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Tailoring the delivery of cancer diagnosis to adolescent and young adult patients displaying strong emotions: An observational study of two cases
LIVE KORSVOLD, MNSc1,2, HANNE CATHRINE LIE, PhD1,2,3, ANNELI VIKTORIA MELLBLOM, PhD1, ELLEN RUUD, PhD2, JON HÅVARD LOGE, PhD1,4 & ARNSTEIN FINSET, PhD1
1Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway, 2Department of Paediatric Medicine, Women and Children's Division, Oslo University Hospital, Oslo, Norway, 3National Resource Center for Late Effects after Cancer Treatment, Oslo University Hospital, Radiumhospitalet, Oslo, Norway, and 4Regional Centre of Excellence in Palliative Care, Oslo University Hospital, Oslo, Norway
Delivering the bad news of a cancer diagnosis to adolescent and young adult (AYA) patients who display strong emotions is particularly challenging not the least because AYAs are at a vulnerable developmental stage. Due to the lack of research on how to personalize the delivery of bad news to AYA patients' emotions we report a case study of the communicative behavior of oncologists in two such consultations to describe the complexity of the phenomena at study. We audio-recorded and transcribed consultations where oncologists delivered cancer diagnoses to nine AYAs aged 12–25 years. Two of these patients displayed particularly strong emotional behavior (anger, fear, and sadness) and were chosen as cases. An interpretative analysis in three steps was applied to investigate the oncologists' communicative behavior when delivering bad news. The focus was on how the oncologists responded to the strong but different emotional behaviors of the AYAs. We also related the oncologists' communicative behavior to elements from a widely used protocol for delivering bad news. We found that the oncologists applied five communication strategies: elicit patient perspective, provide information, respond to patient's expression of emotion (acknowledging and containing emotions), encourage commitment to treatment, and provide hope. The findings illustrate how oncologists' communicative behavior may be tailored to individual expressions of emotions in AYA cancer patients.
Key words: Delivering bad news, oncology, AYA, clinical communication, case study
Citation: Int J Qualitative Stud Health Well-being 2016, 11: 30763 - http://dx.doi.org/10.3402/qhw.v11.30763
Copyright: © 2016 L. Korsvold et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
Accepted: 22 March 2016; Published: 27 April 2016
Competing interests and funding: The authors have not received any funding or benefits from industry or elsewhere to conduct this study.
Correspondence to: L. Korsvold, Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, POB 1111 Blindern, NO-0317 Oslo, Norway. E-mail: firstname.lastname@example.com
Giving diagnostic information on oncology is a challenging task. It has been characterized as being "on the edge of rationality" for both patient and doctor as the bad news may provoke strong emotional reactions in the patient (Maynard & Frankel, 2006, p. 277). There is evidence that the way in which adverse diagnostic information is delivered may influence patients' anxiety and stress (Schofield et al., 2003) and may also impact their satisfaction with care, adherence to treatment, and other health outcomes (Fallowfield & Jenkins, 2004).
A diagnosis of cancer is devastating for anyone but perhaps particularly for adolescents and young adults (AYAs), as they are in a particularly vulnerable developmental stage (Keegan et al., 2012; Kent et al., 2012; Zebrack et al., 2014). At a time in life when they would expect to be making the transition to independence they become dependent on others because of a life-threatening disease (Kent et al., 2012). Delivering a cancer diagnosis to AYAs is therefore a delicate and challenging task for oncologists.
By bad news we mean "any information that produces a negative alteration to a person's expectations about their present and future" (Fallowfield & Jenkins, 2004, p. 312). A cancer diagnosis is an obvious example of bad news. In oncology, two factors complicate the delivery of the diagnosis. First, there may be limited time available to explain the implications of the diagnosis and the treatment options because the medical condition of the patient may require immediate treatment. Second, the giver and the receiver of the diagnosis often meet without substantial previous contact (Fallowfield & Jenkins, 2004).
Most research into delivery of bad news has been descriptive, in the sense that communication patterns during the giving of diagnostic information are described and discussed (Maynard & Frankel, 2006), or based around the development of guidelines and strategies for delivering bad news (Baile et al., 2000; Girgis & Sanson-Fisher, 1995). The most widely quoted guideline in oncology, a six-step protocol for delivering bad news: SETTING up the interview (S); assessing the patient's PERCEPTION of his or her condition (P); obtaining an INVITATION to (I); providing KNOWLEDGE and information to the patient (K); responding empathically to the patient's EMOTIONS (E), and explaining the treatment STRATEGY and providing a SUMMARY of the interview (S), is SPIKES (Baile et al., 2000). SPIKES is based on expert opinion and published by the American Oncologists Association (Baile et al., 2000).
The existing guidelines, including SPIKES have been criticized for not acknowledging the need for a flexible approach and the variety of situations in which bad news is delivered (Eggly et al., 2006). In a meta-synthesis of qualitative studies of breaking bad news in oncology Bousquet et al. (2015) highlighted that one of the communicational challenges in the patient–oncologist encounter was to deal with emotions. Studies have also shown that it is important to deliver bad news in an empathic manner because this reduces the patient's distress and promotes recall of the information given (Van Osch, Sep, Van Vliet, Van Dulmen, & Bensing, 2014). Moreover, patient's value that health care providers acknowledge their reactions and recognize the gravity of the bad news (Back et al., 2011; Fujimori & Uchitomi, 2009; Shaw, Dunn, & Heinrich, 2012). There are individual differences in patients' preferences regarding handling of emotions (Bousquet et al., 2015). It appears important to tailor the providers' communication to the individual patient. Still, little is known of how oncologists preform this tailoring in real time consultations. Maynard and Frankel (2006) studied the delivery of good news and bad news in real time consultations, but they did not focus on the patients' expressions of emotions and how this might influence the delivery of medical news.
Most studies on delivering bad news in cancer care and other medical settings have involved adult patients (Baile et al., 2000) or children (Farrell, Ryan, & Langrick, 2001). We identified only one study with a specific emphasis on adolescents' perspectives on receiving a cancer diagnosis (Stegenga & Ward Smith, 2009) and the focus of this study was the lived experience of being diagnosed with cancer, rather than the communication of the diagnosis. Delivering bad news to AYA patients may pose a particular challenge. Miedema, Hamilton, and Easley (2007) found that AYA survivors had not felt prepared to face a life-threatening disease at their stage of life. Adolescence is a time of strong, often negative, emotions (Arnett, 2014). Results from neuroscience indicate that the traditional subdivision in physical, psychological, and social development might disguise some important insights of the interrelatedness of these developmental domains during adolescence and young adulthood. The results point to how the physiological development and hormonal changes of the brain during adolescence and young adulthood can explain much of the psychological and social development going on at the same time (Casey, Jones, & Hare, 2008). Casey et al. (2008) described how adolescents have a "heightened responsiveness to incentives and socioemotional contexts during this time, when impulse control is relatively immature" (p. 111). Both the physiological development and the hormonal changes contribute to decreased goal-oriented behaviors, organization, planning and impulse control in AYAs compared to adults (Casey et al., 2008; Giedd, 2008; Steinberg, 2010). This may affect AYAs communication style (Colver & Longwell, 2013). The oncologist giving a diagnosis to an AYA may be faced with a strong emotional behavior indicating concern (sadness, surprise, fear, anger, disgust, or shame) (Ekman et al., 1987) and should be prepared to tailor his or her communication style to the individual AYA patient (Stegenga & Ward Smith, 2009). There is, however, a lack of research on how to tailor the delivery of bad news, such as a cancer diagnosis, to AYA patients in general and to AYAs displaying strong emotions in particular. Knowledge about this can be useful for clinicians to be able to personalize communication in this challenging clinical setting (Bousquet et al., 2015).
Our analysis focuses on the pragmatic aspects of communication, that is, the behavioral and relational aspects of communication as opposed to syntax and semantics per se (Watzlawick, Bavelas, & Jackson, 1967). The aim of the present paper thus is to investigate how oncologists delivering cancer diagnoses to AYAs tailored their communication to the patients' expressions of strong emotions (anger, fear, and sadness). We investigated to what extent and how oncologists not only presented medical information in a one-way mode but also engaged in personalized communication behavior with explicit references to the individual patient and possibly also to himself or herself and to the doctor–patient relationship when delivering a cancer diagnosis to AYA patients displaying strong emotions.
The design of the current paper is interpretive and it is based on a pragmatic view of research implying that the research question leads the method and that multiple methods of data collection and analysis can be appropriate to answer this question (Creswell, 2013a, 2013b). We could not find any research on how physicians tailor communication to AYAs displaying strong emotions, therefore we decided to do an in-depth study of communication in real-time consultations. Strong emotions can have different displays, and we applied instrumentive and collective case-study design to be able to investigate the complexity of the issue at study (Creswell, 2013a): how oncologists delivering cancer diagnoses to AYAs tailored their communication to the individual patients' expressions of strong emotions (anger, fear, and sadness)? Yin (2014) supports that such relationship issues are relevant for case studies. Flyvbjerg (2006) holds "that a discipline without exemplars is an ineffective one" (p. 242). We aim to contribute to the discipline of communication in AYA medicine by conducting a case study that provides exemplars of the complex practice of delivering cancer diagnoses to AYA cancer patients displaying strong emotions.
The two cases were taken from a sample of nine audio-recorded consultations from three different hospital wards in Oslo, Norway, in 2012–2013. The nine consultations were sampled to study communication in medical consultations in which oncologists informed AYA patients (12–25 years of age) about a cancer diagnosis and the proposed treatment.
Patients of both sexes were eligible if they were between 12 and 25 years of age at the time of inclusion and were about to be informed about a cancer diagnosis and a subsequent treatment proposal. Moreover, the included patients were required to have adequate Norwegian language proficiencies (no interpreter needed) and to be able to provide informed consent.
We recruited patients from one pediatric ward (aged 12–18 years) and two medical wards for adult patients (aged 19–25 years) at Oslo University Hospital. Eleven patients were invited to participate. Of these patients, one patient refused to participate and one patient terminated the audio recordings and withdrew her consent. A number of eligible patients were not included in the study because of recruitment or logistical problems due to the short timeframe between the patients' arrival at the hospital and the consultations. The exact number of "lost" patients is unknown because the patients often had their treatment at other wards. Patients were recruited to the study between September 2012 and January 2014. The recruitment of patients was challenging, but the audio recordings include the desired age span, female and male patients, and the most common diagnoses at the three different hospital wards. Data collection ended when we considered the amount and quality of the data to be sufficient.
Both audio-recorded consultations took place in the patients' rooms at the oncology wards. In both consultations between oncologist and patient, the patient's mother and a nurse were also present.
The participating oncologists administered the audio recording of the consultations using a small digital voice-recorder placed on the table. We felt the patients had a right to get a copy of their own consultation therefor they received an electronic copy (mp3 format) of his or her consultation about a week later.
The consultations were transcribed verbatim. Profanities were transcribed as "f…" or "s…"; hesitations were transcribed with "eh" or "ehm." Audible nonverbal communication such as pauses and crying has been noted in parentheses. Pauses lasting 2 s or longer are specified in the text. The lines of dialog presented in Tables II–VII are numbered.
Sampling of cases
Although the issue in the current paper pertained to the tailoring of the news, we sampled on AYAs displaying strong emotions. For the current paper we chose two cases following the principles of purposeful intensity sampling (Patton, 2002). Intensity sampling requires some information about potential participants and considerable judgment because it consists of selecting a sample that provides an intense manifestation of the phenomenon of interest (Patton, 2002). LK and AF, using their experience in clinical pediatric oncology nursing (LK), clinical psychology (AF), and communication research (AF), chose the two consultations in which the patients—in one case a male patient with sarcoma and in the other a female patient with leukemia—exhibited a strong, explicit emotional behavior, that is, anger, fear, or sadness. In case study research, one should select data that enable a study of the complexity of the research question and also triangulation of the observations (Hyett, Kenny, & Virginia Dickson-Swift, 2014). Therefore, cases in which the patients displayed contrasting patterns of highly challenging, intensely emotional behavior were chosen.
Background information of the two cases
In both cases, the patients had been told in previous consultations that they might have cancer; however, it was in the consultations that we analyzed that they were given a cancer diagnosis and the proposed treatment was explained. In both cases there was still uncertainty about the exact diagnosis, but the oncologist wanted to start treatment because they had identified the main type of disease, sarcoma (case A), and leukemia (case B). Both oncologists were in their late thirties and worked in adult oncology.
The analysis was an interpretive process in three steps inspired by (Creswell, 2013a). One feature of the analysis is that Discussion is part of the analyzing process (the third step).
First, LK and AF listened to the consultations several times and read the transcripts, independently, in order to identify sequences related to displays of emotional behavior by the patients and how the oncologists responded to these emotional displays. With the information about the aim of the study, the patients and context in mind and in order to triangulate the interpretations, the two analysts (LK an AF) separately identified sequences where the oncologists' communication seemed to be of significance in handling the emotional expressions. For example, both analysts identified sequences of strong expressions of emotion (anger, fear, and sadness) that in some way seemed to affect how the oncologists "did" empathy in the two consultations. Second, the identified sequences were compared and studied in more detail, that is, the example of the different ways to "do" empathy was one of the elements of the oncologists' communicative behavior that seemed relevant to grasp the complexity of the phenomenon at study, see Results. To further reveal the complexity of the cases, the case study report should contain a description of the context of the case (Creswell, 2013a; Hyett et al., 2014), of how it occurs in real-time, and of "the themes or issues that the researcher has uncovered in studying the case" (Creswell, 2013a, p. 99). In Results, the collective context of the two cases as well as the individual contexts of each case is described. Furthermore, to give a sense of story to the presentation (Hyett et al., 2014), the chosen sequences and the analysis of them is presented chronologically for each case. Finally, the third step of the analysis is presented in Discussion where we "analyzed for similarities and differences" (Creswell, 2013a, p. 99) across the two cases. Here, three elements of the oncologists' communicative behavior in the two cases (three overall themes) are discussed. Because the SPIKES protocol (Baile et al., 2000) is so widely used but also because it is criticized for simplifying the delivery of bad news, we chose to relate our findings with the elements in the protocol in Results. This was not done as an analytical tool in Results but to enable further inquiry of how the oncologist communicative behavior relate to the elements in the SPIKES protocol in Discussion. In Discussion, we did an analysis of the overall meaning of the cases and ended up with a conclusion about what people can learn from the case study also called "naturalistic generalizations" (Creswell, 2013a, p. 200).
To ensure the reliability of the analysis we also triangulated the analyses of the two cases by involving all the authors (AVM, HCL, EL, and JHL) in discussions of the interpretations and decisions of presentation. To further explore different ways to interpret the cases, we presented and discussed the analysis of the cases in academic forums.
The Regional Committee for Medical and Health Research Ethics approved the study (reference number 2011/2290). One of the nurses at the wards or the first author (LK) invited the patients, family members, physicians, and nurses to take part in a study in order to investigate real-time communication between AYA cancer patients and health-care providers, and asked for signed consent to audio record the scheduled consultation. The participating patients, parents, oncologists, and nurses provided written consent. The participants had the right to withdraw at any time. To ensure participant confidentiality in the recorded consultations only the members of the research group have listened to the tapes. Personal information about the participants that was not necessary to the transparency of the analysis has been left out to ensure confidentiality in this paper.
Case A: high school male student with sarcoma expressing frustration and anger
At the time of the recorded consultation, the patient had been hospitalized for 3 days. He had previously been admitted to two other hospitals and had undergone multiple tests and examinations to investigate his painful symptoms. At the time of the consultation, the patient was in great pain, and during the consultation, the oncologist informed him that the medical team no longer only presumed but had firmly established that he had a large sarcoma. Eight minutes into the consultation the patient started to express doubts about whether the medical team could help him. The recorded consultation lasted for 21 min.
Early in the consultation, the oncologist explained the results of the CT examination and responded to questions from the patient's mother. The patient responded with sarcastic remarks indicating dissatisfaction with how long the assessment phase had taken. The oncologist concluded by informing the patient that no further examinations would be needed and that they had to wait for all the test results to arrive. So far, the findings indicate a tumor that will respond to chemotherapy (Table I).
In this excerpt, the patient indirectly expressed anger and despair by way of profanities (line 1) and sarcasm (lines 7–8) and also expressed a rather negative attitude to the oncologist. The oncologist, however, did not appear to be influenced by the patient's rudeness. In lines 2–6 and again in lines 9–10, he calmly provided information on why it was considered best to start chemotherapy before surgery ("K" for knowledge in the SPIKES protocol) (Baile et al., 2000).
The patient went on to indicate a wish to seek treatment abroad to speed up surgery, but the mother expressed trust in the medical team. In line 11, Table II, the patient expressed his worry that the tumor will carry on growing:
In line 12, we see a clear shift in the oncologist's communication away from mainly using a rather formal "we" mode and responding to the content of the patient's utterances; here he said, "I realize that you think this is taking too long, John," demonstrating a more personal engagement and showing empathy ("E" for empathy in SPIKES) (Baile et al., 2000), acknowledging that the patient had reason to be impatient. Although he did not explore the patient's emotion he remained patient, using pauses in lines 15 and 22 to give the patient space to react. In line 17, the oncologist explicitly asked if the patient was up for starting treatment ("S" for summary in SPIKES) (Baile et al., 2000). The patient did not answer the question about willingness, instead he asked about hair loss in line 18.
At this point, the oncologist went on to say that they needed to give the patient a Central Venous Device (CVD) to give the chemotherapy safely. He said that they would insert it the next day. The patient's reaction is given in Table III.
In lines 23–24, the patient once again expressed his skepticism that the medical team would be able to help him and said explicitly "I am f(…) aware that I will die." The oncologist continued his straightforward responses and addressed the content and not the emotional component of the patient's utterances (line 25). In lines 27–30, the oncologist once again raised the issue of the patient's readiness to proceed, saying: "We need you to be up for it. If not there is no use in doing what we plan to do." The patient gave his consent in line 31: "No, I'm in but."
After a summary of the conclusions and decisions from the consultation and a few questions and responses, the consultation ended.
Case B: young woman with leukemia expressing sadness and despair
Two days prior to the recorded consultation, the patient had a scheduled pregnancy follow-up appointment with her GP. She was pale and tired, but she thought it was due to her pregnancy. The GP ordered blood tests. Because the hematological findings (white cell count, hemoglobin and platelet count) were abnormal, the patient was referred to the hospital for further tests. Prior to the recorded consultation, the patient had been told she probably had leukemia. She had also been told that it would be necessary to terminate the pregnancy because of the negative effects of chemotherapy on the fetus. The recorded consultation lasted for 9.5 min.
The oncologist started the consultation by eliciting the patient's perspective, asking if the patient had "thought any more about what happens next?" (An illustration of "P" in the SPIKES protocol (Baile et al., 2000)) (Table IV):
The oncologist went on to discuss the abortion procedure but returned quickly to the patient's perspective (Table V):
The oncologist continued by giving information about the deep-freezing of ovarian tissue and concluded, "There are some patients who stay fertile anyway, but it is difficult to say in advance." The patient's reaction is as follows in Table VI.
In lines 51, 54, 59, 63, 66, 69, and 72, we see how the patient expressed strong emotion: she talked in a weak, pained voice, cried, and sobbed. The oncologist responded by giving detailed information about the abortion procedure, the possible harvesting of ovarian tissue and finally about the diagnosis and treatment ("K" for knowledge in SPIKES), not included in dialog samples (Baile et al., 2000). Maybe more striking than the oncologist's approach to information giving is her empathic communication, the "E" in SPIKES (Baile et al., 2000). Her response to the patient's emotional behavior was explicitly empathetic, "yes, yes I can understand that you are devastated about that, you know" (line 50) and "and this is what you have wanted for so long" (line 56). She also explored the patient's emotions (lines 47–48) by asking, "Do you think like that because you have had so much trouble getting pregnant?." Like the oncologist in case A, the oncologist in case B also showed patience and left long pauses to open up space for the patient's reaction (lines 55, 60, and 73). Moreover, the oncologist also expressed hope, saying "…there is a good chance this will work out" (line 61), "this is a disease that usually responds very well to chemotherapy" (line 67), and "so there is a good chance that you will be cancer-free when we get to the time when it is possible to freeze" (lines 70–71). Again like the oncologist in case A, the oncologist in case B used the personal pronoun "we" when she was giving medical information but the more personal "I" when she was expressing empathy (Table VII):
In the final excerpt, we see that the oncologist continued her empathic communication by saying "Mm. It is very much for you in a short day" (line 83) and "yes, you will do that, for sure. It is a huge shock now, but then the days go by and then you will manage very well, I'm sure about that. Okay?" (lines 86–87). In case B, the oncologist did not explicitly ask for the patient's consent to start treatment, but the patient implied it herself saying "yes, it is (sniffles and mumbles, pause 3 s) I think so, I will get through this (on the verge of tears)" in line 84–85 after the oncologist had given information in an empathic way.
The oncologist summarized by saying that the patient will need to have the abortion first and that when they receive the results of all the tests she would tell the patient exactly what her treatment would involve. This brought the consultation to an end.
This inductive qualitative analysis of communication between two AYA oncology patients displaying strong emotions and their oncologists illustrates the complexity of challenges that may arise in the treatment of AYA patients.
Both patients' behavior was characterized by strong emotional displays. They both expressed their emotions indirectly, with few if any explicit verbal expressions of emotion. The patient in case A displayed his emotions in ways typical of adolescents, using profanities and sarcasm which are seen less often in more mature patients (Arnett, 2014). The patient in case B, who found herself in a life crisis specific of a young female patient, faced with concerns about a forthcoming abortion and future reproductive potential (Knight et al., 2015), expressed her emotions nonverbally.
Moreover, both patients had strong preferences for immediate interventions. The patient in case A wanted an immediate operation and had little tolerance for the strategy chosen by the oncologist (chemotherapy before surgery), while the patient in case B preferred her eggs cells to be conserved as soon as possible.
In this discussion, we focus on the relational aspects of communication and on the behaviors, skills, and strategies that the oncologist apply to tailor the communication to the individual patients. We have identified five such behaviors that may be described in terms of interactive tasks to be performed by the oncologist, more or less corresponding to elements in the SPIKES protocol (Baile et al., 2000). First, one of the oncologists actively elicited the patient's perspective in order to handle the strong emotions of the patient (Eliciting Patient Perspective in the SPIKES protocol). Second, both oncologists provided information to the patients. In this information, (knowledge in the SPIKES protocol) the oncologists did not refer to the patient or him/herself. Third, both oncologists tailored their empathic response to the individual patients' emotional displays by acknowledging and containing patients' emotions (empathy in the SPIKES protocol). Fourth, the oncologists not only provided information about treatment but also took pains throughout the consultation to ensure that the patient, his or her strong emotions notwithstanding, understood and accepted the proposed treatment (strategy and summary in the SPIKES protocol). And finally, fifth, the oncologists promoted hope tailored to the emotional displays of the individual patient (strategy and summary in the SPIKES protocol). In Tables I–VII, the interactive tasks performed by the oncologists are referred to in brackets. Interestingly, the oncologists' communication involved frequent shifts in choice of personal pronouns, shifting from the first person plural to, as well as frequent uses of second person (you), the first person singular to communicate personal engagement and emphasis on the doctor–patient relationship in the dialog (Table VIII).
Elicit the patients' perspective: The P for patient perception in SPIKES was only seen in case B. The interactive task performed by the oncologist in case B was to elicit the patient perspective. The patient was referred to directly and in a personal way as "you": "…have you thought more about what happens next?" (line 32).
Provide information: Skelton, Wearn, and Hobbs (2002) reported that the personal pronoun "we" was used more often than "I" in medical consultations; "we" was used in talking about actions, for instance when recommending a particular treatment, whereas "I" was followed by words referring to the oncologist's thoughts. We observed something similar in our recorded consultations (Table VIII). The oncologists used the first person plural "we" when they provided information about medical assessments and treatment plans: "If we are not starting up with chemo now, then you need surgery fast." In this strategy, the interactive task performed by the oncologists did not refer to the patient or the oncologists as him/herself but to the medical team (we). This reference to the medical team (we) might be a way for the oncologist to reassure the patient that the oncologist is not alone doing medical deliberations. Nevertheless, we suggest that oncologists' use of the impersonal "we" can also be understood as a way of distancing themselves from personal engagement and responsibility.
Acknowledge patients' emotion
Both oncologists responded explicitly to the patient's expression of emotion. They acknowledged the emotion of the patient with reference to themselves and the patient by using the more personal first "I" and second person "you" when they made empathic statements: "I realize that you think this takes too long……to you this takes too long" (case A, lines12 and 13), and "Yes, yes I can understand that you are devastated about that" (case B, line 50).
In a recent discussion of the SPIKES protocol, Van Vliet and Epstein (2014) pointed out severely ill patients need to both know and understand and to feel known and understood in clinical communication. The latter requirement implies that clinical staff must be competent in handling emotions, and Van Vliet and Epstein suggested a special emphasis on empathy in the process of delivering bad news to patients with severe disease. The NURSE model (Name the emotion; Express understanding; Respect, Support, and Explore the emotion) (Pollak et al., 2007; Smith & Hoppe, 1991) is a guideline, which places more emphasis on empathy than the SPIKES protocol (Baile et al., 2000). Both the SPIKES (Baile et al., 2000) and the NURSE (Pollak et al., 2007; Smith & Hoppe, 1991) protocols emphasize the importance of the doctor responding in an empathic manner and provide examples of how to demonstrate empathy verbally: ("I am sorry that the x-rays show…") and behaviorally ("moves your chair closer…."). The "E" in SPIKES prompts the doctor to acknowledge major emotions as they arise (Baile et al., 2000). The NURSE model additionally encourages the clinician to respect the patient's emotions (Pollak et al., 2007; Smith & Hoppe, 1991).
In our data, we observed how emotions were acknowledged in both cases but with an explicit naming and expression of understanding of specific emotions only in case B ("I understand that you are devastated…" (line 50)). In her theory of suffering, Morse (2001) points out that a patient in a state of emotional suffering who is displaying his or her emotions openly requires comfort, and both active acknowledgment of emotions and expressions of hope may be comforting the patient.
Contain patients' emotions
A strategy of actively acknowledging emotions was supplemented by more passively containing the emotional expressions and leaving long pauses that opened up for the patient to react, most notably seen in case A. The patient in case A did not express his emotions explicitly, but they were implicitly expressed in his use of profanities, sarcasm, and expressions of distrust. The oncologist patiently tolerated the patient's outbursts ("Yes, that's a good question," line 2) and gave respectful comments in a matter-of-fact way. Half way into the consultation, he markedly altered his communication style and started to address John in a more personal manner: "I realize that you think this is taking too long, John" (line 12). However, he still did not explore, or even name, the patient's emotions but continued in a calm and patient way of talking with long pauses (lines 15 and 22), calm responses to profanities (line 21), and a somewhat downplayed way of expressing hope ("our plan is not you will die," line 25).
The literature on handling emotions in medical consultations, including the NURSE model, tends to emphasize the value of explicit empathic statements and on exploring patients' emotions (Baile et al., 2000; Pollak et al., 2007; Smith & Hoppe, 1991; Zimmermann et al., 2011). Rather than exploring emotions or giving empathic statements, the oncologist in case A contained the emotions without commenting on the emotion.
The oncologist applied a containment strategy, as described by Back and Arnold (2013). The authors point out that patients in emotional chaos may display an emotional volatility, which when started, may spiral out of control. Exploration of emotion may actually trigger resistance. An alternative strategy is an enduring patience and containment of emotions as seen in case A. Similarly, Morse (2001) suggested that doctors should patiently respect but not actively explore the suppressed emotions of patients which are expressed indirectly through profanities and sarcasm, as was the case with the patient in case A.
A containment strategy such as the one the oncologist in case A used is rarely described or discussed in the communication literature in the field of somatic medicine. However, in psychotherapy theory the therapist's tolerance of and patience with the patient's emotions referred to as "containing" is recognized as an important part of the psychotherapeutic relationship (Brown, 2012). Back and Arnold (2013) hold that containment is often required in patient groups that have "high incidence of emotional volatility, low self-regulation, and high impulsiveness" (p. 1431). AYA patients fit well into such a description because they are developmentally prone to behave in a less-controlled manner than adults (Arnett, 2014; Colver & Longwell, 2013).
Encourage commitment to treatment
In most medical consultations, the doctor and the patient agree about treatment and establish common ground without explicitly saying so (Syse, 2009). Some argue that the fact that a patient is at the hospital talking to the doctor is a form of consent to treatment (Syse, 2009). The final step in SPIKES is described as "strategy and summary" and its aim is to provide the patient with a clear plan for the future to reduce unnecessary uncertainty and anxiety (Baile et al., 2000). In our two cases, the oncologists not only summarized at the end of the consultations, they promoted acceptance of treatment throughout the consultations, eliciting statements of consent from the patients: "I'm in" (line 31) and "I think so, I will get through this" (lines 84–84). In case A, the oncologist used the impersonal "we" when addressing the patient as "you" to encourage commitment to treatment "we need you to be up for it." In case B, the oncologist did not perform any explicit interactive task to encourage commitment to treatment. The way in which the both oncologists seemed to follow the patients' lead (Bousquet et al., 2015; Mack & Grier, 2004) and tailored their empathic responses and provision of medical information to the particular AYA patient with whom they were dealing seem equally important to achieving consent to the proposed treatment. By promoting an acceptance throughout the consultation, the oncologists displayed a communicative strategy that in addition to the content level of communication (to get a consent form the patient) also acknowledges that this consent has a relationship aspect (Watzlawick et al., 1967).
Provide hope
The finale communicative strategy, to provide hope, found in our case study is also associated with the S for strategy (and summary) in SPIKES. The interactive task performed in this strategy was to present optimistic projections. Optimistic projections can be misplaced if they are delivered prematurely or in a way not appropriate for the individual patient (Back, Arnold, Baile, Tulsky, & Fryer-Edwards, 2005; Ryan et al., 2005). Conversely, the oncologists in the two cases studied seemed to tailor their optimistic projections to the patients' emotional displays described by Morse (2001) as two distinct emotional states (enduring and emotional suffering) (see above, Morse). In case A, the oncologist used WE, but added YOU to make it more personal: "Our plan is not that you will die" (line 25) and "it's our goal … you will get well" (lines 28–29). The oncologist did not make any promises he could not keep, but he said that it was not their plan that the patient should die. In case B, on the other hand, the oncologists used a number of expressions to promote hope, for example, "So there is a big chance…" (line 70). She was more personal, using I, than the oncologist in case B in conveying hope according to the emotional suffering state of the patient.
The oncologists tailored their empathic response to the emotions expressed by the AYA. Because of the strong and salient nature of the emotional responses in these two consultations, the oncologists adjusted their communication to the patients' emotional behavior throughout the consultation, but with more emphasis on acknowledging and containing rather than exploring them. Our results illustrate how expressions of empathy can be tailored to the individual patient and to the nature of his or her emotional response (anger in case A; sadness in case B) when delivering bad news to AYAs.
By tailoring their communicative behavior in the interactive tasks described above, the oncologists define their relationship with the patient. Sometimes the tailoring is done with words or other active behavior. At other times, it is done more passively by showing patience and allowing long pauses. This finding illustrates how all behavior is communication, also a long pause (Watzlawick et al., 1967).
Limitations and strengths
This study is based on two purposefully sampled consultations, in which we analyzed oncologists' communication with AYA patients who displayed strong emotions. It would be interesting to see if similar communicative behaviors are used in a larger sample of similar bad news, highly emotive consultations with patients from different age groups. The main limitation of our study is that the analysis is based on our interpretations of our observations; we do not know if the oncologists or the patients would agree with our account. Interviews with the parties involved in the consultations would be a useful supplement to our observations and would increase the validity of our interpretations. It would also be interesting to let the patients and oncologists listen to the audiotapes and give us their interpretation of what was going on.
We based our analysis on audio-recordings of consultations, thus limiting analysis to audible aspects of the communication. Although video-recording the consultations would have provided richer information, we deemed it more considerate and less intrusive to use audio recording in such a critical situation.
We have neither considered the family members' or nurses' roles in the consultations nor the possible effects of the sex of the patients and the oncologists. To do so might have added information to our study but we do not think it would change our conclusions about the oncologists' communicative behavior.
The main strength of this study is that it is based on audio-recordings of genuine consultations between AYAs and oncologists at the time of cancer diagnosis, and there is little research available on this topic. Furthermore, the two cases provide examples of AYAs expressing strong emotions in ways, which will be familiar to clinicians.
Conclusion and practical implications
AYAs are more likely than younger and older patients to display strong negative emotions, due to their developmental stage (Arnett, 2014). We suggest that a tailored eliciting of the patient perspective, providing of information, responding to patient's expressions of emotion (acknowledgement and containment), encouragement to commitment to treatment, and providing of hope are communication strategies to use in the delivery of bad news, in these cases a cancer diagnosis. Studies of how oncologists can tailor the delivery of bad news to the individual patient in ways that capture more of the complexity of patients communicative styles than the much used SPIKES protocol (Baile et al., 2000) have been requested (Bousquet et al., 2015). Based on a case study of two real-time consultations, the current study provides such knowledge. The study provides exemplars to clinicians of how communication with AYAs displaying strong emotions may unfold and adds to the knowledge base of the delivery of bad news in oncology in general and in AYA oncology in particular.
Further studies are needed to document general patterns of communication in the delivery of bad news to AYA cancer patients, to investigate the participants' (patients, parents and health-care providers) experiences and opinions, and to investigate potential associations between communicative behaviors and outcomes such as patient satisfaction and adherence to treatment.
The authors would like to thank the participating patients, parents, oncologists, and nurses for giving us the opportunity to study real-time communication in a sensitive clinical situation. We are also grateful to have had the opportunity to collect our data at Oslo University Hospital.
Arnett, J. J. (2014). Adolescence and emerging adulthood (5th ed. Pearson New International Edition. ed.). Boston, MA: Pearson.
Back, A. L., & Arnold, R. M. (2013). "Isn't There Anything More You Can Do?": When empathic statements work, and when they don't. Journal of Palliative Medicine, 16(11), 1429–1432. doi: http://dx.doi.org/10.1089/jpm.2013.0193 PubMed Abstract | Publisher Full Text
Back, A. L., Arnold, R. M., Baile, W. F., Tulsky, J. A., & Fryer-Edwards, K. (2005). Approaching difficult communication tasks in oncology. Ca: A Cancer Journal for Clinicians, 55(3), 164–177. Publisher Full Text
Back, A. L., Trinidad, S. B., Hopley, E. K., Arnold, R. M., Baile, W. F., & Edwards, K. A. (2011). What patients value when oncologists give news of cancer recurrence: Commentary on specific moments in audio-recorded conversations. The Oncologist, 16(3), 342–350. doi: http://dx.doi.org/10.1634/theoncologist.2010-0274 PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5(4), 302–311. doi: http://dx.doi.org/10.1634/theoncologist.5-4-302 PubMed Abstract | Publisher Full Text
Bousquet, G., Orri, M., Winterman, S., Brugiere, C., Verneuil, L., & Revah-Levy, A. (2015). Breaking bad news in oncology: A metasynthesis. Journal of Clinical Oncology, 33(22), 2437–2443. doi: http://dx.doi.org/10.1200/jco.2014.59.6759 PubMed Abstract | Publisher Full Text
Brown, L. J. (2012). Bion's discovery of alpha function: Thinking under fire on the battlefield and in the consulting room. The International Journal of Psychoanalysis, 93(5), 1191–1214. doi: http://dx.doi.org/10.1111/j.1745-8315.2012.00644.x PubMed Abstract | Publisher Full Text
Casey, B., Jones, R. M., & Hare, T. A. (2008). The adolescent brain. Annals of the New York Academy of Sciences, 1124(1), 111–126. doi: http://dx.doi.org/10.1196/annals.1440.010 PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Colver, A., & Longwell, S. (2013). New understanding of adolescent brain development: Relevance to transitional healthcare for young people with long term conditions. Archives of Disease in Childhood, 98(11), 902–907. doi: http://dx.doi.org/10.1136/archdischild-2013-303945 PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Creswell, J. W. (2013a). Qualitative inquiry & research design: Choosing among five approaches (3rd ed.). Los Angeles, CA: Sage.
Creswell, J. W. (2013b). Research design: Qualitative, quantitative, and mixed methods approaches. Los Angeles, CA: Sage.
Eggly, S., Penner, L., Albrecht, T. L., Cline, R. J., Foster, T., Naughton, M., et al. (2006). Discussing bad news in the outpatient oncology clinic: Rethinking current communication guidelines. Journal of Clinical Oncology, 24(4), 716–719. doi: http://dx.doi.org/10.1200/JCO.2005.03.0577 PubMed Abstract | Publisher Full Text
Ekman, P., Friesen, W. V., O'Sullivan, M., Chan, A., Diacoyanni-Tarlatzis, I., Heider, K., et al. (1987). Universals and cultural differences in the judgments of facial expressions of emotion. Journal of Personality and Social Psychology, 53(4), 712. doi: http://dx.doi.org/10.1037/0022-35220.127.116.112 PubMed Abstract | Publisher Full Text
Fallowfield, L., & Jenkins, V. (2004). Communicating sad, bad, and difficult news in medicine. The Lancet, 363(9405), 312–319. doi: http://dx.doi.org/10.1016/S0140-6736(03)15392-5 Publisher Full Text
Farrell, M., Ryan, S., & Langrick, B. (2001). 'Breaking bad news' within a paediatric setting: An evaluation report of a collaborative education workshop to support health professionals. Journal of Advanced Nursing, 36(6), 765–775. doi: http://dx.doi.org/10.1136/bmj.323.7311.521a PubMed Abstract | Publisher Full Text
Flyvbjerg, B. (2006). Five misunderstandings about case-study research. Qualitative Inquiry, 12(2), 219–245. doi: http://dx.doi.org/10.1177/1077800405284363 Publisher Full Text
Fujimori, M., & Uchitomi, Y. (2009). Preferences of cancer patients regarding communication of bad news: A systematic literature review. Japanese Journal of Clinical Oncology, 39(4), 201–216. doi: http://dx.doi.org/10.1093/jjco/hyn159 PubMed Abstract | Publisher Full Text
Giedd, J. N. (2008). The teen brain: Insights from neuroimaging. Journal of Adolescent Health, 42(4), 335–343. doi: http://dx.doi.org/10.1016/j.jadohealth.2008.01.007 PubMed Abstract | Publisher Full Text
Girgis, A., & Sanson-Fisher, R. W. (1995). Breaking bad news: Consensus guidelines for medical practitioners. Journal of Clinical Oncology, 13(9), 2449–2456. PubMed Abstract
Hyett, N., Kenny, A., & Virginia Dickson-Swift, D. (2014). Methodology or method? A critical review of qualitative case study reports. International Journal of Qualitative Studies on Health and Well-being, 9, 23606. doi: http://dx.doi.org/10.3402/qhw.v9.23606 PubMed Central Full Text | Publisher Full Text
Keegan, T. H., Lichtensztajn, D. Y., Kato, I., Kent, E. E., Wu, X.-C., West, M. M., et al. (2012). Unmet adolescent and young adult cancer survivors information and service needs: A population-based cancer registry study. Journal of Cancer Survivorship, 6(3), 239–250. doi: http://dx.doi.org/10.1007/s11764-012-0219-9 PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Kent, E. E., Parry, C., Montoya, M. J., Sender, L. S., Morris, R. A., & Anton-Culver, H. (2012). "You're too young for this": Adolescent and young adults' perspectives on cancer survivorship. Journal of Psychosocial Oncology, 30(2), 260–279. doi: http://dx.doi.org/10.1080/07347332.2011.644396 PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Knight, S., Lorenzo, A., Maloney, A. M., Srikanthan, A., Donen, R., Greenblatt, E., et al. (2015). An approach to fertility preservation in prepubertal and postpubertal females: A critical review of current literature. Pediatric Blood and Cancer, 62(6), 935–939. doi: http//dx.doi.org/10.1002/pbc.25440 PubMed Abstract | Publisher Full Text
Mack, J. W., & Grier, H. E. (2004). The day one talk. Journal of Clinical Oncology, 22(3), 563–566. doi: http://dx.doi.org/10.1200/JCO.2004.04.078 PubMed Abstract | Publisher Full Text
Maynard, D. W., & Frankel, R. M. (2006). On diagnostic rationality: Bad news, good news, and the symptom residue. Studies in Interactional Sociolinguistics, 20, 248.
Miedema, B., Hamilton, R., & Easley, J. (2007). From "invincibility" to "normalcy": Coping strategies of young adults during the cancer journey. Palliat Support Care, 5(1), 41–49. doi: http://dx.doi.org/10.1017/S147895150707006X PubMed Abstract
Morse, J. M. (2001). Toward a praxis theory of suffering. Advances in Nursing Science, 24(1), 47–59. doi: http://dx.doi.org/10.1097/00012272-200109000-00007 PubMed Abstract | Publisher Full Text
Patton, M. Q. (2002). Qualitative research and evaluation methods. Thousand Oaks, CA: Sage.
Pollak, K. I., Arnold, R. M., Jeffreys, A. S., Alexander, S. C., Olsen, M. K., Abernethy, A. P., et al. (2007). Oncologist communication about emotion during visits with patients with advanced cancer. Journal of Clinical Oncology, 25(36), 5748–5752. doi: http://dx.doi.org/10.1200/jco.2007.12.4180 PubMed Abstract | Publisher Full Text
Ryan, H., Schofield, P., Cockburn, J., Butow, P., Tattersall, M., Turner, J. et al. (2005). How to recognize and manage psychological distress in cancer patients. European Journal of Cancer Care, 14(1), 7–15. doi: http://dx.doi.org/10.1111/j.1365-2354.2005.00482.x PubMed Abstract | Publisher Full Text
Schofield, P., Butow, P., Thompson, J., Tattersall, M., Beeney, L., & Dunn, S. (2003). Psychological responses of patients receiving a diagnosis of cancer. Annals of Oncology, 14(1), 48–56. doi: http://dx.doi.org/10.1093/annonc/mdg010 PubMed Abstract | Publisher Full Text
Shaw, J., Dunn, S., & Heinrich, P. (2012). Managing the delivery of bad news: An in-depth analysis of doctors' delivery style. Patient Education and Counseling, 87(2), 186–192. doi: http://dx.doi.org/10.1016/j.pec.2011.08.005 PubMed Abstract | Publisher Full Text
Skelton, J. R., Wearn, A. M., & Hobbs, F. R. (2002). 'I' and 'we': A concordancing analysis of how doctors and patients use first person pronouns in primary care consultations. Family Practice, 19(5), 484–488. doi: http://dx.doi.org/10.1093/fampra/19.5.484 PubMed Abstract | Publisher Full Text
Smith, R. C., & Hoppe, R. B. (1991). The patient's story: Integrating the patient-and physician-centered approaches to interviewing. Annals of Internal Medicine, 115(6), 470–477. doi: http://dx.doi.org/10.7326/0003-4819-115-6-470 PubMed Abstract | Publisher Full Text
Stegenga, K., & Ward Smith, P. (2009). On receiving the diagnosis of cancer: The adolescent perspective. Journal of Pediatric Oncology Nursing, 26(2), 75–80. doi: http://dx.doi.org/10.1177/1043454208328767 PubMed Abstract | Publisher Full Text
Steinberg, L. (2010). A behavioral scientist looks at the science of adolescent brain development. Brain and Cognition, 72(1), 160–164. doi: http://dx.doi.org/10.1016/j.bandc.2009.11.003 PubMed Abstract | PubMed Central Full Text | Publisher Full Text
Syse, A. (2009). Pasientrettighetsloven: Med kommentarer (The Patients' Rights Act, with comments). Oslo: Gyldendal Akademisk.
Van Osch, M., Sep, M., Van Vliet, L. M., Van Dulmen, S., & Bensing, J. M. (2014). Reducing patients' anxiety and uncertainty, and improving recall in bad news consultations. Health Psychology, 33(11), 1382–1390. doi: http://dx.doi.org/10.1037/hea0000097 PubMed Abstract | Publisher Full Text
Van Vliet, L. M., & Epstein, A. S. (2014). Current state of the art and science of patient-clinician communication in progressive disease: Patients' need to know and need to feel known. Journal of Clinical Oncology, 32(31), 3474–3478. doi: http://dx.doi.org/10.1200/jco.2014.56.0425 PubMed Abstract | Publisher Full Text
Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradoxes. New York: Norton.
Yin, R. K. (2014). Case study research: Design and methods. Los Angeles, CA: Sage.
Zebrack, B. J., Corbett, V., Embry, L., Aguilar, C., Meeske, K. A., Hayes-Lattin, B., et al. (2014). Psychological distress and unsatisfied need for psychosocial support in adolescent and young adult cancer patients during the first year following diagnosis. Psycho-Oncology, 23(11), 1267–1275. doi: http://dx.doi.org/10.1002/pon.3533 PubMed Abstract | Publisher Full Text
Zimmermann, C., Del Piccolo, L., Bensing, J., Bergvik, S., De Haes, H., Eide, H., et al. (2011). Coding patient emotional cues and concerns in medical consultations: The Verona coding definitions of emotional sequences (VR-CoDES). Patient Education and Counseling, 82(2), 141–148. doi: http://dx.doi.org/10.1016/j.pec.2010.03.017 PubMed Abstract | Publisher Full Text
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|Houghton - Packhouse 'Professional Four Deck Livestock Transporter' - Lawsons Haulage Ltd., Cockermouth, Cumbria - with Wm. Armstrong Scania R440.
|An impressive Houghton - Packhouse 'Professional Four Deck Livestock Transporter' in the fleet of Lawsons Haulage, Cockermouth being hauled by a 2011 Scania R440 (PX61 CXJ) from the fleet of Wm. Armstrong of Longtown, pictured at Poplar 2000 Services, Lymm, Cheshire on 10th May, 2013. For more on Houghton - Packhouse - www.houghtons.com/en/products/live-stock-transport/profes...
|M6 Lymm Warrington WA13 0SP United Kingdom
|Distance From Village Centre
|4.37 miles away
|Image Hits
|Date Taken
|May 10, 2013
|Camera Used
|Transport In The Frame
|Photographer Name
|Photographer Address


text:
Hide Plug-ins from Editors
I have just installed your plug-in and am wanting to 'hide' the plugins from any editors.
is this possible with your plugin.
Thank you
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Summary:Daniel has his own celebration in mind
Rating: PG-13
A/N: Written for daniel_vala. Thanks to campy for this prompt!
"I think Cameron is drunk already…" Vala announced conspiratorially as she threw herself down into the chaise Daniel was lounging against.
He snorted, opening his eyes to give her an incredulous look over his sunglasses. It was irrelevant to him that the sun had started to make its western descent already.
"I think Cameron has been drunk for three days."
Vala giggled, staring intently down into the tall, oddly shaped glass in her hands. She stuck the straw between her teeth and slurped.
While she was focused on drinking, Daniel shifted into a more upright position and pulled her between his legs.
She let out a sound between a squeak and a laugh. "Darling, wha-"
Daniel cut her off with a hungry kiss, enjoying the taste of Hurricane on her tongue. She was almost pliant at his touch, moaning softly as his fingers caressed the exposed skin at her hips courtesy of her too short shirt.
"Let's stay in tonight." He murmured after pulling his lips from hers noisily. He rested his forehead against hers, moving his hands up to cup the sides of her face.
Vala laughed lightly with surprise. "What?"
He caressed her cheeks with his thumbs, smudging the glittery face makeup she'd had painted on. "Let's stay in." He repeated on a whisper.
"But Daniel," Vala pulled away from him, pushing his sunglasses up into his hair so she could see his eyes. "Tonight is Mardi Gras – the night to party and revel in all forms of debauchery…but publically!"
"I don't care about publically-"
She pouted at him in a fashion that was only Vala. "But I want beads!"
Daniel grinned a Cheshire Cat grin. "I've got plenty of beads to give you…" It was true. He'd gone out of his way to find a whole slew of beads with the hope that Vala would agree to their own personal Mardi Gras.
"Really?" Vala smiledly excited, leaning in so her lips were hovering just inches from his.
Licking his lips, Daniel happily accepted the tantalizing kiss Vala placed there. "Yep." He gazed at her naughtily. "All you've got to do is…" His eyebrows jerked suggestively. "Show me your goodies."
Vala purred appreciatively, capturing his bottom lip between her teeth. Daniel groaned with pleasure before capturing her mouth in another heated kiss. He shifted her on the seat, moving with her so he could lift her into his arms as he stood.
Her legs hooked around his waist like they belonged there. Pulling her lips away from his with another loud slurp, Vala grinned and brought the straw of her drink to her mouth. Ever the 'professional', she had yet to relinquish her hold on it. Daniel kissed the inside of her arm wrapped around his neck tenderly before giving her a seemingly out of place look of love.
Giggling, Vala dropped the arm to place her cheek down on his shoulder. Her lips found their way to his neck, placing soft kisses there. She wrapped her other arm around him and let her dangling glass tap coolly against the back of his neck.
With beads and goodies clouding their minds, they made their way back to their room. They would leave the 'cultural experience' down on the streets to everyone else.
A/N: Sorry for the massive LJ fail. No matter what I did, I could not get this fic to post right. I finally just said 'fuck it' and posted. As always, comments and feedback are definitely appreciated.


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Information technology tools and resources at the UW
Husky OnNet Service Feature Updates and RoadMap
The Husky OnNet team reviews pending & proposed service features and updates this list each month. See the table below for the current service items under development and consideration. If you have questions, or would like to recommend or request service features or capabilities for Husky OnNet, please contact: firstname.lastname@example.com.
Thank you! Jan Eveleth, Husky OnNet Owner and Tobin Wood, Husky OnNet Manager
Pending = in development or awaiting development schedule
Proposed = ideas for features not yet confirmed for development
|Service Feature
|Pending /Proposed
|Estimated Delivery
|Estimated Cost
|Husky OnNet – Department (HON-D) Service
New est: Fall 2017
Original target: Spring 2017
|$560 one-time set-up fee; $52/mo recurring fee
|This service will support depts/units that would like encrypted, authorized access into their specific network subnets. The Husky OnNet-Department (HON-D) service will use a customer-managed UW Group to determine authorized access.
|Linux client support
New est: fall 2017
|Husky OnNet runs on the F5 APM device. The APM device currently runs on version 12.x. The vendor recommends UW upgrade to 13.1 when it is available -possibly summer 2017. 13.1 will include support for the Linux plug in client.
|New WIN and MacOS client packages from UWare
|late summer/ early fall 2017
|The vendor advises keeping the client apps in synch with the central APM version. New version packages for the WIN and MacOS clients will be prepared and delivered when the APM is updated to 13.1.
|Device Authorization for use with Husky OnNet Departmental Slice
|By adding device authorization, a department may use two authentications for access to their Husky OnNet Slice service: 1) UW NetID via UW Groups and 2) device MAC.
Update 6/15/17: initial review finds that the device MAC info is not provided to the central f5 device precluding an authorization step facilitated by the central device.


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United Kingdom - £ - English
- Store Finder
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Tube Skirts
Score some serious style points this summer with New Look's gorgeous range of tube skirts. From timeless black bodycons that look perfect paired with striped tops to stylish patterns and prints that make the trend a new season essential.
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Emerging from Ann Arbor in Michigan amidst a countercultural revolution, The Stooges' powerful and aggressive style of rock and roll blew a crater in the musical landscape of the late 1960s. Assaulting audiences with a blend of rock, blues, R&B, and free jazz, the band planted the seeds for what would be called punk and alternative rock in the decades that followed.
Jarmusch's documentary chronicles the story of The Stooges emergence and relates their adventures and misadventures while charting their inspirations and the reasons behind their initial commercial challenges, as well as their long lasting legacy.
Gimme Danger is out in the US now and arrives in the UK on 18 November.


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- Retraction Regarding Emma Squires Committment
- Margot Hetzke Named Student Assistant Coach
- Safiya Grant Returns As Siena Women's Assistant
- Margo Peterson Commits To Siena
- Oduro Named To Canadian U19 Team
- Bisping To Begin Pro Career In Sweden
- Marquis Wright To Work Out For Washington Wizards
- Christian Bentley Commits To Siena
- Siena Women Receive Commitment From Amari Anthony
- Siena's Gotham Classic Schedule Announced
Siena To Play in 2015 2K Classic
- Updated: April 20, 2015
What do the 2015 National Champion Duke Blue Devils, national runner-up Wisconsin, Georgetown, VCU and Siena have in common? All have been chosen along with Bryant, Prairie View A&M and Radford to take part in the 2015 2K Classic benefiting Wounded Warrior Project this coming November.
National Champion Duke, national runner-up Wisconsin, and NCAA Tournament participants Georgetown and VCU will play in the Championship Rounds of the 21st annual 2K Classic at Madison Square Garden, and each of the four schools will host two Regional Round games.
So, the Saints are assured of playing Regional Round games at two of the four top teams (Duke, Wisconsin, Georgetown and VCU) and two Subregional Round games amongst the other teams in a pair of doubleheaders to be hosted by Bryant on Nov. 20 and 21.
Duke, Wisconsin, Georgetown, and VCU combined for a 119-29 record this season and 104 NCAA Tournament appearances, including 25 Final Fours, overall.
Matchups for the Championship Rounds, Regional Rounds, and Subregional Round will be announced at a later date. While no date has been provided regarding the announcement of the full schedule and matchups for this year's event, last year's schedule was made public in early September.
Here are the profiles of the 2015 Field:
National Champion Duke Blue Devils – Head Coach: Mike Krzyzewski (Atlantic Coast Conference)
Hall of Fame head coach Mike Krzyzewski, the winningest coach in college basketball history with 1,018 wins, led the Blue Devils to their fifth National Championship and a 35-4 record this past season…Duke has a roster boasting only one senior and could return six letterwinners next year…the Blue Devils currently have four McDonald's All-Americans on their roster and will welcome two more (Luke Kennard and Chase Jeter) to next year's squad…Duke will be making its third appearance in the 2K Classic benefiting Wounded Warrior Project (1999 and 2008), winning the 2008 title.
National Runner-Up Wisconsin Badgers – Head Coach: Bo Ryan (Big Ten Conference)
Head coach Bo Ryan is Wisconsin's all-time leader in wins, amassing 357 victories in just 14 seasons…the Badgers claimed the Big Ten regular-season and tournament titles with a 16-2 league mark to go along with a 36-4 overall record in advancing to the Final Four for the second straight year and the Championship Game for the first time since 1941…11 players, including two starters, are expected to return in 2015-16, led by junior forward Nigel Hayes (12.4 ppg, 6.2 rpg) and junior guard Bronson Koenig (8.7 ppg, 98 assists)…Wisconsin will be making its first 2K Classic appearance.
Georgetown Hoyas – Head Coach: John Thompson III (Big East Conference)
The Hoyas went 22-11 under the direction of head coach John Thompson III, who, in 11 seasons at Georgetown, has won 249 games…the Hoyas feature a roster with 10 players expected to return next season, including a trio of starters…junior guard D'Vauntes Smith-Rivera led Georgetown with a 16.3 ppg average as well as with 101 assists in earning first-team All-Big East honors…freshman forward Isaac Copeland averaged 6.8 ppg and 3.8 rpg…this will be Georgetown's first 2K Classic appearance since 1998.
VCU Rams – Head Coach: Will Wade (Atlantic 10 Conference)
VCU will be under the direction of new head coach Will Wade in 2015-16, who returns to VCU after two successful seasons at Chattanooga…the Rams, 26-10 this past season, boast a roster featuring 10 players who are expected to return, including three starters…among those expected to return are junior guard Melvin Johnson (12.4 ppg, 60 assists) as well as sophomore forward Mo Alie-Cox (7.2 ppg, 5.7 rpg)…this is the Rams' first ever 2K Classic appearance.
Bryant Bulldogs – Head Coach: Tim O'Shea (Northeast Conference)
The Bulldogs posted a 16-15 record in advancing to the semifinals of the Northeast Conference tournament…head coach Tim O'Shea will enter his eighth season at Bryant, having taken over when the school made the jump to Division I…three starters return, led by second-team All-Northeast Conference pick Dan Garvin, who was second on the Bulldogs in scoring (10.9 ppg) and first in rebounding (7.9 rpg)…senior guard Shane McLaughlin led Bryant with a 4.8 assist per game average while netting 7.5 ppg.
Prairie View A&M Panthers – Head Coach: Byron Rimm II (Southwestern Athletic Conference)
Head coach Byron Rimm II is in rebuilding mode at Prairie View where he looks to replace four starters from a squad that posted a 15-18 mark a year ago and reached the semifinals of the SWAC tournament…senior guard Jacoby Green played in all 33 games last season, starting 10, and posting an average of 3.7 ppg…junior guard Jayrn Johnson also played in all 33 games and netted 4.4 ppg…the Panthers last appeared in the 2K Classic in 2008.
Radford Highlanders – Head Coach: Mike Jones (Big South Conference)
The Highlanders recorded a 22-12 ledger in advancing to the quarterfinals of the CBI for the second straight season…the 22 wins also marked the second-straight 20-win season for Radford, which won 20 games in consecutive seasons for the first time since 1998…head coach Mike Jones will enter his fifth season at Radford and has turned around the Highlanders, winning 19 games in his first two seasons and 44 in his last two…two senior starters return: guard YaYa Anderson (9.3 ppg, 50 assists) and center Brandon Holcomb (6.0 ppg, 4.5 rpg).
Siena Saints – Head Coach: Jimmy Patsos (Metro Atlantic Athletic Conference)
Siena returns three starters from a year ago, one of which appeared in only six games…senior forward Brett Bisping, the MVP of the 2014 CBI, had surgery on his toe in December and missed the reminder of the season…junior point guard Marquis Wright (12.5 ppg) is the Saints' leading returning scorer while junior swingman Lavon Long posted 10.4 ppg and a team-high 4.9 rpg…head coach Jimmy Patsos is in his third year at Siena.
Wounded Warrior Project is the beneficiary of the 2K Classic. The mission of Wounded Warrior Project (WWP) is to honor and empower wounded warriors. WWP's purpose is to raise awareness and to enlist the public's aid for the needs of injured service members, to help injured servicemen and women aid and assist each other, and to provide unique, direct programs and services to meet their needs. WWP is a national, nonpartisan organization headquartered in Jacksonville, Fla. The 2K Classic benefiting Wounded Warrior Project is produced by the Gazelle Group of Princeton, N.J. The Gazelle Group is a sports marketing firm, specializing in event production and management, client representation, and sponsorship consulting. Gazelle produces numerous nationally-recognized events, such as the Legends Classic, the Gotham Classic, the College Basketball Invitational, and the All-American Championship. For more information on the Gazelle Group, please visit gazellegroup.com.
The Northeast Conference (NEC) is the sponsoring conference of the 2K Classic benefiting Wounded Warrior Project. Now in its 34th season, the NEC is a NCAA Division I collegiate athletic association consisting of 10 institutions of higher learning located throughout six states. For more information on the NEC, visit the official website at www.northeastconference.org or follow on Twitter @NECsports.


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http://www.kgkayaks.co.nz/wp-content/uploads/2016/12/Paddle-in-Paradise-1.3-1.mov">Whale Island video – Paddle in Paradise Whale Island is 9km off the coast from Whakatane and it's a kayaking paradise. We meet at the Whakatane Yacht Club Wharf, close to the i- Site and check you on board the boat, Centaurus, a well appointed sailing catamaran. After a safety briefing from Baz the skipper and with kayaks loaded, we head down the Whakatane River and out on to the ocean for the 30 minute trip to Whale Island. En route we'll give you a little history of the area and of Whale Island itself and discuss kayak safety. We usually start at the most sheltered corner of the Island and give everyone an opportunity to become accustomed to kayaking on the ocean, before heading off on our tour.
Wildlife encounters, whether NZ fur seals, little blue penguins or gannets plunging into the ocean around us are common and the scenery is always breath taking. When the conditions are right we are able to explore the sea caves on the North West corner.
After two hours of paddling, we return to the boat for a home baked morning tea, perhaps a swim and a few yarns from the boat skipper before the return trip to Whakatane. You'll love it ! We do !
Tour time 4 hours +
Departs 8am or by arrangement
SPECIAL SPRINGTIME DEAL – enjoy a one hour bonus sail with lunch included – Quote "KG Spring 17" when booking by email or phone


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DrabbleDrabbleDrabble: Round 50!May. 8th, 2011 08:00 am
The DrabbleDrabbleDrabble contest on the Avatar Spirit forum is celebrating it's 50th Round this week. This round's theme is Language Barriers and it's being run by Loopy. If you're interested, submit a fic. If you win, you get to pick the theme for Round 51 and judge who's the winner! Joining the forum is quick and easy. The criteria for this round is below the cut:
( Read more... )
( Read more... )


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Eaton Corporation RPM 208V BLADEUPS PLUG-20FT (Y03114049100000)Item#: 8918846 | Model#: Y03114049100000
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On his death in 2004, the University of Chicago Press created a website in remembrance of him.
Secret Lives of Teachers
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Foreigners will buy asset shares - Treasury
Foreign corporates could end up with big stakes in state-owned power companies within a decade of them being partially-sold, according to a Treasury assessment.
A ''think piece'' prepared at the end of last year says partial sales of power companies Meridian, Mighty River Power and Genesis and state-owned coal miner Solid Energy could see ''possible cornerstone stakes by energy multinationals'' within ten years.
The prediction could prove embarrassing for National as it tries to garner support for plans to sell up to 49 per cent of the companies.
The Government is also looking to reduce its 75 per cent stake in Air New Zealand, but retain a majority shareholding.
Prime Minister John Key has promised that Kiwis would be first in line to buy up the sold off portions, but has acknowledged it would be difficult to prevent their stakes being onsold to foreign interests.
The purchase of state assets by foreign companies was one of the most controversial aspects of the sales programmes in the 1980s and 1990s.
Labour has already made clear it will raise the spectre of foreign interests gaining big shares in vital infrastructure companies a main part of its campaign against the proposals outlined by Key.
The Treasury has been asked to provide specific advice on the proposals ahead of National finalising any policy on partial sales heading into the election, but the think piece makes clear it is highly unlikely to recommend against the move.
It effectively urges the Government to sell out of all its commercial interests, saying there is no compelling reason for it to stay involved.
''We think full private ownership for all companies over the medium term would be likely to result in moderate economic benefits compared with alternative institutional arrangements ... We do not find any of the arguments for continued Crown ownership particularly convincing ...''
It says partial sales of the three power companies would do the most to meet the Government's need to pay down debt and develop New Zealand's capital markets, given their size.
The paper lays out several options for an asset sales programme, including selling full stakes in everything with no restrictions, sales with restrictions on foreign ownership and shareholdings and partial sales.
It makes clear it was prepared on Treasury's own initiative and not solicited by the Government.
It was released today by Finance Minister Bill English and State Owned Enterprises Minister Simon Power.
They also released a letter requesting Treasury to explore the Government's partial sales proposals, which makes it clear other asset sales options are off the table.
''... the Government is not interested in pursuing all of the options discussed in that paper.
''Only the four companies we have mentioned will be considered for the mixed ownership model already applying to Air New Zealand'.''


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A touch of modern in untouched nature.
The idyllic Snow Hill is situated at Croatia's first National park Plitvice Lakes. We are centrally located in the heart of the National park area and the valley is so picturesque that it definitely merits a visit.These cottages, and the surrounding region, are truly charming! We offer our guests a unique destination for year round activities that appeal to outdoor enthusiasts and nature lovers of all description – swimmers, bikers, snow activities for children and adults, nature watchers.Our vacation rentals have much to offer. Two individual brand new cottages of different sizes. Three room family house as our main building and a lodge. The lodge is located in front of the main house, sharing the same front yard.The front yard area is open yet shaded for gatherings around the fire pit and picnic table, ideal for badminton or Frisbee. The first floor of the cottage (for 7) includes a bathroom with a massage shower, a fully appointed kitchen with all new appliances (dishwasher included). A comfortable open living room provides a relaxing refuge for reading in a leather seating made up of a three-piece suite, watching TV, enjoying a fire in the fireplace, includes a projector for your movie nights and has floor heating. The living room leads out to a large wraparound screened porch with a wooden dining table for spring and summer dining.From the hall near the main entrance there is a staircase to the first floor landing. The first bedroom has two single beds as well as a wardrobe. The second bedroom has a twin bed and one single bed. The third bedroom has one twin bed. All the beds are supplied with sheets & duvets. The first floor also includes a full bathroom with a bath tab. All bedrooms have wonderful views overlooking the valley with the sun setting over horizons that can be seen into the distance. All rooms have balconies. Sauna is located in the basement. The lodge (for 4) provides many of the comforts of home. It is also one floor house with a balcony. When you enter the lodge, there is an open dining space with a kitchen and a stove for wood heating. There is also stairs to the upper gallery including four single beds (rearrangement for couples possible), bathroom, TV with sofa.The lodge is just a few steps from the cottage but affords ample privacy for family guests, parents, in-laws, etc.Both cottages are decorated with care to reflect Lika's simplicity and heritage, all of our rentals have a kitchen with full size appliances, full bathrooms, satellite TV and wireless internet, a sauna and a swimming pool in summer season.Quiet comforting rest can be found in carpeted bedrooms upstairs with walk-out balcony overlooking the idyllic landscape.Both cottages has an open concept living room, dining room & kitchen with a cozy fireplace and a main house additionally offers a floor heating for an extra comfort in cold winter times. From here, there is a 10 min drive to National Park entrance, one of the most beautiful lakes in the world and certainly the best preserved in Europe. For nature lovers, there is also a nice walking tour through untouched nature to other back lakes in this picturesque valley where you can enjoy sun, fresh air and snow activities(URL HIDDEN) We hope you will make Snow Hill a family tradition.