tact with the family, they report that it was easier

to talk with Johnny who was, in turn, more open

with them. Although the loss was still painful, communication was improved. He is now in mid-

dle school and pursuing the usual activities of a

preadolescent. He is outgoing and displays no ap-

parent psychopathology. More importantly, he is

enjoying his role as big brother to his new baby

sister. His parents are active volunteers for some of

the hospital’s fundraising events. The family

seems to have weathered the grief and to have

adjusted remarkably well. What could be done to

promote similar positive outcomes in other siblings

and families?

DISCUSSION

This case history poignantly illustrates the reac-

tions and feelings of a bereaved sibling. The ses- sions provide information that supports research

studies on sibling grief and reinforce the reality

that children do grieve. The sessions suggest goals

and interventions for nurses to use in helping sib-

lings resolve their grief. Goals for the sessions in-

cluded facilitating the process of grief, promoting

family communication and support, and preserving

memories. The nursing interventions, such as ex-

pressive art, family therapy strategies, and thera- peutic communication, emerged from these goals.

Facilitating Normal Grief in Children

Since the grief of children is similar to that of

adults, children may benefit from similar therapeu-

tic approaches (Rosen, 1984; 1986). Guidelines

for working with bereaved children include the fol-

lowing: (1) adjust interventions to the developmen-

tal stage of the child; (2) determine the child’s

thoughts and feelings about the loss; (3) help the

child concretely understand the circumstances of the death; (4) give the child permission to grieve;

(5) promote ventilation of feelings; (6) encourage play as a way of expressing the grief; and (7) iden-

tify magical thinking which might lead to inappro-

priate feelings of guilt (Fox, 1988; Rando, 1984; Rosen, 1984, 1986; Scherago, 1987).

Art was the medium for the nursing intervention of facilitating the child’s normal grieving. Art was chosen as a medium that would enhance commu-

126 SUE P. HEINEY

nication and promote the expression of thoughts and feelings during the sessions. Additionally, art therapy is an ideal strategy for working with chil- dren Artwork may be seen as an extension of the inner world of the child, a projection of the child’s thoughts and feelings. Through drawings, the child is able to express emotions and beliefs in a self- protective manner. Drawings may reveal conflicts and fears that the child is unable to put into words. Additionally, in the process of drawing, the child may work through conflicts, gain self-under- standing, and experience personality reconstruc- tion (Walker, 1989). In this case, Johnny’s draw- ings both elicited previously unexpressed feelings and facilitated the discussion of the session topics. More importantly, the art seemed to provide an outlet for Johnny to work through his grief and have a corrective emotional experience. By talking through his artwork, Johnny was able to let go of his overwhelming sadness and guilt, give up his suicidal ideation, and reconnect with his family.

Promoting Family Communication and Support

Families under intense stress may not commu- nicate effectively and may be unable to support each other (Heiney, 1988). Loss of a child is prob- ably the greatest stress a family will encounter. The searing pain that assaults the family creates a hole in the fabric of the family’s life. Each family member may be paralyzed by her or his own grief and be fearful of hurting other family members. Therefore, they withdraw from each other and avoid discussing their feelings (Johnson, 1987). A major task of therapists working with grieving families is to help the family to reweave the fabric of their life. The therapist must promote the main- tenance of the family system by establishing sup- portive communication patterns and creating a cli- mate in which a variety of emotions and coping strategies are tolerated. In such an atmosphere, family members can work out their very personal grief while permitting the same in other family members (Rosen, 1984; 1986). This case study highlighted the prohibition against mourning and the need for the family to be more open in express- ing their feelings and allowing Johnny to express his sadness and guilt. Through both the individual and family session, the family realized that tears are a way of healing and do not need to be hidden. Before the sessions, Johnny would not talk about his brother because he was afraid of his mother’s

tears. After the interventions, all three family members were more open to each other’s expres- sions of grief.

Memory Preservation

Ideally, when a family member is dying, a dia- logue between the dying person and the remaining family members facilitates grief work. A discus- sion that focuses on the meaning of the person’s life and the future without them helps to preserve the identity of the person by actively remembering his or her life. These remembrances help to ascribe meaning to the purpose of the person’s life. Also, by confronting the changes in the family system that come about due to the loss, the family mem- bers begin to redefine their relationships and see a future without their loved one. This process helps promote grief resolution (Collison, 1987).

When a child dies, his or her brothers and sisters may not be given the opportunity to talk about them. Siblings may be protected, excluded, or ig- nored by parents who are overcome with grief. Therefore, they may not have optimum grief res- olution (Worden, 1982). By focusing on Johnny’s memories in the counseling sessions, the therapists opened the door for grief work to begin. As the sessions proceeded, feelings associated with Bobby were expressed in healthy ways; Johnny’s erroneous magical thinking concerning the cause of death and his guilt was decreased. Therefore, his mourning was facilitated rather than inhibited.

Johnny’s memory book was an important tool in assisting Johnny to talk with the therapists and re- member his brother because, symbolically, he was able to dialogue with his decreased brother. When the sessions were over, he indicated strongly that he wanted to keep the book. He seemed very proud and happy when he put each of the pages into a binder to complete the memory book.

Implications

This case report illustrates the intensity of sib- ling grief and the reactions that nurses may en- counter. The description of the sessions gives pow- erful credence to siblings’ need for support and guidance as they navigate through the storm of bereavement. The experience of one sibling in grief counseling establishes a lighthouse whose beacon may guide nurses to help children deal with the loss of a brother or sister as well as other sig- nificant losses.

SIBLING GRIEF 127

The study has highlighted several areas needing further research. A formal evaluation of the out- comes of grief counseling both individual and

group would provide empirical data to support the

efficacy of these interventions described in this

case report. Additionally, an assessment of family

functioning following the intervention is needed to

document improvement in communication and

support.

ACKNOWLEDGMENT

The project staff wishes to acknowledge the memory

of Carol Collison, Ph.D., and her consultation to the

Bereavement Group Project. The author expresses thanks to Ronnie W. Neuberg, M.D., for his critique

and recommendations regarding this article, and ac-

knowledges Ken Goolsby, M.D., for his assistance with

the support group. A special appreciation is expressed to

R.K. and his family who courageously faced their pain

and taught us so much.

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