English Language Teaching Essay

This paper aims to highlight the importance of teaching sociolinguistic competence to ESL learners in Malaysian schools. Sociolinguistic competence is the knowledge of socio cultural rules of language and of discourse. This type of competence requires an understanding of the socio context in which language is used. It is proposed that carefully designed language activities be carried out by instructors in order to impart sociolinguistic skills to learners. The importance of universal intelligibility should be stressed, as opposed to native accent. Furthermore students should also be taught proper contextual use of English, in accordance to cultural reference and cultural appropriacy should be part of the learners’ core sociolinguistic competence. Keywords: Socio-cultural rules, Sociolinguistic competence, Formal language, Colloquialism 1. Introduction Malaysia is a multi-racial society which is strongly bounded by its system of monarchy. However, Malays form the largest portion of its demography, with Malay as its national language. Though Malay is still the most commonly used lingua franca among Malaysians, English is gaining more importance and relevance in the country. In fact, Malaysians have come to realize that it is no longer necessary, nor desirable to aim at an English native speaker’s speech to achieve their communicative function. However, there has been a strong decline in the levels of English proficiency in the country .This is evident in Malaysians’ everyday speech, which are often marred by grammatical and phonological errors or at times too loaded with â€Å"suffixes† (e.g. lah, lor, meh) and loan words from other languages. English is the second most important language in Malaysia. It is used in  various professions and is an important requirement in Malaysian academic settings. The academic setting is a microcosm of the Malaysian population, which is a mix of interlocutors of different racial and language backgrounds. They may also differ in their English language proficiency levels. Therefore, it could be assumed that in Malaysian schools’ unique language environment, sociolinguistic competence contributes to Malaysian students English language proficiency. 2. Malaysian School Language Policy When Malaysia got its independence in 1957, the government of Malaysia set out on a program to establish Bahasa Melayu as the official language, to be used in all government functions and as the medium of instruction at all levels in the education system. The introduction of a new primary school curriculum which goes by the Malay acronym, KBSR (Kurikulum Bersepadu Sekolah Rendah), and the new secondary school curriculum which goes by the acronym, KBSM (Kurikulum Bersepadu Sekolah Menengah), is an approach to provide holistic, balanced and integrated development of an individual’s potential; intellectual, spiritual, emotional and physical aspect. However in 2002, the government announced a reversal of policy, calling for a switch to English as a medium of instruction for Mathematics and Science at all levels in the education system. Since 2003, Science and Mathematics have been taught in English. Therefore, teachers will be forced to code-switch to make pupils understand the su bject matter. 3. Sociolinguistic Competence Sociolinguistic competence is the knowledge of the sociocultural rules of language and of discourse. This type of competence requires an understanding of the social context in which language is used: the rules of the participants, the information they share, and the functions of the interaction. Only in a full context of this kind can judgement be made on the appropriateness of a ‘particular utterance’, as mentioned by Brown (2000). Lyie Bachman’s (1990) sociolinguistic competence comprises aspects, which deal with factors such as politeness, formality, metaphor, registers, and culturally related aspects of language. For students learning English in Malaysia, sociolinguistic competence should take into account those aspects as proposed by Bachman. Broersma (2001) stated that the process of learning sociolinguistic competence is challenging even in one’s first language. He also proposed that evidence of this can be found in the popularity of â€Å"Miss Manners† columns. He claims if we all had perfect sociolinguistic competence, we wouldn’t need advice about the proper way to send wedding invitations or give a dinner party. Having good sociolinguistic competence means knowing how to â€Å"give every person his or her due.† It means knowing when to be quiet, and when to talk, when to give compliments to others, and when to apologize. It also means being able to read situations and know what is the right thing to say or do. There are an infinite number of combinations of roles, tasks, contexts, and feelings that govern what is appropriate in any given encounter. 4. Sensitivity to Dialect or Variety The standard variety of English used in our country is the variety that is taught formally in schools and the Standard British English is the linguistic model in the education system of Malaysia. However in Malaysia, English, being the second language, is learnt for a functional purpose. The most important measure of success when a language is learnt for a functional purpose is communicative effectiveness; that is, whether the language enabled the learners to achieve the purpose of learning. A dialect is a language variation spoken by a particular ethnic, social or regional group and is an element of the group’s collective identity (Ogbu, 1999). Each dialect within a language is just as logical, complex and  rule-governed as the standard form of the language (often called standard variety). Malaysian English (or Manglish) is a non-native variety of English and is one of the most prominent features of Malaysia’s linguistic corpus. Baskaran (1994) has categorized ‘Manglish’ into three sociolects, which are: †¢ Acrolect (‘high’ social dialect) – used for official or educational purposes, considered to be the standard educated sub-variety that approximates native competence and is used in formal speech as well as in written forms by speakers who have been educated in English; †¢ Mesolect (‘middle’ social dialect) – used in semiformal and casual situations, a sub-variety that is used in informal situations among fellow Malaysians. †¢ Basilect (‘low’ social dialect) – used informally and colloquially as a ‘patois’ shades into a pidgin used mostly by village peddlers when talking to tourists and other potential customers. 5. Different English Varieties. There are different varieties of English used here in Malaysia. The important issue here is what would be considered as an acceptable variety of English for Malaysian students? In Malaysia, there is a strong tradition of teaching English when learners are still very young. Also, due to home language interferences and strong media influence, which at times popularises Manglish as a more convenient spoken variety, Malaysian students might not have enough exposure to models of Standard English. Parents might communicate with their children in  strong accented English which is unique to each cultural/racial group, or/and even in broken or grammatically incorrect English. This variety of English could be incomprehensible at times. 5.1 Malaysian English (ME) Some words of ME reflect the multilingual traits of the country. The existence of loan words in the lexis of ME is very rampant and common, especially since Malaysia is a Malay dominated country both in language and culture. Moreover there are no lexical equivalents of certain Malay words in English. Listed below is a list of commonly used borrowed words and phrases which have made their way into the repertoire of speech among speakers of Manglish. At the lexical level, some words of ME used by students reflect the multilingual traits of the country. There exist loan words from contact languages such as Chinese (ta-paw, pu-yao) and Bahasa Malayu (makan). Using substrate lexemes plural in the usual English way is common, e.g. kopios coffees (kop-o, black coffee), Menteri Besar (head of state government) and pengarahs (directors). Other cultural expressions adopted in ME, for instance: †¢ Kadhi (religious judge) impose a fine for khalwat (illicit proximity to the opposite sex) †¢ Don’t act so ulufied (backward, not hip) Wear something more stylo (stylish) †¢ Lets go ngerdate (dating), an Indonesian slang very common among the Malays. †¢ Hello thamby, (boy) one cup of coffee please. An example of a short conversation in colloquial Malaysian English (non-standard English) may sound like this: Housewife: Your fish so flabby, no good one. Fishmonger : Like that already hard †¢what. How hard one you want? You want stone, want wood. I can’t find. Housewife : You half-past six lawyer one. Give little bit cheap la, this fish. Fishmonger : Oh, that’s why you said that kind, said my thing flabby, you want Cheap-cheap. Housewife : You don’t want give, I look other places. Fishmonger : Look, look la, wait you come back look for me also. (Adibah Aroin, New Straits Times, 3V December 1992) 6. Awareness of language differences in the classroom Though the use of Standard English is very much desired, one must not dismiss the significance of other varieties of the language, particularly Manglish. Students must be made to realise the importance of Standard English in academic and formal settings; but at the same time be conscious of the communicative function of Manglish. Manglish helps learners to bridge the gap between the use of acrolect among proponents in an academic setting and the basilect used among their peers to facilitate understanding. More importantly, Manglish has a social function of fostering ties. It motivates students to move from one speech to another level through the opening up of communication channels across the sociolects. Students must realise that the main objective of learning English is not to acquire native speakers’ competency but rather to be intelligible among international English speakers and those within their ‘community’. Students  must be conscious that dialects are not inferior languages and that they should be respected, and that Standard English is necessary only in a formal context. 6.1 Intercultural Media Language The English language and its varieties would make excellent vehicles to create cross-cultural awareness. Students are able to use print and non-print resources of language such to compare the language used in British newspapers and the local dailies. Students will find differences in the use of lexical items and would be able to familiarize themselves with the constructs of ‘Manglish’. They will then proceed to examine larger texts such as novels and plays. This will encourage students to accept their own variety and ‘overcome reluctance to approach another variety once they found that the texts in these other varieties were accessible to them’ (Kachru and Nelson: 1996) 6.2 New English Literatures An excellent method to introduce other varieties of English is through literature. The area of literature opens up multi-traditional aspects of human life, which encourages students to broaden their horizons. By introducing literatures that is very much Malaysian, students will be exposed to new uses and forms of their own language. 6.3 Manglish Discourse Materials, which have features of ‘Manglish’ such as advertisement, obituaries and excerpts from TV and conversations, provide excellent  resources in discussing discourse markers. In this way, students are able to study speech acts such as negotiating, persuading, and apologizing within the structures and cultural context which is most familiar to them. Rather than perceiving it as an obstacle to learning the English language, the recognition of ‘Manglish’ by educational bodies may perhaps be of a great value. 6.4 Importance of Standard Variety I would suggest that students learn to handle formal language in schools. This is because they can easily revert to conversational and colloquial language as and when the context arises. However if one only learns to speak at the colloquial level, one can never rise up to the occasion to speak formal English when the need arises. Formal English requires usage of proper grammar and syntax with appropriate vocabulary. It takes a lot of practice before one can master English at this level. So why short change our students by accepting communication that is only up to the non- native variety level? In fact there is worry in many English speaking countries that teenagers are so used to using colloquial English in their ‘SMS’, that they cannot manage formal English, especially at the written level 7. Sensitivity to Registers The notion of ‘developing a language’ means, adding to its range of social functions. This is achieved by developing new registers. According to Halliday (1978:195), a register is a set of meanings that is appropriate to a particular function of language, together with the words and structures which express these meanings’. Registers are commonly identified by certain phonological variants, vocabulary, idioms and other expressions that are associated with different occupational or socio-economic groups. 7.1 Importance of Registers to Learners The term register includes different aspects of language in various contexts such as field of discourse, modes of discourse, style of discourse and discourse domain. It is important for students to develop styles and registers and recognize how to use them appropriately and be conscious of the need to do so. 7.1.1 Field of Discourse The knowledge of discourse enables students to have the ability to communicate with specialists in a particular field once they’ve understood the use of terminologies used in that field. In The STAR online, 24h March, there was a write up from a concerned parent who felt that teachers needed help in the field of Maths and Science and how crude errors are made such as ‘8 push 4 is 4’ a literal translation from BM (8 tolak 4 ialah 4). Therefore it is important for students to be exposed to mathematical and scientific terminologies because knowledge is power Having knowledge in various fields will help students in their future studies or career such as being proficient in delivering speeches, conducting negotiations, preparing drafts of agreements and in routine business communication. 7.1.2 Modes of Discourse Modes of discourse can be either written or verbal. Students who are not very well versed in their speech may produce ungrammatical, short, incomplete sentences, filled with false starts, fillers and pauses. Tongue (1968:83) has defined ‘fillers’ as a term used to indicate those items of language which communicate no particular denotative meaning but which are used to indicate the emotive, affective attitudes of the speaker, or sometimes simply to fill a pause or a moment of hesitation or reflection in the stream of speech. The most well known is the â€Å"suffix† lah or sometimes pronounced la, which realises different pragmatic functions as illustrated below: †¢ Emphasizing support e.g. I agree lah †¢ Persuading e.g. †¦ .you must do it in a proper way lah †¢ Complementing e.g. that’s a good idea, good lah Other common fillers used are ‘bah’ (by the Sabahans), ‘mah’ (by the Chinese) and â€Å"a?† or â€Å"ah†. â€Å"Ah† serves to function as fillers or breaking points as well as bringing out a question force as shown below. †¢ No point helping friends who are not interested, do you agree with that, ah? Other features of Malaysianess include the use of tag questions in particular the use of â€Å"isn’t it?† and adding the phrase â€Å"or not† to the preceding instead of presenting two alternatives. †¢ We’ve done it, isn’t it? †¢ You want to follow or not? Students must be mindful that usage of such a variety of English is accepted in informal settings. However in a formal setting, the standard variety of English is necessary and is the acceptable norm. With the changing role and the decline in the standard of English in Malaysia, it is found that instances of deviation from Standard English have increased in frequency. Though there is an attempt to use the Standard English, inadequate exposure and lack of knowledge result in the many basic Standard English deviations, which are found even in the speech of educated users of the language. As far as Malaysian students are concerned, these irregularities are usually tolerated and overlooked, as long as they do not interfere too greatly with communicative purposes. At present, indication of these irregularities may be observed in the spoken mode, as many students seem to feel quite free to incorporate features of the local dialect, into their speech, be it in a formal or informal situation . 7.1.3 Style of Discourse An important issue is how students use their verbal repertoire and what are the uses they will put them to. According to Halliday (1978), there are factors, which affect the way people use language. Halliday classifies this as field, mode and tenor. Field refers to ‘why’ and about what a communication takes place, mode is about ‘how’, and tenor is about to whom. For example, in writing a letter, one might start: â€Å"l am writing to inform you that†¦.† but in another letter, the same person might write: â€Å"I just  want to let you know that†¦Ã¢â‚¬  According to Joos (1967), there are five types of formalities: 1) Frozen style is more characteristic of writing than speech e.g. Students should make their way at once to the upper floor by way of the staircase. 2) Formal style uses sentences that show careful planning and logical development of ideas e.g. Students should go up the stairs at once. People who have limited shared background use consultative style; sentences are complete and some background information is given e.g. Would you mind going upstairs right away, please? People who have a shared background use casual style; it is marked by slang, profanity and incomplete sentences e.g. Time you all went upstairs now. Intimate style is the style, which is highly economical and is accompanied by a lot of non-verbal communication; people who know each other very well use it e.g. Up you go, fellows! It seems to me that it is in the area covered by consultative, formal and frozen, that our students need to be competent in. They ought to know which style to use when an occasion arises. Once a student said to his teacher in class: â€Å"Would you be so kind to explain again?† and a moment later, he said, â€Å"I want you to explain this question again†. This shows that the student is not consistent in the level of formality. In a classroom situation, the second one is acceptable but the first one is too formal. Our students fail to take into account the relationship between participants and situations or settings. Students need to be aware that a formal setting requires formal speech and that they may use colloquial words or phrases in an informal setting. They need to be aware that using language often involves how formal one needs to be in a situation. 8. Cultural References and Figures of Speech An overall understanding of the significant role of cultural variables in cross-cultural interactions will act as a bridge to mutual understanding and acceptance in situations of cultural conflict. Students must be aware that in certain cultures, the people are expected to respond to certain  utterances in an appropriate way, which is of the linguistic norm. 8.1 Importance of Cultural Appropriacy A possible way of dealing with varied cultural behaviour is to sensitise students to the unique characteristics of other cultures. Students should develop cultural tolerance and show understanding for other people’s differences. The ability to be tolerant is necessary for anyone hoping to avoid miscommunication. It involves the learner recognizing that every culture has its own logic, its own integrity and that no one culture is any better (or, for that matter, any worse) than any other. Malaysian idiomatic expressions used by learners could only be understood at the local context. Some are even fond of the idea of contextualization these days. It truly gives a Malaysian flavour to our speech. Localised expression appeals to the average man in the street. Having a common speech pattern somehow helps some students to bond quickly and so it helps to establish friendship between like-minded people. 9. Ways of Improving Students Sociolinguistics Competence The lack in cross-cultural understanding or sensitivity on the part of the teacher has serious implications because it affects classroom management and consequently, student’s learning. There are various activities that can be carried out in classrooms to instil cultural understanding. Learning how to perform particular speech acts in both formal and informal settings,  learning particular â€Å"ways of speaking†, like story telling, narratives, joke-telling, simply learning to chitchat, are all important in learning how to speak proficiently. Syaharom Abdullah (1995) believes that students will become conscious of the values and expectations, which are basic in a culture through dialogue practice or role-play. In learning English, the student has to learn how to use and interpret the sociolinguistic rules of English in various contexts. To achieve this, the learner must develop an awareness of areas in which the sociolinguistic system of his own culture differs from those of other cultures. Teachers can design some problem-solving exercises in order to do so. 10. Conclusion It is obvious that sociolinguistic competence offers more insights in learning a language. Problems may arise for students’ who may not be familiar with the various context of language use. By means of getting acquainted with the various cultures of Englishes and updating their knowledge about language learning, students may be better able to accomplish the goals of engaging themselves in the pragmatic, authentic, functional use of language for meaningful purpose. It is important that the second language instructors in Malaysia be familiar with sociolinguistics. Teaching language is not just about learning the rudiments of the language but also various cultural refinements. Students must be made aware of formal and informal language use. They should be knowledgeable as to appropriate expressions for different context. Students must be mindful as to when they can resort to colloquial language and when formality is necessary. Lastly students need to be made aware that mastering English does not mean acquiring native proficiency, but rather having universal intelligibility. References Adibah A. (1992). The New Straits Times, SO†1 December. Bachman, L. (1990). Fundamental Considerations in Language Testing. Oxford University Press. Baskaran,L. (1994). The Malaysia English Mosaic. English Today 37 Vol. 10. Brown H. Douglas, (2000). Principles of Language Learning and Teaching, Fourth Edition, Longman. Broersma, D. (2001). â€Å"‘You’re So White, So Fat, and So Hairy!†: Developing Sociolinguistic Competence in a Second Language.† In Helping Learners Develop Second Language Proficiency, L. J. Dickerson (Ed.), pp. 200-205. Colorado Springs: Mission Training International. M.A.K. Halliday. (1978). Language as Social Semiotic: The Social Interpretation of Language and Meaning, Baltimore: University Park Press, 1978; London: Edward Arnold, 1978. Joos, Martin. (1967). The Five Clocks, New York: Harcourt, Brace & World. Kachru. B.B. and Nelson, C.L. (1996). World Englishes. In Sociolinguistics and Language Teaching. USA Cambridge University Press. Morias, Elaine. (1994). Malaysian Business Talk: A Study of Conflict and Non-Conflict in Verbal Interactions. PHD Thesis, University of Malaya. Syaharom Abdullah. (1995). Thai Tesol Annual Conference, January 1995, Universiti Utara Malaysia. Test/cultural kind-html. The Star On Line, 24th March, 2003. Tongue, R.K. (1979). The English of Singapore and Malaysia. Singapore, Eastern University Press. Ogbu, J.U. (1999). Beyond Languages: Ebonies, Proper English and Identity in a Black- American Speech Community. American Educational Research Journal, 36 147-184.

Family Nursing Diagnoses Essay

Conducting a family assessment is a challenging and important step in the care of the client. It is essential to identify problems and situations inhibiting a family from practicing healthy behaviors and developing healthy habits to thrive in the home and community. Identifying problems then deciding the family nursing diagnosis and planning interventions beneficial to the family is the next step in the client’s care. Three Family Nursing Diagnoses The three family nursing diagnoses identified to assist SS and her family are anxiety related to several short- and long-term stressors, delayed growth and development related to CS’s handicaps, and chronic pain related to SS’s rheumatoid arthritis. These nursing diagnoses were most appropriate for this family. Healthy People 2020 Indicator The indicator chosen that links to the nursing diagnoses mentioned above is social determinants (â€Å"Healthy People 2020†, 2012). This indicator is relevant to the identified family nursing diagnoses because of numerous reasons. CS has a disorder that has caused him to have developmental delays and numerous health issues. He reports getting bullied at school periodically, is in special needs classes, and will not be able to live independently. The indicator is also relevant because of the number of stressors SS has identified through the family assessment that affects the family’s lives daily. Researching information on Healthy People 2020 and  specifically the social determinants indicator reveals that assisting the client and her family with healthy behaviors, physical activity, assistance with dealing with stress-related issues leads the family to being successful members of the community and being successful in tasks necessary for improved health and longer life expectancy. Linking the indicator to the family nursing diagnoses will also provide the family with strategies to deal with school, community, and workplace issues that are barriers to accomplishments within the family. Opportunities for Community Health Nursing Interventions One opportunity where I can make a positive impact with community health nursing interventions would be providing a lecture at CS’s high school about bullying. This would be beneficial for students in many high school communities. The lecture should include information about why children bully each other, strategies for how to deal with bullies, and why bullying is wrong. Another way to influence in a positive way is provide SS and her family ways to deal with the issues that cause the most stress in the family, whether it is financial concerns, time management issues, or health concerns. Conducting family meetings to share responsibilities for chores around the house, making the children aware of what can be afforded monetarily month to month, and ensuring the family is keeping regular health check ups are a few techniques that may be beneficial. Making sure SS is aware and takes advantage of workplace assistance for a variety of reasons is another opportunity to make a posit ive impact on her family and on the social determinant indicator. Health Education Topics There are a number of topics related to health education that would be beneficial to SS and her family as well as any community. One topic SS may find helpful deals with emotional wellness, which is a subject I have spent time discussing with SS and her family. Finding a balance between everything going on in one’s life, such as school, work, sports, or other activities is necessary in protecting emotional health. Another topic relates to stress, which is another area of concern for SS. There are different levels of stress and they can be short-term and long-term  stressors as SS has identified within the family assessment. Stress does not have to be bad, but how to deal with it is what makes the difference. Developing and learning coping strategies are helpful in managing stress. Here is where the emphasis in education should be. Nutrition and physical activity is another health education topic beneficial for everyone. SS’s oldest son who is in college could be a target of this topic, as college students are not known to have healthy eating or sleeping habits. Diet teaching and assistance with developing a physical activity plan would be a focus of the education (â€Å"Health Education Center†, n.d.). Conclusion A family assessment is a vital step in diagnosing what potential problems and areas for improvement a client may have. Evaluating aspects of the family unit including family history, support system, stressors, and social structure will aid in determining and prioritizing the family diagnoses. Family involvement in decision-making of what diagnoses to conquer and intervention planning will help the success of the plan. What is learned through the family can help develop topics the general public could be educated on and benefit from. References Health Education Center. (n.d.). Retrieved from http://www.healtheducation.uci.edu Healthy People 2020. (2012). Retrieved from http://www.healthypeople.gov Nursing Diagnosis List. (2012). Retrieved from http://www.nandanursingdiagnosislist.org Stanhope, M. (2012). Public Health Nursing: Population-Centered Health Care in the Community (8th ed.). Retrieved from The University of Phoenix eBook Collection. Family Assessment I. Family Demographics a) Family Name-Sindle b) Family Composition-mother, 3 sons c) Type of family form (single parent) d) Cultural Background-English, German, and Cherokee†¦.great., great,  great grandmother was Cherokee Indian e) Religious Affiliation-Baptist and Presbyterian f) Social Class Status-low income class g) Family’s recreational or leisure-time activities-soccer, 2 of 3 boys very involved with soccer teams. Watching movies, riding bikes. II. Developmental Stages and family history a) Family’s present developmental stage-one child in college, one in high school and one in middle school. Mom taking classes part-time to earn nursing degree. b) Nuclear Family History-SS’s parents are originally from Franklin, NC. Mother is of English and German descent and dad is English and Cherokee Indian. I II. Environmental Data a) Characteristics of home-reside in a 2 story home in a single-family dwelling subdivision. Approximately 300 homes in the neighborhood. b) Characteristics of neighborhood and larger community- There is a community park with a small playground used for gatherings. They have neighborhood watch in their subdivision. Gloucester is considered a rural community. It has a large shopping center that has a Walmart, Home Depot, Lowes, Applebees, Chick-fil-a, Pizza Hut, McDonalds, Hardees and Wendy’s. Several churches of various denominations, one free medical clinic, a wellness center, one small hospital, a boys and girls club, several parks with baseball fields, soccer fields, and playground equipment. Family-owned shops on main street with restaurants and banks, a bookstore and antique stores. Volunteer fire stations and rescue squads throughout the county. c) Family’s Geographic mobility- SS was born and raised in Williamsburg, VA. Lived in Tappahannock, VA for a year and then moved to Gloucester, VA where she have resided for 25 years. Her sons have lived in Gloucester since they were born. d) Family’s associations and transactions with community- Her boys participate in parks and rec activities. They go bowling as a family and to the movies occasionally. Attend annual Daffodil festival that is held in the community every spring. e) Family’s social support network-SS has aunts, uncles and a few friends that help out sporadically. Her two youngest boys go to Florida every summer to spend time with their grandparents. SS sees her work environment and peers as a support system as well. Her oldest  child has a support system through his soccer teammates and friends at college. IV. Family Stress and Coping a) Short and long-term familial stressors and strengths: Short term- SS is trying to finish classes so she can start nursing school. Also trying to balance work and school and getting children where they need to go for activities. Long term- son (CS) with special needs-what will he do after he graduates high school in 2 years. Has Williams Syndrome and has cognitive and developmental delays. Finances. Getting oldest son through college. Single parent (children’s father passed away in 2009, he and SS were divorced prior to that). SS has recently been diagnosed with rheumatoid arthritis. CS’s health-worry about his cardiac issues as he gets older, hypertension, and GI issues. b) Extent of family’s ability to respond, based on objective appraisal of stress-producing situations- This family has been able to respond to the stressors that have been placed on them relatively well. They have had their ups and downs, but are a very close family and they rely heavily on ea ch other and help each other out. SS’s sons are very protective of their mother. c) Coping Strategies Utilized by all members of family-They work together as a family to get things accomplished. The boys have had to grow up quick. Working through one issue at a time. Make time for fun and for the 2 boys to participate in soccer. V. Family Functions a) Family’s need-response Patterns (affective function)- Very close knit family. They watch out for each other always. They go to soccer games together as a family to watch the 2 boys play. Take at least 2 family vacations each year with SS’s parents. Watch a lot of family movies together. Watch professional sports on TV. b) Socialization Function (child rearing practices, who is socializing agent for children, cultural beliefs that influence family’s child-rearing patterns)- SS is primary socializing agent. Discipline for bad behavior depends on what the infraction is, ranges from no TV to no friends over for bad grades or if school work not completed. c) Adequacy of home environment for children’s needs to play- have a large fenced-in backyard with an above-ground swimming pool. Pool table, ping-pong table. Bikes, soccer net  and balls, tennis rackets, TV room with xbox 360, DVD player, Computers. d) Health care function-SS has health insurance through her employer. Middle child now 18 and qualifies for Medicaid. The family sees a physician yearly for physicals. CS sees many different specialists. JS has frequent bouts of strep throat which makes him miss several school days each year. SS sees a rheumatologist for her RA.

Hrm/300 Managment Overview

Human Resource Management Overview University of Phoenix HRM/300 November 14, 2012 Human Resource Management Overview Organizations require people to run everyday operations, which mean every organization needs human resource management. Today’s paper will discuss what human resource management is, and its primary function within an organization. Every organization has a strategic plan, and human resource management play a critical role in the implementation and production of that plan. Last, will discuss the role of human resource management in an organization’s strategic planning.What is Human Resource Management? According to Reed (2012), from the University of North Carolina Wilmington, Human resource management or HRM, assist in the development and education of people within the organization. The world is constantly changing and evolving each day. Human resource management must understand many aspects of society and the world to properly prepare an organization for those changes. For example, those changes could be: Globalization, technology, workforce diversity, labor shortages, continuous improvement initiatives, etc†¦ Primary Function of HRMThere are many functions of HRM within an organization. However, the primary function of HRM is to increase the effectiveness and contribution ability of its employees, while attaining the goals and objectives of the organization. This could include continuing education, department cross-training, certification processes, diversity training, etc†¦ (DeCenzo & Robbins, 2007). As stated in the aforementioned paragraph, HRM has many roles within an organization. Some of these roles include compensation, benefits, training and development, employee relations, recruiting, and hiring process.Based on the broad spectrum of responsibilities for HRM, it is crucial for one to behold solid communication skills and decision-making capabilities. One may argue it is also critical to behold strong analytical skills and critical thought processes. These are skills one needs to stay competitive in today’s business world (DeCenzo & Robbins, 2007). HRM’s Role in an Organization’s Strategic Plan After generations of arguing, there is still an ongoing debate about the role HRM play in an organization’s strategic planning process. Some senior management believes HRM’s role is solely as a compliance function.Other senior management looks to HRM as a consultative service. No matter one’s stance on this debate, there is no denying the impact HRM has on the strategic plan of an organization (DeCenzo & Robbins, 2007). HRM professionals continue to fight for the proverbial â€Å"seat at the table† in this debate. HRM has nothing to worry about in most organizations. Successful organizations rarely develop a strategy involving human capital without the consideration of HRM. Even more important, no strategic plan is successful without effective recruiti ng, deployment, and development of human capital.This is exactly why HRM should have a â€Å"seat at the table† at all times (DeCenzo & Robbins, 2007). HRM provides value at every level of the strategic planning cycle by demonstrating knowledge, alignment, success, and vision of the organization. HRM must recruit each candidate that best fits the needs of the business. If the business is suffering or needs improvements in a specific area, HRM will recruit to fill that position based on specific criteria the business is looking for to further advance its position within the competitive market.If HRM does not function at a high level within this one function, the entire business is at risk (DeCenzo & Robbins, 2007). Conclusion Exploiting opportunities and identifying goals are the two most important aspects of strategic planning. HRM plays a critical role during this process, while limiting and considering all associated risks. HRM helps align goals and initiatives while aligni ng all necessary resources to deliver the desired results of its key stakeholders. HRM should be involved in every step of every process. If one can execute successfully these uiding principles throughout each phase of strategic planning, one’s future is bright. Involving HRM will strengthen the position of the strategy by providing fact-based insight to stakeholders. In time, HRM will align the necessary resources to achieve the initiatives and goals of management and the strategic plan. References DeCenzo, D. , & Robbins, S. (2007). Fundamentals of Human Resource Management (9th ed. ). John Wiley and Sons. Reed, D. (2012). University of North Carolina Wilmington. What is human resource management. Retrieved from http://uncw. edu/career/humanresources. html

Assignment 6 Essay Example | Topics and Well Written Essays - 1250 words

Assignment 6 - Essay Example The data obtained reveals that learners are gifted differently, and there is a need to attend to them based on their abilities. This provides a platform for teachers to attend to learners with special needs. Necessary assistance would be extended to such learners. Assessing this type of records would be relatively easy with the assistance from subject teachers and administrators of the school. Working closely with parents would help avail necessary documents of previous performance. The author is involved as a principal in a school in Southern Oregon characterized by transition of leadership, where he replaces a principle that left little to be desired. The school has 86% annual student transient rate with a high teacher turnover. Parents’ involvement is low, and all is left to the teachers. The principal aims to turn things around and pull the high-poverty community together. The new principal is keen to realize the key affected areas in his new school. The teachers are alienated in decision-making, and their opinions are overlooked. The learners are not addressed appropriately, and there is a case of multiage grouping. Such a decision affects the overall performance of the learners, in the long run. Cooperative learning is poorly executed leading to a great deal of â€Å"Davids† in the institutions. Another problem is full class inclusion without paying attention to gifted and learners with special needs. The author further realizes that language learning was a mystery topic. With the involvement of teachers, he engages in an action research with an aim to have things work perfectly. He designs a plan to higher new teachers for the school to meet the demands of the learners. The learners would need instructors competent enough to better them. The principal purposes to meet the key parents for their involvement. They would support teachers establish the most conducive environment in the school. He identified requirements in the new

Auteur Theory and Directorial Burlesque Essay Example | Topics and Well Written Essays - 3000 words

Auteur Theory and Directorial Burlesque - Essay Example In the domain of cinematic extravaganza directorial role evolves as â€Å"consequential volume of discourse on a ?lm’s director and on consecration itself† (Hicks & Petrova, 2006, p. 180). The emergence of the auteur theory circumscribes around the role of the director in a movie. The auteur theory is actually a way of reading or the appraisal of the films through the indentation of an auteur (author) especially the director. The underlying mechanism of the theory states that quality of a film centers around the director as author. The paper will deal with the crux of the auteur theory with reference to a reputed director of Hollywood, M. Night Syamalan and his great works in the field of cinema. Auteur theory Developments and the proponents Historically, the notion of the authorship developed the essence of a secluded individual working fervently for the creation of the bodies of art. As for example the characters in Baz Luhrmann’s Moulin Rouge, there have been a perfect permeation of the romantic stereotype of the tortured Bohemian artist. The term auteur is basically a French word and the word prefixed with it i.e, ‘auoto’ means one. ... In one of the two comparative popular history texts of the recent origin, Nowell-Smith, Sarris and Bogdanovitchare are mentioned. In 2004, the ISI Web of Science Citation Indexes for the arts and the social sciences figured out that Sarris, The American Cinema was cited around 100 times while on the other hand, Truffaut’s phenomenal ‘Politiques des auteurs’ was only cited 12 times (Hicks & Petrova, 2006, p.184). . The notion of the theory The theme of the theory conjectures upon the fact that the director of a film with his or her personal influences and artistic control over their films are so immense and charismatic that the director may be regarded as the their author and their films are recognized collectively as cluster of work sharing common notion or the ambience spread expresses the rigid predominance of the an individual’s style or vision (Auteur Theory, n.d., p. 3). The theory finds its roots of development of the influential essay written by Fran cois Truffaut in Cahiers du Cinema in 1954. The auteur theory differs from the straightforward theory of directors which could be found from Ian Cameron’s article â€Å"Films, Directors, and Critics†, in Movie of September, 1962 where the comment he made goes as follows: â€Å"The assumptions that underlies all the writing in the Movie is that the director is the author of the film, the person who gives it any distinctive quality. The significant premise on which the theory stands is the distinguishable personality of the director as a criterion of the value. Over through a wide array of films, the director wills exposit certain characteristics of style which will be represented as the signature of the director. The way in which the storyline of the movie flows largely depends on the thinking and

The using Okuns law to track and analyze the changes in the Research Paper

The using Okuns law to track and analyze the changes in the unemployment rates over the last decade - Research Paper Example Output and employment have a tendency to more simultaneously. In 1962, Arthur Okun conducted an empirical research over the relation between changes in unemployment to the changes in gross national product in US economy.The Using Okun’s law to track and analyze the changes in the unemployment rates over the last decade.He found that for every 3 percent increase in real output of the country, unemployment decreased by 1 percent. The observers of this result started to dub it as â€Å"Okun’s Law†. Thus for the United States, Okun coefficient is 3. It can logically be expected the output of a country to approximately move one for one with the level of employment. Okun, however, argued that Measures unemployment is less volatile to any economic change than output. This is for, according to him, fluctuations in working hours and labor force participation generally hide underemployment to some extent. (Okun, 1962). Okun coefficients are not same for all countries. It h as been found by the economists that most of the developed or industrialized nations of the world have higher Okun coefficients than United States. It simply implies that, in most of the other industrialized nations of the world the rates of unemployment have a tendency to vary less for a given fluctuation in gross domestic product than in case of the United States. A reason for this could be that in United States labor market is less regulated than in other countries and hence companies can more easily lay off their workers during economic slowdowns. In most of the industrialized countries, there are stronger implicit job protections by the societies, stronger unions, and higher governmental restrictions on laying off workers than in United States. (Kaufman, 1988; Moosa, I. A.(1997) However, over the years, many industrialized countries have undertaken various reform measures to reduce restrictions on labor market so that companies can exercise more freedom in laying off workers at the time of economic downfall. Thus, Okun coefficients of many industrialized countries like UK, Canada, Germany, Japan, France and so on have been lowered in recent time than before. However, USA still has the largest Okun coefficient. (Kaufman, 1988; Moosa, I. A.(1997) One interesting thing about Okun coefficient is that it can change over time as the relationship between output growth and change in unemployment depends to a large extent on a number of other factors like technology, social regulations, demographics, laws, etc. As these factors change, Okun coefficient might also change. (Lee, 2000). Here this Okun’s law will be used to analyze the movement in the rate of unemployment in US over the last decade. Here an attempt will be made to find out whether Okun coefficient is still the same in US as documented by Arthur Okun. The last decade has experienced huge economic fluctuation, and hence it would be quite interesting to find out the value of Okun coefficient under such economic slow down in US. At present, most of the economies throughout the world are going through a critical phase of recession and among all the economies. The situation has been so critical that the most power economies in the world also have not been able to escape this economic crisis. Economies of U.S., Japan, China, U.K. etc are all suffering from severe demand crunch and consequently fall in production and employment. U.S. is the Worst hit country by the current recession. The ongoing economic crisis through out the whole world owes it origin in U.S. following a huge credit crisis in the home loan market. Since early 2008, the U.S. economy has been looming under recession. Many economists are even of the opinion that this recession has started during the last quarter of 2007 itself. The effect of recession has not been confined to U.S. economy only. In late 2007 and even early 2008, most of the stock market indices across the world were touching the sky. Under such sce nario, corporate houses were showing over enthusiasm and in several of countries money was flowing in huge

INSANITY AND MURDER Essay Example | Topics and Well Written Essays - 750 words

INSANITY AND MURDER - Essay Example Women were further forced into the stereotypical passive housewife role† (Frick, 2002). Those women who found this role difficult to assume were often the subjects of harsh treatments or otherwise controlling methods that were designed to bring them back into their socially accepted, and therefore considered natural, roles. â€Å"Cures included bed rest, seclusion, bland food, refrain from mental activities (such as reading), daily massage, and sensory depravation. Though these treatments do not seem too appalling, they were comparable to solitary confinement and would often drive a woman to further insanity† (Frick, 2002). These are the types of women who are often seen gracing the pages of late nineteenth and early 20th century writers such as William Faulkner and Susan Glaspell. In stories like â€Å"A Rose for Emily† (Faulkner) and â€Å"Trifles† (Glaspell), women can be seen to be driven to insanity by the controlling actions of the men. Faulkner introduces Miss Emily Grierson as a woman who has never been provided an opportunity to become comfortable or familiar with the world outside of her father’s old world ideals. â€Å"None of the young men were quite good enough to Miss Emily and such. We had long thought of them as a tableau; Miss Emily a slender figure in white in the background, her father a spraddled silhouette in the foreground, his back to her and clutching a horsewhip, the two of them framed by the back-flung front door† (437). This created a situation in which Miss Emily â€Å"got to be thirty and was still single† (437), forced to live in her maidenhood forever and lacking any connection to the rest of the world. Miss Emily’s inability to relate to the real world outside her fantasy is first manifested completely when she refused to acknowledge her father’s change of state upon his death. â€Å"Miss Emily met them at the door, dressed as usual and with no trace of

Critique of Anand Hollas Article Entitled Obsessed with Your Cell Essay

Critique of Anand Hollas Article Entitled Obsessed with Your Cell Phone - Essay Example The article is timely because the author was able to determine that our dependency towards technology particularly cellphone has already developed to a proportion that is already a disorder. The author intended to create awareness among the readers so that they would examine themselves if they are already addicted to their smartphones by comparing their behaviors to the behaviors cited in the article. And if they are, they can seek help just like what the subjects did in the article. The good thing about this article is that the author made its audience realize that addiction towards cellphone is not healthy. Many people especially teenagers think that their dependency towards their smartphones are cool when it is in fact not. It would be difficult to ascertain with certainty if the author had successfully convinced its audience that smartphone use has already assumed a proportion of disorder. There no surveys included in the article that provided reader response. But personally, I t hink the arguments of the author are quite persuasive. I may not be that totally sold with the point of view yet because I am still looking for more literature to support his claim, but the article has definitely made me think and consider that smartphone dependency of many people is already troublesome. If the study is to be believed smartphone addiction is already â€Å"similar to drugs or cigarette addiction† which is already troublesome. To say that I agree already with the author would be quite premature considering that there is only one point of view that is presented to me and does not have anything to support or refute his arguments. Basing however from experience and observation, I think that the author made a good case and if presented with supporting scientific literature that is peer-reviewed, his case could convince me. Inferring from my observation, I see a lot of young people who are hooked not just with their smartphones but also to social media such as Faceb ook and Twitter. Some are even exclaiming that they cannot live without their smartphones or their Facebook or they could not imagine life without it.     

Meaning of my quote (please look in the details box for the quote) Essay

Meaning of my quote (please look in the details box for the quote) - Essay Example I think that the connection between a leader and the followers is based on the spiritual foundations. The leader sends messages to the followers verbally. This is the most identifiable and easily recognizable form of communication and interaction between the leader and the followers. However, there is something more to it that just the followers can feel and is not overtly visible to the outsiders i.e. the emotional connection. Whatever a leader says or does leaves an impression on the followers. The followers are best in the position to comply with the instructions of the leader when they know what the basis of the demand from the leader to behave or act in a certain way or do certain things is. In order for an individual to be effective as a leader, it is imperative that he/she first earns the trust and confidence of the followers. The leader accomplishes this by assuring the followers that if they comply with the instructions of the leader and do as he/she asks them to, he would lead them to the results they want. Followers only abide by the leader’s instructions when they see their personal benefit in doing this. The personal benefits of followers vary depending upon what are the conditions or context in which they are following the leader. In an organizational setup, subordinates follow the instructions of the management because their wages are decided and performance is evaluated according to their compliance. In the context of a country, people pay taxes to the government because they are confident that this money would be used to provide them with more benefits. My quote emphasizes upon one main objective of leadership i.e. inspiring the followers. There are many ways in which a leader can inspire the followers. Different leaders have different strengths using which they inspire the followers. For example, certain leaders have good vocal skills and inspire the followers through their motivational speeches. Likewise, there are certain leaders

World War II Through the 1970s Coursework Example | Topics and Well Written Essays - 1250 words

World War II Through the 1970s - Coursework Example Additionally, both led to significant developments in the American perspective like sympathy for the incoming president, as well as finding pride in their potent military. 2. The second World War was originally a European conflict. Americans were hesitant to become involved due to a variety of reasons that are discussed below, resulting in a high sense of tension when the country did enter formal battle after the Pearl Harbor attack (Schultz, 2009). The United States had become concerned with Japanese conquests of the Pacific during the war, and this attack proved to be the tipping point for an official American declaration and entry into WWII. Of course, this eventually led to the dropping of the first atomic bombs, and the cessation of fighting at a tremendous cost of human life. These events helped to establish the US as a freedom fighting, militarily dominant international force, and serve as a source of both pride and mourning in American culture. The clear racism displayed by t he Nazis pushed American standards away from assimilation and toward tolerance, laying the ground for civil rights movements. WWII also served as an important revitalization point for many national industries as massive amounts of resources became of use. This economic boon would continue to fuel the American society for decades. JFK was an extremely popular president, displaying charisma in public (Grubbs, 2013), along with a staunch political opposition to communism. This was an especially important quality given the events of the Cold War, and the symbolism that Kennedy represented (freedom, capitalism, etc.) was attuned to the emerging American mindset. JFK's time as president was not without incident, as the Bay of Pigs proved to be an especially embarrassing mark on his career, but his successes are much more apparent. Some of Kennedy's best work includes guiding the country through the Cuban Missile Crisis, and helping to grow the civil rights movement. In November of 1963, J ohn F. Kennedy was assassinated during a motorcade through Dallas, Texas. The event has become so salient in the American consciousness, that it has spawned countless conspiracy theories, pieces of art, popular culture references, and a country-wide awareness of the former president that has also spread among other countries. Kennedy was replaced by a starkly contrasting figure in Lyndon Johnson, changing the course of US politics to focus on the economy and education, but remaining influenced by JFK's legacy. 3. As wars raged in the late 1930s, the United States sought to remain uninvolved in military affairs. The government was concerned with the aggressive actions like Germany, Italy, and Japan, but did not feel it was wise to risk the losses associated with armed combat that were still fresh in the mind from WWI and instead imposed harsh embargoes where appropriate. The depression had pushed the country towards isolation, and they sought to remain this way as economic rebuilding continued. Darker reasons for staying out of the war included a misguided American respect for Hitler, who had pulled Germany out of their own depression, and the uncertainty of public opinion about antisemitism. 4. Victory in WWII would not have been possible without the efforts of American women. The vast number of men called to war left an equally large shortage in the national worker population. Women soon filled these positions as the government campaigned to sway employer attitudes toward hiring female workers, and women became determined to contribute (Capshew & Laszlo, 2010). The domestic economy

Management Strategy Essay Example | Topics and Well Written Essays - 2500 words - 1

Management Strategy - Essay Example It is also through this mission statement that Toyota was able to focus even more in the U.S., its old market and where it gets its high portion of sales and market share. In fact, focusing in the U.S. market was never been a mistake considering that the U.S. is one of the most influential countries in the world when it comes to setting various trends in economics and politics in general. Toyota sales were growing in this country and in fact, Toyota was heading on to even more wider expansion just even as it continues to grow in popularity and acceptance around the world. However, amidst global economic recession, and despite the fact that this strongly caused strong negative impact to every automaker around the world, Toyota is not accustomed to experience them. To wit, Toyota’s experienced troubles are the following (Flint, 2009): In 2007, Toyota was able to sell 9.37 million cars world wide, an indicator that it was then making out well. In fact, it made profits of $2.27 billion beating the General Motors as the world’s largest car maker as of the year 2007 (Japanese economy hitting record lows, 2008). However, it had an operating loss almost $5 billion in 2008 (Flint, 2009). In the last quarter of 2008, the Japanese exports dropped by $60 billion as a result of a rising Yen making cars and electrical goods expensive overseas (Japanese economy hitting record lows, 2008). This made its sales in its biggest market, the USA suffered. Based on last year’s sales, its sales was down 38% in the U.S., 20% in Canada, 30% in Japan and 18% in Europe (Flint, 2009). Toyota has never been accustomed to failures considering that the automotive industry where it belongs identifies it as one of the world’s largest automotive producers which aims to promote quality products in an international scale by making the world’s one of the greatest markets a target, the United States of America. Toyota is also known as the Japanese giant because it is the leading

Deciding my future Essay Example for Free

Deciding my future Essay A dream is not something to scoff at. Dreams always seem out of reach, a siren call that leads you to new, uncharted waters. Achieving one’s dream would be to reach a true pinnacle of life; however, the road to a dream is fraught with risks. To give achieving this dream your all might be the only way to reach one’s true potential, yet it may also lead to a bitter and disappointing end. With this in mind, I have often put off achieving my own dreams. I was so frightened by the possibility of failure that I dared not even try, instead resigning myself to a life of mediocrity. However, my dreams were given life by the encouragement of my parents to not settle for less. My dreams are not a trifle, an easily obtainable goal. My ultimate goal is to be a leading Video Game Designer, to create adventures and stories that resonate with the world and revolutionize storytelling in gaming. The mere immensity of this task was enough to make me shudder in fear. I looked my dream in the eye and thought it too immense. I would have resigned myself to a life of normalcy were it not for my parents, who did not want me to settle for any less then what I was capable of. They had just discovered a college that was about to open up a new major for Video Game Development, and encouraged me to face my fears and try to achieve my dreams. They pushed me to achieve my dreams, knowing that this college would be twice as expensive as a regular school. This encouragement led me to attempting to try and chase my dreams, to have some hope that what I wanted was possible, and to never give up on my dream. Becoming a game designer is not easy. It is even more difficult if you have dreams as large and grand as mine are. The mere thought of the immensity of this task, and my preconceived notions of my own inferiority, drove me away. However, I realized that, although a dream is rarely the easiest path, and instead it is more often than not the hardest path of all, to not even try to reach ones dream is to give up on life. The path I chose may not be the easiest path, and yet I walk down it knowing full well it might end in heartbreak. I do this knowing that, if I had given up, then I would never have known if I could do it, and spend the rest of my life mourning what could have been. Again, were it not for my parents encouragement, I would never have even attempted to chase my dream. No matter how much you want something, it is impossible to achieve it if you have no hope it could succeed. A sense of hope that what you want could be possible is a vital component to making it possible. This was something I had lacked prior to my parents encouragement. I was so frightened by what I wanted to do, I had no hope it was possible. Without hope, I would not even try, for why try when you are certain you will fail? My parents helped me believe that I COULD do it, that there was a chance, and that chance was all I needed. No matter the odds facing me, I had to have hope that it was possible to overcome. Even when you want something and work very hard, it is all too possible you will fail at first. The old adage, â€Å"If at first you don’t succeed, try, try again† works beautifully in this scenario. No matter how many times you are beat down, no matter how many times I fail in convincing people to work to my dream to companies to invest in my dream, I must perspire. If a dream is weak enough to be broken at the first sign of trouble, then it was never truly one of these â€Å"dreams† of which I speak, so much as it was a passing fancy. A true dream is not something one would ever give up on, and neither should I, for although there are many obstacles I must overcome to achieve my dream, to give up my dream would be to give up on my happiness. The dream of which I seek is a lofty one, and there is little chance it will be easy. However, no matter the cost or hurdle I must overcome, I have decided to reach my dream. This courage to face the impossible would not have occurred however without the support of my parents who have helped me and want me to reach my full potential, so thanks to them, even if I do not reach my dream, I will have tried; and the fact that I will try shall be the greatest gift my parents would ever have given me.

An expository sermon on holy living

An expository sermon on holy living An expository sermon on Holy Living Introduction How many of you feel Holy this morning? Dont worry you dont have to lift up your hands. When some one talks about Holiness the first thing I think about it God and His holiness. This morning I want to talk about our call to a holy livinglife. We all know that we are called to live a holy life but what do we do about it. DO we make any effort towards it or are we just praying for God to make us Holy and waiting for fire to fall down from heaven to make us Holy. We live in a world where holiness has lost its meaning. In this contemporary society everything goes, we can do anything as long as we feel good about it. What is our responsibility in this world, What are we called to do in this un holy situation? So we are going to look at the reasons why we are called to live a Holy life. Main Points 1. We are called to live a holy life because He is holy (1: 16) A] Real meaning of holy The word Holy is derived from a cluster of words in Greek. It means to be pure, to be set apart, sanctify and so on. But no meaning of this word can describe it properly.[1] Christ was the perfect example for Holiness. Be Holy for I am Holy is mentioned for about 5 times in the Bible. Holiness is not a new thing which the apostles discovered in the New Testament, it was present from the beginning of the Old Testament. He God gave Moses all the laws not to make their life difficult but to bring them one step closer to holiness; one step closer to Himself. B] One of the fundamental characteristics of God Gods Holiness can neither be understood nor grasped by our human minds. Holiness is one of the images of God which was lost in the garden of Eden. It could be only replaced by God Himself, by dying on the cross and making us pure. HE is always Holy. We are called to live like Him. So we are called to be Holy. When we were made we were made in the image of God. One of His fundamental images is holiness. So we were obviously made Holy. But we fell from our holiness because of our disobedience. We are missing out in one of the fundamental images of God. We have to be made into his image so one day we can see His face. If we are not made into His image we will not see Him face to face. It is just as simple as that; if we are not holy, we will not see God. C] Illustration Once, as an experiment, the great scientist Isaac Newton stared at the image of the sun reflected in a mirror. The brightness burned into his retina, and he suffered temporary blindness. Even after he hid for three days behind closed shutters, still the bright spot would not fade from his vision. I used all means to divert my imagination from the sun, he writes, But if I thought upon him I presently saw his picture though I was in the dark. If he had stared a few minutes longer, Newton might have permanently lost all vision. The chemical receptors that govern eyesight cannot withstand the full force of unfiltered sunlight. There is a parable in Isaac Newtons experiment, This is what the Israelites experienced in the wilderness. They had attempted to live with the Lord of the Universe visibly present in their midst; but, in the end, out of all the thousands who had so gladly fled Egypt, only two survived Gods Presence. They were all revealed and called to be Holy as God. But only two survived in the end.[2] 2. We are called to live a holy life because we do not conform to evil desires (1: 14) A] We also have our share in Holiness (Hebrews 12: 14) It is true that when we come to salvation in Christ He washes all our sins away and makes us Holy. We become perfect and clean through Jesus, but it is our duty to then keep ourselves clean. Holiness is not only what God can give to us but it is also what we can manifest with what He gave us. Paul says it quite clearly in Hebrews 12 : 14 (NIV) To make Make every effort to live in peace with all men and to be Holy. ; Without without which we cannot see Godholiness no one will see the Lord. Holiness is a serious matter. We tend to take God for granted. When we give in or conform to the evil desires of the world, we say that it wasnt our fault but it is our flesh. We blame it on our human nature. Paul challenges us not to try to be holy but take every effort possible in other words we must strive or even fight to be Holy. Effort means to use energy to get something done.[3] Holiness should be such a longing of our heart that we would put our whole energy to get it done. B] No compromise in Holiness Holiness is being spotlessly clean. Without Holiness we can never enter the presence of God. The Old Testament priests were the perfect example of this. The priest entered the presence of God only once a year. They dreaded that moment. Thought it was regarded very high to enter the Holy of Holies, it was dreadful at the same time. In that moment if they were found guilty of sin , there was no time for explanation they were just struck dead. They prepared themselves for the whole year for that one day in Gods presence, the presence of the Holy God. We are so privileged that there is no curtain between God and us, we dont need a high priest to stand in for us anymore, Christ has already done it for us. We can enter Gods presence anytime anywhere we want. As for us its not a once a year thing its an every day thing. WE are living in the age of grace, God does not strike us dead anymore, though grace is available for free it is not cheap, so let us not take it for granted. C] Illustration In the forests of northern Europe and Asia lives little animal called the ermine, known for his snow-white fur in winter. He instinctively protects his white coat against anything that would soil it. Fur hunters take advantage of this unusual trait of the ermine. They dont set a snare to catch him, but instead they find his home, which is usually a cleft in a rock or a hollow in an old tree. They smear the entrance and interior with grime. Then the hunters set their dogs loose to find and chase the ermine. The frightened animal flees toward home but doesnt enter because of the filth. Rather than soil his white coat, he is trapped by the dogs and captured while preserving his purity. For the ermine, purity is more precious than life. HGB[4] It doesnt always cost our lives to be Holy. But most of the time it could cost things or people that are dear to our hearts. When we are of this world, we make the things of the world our own. We usually cling to things and people which could take Gods place in our lives. So when we come to Christ we ought to replace them with Christ. When we do the right thing, even our own friends might not understand us, their there might even come times where we have to give them up for holiness, for there is no compromise on Holiness. 3. We are called to live a holy life because we were redeemed by the precious blood. (1: 23) A] Free access to Holiness The way of Holiness (Isaiah 35 : 8) It is true that we dont have to do anything to become Holy because we are washed by His blood. But we have to take effort in keeping it. It is quite clear in Isaiah 35: 8 that the way to God is holiness, there is no other way. Christ has done his part, by making the way. But to keep our self on the highway or to get kicked off lies on our hands. There is no place for unclean or wicked people on this road. B] Set Apart to be an example We are set apart and called to be holy not to seclude ourselves from the world but to be the light. D.L. Moody, A holy life will make the deepest impression. Lighthouses blow no horns, they just shine. One of the misconceptions in the churches today is that they become holy and they become literally set apart. They dont associate or mingle with the people of this world. They develop something which is famously called as the Holy huddle. They become so holy that the people of this world cannot even get close to them, they just have to be set apart. But that is not what God has called us to be. The difference between the Pharisees and Jesus was that Jesus toughed touched the unclean but they didnt. The Pharisees where were Holy as well, they did everything God commanded them to, but they didnt understand it. We are not called to be a Pharisee but we are called to be more like Him. We are not made Holy to be set in museums as specimens but to reach out to the unclean in turn. When we be come holy day by day let us be humbled by the fact that we dont deserve it , but it is through grace. Reach out to make them Holy. As the story of Isaac Newtons experience let our holiness hurt their eyes, not to chase them away from us but to draw them closer to Him who has called us to be Set apart, to be Holy. In conclusion let us make every effort to be more like Him every day. Let us just not sit back and pray for holiness but take every effort to be holy. Holiness is not only what God gives us but it is what we manifest with what He gave. Let us not compromise with the things of the world. Are we willing to lay down everything to pursue holiness? Holiness is not only works and deeds but is also passionately pursuing a relationship with God. Let us never compromise with holiness. If you are thinking that you have done all these all through out your life. Youve always been pursuing God for holiness and have a wonderful relationship with God, then dont become a Pharisee. Let us not settle down in that place in a holy huddle but let us affect others with our holiness. Let us be a light shining in this unholy land. We are set apart not to be in a museum but to be a light, that hurts the eyes but still draws them closer. Bibliography http://bible.org/illustration/ermine [03 September 2009] Fwd. Ogilvie, L. J. Nelsons Three in One Bible Reference Companion Nashville: Thomas nelson Publisher, 1982 [03 September 2009] Ed.. Martin Ralph p. and Davids, Peter H, Dictionary of the Latter New Testament and its development Leicester: Inter Varsity Press, 1997. [1] Ed. Ralh P. Martin and Peter H. Davids, Dictionary of the Latter New Testament and its development (Leicester: Inter Varsity Press, 1997), p. 485. [2] [03 September 2009] [3] Fwd. Dr. Llyod John Ogilvie, Nelsons Three in One Bible Reference Companion (Nashville: Thomas nelson Publisher, 1982), p. 206. [4] http://bible.org/illustration/ermine [03 September 2009]

Pain and pain management in the dying patient

Pain and pain management in the dying patient For many years there has been a question as to whether or not providing pain medication to a dying patient is ethical or not. This subject practices on what is considered morally ethical as well as medically ethical. Allowing a person to sit in pain at the end of life, hits as both medically and morally unethical. Especially, when health care professionals can manage and control the pain. There are many medical ethics principles as well as the directives that apply from the Catholic religion side of it. Some of the principles that will be discussed are the principle of double effect, informed consent, veracity, beneficence, non-malfeasance, extraordinary versus ordinary means, and proportionate and disproportionate means. This paper is going to discuss the ethical implications regarding the barriers that are encountered when administering pain medications to patients that are in the last part of the dying phase. It is my position that patients that are dying should receive pain medication as desired and expressed by the patient. The pain medications should be administered and titrated accordingly to maintain the appropriate therapeutic level to allow the patient to maintain his or her dignity. There are several barriers that arise when providing pain relief in the dying patient. The barriers include failure of clinicians to identify pain relief as a priority in patient care, insufficient knowledge among clinicians about the assessment and management of pain, fear of regulatory scrutiny of prescribing practices for opioid analgesics, failure of the healthcare system to hold clinicians accountable for pain relief, the persistence of irrational beliefs and unsubstantiated fears about addiction, tolerance, dependence, and adverse effects of opioids, and the resistance of patients and/or their family members to the use of opioid analgesics in the management of pain (Rich, 2000). The most common barrier is under treatment due to fear of hastening death. Assessing pain and the administration of pain medication in the dying client is very important. This nursing assessment is vital through all aspects of life but is also very important in the end of life to try and maintain as much of a persons autonomy and dignity as possible. AS in life people who are dying must also be able to have and make choices surrounding the way in which they choose to spend that last portion of their life. Before getting down to the ethical concerns of pain and pain management, it is important to define what pain is and how it is assessed. Pain and suffering is often linked together and some even use it interchangeably. However, there is a difference between the two. Pain is considered a negative and unpleasant sensory felt by the person that is inhibitory to the comfort of the person, it is considered to be mainly physical in nature (Kelly, 2004). Suffering is considered to be roughly the same as pain but the effects are more geared towards a persons spirituality and mentality (Kelly, 2004). The way in which people experience pain and suffering is different from person to person. Pain is a subjective experience and is to be assessed on an individual basis. There are many ways in which pain can be assessed. There are many different scales that are used to assess pain and each scale has different characteristics that allow health team members to be able to assess every type of person for which they care for. Some of the most common scales used are the descriptive scales in which you circle the word that best describes you ranging from none to excruciating, the numerical scale which is the most common scale used allows a person to say or circle a number that reflects the amount of pain they are in ranging from 0 being no pain to 10 being the worst pain they have ever felt. There is a also a visual analog scale that allows a person to mark a place on a line or pick out a face on a faces scale ranging from no distress/pain to worst pain ever. The last scale mentioned is one of the least used and it is the functional interference scale which allows a person to circle a word that best describes the persons degree of impairment ranging from n one to incapacitated. In addition to these subjective scales there has been evidence that has helped with the ability of healthcare professionals to be able to approach pain from an objective point of view. This approach has been divided up into four different categories: sympathetic discharge signs, positional relief signs, sensory avoidance signs, and common pain distraction signs. Some of the sympathetic signs associated with pain are tachycardia, high blood pressure, dilated pupils and vasoconstriction (Leavitt and Tennant, 2008). There are several more approaches but this is just a few that are used in healthcare. Positional relief signs include; walking imbalanced, leaning while sitting or standing, lying on the floor, and differences in temperature between sides of the body (Leavitt and Tennant, 2008). Sensory avoidance signs include; speaking slowly, delays answering questions, avoids noise, shallow breathing, and wont brush teeth (Leavitt and Tennant, 2008). Some of the common pain distraction s igns include; grinding of teeth, clenching of feet and hands, bites lips, gouges or squeezing of skin (Leavitt and Tennant, 2008). The other aspect to consider is the type of pain medication being administered. When pertaining to the end of life the typical drug of choice are the ones that fall into the opioid family. These drugs are chosen for people that have pain that is moderate to severe in intensity and is unrelieved by non-opioid drugs. These drugs provide pain relief and can cause some adverse effects such as constipation, nausea and vomiting, respiratory depression, fatigue and sometimes light sedation is amongst the most common effects. The amount and type is determined on an individual basis and prolonged use can lead to dependence and the need for increased dosages due to an increased tolerance for the desired therapeutic effect. The way in which drugs are chosen is divided into 3 steps as developed by the World Health Organization. Step one is when the pain is assessed as mild to moderate and has had no previous treatment and so non-opioid drugs are used such as tylenol, ibuprofen, and toradol (Cla sen, Jonas and Whitecar, 2000). Step two is when the pain is measured at a moderate level and has been treated previously but has not responded to the treatments from step one, the medications used in step two are weak analgesics such as Tylenol with codeine, and tramadol (Clasen, Jonas and Whitecar, 2000). Step three is considered when the pain is described as severe pain or pain that does not respond to one and two. In this instance the patients should be treated with strong opioids such as morphine, dilaudid, and Demerol (Clasen, Jonas and Whitecar, 2000). Morphine is one of the most commonly used opioids because there is no therapeutic ceiling and extremely large doses can be used safely and effectively if the drug is titrated properly (Clasen, Jonas and Whitecar, 2000). Part of treating every person as an individual and respecting them as an individual is being sure to respect their autonomy. This principle applies here because to be able to treat a person that is in pain, they have to be assessed individually and be treated according to their individual needs. Every person feels pain differently and every person has a different threshold for pain. What is considered mildly painful to one person may be severe to excruciating to the next. As a health care member you have to be able to allow the patient to express what they are feeling and to allow them to be involved in the decisions regarding their pain management. The ability for them to be able to make decisions allows the people that are dying the ability to be able to have some form of control of how they live the last part of their lives. Allowing the dying person to make small decisions such as whether or not they receive pain medication allows the person to feel as though they still have a voice and a place within the world that they are about to leave. The fear usually involved with giving dying patients pain medication is hastening the death process. However, as the health care members the opinions that we may have about whether or not it does hasten death does not matter because the patient has the right to make his or her own decisions regarding their personal healthcare interventions. Due to the fact that pain is mostly a subjective matter healthcare members do not have the authority to decide whether or not a patient is in fact in pain or not. Withholding pain medication in the dying patient would be a violation against the patients human rights by allowing that person to die in pain. Allowing a person to die in pain does not allow the person to be able to concentrate on their spiritual needs, psychological needs, and family needs at the time of death. Violation of the ethical principle of autonomy is a violation of ones human rights. â€Å"There will be times when it easier to surrender to the determination, decisions, and goals of influential parties such as the primary physician† (Andrews, Constantino, and Zalon, 2008, Pg. 94). Furthermore the ANA Code of Ethics for Nurses requires that nurses practice â€Å"with compassion, and respect for the inherent dignity, worth, and uniqueness of every individual† (ANA, 2001). As nurses we are obligated to do everything within our power to relieve the persons pain when the person is requesting pain relief. It is also our responsibility to reassess the persons pain without prompt by the patient. Another responsibility that nurses own is providing accurate information to the patient regarding the medications ordered for pain, so as to allow the patient to make informed decisions about receiving the medications or not. The next principle is veracity, veracity is when a person tells another person the truth without any form of deception. In this case it would be the health care member speaking truthfully to the dying patient. Under this principle the nurse has the obligation to provide the patient with accurate information about his or her right to effective pain relief. The nurse also has the obligation to provide information about the pain medication being administered. The other thing to remember when this principle is applied is that nurses need to be aware that people that experience chronic pain exhibit behaviors that are vastly different than those who are experiencing acute pain. This becomes a very important principle because there have been instances in which the nurse will just bring in a medication and just tell the patient that the medication is for pain. Little does the patient know that the medication the nurse is administering is tylenol or ibuprofen. The patient trusts the nurse and assumes that their pain will be taken care of. Instead without directly having to lie to the patient, the patient is deceived. Granted the medication given is for pain but, the type of pain being referred to in the end of life is usually moderate to severe and the medications listed above are not made for intense pain. Violation of this principle is what leads patients to distrust the healthcare providers and the care that they are given. From this, patients start to feel they need second opinions and the continuity of care for the patient is then lacking. As we know to be able to properly control pain in our patients it has to be done with trust between the patient and healthcare members as well trust between the nurses and other members of the healthcare team. According to the ANA Code of Ethics for Nurses, the nurses primary responsibility is to the patient (ANA, 2001). So, if the patient is not given the proper information about the pain medications being used and it isnt being treated effectively the patient then loses part of their dignity and we as the healthcare members just robbed the patient of any value they might have felt like they had left. Before a person can make a decision about accepting or denying an intervention of any kind, that person has to be completely informed. This begins the discussion of the principle of informed consent. This principle is very important because it allows the person that is dying to be able to continue to make decisions about their lives all the way to death. When administering pain medication to a person that is dying it would be unethical to not inform that person of the affects that the pain medication may have on them. If medication was given to the patient and it either sedated them or it did hasten their death, their dignity and autonomy would have been taken away from them. That person would not have been able to decide whether or not they wanted to make preparations for the remainder of their life. The ability of a person that is approaching death to be able to maintain a sense of belonging and still feel as though they have authority over themselves allows for a sense of calm. The patient is able to make amends if wanted or needed. By informing them of the affects of the pain medications that person can feel comfortable about taking them and as that person is passing they wont be wondering â€Å"what if† when it is time for them to pass. Every person has the right to decide how they are going to die. The benefit of doing it pain free or as close to pain free as they can get is that it leaves the person in a state where they are more able to concentrate on important things. Such things include their spirituality, family, and even death preparations. â€Å"Do unto others as you would have them do unto you,† this is a very important saying that we are taught and is reinforced throughout our entire lives. This word of advice rolls into the next principle I would like to talk about and it is beneficence. Beneficence requires that the duty is to help the patient by managing the pain effectively. This principle goes as far as to say that not only will the nurse not harm the patient but is obligated to take positive actions that will benefit the patient whenever applicable. It would be a violation of this principle if the nurse was to give the patient pain medication and did not follow up with the patient to see if the pain has been reduced or if the dosage of the medication needed to be titrated. Any nurse can give their dying patient pain medication but it takes follow through and communication with the patient to ensure that the pain is being managed. The act of giving the pain medication is the part that is considered not doing harm to the patient. The follow through and reassessment of pain as well as dosage of medication is what is considered taking positive actions to benefit the patient. The ANA Code of Ethics for Nurses states that nurses are responsible for their practice and are therefore required to provide a standard of care that takes an appropriate action to manage the pain in their patients (ANA, 2001). This can be stretched even further by stating that they are expected to take action when incompetence, unethical, illegal, and impaired practices are suspected. This goes back to the age old fundamental nursing practice of advocating for your patient. Nurses are to be the advocates as well as the educators for their patients. If a nurse is caring for a dying person that person may assume that after so much pain medication that they will not be able to experience relief and as said before it is then the nurses duty to educate that patient about the ability to switch drugs or to increase dosages in cases of increased tolerance. Non-Malfeasance has a lot to do with beneficence; you wont normally see one without the other. Non-malfeasance is just the simple task of doing no harm to your patient. In the dying patient the nurse has a duty to protect the patient from pain. Suffering plays a big role in this principle. As recalled from earlier in this paper suffering is more of the emotional and mental effects that pain has on the patient. The patient is most likely to suffer if they are not properly medicated for their constant pain. The suffering is what inhibits the patient from being able to enjoy and participate in the final moments of their lives. Allowing the patient to go under medicated and allow their mental capacity to reduce to a suffering state is a violation of the principle of non-malfeasance. This impacts their dignity by not allowing them to eat, dress themselves, helping with a transfer, or walking around if they are permitted to do so. This could result in the patients last and even most precious moments of their lives to be reduced to a non-significant and traumatic experience. By withholding or under treating someone for pain it is indirectly causing harm to the patient. Another way to look at it would be that under prescribing the pain medication is the same thing as inflicting pain on the person. Looking at it from this point has made it so that I look at my own practices and every time that I think about the times that I didnt ask patients if they were in pain I was consequently inflicting pain and suffering thereby doing harm which is a direct violation of the principle of non-malfeasance. The competence of the nurse plays a large role within this principle. To properly be able to prevent doing harm to the patient the nurse must be aware and competent regarding pain and the medications or techniques that are used to manage the pain. â€Å"Further, competence in pain management entails demonstrating a basic knowledge of the nature and action of the drug, proper dosages, the length of coverage, the time it takes for the drug to take effect, the variety of routes of administration, the recognition of drug tolerance, and dealing with problems with break-through pain† (Silverman, Croker, 2001, Pg. 185). When talking about the care of dying patients, it cannot be forgotten that even though the client that is dying needs care, usually that patient is not the only person that the nurse is caring for. Time is one of the worst barriers for most nurses and although everyone that is in the hospital and needs care deserves the undivided attention of the nurse, this is just not reality. According to the principle of justice every patient has the right to be given their â€Å"dues.† This doesnt mean just fairness; it is giving something to a person to which they are entitled. Every dying person is entitled to being as pain free as possible by the healthcare members, especially when it comes to providing pain medication. This can become an issue for nurses caring for these patients because there are not enough nurses to be able to adequately staff to be able to provide the closer one on one care that may be needed. This becomes a dilemma because the nurses then have to then make decisions that result in less care being provided to one or all of the other patients. Under treating for pain in the dying patient is a violation of the principle of justice because everyone is entitled to a pain free death. The technology and advancements are available to make this happen and again this allows the patient to be able to address other needs at the time of death other than concentrating on how much pain they might be in. A good way to help in this type of situation would be a PCA pump, which allows the patient to manage their pain, but also allows the nurse to concentrate more on the other needs of the patient. Allowing the patient the extra time and energy to spend with their families or to spend relaxing is a right that all people have and should be upheld to the very last breathe that the person takes. Although administering pain medication to dying patients that are in pain produces a good effect by relieving the patients pain, it can also produce a negative affect that was unintended such as hastening death. The principle that this relates to is the principle of double effect. The true definition of this principle is that the â€Å"action that is good in itself that has two effects, an intended and otherwise not reasonably attainable good effect, and an unintended yet unforeseen evil effect† (NCBC, 2006). This principle has to be considered when there is a question or a discrepancy between doing good (beneficence) and doing no harm (non-malfeasance). The problem with this principle is that most healthcare professionals believe in it and therefore giving higher dosages of pain medication does in fact hasten death. Studies have been performed and revealed that although 89% of physicians and nurses agreed that sometimes it is appropriate to give pain medication to relieve suffering, even if it may hasten a patients death (Fohr, 2005). Out of the 89%, 41% agreed that clinicians give inadequate pain medication most often out of fear of hastening a patients death (Fohr, 2005). â€Å"Fohr has found that there is little research to support the notion that increasing the dose of opioid analgesics for terminally ill patients hastens their death† (Fohr, 2005). The belief in this principle has in fact allowed and caused unnecessary suffering in the dying patients. There are also state by state statutes that have been developed to protect health care members in instances such as this. The Indiana statute states as follows: â€Å"This statute provides that a licensed health care provider who administers, prescribes, or dispenses medications or procedures to relieve a persons pain or discomfort, even if the medication or procedure may hasten or increase the risk of death, unless such medications or procedures are intended to cause death is not liable for assisting suicide† (Sexton, 2000). There are four criteria that pertain to the double effect principle and the action has to meet these criterions to make the action morally ethical. The first criteria is that the action has to be good and that the action can be acceptable by Gods standards and must be considered good to the other person as well as yourself (NCBC, 2006). The second criterion that has to be accomplished is that the act that is to be good cannot come from or be the effect of a bad act (NCBC, 2006). So, the act of providing pain relief cannot be as a result of hastening the patients death. Hastening the patients death is in fact the unforeseen effect of the good action provide pain relief. The third criterion states that there is an equal or greater proportion that exists between the good effect of the action and the bad effect of the action (NCBC, 2006). The last criterion suggests that the person the action was used upon has to be moved more towards the good effect of the act of giving the pain medicat ion in the dying person. The untoward effect has to be just tolerated and prevented as much as possible by the healthcare members. To administer the medication to a dying patient in severe pain would be acting morally ethical according to the principle of double effect. The action which would be administering the drug is considered to be a good action because it is relieving a persons pain and suffering. The intention of using the pain medication and administering it was to just relieve the pain of that person; the intention was not to harm or hasten death. Giving the medication to the patient achieves pain relief so that relief was brought about by mean of the good act not the bad effect of early death. Lastly the pain felt by most people that are dying is so severe that treating it is completely justifiable although a side effect could in fact produce an early death. If any of these criteria is violated then it can be considered as euthanasia or physician assisted suicide. Another question to be asked in this scenario is whether or not the action of giving pain medication is proportionate to the condition. In this case the condition is the severe amount of pain that the patient is feeling. There are two principles that are brought up here and they are the principle of proportionate and disproportionate means and the principle of ordinary and extraordinary means. These two principles are usually together and one is not usually applied without the other. These two principles are very important when making end of life decisions because they are about what is considered ethically acceptable when making end of life decisions and which ones are not according to Catholic ethics. These two principles generally refer to life sustaining actions by the health care staff but it can be expanded into what is considered proportionate or disproportionate interventions when caring for a patient that is dying and is in severe pain. In a situation in which a person is dying and is in severe pain, providing them with pain medication would not be considered disproportionate or extraordinary. Giving a person pain medication is not considered making a decision of whether or not that person should undergo or forgo a type of treatment. It is not making the decision of whether or not to sustain life. Providing the person in pain who is also dying is providing that person with a better quality of life for their end of life. The fact is, is that there has not been enough evidence to prove that administration of pain medication does promote an earlier death. It cannot be concluded that the giving of the persons medication and maintaining a persons pain by increasing the medication if needed does hasten death. There is no good or easy answer when tragedies occur. But to try and understand, we must step back and look at the big picture. God made everything perfect. When man sinned, that perfection was spoiled and our entire environment was tainted. The fact is we live in a world where evil abounds. It is rampant throughout every aspect of creation. We are subject to the actions of the people around us. God can and does intervene in some events, but why not others? Only he knows that answer, but the Bible teaches that there will be a time when he will end this world as we know it. In heaven, there will be no more death, sadness, pain, sickness, or suffering of any kind. One reason many of us suffer is because we do things that cause us pain. We dont eat right, so we have heart attacks. We drive carelessly or fast, so we have accidents. We smoke, so we get lung cancer. What about innocent children who are not responsible for their suffering? Why do they get sick? Maybe its because we do not live in a perfect world. God intended for us to have perfect bodies, perfect health, and freedom from pain and suffering. The world He created was originally perfect, just as he had planned it. But evil destroyed our perfect world. When sin entered the picture, it brought with it death, pain, and suffering. Dont misunderstand me, people do not suffer because of their own personal sins, necessarily; but because the world is changed because of sin being in the world. Jesus said, In this world, you will have tribulation. Just as in the case with Job, I believe that evil forces attack us and cause much suffering in an attempt to get people to blame God and turn away f rom Him. In order for God to preserve our rights as individuals (to choose for ourselves), he had to allow us the freedom to sin. He also had to allow the consequences of our behaviors. That means that he does not normally interfere with things which happen naturally in this world, such as sickness and disease caused by toxins in the environment, accidents as a result of risky behaviors, and natural disasters. God does not cause these natural consequences, but he does allow them. However, many times, he does intervene miraculously or work even in the worst of situations to bring about something good from them. Why would God allow anyone to suffer? Maybe so that people can increase their faith in him, increases their compassion for others, or be better able to encourage and help other hurting people (2 Corinthians 1:3-5). When reading through the Ethical and Religious Directives for Catholic Health Care Services, there is one important directive that particularly applies to this situation. Directive number 61 states that all patients should be kept as free from pain as possible. This again goes to say that people that are dying need to be able to die with their dignity intact. It also states that a dying person should not be denied pain medication even if the indirect action of shortening their life occurs. There is one stipulation that applies to this directive. If the medications being used cause sedation of any kind, the health care member has an obligation of informing the patient of the effect. â€Å"The dying person has the right to be able to prepare for their death while being completely conscious† (USCCB, 2005). If for any reason that person is not able to be conscious there has to be a legitimate medical reason behind the decision. Under treating has become a large ethical dilemma in the healthcare world. More often than not there are people that are living and dying in pain. The problem with this is that with the readily available drugs that are out there to treat this problem, they are not being utilized (Miller, 2009). One of the biggest problems that arises is the lack of education amongst the health care professionals. The insufficient knowledge base surrounding the different pain medications and the research surrounding the effects on death has not been incorporated into the plan of care. As stated above the principle of double effect creates a problem for the health care professionals. The belief in this principle prevents them from properly treating the patient who is dying and has a severe amount of pain. The dignity of the patient has to remain as the top priority when approaching death. Part of maintaining a persons dignity is allowing the patient to make the informed decision of receiving pain medication. Every person has the right to a peaceful and painless death. It is essential that patients are given the proper types of medication needed for the type of pain they might be experiencing. The type of pain most commonly referred to at the end of life is moderate to severe pain. This requires due diligence on all health care professionals side of it. If the medication that is prescribed is no longer providing effective pain relief then the drug needs to be titrated accordingly. If the medication being used is at its highest dosage amount, then the drug needs to be changed. If this is the case then the patient needs to be informed of the change and educated on the new drug. This again allows the patient to be able to make decisions in their care, and allows them the sense of belonging that is still needed at the time of death. When the pain is not being managed in a person that is dying it is taking away their ability to be able to have the calm, spiritual, and family and friend oriented passing that is usually needed amongst the dying. By administering pain medication the patient is then able to concentrate on more important aspects of their life. Health care professionals have the ability to be able to control pain and suffering. To allow someone to die in pain or suffer would be not only medically immoral but it woul