|
|
|
|
|
HOME » News » Commentary » Life Matters; Death Matters | |
|
Life Matters; Death Matters by David R. Kuhl, MD, PhD
The WSAVA International Lecture It is known that the greatest anxiety we have is a death anxiety. The second greatest anxiety is to speak in public. I’ll cover both anxieties today. I am involved in teaching medical ethics at St. Paul’s Hospital, a tertiary care facility, part of the University of British Columbia. Several years ago a veterinarian working in an intensive care facility attended one of my lectures. Subsequently she invited me to give the same lecture to the staff working at her facility. The topic of the lecture was ‘ethical decision making at the end of life’. The decision making process includes the patient, the people who are important to the patient and health care providers involved in the care of the patient. It is based in part on principles such as beneficence, nonmaleficence, autonomy, futility, utility and justice. The purpose of the process is to develop a plan of action appropriate to the estimated amount of time and energy available to the patient. It attempts to ‘put the cards on the table’ so the plan that is made is based on the best information available. In speaking to the staff at the veterinary intensive care facility I soon realized why I had been invited to give the talk, in that we had a lot in common: giving bad news, decision making at the end of life, cost (financial and emotional), addressing pain and suffering, issues and concerns pertaining to euthanasia, dying and death. At that time I also realized that features of a qualitative study I had completed, Exploring Spiritual and Psychological Issues at the End of Life, were in some way inherent in the provision of care for pets and their owners. The lessons I learned from the people in the study might give an insight for veterinarians as well, especially because of the suffering of the pet owners. The study I speak of was supported by the Faculty Scholars Program, Project on Death in America, New York, St. Paul’s Hospital, and the University of British Columbia (Kuhl, 1999, 2002). Let me tell you about it. I begin with a disclaimer. Despite spending many years at the bedside of people who are dying, most recently that of my sister, I do not know what it means to have cancer or any other terminal illness. I can only work to understand the experience of another. Secondly, my work differs from yours. I do not know what it means to work as a veterinarian. I can only try to understand what that means. I started working in providing care for people at the end of life, also known as hospice or palliative care, 15 years ago. The palliative care program at St. Paul’s Hospital was started in 1989, initially focusing on care for persons with cancer or AIDS. Since its inception we have provided care for well over 3000 people. The genesis of the study is based on my clinical experience on that unit. It is based on working at the bedside of dying people. I remember one woman in particular who had lung cancer. She had been admitted to the hospital for pain management. By initial assessment it seemed that her pain would not be difficult to control. Every day I went in to her room to speak to her about the pain, and every day she responded with “Since my second day here, my pain hasn’t really changed a lot.” It had improved initially and then, much to my chagrin, she had no further relief from the pain. How could that be? We were managing her in the same way that we had managed many others before her, some with apparently more complex pain issues. I remember feeling somewhat frustrated. Perhaps it was the frustration that lead me to ask her about the pain in a different way. The next morning I said, “It seems to me that apart from the pain you first described, you have a pain in your ‘heart’, a pain that medication will not touch.” Tears welled up in her eyes as she told me about a recent estrangement between herself and her only child, a daughter who was about to be married. The man she was marrying was not someone the woman would have chosen for her daughter, and she decided to tell her daughter that not only would she not choose him, but also she was concerned that he might hurt her in some way. The daughter chose the man over her mother, despite the fact that her mother was dying. Her mother was filled with grief, not only because of the estrangement but also because, if she were correct, she would not be alive when her daughter needed her. Indeed, it was a pain no medication would alleviate. And in fact, it was preposterous to think that I could affect the pain which resulted from a broken relationship between a mother and her daughter. In meeting that woman, and others like her, I began to appreciate that my knowledge of palliative care as I knew it at that time was limited. It was for that reason that I conducted the study. My research question was: “What is the lived experience of knowing one has a terminal illness.” That is, what is it like to live each day with the knowledge that the disease process going on within you will likely be the cause of your death? The methodology of the study was existential phenomenology. I was a doctoral student at the time. I needed all three years of the program to be able to say ‘existential phenomenology’ without stumbling over the words. The methodology is such that the researcher attempts to: The people who participated in the study had either a diagnosis of cancer or AIDS. They spoke English fluently and had unimpaired cognitive function. Most of the interviews, which were taped (audio and video), were conducted in the homes of the participants. They were transcribed and themes were identified. I went back to the people for validation. They confirmed, corrected, and deleted the themes as presented to them. Some were seen once or twice, others were followed for nearly a year with ten or eleven interviews. Who were these people? The common feature was that they had a terminal illness. They knew what it meant to be partnered, married, divorced, widowed, dating, separated. Some were gay, some were straight. There were those who were childless. Some had children, some had adopted children, some were adopted, some had grandchildren. Their ages ranged from the mid 20’s to the mid 80’s. Their careers included teaching, studying, carpentry, nursing, public relations, waitressing, counselling, construction work. They lived in the poorest areas and the wealthiest areas of the city. Some were dependent on welfare, others were able to do anything they chose to do - lack of money was not a deterrent to the things they wanted to do or to buy. These people spoke of roles as parents, as children, as employees, as friends. A few of them spoke of being lovers. They spoke of their: And in the midst of their conversations with me, major themes emerged: A. Communication There are three occasions when the communication between the health care provider and the patient are particularly important, namely, at the first visit, at the time of diagnosis and while receiving care at the end of life. I remind you that speech is verbal and nonverbal. Publius Syrus, a philosopher who lived in 1 BC said “Speech is a mirror of the soul: as a man speaks, so is he.” And Robert Frost spoke of the nonverbal component of communication when he said “There are tones of voice that mean more than words.” (Untermeyer, 1977) I read a quote from Peggy, a woman in her early 60’s, who had lung cancer: “I guess the first thing is I trust all my physicians. They’ve been totally up front and answered questions in detail. I couldn’t have asked for it to be handled better. They have told me what it might be, what it might not be, they couldn’t have been more honest. It didn’t come as a shock, a bolt out of the blue. It was just one of those case scenarios they described that they hoped it wouldn’t be. Dr. P. has at all times taken time to talk, not just to me, but to my whole family... with a lot of empathy and sort of touching me from time to time while he was talking to them.” Always there are two experts in the room, the one with the knowledge about the disease and the disease process, and the one who knows how that disease will affect his/her life. Max, a man in his twenties had a different experience: “...then all things are starting to flow by me. Having the CT scan done and turning over and seeing six or seven physicians there pointing and looking at the computer screens, trying to read their faces. Not one of them showing any bit of emotion whatsoever or coming in to calm me down.” Max told me that after three weeks in hospital, he still didn’t know his diagnosis. (I do not know what he had been told as none of his care providers were interviewed. I only present his story.) He did know that when the nurses changed their shift, the chart rack was unattended. So one day he went to the chart rack to look at his chart. He flipped through it to find a diagnosis of metastatic carcinoma. He didn’t know what that meant, so he asked his nurse on the next shift for a dictionary. He found the definition: spreading cancer. He was still somewhat uncertain as to what that meant for him. He was transferred to another institution the next day. His initial encounter with the nurse was one in which he expressed a sense of loss at being transferred from the other hospital. Her response: “What do you think this is, the Bayshore Inn?” (The Bayshore Inn is one of the more prestigious hotels in Vancouver). Shortly after that, the doctor walked into the room, and with surprise in her voice stated “Oh, you can talk, I thought that by the description they gave me, you would be unresponsive. I’m not certain about the diagnosis, but I’ll check into it over the weekend and get back to you next week.” The moment of telling someone about a terminal illness is a moment of suffering for the messenger as well as the one who receives the message. Perhaps, it is the moment in time when the person receiving the message may experience the greatest psychological and spiritual need they have ever known. It may also be the moment in time for which the doctor has the least amount of training. Both people are confronted by mortality in some way. It is the point in time when the patient asks for attention from the heart rather than from the mind. How the message is given may result in: B. Iatrogenic Suffering “The way health care providers talked to me caused me more pain than the disease itself.” This is the theme which came as the greatest surprise. It is one I didn’t want to hear. Initially I dismissed and trivialized the experience of the co-researchers. But it is a theme that could not be ignored for long. Marjorie, a woman in her eighties got her diagnosis from the door of her hospital room. Despite the fact that the interaction had happened 10 years earlier, she remembered it as thought it had happened the day before I visited her. She had a mass in her right axilla which had been there for several months. The surgeon was ‘following it’, believing that it was benign, assuring Marjorie of the same. Because the rate of growth seemed to be increasing, the surgeon decided to excise the mass. While Marjorie was waking from the anaesthetic, but still groggy, the surgeon, from the doorway of her room stated “Oh, by the way we were wrong, its cancer. I have made an appointment for you to see the oncologist in a few days.” He left. No interaction, no discussion, no hope. She was then seen by the nurse who came to discharge her from the hospital to her home. Marjorie said “I’m not generally an angry person, but I was angry and told the nurse that I would not go home until the doctor came back and did it right.” Deciding to learn from her, I asked how he might have done it right. She said “It’s not that hard, David. Come into the room, put your arm around me and talk to me as thought I’m someone you care about. I know all about male doctors touching female patients. However, knees, elbows and shoulders are safe.” The man I told you about earlier felt that the Lion’s Gate Bridge (a suicide spot) became a viable option when he was told about his diagnosis of cancer. It had more to do with how he was told than the content of the message. For him, all hope was destroyed in a matter of seconds. Another man actually tried to commit suicide because of how he was given the message of having a terminal illness. How is it that this moment has such catastrophic effects? I am working to understand that moment, to find an answer to the question. At present, I believe that it includes components of the following features: 1. Unresolved Emotion of the Caregiver For the first feature, I borrow a concept from Jung. About a parent/child relationship he said “The greatest burden a child must bear is the unlived life of the parent.” (Hollis, 1993) Adapting that to the doctor/patient relationship I say: “The greatest burden a patient must bear is the unknown, unresolved emotion of the caregiver.” Our fears of death, of failure, of uncertainty, of isolation and despair may in some way be projected onto the patient. So we delay giving the message, trivialize its impact, or speak coldly about a matter of life and death. Catherine Heaven and Peter Maguire (1996), a nurse and a physician, have given us some evidence in this regard, in that patients who received care at the end of life were asked about the conversations they had with care providers. Many stated that there were certain topics for some care providers which were taboo. If those were raised the care provider would leave, change the subject, or in some way be less accessible to the patient. The patients stopped talking about those topics, and in that way began to take care of the health care provider. 2. Receiving Bad News About receiving bad news, consider the following myth adapted from the writings of Evslin and Evslin (1967), and Philip (1995). King Acrisius of Argos was brooding about the dreams of his daughter, Danae, for marriage. He feared that a son-in-law would be waiting for King Acrisius to die so that he could take the throne. He might even attempt to hasten the event—a forboding and frightening thought. He decided to consult the oracle. The message he received from the prophet was that his daughter would bear a son who would one day kill the king. The king had the messenger beheaded for bringing the bad news to him and imprisoned his daughter in an attempt to prevent the fulfillment of the prophecy. Zeus, the greatest of the gods, who desired Danae, poured himself into her lap through an opening in the roof of the chamber that imprisoned her, by transforming himself into a shower of gold. Subsequently she bore a son, whom she named Perseus. When Acrisius heard Perseus crying, he shut Danae and the baby into a great chest and set them out to sea. They floated on and on until, in time, they were rescued by a fisherman. Perseus was strong, athletic, and fearless, talented in a wide range of sporting events. For that reason he returned to the land of his grandfather to compete in some athletic games in which he threw the discus. A disc he threw accidentally struck and killed Acrisius, thereby fulfilling the prophecy. When Acrisius sent to the Delphi Oracle, he expected to hear about the prospects of his daughter’s future husband with an awareness that his son-in-law could some day seek to overthrow him. He did not expect to hear that it would be his grandson, and not his son-in-law who would kill him. Although he had some reservation, he wanted a message of hope. He was most certainly not wanting to hear a message of his own demise. Because he did not want to hear the ‘bad news’ Acrisius killed the messenger. That didn’t change the outcome. The truth of the message prevailed, although his grandson killed him, not through malice, but by accident. How do people want to hear bad news? They don’t! Nobody wants to hear bad news! People generally visit physicians with the hope and belief that the physician will do something which will cure them, heal them or at least help them to feel better. They don’t go to hear the message that cure is not possible and that death is inevitable. As in the myth, hearing bad news often results in anger: anger at change, anger at the information, anger at life, at illness, at mortality and at the messenger. How the message is given can affect the emotional response. My sense is that giving bad news to pet owners about their pets is as delicate a situation as that of giving bad news to a patient. 3. Grief Grief is born from wanting more of what one will never get again. Grief begets grief. Grief is usually a combination of anger and sadness. Grief in the present often links to unresolved grief of the past. Grief is not rational; it is a pain, a great pain, not in one’s mind, but in the heart, in the soul, at the core of one’s being. It numbs the emotions, it diminishes spontaneity, it isolates. Grief is a beacon to loss, loss of what we do and who we are, loss of self, loss of relationship. Grief must be felt, experienced, and expressed in order to be resolved, in order to rid one of its effects. Often people who are filled with grief expend a great deal of energy to suppress it, as its expression results in pain and is not generally welcomed by those around us. As much as grief is suppressed so are the other emotions we might experience. Only people who feel and express their grief recover from their grief. Unless grief is resolved, one remains attached to the object, person, or relationship that is lost. That includes pets. Perhaps, as care givers, we too hold our grief within. One of the greatest causes of traumatic stress has to do with a sense of helplessness in the face of tragedy. In my work I see endless pain, endless suffering, endless loss, endless death. How do I express my grief? It is a question I ask myself on a regular basis. I am told that a certain percentage of the pet owners you meet have a stronger attachment and commitment to their pets than they do to any human being. In light of those relationships think of the grief that is experienced when it is known that a pet is dying, or that a pet has died. For some people, the death of a pet results in a deeper grief than the grief resulting from the death of a person. Their joy, their greatest sense of ‘connectedness’ dies with the pet - it goes to the grave of the pet. C. Time Augustine said we all know what time is until we have to define it. We share chronological time: 60 seconds in a minute, 60 minutes in an hour etc. Ken Wilber (1983), a well known psychologist, describes narrative time: the time that marks the history of one’s own life story or self; the time that carries and recreates hopes and ideals, plans and ambitions, goals and visions; the subtle time that can speed up or slow down, expand or collapse, transcend or concentrate, according to its interest. And in the case of pet owners, time has to do with the relationship between them and their pet. How much of the life of the owner has been shared by the pet? How many years have they been together, and what experiences might they have shared? I quote from one of the people who participated in my study: “...I have no idea whether I’m going to live a year or I’m going to live a month. That’s very hard to take, especially when I’m just living to live, that’s what I’m doing. I live to take the puffers six times a day, to take the pills so many times a day, to fill the pills up every four days...all I’m doing is working with pills and puffers...It absolutely controls my life.” For her there seemed to be no life outside the medication she was taking because of her illness. There is an ambivalence that is introduced by the diagnosis. Time stops when the patient hears words like cancer, AIDS, etc. One cannot return to that second before the diagnosis was spoken. Time is irreversible. One is left with the question: Do I embrace life or do I prepare to die? When has my pet suffered enough? When is the suffering of my pet my suffering? When is my suffering my pet’s suffering? Who determines that and how? D. Pain Pain is part of the experience of living with a terminal illness: When pain is present, it becomes the focus of existence! I quote: “I’m only afraid of pain. I’m not afraid of death. I’m not afraid of dying. I’m afraid of pain. I’m terrified of pain; bad pain, because I’ve gone through so much of it.” I would believe that to be true for pet owners as well. E. Touch Touch is healing, emotionally and psychologically. It is essential to one’s sense of well-being. I quote: “All I cared about was that someone was touching me and I knew that I wasn’t alone, it’s so important, it’s so important.” Touch counteracts the sense of aloneness, the sense of being out of touch, of being untouchable. Frederick Buechner (1991), a theologian, said “Whatever else we are, we are bodies and as bodies we need to touch and be touched by each other as much as we need to laugh and cry and play and talk and work with each other.” And I quote from another one of the study participants: “Touch is almost a necessity of life, yes it is a necessity of life.” For how many people is the need for touch met by their pets? F. Life Review About life review Derrickson (1996) said that it allows us “to affirm an essential goodness in life and to bless our participation in that goodness. If our lives have been tragic or we have participated in life in an evil or negative way, and these issues remain unresolved, we will struggle. If we are unable to view joy and tragedy as two poles on the continuum of life, we will struggle.” I quote: “I do a lot more thinking now, about my life, how it was and is, what I’ve done and things like that...the guilt feeling of the things I’ve done is much greater than the good things that brought you happiness. The guilt takes priority. Most of the stuff I wish I could forget about, but it’s all coming up.” Alice Miller (1994) said “Our true, repressed life history is stored up in our body which attempts to recount it and to be listened to...This is in fact for our own well-being, as denial is highly destructive to the adult.” It has to do with ‘re-membering’ - taking the parts of one’s life that have been forgotten and integrating them into a new wholeness. And when our history is too painful to share, to speak about, to explore, perhaps a pet has been there and has shared in the tears, the anger, the sorrow, the elation. The Siamese cat that was present during the celebration of an engagement and a wedding, followed 5 years later by the anger and grief of a divorce, the lhasa apso who travelled with the family for all those trips you took while the children were growing up, the cocker spaniel that bore your grief when your spouse died 2 years ago. With the memories there may be guilt, there may be grief. As stated earlier, grief is born from recognizing what one will never get, the emotion one feels when one knows that what one wants more of, is no longer available. For example, the companionship of a dog - the hours of being together, the walks, the times the dog listened when there wasn’t a human being available to provide the same attention - is no longer possible after the death of that dog. For some people, grief stems from realizing they will never get what they truly deserved: unconditional love and being taken seriously, being seen for who they truly were. It is my sense that this may be the most significant commonality between this study and your work. It has to do with the feature that Jungian psychologists would define as projection: an automatic process whereby contents of one’s own unconscious are perceived to be in others. ‘Others’ includes people, animate and inanimate objects. Our need, for example, of unconditional love, which may never have been provided by another person, may seem to be given by a pet. Intimacy, companionship, loyalty, confidentiality - features of relationship can easily be received from our pets. We are anthropomorphic - we attribute human characteristics or behaviour to a god, animal or object. My children make up entire stories about their cat. The other day I found myself doing the same thing. For some reason, our cat, Mischa, has been sitting at the end of our driveway for long periods of time, looking in both directions, as if anticipating the arrival of a friend. The other day, I called my daughters and said ‘Look at Mischa, she’s waiting for the bus. Somebody better tell her that the buses are on strike and that she will have a very long wait.’ (Prior to this week, there has been a longstanding bus strike in this province.) The kids loved the anthropomorphism. It wasn’t long before some of their friends were telling me, that if I cared at all, it would be a good idea for me to drive the cat to wherever the cat would like to go - some field full of mice and snakes, she seems to cherish both. G. Truth The Concise Oxford Dictionary defines truth as ‘showing life as it really is’ (Sykes, 1976). Here is a series of quotes from a number of study participants. Truth: “only in addressing unfinished business is one able to come to healing and peace, to wholeness.” “...don’t lie to yourself. By telling yourself the truth you allow yourself to heal. The mind and the body work together. It is so funny how people deny it until they die” Truth and hope are not mutually exclusive. In fact, without the truth some people cling to a false hope, which will likely have an impact on their grieving process. H. Who am I? “Not all, but most people wear a mask of what they think people want them to be.” “That’s what I think makes us lucky people who do come close to death. All that crap just flies off you, it just comes off like layers of skin. All of a sudden you’re just like when you were born. All of that stuff is gone, you have none of than any more and you’re starting from scratch. I think that’s what makes it different. All of those messages that you were taught, all of the negative stuff that you were taught is now replaced with positive things, loving things, caring things, things that make you a better, happier person. Funny how it affected me that way.” “I have faith and believe in myself now that I never had before...and in being who I am, I’m not afraid of being who I am.” “I think I can face death liking myself now, and I never, never would have been able to say that. I think that’s the big difference...it’s shown me that I have got the inner strength—that’s the essence of it.” Again I quote from Buechner (1991): “The world sets in to making us into what the world would like us to be, and because we have to survive after all, we try to make ourselves into something that we hope the world will like better than it apparently did the selves we originally were. That is the story of all of our lives, needless to say, and in the process of living out that story, the original, shimmering self gets buried so deep that most of us end up hardly living out of it at all. Instead we live out all the other selves which we are constantly putting on and taking off like coats and hats against the world’s weather.” H. Transcendence If one were to create a composite experience of spirituality for persons who know they have a terminal illness, one would generally address this Being as a Higher Power, a Being which has the capacity to love individuals unconditionally thereby in turn, enabling the individual to love themselves unconditionally as well. In the context of that love, the individual accepts him/herself with the awareness of the impact of wounds experienced throughout one’s lifetime beginning in childhood. Hence, one is able to extend that acceptance to others as well. Because the Higher Power is able to forgive, and to love without judgment or imposition of punishment, the individual is also able to forgive self and others for all transgressions imposed on others or experienced personally. In the strength of this Higher Power, one experiences healing and is able to resolve personal and relationship issues some of which have resulted in self loathing, and great difficulty to forgive. One experiences a greater connectedness to others and finds deeper meaning in relationships. The experience of the Higher Power is very personal and private. One no longer feels the boundaries and limits of self, for strength, love and integrity result in a wholeness not previously experienced. This is strongly felt in nature, from the smallest bird, through the eyes of a doe, embracing a tree, or looking to the mountains. There is a wholeness and a oneness with nature, which includes an extension of the self, beyond the self, to the Higher Power. In this context, one is filled with joy, purpose and loses all fear of death. The work you do is very important work. Pets provide companionship, intimacy, and for many people a connection to a Higher Power. Your communication and compassion are two of the greatest ways in which you can make a difficult journey less painful. That is our role. And then to take care of our own sorrow, grief, fears of failure, and death anxiety. Working with the very ill, the traumatized and the dying affects each of us who do that work. We are not immune from the effects of providing care in that context. I don’t think it makes a difference whether it’s people, pets, or pet owners - each of them trigger our own grief, our own death awareness and anxiety, our own sense of suffering. I conclude with a quote from one of the participants in the study and a story. First the quote, “I was where I wanted to be. I was in the forest, I was surrounded by nature, and the trees. When I woke in the morning here was my tree and in it was a little nest of birds...I think it helped me to live. I was surrounded by healing.” And in terms of taking care of ourselves: I know that getting accepted into medical school is a competitive process. And being independent and autonomous are rewarded and held in regard by the profession. At times that leaves us alone and isolated, the isolation being increased by the grief we experience in the context of our work. It is for that reason I tell you this story by Clarrisa Pinkola Estes (1992), taken from her book Women Who Run With the Wolves. One Stick, Two Stick An old man is dying. He calls his people to his side. He gives a short, sturdy stick to each of his many offspring, wives and relatives. ‘Break the stick’ he instructs them. With some effort, they all snap their sticks in half. ‘This is how it is when a soul is alone and without anyone. They can be easily broken.’ The old man next gives each of his kin another stick, and says, ‘This is how I would like you to live after I pass. Tie your sticks together in bundles of twos and threes.’ He waits quietly as his family ties the sticks together. There are many bundles, some of two sticks, some of three sticks. ‘Now, break these bundles in half.’ No one can break the sticks when there are two or more in a bundle. The old man smiles. ‘We are strong when we stand with another soul. When we are with others, we cannot be broken.’ References Buechner, F. (1991) In: Telling secrets. New York: Harper Collins Publishers. p 45, 74-75 Derrickson, B.S. (1996) The spiritual work of the dying: A framework and case studies. The Hospice Journal, 11 (2), 11-30. Estés, Clarissa Pinkola (1992) In: Women Who Run With The Wolves. New York: Ballantine Books. p 508 Evslin, Bernard and Evslin, Dorothy (1967) In: Heroes and Monsters of Greek Myth. New York: Scholastic Inc. pp 7-32 Heaven, C.M., & Maguire, P. (1996) Training hospice nurses to elicit patient concerns. Journal of Advanced Nursing 23, 280-286 Hollis, James (1993) In: The Middle Passage From Misery to Meaning in Midlife. Toronto: Inner City Books. p 64 Kuhl, D. R. (1999) Exploring Spiritual and Psychological Issues at the End of Life, A Dissertation (Unpublished) Vancouver: University of British Columbia Kuhl, D.R. (2002) What Dying People Want: Practical Wisdom at the End of Life. Toronto: Doubleday, Canada Miller, Alice (1994) In: The Drama of the Gifted Child The search for the true self. New York: Basic Books. p 7 Philip, Neil (1995). The Illustrated Book of Myths: Tales and Legends of the World. New York: Dorling Kindersley, p. 148 Sykes, J.B. (1976) In: The Concise Oxford Dictionary of Current English. Oxford: Oxford University Press. p1246 Untermeyer, Louis (1977) In: New Enlarged Pocket Anthology of Robert Frost’s Poems. New York: Washington Square Press. p 223 Wilber, K. (1983) In: Eye to Eye The Quest for the New Paradigm. New York: Anchor Press, Doubleday. p 77-78 |
 |
info@wsava.org
Copyright WSAVA |
