DOCTOR PATIENT DOCTOR PATIENT RELATIONSHIPRELATIONSHIP

INTRODUCTIONINTRODUCTION

““The duty of the doctor is to The duty of the doctor is to provide solace. It is for the GOD provide solace. It is for the GOD ALMIGHTY to cure the illness”. ALMIGHTY to cure the illness”. ((Hadis-e-Qudsi).Hadis-e-Qudsi).

““Each person who is admitted to a hospital Each person who is admitted to a hospital brings with him not only a physical illness brings with him not only a physical illness but also a definite mental set that will but also a definite mental set that will influence both the manner in which he influence both the manner in which he assumes his role as a patient and the assumes his role as a patient and the course of his hospitalization”.course of his hospitalization”. Robinson,1984Robinson,1984  

OBJECTIVESOBJECTIVES Improves careImproves care Improves your clinical skillsImproves your clinical skills Fosters participation in Fosters participation in

treatmenttreatment Facilitates holistic approach to Facilitates holistic approach to

carecare

OUTLINE OF LECTUREOUTLINE OF LECTURE1.1. Clarification of concepts in doctor-patient Clarification of concepts in doctor-patient

relationshiprelationship2.2. Biopsychosocial model of therapyBiopsychosocial model of therapy3.3. Interview methodology and environmentInterview methodology and environment4.4. Communication/interaction and Communication/interaction and

counselingcounseling5.5. Medical ethics Medical ethics 6.6. Islamic oath for practice of medicineIslamic oath for practice of medicine7.7. Hippocratic OathHippocratic Oath8.8. The dying person’s bill of rightsThe dying person’s bill of rights

RAPPORTRAPPORT Spontaneous and conscious feeling Spontaneous and conscious feeling

of harmonious responsiveness that of harmonious responsiveness that facilitates a useful therapeutic facilitates a useful therapeutic relationship.relationship.

Basis of understanding and trust Basis of understanding and trust between the therapist and the patient. between the therapist and the patient.

Gives a feeling of acceptance and to Gives a feeling of acceptance and to share the problem with the doctor.share the problem with the doctor.

SPIRITUALITYSPIRITUALITY Gaining increased importance in Gaining increased importance in

every society and culture both in every society and culture both in health and sickness.health and sickness.

Patient’s mental and physical Patient’s mental and physical health is influenced significantly health is influenced significantly by spiritual and religious beliefs by spiritual and religious beliefs and commitments. and commitments.

Therapists act asTherapists act as religious religious counselors.counselors.

ILLNESS BEHAVIORILLNESS BEHAVIOR ““patient’s reaction to the patient’s reaction to the experience of being sick or experience of being sick or

disabled.” disabled.”

Synonymous toSynonymous to sick rolesick role Habitual modes of thinking and Habitual modes of thinking and

feelings further shape the sick role.feelings further shape the sick role. Contd.Contd.

Largely depends on patient’s Largely depends on patient’s past experience, personality, past experience, personality, attitude of the family during attitude of the family during sickness and the extent of relief sickness and the extent of relief from personal or social from personal or social obligations due to illness.obligations due to illness.

TRANSFERENCE AND TRANSFERENCE AND COUNTER COUNTER

TRANSFERENCETRANSFERENCE Origin inOrigin in PsychoanalysisPsychoanalysis.. The views and attitudes of patients The views and attitudes of patients

and doctors about each other which and doctors about each other which may be reality orientated or based on may be reality orientated or based on the experiences and their relationship the experiences and their relationship with parents during childhood. with parents during childhood.

Contd.Contd.

Such views affect positively or Such views affect positively or negatively doctor patient interaction.negatively doctor patient interaction.

TRANSFERENCETRANSFERENCE A process of patient’sA process of patient’s unconscious unconscious

attributionattribution of feelings to doctor in of feelings to doctor in the background of his / her emotional the background of his / her emotional relationship with parents. relationship with parents.

The patient’s behavior may be The patient’s behavior may be demanding, harsh, caring or even demanding, harsh, caring or even seductive. seductive.

Contd.Contd.

Infact the transfer of past Infact the transfer of past feelings to the doctors. feelings to the doctors.

Encouraging transference Encouraging transference reaction is at times an integral reaction is at times an integral part of psychotherapy.part of psychotherapy.

COUNTER COUNTER TRANSFERENCETRANSFERENCE

The process by which a doctorThe process by which a doctor unconsciously attributesunconsciously attributes his his feeling to the patient in the feeling to the patient in the background of his past background of his past relationshiprelationship

It may take the form of negative It may take the form of negative feelings or positive idealizing and feelings or positive idealizing and even eroticizing reactionseven eroticizing reactions..

Doctors need to be insightful to Doctors need to be insightful to such reactions and should rise such reactions and should rise above such emotions for the above such emotions for the sake of better doctor patient sake of better doctor patient interaction.interaction.

THERAPEUTIC MODELTHERAPEUTIC MODEL Biopsychosocial ModelBiopsychosocial Model The concept of Biopsychosocial The concept of Biopsychosocial

Model of therapy is a relatively new Model of therapy is a relatively new concept since the patient is exposed concept since the patient is exposed to a complex physical and to a complex physical and psychological make up during psychological make up during sickness. Therefore, the psychosocial sickness. Therefore, the psychosocial environment is likely to influence the environment is likely to influence the behavior, the outcome and the behavior, the outcome and the ultimate prognosis of the underlying ultimate prognosis of the underlying physical disability.physical disability.

The psychological constitution The psychological constitution provides an elaborate provides an elaborate personality structure as well as personality structure as well as the attitudes and the reaction the attitudes and the reaction pattern of an individual and his pattern of an individual and his illness behavior. illness behavior.

This behavior is also shaped by This behavior is also shaped by culture, the society and social culture, the society and social support during times of crises.support during times of crises.

By understanding of this By understanding of this complex era of the interaction complex era of the interaction between different biochemical, between different biochemical, psychological and social factors psychological and social factors the therapist can plan an the therapist can plan an effective treatment strategy as effective treatment strategy as well as can manipulate those well as can manipulate those variety of factors in the variety of factors in the management of the sickness.management of the sickness.

It should be emphasized that the It should be emphasized that the events following sickness of the events following sickness of the person/relatives whether pleasant person/relatives whether pleasant or unpleasant also determine the or unpleasant also determine the reaction pattern of the people. reaction pattern of the people.

The knowledge of this aspect of The knowledge of this aspect of clinical medicine is another clinical medicine is another foundation in doctor-patient foundation in doctor-patient relationship apart from relationship apart from communication and interaction communication and interaction skills. skills.

MEDICAL INTERVIEWSMEDICAL INTERVIEWS Aspects of an effective Aspects of an effective

interviewing include:interviewing include: Patient’s factorsPatient’s factors like like

personality, character style and personality, character style and emotional status.emotional status.

Clinical settingsClinical settings like like interviewing the patient in interviewing the patient in emergency room, hospital emergency room, hospital wards, out patient department wards, out patient department or a psychiatric ward.or a psychiatric ward.

Frequent interruptions Frequent interruptions throughthrough:: telephone callstelephone calls presence of an interpreterpresence of an interpreter note takingnote taking nature of patient’s nature of patient’s problem/illnessproblem/illness interviewer’s methodologyinterviewer’s methodology his experience and his experience and his theoretical orientation also his theoretical orientation also have impact an interviewing.have impact an interviewing.

THREE MAIN FUNCTIONS THREE MAIN FUNCTIONS OF A MEDICAL OF A MEDICAL

INTERVIEWINTERVIEW 1.1. Determining the Determining the nature of the problemnature of the problem

2.2. Developing and Developing and maintaining a maintaining a

therapeutic relationship.therapeutic relationship.3.3. Communicating Communicating

information and information and implementing a implementing a

treatment plan.treatment plan.

COMMUNICATION/COMMUNICATION/INTERACTIONINTERACTION

a.a. Provides concise, accurate, and Provides concise, accurate, and timely overview of client’s timely overview of client’s statements and help them to statements and help them to organize their thoughtsorganize their thoughts

b.b. Helps a client to review what has Helps a client to review what has been saidbeen said

c.c. Stimulates a thorough exploration Stimulates a thorough exploration of themes that are important to the of themes that are important to the clientclient

You can summarize:You can summarize: Non verbal communication, Non verbal communication,

active listening and verbal active listening and verbal expressions are some of the expressions are some of the essential components of an essential components of an effective communication.effective communication.

Q. Which of the following kinds of Q. Which of the following kinds of communication is most effective communication is most effective in delivering information?in delivering information?

a)a) VerbalVerbalb)b) Tone of the voice and accentTone of the voice and accentc)c) Facial expressionsFacial expressionsd)d) Eye contactEye contact

THERAPEUTIC THERAPEUTIC COMMUNICATION/ COMMUNICATION/

INTERACTIONSINTERACTIONS Therapeutic Therapeutic

interaction facilitates interaction facilitates growth, development, growth, development, maturity, improved maturity, improved functioning and functioning and improved coping.improved coping.

Social InteractionsSocial Interactions

It occurs daily as the staff greets It occurs daily as the staff greets the patient with the patient with comments/questions such as;comments/questions such as;“ Good Morning”. “ Good Morning”. “ How are your Children?”. “ How are your Children?”. “ Has anybody visited you “ Has anybody visited you yesterday?”yesterday?”

Therapeutic InteractionsTherapeutic Interactions During this the staff helps the During this the staff helps the

patient to communicate feelings, patient to communicate feelings, fears, anxieties, frustrations etc. fears, anxieties, frustrations etc. with comments such as;with comments such as;

“ “ You look upset. Would you You look upset. Would you like to share your feelings with like to share your feelings with me? I will sit with you till the me? I will sit with you till the pain medication takes effect”.pain medication takes effect”.

EFFECTIVE EFFECTIVE COUNSELORCOUNSELOR

Self awarenessSelf awareness Awareness of cultural Awareness of cultural

experiencesexperiences Empathy, genuineness and Empathy, genuineness and

non-judgmental attitudenon-judgmental attitude Ability to communicate and to Ability to communicate and to

understand the expectations of understand the expectations of the patientthe patient

Knowledge & intellectual Knowledge & intellectual competencecompetence

Immediacy of relationshipImmediacy of relationship AttractivenessAttractiveness Honesty Honesty TrustworthinessTrustworthiness

NON-VERBAL NON-VERBAL COMMUNICATIONCOMMUNICATION

Non-verbal communication or Non-verbal communication or body language plays an body language plays an important part in the messages important part in the messages we relay to other people. we relay to other people.

It also refers to the way in which It also refers to the way in which the words are projected.the words are projected.

It can hinder or facilitate the It can hinder or facilitate the communication depending communication depending upon the mode of delivery of upon the mode of delivery of the wordsthe words and expressions of and expressions of the communicator.the communicator.

The important variables in non The important variables in non verbal communication are:verbal communication are:

a)a) Posture Posture b)b) Personal space Personal space c)c) Eye contactEye contactd)d) Head nodsHead nodse)e) Facial expressionsFacial expressionsf)f) Body movements and hand Body movements and hand

gesturesgesturesg)g) Tone of voiceTone of voice

Breaking News Of A Breaking News Of A Serious And A Terminal Serious And A Terminal

IllnessIllness1.1. Plan in mind before startingPlan in mind before starting2.2. Imparting adequate information to Imparting adequate information to the patientthe patient a.a. Be honest and know about Be honest and know about

your limitations and uncertainty of your limitations and uncertainty of diagnosisdiagnosis

b.b. Be warm and understandingBe warm and understanding c.c. Use basic counseling skillsUse basic counseling skills d.d. Be a source of support and Be a source of support and

encouragement and know that encouragement and know that grief, anger and despair are normal grief, anger and despair are normal

e.e. Encourage questionsEncourage questions f.f. Be prepared to spend more time Be prepared to spend more time

with the patient for exploring with the patient for exploring alternative management strategiesalternative management strategies

3.3. Environment:Environment: i.i. What to say and when to say What to say and when to say ii.ii. Presence of other close Presence of other close

associatesassociates

How To SayHow To Say1.1. Introduce yourself and the Introduce yourself and the

subject of discussionssubject of discussions2.2. Feel concerned, ensure eye Feel concerned, ensure eye

contact and be humanecontact and be humane3.3. Use simple language with warmthUse simple language with warmth4.4. Indicate facts and ensure detailsIndicate facts and ensure details5.5. Give sufficient time for questions Give sufficient time for questions

and inquiriesand inquiries

6.6. Allow the patient to be with Allow the patient to be with relatives for time in order to relatives for time in order to enable the patient to generate enable the patient to generate inner strength and supportinner strength and support

7.7. Give patient time to integrate Give patient time to integrate and don’t try to stop the flow of and don’t try to stop the flow of emotionsemotions

8.8. Soften the bad news with good Soften the bad news with good news or at least hopenews or at least hope

Further Plan of ActionFurther Plan of Action Speak honestly and in terms of the Speak honestly and in terms of the

range of the possibilities especially range of the possibilities especially when the diagnosis is malignancy when the diagnosis is malignancy (cancer)(cancer)

The dialogue and mutual confidence The dialogue and mutual confidence should continueshould continue

Continue instilling hopeContinue instilling hope Try to mobilize coping mechanisms Try to mobilize coping mechanisms

of the patient after sudden disclosure of the patient after sudden disclosure of painful informationof painful information

Participate in decision making Participate in decision making for further treatmentfor further treatment

The mechanism of denial The mechanism of denial should be owned initially should be owned initially because it is a protective because it is a protective mechanismmechanism

Encourage patient to make Encourage patient to make intelligent decisions about intelligent decisions about his/her own treatmenthis/her own treatment

See patients’ relatives See patients’ relatives individually to address their fears individually to address their fears and for mobilization of supportand for mobilization of support

Models of InteractionModels of Interaction

1.1. Paternalistic modelPaternalistic model 2.2. Informative modelInformative model3.3. Interpretive model Interpretive model 4.4. Deliberative model Deliberative model

MEDICAL ETHICSMEDICAL ETHICSQ. A 25-year-old man who is HIV-positive Q. A 25-year-old man who is HIV-positive

comes to a physician’s office for comes to a physician’s office for treatment of a skin lesion. Because treatment of a skin lesion. Because she is afraid of infection, the physician she is afraid of infection, the physician refuses to treat him. This physician's refuses to treat him. This physician's refusal to treat the patient is best refusal to treat the patient is best described as:described as:

a.a. Unethical and illegalUnethical and illegalb.b. Ethical and legalEthical and legalc.c. Unethical but legalUnethical but legald.d. Ethical but illegalEthical but illegal

MEDICAL ETHICSMEDICAL ETHICS The ethical concerns of care The ethical concerns of care are an integral part of medicine are an integral part of medicine & doctor-patient relationship. & doctor-patient relationship. A modern branch of moral A modern branch of moral philosophy concerned with philosophy concerned with moral problems in medical moral problems in medical practice, policy and research. practice, policy and research.

These also include legal issues such These also include legal issues such as informed consent and termination as informed consent and termination of care.of care.

Psychiatric and behavior medicine Psychiatric and behavior medicine issues are another important issues are another important consideration of medical ethics.consideration of medical ethics.

In due course issues like In due course issues like E-consultations, relationship with E-consultations, relationship with

Media and pharmaceutical industry will Media and pharmaceutical industry will have to be considered and addressed.have to be considered and addressed.

Medical Ethics also include moral, legal and religious issues related to: Tissue transplant Organ transplant, IVF (Test tube babies) Diagnostic procedures (Amniocentesis) Termination of pregnancy etc.

Q. A 16 years old male high school Q. A 16 years old male high school student has an appointment with student has an appointment with the physician because of recurrent the physician because of recurrent pain abdomen for the past one pain abdomen for the past one month. The primary concern in the month. The primary concern in the patient mind is:patient mind is:

a.a. ConfidentialityConfidentialityb.b. Reassurance that the illness is not Reassurance that the illness is not

seriousseriousc.c. Competence of the physician Competence of the physician d.d. How to explain illness to his mates How to explain illness to his mates

by the patientby the patient

INFORMED CONSENTINFORMED CONSENT

CONFIDENTIALITYCONFIDENTIALITY It may be necessary to reassure It may be necessary to reassure a patient that confidentiality will a patient that confidentiality will

be maintained except when: be maintained except when: Information may be harmful to Information may be harmful to the patient or others.the patient or others. Patient does not intend to comply Patient does not intend to comply with the treatment planwith the treatment plan Patient threatens Patient threatens self-harm.self-harm.

EUTHANASIAEUTHANASIA(Mercy Killing)(Mercy Killing)

It is defined as a physician’s It is defined as a physician’s deliberate act to cause a patient deliberate act to cause a patient death in hopelessly ill or injured death in hopelessly ill or injured patients. patients. Active EuthanasiaActive Euthanasia Passive EuthanasiaPassive Euthanasia Voluntary EuthanasiaVoluntary Euthanasia Involuntary EuthanasiaInvoluntary Euthanasia

ISLAMIC OATHISLAMIC OATH““IN THE NAME OF ALLAH, MOST IN THE NAME OF ALLAH, MOST GRACIOUS, MOST MERVCIFUL”GRACIOUS, MOST MERVCIFUL”

““Praise to be Allah, the Praise to be Allah, the Sustainer of His Creation, the Sustainer of His Creation, the All-knowing. Glory be to Him, All-knowing. Glory be to Him,

the Eternal, the All-Pervading”the Eternal, the All-Pervading”

““O Allah, Thou art the only O Allah, Thou art the only Healer, I serve none but Healer, I serve none but

thee, and, as the instrument thee, and, as the instrument of Thy Will, I commit myself of Thy Will, I commit myself

to Thee”to Thee”

I Dr------------------------- render this I Dr------------------------- render this Oath in Thy Holy Name and I Oath in Thy Holy Name and I undertake:undertake:

To be the instrument of Thy Will To be the instrument of Thy Will and Mercy, and, in all and Mercy, and, in all humbleness, to exercise humbleness, to exercise justice, love and compassion justice, love and compassion for all Thy Creation;for all Thy Creation;

To extend my hand of service to one To extend my hand of service to one and all, to the rich and to the poor, and all, to the rich and to the poor, to friend and foe alike, regardless to friend and foe alike, regardless of race, religion or colour;of race, religion or colour;

To hold human life as precious and To hold human life as precious and sacred, and to protect and honour sacred, and to protect and honour it at all times and under all it at all times and under all circumstances in accordance with circumstances in accordance with Thy Law;Thy Law;

To do my utmost to alleviate pain and To do my utmost to alleviate pain and misery, and to comfort and counsel misery, and to comfort and counsel human beings in sickness and in human beings in sickness and in anxiety; To respect the confidence anxiety; To respect the confidence and guard the secrets of all my and guard the secrets of all my patients;patients;

To maintain the dignity of health care, To maintain the dignity of health care, and to honour the teachers, and to honour the teachers, students, and members of my students, and members of my profession;profession;

To strive in the pursuit of knowledge To strive in the pursuit of knowledge in Thy name for the benefit of in Thy name for the benefit of mankind, and to uphold human mankind, and to uphold human honour and dignity;honour and dignity;

To acquire the courage to admit my To acquire the courage to admit my mistakes, mend my ways and to mistakes, mend my ways and to forgive the wrongs of others;forgive the wrongs of others;

To be ever-conscious of my duty to To be ever-conscious of my duty to Allah and His Messenger (S.A.W.), Allah and His Messenger (S.A.W.), and to follow the precepts of and to follow the precepts of Islam in private and in public.Islam in private and in public.

““Allah grant me the strength, Allah grant me the strength, patience and dedication to patience and dedication to

adhere to this Oath at all times”adhere to this Oath at all times”

HIPPOCRATIC OATHHIPPOCRATIC OATH II swear by Apollo the physician, swear by Apollo the physician,

and Aesculapius, Hygeia and and Aesculapius, Hygeia and Panacea and all the gods and Panacea and all the gods and goddesses, that,goddesses, that,according to my ability and according to my ability and judgment, I will keep this Oath judgment, I will keep this Oath and this covenant.and this covenant.

To reckon him who taught me this To reckon him who taught me this Art equally dear to me as my parents, Art equally dear to me as my parents, to share my substance with him, and to share my substance with him, and relieve his necessities if required; to relieve his necessities if required; to look upon his offspring on the same look upon his offspring on the same footing as my own brothers, and to footing as my own brothers, and to teach them this Art, if they shall wish teach them this Art, if they shall wish to learn it, without fee or stipulation; to learn it, without fee or stipulation; and that by precept, lecture, and and that by precept, lecture, and every other mode of instruction,……..every other mode of instruction,……..

Contd Contd

I will impart a knowledge of the I will impart a knowledge of the Art to my own sons, and those of Art to my own sons, and those of my teachers, and to disciples my teachers, and to disciples who have signed the covenant who have signed the covenant and have taken an oath and have taken an oath according to the law of medicine, according to the law of medicine, but no one else.but no one else.

I will follow that system of regimen I will follow that system of regimen which, according to my ability and which, according to my ability and judgment, I consider for the benefit of judgment, I consider for the benefit of my patients, and abstain from whatever my patients, and abstain from whatever is deleterious and mischievous.  I will is deleterious and mischievous.  I will give no deadly medicine to anyone if give no deadly medicine to anyone if asked, nor suggest any such counsel; asked, nor suggest any such counsel; and in like manner I will not give to a and in like manner I will not give to a woman an abortive remedy. With purity woman an abortive remedy. With purity and with holiness I will pass my life and and with holiness I will pass my life and practice my Art.practice my Art.

I will not cut persons labouring I will not cut persons labouring under the stone, but will leave this under the stone, but will leave this to be done by such men as are to be done by such men as are practitioners of this work.  Into practitioners of this work.  Into whatever houses I enter, I will go whatever houses I enter, I will go into them for the benefit of the sick, into them for the benefit of the sick, and will abstain from every and will abstain from every voluntary act of mischief and voluntary act of mischief and corruption; and, further, from the corruption; and, further, from the seduction of females or males, of seduction of females or males, of freemen and slaves.freemen and slaves.

Whatever, in connection with my Whatever, in connection with my professional practice, or not in professional practice, or not in connection with it, I see or hear, connection with it, I see or hear, in the life of men, which ought in the life of men, which ought not to be spoken of abroad, I will not to be spoken of abroad, I will not divulge, as reckoning that all not divulge, as reckoning that all such should be kept secret.  such should be kept secret. 

While I continue to keep this Oath While I continue to keep this Oath unviolated, may it be granted to unviolated, may it be granted to

me to enjoy life and practice of me to enjoy life and practice of the Art, respected by all men, in the Art, respected by all men, in all times. But should I trespass all times. But should I trespass and violate this Oath, may the and violate this Oath, may the reverse be my lot.reverse be my lot.

Needs of the Dying Needs of the Dying PatientPatient

Holist (1984) statesHolist (1984) states “families and “families and patients may die patients may die too many things too many things before the disease before the disease finally takes life”.finally takes life”.

Optimism, spontaneity, holidays, Optimism, spontaneity, holidays, long – range planning, dreams, long – range planning, dreams, retirement, and grandparenthood are retirement, and grandparenthood are but a few of the many things that die but a few of the many things that die as a person and her or his family live as a person and her or his family live with a terminal illnesswith a terminal illness..

The Dying Person’s Bill of The Dying Person’s Bill of RightsRights

I have the right to be treated as a I have the right to be treated as a living human being until die.living human being until die.I have the right to maintain a sense of I have the right to maintain a sense of hopefulness however changing its focus hopefulness however changing its focus may be.may be.I have the right to be cared for by those I have the right to be cared for by those who can maintain a sense of who can maintain a sense of hopefulness, however changing this hopefulness, however changing this might be.might be.

I have the right to express my I have the right to express my feelings and emotions about my feelings and emotions about my approaching death in my own say.approaching death in my own say.I have the right to expect continuing I have the right to expect continuing medical and nursing attention even medical and nursing attention even though “cure” goals must be though “cure” goals must be changed to “comfort goals”changed to “comfort goals”I have the right not to die alone.I have the right not to die alone.

I have the right to have my I have the right to have my questions answered honestly.questions answered honestly.I have the right not to be deceived.I have the right not to be deceived.I have the right to have help from I have the right to have help from and for my family in accepting my and for my family in accepting my death.death.I have the right to die in peace and I have the right to die in peace and with dignity.with dignity.

I have the right to retain my I have the right to retain my individuality and not be judged individuality and not be judged for my decision, which may be for my decision, which may be contrary to beliefs or others. contrary to beliefs or others. I have the right to discuss and I have the right to discuss and enlarge my religious and / or enlarge my religious and / or spiritual experiences, whatever spiritual experiences, whatever these may mean to others.these may mean to others.

I have the right to expect that I have the right to expect that the sanctity of the human body the sanctity of the human body will be respected after death.will be respected after death.I have the right to be cared for by I have the right to be cared for by caring, sensitive, knowledgeable caring, sensitive, knowledgeable people who will attempt to people who will attempt to understand my needs and will be understand my needs and will be ale to gain some satisfaction in ale to gain some satisfaction in helping me to face my death.helping me to face my death.

Image Of Doctors In The Image Of Doctors In The CommunityCommunity

CONCLUSIONCONCLUSION