Historical Changes Affecting End-of-Life Care
Conclusion
Common Challenges at the End of Life
End-of-Life Tasks and Decisions
Futility
Advance Care Directives
Terminology, Definitions, and Other Barriers to Communication
The Term "Hastened Death"
The Term "Assisted Suicide"
Conclusion
Critical Contextual Issues
Issues of Access and Variability in Health Care at the End of Life
Conclusion
Diversity Issues in End-of-Life Decision-Making
Conclusion
Conclusion to Section One

In 1900, the average lifespan was 47.3 years; by 1997 it had increased to 76.5 years, a gain of 29.2 years in less than a century (Kramarow, Lentzner, Rooks, Weeks, & Saydah, 1999). This overall gain in length of life obscures important differences in longevity across demographic groups. For example, women currently live seven years longer than men do. Among those 85 and older, there are five women for every two men (Bureau of the Census, 1996). An African American woman can expect to live 74 years, compared to 80 years for a European American woman. The estimated life expectancy at birth for African American men is 65 years, as compared to 73 for European Americans (Field & Cassel, 1997). Social class factors, including income and education levels, also affect longevity.

The age distribution of the population in the United States has changed substantially in this century. The number of persons under age 65 has tripled in this period of time while the number of persons 65 or over has jumped by a factor of 11 (Bureau of the Census, 1996). It is particularly noteworthy that the rate of aging of the population is expected to accelerate for the next half century. In 1994, one in every eight persons in the United States was over 65. By the year 2050, the older adult population is expected to more than double, resulting in a ratio of one older adult to five younger persons. The "old-old," those 85 and over, are the most rapidly growing sector of the aged. By the year 2050, people over 85 are expected to make up 24% of older persons and 5% of the entire population in the United States, numbering over 19 million. Today, three-fourths of those who die annually are older adults. Assuming continued increases in longevity, the proportion of those who die past age 75 will also increase (Field & Cassel, 1997).

The causes of death have also changed dramatically. In 1900, the ten leading causes of death were pneumonia, tuberculosis, diarrhea and enteritis, heart disease, stroke, liver disease, injuries, cancer, senility, and diphtheria (Centers for Disease Control and Prevention, 1999). Most people died from infectious illnesses that caused death with certainty and relative rapidity. By 1998, the ten leading causes were heart disease, cancer, stroke, chronic lung disease, pneumonia and influenza, accidents, diabetes, suicide, kidney disease, and chronic liver disease (Martin, Smith, Mathews, & Ventura, 1999). Thus, the contemporary list includes only two causes of death (accidents and suicide) that lead to a quick death. It has been estimated that 70-80% of people in advanced industrial nations now face death later in life from chronic or degenerative diseases characterized by late, slow onset and extended decline (Battin, 1996).

The location where death typically occurs has also changed, moving from the home to technologically sophisticated and often impersonal settings. It has been estimated that in the United States nearly 60 percent of all deaths occur in hospitals or medical centers. Another 16 percent occur in other institutions, such as nursing homes or hospices (Benoliel & Degner, 1995). Only a minority of people die in the care of formal hospice programs, and the majority of these hospice deaths involve cancer diagnoses. More recently, the proportion of those who die at home has begun to increase because changes in Medicare benefits have led to increased availability of home hospice services (Field & Cassel, 1997).

The timing of an individual's death has also changed. As the dying process and death have moved from taking place at home to medical settings, professionals have exerted more control over the timing of dying. Technology now permits life to be greatly extended. It appears that in a growing number of terminal cases medical decisions are made to withhold or withdraw treatment (Field & Cassel, 1997).. In 1992, it was estimated that 70 percent of the 6,000 deaths that occur daily in the United States are somehow timed or negotiated with family, doctors, and the dying person when competent, quietly agreeing to not use death delaying technology (In re L.W., 1992).

Scientific advances in medicine have produced an expanded array of interventions that present individuals, families, and health care professionals with an increased number of very difficult decisions about the timing and course of the dying process. This change has resulted in an expanded role for bioethical review teams in many clinical settings. In 1983, one percent of all medical facilities in the United States had ethics committees and/or multidisciplinary teams that served to oversee difficult medical decisions. By 1993, the American Hospital Association estimated that 60-85% of hospitals had ethics committees (Webb, 1997).

The life-extending potential of medical interventions has also led to the development of a whole new body of end-of-life laws. All 50 states have addressed end-of-life issues either by legalizing some form of advance directive or by enacting alternative provisions for end-of-life decisions in the form of family consent, surrogacy, or succession laws that do not require a document to be signed prior to loss of competence. Although it is beyond the scope of this report to detail all of the changes in end-of-life legislation, three recent legal developments are worth noting because they have widespread significance for end-of-life care and they continue to be the focus of high-profile debates in both politics and the press. One is The Oregon Death with Dignity Act, which was first implemented in 1997 and permits physician-assisted suicide under limited, carefully specified conditions. The second one are the rulings of the U.S. Supreme Court, in June of 1997, that there is no constitutional right to physician-assisted suicide and that states are free to decide whether they wish to legalize this practice (Vacco v. Quill, 1997; Washington v. Glucksberg, 1997). The last one is The Pain Relief Promotion Act, introduced in the United States Congress in 1999. If enacted, funding for training in palliative care would be provided but physicians would be in violation of the Federal Controlled Substances Act if they prescribed or administered opioids, barbiturates, or other controlled medications with the purpose of helping a person to die. Thus, passage of The Pain Relief Promotion Act would functionally negate the Oregon law and prohibit other states from enacting similar laws.

Changes in public attitudes about participation in medical decision making and about seeking help from mental health professionals are likely to produce corresponding changes in expectations about end-of-life care. In the past two decades, there has been an increased demand by individuals and families for active participation in medical decision making, especially among well-educated and middle class populations. With the coming of age of the baby boom generation, larger numbers of people in the United States have come to accept mental health services as an important resource for dealing with difficult decisions and emotionally challenging situations. These shifts in attitude, combined with the fact that the baby boom generation is increasingly dealing with end-of-life care for their parents and the prospect of their own mortality, suggest the likelihood of an increasingly sophisticated demand for psychosocial services in dealing with end-of-life decisions.

Sweeping advances in public health, biomedical sciences, and clinical medicine over the course of the twentieth century have dramatically altered the ways in which people die in the United States. During the last 100 years there have been changes in longevity as well as in patterns, causes, and places of death. In some respects these changes "have made living easier and dying harder" (Field & Cassel, 1997, p. 14). More effective treatments may significantly extend life but may also confront dying individuals, their families, and health care providers with a prolonged period of dying that involves complex choices about end-of life care. These changes have resulted in the need to address end-of-life decision-making from many perspectives including medical, legal, ethical, moral, spiritual, economic, and psychosocial dimensions. There is likely to be an increasingly sophisticated demand for psychosocial services in dealing with end-of-life decisions. Furthermore, the specific issue of assisted suicide promises to become one of the most contentious and difficult social issues of our time.

As people approach the end of their lives, they and their families commonly face tasks and decisions that include a broad array of choices ranging from simple to extremely complex. They may be practical, psychosocial, spiritual, legal, existential, or medical in nature. For example, dying persons and their families are faced with choices about what kind of caregiver help they want or need and whether to receive care at home or in an institutional treatment setting. Dying persons may have to make choices about the desired degree of family involvement in caregiving and decision-making. They frequently make legal decisions about wills, advanced directives, and durable powers of attorney. They may make choices about how to expend their limited time and energy. Some may want to reflect on the meaning of life, and some may decide to do a final life review or to deal with psychologically unfinished business. Some may want to participate in planning rituals before or after death. In some religious traditions, confession of sins, preparation to "meet one's maker," or asking forgiveness from those who may have been wronged can be part of end-of-life concerns. In other cultural traditions, planning or even discussing death is considered inappropriate, uncaring, and even dangerous, as it is viewed as inviting death (Carrese & Rhodes, 1995).

All end-of-life choices and medical decisions have complex psychosocial components, ramifications, and consequences that have a significant impact on suffering and the quality of living and dying. However, the medical end-of-life decisions are often the most challenging for terminally ill people and those who care about them. Each of these decisions should ideally be considered in terms of the relief of suffering and the values and beliefs of the dying individual and his or her family. In addition, any system of medical care has its own primary values that may or may not coincide with the values of the person. For example, in most Western medical systems the principles of individual autonomy (though not to the exclusion of family members and intimates) and informed consent are primary. In contrast, many cultures eschew the principle of autonomy and the principle of interactive, community decision-making is thought to be the ideal. Therefore, well-intentioned presentations of treatment or care possibilities by health care providers may overlook a particular person's wish not to discuss death.

Perhaps the most difficult decisions confronting people at the end of life are those about discontinuing life-extending treatment. Frequently, in the course of caring for a critically ill person, it may become apparent that further intervention will only prolong the dying process and not improve quality of life. Decisions to withhold or discontinue treatment are determined by a variety of factors, including judgments of medical futility and the emotional status and coping styles of the family members and the dying person. At that point, additional treatment is often described as futile. The concept of medical futility takes shape in sociocultural and interpersonal contexts, and conflicts about whether a situation is futile may arise for several reasons. Family members may disagree about future treatment or may oppose the physician's recommendation to discontinue life support. The physician may want to continue treatment and be opposed by either the family or other medical professionals. Legal or ethical issues may also play a role in the decision to stop or maintain life supports. Issues of resource allocation can also influence judgments of futility and life-extending care. Some argue that discontinuation of futile care is good for individuals, families, and society. Others have countered that costs may be a primary motive behind assessments of futility, which disproportionately discriminates against dying persons with limited resources.

Because decisions concerning futility often involve people who lack the capacity to understand their medical situation or communicate their wishes, there has been a movement to encourage everyone to create advance directives about their medical care while they are still competent. The intention is that by getting a person's desires about end of-care in writing or by designating a health care proxy, the complexities of making decisions when the dying person's judgment is impaired by the physical and emotional effects of the illness would be reduced. Examples of advance care directives include descriptions of circumstances in which treatment should be received or refused, what extraordinary measures (if any) should be taken to preserve life, and what kind of pain management is wanted. Some of these decisions may impact the time of death but they generally call for widely accepted, legal components of end-of-life care, such as withholding or withdrawing life-sustaining treatments.

It is important to note that advance directives are not without their problems or limitations. Some of the common issues cited in the literature include:

• Few people prepare advance directives, in part because of a generalized reluctance to face death;
• Even if people do have them, their wishes may not be followed;
• The kind of planning for death which is required in advance directives goes against the values of many cultural and religious communities, including the perceived duties of dying persons and their families;
• Individual preferences for life-sustaining medical treatments are only moderately stable within the short term (up to six months) and are even less stable over longer periods;
• Healthy individuals appear to be unable to predict their own preferences under states of impaired health;
• Substantial fluctuations in the will to live have been documented in terminally ill people in palliative care settings;
• Among the factors that appear to play a role in the refusal of life sustaining treatments are depression and family support;
• Concerns about costs influence the preferences of individuals and family members about life-extending measures.

Health care providers must be sensitive to the limitations of an advance directive for a particular individual over time, the need for ongoing exploration of the desires and needs of dying people and their loved ones, and the likelihood that such directives may be in conflict with some people's values and traditions.

Discussions about end-of-life issues can be difficult for many reasons. First, dying and death are not openly discussed in many cultures. Second, the rapid pace of change in medical technology has made it difficult to develop a standard terminology for discussing dying and death. Third, dying and death are so rooted in cultural customs and individual beliefs and behaviors that a universal vocabulary has not evolved. The same words have different meanings to different people. Fourth, issues of life and death are deeply personal, tapping our most basic human values.

Discussion about end-of-life decisions are particularly difficult because of a lack of consensus about descriptive terminology. Different words may be used by different writers for the same concept, or the same terminology may be used but with a variety of meanings. In order to clarify the meaning of key words used in this report, a glossary has been included in Appendix C. Many of the terms in it are straightforward and utilized in a relatively uniform and systematic way in the literature. Other terms are used selectively to frame arguments or positions. Roy and McDonald (1998) have noted that the language used to describe end-of life decisions that shorten or do not prolong life can "signify opening moves in a moral debate" (p. 123). Two commonly used terms that frequently generate confusion or controversy are "hastened death" and "assisted suicide."

Some authorities believe that the psychosocial, cultural, medical, and ethical issues associated with all end-of-life decisions affecting the time of death are similar. They use the term "hastened death" to refer to a variety of interventions including voluntary cessation of eating and drinking, withholding and withdrawing life-sustaining treatment, the double effect phenomenon, terminal sedation, assisted suicide, and voluntary (but not involuntary) euthanasia (Cantor & Thomas, in press). Others limit the term to include only double effect, terminal sedation, and assisted suicide (Alpers & Lo, 1999). Still others use the term to include only assisted suicide and euthanasia (Block & Billings, 1998). Others do not use the term at all but prefer to describe the specific intervention under discussion.

Differences in the use of the term "hastened death" arise from disagreements about what types of interventions can rightfully be likened to others. For example, some would argue that withdrawing life sustaining treatment can be placed on the same continuum as assisted suicide because they both speed up the dying process. Others would argue that to place such terms under the single rubric of hastening death creates an unacceptable perception of permissibility for certain interventions like assisted suicide that should never be allowed. In this view assisted suicide is sharply distinguished from "letting the person die" from the underlying disease process by, for example, withholding or withdrawing treatment. In general, differences in use of the term hastened death represent different views about what types of interventions are permissible under what circumstances as well as different views about the potential for abuse associated with different end-of-life interventions.

In the United States, the term "assisted suicide" commonly refers to situations in which people with incurable, and ultimately terminal, illnesses, request the help of others in ending their lives. Assisted suicide has been defined by the American Association of Suicidology (1996) as "the deliberate and knowing provision of information, the means, and/or help to another person for an act of suicide" (p. 6). Those who reject the use of the word "suicide" in end-of-life contexts focus on at least two major points. First, they argue that the use of the term may be an inappropriate extension of the model of suicide (Sullivan & Youngner, 1994). According to this view, "the cutting short of a viable life, as generally connoted by the term 'suicide', differs from a terminally ill patient's attempt to exercise some control over their dying process" (Farrenkopf & Bryan, 1999, p. 245). They suggest that the traditional view of suicide as a self-destructive act that is motivated primarily by emotional distress or psychopathology does not apply to all situations in which a terminally ill person wants to exercise control over the timing and manner of death. A second argument of those who do not like the term is that most of the suicidology literature is based on the contention that all people who want to die have significant psychopathology and should be prevented from dying (Society for Health & Human Values, 1995). Those who argue against the use of the term "assisted suicide" point to evidence that indicates that some decisions to die are not motivated by clinical depression or other psychopathology (MacDonald, 1999). Third, in general, those who view helping an incurable, terminally ill person to die as a legitimate issue to be considered along with other end-of-life decisions believe that using the word "suicide" in the end-of-life context may negatively bias discussion and decision-making. For example, The Oregon Death with Dignity Act (1995) states that "under the Act, ending one's life in accordance with the law does not constitute suicide." The Act specifically prohibits euthanasia, where a physician or other person directly administers a medication to end another's life.

Those who prefer the term "assisted suicide" in the context of end of-life decision-making see the action as qualitatively different from other medical decisions that may affect the time of death. First, they assert that the suicide prevention model is applicable even at the end of life since there is evidence that terminally ill people who want to die are clinically depressed (Chochinov et al., 1995, Canetto & Hollenshead, 1999). They hold that the term "assisted suicide" carries implications for prevention and promotes caution in responding to requests. Second, they argue that incurability and terminal status are hard to diagnose definitively. Third, they argue that requests for assisted suicide can almost always be addressed by exploring and treating unmet needs of dying people (Emanuel, 1998). They point out that there are higher costs associated with decisions leading to death because they are irreversible and subject to abuse and to medical error. Fourth, some equate assisted suicide with killing. Therefore, they believe that using the term assisted suicide or physician-assisted suicide is the most accurate descriptor that does not obscure, embellish, or use euphemisms for what is happening.

This report does not take a stand on any of the views described above. However, the term "assisted suicide" is used in this report because it is widely used in the medical, legal, psychological, and popular literature to describe the voluntary self-administration of medication for the purpose of ending life (Sullivan, Hedberg, & Fleming, 2000b) and thus it is well-understood.

End-of-life decision-making subsumes a broad array of medical, psychological, existential, spiritual, legal, family, and economic decisions. Words shape debate, discussion, attitudes, and public policy. Even when well-meaning people try to be neutral in presenting material, word choice can unintentionally bias thinking and debate. The discussion above and the definitions included in the glossary of this report are intended to provide as much clarity as possible in an area that is complex and often emotionally charged and highly politicized.

A thoughtful discussion of issues at the end of life requires consideration of the social, economic, and cultural contexts in which these issues unfold. In the United States, unique dilemmas in end-of-life decisions are created by a combination of a lack of a national health care system and the social, economic, and cultural diversity of the country's population.

The national debate about end-of-life care typically focuses on choices about treatment options and about who has the right or expertise to make the choices. This debate assumes that people have options about their care. Although the medical system in the United States offers excellent care choices, the options are largely available only for those who have money or are insured. Individuals who do not have access to private health care insurance often suffer from insufficient and/or poor quality care. Most of the uninsured are older women, children, and ethnic minorities. Access to life-extending medical technology is similarly a function of resources. Higher income individuals are more likely to have a private attending physician, which is related to maintenance of life sustaining care (Mishara, 1999). As noted by Field and Cassel (1997), "people may have the theoretical right to make their own medical choices, but many do not have the financial access to minimal care necessary for implementation of those choices" (p. 48). It should be noted that concerns about costs also influence the preferences of individuals and family members about life-extending measures (Covinsky et al., 1996).

Even when dying people have access to medical care, the quality of care is highly variable and less than desirable. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT Principal Investigators, 1995) conducted from 1989 to 1994 is the most massive research effort to date associated with the process of dying in America. The study tracked some nine thousand people with various serious and terminal illnesses during the final stages of their life. It also included a large slice of the medical establishment, involving interviews with some 1600 physicians, 500 nurses, and many other health care professionals at numerous prestigious medical institutions. In Phase I of the study, researchers examined how people were treated when they entered the hospital, how medical decisions were made, and what happened to them and their families during the acute treatment period and for six months afterward. Findings from the study were quite dramatic:

• Half of the people who were still conscious had moderate to severe pain at least half of the time before they died;
• More than half of the doctors in the study did not know about their patients' preferences for life-sustaining treatment;
• Nearly 40% of the individuals spent at least 10 days in an intensive care unit.

In Phase II of the study, a number of interventions were put in place that a large panel of experts on end-of-life medicine and law thought would change treatment patterns and make the process of dying more comfortable. In the end, those patients who received the interventions were treated the same as those patients for whom no such efforts were made.

In the United States there are serious inequities in access to medical care, based on income and paid labor history, so that technological advances in medicine are not uniformly available to all segments of the population. Women, children, and ethnic minorities are over-represented among the poor and uninsured and they have fewer health care options available to them. Even when there is access to care, findings from the SUPPORT study suggest that many people may suffer from under-treated pain and that physicians are often unaware of their patient's preferences for life-sustaining treatment.

In the United States, the dominant discourse about illness, dying and death focuses on autonomy, independence, self-control, and individual choice. The health care system reinforces this individualistic focus through the legal structures of advance directives and informed consent. This focus on the individual and on planning for death presupposes a particular situation and assumptive world that include the following elements:

• the individual is the primary decision-maker;
• the individual has an interest in being in charge;
• there is a clear communication and understanding between the individual and the medical team about diagnosis, prognosis, and options;
• the individual has equal financial access to the different options offered;
• the individual has the power and sense of entitlement to make whatever choice is desired;
• the individual is competent to make choices;
• the individual values discussing and planning for death;
• the individual has a spiritual orientation that does not emphasize divine interventions, and allows for choice in time and manner of death (Koenig, 1997).

There are many people in the United States for whom at least some of these conditions do not pertain. The model above is particularly inadequate to account for the experiences and values of persons who are in one way or another culturally different or socially disadvantaged. This includes ethnic and religious minorities for whom individual decision making is not a priority. Persons who are economically disadvantaged also do not fit the conditions of an end-of-life model that assumes equal access to different options. The same may be true of persons with disability. In fact, a social or minority model for conceptualizing disability may be more suitable than the medical model because many of the barriers that confront disabled people are of social origin, involving widespread devaluation of this particular form of diversity.

Social and cultural groups vary with regard to beliefs and opinions regarding end-of-life decision-making. This includes the appropriateness of talking about and planning for death, informing persons that they are dying, and the roles of the individual, family members, and physicians regarding end-of-life decisions. These groups also vary in even more basic dimensions (such as orientation to the future, conceptions of the self and personhood, and beliefs about the rights of the individual) that may have implications for end-of-life decision-making. In addition, individual differences within social groups can be as great as, or greater than, differences between groups because individuals are often exposed to multiple and sometimes contradictory systems of values. Similarly, individuals from the same demographic group do not all think the same way. Another variable is that group experiences and the system of values affecting attitudes and behavior are not fixed. Rather they are constantly evolving within specific social and historical contexts. Finally, diversity factors do not apply to minorities only, and are relevant not only to individuals and their families, but also to professional care providers (Koenig, 1997). Diversity considerations are therefore critical in developing a psychological agenda for end-of-life issues, especially in a demographically diverse and socially stratified country like the United States.

A diversity perspective shows that the ethical and practical questions that have dominated the national debate on the end of life are not universal concerns. For example, persons of Chinese descent may place a value on protecting the dying person from negative information (Hallenbeck, Goldstein, & Mebane, 1996), and therefore may not discuss impending death with the dying person. Similarly, family dynamics in recent immigrants from Mexico or Korea may tolerate less individual autonomy than is permitted in families of European or African descent that have not recently immigrated (Field & Cassel, 1997). In addition, in many cultural and religious traditions, there may be an expectation that women rely on the authority and advice of male authorities (e.g., family members, professionals, etc.) for decision-making. In some traditions, there may also be an expectation of women's self-sacrifice (Wolf, 1996). Further, planning about dying is contrary to traditional Navajo values, particularly the value of "avoiding thinking or speaking in a negative way ('doo'ajíniidah')" (Carrese & Rhodes, 1995, p. 828). In this tradition, discussion of negative information is harmful in that it may bring about a feared negative outcome. Finally, among some ethnic minorities, longevity may be an intrinsic good, independent of health status.

Studies have found that African Americans and Hispanics are more likely than European Americans to express a preference for life sustaining treatment, regardless of the state of the disease, and independent of educational level (Caralis, Davis, Wright, & Marcial, 1993; Morrison, Zayas, Mulvihill, Baskin, & Meier, 1998). These preferences may be related to negative experiences with the medical system (including inadequate care, as well as difficulties in negotiating their needs), leading to a lack of trust in professional advice (Hallenbeck et al., 1996; Koenig, 1997).

Further examples of diverse positions that are socially based include people in the disability community, who express serious concern about sanctioning assisted suicide. A common attitude among the non disabled indicates that some would rather be dead than disabled, which, taken in the context of medical-industry emphasis on cost savings, could lead to withholding critical services to people with disabilities. Such concerns regarding the effects of devaluation and cost-saving strategies are also highly relevant to other disenfranchised groups such as people suffering from alcohol and drug abuse or dependence.

Issues of social, economic, and cultural diversity become even more critical in decisions that may affect the timing of death. In the United States, no matter how carefully any safeguards are framed, such decisions are practiced in a context of social inequality, bias, and unequal access to services. In regard to assisted suicide and euthanasia, it has been argued that the persons who are the most vulnerable to coercion or abuse are those "whose autonomy and well-being are already compromised by poverty, lack of access to good medical care, or membership in a stigmatized social group" (New York State Task Force on Life and the Law, 1994, pp. vii-viii). This argument has been extended to include all types of end-of-life decisions (Canetto & Hollenshead, 1999; Orentlicher, 1997). Older persons, women, religious and ethnic minorities, sexual minorities, and persons with disabilities who are seriously ill, may be particularly likely to be perceived as burdensome by the medical system. Furthermore, they may also have a lower sense of entitlement to resources, and may come to see themselves as appropriate candidates for an accelerated death.

In a diverse society with a variety of social and cultural values as well as a history of unequal access to medical care, issues surrounding dying and death become more complicated than in more homogeneous societies. Those working with dying persons and their families must be aware of the enormous inequities in access to and quality of health care and of the influence of profound differences in beliefs, values, and self concepts of disenfranchised people on end-of-life decision-making.

This section reviewed the impact of medical technology and biomedical advances that have dramatically altered how people experience the dying process and dying; the impact of terminology on end-of-life discussions; the unequal access to, and degree of responsiveness from, the U. S. health care system; and, the critical impact of the wide range of every kind of diversity in our culture. All these factors will inevitably affect the quality of living and dying for everyone in the United States. Psychologists are particularly well-suited, by virtue of their discipline and their specialized skills to assess and work with the psychosocial aspects of these challenging realities.

Introduction
Section 1 | Section 2 | Section 3 | Section 4
References
Appendix A | Appendix B | Appendix C
Appendix D | Appendix E | Appendix F
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