DNR (do not resuscitate or no CPR) does not mean do not treat or do not care. A warning for all of us.

Dear Viki,

I noticed that after my dad became a DNR in the hospital, the nurses didn’t come into the room as often anymore and the doctor didn’t visit the way he used to. Just because my dad didn’t want to have CPR didn’t mean that he still didn’t want to fight his cancer. But it seemed like everybody gave up on him. Did the DNR (do not resuscitate) decision really mean, Do Not Care?

I realize that not only are patients confused about what DNR means (do not do CPR), but nurses and physicians are also confused. I know that’s not what you want to hear, but it’s true. Somehow DNR has become a decision about treatment choices instead of just CPR. What DNR should mean is only one thing, do not do cardiopulmonary resuscitation.

Research has found that if a patient is a DNR, then healthcare professionals may believe that the patient doesn’t want any other types of aggressive treatment. But this isn’t true. A patient may want chemotherapy, surgery, radiation therapy or other kinds of aggressive treatments, and still not want to receive CPR. A DNR doesn’t tell you anything about what other treatments the patient might or might not want to receive.

I’m not telling you this to scare you out of being a DNR. Not at all. I am just reminding all of us that one part of the end-of-life decision making process does not dictate everything else we might want. So yes, you can be a DNR and still have appropriate aggressive medical treatments. Or you can be a DNR and choose only to have hospice care. Or you can be on hospice and not be a DNR. Or you can choose some of the medical treatments being offered and refuse others. These are all separate decisions. You get to choose from all of the appropriate medical options available. Choose some, choose all or choose none. It is up to you. The only thing you can’t choose is a treatment that is not a valid medical option. You cannot make the doctor gave you ineffective or non-beneficial treatments. You are only allowed to choose from the list of medically appropriate treatments for your condition.

Lastly, as a reminder to all the healthcare professionals. A DNR never represents a do not care order. We should still be going into their hospital room as often as we would for someone without a DNR. We should always treat the patient with respect and dignity and provide comfort care to manage their suffering.

Have a kind and respectful day.

When A Stranger Decides If You Should Live Or Die

There are so many things that happen behind the scenes in healthcare when it comes to dying. One of the hardest things for me to witness is when a patient has no one to speak for them at the end. We call this person the unrepresented patient or the unbefriended person. This is a person without any friends or family who can make sure they have a good death. So what happens to them? In some cases, a public conservator or guardian is appointed to make their decisions for them. This is a stranger making decisions for another stranger. There is nothing personal or meaningful in this process. The other thing that happens, if there isn’t a guardian available, is a group of people at the hospital will make the decision for this person. Sometimes we call this an advocate team and or a moral community. This group usually consists of a doctor, nurse, social worker, chaplain, members of the ethics committee and community members. As a group they will make the decision whether this person should live or die. Unfortunately this decision is based on very little information about who this person is or what would is important to them in their life. It is usually a medical decision instead of a human decision. Not that the advocate team doesn’t try to make it personal.

Let me tell you about one such patient who had this group of strangers make his decisions for him. This was an 83-year-old gentleman who had been living in a nursing home for the past 12 years. At the nursing home, he was able to eat and walk around, but he had severe dementia and could not communicate with the staff. In the 12 years he had been living there, nobody ever visited, nobody ever called and nobody sent him a letter. He had become invisible. The staff cared about him and took good care of him but they were not family. Just before I met this man, he had a massive stroke which left him paralyzed, in a coma, unable to eat or drink and dying. The social workers at the hospital did everything they could to try to find somebody who knew this man but nobody could be found. I live in Los Angeles and we don’t have enough people who are willing to be a public conservator or guardian. So now we use advocate teams to help make decisions for those who are completely alone and silenced by their disease.

I came into the hospital that day and I went to the patient’s bedside because I refuse to make a decision for somebody that I haven’t met or tried to connect with. I knew this person wasn’t going to be able to communicate back to me, but as I sat at his bedside, I held his hand and connected with the human inside this body in the bed. The only noise in the room was the sound of the machines breathing for him. His body was a shell and it seemed like he was already gone. I sat with him and talked to him and told him that I would try to do right by him. I cried a few tears as I realized he was already gone. These are the difficult moments in my job.

I went to the meeting and heard what the doctors had to say and listened to what the social worker had discovered about this man. This was a man who was dying and there was nothing we could do to change it. We asked all the questions we could think of about his medical condition and if there was any hope. We were told there was not. I then asked the social worker about who this person had been at the nursing home. Had he enjoyed his meals? Had he enjoyed interacting with others? What had brought him joy even in his limited condition? He had been living a life with small pleasures and not too much suffering. But now, he couldn’t feel anything. He couldn’t enjoy eating a cupcake, watching something on TV or going to the sing-along in the activity room.

In the advocate team meeting, we all have to agree on what we think we should do. In this team meeting, we decided that there was no way he was going to be able to return to enjoy any part of his life. He was dying and there was no turning back. Our team agreed that he should be made comfortable and be allowed to die a natural death. This included being taken off the ventilator and being allowed to die.

I wasn’t going to tell you his name because he had become invisible to the world. But I have changed my mind because he wasn’t invisible to me. His name was James and I was part of his life and his death.

These are really difficult decisions. These are decisions that should not be made by strangers. But people in hospitals all over the nation are having their life and death decisions made by committee. This is not how it’s supposed to be. People shouldn’t be dying alone and they shouldn’t be living for 12 years without one person visiting them.

Sometimes it’s hard to do the work I do. Sometimes it breaks my heart. But I have the courage to walk into the darkness with people. Whether it’s the family who is grieving at the bedside, the patient who is afraid of what is happening to their body or the health care professional who can’t bear to participate in one more death. I walk with people on this journey and ease their way.

Have a kind and respectful day.

“Medical Futility and a Legal Update From Across the Nation” Interview with Thaddeus Pope J.D, of the MedicalFutility.blogspot.com. August 4th, 10am, pacific. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

I am honored to be interviewing the legal expert on futility, Thaddeus Pope J.D, regarding the issue of medical futility. You may not have heard much about this issue but you are going to be hearing a lot about it in the upcoming debate on healthcare reform. Every time President Obama says that we have to stop paying for treatments that will not work, he is talking about medical futility. Or when the politicians discuss using our healthcare dollars wisely, they are talking about medical futility. In healthcare, the number one problem being brought to bioethics committees is dealing with requests for treatments that are medically inappropriate or will not work. I encourage you to listen to this interview because when you or your loved one is in the hospital, this issue will be playing a factor in your treatment decisions. And even more importantly, this issue will be shaping the healthcare plan that is being proposed. Please let me know where you stand on this issue and feel free to call in with your questions.

“Medical Futility and a Legal Update from across the nation” interview with Thaddeus Pope J.D, of the MedicalFutility.blogspot.com and www.thaddeuspope.com. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

Thaddeus Pope is an Associate Professor of Law and member of the Health Law Institute at Widener University School of Law. He came to Widener in 2007, after teaching at the University of Memphis since 2005. Before entering academia, he worked seven years for Arnold & Porter LLP (in Los Angeles and Washington, DC), and clerked for the U.S. Court of Appeals for the Seventh Circuit. He earned both my J.D. and Ph.D. (in philosophy & bioethics) from Georgetown University.

His current research focuses on:
Medical Futility and other legal obstacles to good end-of-life care
Internal Dispute Resolution mechanisms in healthcare, particularly ethics committees
Tort Law, particularly consent and the assumption of risk doctrine
Public Health Law, particularly the legitimacy of restricting voluntary self-regarding conduct
Normative Jurisprudence, particularly the justifiability of hard paternalism

He teaches the following courses:
Health Law I (Patient Care & Liability), End-of-Life Decisions Law, Health Law II (Finance & Regulation), Bioethics, Torts, Public Health Law, Business Organizations, Health Law Thesis

You can get copies of the articles he has written at:
www.thaddeuspope.com
http://works.bepress.com/thaddeus_pope/
http://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=180178

For more information about Thaddeus Pope go to: http://thaddeuspope.com/images/Pope_Bio_1p_-_futility_.pdf

“The Compassion Fatigue Project” Interview with Patricia Smith, August 3rd, at 9AM pacific. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

“The Compassion Fatigue Project” Interview with Patricia Smith, August 3rd, at 9AM pacific. Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics.

Patricia Smith, founder of the Compassion Fatigue Awareness Project,
has published To Weep For A Stranger: Compassion Fatigue In
Caregiving. Along with in-depth explanations of compassion fatigue and
its symptoms and causes, the paperback features the following
comprehensive chapters:

Chapter 1: When Caring Too Much Hurts
Chapter 2: What Is Compassion Fatigue?
Chapter 3: Burdens Of The Chosen
Chapter 4: The Decision To Heal
Chapter 5: Standards Of Self-Care
Chapter 6: To Family Caregivers
Chapter 7: To Those Entering The Helping Professions
Chapter 8: When the Workplace Suffers
Chapter 9: To Weep For A Stranger

To order direct from the Createspace website for only $15, visit:

http://www.createspace.com/3393286

Workbooks:
Healthy Caregiving: A Guide to Recognizing and Managing Compassion Fatigue Level 1 –
Presenter’s Guide www.createspace.com/3363699

Healthy Caregiving: A Guide to Recognizing and Managing Compassion Fatigue Level 1 –
Student Guide www.createspace.com/3363698

CF Marketplace: http://www.cafepress.com/CFMarketplace

To Weep for a Stranger: Compassion Fatigue in Caregiving
www.createspace.com/3393286 (available 7/14/09

Have a kind and respectful day.

A Timeline Tool For When You Are In The Emergency Room

Dear Viki,

I got a call from someone as her grandmother was being taken to the hospital. Her grandmother’s doctor wouldn’t come to the hospital even though her mom had chest pain and very high blood pressure. After asking more questions, I explained to her that the probable reason the doctor wouldn’t come to the hospital was that he didn’t want to interrupt his weekend plans. I know it is cruel to say, but it is probably true. I know there are lots of great doctors out there but you have to realize that I only get called when there is a problem. (Now before the doctors reading this get angry, the person had a blood pressure of 240 over 110, chest pain, vomiting and the doctor said to not take her to the hospital. And the doctor was on call that weekend.) I also know that doctors are real people and they hate being on call on a holiday weekend. I don’t blame them. How would you like to have your day interrupted and have to leave in the middle of your most precious family events? This is one of the sacrifices they make for us.

So back to the story:

I talked the person through what to say to the ER doctors to make sure they got what they needed. I explained how to get the services she needs by using respect and good communication. You have to make it easy for the doctor because time is limited. You need to organize what you are going to say, be clear and give both the current facts as well as the past medical history. Here is where you have to be careful. You have to focus on telling them what is relevant to this situation. My dad would go to the doctor for a pain in his leg and then spend his time talking about his dysentery from World War 2. It was not the same body part and it was 60 years ago. Yes, you should give information about the person’s medical past but try to make sure it is relevant to the situation. But you may not know what is relevant so instead you can create a timeline for the doctor. (Keep a copy with you and with the patient for emergencies.)

One way you can do this is to construct a written timeline of the patient’s health. Here is an example:

1945: dysentery during the war
1988: cataracts diagnosed
1998: double bypass surgery
1999: cataract surgery
2001: prostate surgery for enlarged prostate
2002: allergic reaction to sulfa drugs
Include a list of medications and allergies

Now the doctor can see all the important events and he can get to the information quickly and effectively. Then you can spend more time talking about the present situation. The more you help the doctor whether it is in the office or in the hospital, the more they can help you.

Have a kind and respectful day. Viki Kind at KindEthics.com

Why isn’t the insurance company paying my bill?

Dear Viki,

I just got a bill from the hospital, but I don’t think it is right. It says I owe money but I have insurance. Why isn’t the insurance company paying my bill? What do I do next?

There are so many reasons your insurance isn’t paying the bill. And I know that it can get overwhelming as you receive bills from different offices, different doctors, different labs and from people you’ve never even heard of. Instead of getting frustrated, ask for help. If the person you’re working with is not helping you, ask for someone else in the department. Unfortunately many people who work in medical billing are often under trained, underpaid and overwhelmed. So it may take talking to many different people to get the help you need. For me the first thing I do is to take all the bills and organize them by date of service. Then I can match what was done to me with the bills I have in front of me. And then I begin following the instructions I have listed below.

Let’s start from the beginning of the story and find out what might have gone wrong.

1. When you went into the doctor’s office or hospital, did you give them your correct insurance information? Not the old card, but the newly updated card?
2. Do they have the right address for your insurance company?
3. Have you been paying your insurance premium so your insurance is still in place?
4. If you have two insurances, did you tell them which insurance is primary, so they billed the right insurance first? Do you know which insurance is your primary insurance?
5. Did the office or hospital ever send the insurance company the bill? Surprisingly, the billing staff does not always do their job so sometimes the reason the insurance doesn’t pay the bill, is because they never got the bill. Call your insurance directly and ask if they have a copy of the bill and if so, why they didn’t pay it? If they don’t have the bill, ask them for a direct name and fax number that the bill where the bill can be sent. Then give this information to the doctors or hospital’s billing department and then follow up with them in one week.
6. Now let’s talk about the referral/authorization process. For many people’s insurance, you have to have a referral before you see certain doctors or receive certain tests or procedures. Or if you are in the emergency room, have someone in your family call your insurance right away and get the authorization for you to be in the emergency room. Did you get that referral? Did the office staff call for your referral? Did you call the insurance company to make sure the referral was done before your surgery? And did you make sure that all of the doctors that would be working on you during your surgery are covered under your insurance plan? If you don’t get the referral, you may be responsible for the entire bill and you definitely don’t want this. Never assume that it is all taken care of. Make sure you call the insurance company and get the referral number yourself. They should also send you a piece of paper that tells you that you have been okayed to have the test or surgery or see the specialist that your doctor recommended. You have to be an active participant if you want the bills to get paid.
7. Maybe your doctor’s office did everything right, had the right insurance card, got the referral ahead of time, billed the right insurance but still there is no payment. Now it is time for you to get on the phone and ask the insurance company what the problem is and why there is a delay in sending out the payment. You may also want to go to the doctor’s office and have the billing person call the insurance company while you wait. That way, if there is a question, you can be there to help and to make sure it got done.
8. Now many doctors offices use outside billing departments and the person you need to talk to will only be available by phone. This is when you have to hold your temper. I know you are frustrated but if you yell at them they won’t help you and you’re going to get stuck with the bill. So calmly, talk to the billing person and find out what they think is going on. You can offer to call the insurance company yourself to help them solve this problem. Since you want them to be on your side, remember that they will be more willing to help a polite person than a screamer. Thank them for all of their effort even if the problem isn’t completely solved because you will probably be working with them again when they mess up your bill the next time.
9. Many times, the bill itself was not created correctly. There are codes and details that must be typed in and sometimes these are typed in incorrectly for whatever reason. This is when you need to ask for a billing manager to help you check that the codes that were used were the right codes and that the details on the form match your insurance and personal information. It may be as simple as your insurance number was typed in incorrectly or it was sent to the wrong address.
10. After you do everything you can to get the correct bill to the correct department of the insurance they still may not pay your bill. If they won’t pay the bill you can appeal their decision. You will need to ask the insurance company how to appeal their decision and what you will need to do to provide the information they will need to change their minds. Sometimes, the doctor needs to send more documentation or a different code needs to be used. Even after the appeal, you may still be responsible for this bill. The worst thing that happens is when you didn’t get the appropriate referral and now it is too late. This is why getting the referral is crucial before you go to specialist, go to the emergency room, have the procedure or have the surgery.
11. I want to caution you to not get frustrated and to stop working on this situation. The doctor’s office will eventually send you to collections and the collection agency will eventually report your delinquent bill on your credit report. Then you are in worse trouble. The collection agency knows even less about getting the insurance company to pay and they are not particularly interested in helping you, just getting the money from you. And they will sue you. This is when you have to take immediate action before the collection agency takes action against you. Call the insurance company for help and go back through the steps above. The doctor’s office will not help you at this point as they have referred you to collections. You can try begging the doctor to take your bill out of collections but that rarely works. The doctor’s office or hospital has already tried to get you to pay for months and are frustrated with you. Please try to take care of this problem before it gets to this point. If it gets to this point, it may be too late now and you may be stuck paying this bill.

If you really do owe the money after the insurance paid their part:

Now your insurance paid, but now the doctor is asking you for money that you don’t think you owe. There can be lots of confusion. You may be right or you may be wrong. The first thing you want to look at is something called the EOB or the explanation of benefits. This is the form the insurance company sends the doctor and hopefully you, which explains why they paid what they paid and who was responsible for the balance. When you look at the explanation of benefits you are looking for the word’s “patient portion” to figure out how much you owe. This is another place where the billing department may make mistakes. They may forget to do the write off that is required by the insurance contract with the doctor’s office. And they may be billing you for the wrong amount.

You may also be the problem. You may not understand what your policy requires and what your portion of the bill should be. Before you get really angry, call the insurance and have them talk you through it. If the doctor’s office is wrong, ask them to make the corrections and to let you know when it’s accomplished. Put it on your calendar to call them in a week to make sure it really got done. You don’t want a surprise letter from a collection agency in your mailbox.

If you do owe the bill, whether it’s to a doctor’s office or a hospital, if you call right away they may be willing to set up a payment plan. The longer you delay, the less likely they will be to work with you. They may also have a special program set aside for people who cannot pay their bills. Again, it is better to communicate directly and work with them to solve these issues. The billing department may also be able to help you sign up for services such as MediCal or MediCaid.

Create a caregiver manual to help you train your next caregiver.

Dear Viki,

I have to hire a new caregiver for my dad. I get so tired of having to take time off of work to train the new person. Is there anything I can do to make this easier?

Yes, I recommend creating a caregiver manual just like you might have an employee manual at work. The way to do this is when you are training this new caregiver, write down everything you are telling the new person. Write down things like how your dad likes his sandwich made or what time he takes his naps. Create categories such as food preferences, activity preferences, clothing preferences, schedule preferences, medications, allergies, emergency numbers etc. Whether you write it down in a notebook or on the computer, keep adding to it as you train the person. Then give the new caregiver a copy so they can refer back to it. You can also ask the caregiver to write notes in it as things change or as she/he learns new things about your dad. This way, the next time you have to hire a caregiver, you have a head start. You can give the training manual to the new person to read before they start and they can use it as a reference for those first days when you leave them on their own. This doesn’t mean you won’t have to train them. You just won’t have to make yourself crazy trying to remember if you have gone over everything with them and you won’t forget to mention something important. (Keep an extra copy in a safe place. You don’t want a disgruntled employee to take off with your only copy.)

Have a kind and respectful day.

“Changing your Nursing Home Culture and Environment.” Part 2 of Interview with Frances Shani Parker, author of “Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes” on July 31st, 12pm PST.

Changing your Nursing Home Culture and Environment.” Part 2 of Interview with Frances Shani Parker, author of “Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes” on July 31st, 12pm PST.

Call in to listen live at (347) 945-5152 or listen online at blogtalkradio.com/kindethics. To listen to Part 1: http://tinyurl.com/rdsf58

An award-winning writer, consultant, and former school principal, Frances shares insights and experiences about her years of hospice volunteering in Detroit nursing homes. Using stories, poems, and general information, she has written a groundbreaking book that is an inclusive and literal guide for becoming dead the right way. Topics include hospice, caregiving, dementia, death, bereavement, and strategies for improving eldercare and nursing homes. While universal perspectives are presented, the often missing views of people of color and residents in urban nursing homes are examined.

Frances’ background as an educator and her upbringing in New Orleans, LA add interesting layers to her problem solving in nursing homes and to her descriptive storytelling. She uses her writing and public speaking skills to advocate for senior citizens and promote conversations empowering others to have dignified death journeys. Her favorite anonymous quote is “If you think one person can’t make a difference, you haven’t been to bed with a mosquito.” Visit Frances in cyberspace at www.francesshaniparker.com and at her blog titled “Hospice and Nursing Homes http://hospiceandnursinghomes.blogspot.com

Video Poem: Reflections of a Hospice Volunteer (Hospice, Nursing Homes, Eldercare) 3:25 mins.

http://www.youtube.com/watch?v=LeBl5QtlPxg

Video Poem: “Pieces of Our Minds” (Dementia, Alzheimer’s Disease, Hospice, Nursing Homes) 2:24 mins.

http://www.youtube.com/watch?v=LgRoKDUEOUk

(Search under FrancesShaniParker on youtube.com.)

Have a kind and respectful day.

When you hear the words, “There is nothing more we can do.”

As a patient, there may come a time where you hear the words, “I’m sorry, there’s nothing more we can do.” I want to apologize for the doctor’s abrupt words. Many doctors have had little training in having these types of conversations and are incredibly uncomfortable. What your doctor should really be saying is, “Even though there is nothing more we can do to cure you, there’s lots more I can do. I can do plenty to keep you or your loved one comfortable, out of pain, minimize your suffering, refer them to hospice, get your religious leader in here to pray and help provide a peaceful and dignified death.” Just because you don’t hear this doesn’t mean you shouldn’t ask for this. You should advocate that the doctor makes sure you get what you need as your disease progresses and as you die. Help the doctor help you by asking for a palliative care referral if you are having problems with pain. Ask for a referral to hospice when the patient is sleeping more and eating less. You want to stay connected to the doctor even if the direction of treatment has turned to comfort and care.

As a patient or a loved one, you will have a strong grief reaction to these words. You may be in denial, in disbelief, in numbness or feel some other strong emotions. If you are in denial, you will not believe that what you were just told is true. This is okay as it is the way your brain protects you from bad news. Eventually, you will hopefully come out of denial so you can use your remaining days wisely. Or you may find yourself in disbelief. Disbelief is where you keep saying to yourself, “I know the doctor just said ______ but I can’t believe it’s true.” In this situation, you may want 2nd opinions or repeated tests. This is disbelief. Your brain knows it’s true but it is not ready to accept this news. This is also okay and normal. Or you may be numb. This can really be a problem when the doctors want you to make decisions. Ask for a few days so you can process what you have been told before you make these final decisions. You may also have many other types of emotions: anger, fear, hopelessness, helplessness, sadness, etc. These are also normal as you come to terms with your life’s expiration date.

You get to choose how you want to spend your remaining days, months or years. Choose carefully as you won’t get these days back. And if you are like someone I knew who was waiting until they got closer to death to write love letters to his children and his wife, realize that sometimes when get closer to death, you may not have the energy or strength left to finish your goals. Please use your time wisely.

Have a kind and respectful day.

When you have to say, “There is nothing more we can do”, there’s a better way to do it.

Unfortunately, there comes a time in a patient’s life where you have to say to the patient or their family, “I’m sorry, there’s nothing more we can do.” This is the wrong thing to say and let me explain why. I know what you’re trying to say is, “there is nothing more we can do to cure your disease” but what the patient or loved one hears is, “I’m giving up and walking out this door and never coming back.” I know that’s irrational and that’s not what you meant to say but unfortunately these words sound like abandonment to the patient or family.

I believe it’s important to tell the truth about prognosis (if the patient wants to hear it), even if you can’t give them an exact time give them an estimate. You can say days to weeks, weeks to months, months to years. People deserve the opportunity and time to clean up their lives. So, when you have to say that there really is nothing more you can do, you may be missing a really important piece to this conversation. Here is how to solve this. Go ahead and tell them that there’s nothing more you can do to cure the disease, and then continue on and say, “But there’s lots more I can do. I can do plenty to keep your loved one comfortable, out of pain, minimize their suffering, refer them to hospice, get your religious leader in here to pray and help provide a peaceful and dignified death.” Helping someone to have a pain-free and dignified death is substantial. I don’t know if you realize this but palliative care specialists have the highest satisfaction rate of all medical specialties. And why is this? It’s because this is profound and meaningful work. You really matter to the patient and the family on those last days of life. It is wonderful if you can say to the patient that you’re going to walk on this journey with them no matter where it takes you. Then they won’t feel abandoned and alone. You will still be the healer, but now the focus of your healing is to heal suffering, not the disease.

The other reason this technique works is because whenever you have to say no to a patient, it is always important to offer them something else in exchange. I don’t know if you’ve had this experience with young children when trying to take a breakable item out of their hands. A smart parent grabs their favorite toy and exchanges it with them or distracts them toward something else. The same thing can happen in medicine. If you have to say no to a patient then offer something that you can say yes to. Even if all it is good pain management or the hope for a peaceful death.

Have a kind and respectful day.

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