Family presence and the physician in charge
April 3, 2006 -- This week's issue of The New Yorker included an article by Jerome Groopman, M.D., about the trend toward allowing "family presence" during resuscitations. The piece ably summarizes some apparent pros and cons of allowing family members to witness attempts to revive loved ones, efforts that it notes can be scary and are usually unsuccessful (except in Hollywood). "Being There" recognizes that nurses and chaplains have played the leading role in advocating for family presence, often despite the objections of physicians. And to its credit, the piece briefly quotes two nurse experts, giving nursing some voice on the issue. The piece says that the growth in family presence reflects the decline in physicians' formerly absolute power over clinical settings. Yet the article itself seems to assume that physicians remain in charge. Accordingly, its focus is the extent to which physicians have accepted family presence. So the piece relies overwhelmingly on physician expert comment, and discusses a number of articles published in medical journals, but none from nursing journals. Perhaps as a result, Groopman seriously undervalues the nursing research showing the benefits of family presence. He presents trauma surgeon claims that family presence can distract code teams, and that nurses are more focused on emotional needs than quality clinical care. But he does not subject those claims to the same scrutiny as he does nurses' arguments that family presence aids in grieving. The piece does not explore measures that could reduce any adverse effects of family presence, misses the potential benefit patients themselves may derive from the practice, and fails to mention some less flattering potential reasons for opposition to it, such as lingering paternalism, fear of liability, and difficulty in seeing the big health care picture.
Groopman begins with what he suggests was a key moment in the development of family presence in the U.S. In 1982, Rev. Hank Post, a chaplain at Foote Hospital in Michigan, persuaded a resuscitation team to allow the wife of a mortally wounded state trooper to observe their efforts. Post continued to push for the practice in later years, seeing it as a campaign for human rights. The piece notes that the practice of allowing family presence has grown, "promoted in many instances by chaplains and nurses over the objections of doctors," and that as many as half of U.S. hospitals may now allow some form of it.
The piece notes that in 1993, the Emergency Nurses Association overwhelmingly passed a resolution endorsing family presence because of its potential benefits in the grieving process. That surprised the sponsor, Patricia Howard. The piece quotes Howard, who it notes has since served as ENA president, as saying: "We've always taken excellent clinical care, but not always excellent psychosocial care." Howard also notes that families can help decide when to end resuscitation efforts. And the piece says that, "[l]ike many proponents of family presence, she argues that today Americans are better prepared for the gore of resuscitations than they were ten years ago, because they have seen realistic imitations of such procedures on television." Howard: "'ER' and a lot of graphic programs have made the difference in terms of public expectations and knowledge."
This leads to a long discussion of the effect of TV hospital shows on the public's views of resuscitation efforts. But rather than explore whether Howard is correct that the shows have acclimated the public to the gore, or whether they have increased interest in seeing loved ones during codes, the focus is the extent to which the shows create unrealistic expectations that the efforts will succeed. This choice itself suggests the two different perspectives: nurses care about emotion, and physicians about hard clinical data. Left unstated is exactly why it would be a problem for family members to have unrealistic expectations. Will they be more disappointed actually seeing a resuscitation fail than hearing about it? Or is it that they will be more likely to second-guess health worker efforts, and maybe find lawyers, if they actually see it fail?
Groopman explains how gritty, seemingly realistic shows like "ER" differ from the old "Ben Casey" school of "pristine white lab coats." But he describes research showing that two thirds of the resuscitations on such shows are successful, even though in real life, at most 15% are. The piece also notes that other studies suggest that such television shows have in fact persuaded viewers that CPR is far more likely to succeed than it really is.
But the piece ignores one of the most relevant issues, namely how these shows treat family presence itself. As it happens, prime time dramas regularly employ the dramatic device of showing family members making a spectacle of themselves and interfering in code scenes, and wise physicians sternly commanding that they be ejected. Certainly there have been scenes in which family members observe codes without causing much trouble. But we have never seen the practice of family presence specifically discussed, and rarely if ever seen it recognized as beneficial, rather than something that might be tolerable sometimes. We imagine it's just a coincidence that physicians are generally the only health professionals who have meaningful input on the scripts of such dramas.
The Center has long argued that such fictional media has a significant effect on health care views and actions, as many studies have shown. Indeed, physician-driven studies like those cited here have often found that such media affects public understanding of diseases and health care generally, and we are aware of little questioning of those conclusions from the media or the public. However, when nurses argue that this same media's wildly inaccurate depiction of nurses and their work has a similar effect on how the public thinks and acts, and even cite research suggesting that is the case, they are met with rolling eyes and assurances that the media has no such effect. Apparently, viewers learn about codes from prime time dramas and about HIV from soap operas, but they know instinctively that real nurses are nothing like the mute, faceless servants they occasionally see on "House" and "Grey's Anatomy," and that nurses actually provide half the important care they see physician characters do on these shows.
Groopman goes on to explain that another factor in the growth of family presence is the increasing influence of patients and families in all aspects of modern care. However, he suggests that family presence remains controversial because "[n]ot only does it represent an incursion by the public into medicine's inner sanctum; more than any other recent development, it reveals the extent to which the power to decide the way medicine is practiced is no longer an exclusive province of doctors." (Of course, the growth in advanced practice nursing would seem to be at least as significant.) Pursuing this power theme later in the piece, Groopman argues that the debate over family presence
is a sign of how power has shifted within the hospital; a movement led by chaplains and nurses to change a long-standing medical protocol would have been inconceivable when I was a medical resident 30 years ago. (Chaplains' tasks were limited to assisting patients with prayer and last rites, and nurses, particularly in surgery, were viewed as handmaidens who should take orders but never give them.)
It seems pretty clear that when Groopman (like so many others) uses the terms "medicine" and "medical," he is not just referring to the work of physicians, but to the whole of health care. He is saying that at least as late as 1976, physicians had absolute power over all health care. We imagine some nurses might disagree. In any event, Groopman is careful to make no explicit value judgment as to either the current or former state of affairs. Note his "were viewed as" language: someone thought those nurses were just brainless flunkeys, but I have no idea who, or why, or whether that was correct. Today, they have more power, but who knows whether they deserve it, whether it has improved patient outcomes, or even whether whoever used to think they were handmaidens has changed his mind. Should physicians have absolute power over all health care as a matter of course? Who knows? Dr. Groopman may hold the Recanati Chair of Medicine at Harvard and serve as Chief of Experimental Medicine at Beth Israel Deaconess, but evidently he has no opinion on such issues.
In fairness, some of the piece does accord nurses something like a voice on the issue of family presence, and does at least depict them as part of the resuscitation team, the kind of thing that many pieces in elite publications commonly fail to do. In addition to the short passage relying on the ENA's Patricia Howard, Groopman also describes a little of the role of psychiatric clinical nurse specialist Patricia Mian in a recent case at Massachusetts General Hospital. The lengthy account of this case is the article's main clinical illustration of the dynamics of family presence.
We learn that Mian met the ambulance carrying this patient at the hospital, and that she informed the daughter-in-law of the option to stay with the patient, which she chose. Mian offered to stay with the daughter-in-law, "explaining everything that happens," and Mian escorted her to the head of the bed. In the long account of the unsuccessful revival efforts that ensued, Mian reappears twice for brief indirect quotes: once to encourage the daughter-in-law to talk to the patient, and at the end to ask an unnamed nurse to close the deceased patient's eyelids, at the daughter-in-law's request. All of that is good, if limited. We actually don't see that she explains anything that happens, much less "everything," and we get no expert comment from her. As for other nurses, nurse Eric Driscoll is described four times as making notes of what is happening. Unnamed nurses cut away the patient's clothes, attach a bag of saline to a catheter, inject medicines to stimulate the patient's heart, and force air into his lungs by squeezing a bag. The daughter-in-law also notes that because she was present, she "knew the doctors and nurses did everything they could."
Meanwhile, named physicians are depicted as doing quite a bit more. They issue dramatic commands and technical statements about the patient's condition that clearly suggest they are indeed "in charge," and that their actions are the ones of real consequence. In fact, Groopman says that Kriti Bhatia, who seems to be the star of this show, is the "senior resident in charge of the resuscitation." Her co-star is attending Keith Marrill. (An unnamed surgical resident starts a femoral line, a procedure that is presented as being somewhat complex, and an unnamed intern also does chest compressions.)
In contrast to the bland descriptions and occasional indirect quotes the nurses get, Bhatia and Marrill are presented through a long series of punchy direct quotes, including technical jargon. As the code progresses, Bhatia asks for the femoral line, announces that the patient is in "P.E.A.," requests epinephrine and atropine, worries about the patient's potassium," asks for "a bolus of D50, ten units of insulin, with calcium and bicarb," announces the heart rate, asks for an ultrasound, and asks the final questions leading up to the declaration of death (to her credit, she asks if "anyone" has any other ideas, and to Groopman's credit, he writes that the "doctors and nurses looked at her in silence"). Likewise, the story has Marrill announcing when the patient loses and regains a pulse, asking the surgeon to try his best to hit the femoral vein, announcing that the monitor showed a "wide complex with an accelerated ventricular escape rhythm," and doing the final check of vitals before the declaration of death. During all this, it's not clear from the account if any nurses even spoke, except for the two brief indirect statements by Mian.
Certainly, this account could have been given with no mention of nurses at all, and much of the media regularly tells such stories that way. So Groopman deserves credit for a presentation that is relatively evolved. But the account still reflects the incorrect assumption that physicians remain more or less in charge of hospital care, and they're the ones whose work and views really matter. And you could argue that the greater realism here actually makes the physician-centrism more powerful, just as "ER" is a far more persuasive account of what happens in a hospital than, say, an absurd fantasy like "House." The account of the code here will still suggest to many readers that nurses have no great clinical skill, but are more about emotional needs and following physician orders. The only nurse who seems to take any initiative, and who gets even a minor indirect quote, is Mian, who is presented here as providing emotional support. Mian has a master's degree, but we are given no sense of that, and despite all the clinical skill that goes into what she does with patients and families, most readers will likely see her as conforming to their existing impression of nurses as hand-holders. It seems likely that Groopman got his account of the resuscitation primarily or exclusively from the physicians. In fairness, that may not have been entirely his choice; unlike most physicians, many nurses are reluctant to speak up about their work, as Bernice Buresh and Suzanne Gordon stressed in "From Silence to Voice."
Groopman describes what he considers the meager research on the psychological impact of family presence, especially on families. The article discusses several studies, including one 1998 English study that he says has "been cited repeatedly in medical and nursing journals as proof of the therapeutic value of family presence," despite its small size. We appreciate the indication that nursing journals even exist--another media rarity--but we wish he had actually discussed the work on family presence in those journals. In fact, extensive nursing research has shown that families overwhelmingly value the family presence option (See Halm, "Family presence during resuscitation: a critical review of the literature," American Journal of Critical Care, Nov. 2005, 14(6):494-511). But we hear only about various surveys and reports done by physician groups and published in medical journals. One thing these studies do make clear, and that Groopman deserves credit for noting, is that nurses are far more supportive of family presence than physicians. But Groopman says that the American Association for the Surgery of Trauma (AAST), which "actively" opposes family presence, and its R. Stephen Smith, a Kansas trauma surgeon, have a ready explanation for that difference.
Smith argues that the debate over family presence has exposed a conflict in medicine between, on the one side, chaplains and nurses, who worry about families' emotional needs, and, on the other, physicians, who are primarily concerned about the quality of clinical care.
Groopman gives Smith plenty of space, but there is no rebuttal from any nurse. Smith's generalization has some substance--most nurses do have a more holistic focus than most physicians, and most nurses are more likely to consider emotional needs. But the simplistic formulation in the article wrongly implies that nurses are not focused on clinical excellence, and assumes that clinical care and emotional needs are somehow mutually exclusive. ENA nurse Howard's statement about clinical and psychosocial care may seem to support this distinction, but we doubt she would accept the suggestion that nurses just "worry" about emotions and are not "concerned about the quality of clinical care." Of course, getting these points across would probably require more expert comment from nurses. And though Groopman does include the brief quotes from Howard and CNS Mian, the piece is dominated by expert quotes from medical journals and at least five named physicians, not counting the author of the article.
Groopman says that Smith's hospital has devised a "compromise" in which family members may be permitted to be with patients after "invasive" procedures are completed and "at the discretion of the trauma surgeon." This "compromise" could also be described as formalizing physicians' absolute discretion over family presence. Even then, Smith says family presence has at times been disruptive, citing an example of a woman with multiple injuries whose husband wanted to join her in the ED. According to Groopman, the "physicians" suspected (and "doctors" later "determined") that she was the victim of domestic violence, and they felt she might have been reluctant to recount her true health history. This is an egregious red herring. No responsible family presence advocate would push for a system that allowed no discretion for the health care team to exclude a family member whose particular presence was an evident threat to the patient's wellbeing. And the repeated implications that only physicians are or should be involved in making such determinations are hard to excuse, since nurses generally have greater psychosocial expertise and are more likely to pursue such concerns in order to protect their patients.
Groopman also presents an argument drawn from a 1999 report by Smith and others to the ASST. This report cited Federal Aviation Administration regulations designed to reduce accidents caused by distracted flight crews, in part by limiting unnecessary communication, and argued that resuscitations are similarly complex tasks that require similar rules. The presence of a family member, in the surgeons' view, "could jeopardize the success of a resuscitation."
That's certainly a rational argument. But we can't help but wonder why Groopman does not immediately descend on it with his evidence-based scalpel. Why not make a point of noting that that there are no studies to support Smith's distraction argument, as the piece does with the idea that there's no proven therapeutic benefit to family presence? Red herring anecdotes and airline regulations do not prove clinical detriment. Is it important to perform exhaustive research on ideas that challenge traditional physician assumptions, but not to test the basis for those assumptions? As it happens, some nursing research has indicated that family presence does not generally disrupt care during resuscitations. (See Meyers, American Journal of Nursing, 2000, 100:32-42; Mangurten, Journal of Emergency Nursing, June 2006, in press.)
And even if some distraction were shown, perhaps through increased errors, it's not clear that the solution is to ban families from resuscitations. Inexperienced health workers are more likely to make errors, yet they are not banished from the bedside, because the health care system believes their involvement is a necessary part of training the next generation of health professionals. Instead, safeguards are established to minimize the risk. Similarly, before rejecting family presence, might we explore the extent to which care givers need to adjust their own attitudes and make better accommodations, so that the practice is less likely to distract? Isn't it also possible that at least some of the opposition to family practice is driven by factors that have nothing to do with the wellbeing of patients, such as paternalistic attitudes, fear of legal claims by family members who may not like something they see, and continuing difficulty in seeing the big health care picture, like those trivial "emotional needs?"
And speaking of those, what about the potential benefits to patients themselves from family presence, which the piece fails to consider directly (though a couple of quotes could be read to touch on it)? The data is apparently limited, but there is some research to suggest that patients appreciate the support of loved ones in such situations. (See Guzzetta CE, Clark AP, Wright JL, "Family Presence in Emergency Medical Services for Children," Clinical Pediatric Emergency Medicine, 2006, 7(1): 15-24, at p. 18; Eichhorn DJ, Meyers TA, Guzzetta CE, Clark AP, Klein JD, Taliaferro E, et al, "Family presence during invasive procedures and resuscitation: Hearing the voice of the patient," American Journal of Nursing, 2001, 101(5):26-33.) In view of that, it also seems reasonable to think that family presence could contribute to better outcomes. But with little nurse input, most readers are unlikely to see any of these issues.
The piece concludes with a discussion of family presence at Boston's Beth Israel Deaconess, where Groopman practices, and particularly how Groopman and other physicians feel about it. The hospital does not "encourage" family presence, but it has no written policy. The internist who directs the hospital's ethics program notes that some "doctors" support family presence because they believe relatives who see violent resuscitations may be more likely to agree to end them sooner. But this physician says that "there is no solid evidence to support this view," and "no proof" that seeing a failed resuscitation is "more therapeutic" than being told about it later. But once again, is there evidence to support a contrary view? What do Beth Israel's nurses think?
The piece closes with a long series of quotes from the hospital's chief of emergency services, Alasdair Conn. This physician discusses the new "era of openness" in all fields, and notes that today, patients' families are more likely to question what has been done for patients whether they see it or not. The piece closes with a long quote from Conn, who says he opposed family presence until he imagined himself as the distraught relative:
Suppose you had the opportunity to spend the last three minutes on earth with your wife. She was just brought into the emergency room. She is semi-conscious, and she is probably going to die. Would you want to say a few words to her, or would you rather be someplace else? I think most people would say that they want to be with her.
This goes a long way toward giving the article a rough overall balance regarding family presence. But note how it's all delivered like it was some revelation. A major theme here seems to be to chart the evolving thinking of physicians on the practice, as if that were pretty much all that mattered in the end. Conn's analysis amounts to a recognition of something that most nurses who have considered the issue have long understood, consistent with their holistic focus as patient advocates and serious clinicians. But now it's worth considering, we suppose, because a physician has realized it.
See two letters to the New Yorker's editor by nurse experts who make clear the basic deficiencies in the article's discussion of the research on family presence.
Share your thoughts on the family presence article with Jerome Groopman at firstname.lastname@example.org
Jerome Elliot Groopman, MD
Recanati Professor of Medicine
Beth Israel Deaconess Medical Center
4 Blackfan Cir
Boston MA 02115
Family Presence during Resuscitation
Families encounter it every day in emergency departments nationwide - a seriously ill patient is rushed off to a treatment room leaving family members behind to await information about their loved one’s condition. It is standard protocol in most hospitals: families are not allowed in the patient’s room during emergency procedures. This unwritten rule is based on fears that families will be traumatized by the event, lose emotional control, or interrupt patient care. There is no scientific evidence to support these fears. In fact, in two research studies we mentored that evaluated over 100 family presence events (Meyers, Am. J. Nurs. 2000;100:32-42; Mangurten, J. Emerg. Nurs. June 2006, in press), patient care was not interrupted and the family benefits of ‘being there’ were clear. And although not all families want to be there, national opinion polls document that most do (60-80%). Yet only 5% of US hospitals nationally have written policies allowing family presence (MacLean, Am. J. Crit. Care. 2003;12:246-257). The practice of bringing families to the bedside during resuscitation likely will evolve much like the practice of bringing fathers into the delivery room. It is the consumer who has the power to make it happen. Family presence is an option, not an expectation, but it should be available to all of those who want that choice.
Cathie E. Guzzetta, RN, PhD, AHN-BC, FAAN
Director, Holistic Nursing Consultants, Washington, DC
4598 Laverock Place NW
Washington, DC 20007
Angela P. Clark, RN, PhD, CNS, FAAN, FAHA
Associate Professor of Nursing
University of Texas at Austin
1700 Red River, Austin, Texas 78701
Family Presence during CPR
Groopman gives an accurate portrayal of the sociocultural changes behind the family presence movement ("Being There", April 3rd ). He seriously fails, however, to fully inform the public about the available scientific evidence: "Few attempts have been made to measure the psychological impact of family presence ... Most studies consist of surveys and involve so few people they cannot be considered significant." In a systematic review I conducted on family presence (American Journal of Critical Care, Nov. 2005), the cumulative findings of multiple research surveys across the lifespan are consistently clear: Families overwhelmingly valued their option to be present, and would do so again - hands down - to support, comfort and give honor to what could, quite possibly, be the end of a treasured life together. And while Groopman reports the findings of one experimental study, he leaves out the most important point -- Robinson stopped his study before it was finished because the researchers became convinced of its' positive effects for families. While more research is needed, we cannot ignore the evidence that currently exists.
Margo A. Halm, RN, PhD, APRN-BC, CCRN
Director of Nursing Research & Quality
333 N. Smith Ave
Saint Paul, Minnesota 55102
August 2006--Recently the Center received a powerful letter from Rev. Hank Post about our piece on the April New Yorker article on family presence, which was written by Dr. Jerome Groopman. Rev. Post is the Foote Hospital (Michigan) chaplain who has played a critical role in efforts to promote and assess the impact of family presence during resuscitations. His letter, which also discusses the key role of nurses in making family presence work, appears below.
Dear Members of the Center for Nursing Advocacy:
Thank you for your helpful critique of Dr. Groopman's article on "Being There" in the April 3, 2006 issue of the New Yorker. I felt many of your criticisms were valid. I was disappointed Dr. Groopman seemed to view as insignificant the mounting clinical data that indicates families benefit when they are at the bedside of a dying relative and not sequestered in a waiting area.
As you are likely aware, the key to initiating and maintaining protocols regarding family presence is to place such protocols in the policy and procedure manuals maintained in Emergency Departments and on other hospital units as well. When the family presence protocol had become a common practice over several years in the ED at Foote Hospital where I served as a chaplain from '76 to '90, the emergency physicians, supervisory nursing staff, and the pastoral care department developed a policy regarding families that was included in the policy book. I am told by friends still working at Foote that this same policy continues to be a part of the policy book in the ED at Foote, twenty years after it was initially created. At Foote, families continue to be approached about choosing to be present during resuscitation or to defer.
Dr. Groopman and I spent several hours discussing family presence. I was disappointed he did not choose to include crucial details of the policy at Foote. In the practice at Foote, the nursing supervisor was responsible to orient staff to call for a chaplain or other staff member to meet the family of a person being resuscitated and to do so immediately upon their arrival at the ED. The chaplain/social worker/nurse would take the family to a waiting room, explain what was being done for their loved one in the trauma room, and then tell the family that if they wished, they were welcome to sit by their loved one during resuscitation. The policy indicated the importance of both raising the choice to families and also not influencing them when they made the choice. In my experience, well over 95% of families wanted to 'see what is going on' and elected to be present for at least part of the treatment effort. A chaplain or other staff member was assigned to be present with the family. I never saw a family member interfere with treatment. I know of no family member who later initiated litigation because of something they witnessed during their presence.
The trauma rooms at Foote were quite small, and when more than one or two family wished to be present, staff encouraged families to work out a plan among themselves for members to rotate their presence. The survivor(s) were provided a chair and physical access at the bedside of their loved one. After a pilot protocol had been implemented for a time, staff gradually became comfortable with family presence. All the staff I worked with suggested their professional caregiving was not compromised by this protocol. Eventually, even the ED physicians began to explain to families in lay terms what medications were being given and how the resuscitation was progressing. Oftentimes, families themselves encouraged staff to stop an obviously hopeless effort, recognizing their loved one had died. Not a single survivor of the forty seven I interviewed myself in our first study (August, 1985) indicated that they were in any way unhappy with what was done for their loved one. Most thanked the staff for being able to 'say goodbye' when the survivor could decide the dying relative might still hear them.
I had some concern that from part of Dr. Groopman's article, one could get the idea that family coming to Foote ED were coerced in some way to choose to be present. I do not recall that this ever happened, but, of course, the possibility exists that some enthusiastic staff member who felt presence was helpful might make a comment suggesting the positives of being there. From my own view, the most important issue here is choice. All human rights issues are about choice. This choice to be present needs to be offered (how else would family know?), but then families should be permitted to discuss whether they want to exercise the option or not.
In our conversations, Dr. Groopman seemed fascinated that family presence was being considered. He did share that colleagues at his hospital were generally quite opposed to the whole idea. I think he wanted to remain neutral in the article. Some of the quotes from physicians graphically describing the cracking of chests and similar procedures seemed somewhat prejudicial. I can recall only one instance when I did discourage a family from viewing remains of family already dead. The bodies had been charred into nothing but a lump of unrecognizable substance that included an almost unbearable stench as well. The dead had been in an air crash and the plane had exploded upon impact. When the chaplain/nurse/social worker meets the family, and if the resuscitation scene seems a bit gruesome, the family should be adequately oriented to what they will witness, but still given the choice. I can recall mopping up blood on the floor before family entered to diminish the shock a little. I've met at least a dozen physicians who adamantly opposed family presence. When one of them found himself in Foote's ED during a heart attack, he told me later he feared he would die. 'If I were to die there,' he said, 'I'd want to have at least one loved one holding my hand and hear one familiar voice instead of dying in the exclusive presence of white coated people with stethoscopes.'
Please keep up this discussion about family presence. Nursing advocates seem to be the most successful of all medical personnel at initiating practices that increase levels of family involvement with their loved one while the latter is a 'patient' in a medical environment. Are not the nursing personnel the persons who manage Emergency Departments and write policy? Indeed, they are. The nursing staff at Foote Hospital, along with three ER physicians who were willing to begin including surviving family as part of a sudden death event, are the real heroes in this early attempt to promote family bondings, protect human rights, and bring a new humanness to patient care. To my knowledge, the pro-active protocols regarding family presence still being implemented at Foote Hospital are not fully duplicated anywhere else. How long will it be before survivors pound on the doors of ED like fathers once did on the doors of birthing rooms? If family and community life is enriched by physical family presence at the birth of a child, why cannot the same protocols be implemented at the time of death as well?
Thank you for your continued interest in this topic. I am now retired from active pastoral care ministry, but I feel just as passionately about family choices during resuscitation as I did twenty years ago.
Reverend Hank Post
Grand Rapids, Michigan