Spirituality: Faith and Healthcare Presented by Chaplain Dana Bratton “We are not human beings having a spiritual experience. We are spiritual beings having a human experience. ” -Teilhard de Chardin
Presentation Outcome Goals Participants will be able to: l Define spirituality and religion, and have awareness of the benefits of spirituality in the care of patients, especially patients at the end of life as based on the examination of research. l Identify what spiritual needs are, and how to respond to spiritual and emotional needs. l Recognize that one’s own spirituality might affect how one might relate to, and provide care to patients. Develop awareness of personal issues that might hinder one from providing spiritual care.
l Have the ability to assist with the faith of others without proselytizing l Have spiritual assessment tools l Identify chaplain’s role as part of the health care team and in the spiritual care of the hospice patient l Identify other areas of available support for spirituality in patient care.
Definitions 1) Spirituality l Spirituality refers to a belief in a higher power, an awareness of life and its meaning, the centering of a person with purpose in life. It involves relationships with a higher being, with self, and with the world around the individual. . Spirituality implies living with moral standards. “The spirit of a human is his essence, that part of him or her that is not visible. The part that does not die but is immortal. Webster defines spirit as “ a life giving force” and as the “active presence of God in human life. ” (National Center of Continuing Education, Inc. Death and Dying, pg. 23)
MSOP Report III regarding spirituality Spirituality is recognized as a factor that contributes to health in many persons. The concept of spirituality is found in all cultures and societies. It is expressed in an individual’s search for ultimate meaning through participation in religion and / or belief in God, family, naturalism, rationalism, humanism and the arts. All these factors can influence how patients and health care professionals perceive health and illness and how they interact with one another. 3/15/2018 MSOP Report III. Association of American Medical Colleges, 1999
2) Religion l Religion is an organized and public belief system of worship and practices that generally has a focus on a god or supernatural power. It generally offers an arrangement of symbols and rituals that are meaningful and understood by it’s followers. “Religion is primarily a set of beliefs, a collection of prayers, or rituals. Religion is first and foremost a way of seeing. It can’t change the facts about the world we live in, but it can change the ways we see those facts, and that in itself can often make a difference. ” (Harold Kushner)
Major World Religions – Christianity l Catholic, Lutheran, Presbyterian, Methodist, Nazarene, Episcopal l Baptist (largest protestant denomination in US) l Non-denominational l Other Western faiths – Judaism l Reform, Conservative, and Orthodox – Hinduism – Buddhism – Islam (Muslims) George Ann Daniels MS, RN
Spirituality l Spirituality fulfills specific needs – Meaning to life, illness, crises, and death – Sense of security for present and future – Guides daily habits – Elicits acceptance or rejection of other people – Provides psychosocial support in a group of like-minded people – Strength when facing life’s crises – Healing strength and support George Ann Daniels MS, RN
Spiritual Care • Practice of compassionate presence • Listening to patient’s fears, hopes, pain, dreams • Obtaining a spiritual history • Attentiveness to all dimensions of the patient and patient’s family: body, mind and spirit • Incorporation of spiritual practices as appropriate • Involve chaplains as members of the interdisciplinary healthcare team George Ann Daniels MS, RN
A More Compassionate Model of Care Focus on The Whole Person Physical Emotional Social Spiritual 3/15/2018
Bio-Psycho-Social-Spiritual l Schools of Medicine have been slow to recognize & appropriate this model of whole person care. l The Nursing profession has long recognized the spiritual aspects of patient care. l Chaplains and clergy have often assisted patients with the spiritual aspects of illness and the search for meaning & purpose. George H. Grant, M. Div. , Ph. C.
Spiritual care defined Spiritual care is recognizing and responding to the multifaceted expressions of spirituality we encounter in our patients and their families. The purpose is to determine the nature of a person’s relationship to God and other people, and to give the person the opportunity to accept spiritual support. Themes such as the search for meaning, feelings of connection or isolation, hope or hopelessness, and fear of dying are all clues that a person is struggling with spiritual issues. Chaplain Loyal Ward
Research in Spirituality and Health Medical Compliance: Study of Heart Transplant Patients at University of Pittsburgh • Those who participated in religious activities and said their beliefs were important showed: - better compliance with follow-up treatment - improved physical functioning at the 12 -month follow-up - higher levels of self-esteem - less anxiety and fewer health worries Hams, RC et. al. Journal of Religion and Health. 1995: 34(1) 17 -32 3/15/2018
Research in Spirituality and Health Immune System Functioning: Study of 1, 700 older adults • Those attending church were half as likely to have elevated levels if IL-6 • Increased levels of IL-6 associated with increased incidence of disease • Hypothesis: religious commitment may improve stress control by: - better coping mechanisms - richer social support - strength of personal values and world-view may be mechanism for increased mortality observed in other studies 3/15/2018 Koenig, HG et. al. International Journal of Psychiatry in Medicine. 1997 27(3) 233 -250
Research in Spirituality and Health Coping: Pain questionnaire by American Pain Society to hospitalized patients • Personal Prayer is the most commonly used non-drug method for pain management: - Pain Pills 82% - Prayer 76% - Pain IV med 66% - Pain injections 62% - Relaxation 33% - Touch 19% - Massage 9% Mc. Neil, JA et al. J of Pain and Symptom Management. 1998: 16(1) 29 -40 3/15/2018
Research in spirituality and health Coping: Bereavement • Study of 145 parents of children who died of cancer: - 80% reported receiving comfort from their religious beliefs one year after their child’s death - those parents had better physiologic and emotional adjustment - 40% of those parents reported strengthening of their own religions commitment over the course of the year prior to their child’s death 3/15/2018 Cook. J Sci Sudy of Religion. 1983: 222 -238.
Research in spirituality and health Coping: Study of 108 women undergoing treatment for GYN cancers • When asked what helped them cope with their cancer, the patients answered: - 93% their spiritual beliefs - 75% noted their religion had a significant place in their lives - 49% became more spiritual after their diagnosis Roberts, JA et. al. American Journal of Obstetrics and Gynecology. 1997. 176(1) 166 -172 3/15/2018
Gallup survey key findings Reassurances that gave comfort 89% Believing that you will be in the loving presence of God or a higher power 87% Believing that death is not the end but a passage 87% Believing that part of you will live on through your children and descendants 85% Feeling that you are reconciled with those you have hurt or who have hurt you 3/15/2018 George H. Gallup International Institute. “Spiritual Belief and the Dying Process: A Report on a National Survey, ” 1997.
Americans have long recognized the healing power of faith and prayer. 82%: believe in the healing power of prayer 64%: feel MDs should pray with those patients who request it 63%: want MDs to discuss matters of faith. Almost 99% of MDs say religious beliefs can make a positive contribution to the healing process. Yet, until recently, most medical studies failed to consider the impact of spirituality in disease prevention or the healing process. Faith was the forgotten factor that was relegated by healthcare providers to the chaplain's office. CMDS
l Fortunately, there is change. Scientists are realizing what people already know, that a personal spiritual relationship helps us make sense out of illness. It gives hope. It changes health-related behavior and thus reduces the risk of disease. l But faith has an even greater impact. Studies have revealed that faith improves the immune system, enhances healing, reduces complications during major illnesses and much more. CMDS
Clinical Questions • Does spirituality play a role in end-of-life care? How? • Should nurses address spirituality with their patients and how? • What is the role of the interdisciplinary team with respect to the needs of the patient? • How does paying attention to patients’ spiritual needs help with delivery of compassionate care?
Where does spirituality fit? l Patients may have coping mechanisms related to their belief l May be supported by a community of caring others. l May feel themselves to be in the company of God who gives them peace and comfort. George H. Grant, M. Div. , Ph. C.
Spiritual Needs • May be dynamic in patient understanding of illness • Religious convictions / beliefs may affect healthcare decision-making • May be a patient need • May be important in patient coping • Integral to whole patient care 3/15/2018
Five basic spiritual needs of every person: l A meaningful philosophy of life (values, and moral sense). l A sense of the transcendent (outside of self, view of God and something beyond the immediate life, having hope. ) l A trusting relationship with God (faith). l A relatedness to nature and people (friendship). Experiencing love and forgiveness. l A sense of life meaning.
Needs The need for meaning and purpose l The search for meaning is one of the primary motivators that keeps us going. When a person comes to a place where his or her life makes no sense, and the seems to be no meaning or purpose, depression and indifference set in. l If the person can find no help for meaning and purpose in the future, he or she longs for death. National Center of Continuing Education, Inc. Death and Dying, pg. 24
Man’s Search for Meaning Victor Frankl l Sometimes external circumstances in our life situation are beyond our control. l Frankl maintains that the attitude we choose to take toward our life situation is within our control. l The spiritual journey relates to our inner struggle to shape our attitude toward illness and even death itself. l A relationship with God gives meaning to life. George H. Grant, M. Div. , Ph. C.
Where do we find hope? l Ultimately from our faith or understanding of our relationship to a higher power. l The belief that a higher eternal power is in control provides meaning and purpose to any situation.
The need for love and relationships l We were created with this need. Humans are social beings. l The emotional need for love and relationship is met in the context of significant human relationships. l The spiritual need for love and fellowship is met only through a personal relationship with God. National Center of Continuing Education, Inc. Death and Dying, pg. 24
Three kinds of love l Eros -If you satisfy my needs then I will love you. A physical love. l Phileo - a brotherly love, a friendship live. I love you because of what you have or who you are. This may be conditional love also, because things might change. l Agape – God’s kind of love. I love you, in spite of …, I love you no matter what. Not deserved, not earned. Freely given. Unconditional.
Unconditional love l Important for the dying person because he or she is no longer in a position to earn love. Therefore it is important to encourage and support the person’s belief in and relationship to God who offers unconditional love. Examples of how a person might experience this might be through prayer, and the appropriate use of Scripture. National Center of Continuing Education, Inc. Death and Dying, pg. 24
The need forgiveness l Guilt is one of the biggest burdens in our lives. It results from the failure to live up to expectations, either our own or those of others. l True guilt may come as a result of rebelling against the belief in God, and the consequences of that rebellion. l A sense of forgiveness within the context of one’s faith, often brings a sense of inner peace for that person in their relationship with God, self, and others. National Center of Continuing Education, Inc. Death and Dying, pg. 25
Forgiveness results in: l Less anxiety and depression l Better health outcomes l Increased coping with stress l Closeness to God and others l Resolves guilt l Restored relationships “Beware lest anyone resist the grace of God and a root of bitterness spring up in you and many be defiled” Hebrews 12: 15 3/15/2018
Sharing the patient’s faith l Ask questions. Allow people to discover the truth for themselves by stimulating their thinking through questions, which is much more powerful than having them simply listen to your thoughts. l Don't react negatively to objections. Realize that expressing doubt is actually a good thing because it means that someone is genuinely thinking about an issue. Expect emotions such as anger and hostility to surface during an exploration of faith as people wrestle with the most important issues in life. Don't take objections personally as people go through this process. Express your disagreements with respect, affirming the value of the people with whom you speak and leaving the door open for further discussions.
Sharing the patient’s faith l If the patient expresses a need for assist with their spiritual situation, a chaplain should be made available. In the effort to assist the patient to understand their faith, the chaplain might ask these questions: "Who is God? , " "Who are We? , " "Who is Jesus? , " "What Did Jesus Do? , " "What Can We Not Do? , " "What Do We Have to Do? , " and "What Does God Promise to Those Who Believe? . ” l l Don't discount the beliefs or experiences of others. Show respect for them. Simply ask people to evaluate how their current belief system is working in their lives. Don’t proselytize. When appropriate, sharing your own testimony can be powerful.
Question: Should nurses talk about religion or spirituality with patients? l A. You may say no, because a nurse can not be expected to be conversant with all religions. l B. You may say no, because the nurse may be an atheist or non-believer. (Though I’ve met very few nurses who are. ) l C. You may say no, that would be an unethical intrusion into the privacy of the patient. l D. But the answer is yes, particularly when there are indications of patient interest or need.
The nurse’s role in spirituality l Define your own philosophy of life and death. What do you believe? What does human life mean to you? What does death mean? Is there life beyond? Is there a God? Is there a Heaven and a Hell? l You must be comfortable and confident in what you believe in order to help others. Or you will be threatened and fearful when confronting death and dying in your patients. l Identify your emotional and physical limitations. National Center of Continuing Education, Inc. Death and Dying, pg. 29
Ethics & professional boundaries l Spiritual History: patient-centered l Recognition of pastoral care professionals as experts l More in-depth spiritual counseling should be under the direction of chaplains and other spiritual leaders l Praying with patients: You can, if the patient requests, or make a referral to pastoral care for chaplain led prayer.
9 dimensions of patient assessment 1. Illness / treatment summary 2. Physical 3. Psychological 4. Decision making 5. Communication EPEC- AMA 6. Social 7. Spiritual 8. Practical 9. Anticipatory planning for death
Approach to spiritual assessment l Suspect spiritual pain l Establish a conducive atmosphere l Express interest, ask specific questions l Listen for broader meanings l Be aware of your own beliefs and biases EPEC- AMA
A Spiritual Inventory might include questions about: l The patient’s perception of what is going on. l What gives meaning and purpose to life? l How, or whether belief and faith enter in. l Love: By whom do you feel loved-accepted? l Forgiveness--need it? Do you need to grant it to others? l Prayer--What do you pray for? l Quiet and meditation--What helps get you on center? George H. Grant, M. Div. , Ph. C.
Spiritual assessment l Meaning, value – personal, of the illness – burden, control, independence, dignity l Faith l Religious life, spiritual life l Identify areas of spiritual crises. Would pastoral intervention be needed or desired – their own pastor or the hospital or hospice chaplain? EPEC- AMA
Spiritual assessment l Spiritual assessment should, at a minimum, determine the patient’s denomination, beliefs, and what spiritual practices are important to the patient. l This information assists in determining the impact of spirituality, on the care and services being provide, and will identify if further assessment or services are needed. Chaplain Loyal Ward
Spiritual Assessment l An integral part of a patient’s initial assessment should include data about the patient’s spiritual and religious beliefs. l Several tools exist for spiritual assessment. l Spiritual care needs to be individualized, with the patient given the opportunity to participate George Ann Daniels MS, RN
l Open ended questions that are specific regarding beliefs can be helpful. A formal assessment guide can provide a review of the strength and meaning of person’s religious practices that can open the door to helping the person establish a meaningful relationship with their higher power. Chaplain Loyal Ward
Spiritual History • Taken at initial visit as part of the social history, and at follow-up visits as appropriate • Recognition of cases to refer to chaplains • Opens the door to conversation about values and beliefs • Uncovers coping mechanism and support systems • Reveals positive and negative spiritual coping • Opportunity for compassionate care 3/15/2018
Taking a spiritual history. . . l S Spiritual Belief System l P Personal Spirituality l I Integration in a Spiritual Community l R Ritualized Practices and Restrictions l I Implications for Health Care l T Terminal Events Planning (advance directives, DNR wishes, DPOA etc. . ) George H. Grant, M. Div. , Ph. C.
Assess for spiritual activities l Religious denomination (past or present) Where do you go to church when you are able? l Activity level Do you go all the time? l Prayer / scriptural resources Do you read your Bible? Do you pray much?
Assess for spiritual crises l Search for meaning or purpose in one’s life. l Loss of a sense of connection with people or God. l Feelings of guilt or unworthiness l No relationship with God l Anger, denial, and bitterness expressed toward self, others, or God. Questioning of faith l Desire forgiveness l Sense of abandonment by God
Spiritual Assessment Tools l SPIRIT l FICA (Pulchalski 1999) l LET GO (Storey and Knight 1997) l Nurses and MDs should know the patient’s personal values and wishes. The patients religion is specified in the medical record. “The secret in the care of the patient is in caring for the patient. ” l Francis Peabody
FICA assessment tool F I C A 3/15/2018 Faith, Belief, Meaning Importance and Influence Community Address
The HOPE Questions l H: Sources of hope, meaning, comfort, strength, peace, love and connection l O: Organized religion l P: Personal spirituality and practices l E: Effects on medical care and end-of-life issues
LET GO l Listening to the patient’s story l Encouraging the search for meaning l Telling of your concern and acknowledging the pain of loss l Generating hope whenever possible l Owning your limitations
Spiritual History F Do you have a spiritual belief? Faith? Do you have spiritual beliefs that help you cope with stress? What gives your life meaning? I Are these beliefs important to you? How do they influence you in how you care for yourself? C Are you part of a spiritual or religious community? A How would you like your healthcare provider to address these issues with you? 3/15/2018
Ritualized Practices and Restrictions l Patients may especially value the rituals of their faith community: l Anointing (last rites) of a dying person l Scripture l Prayer l Communion George H. Grant, M. Div. , Ph. C.
Spiritual needs neglected l Why? Many people have not recognized their own spiritual needs, and thus are uncomfortable in assessing them in others. l Religion is often considered a private matter and one not to be discussed. l It is important in medicine to assess a person’s physical situation related to his bowel movements or his or her sex life. Aren’t these private matters as well? l Should a nurse be interested in spiritual needs in their patients? Yes. National Center of Continuing Education, Inc. Death and Dying, pg. 26
Patient care is done by a team of interfacing disciplines l Medical specialties l Nursing and allied health professions l Psychology l Pastoral care/health chaplaincy l Philosophy: bioethics l Community services: faith or need based service groups l Hospice and parish nursing Each discipline contributes a special perspective on human experience, which when taken together, can lead to a general understanding of the healing process. Chaplain Loyal Ward
Four resources The therapeutic use of yourself. We affirm to each patient that he or she is worthy of our time and involvement, relating in a supportive caring way. l The use of prayer when appropriate. Dialogue within the context of your own religious beliefs about your concerns for the patient. l When appropriate, the use of Scripture. They are God’s communication to us. Teaching to live in harmony with God, ourselves, and others. l Referrals to clergy and chaplains l National Center of Continuing Education, Inc. Death and Dying, pg. 27 -28
Life Goals l A meaningful life l A peaceful, dignified death “There is a time for everything, and a season for every activity under heaven: a time to be born and a time to die…. ” Ecclesiastes 3: 1 -2
Questions asked by dying and chronically ill patients • Why is this happening to me now? • What will happen to me after I die? • Will my family survive my loss? • Will I be missed? Will I be remembered? • Is there a God? If so, will He be there for me? • Will I have time to finish my life’s work? 3/15/2018
“The uncertainty is not the dying, it’s the preparation. We need to know how to deal with the inevitable deaths of loved ones and friends and patients. Death is the last enemy, but one that need not be feared. ” Billy Graham Death and the Life After
Conspiracy of silence l Reluctance to discuss death and dying l Cultural practices regarding truth telling l MD and patient each wait for the other to initiate discussion. Even more so in the case of family members. l Avoidance: “I’m healthy. I’m busy. No time. My family will take care of it. ” l Discussing specific treatments and procedures instead of confronting the issue of impending death
Medical team’s responsibilities l Initiate discussion of end-of-life issues l Help patients articulate their goals for care – Clarify treatment preferences – Uncover personal values l Establish and maintain caring, trusting relationship l Acknowledge importance of spiritual dimension in the dying process
End-of life discussions: how l Establish rapport and a caring relationship l Ask about death-related beliefs and concerns l Take time to listen l Communicate empathy and respect l Be nonjudgmental “Put your house in order because you are going to die; you will not recover. ” 2 Kings 20: 1
End-of life discussions-how l Become aware of patient’s cultural, ethnic, religious background l Be honest and compassionate l Silence is a powerful tool l Any person on the team- doctor, nurse, social worker, may recommend and refer to chaplains or other clergy or other team members.
End-of-life discussions - when? l Urgently : – Imminent death – Patient talks about dying – Questions about hospice or palliative care – Recent admission for severe, progressive illness – Severe suffering and poor prognosis – Initial assessment when coming on hospice Quill 2000. JAMA 284: 2502
Initiating end-of-life discussions - when? l Routinely when: – Discussing prognosis – Discussing treatment with low probability of success – Discussing hopes and fears – MD would not be surprised if patient died in 6 -12 months Quill 2000. JAMA 284: 2502
A Shift of focus: from the biomedical to the psycho-social-spiritual l For many patients facing serious illness or the end of life, the focus shifts from the biomedical to the spiritual. l When symptom management and pain control are appropriately provided, patients are set free to address their “final agenda. ” l This may be seen as the last chapter in one’s spiritual journey. (Mary Levine) George H. Grant, M. Div. , Ph. C.
Spiritual Issues The struggle with serious illness is ultimately a spiritual struggle. l Suffering l Meaning and Purpose l Loss or Abandonment l Guilt or Shame l Trust l Reconciliation l Hope 3/15/2018
Spiritual Identifiers in Dying Patients • Is there purpose or value to their life? • Are they able to transcend their suffering? • Are they at peace with themselves and others? • Are they hopeful, or are they despairing? • What nourishes their personal sense of value: prayer, religious commitment, personal faith, relationship with others? • Do their beliefs help them cope with their anxiety about death and with their pain, and do they aid them in attaining peace?
Patients raise spiritual questions l Who am I, now that I am sick or dying? l What is the meaning of my life when I am no longer productive and independent? l Where am I connected to others who value me and see me as a person of worth? l What is my relationship to God and am I going to Heaven? l What do I now value most in the time that is left to me? George H. Grant, M. Div. , Ph. C.
Unresolved issues and fears l Old feuds or broken relations l Last visits, seeing people for the last time l Lifetime project l Unfinished business l Funeral plans l Financial plans l Need to forgive or be forgiven l Loss of control and dignity l Loss of relationships l Being a burden l Physical suffering
Spiritual Coping • Hope: for cure, for healing, for finishing important goals, for a peaceful death • Sense of control • Acceptance of situation • Strength to deal with situation • Meaning and purpose: in life in midst of suffering 3/15/2018
Spiritual Care for the dying • Practice of compassionate presence • Listening to patient’s fears, hopes, pain, dreams • Obtaining a spiritual history • Attentiveness to all dimensions of the patient and patient’s family: body, mind and spirit • Incorporation of spiritual practices as appropriate • Involve chaplains as members of the interdisciplinary healthcare team 3/15/2018
Community support l Sources of assistance l Church l Disease support groups l Hospice l Social groups l Friends, neighbors, and employment peers
Nurses must be compassionate and empathic in caring for patients… In all of their interactions with patients they must seek to understand the meaning of the patients’ stories in the context of the patients’ beliefs and family and cultural values…. They must continue to care for dying patients even when disease-specific therapy is no longer available or desired. 3/15/2018 MSOP Report I, Association of American Medical colleges, 1998
Grief l An emotion or complex of emotions we experience when we lose someone or something we value. National Center of Continuing Education, Inc. Death and Dying, pg. 37
Assessment of the Meeting of Spiritual Needs • Does the health care provider listen to their beliefs, faith, pain, hope or despair? • Are patients able to express their spirituality through prayer, art, writing, reflections, guided imagery, religious or spiritual reading, ritual, or connection to others of God? • Are referrals made to chaplains, counselors, or spiritual directors when appropriate? George Ann Daniels MS, RN
Case 1: Clarifying religious statements by patients Mr. R is a 77 year-old, white, retired mechanic who has class II congestive heart failure and coronary artery disease that cannot be revascularized. After an emergency department visit for an exacerbation of congestive heart failure, his physician raises the issue of a DNR order. The following conversation occurs: Physician: “In your situation, CPR is very unlikely to succeed. What do you think about what I have said? ” Mr. R: “Well, I want you to do what you can. I trust that God will decide when it’s my time. ”
Case 2: Responding to religious reasons for rejecting the physician’s medical recommendations Mrs. M is a 72 year-old black woman with chronic obstructive pulmonary disease who has been receiving mechanical ventilation for 2 months because of acute respiratory distress syndrome and multiorgan failure. Believing that Mrs. M now has only a 1% chance of being successfully extubated, her physicians begin to discuss limiting life-sustaining interventions. Mrs. M is unable to participate in these discussions. She had previously indicated that her husband should act as her surrogate but did not provide specific directives for her care. Mr. M and their 2 children insist that mechanical ventilation be continued, believing that God will answer their prayers and work a miracle.
General Recommendations Consider spirituality as a potentially important component of every patient’s physical well-being and mental health. Address spirituality in your initial assessment; continue addressing it at follow-up visits if appropriate. In patient care, spirituality is an ongoing issue. Respect patient’s privacy regarding spiritual beliefs; don’t impose your beliefs on others. 3/15/2018
General Recommendations, cont… • Make referrals to chaplains, spiritual directors, or community resources as appropriate • Awareness of your own spirituality will not only help you personally, but will also overflow in your encounters with those for whom you care. 3/15/2018
Religious Beliefs Related to Health Care l What are the health related beliefs of these major religions? – Buddhism – Christianity – Hinduism – Judaism – Islam – Atheism That’s your homework. Thanks and may God bless your ministry in caring for people.
Скачать презентацию Spirituality Faith and Healthcare Presented by Chaplain Dana
eebdd9cd54e5950d303cbdeca52e2753.ppt