Caring for Children with
Life-Threatening Illness:
Can we do better?
Joanne Wolfe, MD, MPH
Division Chief, Pediatric Palli...
Disclosures
• No financial interests to disclose.
Objectives
Part I
• Scope of Pediatric Palliative Care (PPC)
• Scope of Suffering
Part II
• The Boston PPC Experience
Part...
Part I
15-19 years
25.3%
10-14 years
7.6%
5-9 years
6.4%
1-4 years
9.6%
Postneonatal
16.9%
Neonatal
34.3%
In the US, 500,000 chil...
Percentage of total childhood deaths
by major causes
Unintentional Injuries
22%
Homicide & Suicide
8%
Other
33%
Cancer
4%
...
Diagnoses in patients receiving PPC
0
5
10
15
20
25
30
35
40
45
G
enetic/Congenital
Neurom
uscular
CancerRespiratory
O
the...
Survival of patients receiving PPC
Feudtner et al, Pediatrics 2011
Feudtner et al, Pediatrics 2011
Signs and
symptoms of
patients receiving
PPC services
Drugs received by patients receiving PPC
Feudtner et al, Pediatrics 2011
Technology in patients receiving PPC
0
10
20
30
40
50
60
70
None
Feeding
tube
CentralVenous
C
atheter
Tracheostom
y
Noninv...
Hope for cure, life extension, a miracle…
Hope for comfort, meaning…
Individualized blending of care directed
at underlyin...
Suffering
Suffering is a specific state of distress that occurs
when the intactness or integrity of the person is
threaten...
“Visible” threats
Life-threatening illness
Symptoms
Emotional Factors
“Invisible” threats
Disruptions from "normal life”
E...
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%
Pain
Fatigue
Drowsy
Irritability
Nausea
Anorexia
Sleep
Diarrhea
Vomiting
Nervousn...
• Study to detail the everyday occurrence of pain in non-
communicating children with cognitive impairment
• 34 parents co...
Additional Domains of Family
Suffering
• Spiritual distress (Robinson, Pediatrics 2006)
• Psychological distress (Rosenber...
Parental Psychological Distress
Rosenberg et al, JAMA Pediatrics 2013
Family Financial Distress
Bona et al, J Pain Sx Mgmt 2013
“Visible” threats
Life-threatening illness
Symptoms
Emotional Factors
“Invisible” threats
Disruptions from "normal life”
E...
Part II
Joanne Wolfe, MD, MPH
The Boston
Pediatric Palliative Care
Experience
Core Ideals
Meaningful
Experiences
Open
Communication
Intensive
Symptom
Management
Timely Access to
Care
Flexibility
Psych...
Interdisciplinary Team
Patient
and
Family
Physician
Nurse
Practitioner
Nurse
Chaplain
Social
Worker
Pharmacist
Child-life
...
Primary vs Subspecialty PPC
• Primary
– Team provides interdisciplinary support
• Subspecialty
Clinical: more complex care...
PACT Beginnings
• 1997: Demonstration project in pediatric
oncology
• 2001: Expanded to care for children with
non-cancer ...
PACT Strategies
• Consults
• Education/Training
– Across all disciplines
– Interdisciplinary fellowship
programs
– Visitor...
PACT Physician Fellows
Jenny Mack Fellowship Director, Pediatric Hematology/Oncology DFCHCC, MA
Craig Hurwitz Director, Pa...
Core Team Members
Physicians (2.6 FTE)
Nurse practitioner (2.0 FTE)
Social worker (1 FTE)
Administrators (2.0 FTE)
Trainee...
DFCI/CHB PACT Clinical Activity
0
100
200
300
400
500
600
700
New Consults
On-Going
Total Patient Census
Deaths
Referring Services FY 2012
173 New Patients
Onc
47
27% Pulm
5
3%
Gen & Metab
22
13%
Cardio
30
17%
Neuro
63
36%
Other
7
4%
Patient/ family and provider satisfaction
Data source: Family satisfaction survey as of 2/10/12, n=39
Aspect of Care Weigh...
0
20
40
60
80
100
PercentofChildren
Symptom Prevalence
Suffering
Wolfe et al. NEJM 2000.
Before
After…
PPC Saves Resources!
Results of Pre-Post Analysis
Rates Pre-Service Post-Service p Value
Inpatient Stays/year (95% CI) 4.6...
PACT Pearls…
What are the five cardinal questions?
Goals of Care Discussion
1. Tell us about your child, what is s/he like
as a person?
2. What is your understanding of your...
Choose your words carefully
“Similar to scalpels for surgeons, words
are the palliative care clinician’s greatest
tools. S...
Examples of Forbidden
Language
Frequently used phrases:
What would you like us to
do?
The parents signed a DNR
The patient...
Strategies to Ease Distress
Live as long as
possible
Live as long as
possible and as well
as possible
Live as comfortably
...
Partnering with Community
Massachusetts Pediatric Palliative
Care Legislation May 2006
Monday, February 26, 2007
Help and hope
New palliative progra...
PACT Advocacy – Massachusetts
Pediatric Palliative Care Program
7
4
22
13
42
50
18
35
12
18 5
Always maintain hope!
Part III
Knapp et al, Pediatric Blood Cancer 2011
Level 1 No known ppc activity
Level 2 Capacity building activity identified
Level...
Levels of PPC provision around
the world
Knapp et al, Pediatric Blood Cancer 2011
Availability of palliative care services
for children with cancer in economically
diverse regions of the world
• 262 compl...
Physician-reported availability of specialized
services to their patients
Physician rated quality of palliative care
elements
Physician responses to the following
statements
Comfort care medications available to more than
50% of respondents patients
Study Question
1. Available resources.
2. Availabiliy and access to pediatric specialists
3. Availability and access to dr...
PPC Providers
 PPC Teams (n=8)
 PPC Specialists (n= 6)
 PPC providers with less than 2
years of experience (n= 7)
 Adu...
Oncology teams PPC teams NGOs
Insufficient staff
Low interaction between
oncology teams
(hematologists/oncologists)
Intera...
Opioid Availability
• Intravenous morphine was available in all institutions while oral morphine was
available in 88% of v...
Summary
• PPC involves an extra layer of
interdisciplinary support
• Simple strategies can go a long way
• Internationally...
A Mission of Accompaniment
“It’s all very sad, but there’s a lot of collateral
beauty along the way.”
Loorie Moore (Mother)
Conferencia de la Dra. Joanne Wolfe sobre Cuidados Paliativos Pediátricos, en Paraguay (20-09-13)
Conferencia de la Dra. Joanne Wolfe sobre Cuidados Paliativos Pediátricos, en Paraguay (20-09-13)
Conferencia de la Dra. Joanne Wolfe sobre Cuidados Paliativos Pediátricos, en Paraguay (20-09-13)
Conferencia de la Dra. Joanne Wolfe sobre Cuidados Paliativos Pediátricos, en Paraguay (20-09-13)
Conferencia de la Dra. Joanne Wolfe sobre Cuidados Paliativos Pediátricos, en Paraguay (20-09-13)
Upcoming SlideShare
Loading in …5
×

Conferencia de la Dra. Joanne Wolfe sobre Cuidados Paliativos Pediátricos, en Paraguay (20-09-13)

866 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
866
On SlideShare
0
From Embeds
0
Number of Embeds
30
Actions
Shares
0
Downloads
12
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • When we think about a patient’s suffering, we generally conceptualize the family as the unit we are thinking about rather than just the patient.We conceptualize the threats to the family unit as being “Visible” and “Invisible.”These threats lead to suffering.As doctors, we need to be able to identify these threats, so that we can help to administer “Targeted interventions” and “Global Interventions” to guide the family to develop a new integrity.
  • When we think about a patient’s suffering, we generally conceptualize the family as the unit we are thinking about rather than just the patient.We conceptualize the threats to the family unit as being “Visible” and “Invisible.”These threats lead to suffering.As doctors, we need to be able to identify these threats, so that we can help to administer “Targeted interventions” and “Global Interventions” to guide the family to develop a new integrity.
  • The Core Ideals of palliative care are all a part of helping patients have a meaningful experience while coping with serious illness.Our core values include:Open communicationIntensive symptom managementTimely access to careFlexibilityPsychosocial and Spiritual SupportPatient oriented and family oriented careCare that can be delivered at any place and any time
  • While each member of the interdisciplinary team brings a unique skill and perspective to the care of the patient, the real strength of this model of care is that we have open communication with each other and share all information gathered and incorporate multiple perspectives into the recommendations we give our patients.For patients who are in the Inpatient Palliative Care Unit (or IPCU) at BWH/DFCI, we always have a pharmacist, social worker, NP, and MD as part of the rounding team. During our weekly interdisciplinary rounds, that same team meets along with an chaplain, ethicist, and representative from nursing.
  • Conferencia de la Dra. Joanne Wolfe sobre Cuidados Paliativos Pediátricos, en Paraguay (20-09-13)

    1. 1. Caring for Children with Life-Threatening Illness: Can we do better? Joanne Wolfe, MD, MPH Division Chief, Pediatric Palliative Care Department of Psychosocial Oncology and Palliative Care Dana-Farber Cancer Institute Director, Pediatric Palliative Care Children’s Hospital Boston
    2. 2. Disclosures • No financial interests to disclose.
    3. 3. Objectives Part I • Scope of Pediatric Palliative Care (PPC) • Scope of Suffering Part II • The Boston PPC Experience Part III • Adapting the PPC Model to Low and Middle Income Countries
    4. 4. Part I
    5. 5. 15-19 years 25.3% 10-14 years 7.6% 5-9 years 6.4% 1-4 years 9.6% Postneonatal 16.9% Neonatal 34.3% In the US, 500,000 children live with complex chronic conditions 55,000 children ages 0 to 19 die annually IOM report 2003, NEJM 2004
    6. 6. Percentage of total childhood deaths by major causes Unintentional Injuries 22% Homicide & Suicide 8% Other 33% Cancer 4% Respiratory Distress 2% Heart Disease 2% SIDS 5% Short Gestation 8% Complications of Pregnancy 2% Congenital Anomalies 12% Placental Cord Membranes 2% IOM report 2003
    7. 7. Diagnoses in patients receiving PPC 0 5 10 15 20 25 30 35 40 45 G enetic/Congenital Neurom uscular CancerRespiratory O ther G astrointestinal Cardiovascular Renal Im m unologic Percent Feudtner et al, Pediatrics 2011
    8. 8. Survival of patients receiving PPC Feudtner et al, Pediatrics 2011
    9. 9. Feudtner et al, Pediatrics 2011 Signs and symptoms of patients receiving PPC services
    10. 10. Drugs received by patients receiving PPC Feudtner et al, Pediatrics 2011
    11. 11. Technology in patients receiving PPC 0 10 20 30 40 50 60 70 None Feeding tube CentralVenous C atheter Tracheostom y Noninvasive Ventilation Ventilatory-dependent Percent Feudtner et al, Pediatrics 2011
    12. 12. Hope for cure, life extension, a miracle… Hope for comfort, meaning… Individualized blending of care directed at underlying illness and physical, emotional, social, and spiritual needs of child and family with continuous reevaluation and adjustment End-of- life care Bereavement care Pediatric Palliative Care
    13. 13. Suffering Suffering is a specific state of distress that occurs when the intactness or integrity of the person is threatened or disrupted. It lasts until the threat is gone or integrity is restored. The meanings and the fear are personal and individual, so that even if two patients have the same symptoms, their suffering would be different. Eric Cassel, MD
    14. 14. “Visible” threats Life-threatening illness Symptoms Emotional Factors “Invisible” threats Disruptions from "normal life” Emotional factors Existential concerns Socio-demographic concerns SUFFERING A Framework of Suffering PATIENT PARENTS Family‟s Self Integrity SIBLINGS
    15. 15. 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Pain Fatigue Drowsy Irritability Nausea Anorexia Sleep Diarrhea Vomiting Nervousness Sadness Cough Worrying Concentration Itching Skin issues Constipation Dyspnea Image Dry mouth Numbness Sweating Dysphagia Dysuria Child self-reported symptoms 20 weeks of follow up Prevalence and proportion with moderate to severe distress (n=704 surveys) Mod-Sev distress
    16. 16. • Study to detail the everyday occurrence of pain in non- communicating children with cognitive impairment • 34 parents completed daily pain diaries for two weeks, each day for 5 defined periods rating whether their child had been in pain and its duration and severity. • Results – 74% of children experienced pain on at least one day – 68% with moderate or severe pain on at least one day – 12% with mod-severe pain lasting greater than 30 minutes on 5 or more days – NO CHILD WAS RECEIVING PAIN MEDICATION Distress in cognitively impaired, non- communicating children Stallard et al Arch Dis Child 2001
    17. 17. Additional Domains of Family Suffering • Spiritual distress (Robinson, Pediatrics 2006) • Psychological distress (Rosenberg, JAMA Pediatrics 2013) • Financial distress (Dussel, JCO 2011)
    18. 18. Parental Psychological Distress Rosenberg et al, JAMA Pediatrics 2013
    19. 19. Family Financial Distress Bona et al, J Pain Sx Mgmt 2013
    20. 20. “Visible” threats Life-threatening illness Symptoms Emotional Factors “Invisible” threats Disruptions from "normal life” Emotional factors Existential concerns Socio-demographic concerns SUFFERING Targeted Interventions (e.g. symptom treatment trials) Global Interventions (e.g. MA PPC Network) A Framework for Easing Suffering PATIENT PARENTS Family Integrity PATIENT SIBLINGSPARENTS “NEW” Family Integrity SIBLINGS
    21. 21. Part II
    22. 22. Joanne Wolfe, MD, MPH The Boston Pediatric Palliative Care Experience
    23. 23. Core Ideals Meaningful Experiences Open Communication Intensive Symptom Management Timely Access to Care Flexibility Psychosocial and Spiritual Support Patient Oriented, Family Oriented Any place, Any time
    24. 24. Interdisciplinary Team Patient and Family Physician Nurse Practitioner Nurse Chaplain Social Worker Pharmacist Child-life Therapist
    25. 25. Primary vs Subspecialty PPC • Primary – Team provides interdisciplinary support • Subspecialty Clinical: more complex care Education: enhance knowledge, skills, behaviors and attitudes Innovation and research: advancing the field Advocacy: system wide changes
    26. 26. PACT Beginnings • 1997: Demonstration project in pediatric oncology • 2001: Expanded to care for children with non-cancer diagnoses • 2003: Improved outcomes in children with cancer, greater institutional support • 2003: Fellowship program
    27. 27. PACT Strategies • Consults • Education/Training – Across all disciplines – Interdisciplinary fellowship programs – Visitor program • Interventions – Direct admission policy – Emergency medication work sheet – Inpatient orders for uncontrolled pain, dyspnea and/or agitation – “Intervention orders for persons with advanced Illness” – Comfort Corner • Bereavement programs – Family – Caregivers • Research program
    28. 28. PACT Physician Fellows Jenny Mack Fellowship Director, Pediatric Hematology/Oncology DFCHCC, MA Craig Hurwitz Director, Palliative Care, Dell Children’s Hospital, Austin, TX Todd Pearson Medical Director, Pediatric Palliative Care, Cook Children’s Medical Hospital, Fort Worth TX Christina Ullrich PACT and Stem Cell Transplant Physician, DFCHCC Julie Hauer Medical Director, Seven Hills Pediatric Center, MA Bradd Hemker Palliative Care and Heme/Onc Attending, Helen DeVos Children's Hospital, Grand Rapids, MI Tamara Vern-Gross Proton Beam Fellow, Wake Forest, Baptist Health, NC Jennifer Linebarger Medical Director, Pediatric Palliative Care, Children’s Mercy Hospitals and Clinics, Kansas City, MO Kate Nelson Health Services Research Fellow, Hospital for Sick Children, Toronto, ON Kevin Weingarten Palliative Care Physician and Medical Ethics Fellow, Hospital for Sick Children, Toronto, ON Elisha Waldman Medical Director, Pediatric Palliative Care, Hadassah Hospital, Jerusalem, Israel Todd Barrett Adult and Pediatric Palliative Care, Cedars-Sinai, Los Angeles, CA PACT Social Work Fellows Kristen Caminiti Social Worker, Children's National Medical Center, Washington DC Katie Sweeney Social Worker, Connecticut Hospice, CT Kate Lindy Social Worker, Intermediate Care Unit, BCH, MA Arden O’Donnell Social Worker, Adult Palliative Care, DFCI/BWH, MA Kate Evans Social Worker, Pediatric Hospice, Denver ,CO Nicholas Purol Social Worker, Merrimack Valley Hospice, MA Jordan Miraglia Social Worker and Bereavement Coordinator, Hands of Hope, Hospice Care of South Carolina, SC Bryce Moffet Social Worker, Boston Health Care for the Homeless, MA PACT Nurse Practitioner Fellows Ashley Atkins Pediatric NP, Joslin Diabetes Center, Boston, MA Gaby Harrison Pediatric NP, Merrimack Valley Hospice, MA Meghan Tracewski Pediatric NP, Pediatric Advanced Care team, Children’s Health Care of Atlanta, GA Anna Roche Pediatric NP, DFCHCC, MA Macallagh McEvoy Pediatric NP, Seattle Children’s Hospital, WA
    29. 29. Core Team Members Physicians (2.6 FTE) Nurse practitioner (2.0 FTE) Social worker (1 FTE) Administrators (2.0 FTE) Trainees: Physician Palliative care fellow (2 FTE) Nurse practitioner fellow (1 FTE) Social work fellow (1 FTE) PACT Interdisciplinary Team Committee Members ICU, NICU & BMT nurses Ambulatory clinic nurses Patient Care Coordinator Parent representatives Pain Team Specialist Intensivist/Coordinated Care physician Psychiatrist Physical Therapist Psychologist Social worker Chaplain Child-life specialists Pharmacist Communication enhancement specialist Genetic Counselor
    30. 30. DFCI/CHB PACT Clinical Activity 0 100 200 300 400 500 600 700 New Consults On-Going Total Patient Census Deaths
    31. 31. Referring Services FY 2012 173 New Patients Onc 47 27% Pulm 5 3% Gen & Metab 22 13% Cardio 30 17% Neuro 63 36% Other 7 4%
    32. 32. Patient/ family and provider satisfaction Data source: Family satisfaction survey as of 2/10/12, n=39 Aspect of Care Weighted Average (1-5, 5 is highest score) Concern and caring to child 4.9 Symptom management 4.3 Emotional support to child 4.6 Concern and caring to family 4.9 Emotional support to family 4.4 Included in decision-making 4.7 Recommend PACT 3.9 (1-4, 4 is highest score) • Example scores from the patient/ family satisfaction survey • Example scores from the provider satisfaction survey Aspect of Care Weighted Average How valuable is it to have PACT 4.82 (1-5, 5 is highest score) Would you recommend PACT to a colleague 3.87 (1-4, 4 is highest score) Aspect of Care Weighted Average (1-5, 5 is highest score) Concurrent consultation by PACT No PACT consultation Management of physical symptoms such as pain, nausea, dyspnea 4.33 3.88 Management of psychosocial distress of patients and families 4.36 3.92
    33. 33. 0 20 40 60 80 100 PercentofChildren Symptom Prevalence Suffering Wolfe et al. NEJM 2000. Before After…
    34. 34. PPC Saves Resources! Results of Pre-Post Analysis Rates Pre-Service Post-Service p Value Inpatient Stays/year (95% CI) 4.64 (4.3, 5.0) 3.72 ( 3.4, 4.1) <0.001 ED visits/year (95% CI) 0.89 ( 0.7, 1.1) 0.57 ( 0.4, 0.7) 0.003 Bed Days/year (95% CI) 44.17 ( 43.1, 45.3) 42.37 ( 41.3, 43.4) 0.019 0.0 1.0 2.0 3.0 4.0 5.0 Inpatient Stays/year ED Visits/year Rate/year Pre-Service Service 40.0 42.0 44.0 46.0 48.0 50.0 Bed Days/year Rate/year Pre-Service Service
    35. 35. PACT Pearls…
    36. 36. What are the five cardinal questions?
    37. 37. Goals of Care Discussion 1. Tell us about your child, what is s/he like as a person? 2. What is your understanding of your child’s illness? 3. In light of your understanding, what’s most important to you? 4. What are your hoping for? What are your worries? 5. Where do you find your strength?
    38. 38. Choose your words carefully “Similar to scalpels for surgeons, words are the palliative care clinician’s greatest tools. Surgeons learn to use their tools with extreme precision, because any error can be devastating. So too should clinicians who rely on words”
    39. 39. Examples of Forbidden Language Frequently used phrases: What would you like us to do? The parents signed a DNR The patient is DNR Narcotics Alternatives: Based on my understanding of your goals, I would recommend… A resuscitation status order was placed in the chart Pain medications such as morphine, opioids
    40. 40. Strategies to Ease Distress Live as long as possible Live as long as possible and as well as possible Live as comfortably as possible Differential diagnosis Differential diagnosis Differential diagnosis Intensive assessment Targeted assessment Limited-target assessment Intensive treatment Targeted treatment Flexible and at times empiric treatment Intensive follow-up Intensive follow-up Intensive follow-up Guided by Goals of Care
    41. 41. Partnering with Community
    42. 42. Massachusetts Pediatric Palliative Care Legislation May 2006 Monday, February 26, 2007 Help and hope New palliative program offers „total approach to care‟ for children being treated for serious illnesses – and their families…
    43. 43. PACT Advocacy – Massachusetts Pediatric Palliative Care Program 7 4 22 13 42 50 18 35 12 18 5
    44. 44. Always maintain hope!
    45. 45. Part III
    46. 46. Knapp et al, Pediatric Blood Cancer 2011 Level 1 No known ppc activity Level 2 Capacity building activity identified Level 3 Localized provision of PPC Level 4 Integration with main stream service providers Levels of PPC provision around the world
    47. 47. Levels of PPC provision around the world Knapp et al, Pediatric Blood Cancer 2011
    48. 48. Availability of palliative care services for children with cancer in economically diverse regions of the world • 262 completed questionnaires from 58 countries (response rate, 59.8%) • Regular users of Cure4Kids (St. Jude) Delgado et al European J of Cancer 2010
    49. 49. Physician-reported availability of specialized services to their patients
    50. 50. Physician rated quality of palliative care elements
    51. 51. Physician responses to the following statements
    52. 52. Comfort care medications available to more than 50% of respondents patients
    53. 53. Study Question 1. Available resources. 2. Availabiliy and access to pediatric specialists 3. Availability and access to drugs (opioids and other drugs). 4. Degree of integration of palliative care practices into pediatric cancer care • Symptom Control • Medical decision making processes • Care provided to families that need to migrate • Advanced care planning and care at the end of life • Location of death • Bereavement 5. Palliative care specialist’s role Assessed Domains Is palliative care provided to children with advanced cancer in Argentina? Dussel et al
    54. 54. PPC Providers  PPC Teams (n=8)  PPC Specialists (n= 6)  PPC providers with less than 2 years of experience (n= 7)  Adult PC providers (n=3)  “Obliged” PPC providers (n=5)  No PPC provider identified (n=7) Available Resources
    55. 55. Oncology teams PPC teams NGOs Insufficient staff Low interaction between oncology teams (hematologists/oncologists) Interaction with other teams: is lower with pain specialists, PPC providers and social service is higher with psychological area High regional and institutional variability High staff turnover (lack of funding, emotional impact of the task, etc.) Low interaction between PPC teams across the country Wide range of services Different agendas between NGOs and health providers Networking between NGOs and health providers improves their interaction: > interaction> equity in access to services provided by NGOs Resistence to NGOs presence in hospitals Under utilization of NGOs resources Available Resources
    56. 56. Opioid Availability • Intravenous morphine was available in all institutions while oral morphine was available in 88% of visited centers and methadone in only 35% of institutions. • Other opioid drugs useful for cancer pain treatment such as oxycodone were not available in any of the visited centers. • Key informants identified at least two provinces that do not have opioids at all (not included in this sample). • Specialists reported problems with treatment options, e.g. opioid rotation. “We have few tools, here we have morphine, or morphine, and we have morphine as well ... or morphine ... In other words, I have nothing! If I have to rotate opioids, I can’t. At this moment I have one [patient] who suffers from hallucinations [secondary to morphine], she lives 70 km away and I don’t know how to help her; [silence] with the few tools we have, we do a lot.” (PPC specialist)
    57. 57. Summary • PPC involves an extra layer of interdisciplinary support • Simple strategies can go a long way • Internationally, there is much work to be done to ensure that every child with a life- threatening illness has access to basic PPC. Thank you
    58. 58. A Mission of Accompaniment “It’s all very sad, but there’s a lot of collateral beauty along the way.” Loorie Moore (Mother)

    ×