text: Organ Donation and ProcurementGrief, Stress, Trauma, and Support During the Organ Donation ProcessDicks, Sean G. MA1,2; Burkolter, Nadia MNursing2; Jackson, Lyndall C. GradCertMNursing and GradCertNursing Nursing2; Northam, Holly L. PhD1; Boer, Douglas P. PhD1; van Haren, Frank M.P. PhD1,2,3Author Information 1Faculty of Health, University of Canberra, Canberra, ACT, Australia. 2Canberra Health Services, Canberra, ACT, Australia. 3School of Medicine, Australian National University, Canberra, ACT, Australia. Published online 12 December, 2019. Received 30 April 2019. Revision received 21 October 2019. Accepted 22 October 2019. The authors declare no conflicts of interest. All the authors made significant contributions to the manuscript. S.G.D. developed the original plan and applied for a Research Support Grant. S.G.D. and N.B. contributed to further development of the plan and identification of literature search criteria. S.G.D. conducted the electronic search, and S.G.D., N.B., and L.C.J. screened sources and reviewed reference sections and citation histories to identify further sources. S.G.D. iteratively drafted and redrafted the manuscript in response to input from all other authors and later in response to comments made by anonymous reviewers. PhD supervisors (H.L.N., D.P.B., and F.M.P.V.) provided input and guidance throughout the abovementioned process. S.G.D., N.B., and L.C.J. acknowledge the receipt of an Allied Health Research Support Grant from the Australian Capital Territory Health Directorate (ACT Health). Australian Capital Territory (ACT). S.G.D. acknowledges that, as a PhD candidate, support was received through an Australian Government Research Training Program Scholarship. Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.transplantationdirect.com). Correspondence: Sean G. Dicks, PhD Candidate, Department of Psychology, University of Canberra, GPO Box 2148, Canberra, ACT 2601, Australia. (firstname.lastname@example.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Transplantation Direct: January 2020 - Volume 6 - Issue 1 - p e512 doi: 10.1097/TXD.0000000000000957 Open SDC Metrics Abstract The organ donation process is complex and stressful for the family of the potential donor and members of the multidisciplinary team who may experience grief, ethical dilemmas, vicarious trauma, or compassion fatigue. Several studies each explore the role of a specific healthcare group and the impact of inhospital processes on group members. We conducted a systematic literature search to identify such studies and a qualitative synthesis to consolidate findings and highlight features of the interaction and relationships between role players. Our results suggest that, while healthcare professionals have different roles, attitudes, and views, the experience of stressors and interdisciplinary tension is common. Nevertheless, staff are united by the goal of caring for the patient and family. We therefore propose that, while focusing on bereavement care and other aspects of the family's experience, staff can find other shared goals and develop understanding, trust, empathy, and respect for each other's positions, thereby improving functioning in the complex adaptive system that forms at this time. Education and training can equip staff to facilitate anticipatory mourning, family-led activities, and a meaningful parting from their relative, assisting families with their grief and increasing staff members' efficacy, confidence, and interdisciplinary teamwork. Knowledge of systems thinking and opportunities to share ideas and experiences will enable staff to appreciate each other's roles, while supportive mentors, self-care strategies, and meaningful feedback between role players will foster healthy adjustment and shared learning. A focus on psychosocial outcomes such as family satisfaction with the process, collaboration within the multidisciplinary team, and reduction in the role stress of healthcare professionals will contribute to family well-being as well as personal and professional growth for staff. Participation in the ad hoc system forming when a potential organ donor is identified is stressful for families facing an unexpected death in an unfamiliar environment1-3 and for healthcare professionals (HCPs) who provide medical care, information, and emotional support.4,5 Before considering organ donation, family members must accept that their relative is brain dead, making donation possible via the donation after brain death pathway,6,7 or that further medical treatment would be futile in the case of the potential to donate organs after withdrawal of cardiorespiratory support and circulatory death (the donation after circulatory death [DCD] pathway).8 Consenting families must also accept that medical and logistical factors may nevertheless prevent organ donation.9 Inhospital events influence HCPs10 and family grief11-19 regardless of the donation decision.20-22 Family and staff well-being must therefore be monitored, and practices that are theoretically grounded and empirically validated23 should be implemented to assist family members11,24 and HCPs.10,25-28 However, although much research explores the donation request process,29-32 bereavement care has received less attention.21,33,34 Consequently, while expressing confidence in task-oriented aspects of this context, staff often report uncertainty when providing emotional support22,35 or managing their own grief.10,36,37 Factors influencing inhospital outcomes include staff knowledge and attitudes,38 suggesting that the content of university courses is important;39 policies and procedures, suggesting that policy makers play a role;38-40 and medical aspects of the particular admission.41 We will not explore these factors in detail but rather focus on psychosocial experiences of HCPs involved during the inhospital process. The terms HCPs or staff will be used when content refers to several roles, and specific roles will be named when this is appropriate. According to a complex adaptive system (CAS) framework, dynamic systems cannot be understood by exploring individual roles alone. Therefore, we assume that links and interaction between role players influence emerging properties and outcomes.42-47 AIM We aim to foster empathy and understanding of the impact that processes have on HCPs playing different roles in the CAS. We will also demonstrate that it is useful to view this context through the lenses of grief and systems theory, and we suggest leverage points that could enhance staff well-being and system functioning. We hope to encourage those working in this field to reflect on the impact that the context has on them and the impact of their actions on the experiences of others.Box 1: Summary of our method and findings Rather than selecting studies adhering to strict predetermined criteria and then evaluating the methods, analysis, and findings, we selected diverse sources focused on the experiences of various HCPs at the time of the potential for organ donation. Data from these sources were blended to create an informative narrative to provide readers with empathic understanding of challenges faced in this context. Thematic analysis identified 6 themes and highlighted 3 leverage points, which can assist role players to optimize functioning and coping in the ad hoc system that forms when a potential organ donor is identified.MATERIALS AND METHODS A systematic literature search identified sources describing the participation of several role players in the organ donation context. Sources describing HCP experiences of inhospital stress, grief, family care, and staff care were selected, while those focusing on raising awareness of technical or medical aspects were excluded. Our synthesis differs from a standard systematic review in that it aims to contribute to empathetic understanding of the system rather than a critical appraisal of studies or consolidation of what is known about prespecified variables. Projects such as the Organ Donation Collaborative in the United States of America,48 the Organ Donation Taskforce in the United Kingdom,49 and the Organ and Tissue Donation Authority in Australia50 currently shape the international organ donation context. We therefore sought sources published between 2010 and 2018 to capture present understanding and practice. However, while several sources published during this period explore experiences of medical and nursing staff, fewer were found addressing participation of nonmedical staff. Therefore, sources addressing experiences of allied HCPs were included if published between 2000 and 2018. An electronic search identified 662 sources, and 53 that were known to authors were added. After removing duplicates and screening titles, abstracts, and full-text copies, 63 sources remained. Another 15 were identified by searching reference sections and citation histories. While drafting the manuscript, search alerts were left active, contributing to the identification of 6 new articles and a total of 84 sources (see Figure S1, SDC, http://links.lww.com/TXD/A229). These include original research articles, book chapters, systematic reviews, case studies, PhD theses, best practice guidelines, and editorial comments (see Table S1, SDC, http://links.lww.com/TXD/A230). We used the criteria of credibility, dependability, and transferability to evaluate our manuscript.51 The literature search identified a rich dataset consisting of multiple, relevant peer-reviewed sources that met inclusion criteria. We then developed a credible narrative that reflects the findings of those sources. This narrative and our later discussion can be traced to the selected sources using the citations provided, thereby demonstrating dependability. Dialogue within the multidisciplinary authorship team ensured congruence between this narrative, current practice and HCP experiences, thereby increasing transferability. The narrative style of the "RESULTS" section enables readers to become familiar with the literature without our interpretations so that they may judge the appropriateness of our synthesis and recommendations that are presented in the "DISCUSSION" section. RESULTS After highlighting the relevance of preexisting psychosocial factors, HCPs' experiences are explored by following the possible journey of the potential donor and their family through the hospital. We include descriptions of the emergency department (ED), intensive care unit (ICU), and operating theater (OT) and introduce the donation coordinator and support coordinator (who participate across settings) and visiting transplant surgeons at appropriate places. Stressors and opportunities are introduced at logical points without implying that some HCP groups experience these features, while others do not.Box 2: Interaction contributes to the psychosocial context We have included reference to the identification and response to family needs throughout the article, because family reactions and coping styles contribute to the psychosocial context and because assisting the family is consistently described as being important to staff meaning making. Likewise, relationships between different staff groups are described, because these are also significant features of the inhospital environment.Preexisting Psychosocial Factors The event causing death, the deceased's role in the family, family dynamics, culture,52 and other factors influence HCPs' experiences and grief.53-56 Mental associations between HCPs' personal narrative and characteristics of the patient are important, and preexisting capacity to provide and receive support is also relevant.57,58 The ED In emergencies, families hope that arrival at an ED will enable life-saving treatment.59 However, ED physicians will need to inform family members of potential organ donors that their relative will not survive. Physicians may experience an ethical dilemma when they are expected to then refer the family to an organ donation agency.26 Several physicians feel that this creates a dual role, conflicts with their duty of care, and reflects their failure to save the patient.25,26,59-63 In addition, they acknowledge that there is little time for physicians to explore organ donation with families.59,61 To resolve these dilemmas, some adopt a neutral position when mentioning organ donation.26 However, this may contribute to lack of understanding which could harm trust, especially if family members develop a false impression regarding the patient's prognosis and the family's options.59,61 Lack of clarity has also been associated with family ambivalence, regret,58 intrusive thoughts,64 depression,14 complications in bereavement,6,65 and posttraumatic stress disorder.16,66 Some physicians are unwilling to transfer a potential donor to ICU, except after consent for donation has been obtained, while others feel that the patient should be declared brain dead before a referral is made to an organ donation agency.26 These views hinder the opportunity for coordinators to develop relationships with family members and exclude the referral of potential DCD donors. Although some physicians argue that ethical dilemmas are reduced when families raise organ donation themselves,26 researchers warn that families acting based on their relative's preferences or family members' prodonation views alone may underestimate the complexity of the processes.67 Although the situation is complicated, little attention has been given to these challenges.68 Given that physicians cannot know the most suitable way forward on their own, they should assist families to make informed decisions about their relative's death.69,70 It has been argued that clear descriptions of treatment provided, the patient's prognosis, and the family's options,59 delivered by the treating physician and an organ donation specialist, are appropriate.58,71 Explanations provided should balance availability of information and the family's ability to comprehend that information.3,72,73 Because sharing bad news at this time is delicate,74 training is necessary to assist HCPs to respond to the family and manage their own stress.8,62,75-77 Knowledge of crisis intervention techniques would assist HCPs to support family members and colleagues in ways that foster creativity and resilience.58,78,79 Although HCPs identify several ethical issues in this context, families often focus on other matters. Many report that clarity and respectful communication is appreciated, and they therefore feel that someone able to answer questions about processes and options should be present when organ donation is first raised.80 Being present would also be useful to coordinators, because they would know what information was shared with the family, enabling repetition where necessary.3 Family and staff require a palliative care approach that includes addressing their grief.81-85 HCPs must make sense of what happened, understand its significance, and find meaning.86,87 However, with little time to consider options when efforts to save the patient's life were not successful,88 they may struggle to shift their attention to another goal.89 This may explain why, although most physicians express general support for organ donation,8 some are hesitant to refer a potential organ donor.26,61 On the other hand, several families have reported that the transfer to ICU enabled them to buy time, allowing family and friends to arrive, while also providing a last opportunity for their relative's recovery.3,13 This extra time can enable family members and HCPs to come to terms with the situation and make nonreactive decisions.6,90 Family Stressors and Opportunities Consideration of organ donation contributes to stress,3,13,20 especially when family members struggle to comprehend aspects such as brain death or futility of treatment17 or when they do not know their relative's preferences.6 However, because understanding these concepts is critical to their acceptance of their relative's death and their later bereavement, whether they consider organ donation or not, families must be assisted to tolerate this stress while preparing to make informed decisions.3,58,91-93 Research suggests that in a family-centered environment, consideration of organ donation does not negatively impact grief.94 Through conversation, families construct the postdeath identity and biography of their relative95 and contribute to a psychological bond and family narrative.12,86,96 However, many families are spread out geographically and unable to grieve together after leaving the hospital. It is therefore vital to use available opportunities for togetherness at the hospital to foster personal growth97 and appreciation of life.98 HCPs report that assisting families at this time is emotionally and professionally satisfying99 regardless of the pathway or donation decision58,100 or whether medical and logistical factors allow donation.9,72,101 Families report that support contributes to increased hope81,82 and resilience.93,102,103 HCP Stressors and Opportunities HCP grief challenges personal and professional roles37,104 contributing to uncertainty71,105 and evoking tension between concern for the patient's family and the expectation of professional detachment.106 In response, some HCPs may adopt ineffective coping mechanisms including excessive avoidance of grief,107 while others may find a constructive balance between sharing grief with colleagues and managing grief on their own.37 In a complex environment, role players each have a limited view of unfolding events. These horizons mean that individual HCPs cannot observe the family's journey in totality108 and may consequently aim to protect the family from further complexity and themselves from dilemmas such as those described earlier. However, with a holistic understanding and information from trusted sources, HCPs can make a referral for consideration of organ donation knowing that their patient and his/her family will be cared for. For example, referring to a letter received from parents of a young organ donor, a physician describes the value of family feedback: I found myself crying, and still do when I think about that letter. It was honest. It is what we all need. Reaching out to each other to share the joys and the despairs of life. It is the answer to my questions.109 It is vital that HCPs receive support25,110,111 and maintain their mental health, because repeated exposure to traumatic circumstances and death can contribute to compassion fatigue (CF)112,113 and vicarious trauma (VT).114,115 Symptoms associated with CF include exhaustion and decreased compassion,112 while VT involves physical, affective, and cognitive symptoms,115 including nausea, tiredness, insomnia, helplessness, frustration, powerlessness, despair, and the loss of a positive outlook.114 On the other hand, with appropriate support and a positive team culture,116 HCPs can experience vicarious posttraumatic growth characterized by appreciation of life, clear perspectives, being more accepting of others, self-awareness, and empowerment.114 The Donation Coordinator Donation coordinators must be able to make connections,117 show cognitive flexibility, and read nonverbal cues.118 The requester's communication style29-31 contributes to the family's experience119 with an empathic, family-centered approach balancing bereavement care and assisting families to make informed decisions.29 Although links between the donation coordinator and treating team are vital and can contribute to positive relationships and shared responses to challenges,62,120 HCPs have expressed concern that donation coordinators are not always transparent.108 This perception relates to referrals and assessment of the potential donor's suitability being made without family knowledge and to coordinators introducing themselves without disclosing their role.108 Coordinators experience a dilemma in that, to obtain consent to assess suitability for donation, detailed conversations with families would be required, while without some information, it would be unclear whether the discussion with the family was appropriate.117,118 The Support Coordinator(s) HCPs have reported that when their duty of care to the patient and the family seems to contradict hospital or national policies that prioritize identification and referral of potential organ donors, role conflict is experienced.26,121 On the other hand, when referring a family to an organ donation agency, simultaneous referral to a support coordinator can reduce this conflict.122 A palliative care team,123 pastoral carer,6,121 or social worker122 with expertise in crisis management, grief counseling, and resource mobilization could perform this role. Support coordinators can monitor dynamics within and between the family and staff systems and ensure that staff identify and respond to family needs.120-127 Collaboration with a family member or family friend who is less traumatized by the event,18 and therefore able to clarify matters for other family members, can contribute to shared ownership of the process.128 At the same time, linking with key staff members could ensure that staff support needs are met.57,129 To prepare for their roles, support coordinators should learn about the organ donation context and medical aspects of donation after brain death and DCD,121 possibly by means of a simulation.130,131 The ICU To family members and HCPs in the ICU, mechanical ventilation creates the appearance that the patient is merely sleeping. This could contribute to ambiguous loss, where the dying or deceased person seems present but has lost the persona they once had.132 ICU nurses report that caring for a potential organ donor and family members is challenging but also meaningful.27,57,99,121,133 Because HCPs' perceptions and attitudes regarding organ donation influence their decisions and behavior,100 staff should analyze their feelings and values before advising or advocating for families134-138 to ensure that decisions reflect family priorities.3,58,100 When donation has been declined, HCPs can find meaning by assisting the family to create a respectful environment during withdrawal of cardiorespiratory support,99 while when families consent to donation, it is also vital that HCPs continue to provide support. However, in this busy environment, families have noticed that when ICU staff are overloaded with responsibilities, care of the patient and addressing of the family's practical needs take priority, leaving little time for attention to emotional needs.139 Some consenting families prefer to part from their relative before surgery, while others appreciate assistance to create a meaningful farewell after surgery. This highlights the importance of awareness and respect for family needs and preferences.13,140 HCPs should also be encouraged to say their goodbyes to the patient and their family,57 acknowledging the emergence of shared experiences and hopes in this context.81 The OT Assisting during organ retrieval surgery can be difficult for OT nurses.141 Many feel unprepared and overwhelmed but hide these feelings and receive little support,10,28 while some report disappointment when they are not given the option of declining participation.142 Some OT staff find that meaning based on honoring the preferences of the donor and respecting the family's decision help reduce personal concerns.5,143 Many HCPs feel that they cannot express their grief because of the need to maintain professional boundaries, contributing to disenfranchised grief that is not acknowledged or socially supported.36 In response to concerns that ways of showing respect to organ donors and their families were lacking in the OT, a center introduced a practice where a short family-designed statement was read aloud and followed by a 15-second silence before surgery.144 This intervention assisted OT staff and families to make sense of the context while establishing positive links between families, ICU, and OT.144,145 Transplant Surgeons Transplant surgeons work long, irregular hours, traveling to various hospitals and interacting with unfamiliar OT teams. Compared to other surgeons, they report the highest rates of depression, the most nights on call, and the most hours worked per week (average 69.5 hours).146 These demands can contribute to burnout, emotional exhaustion, and interpersonal stress, leading to surgeons distancing themselves from others.146 This correlates with OT nurses' descriptions of visiting surgical teams as disconnected and unsupportive.5,10,28 During donation surgery, surgeons and OT nurses tend to get on with their roles with little interaction or support except when directly related to their respective tasks. Nevertheless, despite stressors experienced, transplant surgeons report high levels of professional satisfaction and active participation in their work.146,147 DISCUSSION Themes extracted from the results section include (1) misunderstanding and the emergence of distrust; (2) multiple settings and the emergence of blind spots; (3) stressors and the emergence of physical, affective, and cognitive symptoms; (4) disenfranchised grief, excessive avoidance of reactions to the patient's death and the lack of avenues for staff support; and (5) excessive task-oriented interaction and the emergence of relationships that lack depth and empathy. The potential for misunderstanding and distrust is shown when policies are seen to value organ donation rather than patient care; when ED physicians are seen to hinder the potential for organ donation by being hesitant to make referrals; when donation coordinators are seen to lack transparency, because they do not fully disclose their role when introducing themselves; and when transplant surgeons are seen to lack empathy when they quickly perform surgery and leave. The multiple settings involved in the organ donation process contribute to blind spots, where role players are unable to see beyond given horizons to grasp the complexities and opportunities inherent in the process as a whole. We have described some of the stressors encountered in this context, including ethical dilemmas, perceived conflicts of interest, ambivalence, ambiguous loss, VT, CF, and burnout, and we have highlighted associated symptoms. While research shows that staff grieve when patients die, included sources highlight HCPs' struggle to balance professional distance, acknowledgement of grief, and emotional expression. Not being able to resolve this struggle can intensify the experience of disenfranchised grief. Excessive task orientation is highlighted when HCPs have difficulty shifting from the task of saving the patient to consideration of other possibilities; when donation coordinators focus on donation-related tasks without showing openness with the treating team; when ICU staff focus on care of the potential donor and miss opportunities for family care; and when transplant surgeons and OT staff focus on surgery while neglecting their relationship or the need for shared meaning. On the other hand, compassionate interaction with the family19,58 and collaboration within the multidisciplinary team4,121 were highlighted as factors crucial to staff members' meaning making and adjustment. This contributes to a sixth theme of personal and professional growth emerging when effective relationships contribute to a supportive environment. We propose that this theme can be activated by (1) offering training that assists staff to balance task orientation with attention to relationships and other psychosocial features of the context; (2) implementing care strategies for staff to improve their ability to cope with grief and role-related stressors; and (3) creating opportunities for feedback and shared learning to foster understanding, trust, and appreciation of the synergistic system. Figure 1 (created using Kumu mapping software, https://kumu.io/) demonstrates how organizational inputs at these 3 leverage points could contribute to immediate outcomes influencing role players' understanding and behavior and emerging outcomes on the level of the system as a whole. Although it is possible to include additional connections between factors or additional factors in our diagram, we feel that for the purposes of clarity, those shown are sufficient. The leverage points are explored in more detail below:FIGURE 1.: Leverage points and expected outcomes.Training to Assist HCPs to Balance Psychosocial Care and Other TasksBox 3: Effective connections contribute to a supportive environment Working in this context can be both stressful, contributing to physical, affective, and emotional symptoms, and rewarding, contributing to professional and personal growth. By monitoring the quality and quantity of connections between members of the multidisciplinary team, HCPs can assist each other to tolerate ambiguities and find novel solutions, contributing to a supportive environment and a balance between psychosocial care and attention to other important tasks.The nature of relationships between role players influences service quality and other emerging outcomes. Seven key characteristics of relationships in successful systems have been identified148,149 as trust; openness to new ideas; attending to relevant tasks while appreciating the impact of one's actions; respectfulness; tolerance of diverse perspectives; relationships based on a blend of personal, social, and work-related dimensions; and using communication that fits (in ambiguous situations face-to-face communication is advised, and language should be clear and jargon free).148,149 To activate these features, reflection, meaning making, and openness to continual learning are also necessary.148-150 Staff should continually ask themselves, "How is this affecting me?" and "How is my behavior affecting others?" Following the death of a relative (and patient), and at other times when there are significant changes in the goals and activities of the system, families (and HCPs) no longer experience stability, and encounter the edge of chaos, where it is necessary to shift goals and hopes. Systems that function successfully on the edge of chaos are neither too stable nor too unstable and can tolerate incongruence while new paths are created and tested. At this time, the quantity of connections between role players, their tasks, and other members of the multidisciplinary team influences system functioning. While systems with too few connections may become stuck and have difficulty adapting, systems with too many connections may experience an overload contributing to the lack of stable patterns.45,151 For example, information sharing between team members may become inconsistent at times when many tasks simultaneously demand attention. This could occur after a family has consented to donation, and nursing care of the potential donor intensifies, while at the same time increased negotiation with transplant teams and OTs is required. Research suggests that for optimal functioning in complex systems, each party should be significantly connected to only 2 or 3 others at a given time152 to reduce the risk of overload or distraction from key tasks and opportunities. Training and resources should equip role players to carefully decide where to invest their attention and effort for maximum benefit, and team members must work together in a sustainable way. For example, support coordinators should play a greater role in relation to the family when donation coordinators and nurses need to attend to logistical priorities but can step back and enable other staff to be involved in family care when this is suitable. Care Strategies for StaffBox 4: Provision of care for staff working in this context is vital Care and support to assist staff to cope with grief and other stressors can be offered on the level of the organization (including training, support groups, and debriefing sessions), the team (including mentoring and emotional support), and by the promotion of individual strategies such as finding meaning in family care, self-reflection, and expression of grief.To create a supportive environment, staff must work collaboratively, support each other,27,153 and access support individually. In addition to reducing the impact of the death on HCPs,5,37,105,141 expression of grief can allow them to function more effectively,36,154,155 increasing professional and personal satisfaction.107 It has been suggested that organizational support, peer or team support, and personal coping strategies are helpful,114,154 especially in response to patient deaths early in a HCP's career.36,106,107 Organizational responses to HCP grief could include assisting staff to manage and diversify their workload, access to flexible scheduling,141 and attending support groups72,114,155 or debriefing sessions.156,157 An important aspect of psychological debriefing sessions is the expertise of the facilitator who should have training in group processes and bereavement care as well as knowledge of the organ donation context.154 Within specific teams, supervisors must receive training to enable them to recognize and respond to HCP grief and stress by offering support or making referrals.100,141 Psychosocial support and a caring mentor foster self-awareness and professional development, assisting HCPs to find meaning in their contribution to patient and family care. Peer support with colleagues who shared the experience is also meaningful.37,141 On an individual level, when compassion is experienced and shown without attachment to an eventual outcome (eg, survival of the patient), HCP adjustment is fostered by the realization that they can make positive contributions even if the patient dies.155 Organizations should provide access to individual counseling independent of the work environment, because social support may not be effective for those dealing with a personal trauma history. Creating Opportunities for Feedback and Shared LearningBox 5: Empathy and understanding between role players enhance outcomes We argue that when members of the multidisciplinary treating team understand each other's actions and stressors, the emergence of trust, empathy, respect, and collaboration will contribute to improved outcomes for all involved. Increased monitoring of psychosocial features relevant to family members and staff is expected to contribute to personal growth and the effectiveness of the system as a whole.Researchers suggest that experiences of staff from different disciplines need to be connected enabling appreciation of the bigger picture,10,44 shared learning,154 empathy, and trust between HCPs.5,154 Trust and empathy would then, in turn, foster collaboration and consistency in relationships.35,60,117,158-161 When organ donation has occurred, a de-identified report about the transplants may assist HCPs' meaning making,27,121,143,157,162 and receiving feedback from the family of the donor about their experience has been found to be valuable.26,100,109,163,164 Family feedback would also be useful when cases do not conclude with consent and organ donation. Sharing information about their experiences can be meaningful for family members too, enabling them to show gratitude for compassionate care, to make sense of their experience, and to contribute to improvement of inhospital processes, thereby helping others.163-165 In addition to promoting improved service delivery, a follow-up meeting can be meaningful for HCPs and family members on a personal level.57 This fits with the view that for vicarious posttraumatic growth to occur, HCPs must be exposed to the family's growth114 and is supported by findings indicating that many family members appreciate meeting HCPs a few months after the death to review inhospital events.166,167 Outcomes of the inhospital process are often measured in terms of consent rate (proportion of families consenting to donation in relation to families approached). However, because this provides a simplistic view,6,91 additional measures are needed to enhance understanding and ensure that adjustment and growth are promoted.4 Outcomes monitored should include interpersonal81 and staff-related factors such as role stress,4 collaboration in the multidisciplinary team, and support provided in response to staff grief.36 The extent to which HCPs have assisted family members to manage acute stress, find hope, and make informed decisions is an important outcome too.20,57,91 Strengths and Limitations This review combined a multidisciplinary authorship team and a wide range of peer-reviewed sources to illuminate the CAS forming when a potential organ donor is identified. The synthesis will assist staff and organizational decision makers to make sense of and respond to grief and stress in ways that foster coping and growth for families and HCPs.168 However, although originating in various countries, only English sources were used, and the impact of culture and religion was not explored. The synthesis is based on a blend of published empirical evidence, theory, and the authors' understanding of the context. Further research is needed to test our hypotheses. Offering bereavement care (for family members and staff) tailored to this unique context emerged as a shared goal in the multidisciplinary team. However, a guiding theoretical framework is required, and the actual nature of a specialized bereavement support program must be determined. The chosen scope of this article included illuminating the links between inhospital factors (such as balancing attention to technical tasks and psychosocial features, providing family support, developing staff confidence, and encouraging collaboration between staff) on the one hand, and staff members' adjustment to the patient's death and their professional roles on the other hand. The effect that these factors can have on the family's ability to cope with the death of their relative and other aspects of the inhospital process was also explored. Studies have demonstrated that support provided by a trained coordinator throughout the inhospital process can contribute to an increase in consent rates too.169,170 We did not explore this connection, and further research could be conducted to determine how the variables and outcomes that we have highlighted are related to consent rates. The scope of the article was also limited to an exploration of inhospital processes. In addition to optimizing this context, researchers highlight the need to understand how events at the hospital influence the bereavement of families in the months that follow,166 including declining families127 and consenting families, where donation did not proceed.11,19,101 Likewise, patient deaths can be expected to influence HCPs for some time after the family has left the hospital. However, the long-term impact of inhospital experiences on family and staff well-being has received little attention,7 and research on follow-up programs is scarce.13 Attention to these areas will improve understanding of family and staff needs and promote improved care for both groups. CONCLUSION The identification of a potential organ donor contributes to a dynamic context that has implications for family members and HCPs. The cause of death, the family's reaction, the need to attend to technical and logistical tasks, and other stressors shape staff members' experiences, potentially increasing the risk of VT, CF, or burnout. This context also contains opportunities for meaning making, purposeful action, and support. Implementing care strategies and empowering HCPs by providing education and training in bereavement care, self-care, and other psychosocial features will contribute to resilience, while appreciation of the systemic nature of inhospital processes will foster shared learning and mutual understanding. We hypothesize that this can empower role players to make nonreactive decisions and respond in ways that fit on the day and contribute to ongoing adjustment. ACKNOWLEDGMENT The valuable input of the anonymous reviewers is acknowledged.REFERENCES 1. Jacoby LH, Breitkopf CR, Pease EA. A qualitative examination of the needs of families faced with the option of organ donation. Dimens Crit Care Nurs. 2005; 24(4):183–189 Cited Here 2. Lloyd-Williams M, Morton J, Peters S. The end-of-life care experiences of relatives of brain dead intensive care patients. J Pain Symptom Manage. 2009; 37(4):659–664 Cited Here 3. Manuel A, Solberg S, MacDonald S. Organ donation experiences of family members. Nephrol Nurs J. 2010; 37(3):229–236. quiz 237 Cited Here 4. Dodd-McCue D. Siegel, J, Alvaro, E. Behavioral research in hospital settings: the family communication coordinator (FCC) protocol and research applications in organ donation. Understanding Organ Donation: Applied Behavioral Science Perspectives. 2010. Chichester, UK: John Wiley & Sons149–163 Cited Here 5. Smith Z, Leslie G, Wynaden D. Coping and caring: support resources integral to perioperative nurses during the process of organ procurement surgery. J Clin Nurs. 2017; 26(21–22):3305–3317 Cited Here 6. de Groot J, Vernooij-Dassen M, Hoedemaekers C, et al. Decision making by relatives about brain death organ donation: an integrative review. Transplantation. 2012; 93(12):1196–1211 Cited Here 7. Kentish-Barnes N, Siminoff LA, Walker W, et al. A narrative review of family members' experience of organ donation request after brain death in the critical care setting. Intensive Care Med. 2019; 45(3):331–342 Cited Here 8. Lee YY, Ranse K, Silvester W, et al. Attitudes and self-reported end-of-life care of Australian and New Zealand intensive care doctors in the context of organ donation after circulatory death. Anaesth Intensive Care. 2018; 46(5):488–497 Cited Here 9. Hoover SM, Bratton SL, Roach E, et al. Parental experiences and recommendations in donation after circulatory determination of death*. Pediatr Crit Care Med. 2014; 15(2):105–111 Cited Here 10. Smith Z, Leslie G, Wynaden D. Australian perioperative nurses' experiences of assisting in multi-organ procurement surgery: a grounded theory study. Int J Nurs Stud. 2015; 52(3):705–715 Cited Here 11. Ahmadian S, Rahimi A, Khaleghi E. Outcomes of organ donation in brain-dead patient's families: ethical perspective. Nurs Ethics. 2019; 26(1):256–269 Cited Here 12. Ashkenazi T, Cohen J. Interactions between health care personnel and parents approached for organ and/or tissue donation: influences on parents' adjustment to loss. Prog Transplant. 2015; 25(2):124–130 Cited Here 13. Berntzen H, Bjørk IT. Experiences of donor families after consenting to organ donation: a qualitative study. Intensive Crit Care Nurs. 2014; 30(5):266–274 Cited Here 14. Cleiren MP, Van Zoelen AA. Post-mortem organ donation and grief: a study of consent, refusal and well-being in bereavement. Death Stud. 2002; 26(10):837–849 Cited Here 15. Jensen A. Searching for meaningful aftermaths: donor family experiences and expressions in New York and Denmark. Sites. 2011; 8(1):129–148 Cited Here 16. Kesselring A, Kainz M, Kiss A. Traumatic memories of relatives regarding brain death, request for organ donation and interactions with professionals in the ICU. Am J Transplant. 2007; 7(1):211–217 Cited Here 17. Sque M, Payne SA. Dissonant loss: the experiences of donor relatives. Soc Sci Med. 1996; 43(9):1359–1370 Cited Here 18. Sque M, Long T, Payne S. Organ and Tissue Donation: Exploring the Needs of Families. Final Report of a Three-year Study Commissioned by the British Organ Donor Society, Funded by the National Lottery Community Fund. 2003. Southampton: University of Southampton Cited Here 19. Walker W, Sque M. Balancing hope and despair at the end of life: the contribution of organ and tissue donation. J Crit Care. 2016; 3273–78 Cited Here 20. Manzari ZS, Mohammadi E, Heydari A, et al. Exploring families' experiences of an organ donation request after brain death. Nurs Ethics. 2012; 19(5):654–665 Cited Here 21. Smudla A, Hegedűs K, Miháy S, et al. The HELLP concept - relatives of deceased donors need the help earlier in parallel with loss of a loved person. Ann Transplant. 2012; 17(2):18–28 Cited Here 22. Smudla A, Mihály S, Okrös I, et al. The attitude and knowledge of intensive care physicians and nurses regarding organ donation in Hungary–it needs to be changed. Ann Transplant. 2012; 17(3):93–102 Cited Here 23. Thirsk LM, Moules NJ. "I can just be me": advanced practice nursing with families experiencing grief. J Fam Nurs. 2013; 19(1):74–98 Cited Here 24. Kim HS, Yoo YS, Cho OH. Satisfaction with the organ donation process of brain dead donors' families in Korea. Transplant Proc. 2014; 46(10):3253–3256 Cited Here 25. Kentish-Barnes N, Duranteau J, Montlahuc C, et al. Clinicians' perception and experience of organ donation from brain-dead patients. Crit Care Med. 2017; 45(9):1489–1499 Cited Here 26. Macvean E, Yuen EY, Tooley G, et al. Attitudes of intensive care and emergency physicians in Australia with regard to the organ donation process: A qualitative analysis [published online April 4, 2018]. J Health Psychol. doi: 10.1177/1359105318765619 Cited Here 27. Pelletier-Hibbert M. Coping strategies used by nurses to deal with the care of organ donors and their families. Heart Lung. 1998; 27(4):230–237 Cited Here 28. Smith Z, Leslie G, Wynaden D. Experiential learning not enough for organ procurement surgery: implications for perioperative nursing education. Prog Transplant. 2015; 25(4):339–350 Cited Here 29. Anker A. Laurie, MA. Critical conversations: organ procurement coordinators' interpersonal communication during donation requests. Organ Donation and Transplantation. 2013. USA: Nova Science Publishers189–221 Cited Here 30. Siminoff LA, Traino MH, Genderson WM. Communicating effectively about organ donation: a randomized trial of a behavioral communication intervention to improve discussions about donation. Transplant Direct. 2015; 1(2):1–9 Cited Here 31. Siminoff LA, Marshall HM, Dumenci L, et al. Communicating effectively about donation: an educational intervention to increase consent to donation. Prog Transplant. 2009; 19(1):35–43 Cited Here 32. Simpkin AL, Robertson LC, Barber VS, et al. Modifiable factors influencing relatives' decision to offer organ donation: systematic review. BMJ. 2009; 338b991 Cited Here 33. Stouder DB, Schmid A, Ross SS, et al. Family, friends, and faith: how organ donor families heal. Prog Transplant. 2009; 19(4):358–361 Cited Here 34. Walker W, Sque M. Family bereavement: a case study of controlled organ donation after circulatory death. Nurs Crit Care. 2019; 24(4):229–234 Cited Here 35. Maloney R, Altmaier E. Caring for bereaved families: self-efficacy in the donation request process. J Clin Psychol Med Settings. 2003; 10(4):251–258 Cited Here 36. Meller N, Parker D, Hatcher D, et al. Grief experiences of nurses after the death of an adult patient in an acute hospital setting: an integrative review of literature. Collegian. 2019; 26(2):302–310 Cited Here 37. Papadatou D, Bellali T, Papazoglou I, et al. Greek nurse and physician grief as a result of caring for children dying of cancer. Pediatr Nurs. 2002; 28(4):345–353 Cited Here 38. Fabian J, Crymble K. End-of-life care and organ donation in South Africa - it's time for national policy to lead the way. S Afr Med J. 2017; 107(7):11947 Cited Here 39. Moghaddam HY, Manzari ZS, Heydari A, et al. Explaining nurses' experiences of caring for brain dead patients: a content analysis. Electron Physician. 2018; 10(8):7205–7216 Cited Here 40. Crymble K, Fabian J, Etheredge H, et al. Perceptions of nurses' roles in end-of-life care and organ donation - imposition or obligation? S Afr Med J. 2017; 107(7):573–575 Cited Here 41. Cignarella A, Redley B, Bucknall T. Organ donation within the intensive care unit: a retrospective audit. Aust Crit Care. [published online February 19, 2019]. doi: 10.1016/j.aucc.2018.12.006 Cited Here 42. Jordan ME, Lanham HJ, Crabtree BF, et al. The role of conversation in health care interventions: enabling sensemaking and learning. Implement Sci. 2009; 415 Cited Here 43. Manzano A, Pawson R. Evaluating deceased organ donation: a programme theory approach. J Health Organ Manag. 2014; 28(3):366–385 Cited Here 44. Nugus P, Carroll K, Hewett DG, et al. Integrated care in the emergency department: a complex adaptive systems perspective. Soc Sci Med. 2010; 71(11):1997–2004 Cited Here 45. Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ. 2001; 323(7313):625–628 Cited Here 46. Rowe A, Hogarth A. Use of complex adaptive systems metaphor to achieve professional and organizational change. J Adv Nurs. 2005; 51(4):396–405 Cited Here 47. Dicks SG, Ranse K, van Haren FM, et al. In-hospital experiences of families of potential organ donors: a systematic review and qualitative synthesis. Health Psychol Open. 2017; 4(2):2055102917709375 Cited Here 48. Shafer TJ, Wagner D, Chessare J, et al. Organ donation breakthrough collaborative: increasing organ donation through system redesign. Crit Care Nurse. 2006; 26(2):33–42, 44 Cited Here 49. Department of Health. Organs for transplant: a report from the Organ Donation Taskforce. 2008. Available at https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/4245/organsfortransplantstheorgandonortaskforce1streport.pdf. Published. Accessed August 1, 2018. Cited Here 50. Australian Organ and Tissue Donation and Transplantation Authority Act 2008;2(0). Available at https://www.legislation.gov.au/Details/C2017C00206/Html/Text. Accessed August 1, 2018. Cited Here 51. Porritt K, Gomersall J, Lockwood C. JBI's systematic reviews: study selection and critical appraisal. Am J Nurs. 2014; 114(6):47–52 Cited Here 52. Shih FJ, Lai MK, Lin MH, et al. Impact of cadaveric organ donation on Taiwanese donor families during the first 6 months after donation. Psychosom Med. 2001; 63(1):69–78 Cited Here 53. Holtkamp S. Wrapped in Mourning: The Gift of Life and the Donor Family Trauma. 2002. New York: Taylor & Francis Cited Here 54. Bellet BW, Jones PJ, Neimeyer RA, et al. Bereavement outcomes as causal systems: a network analysis of the co-occurrence of complicated grief and posttraumatic growth. Clin Psychol Sci. 2018; 6(6):797–809 Cited Here 55. Bellali T, Papadatou D. The decision-making process of parents regarding organ donation of their brain dead child: a Greek study. Soc Sci Med. 2007; 64(2):439–450 Cited Here 56. Hogan NS, Schmidt LA. Testing the grief to personal growth model using structural equation modeling. Death Stud. 2002; 26(8):615–634 Cited Here 57. Forsberg A, Flodén A, Lennerling A, et al. The core of after death care in relation to organ donation - a grounded theory study. Intensive Crit Care Nurs. 2014; 30(5):275–282 Cited Here 58. Mills L, Koulouglioti C. How can nurses support relatives of a dying patient with the organ donation option? Nurs Crit Care. 2016; 21(4):214–224 Cited Here 59. Venkat A, Baker EF, Schears RM. Ethical controversies surrounding the management of potential organ donors in the emergency department. J Emerg Med. 2014; 47(2):232–236 Cited Here 60. Jawoniyi O, Gormley K, McGleenan E, et al. Organ donation and transplantation: awareness and roles of healthcare professionals-a systematic literature review. J Clin Nurs. 2018; 27(56):XXXe726–e738 Cited Here 61. Miller LD, Gardiner SK, Gubler KD. Emergency department referral for organ donation: more organ donors and more organs per donor. Am J Surg. 2014; 207(5):728–733. discussion 733 Cited Here 62. Peltier JW, D'Alessandro AM, Hsu M, et al. A hierarchical communication model of the antecedents of health care professionals' support for donations after cardiac death. Am J Transplant. 2011; 11(3):591–598 Cited Here 63. Etheredge HR, Penn C, Watermeyer J. A qualitative analysis of South African health professionals' discussion on distrust and unwillingness to refer organ donors. Prog Transplant. 2018; 28(2):163–169 Cited Here 64. Rodrigue JR, Cornell DL, Howard RJ. The instability of organ donation decisions by next-of-kin and factors that predict it. Am J Transplant. 2008; 8(12):2661–2667 Cited Here 65. Ashkenazi T. The ramifications of child organ and tissue donations in the mourning process and parents' adjustment to loss: a comparative study of parents choosing to donate organs and those choosing not to donate. 2010. Tel Aviv: Tel Aviv University. [PhD thesis] Cited Here 66. Yousefi H, Roshani A, Nazari F. Experiences of the families concerning organ donation of a family member with brain death. Iran J Nurs Midwifery Res. 2014; 19(3):323–330 Cited Here 67. Rodrigue JR, Cornell DL, Krouse J, et al. Family initiated discussions about organ donation at the time of death. Clin Transplant. 2010; 24(4):493–499 Cited Here 68. Michael GE, Jesus JE. Treatment of potential organ donors in the emergency department: a review. Ann Emerg Med. 2012; 60(4):485–491 Cited Here 69. Skott C. Storied ethics: conversations in nursing care. Nurs Ethics. 2003; 10(4):368–376 Cited Here 70. Witjes M, Kotsopoulos AM, Otterspoor L, et al. The implementation of a multidisciplinary approach for potential organ donors in the emergency department. Transplantation. [published online March 12, 2019]. doi: 10.1097/TP.0000000000002701 Cited Here 71. Monforte-Royo C, Roqué MV. The organ donation process: a humanist perspective based on the experience of nursing care. Nurs Philos. 2012; 13(4):295–301 Cited Here 72. Hibbert M. Stressors experienced by nurses while caring for organ donors and their families. Heart Lung. 1995; 24(5):399–407 Cited Here 73. Orøy A, Strømskag KE, Gjengedal E. Approaching families on the subject of organ donation: a phenomenological study of the experience of healthcare professionals. Intensive Crit Care Nurs. 2013; 29(4):202–211 Cited Here 74. Shemie SD, Robertson A, Beitel J, et al.; EOL Conversations with Families of Potential Donors participants. End-of-life conversations with families of potential donors: leading practices in offering the opportunity for organ donation. Transplantation. 2017; 101(5S Suppl 1):S17–S26 Cited Here 75. Jelinek GA, Marck CH, Weiland TJ, et al. Organ and tissue donation-related attitudes, education and practices of emergency department clinicians in Australia. Emerg Med Australas. 2012; 24(3):244–250 Cited Here 76. Marck CH, Neate SL, Weiland TJ, et al. Donation after cardiac death: are Australian emergency clinicians supportive? Intern Med J. 2013; 43(7):816–819 Cited Here 77. Neate S, Marck CH, Weiland TJ, et al. Australian emergency clinicians' perceptions and use of the GIVE clinical trigger for identification of potential organ and tissue donors. Emerg Med Australas. 2012; 24(5):501–509 Cited Here 78. Moraes EL, Neves FF, Santos MJ, et al. Experiences and expectations of nurses in caring for organ donors and their families. Rev Esc Enferm USP. 2015; 49 Spec No129–135 Cited Here 79. de Moraes EL, dos Santos MJ, Merighi MA, et al. Experience of nurses in the process of donation of organs and tissues for transplant. Rev Lat Am Enfermagem. 2014; 22(2):226–233 Cited Here 80. Syversen TB, Sørensen DW, Foss S, et al. Donation after circulatory death - an expanded opportunity for donation appreciated by families. J Crit Care. 2018; 43306–311 Cited Here 81. Jensen AM. "Make sure somebody will survive from this": transformative practices of hope among Danish organ donor families. Med Anthropol Q. 2016; 30(3):378–394 Cited Here 82. Northam H. Hope for a peaceful death and organ donation. 2015. Canberra: University of Canberra. [PhD Thesis] Cited Here 83. Sque M, Long T, Payne S, et al. Why relatives do not donate organs for transplants: 'sacrifice' or 'gift of life'? J Adv Nurs. 2008; 61(2):134–144 Cited Here 84. Sque M, Payne S, Macleod Clark J. Gift of life or sacrifice?: Key discourses to understanding organ donor families' decision-making. Mortality. 2006; 11(2):117–132 Cited Here 85. World Health Organisation (WHO). World Health Organisation (WHO) definition of palliative care. World Health Organization. Available at http://www.who.int/cancer/palliative/definition/en. Accessed October 22, 2019 Cited Here 86. Neimeyer RA, Klass D, Dennis MR. A social constructionist account of grief: loss and the narration of meaning. Death Stud. 2014; 38(610):XXX485–498 Cited Here 87. Park CL. Making sense of the meaning literature: an integrative review of meaning making and its effects on adjustment to stressful life events. Psychol Bull. 2010; 136(2):257–301 Cited Here 88. Greene J. Organ donation in the emergency department; a missed opportunity? Ann Emerg Med. 2012; 59(4):A19–A21 Cited Here 89. Gustavson DE, Altamirano LJ, Johnson DP, et al. Is set shifting really impaired in trait anxiety? Only when switching away from an effortfully established task set. Emotion. 2017; 17(1):88–101 Cited Here 90. de Groot J, Vernooij-Dassen M, de Vries A, et al. Intensive care staff, the donation request and relatives' satisfaction with the decision: a focus group study. BMC Anesthesiol. 2014; 1452 Cited Here 91. Marck CH, Neate SL, Skinner M, et al. Potential donor families' experiences of organ and tissue donation-related communication, processes and outcome. Anaesth Intensive Care. 2016; 44(1):99–106 Cited Here 92. Sque M, Long T, Payne S. Organ donation: key factors influencing families' decision-making. Transplant Proc. 2005; 37(2):543–546 Cited Here 93. Bonanno GA. Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol. 2004; 59(1):20–28 Cited Here 94. Marck CH, Weiland TJ, Neate SL, et al. Personal attitudes and beliefs regarding organ and tissue donation: a cross-sectional survey of Australian emergency department clinicians. Prog Transplant. 2012; 22(3):317–322 Cited Here 95. Walter T. A new model of grief: bereavement and biography. Mortality. 1996; 1(1):7–25 Cited Here 96. Holtkamp S. Rando, T. Anticipatory mourning and organ donation. Clinical Dimensions of Anticipatory Mourning: Theory and Practice in Working with the Dying, Their Loved Ones and Their Care Givers. 2000. Champaign, IL: Research Press511–536 Cited Here 97. Nerken IR. Grief and the reflective self: toward a clearer model of loss resolution and growth. Death Stud. 1993; 17(1):1–26 Cited Here 98. Tedeschi RG, Calhoun LG. Beyond the concept of recovery: growth and the experience of loss. Death Stud. 2008; 32(1):27–39 Cited Here 99. Meyer K, Bjørk IT, Eide H. Intensive care nurses' perceptions of their professional competence in the organ donor process: a national survey. J Adv Nurs. 2012; 68(1):104–115 Cited Here 100. Flodén A, Berg M, Forsberg A. ICU nurses' perceptions of responsibilities and organisation in relation to organ donation–a phenomenographic study. Intensive Crit Care Nurs. 2011; 27(6):305–316 Cited Here 101. Taylor LJ, Buffington A, Scalea JR, et al. Harms of unsuccessful donation after circulatory death: an exploratory study. Am J Transplant. 2018; 18(2):402–409 Cited Here 102. Bonanno GA, Wortman CB, Lehman DR, et al. Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. J Pers Soc Psychol. 2002; 83(5):1150–1164 Cited Here 103. Walsh F. Family resilience: a developmental systems framework. Eur J Dev Psychol. 2016; 13(3):313–324 Cited Here 104. Allison M. Reflections on the grief of nurses. Grief Matters. 2012; 15(1):14–17 Cited Here 105. Sansone RA, Sansone LA. Physician grief with patient death. Innov Clin Neurosci. 2012; 9(4):22–26 Cited Here 106. Kelly E, Nisker J. Medical students' first clinical experiences of death. Med Educ. 2010; 44(4):421–428 Cited Here 107. Gerow L, Conejo P, Alonzo A, et al. Creating a curtain of protection: nurses' experiences of grief following patient death. J Nurs Scholarsh. 2010; 42(2):122–129 Cited Here 108. Bleakley G. A grounded theory study exploring critical care staff experiences of approaching relatives for organ donation. 2018. Salford: University of Salford Cited Here 109. Markowitz AJ, McPhee SJ. Sudden traumatic death in children: "we did everything but your child didn't survive". Jama. 2006; 296(11):1393 Cited Here 110. Domínguez-Gil B, Murphy P, Procaccio F. Ten changes that could improve organ donation in the intensive care unit. Intensive Care Med. 2016; 42(2):264–267 Cited Here 111. Masoumian Hoseini ST, Manzari Z, Khaleghi I. ICU nurses' knowledge, attitude, and practice towards their role in the organ donation process from brain-dead patients and factors influencing it in Iran. Int J Organ Transplant Med. 2015; 6(3):105–113 Cited Here 112. Nolte AG, Downing C, Temane A, et al. Compassion fatigue in nurses: a metasynthesis. J Clin Nurs. 2017; 26(2324):XXX4364–4378 Cited Here 113. Ainsworth K, Sgorbini M. Compassion fatigue: Who cares for the carers? Transplant J Australas. 2010; 19(2):21–25 Cited Here 114. Cohen K, Collens P. The impact of trauma work on trauma workers: a metasynthesis on vicarious trauma and vicarious posttraumatic growth. Psychol Trauma. 2013; 5(6):570–580 Cited Here 115. Aparicio E, Michalopoulos LM, Unick GJ. An examination of the psychometric properties of the vicarious trauma scale in a sample of licensed social workers. Health Soc Work. 2013; 38(4):199–206 Cited Here 116. Lagacé AM, Charbonney E, Marsolais P. Experience and perception in organ donation: a matter of team work. Crit Care Med. 2018; 46(6):e621 Cited Here 117. Blumenthal PA. "It's not a job; it's a lifestyle": the experience of being a donation coordinator. Prog Transplant. 2007; 17(1):8–22 Cited Here 118. Schwartz KA. Decoding the ideal organ donation requestor. 2012. Denver: The University of the Rockies Cited Here 119. Bocci M, Prestifilippo A, D'Alò C, et al. Tsoulfas, G. Family-centred care to improve family consent for organ donation. Organ Donation and Transplantation. 2018. London: Intech Open89–104 Cited Here 120. Oczkowski S, Arnold E, Centofanti J, et al. A mixed-methods study of organ donation in the intensive care unit: 22 actionable practices to improve organ donation. Can J Anesth. 20191–10 Cited Here 121. Dodd-McCue D, Tartaglia A. The impact of the family communication coordinator (FCC) protocol on the role stress of hospital chaplains. J Pastoral Care Counsel. 2005; 59(4):345–360 Cited Here 122. Leahy D. Improving the organ donation process: Can social work help? [PhD thesis]. 2002. Pittsburgh: University of Pittsburgh Cited Here 123. Markham KC. Improving incidence of referrals for psychosocial and spiritual transdisciplinary care in a palliative care service: focus on brain death. Omega (Westport). 2013; 67(12):XXX155–160 Cited Here 124. Prommer E. The role of palliative medicine in organ donation: from bedside to operating room. J Pain Symptom Manage. 2011; 41(1):304 Cited Here 125. Azoulay E, Pochard F, Kentish-Barnes N, et al.; FAMIREA Study Group. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005; 171(9):987–994 Cited Here 126. Fernandes ME, Bittencourt ZZ, Boin Ide F. Experiencing organ donation: feelings of relatives after consent. Rev Lat Am Enfermagem. 2015; 23(5):895–901 Cited Here 127. Kentish-Barnes N, Chevret S, Cheisson G, et al. Grief symptoms in relatives who experienced organ donation requests in the ICU. Am J Respir Crit Care Med. 2018; 198(6):751–758 Cited Here 128. López Martínez JS, Martín López MJ, Scandroglio B, et al. Family perception of the process of organ donation. Qualitative psychosocial analysis of the subjective interpretation of donor and nondonor families. Span J Psychol. 2008; 11(1):125–136 Cited Here 129. O'Meeghan R, Pedral L. Organ donation work flows: what ownership brings. Transplant Proc. 2016; 48(7):2415–2417 Cited Here 130. Wood C, Buss C, Buttery A, et al. Evaluation of deceased donation simulation. J Intensive Care Soc. 2012; 13(2):107–114 Cited Here 131. Potter JE, Gatward JJ, Kelly MA, et al. Simulation-based communication skills training for experienced clinicians to improve family conversations about organ and tissue donation. Prog Transplant. 2017; 27(4):339–345 Cited Here 132. Kain V. An exploration of grief in contemporary nursing. Grief Matters. 2012; 15(1):4–6 Cited Here 133. Kent BC. Protection behaviour: a phenomenon affecting organ and tissue donation in the 21st century? Int J Nurs Stud. 2004; 41(3):273–284 Cited Here 134. Hart D. Helping the family of the potential organ donor: crisis intervention and decision making. J Emerg Nurs. 1986; 12(4):210–212 Cited Here 135. Pearson IY, Bazeley P, Spencer-Plane T, et al. A survey of families of brain dead patients: their experiences, attitudes to organ donation and transplantation. Anaesth Intensive Care. 1995; 23(1):88–95 Cited Here 136. Perkins KA. The shortage of cadaver donor organs for transplantation. Can psychology help? Am Psychol. 1987; 42(10):921–930 Cited Here 137. Riley LP, Coolican MB. Needs of families of organ donors: facing death and life. Crit Care Nurse. 1999; 19(2):53–59 Cited Here 138. Bocci MG, D'Alò C, Barelli R, et al. Taking care of relationships in the intensive care unit: positive impact on family consent for organ donation. Transplant Proc. 2016; 48(10):3245–3250 Cited Here 139. de Groot J, van Hoek M, Hoedemaekers C, et al. Request for organ donation without donor registration: a qualitative study of the perspectives of bereaved relatives. BMC Med Ethics. 2016; 17(1):38 Cited Here 140. Prescott J, Gardiner D, Hogg L, et al. How the mode of organ donation affects family behaviour at the time of organ donation. J Intensive Care Soc. 2019; 20(3):204–207 Cited Here 141. Perrin K, Jones B, Winkelman C. The co-existence of life and death for the perioperative nurse. Death Stud. 2013; 37(9):789–802 Cited Here 142. Smith Z. Duty and dilemma: perioperative nurses hiding an objection to participate in organ procurement surgery. Nurs Inq. 2017; 24(3):e12173 Cited Here 143. Gao W, Plummer V, Williams A. Perioperative nurses' attitudes towards organ procurement: a systematic review. J Clin Nurs. 2017; 26(34):XXX302–319 Cited Here 144. Neidlinger N, Gleason B, Cheng J. Honoring deceased donors with a unique family-designed statement followed by a moment of silence: effect on donation outcomes. Prog Transplant. 2013; 23(2):188–193 Cited Here 145. Flodén A. Operating theatre nurses' experiences of participating in the organ donation process in the perioperative setting. Transplantation. 2017; 101S28 Cited Here 146. Jesse MT, Abouljoud M, Eshelman A. Determinants of burnout among transplant surgeons: a national survey in the united states. Am J Transplant. 2015; 15(3):772–778 Cited Here 147. Jesse MT, Abouljoud M, Eshelman A, et al. Professional interpersonal dynamics and burnout in European transplant surgeons. Clin Transplant. 2017; 31(4):e12928 Cited Here 148. Lanham HJ, McDaniel RR Jr, Crabtree BF, et al. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Jt Comm J Qual Patient Saf. 2009; 35(9):457–466 Cited Here 149. Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. Theory, evidence, and practice. J Gen Intern Med. 2006; 21 Suppl 1S9–S15 Cited Here 150. Ceyhan Ö, Özen B, Zincir H, et al. How intensive care nurses perceive good death. Death Stud. 2018; 42(10):667–672 Cited Here 151. Coetzee C, Van Niekerk D. Should all disaster risks be reduced? A perspective from the systems concept of the edge of chaos. Environmental Hazards. 2018; 17(5):470–481 Cited Here 152. Carroll T, Burton R. Organizations and complexity: searching for the edge of chaos. Comput Math Organ Theory. 2000; 6(4):319–337 Cited Here 153. Pelletier M. Morgan, J. Role of organ donation in helping family members cope with grief. Personal Care in an Impersonal World: A Multidimensional Look at Bereavement. 1993. New York: Baywood Publishing Company Inc157–166 Cited Here 154. Rushton CH, Reder E, Hall B, et al. Interdisciplinary interventions to improve pediatric palliative care and reduce health care professional suffering. J Palliat Med. 2006; 9(4):922–933 Cited Here 155. Vachon MLS. Reflections on the grief of nurses. Grief Matters. 2012; 15(1):8–12 Cited Here 156. Keene EA, Hutton N, Hall B, et al. Bereavement debriefing sessions: an intervention to support health care professionals in managing their grief after the death of a patient. Pediatr Nurs. 2010; 36(4):185–9. quiz 190 Cited Here 157. Kelso CM, Lyckholm LJ, Coyne PJ, et al. Palliative care consultation in the process of organ donation after cardiac death. J Palliat Med. 2007; 10(1):118–126 Cited Here 158. Batten HL, Prottas JM. Kind strangers: the families of organ donors. Health Aff (Millwood). 1987; 6(2):35–47 Cited Here 159. Bellali T, Papadatou D. Parental grief following the brain death of a child: does consent or refusal to organ donation affect their grief? Death Stud. 2006; 30(10):883–917 Cited Here 160. La Spina F, Sedda L, Pizzi C, et al. Donor families' attitude toward organ donation. The North Italy Transplant Program. Transplant Proc. 1993; 25(1 Pt 2):1699–1701 Cited Here 161. Willis R, Skelley L. Serving the needs of donor families: the role of the critical care nurse. Crit Care Nurs Clin North Am. 1992; 4(1):63–77 Cited Here 162. Michael GE, O'Connor RE. The importance of emergency medicine in organ donation: successful donation is more likely when potential donors are referred from the emergency department. Acad Emerg Med. 2009; 16(9):850–858 Cited Here 163. Giddings G. The ties that bind: a reflection on physician grief. Support Care Cancer. 2010; 18(10):1355–1357 Cited Here 164. Meert KL, Eggly S, Kavanaugh K, et al. Meaning making during parent-physician bereavement meetings after a child's death. Health Psychol. 2015; 34(4):453–461 Cited Here 165. Alspach JG. Trauma, tragedy, and heartfelt thanks. Crit Care Nurse. 2013; 33(5):9–12 Cited Here 166. Downar J, Barua R, Sinuff T. The desirability of an intensive care unit (ICU) clinician-led bereavement screening and support program for family members of ICU decedents (ICU bereave). J Crit Care. 2014; 29(2):311.e9–311.16 Cited Here 167. Shih FJ, Lai MK, Lin MH, et al. The dilemma of "to-be or not-to-be": needs and expectations of the Taiwanese cadaveric organ donor families during the pre-donation transition. Soc Sci Med. 2001; 53(6):693–706 Cited Here 168. Holmes BJ, Best A, Davies H, et al. Mobilising knowledge in complex health systems: a call to action. Evid Policy. 2017; 13(3):539–560 Cited Here 169. Jansen NE, van Leiden HA, Haase-Kromwijk BJ, et al. Appointing 'trained donation practitioners' results in a higher family consent rate in the Netherlands: a multicenter study. Transpl Int. 2011; 24(12):1189–1197 Cited Here 170. Witjes M, Jansen NE, van Dongen J, et al. Appointing nurses trained in organ donation to improve family consent rates [published online July 11, 2019]. Nurs Crit Care. doi: 10.1111/nicc.12462 Cited Here Supplemental Digital Content TXD_1_1_2019_10_30_DICKS_TXD-2019-0051_SDC1.docx; [Word] (69 KB) TXD_1_1_2019_10_30_DICKS_TXD-2019-0051_SDC2.docx; [Word] (45 KB) Copyright © 2019 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.View full article text


text:
Surveying Equipment
Opti-cal Survey Equipment has been supplying precision measurement technology to surveyors for the past decade, and with service and distribution partnerships with Leica Geosystems, FARO Technologies and SPX Radiodetection, we are fast becoming the number one choice in the UK and Ireland for survey professionals to source their instrumentation.
Whether you are looking for Lasers and Levels, Total Stations, GPS kit or state-of-the-art 3D Laser Scanners, you will find it all here.
Leica NA320 Automatic Level
Automatic levels for daily levelling tasks Unique, accurate and simple Professionals face many obstructions on site. Whatever the leveling challenge, Leica NA300 Series levels overcome. Rely on the known expertise of Leica Geosystems for the best quality and performance. On your terms, on your site, Leica Geosystems and the Leica NA300 Series are your trusted partners for accurate measurements every time.Learn More£134.00 exc. VAT £160.80 inc. VAT
Leica Viva GS16
The Leica Viva GS16 is the most compact and powerful, self-learning GNSS smart antenna. Working with the leading RTK technology, the Viva GS16 meets the highest standards in measurement excellence with RTKplus and SmartLink. The growing number of signals from an ever increasing satellite constellation demands a GNSS receiver to be smarter than ever before. RTKplus intelligently adapts to changing conditions by selecting the optimal signals to deliver the most accurate positions.Learn MoreCall For Price
Leica Rugby CLA Laser Level
With the unique capability to adapt to any application needs through software upgrades, the Leica Rugby CLA is the first upgradable laser to maximised productivity and performance on-site. The upgrade options deliver the unmatched performance in any levelling, aligning and squaring tasks, making it a true all-rounder.Learn More£1,160.00 exc. VAT £1,392.00 inc. VAT
Leica GS07 NetRover
The GS07 is the new mid-range Smart Antenna, light weight but robust. Guaranteeing fast and reliable stake out and data capture, combined in an easy-to-use rover with 320 channels, multi frequency and multi constellation.Learn MoreCall For Price
Leica FlexLine TS07 Total Station
A manual total station, enabling you to carry out mid-to high-accuracy survey and stakeout tasks easily and efficiently. The TS07 offers the world's first AutoHeight feature as an option. AutoHeight enables the instrument to automatically measure, read and set its instrument height. Prevent time consuming manual effort and eliminate critical errors during the instrument setup when this revolutionary feature uses a laser from the instrument to measure to the ground and automatically passes the measurement to the software.Learn MoreCall For Price
Leica NA730 Automatic Level
Built for builders, engineers and surveyors.Learn More
Nothing stops a Leica NA730 level. A short drop onto the ground, a fall into water, vibration from heavy machinery - with a Leica NA730 level you just carry on working. No time-consuming checking or readjustment required.£458.99 exc. VAT £550.79 inc. VAT
Leica Viva GS14 SmartRover
Leica Viva GS14 SmartRover with the all new CS20 Controller The Leica Viva GS14 Smart Antenna and CS20 Controller combine to provide ultimate control with complete mobility when on any job site.Learn More£14,995.00 exc. VAT £17,994.00 inc. VAT
Leica NA324 Automatic Level
Automatic levels for daily levelling tasks Unique, accurate and simple Professionals face many obstructions on site. Whatever the leveling challenge, Leica NA300 Series levels overcome. Rely on the known expertise of Leica Geosystems for the best quality and performance. On your terms, on your site, Leica Geosystems and the Leica NA300 Series are your trusted partners for accurate measurements every time.Learn More£148.99 exc. VAT £178.79 inc. VAT
Leica GS18 T GNSS Smart Antenna
Leica GS18 T – World's Fastest GNSS RTK Rover Immune to magnetic disturbances and calibration-free – no need to level You no longer need to hold the pole vertical to level the bubble with the new Leica GS18 T, the fastest and easiest-to-use GNSS smart antenna and RTK rover. This latest innovation combines GNSS and inertial micro units (IMUs) to be the first true tilt compensation solution immune to magnetic disturbances and is calibration-free.Learn MoreCall For Price
Aerialtronics Altura Zenith UAV
The Altura Zenith sets a precedent for the design of unmanned aircraft systems, by combining state-of-the-art technology with a remarkably flat, compact and lightweight carbon fibre design.Learn MoreCall For Price

subset: commoncrawl


text:
Our strongest toner with a blend of Glycolic Acid, Citric Acid & Salicylic Acid to clear environmental residues & dead skin cells.
Normalizing Tonic Forte
Normalizing Tonic Forte provides additional exfoliation and is a stronger formula than the Normalizing Tonic. This product promotes cell turnover, aids in the treatment of acne and aging skin, and prepares the skin surface to better receive additional face products. Continued use can diminish the appearance of pores and restore the skin's natural pH balance. For very oily and resistant skin.
Begin use every other day for the first two weeks. Moisten a cotton pad with tonic and wipe all over face, neck, and chest. After two weeks, apply daily.


text:
Sexy chubby teen with big boobs having sex with a skinny guy. Playlists Containing: Hot MILF fucks her Doctor! Mom and Karen came back with boxes and boxes of wine. Bodies in any position without that annoying gravity. In silence, we looked at one another, acknowledging that each of us had experienced this at some point in our caregiving experience.
Gay video Seth downright dominates Miles in this xxx video, london keyes movies. Succulent amateur Tiffany Starr is one of the loveliest shemales in the business. Watch Girl doing Gay in Pissing straight men and free gay homo porn Straight youngster Cooper is on Mofosex. He came so much most of his cum just ran out of my little pussy. Steamy porn scene featuring dark skinned actress Mahlia Milian.
There is no way I could last as long as this guy did with her sucking on my little weenie like that.
You will nod your head up and down for yes, and side to side for no.Every second of this looks like it felt incredible! Seka and Ken Yontz take a couple with them to the ultimate orgy.
Secreating orgasms keyes movies
Special thanks to Dixie and Charles for their help with finding the missing files! Britney Amber, Chanel Preston and Helly Hellfire are all over James Deens. She she is very sexy and can get anyone to fuck her at any time. Famous people porn lets celebrity fans and people that are just curious see their idols with no clothes on.
So women and men out there pick an airline that cares about your safety. The walkthrough marks inventory items with a number. New to modeling, she does a shoot thinking it will be tame damsel in distress style bondage. She eyed the cock jerking in her fist as if she were totally fascinated by it, london keyes movies.
We have 921 full length hd movies with Nipple Twisting in our database available for free streaming. If you want to have intense anal play, you can still do it with care. My one hand was on the mirror atop the basin and the other on the window beside for support. Lucky decided that the adult industry was for her. The UK has some of the hottest gurls and crossdressers.
Sandra seemed more used to it because she seemed to have far less trouble with them. Free collection of photo galleries with brand new milf porn for desktop, tablets or mobile device. Chubby light haired mom Dia Zerva is all naked gets her body locked in metal device.
Lucky guy and a totally unbelievably gorgeous cock! They eventually did and I was taken to the local city jail. If you ever need an example of what a whore is, just watch this porno. Pole dance Prague could make a nice representation of such improvement.
Man who works for the mafia is giving two options on his wedding day: allow the boss fuck your wife or risk losing your life! So I pushed him away from me and got to his pants immediately. Horace was working on the shower plumbing, while Dkembe, Janie and Gabrielle were splitting huge bamboo trunks in half longways.
|Sexy high arches in mud
|Learn where to find a lady to give you a blowjob in St.
|Busty blonde milf hardcore video
|Really hot girls having anal is just amazing and beautiful.
|Other major male porn stars in straight porn who have done gay porn are Marc Wallice, Rocco Reed and Jamie Gillis.


text:
The Team
Our trusted team of experts have deep domain expertise across all market sectors, provide objective advice and exceptional client servicing.
We are a team of diverse professionals, from corporate finance, entrepreneurship, law and social impact backgrounds.
We are committed to building a financial system that accounts for social and environmental impact and supports entrepreneurs, charities and businesses to do good while they are doing well.


text:
Primary Care Optometry
ST. LOUIS – RightEye announced an extension of its partnership with USA Baseball here at Optometry's Meeting.
RightEye President Barbara Barclay explained that teens participating in the Prospect Development Pipeline, a collaboration between USA Baseball and Major League Baseball, are being tested for not only their athletic skills but also their sports and functional vision. Youths who test below normal levels are referred to an optometrist.
Tell us what you think about Healio.com »
Get the latest news and education delivered to your inbox
©2020 Healio All Rights Reserved.


text:
The gears grind
My breath
You turn and the earth axle is seized
and it rolls
back and over to when
and I catch you in my hands
but I don't catch you it is smoke
and the gears grind
when is then and now is nothing
Like a visit from a dead friend
unexpected, welcome, macabre
The Birthday Meal
Screwed up ball of grey paper over there
That's my mother
Frightened child eyes
Skin balloon with all the blow gone from it
She's plucked the teeth from her once handsome face
Now fleshless and chinless as an addict
I shuffled her, bent legged, down the road
And wished myself away
On the day the old man died
Twenty two years and a lost hope ago
Sorry mate
I rode past a stubble field
peppered with rooks today
it was raining
and I was thinking of you
"since Keith died"
I wasn't ready for that one
Behind every twisted smile
There is a shadow in shirtsleeves
Working for your soul
Clear evening this.
All those stars. All that pathetic light limping across
space in an effort to testify that something bigger than
you and me exists.
An extraterrestrial perspective conspiracy.
I like that.
And who shall remember them?
the launderers
and the poets
I once was a poet until I was washed
clean of it
now I find myself
Time enough to put my
clean hands
back to the pen and let them
be grained with it?
Bees, oceans, ends
Pulling a half-life
(sweating and balding)
(blunt, hacking, clumsy, ignorant)
uncared for not dead yet corpse
through the purple fleshy drapes
of another poisoning
I wonder
How was it that I picked the grains of sand
from our feet
and rested my eyes from the sun for so long
so long
that I forget the hot fat slap of it?
Tell me in which box of so many boxes
have I left the words I didn't use?
standing on a dark beach in the wind
of a southern sea under strings
nothing until the ice
If that journey unravels to a third,
a fourth or fifth glass and
my failing eyes smeared on the spines of books
what of it?
There is no debt or purpose and when
as they surely may
the bees all reach an ending
so shall we, in a cough
Threadless lament
I've lost the sew of it now
a finger and an eye short of my best
My best,
when my skin leaned in and
point pierced as the
surfacing steel, a tiny porpoise
took air and dived again
hem button pleating cuff collar and fly
there was a satisfactory dance
in the loop and pull through of it
and the spotting of knotting
unravel or be bound
the wearer carried me with them then
into the ripped world
And now?
I'd sit all night, eye thrashed
if I'd let me
stabbing the scars and dreaming
into a bloodied waistband
Shelf dreams
Down your gathering smile
An adventure, a moist fall
You had a taste of me
when the clocks had mostly stopped
and it seemed all the books
that needed reading
had been read
From the place you left me
high on this shelf
I watched your back and your hand
on the light switch
not turning
I wondered if an opportunity could have
been written? Or was it done
And suppose I resented that scripting?
I guess it doesn't matter
the door will open again some time
to someone, so maybe I'll just
doze here between the read books
on the high shelf
and dream some different words into them
Scent, breezed
Hefting cudgel hands
over gentler tasks and
spilling, dropping, breaking the shells
it's not how I'd thought, so best
curl quiet when I can bear to, and
make paper promises not to remember
before these rutted fingertips lost
their taste
for skinned light
tiny hairs in the eye's gather
or in warm tar dark and gentle
all that is unknown, felt and believed
strummed on pain and beauty
before I was wise enough, now wisdom
is a shade
taunting me with a maybe life
WSG || C || & me
Percipient nibbed skitter
over the blotting page
has held me leaning in
long enough unbalanced and oft
to totter and overboard myself
in your jasper sea
Bobbing upsprouts of veinous named
fancied fragments
lyric syllables drifting from
the knowing of your smoked hearthstone
in the keen slope of the wind
Elizabeth and the boy
Library of weathers and words
hauled down from one craggy land to
another and once more set out on the rock
If you'll but shrug and blind to me
in these tired drying steps, soft
as the light folded horizon
I'll follow, some leagues behind
your coarse cut marmalade lilt
onto the the first flight
that thermal stair
Was it last year
Or this morning
We woke to hear birds singing?
The breeze through our same window
Shaped curtains into whispers
Some other time than now wondering
How it might end
Missed its passing
I watch cats prowl beneath birded trees
Dampening forehead pressed against the
Closed window
Take off your clothes
They said
Where no cars were, by the big wall
I shivered and they shone a light
Right through me
I watched you curling up
Where my heart would have been
I watched until it went dark and later I dressed
Tyto Alba
field flash
ice in the air
blurred branches
earth to sky
once and only
this heart should rightly have burst
but beauty, but beauty
cold, hard beauty
the slow beat of it holds me
from my claw cradle
those beats
impossible chews of air
casting before behind
mastering the unseen
in colourless unblinking scorn
I am given, Tyto alba
I'll be that crimson cry
on your pale feather parchment
unknown, but knowing all in
awed assent
feeding your cold white fury
I am not old by years but often I feel with mountains. It began before I had memory and will end so.
My son looks at me stupidly, seeing only a hollow cough.
The rot within me will conquer; I feel it sucking even now, now when I know it can never conquer, now when I know I have conquered, now when it ceases to matter. Now.
No, not wasted, that much I know, of that at least I am sure. I have been where the moon only, where beyond and into life the moonlight shines. My skin, dying, but alive there under the moon on my hands, my face throbbing under the soft lapping of moonlight. I have held the moonlight in my cupped hands.
I used to walk and climb among trees, grazing my pale skin on the deep bark of trees, my blood flowing, mixing with the sap of the trees, my arms hanging on the limbs of the trees.
Also at sunset. The sun. I remember now. Walking to sunset I laid the taut skin of my soul before the sun, washed it in the dew blood of the wounded day, lay it again before the sun, warmed it in the heavy breath of the dying sun, clasped it to me, my soul; my sun soul.
There are no others. She has always been silent.
In the mountains I could sit now, folding myself among the rocks, in the snow. I could press my face to the cold snow and push my fingers into the rocks; my face and fingers closing with the mountain, my soul buried in the mountain.
I have no fear of dying. Or living. Only of ceasing to live. But that is spared me now.
I know what it will be like.
I should tell her what it will be like. Even in daytime the stars go out and a deeper blue than the ocean or the night sky has come blistering and frothing out of the sky below me till I am lost and alone in the depth of the falling blue and roaring of coldness as it hisses and plummets away from my shores and I know it will not be this time.
Soon it will be this time.
I cannot leave her my sun and moon. She has always been silent. To me. Always.
If I give you my sun, my sun soul. If I empty my cupped hands, spilling moonlight in your lap, you will only smile at me.
My sun and moon. Mine.
What is it that you are saying with your smile? Why are you silent with me? Why do you smile at me? What right have you to my sun soul? My moonlight? Why do you leave footprints in the snow on my mountain?
In the dark blue that is coming now I will no longer need my mountain, my sun and moon.
It is I who have always been silent.
There's morphine in your kisses
There's cocaine in your smile
To taste your deadly blisses
We trudge in single file
Ever feel like
a wish
someone forgot to have?
The boy wakes on the beach
His hands clutch at the wet sand
He is alone
Gulls cursing at an empty sea
In grey
Behind him
Tall nested cliffs
Are exultant
The warm sun finds him
Alone there
I don't give a fuck for your future mate
I don't give a fuck for your past
I'm living in a world of make believe
And I'm going to make it last
Made up days
It's only this hard
Against easy imaginings
All the scents on the scented breeze
Were sweeter
I looked and moved against glass
We were together in the light
Something chill
Pulled at the hilled hairs
On your bare arms
A door opened and then slammed
Spat music at us in scratched chords
A monochrome cat paused
Paper romance
Those were the years of cigarettes
Telephones in cold places
Made up days
Waiting for breezes
Hissing at cats
Broken man
At bottom of my empty cage
Lies a dead bird
On quiet roads
I pass from echoes
To my last sleep
Footsteps and laughter
On green years
In my final sleep
Death in Venice
The sand
In sun the sand
And water lapping
Slapping on sand under
Silver water with orange and blue
Dark narrow streets
And streets with high walls
Damp walls and pavement
And damp shadows
Hanging in heavy air
Sickly sweet stench of decay
The harsh and lonely sound
Of fading footsteps round corners
Footprints in sand
Flash of running feet
Dancing voices
Splash of broken water
Silver and living in sunlight
Orange burning and purple
Of dying sun
Quietly yet heart beating
As slow rolling over sand
Comes the heavy dank breath
Of final sunset
Those are birds on the wing
You follow
Taking the high arc
Red rust, rutted and a slow road
You knew my door was always open
And some cup or other
Laid over a cuss
At the kitchen table
They pulled a grey blanket about you
And made you sleep longer
Than the light in your eyes could fathom
Sometimes you get so down
You feel like your mule just won't budge
And all you can do is write
Somewhere people will see
The smile
When Gibbel returns
Out of this muck gardened
yowling bin dead grassed bog trudge
there will be a way
there will be a way
If I have to carve it with my
bleached bones or the
unpardoned edge of the words
I chose to leave unsaid
Look at yourself and your
tiny needs
look at yourself I have I have I am I did
We were at the very centre of the lake
when a wind came up
as it always must
and then you began to smile
Melancholy saxophone refrain
Comes creeping through my window once again
I don't need illumination
To perceive the situation
In the morning
I'll come yawning
To the blues once again
Saying "sunset"
He said "sunset"
With the pipe half empty
And great worn patches
On his shirtsleeves
"Sunset" and the moving of feet
As the hands fold about heads
Off they go to sunset
Off they go
To the setting sun
The sunset
Off they go
The book
Today I rode down
between birds calling and the yet unmelted snow
in dirty arches
over busy ditches
arcing sludge droplet tangents as
tyres waltzed around the shit and standing water
to where they empty their ashtrays out of car windows
on days when hope seems infantile
those deliberate monuments –
mattress, microwave, monitor and beer cans,
the endless waste of babies
There, beside the gaudy discards of those
best unmet,
spine upright as though in defiance
a burnt black book
blistered at the cover
fanned leaves fire shred edged
a smoulder of sentences risen and freed from stops
Lost of all meaning
except at that eyed moment, when it seemed
reason gave in to
the flamed despair of immolation
We dined by the river
I passed her a sliver
Of my heart
On a plate silver tray
She graciously took it
But blindly mistook it
For salami
And threw it away
I passed her another
But just like its brother
She ditched it
Despite all my hints
I should mention two fishes
In spite of my wishes
Have followed me round
Ever since


text:
Jane, Joseph & John; Their Book of Verses
Boston: The Atlantic Monthly Press, (ca. 1918). Day, Maurice E.; Hapgood, T. B. First Edition. Hardcover. Quarto size, 64 pp., with original glassine wrapper and publisher's box. Ralph Bergengren (1871-1947) was an American humourist and children's poet, who wrote charming poems for children with light-hearted rhyme and metre; this book..... More


text:
Experience a variety of out-door events organised by the hotel, depending on weather conditions and the tides, the events take place either on the beach, close to the beach or around the pool. Soak in spectacular sunsets while sipping sundowners on the Roof Top bar or take part in our themed events:
Swahili Sunday – a traditional Swahili buffet served around the Pool with traditional live entertainment
Mongolian / Asian Wednesday – served around the Pool with live entertainment
Friday Seafood beach BBQ – served at the Beach with live music.
Cultural outdoor entertainment
Nungwi Dreams offers a cultural extravaganza


text:
Terms and conditions of BLUE POT Internet Shop
- Definitions
- Customer-public person ,legal entity or organisation not being legal entity which all regulations confers special legal rights when places an order on the shop webside.
- Client -public person who according to law makes agreement with entrepreneur not directly related with his business or professional activity.
- Terms and conditions – regulations of services offered electronically within internet shop web side (Blue Pot).
- Internet shop (web side)- internet service by which a customer may mainly place an order.
- Items(products)- products presented on shop web side.
- Sell agreement -sell between Blue Pot and customer concluded via web side.
- An order- declaration aiming directly to sale agreement describing mainly type and amount of products.
2.General resolutions
- Terms and conditions state regulations of using internet shop
- Internet Shop Blue Pot address 98 JKL Street Edenderry e mail firstname.lastname@example.com
- Terms and conditions includes :
- terms and conditions of placing an order electronically within Internet Shop
- rules of placing order within Internet shop by using services provided on shop web side
- In order to use Internet Shop customer needs to have access to computer with access to internet.
- According to law Blue Pot preserves the right to decline concluding a sale agreement with people who are under 18 years of age. In this situation customers will be notified.
- The photographs and descriptions under the items (products)come from Blue Pot or third party e.g. manufacturers(producers). The photographs may slightly differ from the actual products. Taking into consideration handmade character of boleslawiec crafts some slightly differences in details, shapes and paint decorations among products are natural and characteristic for handmade artistic products.
- Customers can see terms and conditions always by pressing the appropriate option implemented on the main page of Blue Pot.
3.Rules of using internet shop
- Customer may place an order in the shop after reading and approving terms and conditions
- Customer is obliged to:
- not placing and transmitting forbidden texts by law for example all contents popularizing violence , bringing down reputation braking human rights of third party
- using internet shop in a way which will not disturb its function especially by using certain programmes and equipment
- not sending or placing on the shop web side not ordered information (spam)
- using internet shop in a way in which is burdensome (offensive)for other customers
- using all contents placed on the shop web side only for their own purposes
4.Procedure of concluding a sale agreement
- In order to place an order by using internet shop customer should enter Blue Pot internet shop web side and choose an item(product)by undertaking technical actions following all instructions and information provided on the web side.
- Customer is choosing items by adding them to a shopping cart.
- During placing an order until to the moment of processing the option to confirm the order the customer has a right to modify the items added and the details. In this situation the customer should follow all communications and information provided on the web side.
- After giving by customer all necessary details the summary of order will be displayed. The summary of order will include description of items (products)or services prices and all additional costs
- Delivery of products is restricted to Ireland and all products are sent to the addresses stated by customer when placing an order.
- Delivery of orders products is done by An Post. There is a possibility to collect an order in our shop Blue Pot 198 JKL Street Edenderry Co. Offaly. Items can be collected from Monday to Friday from 10.00 a.m. till 5 p.m. and on Saturdays from 10 a.m. till 2 p.m. within 7 days from the order confirmation unless products are by special order in such cases the delivery time of the order extends to 21 days. When collecting an order you can pay by cash.
- Delivery time is from 2-7 working days counted from customers order and full payment.
- Blue Pot reserves the right to process the order not in full informing customers by e mail about missing items in the order. In this situation the customer has a right to cancel the order.
6.Prices and payment methods
- Prices are located under the photographs
- Method of payment Pay Pal