Friday, July 29, 2011

Letter to a Rehab Director: Part IV (conclusion of four part series)

This is Part IV of the series. (click for Part I)  (click for Part II)  (click for Part III)

SUMMATION:  Caveats about Elder Care in Rehab Centers and Nursing Homes

The letter to fictionalized "Katherine Doe, Executive Director of Pillow Elder Home"  in (Part I) (Part II) and (Part III) identifies issues typical of nursing homes and rehabs. I know this because friends' parents have ended up there or in nursing homes and they have told me their experiences or I have seen the places for myself. 

From the letter, we see that Mrs. White hired a personal assistant, who with additional help from nieces and other family cleaned up Mrs. White and changed her bag, brought in quality food, dressed her, washed her hair, put on her make up, gave her additional PT and OT and fulfilled her needs. Why? The rehab nurses and aides were lovely, but the rehab was understaffed.  

This impacted the overall quality of care spreading the staff so thin to produce a situation of neglect. The situation forced Mrs. White to be left in her feces at times for up to an hour. Staff, busy with other things, overlooked her Thrush. Staff could care less she wasn't eating. (What could they do about it? Whose responsibility is it that the food is bad?)  Whose responsibility is it that the rehab didn't give her PT and OT 6 days a week and when it was given it was scheduled in a disorganized fashion? Such problems are systemic; such issues are organizational; one can easily push the blame toward others. And if you add quality control it is time consuming, adds paper work and can further gum up the mess which really relates to understaffing. This is typical of a bureaucracy.

So Mrs. White paid double for her care in the rehab. First, she paid her federal taxes going to Medicare and Medicare insurance, and then she hired her personal assistant (and a second one the last four days she was there). This is in addition to her nieces flying in from Florida and Rhode Island (taking off from work, using their paid leave time or taking the hit of not being paid at all) my care giving (I am retired.) and the visits of friends and other family who brought food, friendship and emotional support to reduce Mrs. White's stress level. Need I remind of the lack of sleep one gets in these places? Sleep is one of the most critical components of healing...that and low levels of stress as the body is already stressed by surgical intervention, medications, catheters, poking and prodding and complete lack of stabilization. Naturally, institutional healing takes twice as long if not longer, especially for the elderly because of lack of restful sleep and stress.

In spite of these issues, Mrs. White was lucky and maybe it wasn't all luck. First, she had the means to hire personal assistants and she had extended caring family who wanted to give back the generosity she had shown them over the years. Most elderly do not have this tremendous support network. They end up not rehabbing in a month's time because of issues similar to the ones Mrs. White experienced (and they aren't as sick as Mrs. White was...some just fall and don't even break bones, but falls take a toll on the elderly). Oftentimes, they don't recover and many don't because of the issues listed (1. PT and OT are not administered consistently-6 days a week; 2. The elderly are overmedicated (sedatives) or with drugs that have little effect (aracet, namenda...for dementia) and negative side effects; 3. They have Thrush which decreases their appetite and weakens their immune system; 4. On top of that the rehab food is unappetizing, not fresh and mostly processed...all decreasing the elderly's strength and immune systems.) If they don't recover quickly enough, they are put in nursing homes. This occurs especially if there is no one to care for them and they need 24/7 care.

This happened to my friend's mother and another relative of mine. Both had been initially living at home and managing; in the instance of my cousin, her mother needed care because of her senility and it was decided by siblings that their mom would be better off not living at home. Their mother was placed in a typical nursing home with a fairly good reputation. The average time given for patients to live in nursing home facilities is two years. In great physical condition, she is still there four + years later. However, mentally she has deteriorated greatly; her appearance which had looked better (even in her early 90s) is now crone-like. I attribute this to neglect, poor facility implementation of their "mission statement," lack of concern from an understaffed, youthful population of staffers with a skewed set of values and non empathetic imaginations, a non stimulative program and routine and general malaise of "we're just the gatekeepers to usher them into the next world" mentality. Sorry, but there it is.

My friend's mom, has been in an assisted living center because she cannot have 24/7 care at home. Initially, she had fallen and was taken to a hospital. She had no broken bones, but it took her a long time to rehab and PT and OT did not feel she was ready to be released. (I wonder why????) She went from the hospital to the rehab center and then to a nursing home (not a rehab which must make you mobile) which she disliked intensely and then to the assisted living center. She has not recovered to where she was before she fell. She has a walker; she is on Depends; she is weakened; she says the food tastes bad, something she complained about in the nursing home. (She has been on antibiotics. And she is on a med for dementia, though physically she has no other diseases like diabetes, etc.) She used to take great care of her personal appearance, going out, having her hair done, and this was at 88; she will be 89. Now my friend tells me her mom looks old; her hair is a mess and she is a picture of neglect. No one cares, least of all she. She is not actively engaged in much of anything; she doesn't play the piano any more. She does not attend church and officiate like she used to during the service. There is little stimulation; there is deterioration.

My relative and my friend's mom are the same age. The difference is in the social network. With my relative, there was a vast social network that teamed support: family and friends. They pushed hard, the doctors, the rehab, the OT and PT because they were THERE, PRESENT AND WATCHFUL. They were Mrs. White's advocates. On the other hand, my friend was unable to do the same for her mom. There wasn't a vast social network; the siblings were spread far and wide and there wasn't the monetary means to fill in when friends and family could not. 

Then again, one can have the means, but if the caretakers are wicked, then the elderly person is lost. The Astors had the means and look what happened to Mrs. Astor? Her caretakers abused their fiduciary responsibility of managing her estate and her resultant lack of care augmented to egregious negligence when her old age could have been in a time of comfort. The old are vulnerable even if they are billionaires. So it isn't always about having the means. Perhaps it gets down to the basics: empathy and the golden rule (do unto others...). Oh, and there's one more quality, let's see...what is it?  Duh....LOVE?

Some would say "These are elderly folks. What do you expect? You want them to live forever? Be reasonable! They are on their way out and if the inefficient, negligent and incompetent care in these facilities hurries the ancient toward the grim reaper's scythe, isn't that merciful?" AFTER ALL, IT'S A BOON FOR THE CEOs and UPPER LEVEL MANAGEMENT. Wow!  Head up a predominately Medicare patiented facility and GO TO TOWN! $$$$$ Sky's the limit! Who's really watching and better than that...enforcing? Haven't you heard...enforcement is down in every government department. Budgets? Ha, ha. The country is going to default. So, regulations? Easily gotten around. Quality control issues. Ha, ha, ha. The government requires the minimum of bureaucracies. LOOK AT CONGRESS' RECENT BEHAVIOR!!!! 

The only problem for CEOs and the officials is extended social networks of loving family and friends who ARE AROUND AND ADVOCATING AND PAINS IN THE ASS (sorry P-G ratings). And I don't mean virtual networks...which are abjectly useless in this instance...unless the elderly have webcams posted in front of their faces day and night linked to the internet of some nonprofit monitoring of the elderly in rehabs and nursing homes, a sort of Amnesty Greys for the ancient. Hmmmm, not a bad idea.

Old age is a hard pill for everyone to swallow. And everyone will get there, unless they find a way out sooner (Suicide is painless.) But for those who have made it and have thrived to reach their 80s and 90s, those who are walking, sentient and purposeful, don't we owe it to honor them for their guts, their grace, their persistence and long suffering through this tough existence we refer to as "life?" Or should we look at them and ultimately ourselves as "throw-aways," not fit for the dust heaps after the age of 80?  And thus, by degrees, low class and cruel, should we slowly doom them and ourselves to a gradual weakening and decline, by not helping them recover to full strength from a fall or whatever? We can do this because we can. They are old and vulnerable and no one is around to pounce like a vulture if they are neglected, given substandard care and shoved into a much worse state (than before they arrived at the hospital or rehab or nursing home) because of systemic institutionalized neglect.

Healing? Stress. Healing? Stress. What happens to a culture that neglects its young and old? What happens to a ruling elite that through its own incompetence and shameful failures of mission promotes such neglect? Nada? I think not. The neglect of the young and old is representative of what lies beneath in each of our government bureaucracies. The waste and mismanagement has burgeoned and "whomever is responsible" has neglected to do anything to change or reform it. And of course, no one is responsible...the "other party" is responsible...the Council of 300 are responsible, The Bilderberg Group are responsible, the Illuminati are responsible...the Taliban is responsible. Everyone is responsible. Ad nauseum. You see how effective passing the blame is.

Neglect has a horrible way of coming back like a monstrous nightmare that can only be ended upon the death of the mind dreaming it. Neglect breeds inefficiency and waste. Inefficiency and waste breed debt. Debt breeds default. The neglect is systemic, running all throughout the system, like a fungal Thrush. And those in power, including the officials who are in charge of Rehabs seem to have no appetite for reform's uncertainty. Nor do they appear to have the strength and will to envision and perpetrate a successful system beyond "doing the minimum" of what regulations require. They need to go to hospital, then to rehab, to see for themselves, that what is needed is basic humanity and empathy. There's nothing like a little concern for someone else to heal what's ailing oneself. And no joke, these folks (power elites and those in charge) are ailing...riddled with sickness...immobile, inactive. And all the medicine in the world won't help.

Thursday, July 28, 2011

Letter to a Rehab Director: Part III (four part series)

This is the third post of the series.   (click here to read Part I)     (click here to read Part II) 

My elderly relative was recuperating in a Rehab center. This list of problem issues was found at the Rehab. To read the entire letter, you must click on Part I and Part II of "Letter to a Rehab Director" series.

Nutrition is a critical part of healing and rehabbing. In order to receive good nutrition, one must eat good food, food that is appetizing, food that is healthful. The food at The Pillow Elderly Home reminded me of public school cafeteria food served in the 1950s when Velveeta, processed cheese food, was considered cheese, Wonder Bread was considered bread and Geritol was miraculous for your health: products heavily marketed and highly suspicious. Pillow Elderly Home's food was heavily marketed, processed and highly suspicious. Evocative of Tom Colicchio's culinary endeavors or a typical NYC restaurant's achievements, your menus sounded great on paper. And that's about it. If this is hyperbole, then why did I see a lot of the patients' trays left in the kitchen area half full of food and the refrigerator stuffed with food items brought by patients' family members from the outside, something our family and friends also did. Mrs. White ate very little of your food. Aesthetics fast. Perhaps you are encouraging an aesthetic, monastic existence. Fine. Our family does have a dear cousin in Frosolone, Italy who is a Catholic and of the Franciscan Order. He is a monk and he often fasts for his church members' healing. However, he never has those who come for prayer, fast, especially when they have been weakened by surgery, achy immobility, side effects of meds and stress, and need to be strengthened and healed. If you are going to encourage your patients to live the fasted life, please give them a choice whether or not they would like to achieve healing through alternative fasting treatments like The Master Cleanse, but don't advertise your rehab as a rehab which provides good nutrition and healthy food choices encouraged by appetizing meals. Yes, you are a large institution. But Jacques Pepin prepared industrial sized meal portions for Howard Johnsons when old Mr. Johnson was thriving as were his restaurants. It can be done! I am not suggesting you hire someone like Jacques Pepin (before he was a "celebrity chef"). I am suggesting that you BEGIN TO CONSIDER the nature of healing and how nutrition, healthy food and proper preparation is a critical part of it, especially for the elderly who are very prone to not receiving the full benefit of nutrition because their digestive systems don't efficiently process nutrients as younger bodies do to receive optimum fuel for body restoration, so integral to healing.  I am suggesting you live up to your quality of care mission statement. And that involves being concerned about appetizing, healthful food which doesn't need necessarily to be "expensively" prepared. It should be carefully prepared, with ingredients which were fresh at the inception of preparation; if they are frozen later on, fine. But let them be fresh, not processed, with as few additives (chemicals) as possible.

Thrush is a fungal disease individuals can get when they are on antibiotics for a long period of time. All of your nursing staff, even your aides should be on the lookout for Thrush when patients come from any of the hospitals, their bodies saturated with antibiotics, their immune systems weakened. Thrush coats a patient's tongue white. Thrush nullifies one's taste buds and decreases their appetite. It is fungal and the elderly, (particularly those with catheters and Urinary Track Infections, taking antibiotics)...and those taking antibiotics to stave off infection so their surgery can heal...get Thrush. It is underdiagnosed. And this is a problem because patients need optimum nutrition and a strengthened immune system. Thrush debilitates both. With Thrush and bad food, the elderly don't get optimum nutrition; their immune system is further weakened when it should be strengthened. If unappetizing food is being served, all the more reason NOT TO EAT IT!  With Thrush it is twice as unappetizing; in fact it tastes downright horrible. When my relative was admitted to your rehab, we knew she was battling Thrush. By then she was on the medication and mouth wash and we were bringing her food from the outside and special protein shakes and yogurt, phyto greens and her vitamins and organic soups and home cooked meals or take-out and she was eating despite still getting over the Thrush. Mrs. White didn't know she had contracted Thrush; she didn't feel like eating and didn't feel right. Her niece, remembering her mother had it, identified it in Mrs. White's mouth. Then both nieces created a food plan including yogurt and the protein shakes and Mrs. White gained weight. Even with the medication abating the Thrush, none of the family believe that Mrs. White would have gained weight and recovered as quickly as she did on the rehab food. It was so unappetizing, she would have gone hungry rather than eat it; going hungry, her stomach would have shrunk and she would have lost more weight instead of strengthening her immune system. Your rehab food is obviously not a priority but it should be. You do not want to waste money on food that is mostly thrown away. Thrush and/or other side effects of meds that kill your patients' appetites and skew their taste buds are most likely a contributing cause to your food being left uneaten. Checking to see if patients have Thrush should be a priority. The quality of the food should be improved. Patients need to be given every chance at their disposal to want to eat. They should not be given every excuse at their disposal not to eat. They need to rehab...become stronger, not weaker. I asked my nurse friend about your poor quality of food. She did say not all hospital food and rehab food are created the same. And that is the point!!! My sister-in-law was rehabbed at Rehab Y out on LI. She particularly commented that the food in the rehab was better than the food at the hospital (Hospital Blue). If there were any place perhaps that you could shine and show a difference and compete, it might be in your food plan and your staff's diligence in checking for something that kills the appetite like Thrush.

Sleep and rest are critical to healing. My relative was awakened many nights overhearing the aides laughing and joking in the hallways. She could not get back to sleep after she was awakened. Then she was expected to rise early in the morning when the aide came in. But she was exhausted because she was up a good part of the night because of the loud noise and activity in the hallway. Aides must respect the patients' needs to heal and rest. Social networking should be done outside the rehab, not during evening hours when patients need quiet to sleep. 

(click to read Part IV, the conclusion of the series)

Wednesday, July 27, 2011

Letter to a Rehab Director: Part II (four part series)

This is the first segment of the list of issues enumerated in the letter that is being sent to a rehab in response to the care my relative received. The rehab needs to improve its procedures; and as you read this list of problem areas in this post and the ones that follow, you will begin to see problematic issues that are most likely happening in rehabs and nursing homes across the nation. The names and places are masked/fictionalized; the experiences occurred.  (click here for beginning of the series)

From a letter to Executive Director, Katherine Doe of Pillow Elder Home and Rehab Center
(list of problem areas)
  • The coordination of care between shifts was not seamless nor was it smooth. Mrs. White noticed that various aides were not apprised of her condition after the "changing of the guard" into the evening shift. There seemed to be no follow up from one shift to the next, to maintain a consistent quality of care. Secondly, if she needed help with the ostomy bag and would ring the bell, the system was redundant. First, an aide would come to tell Mrs. White it was "not her job," but the nurse's job to drain the bag, change it or do anything with it. Forty-five minutes later, the nurse, having been busy with patients would come to deal with either draining or changing the bag. By that point, Mrs. White had been waiting with feces all over her because the bag had leaked. There was no easy way to prevent this from occurring short of putting on additional staff (aide and nurse) for ostomy care (and inevitably to change the bed linens which would be soiled). To forestall this problem the nurse and aides might have scheduled particular and frequent times for the nurse/aides to drain the bags so they would leak less frequently. Mrs. White was not mobile to clean herself up. If Mrs. White was less sentient, it wouldn't have mattered if the wait to clean up her feces ranged from forty-five minutes to five hours. But a sentient person is not happy to be covered in feces for any length of time. Perhaps, the metaphor is too painful to endure emotionally and it certainly contributed to Mrs. White's upset and nervousness and need for anti-anxiety medication. (I note your poor rating in keeping patients' emotional well being stable in comparison with other similar facilities across the state. Reducing stress is critical to promoting healing. High stress levels slow down the healing process. So emotional well being and comfort should be a priority at your facility to get patients well to leave the rehab. It appears to be low on your list of priorities; just giving someone a pill to shut them up or quiet them down is not the answer. Being attentive to a patient's needs is the answer. Mrs. White's needs to be cleaned up in a timely fashion because of bags leaking and being put on improperly were not met and induced a high stress level for her, decreasing her well being and decreasing more rapid healing.
  • Not all of the nurses were familiar with the types of bags used for ostomy care. What was frustrating was when one type of bag was chosen from Hospital X, a few of the nurses at Pillow Elderly Home had to be shown how to put it on and drain it. At other times, the bag was put on incorrectly so as to increase the likelihood of its leaking feces. Suggestion, if an ostomy patient is coming to rehab, the nurses should be familiar with all the care that pertains, supplies to ease the pain of the bags being taken on and off, familiarity with all the types of bags and how to put them on properly, familiarity with understanding the necessity of their frequent drainage in addition to the necessity of anticipating when to order sufficient bags and attendant supplies so there is no running out. Yes, the situation is one of trial and error. But that is easily said when one is not the recipient of the caregivers' "trial and error," in getting it right. (an often painful process when the bag is repeatedly taken off and the skin around the stoma opening is raw and red...and there are no supplies to ease the pain or abate the redness which is the beginning of a skin breakdown...which was the situation that happened with Mrs. White.)
  • There was a lack of communication between the nursing station on the fourth floor and Physical Therapy or Occupational Therapy. I was present when Mrs. White was supposed to receive OT. We were waiting; I checked with the desk. OT had been changed with PT. No one had told Mrs. White or me. I went to PT on the 14th floor checking to see if PT was coming and I was assured by the one in charge that a gentleman was coming to give Mrs. White PT. We waited an hour. I checked back with the desk and got a different story. Purely by chance, the Social Worker came in on another matter and Mrs. White told her she was disgusted; here she was supposed to be receiving rehab and not only was there no rehab on Saturday and Sunday, but there was no rehabbing being done that Friday afternoon. The Social Worker spoke to the nurse who had to call PT. Then it was revealed that the person we were waiting for had left for the day (hours before). No one told the desk; no one told us. I and Mrs. White's personal assistant ended up giving her the PT. (They also made it up to her by giving her PT on Saturday, thankfully.) In regard to PT and OT, we never knew which was coming. We weren't sure when they were coming...a specific time, per se. If there is there a set schedule of times or a "fly by the seat of your pants" arrangement, we never knew which was in operation and neither did the nurse's station which was not always in the loop. The inefficiency declines the overall quality care given at this facility. The elderly need routines to promote their sense of calm; chaos does not promote calm, but quite the opposite...their agitation. Such was the case with Mrs. White.
  • PT and OT are only given five days. This doesn't progress the patients as quickly as they should be progressed, especially for the elderly who have to wait two days, Friday to Monday to work on their mobility again. When the elderly arrive at PT and OT on Monday, they are stiff, achy and not mobile. Why? They have not been moving over the weekend; this is really untenable. Medicare is paying for a day when there is mobility for others, only not the patients who are supposed to be in rehab for the PT and OT. If I and Mrs. White's personal assistant and nieces weren't there to work with her physically on the "staff's days off," and intermittently during the day she would still be in rehab or moved to the connected nursing home because her 30 day Medicare would have run out. I spoke to a friend of mine who is a nurse with a Master's Degree from Stony Brook University; she works at North Shore Long Island Jewish. I told her the situation. She responded, "It's not a good rehab. They are open 24/7 and they should be giving PT and OT six days a week." I pressed the issue, dubious about what my nurse friend was saying. She affirmed, "It's not a good rehab!" I would like to think my cousin Mrs. White was at a good rehab. Now I don't know. Maybe I shouldn't ask such questions of a professional who is in a position to deliver an informed judgment. Maybe I should just live in a delusion, forgetting what I saw and what my relative experienced!
    Letter Continued July 28, 2011  Part III (of the series)

Tuesday, July 26, 2011

Letter to a Rehab Director: Part I (four part series)

This is Part I of a series of posts to follow the rest of the week.

An elderly relative who was recovering from surgery spent a month in a rehab in a large city. There were a number of problems with the quality of care there, and this rehab, attached to a nursing home facility had a good reputation. But one never really knows unless one experiences the care first hand. Oftentimes, families do not have the luxury of caring for their loved one with numbers of family and friends around. They work, can't take the time off, siblings are far away, and the elderly loved one must fend for themselves, doing the best they can under the circumstances.

The more elderly they are, the more they can fall through the cracks, especially with the siege mentality of the health care industry regarding elder care. Medicare pays regardless if the rehab is working diligently to progress their patients to go back home or it isn't. In instances where patients might not be able to go home to the care of someone, then the likelihood increases that the rehab will not work as diligently and will merely send the patient to the nursing facility attached to the rehab/nursing home facility. This happened to a friend's mother, unlike my elderly cousin. However, my cousin had the means; she had continual and ongoing friend and family advocacy. And still there were problems as you will see in the following letter written about the care given in the facility. The letter is being posted in the hope that readers will see the great necessity of patient advocacy, especially for the elderly. Names and dates have been masked.

Katherine Doe
Executive Director
Pillow Elderly Home
Rehabilitation Center
City, State, USA

Dear Katherine Doe: 

I am writing on behalf of Mrs. White a former resident of your rehabilitation facility at Pillow Elderly Home. Mrs. White was a patient from Tuesday, August 14, 2010 to Friday, September 16, 2010. Mrs. White was recuperating from bladder surgery and surgery on her sigmoid colon, which involved a resectioning. She needed ostomy care, physical therapy, occupational therapy and proper nutrition to return her to a stronger physical state so she could be discharged in a timely fashion to further heal and recuperate at home. Mrs. White found the staff, with a few exceptions, personable and kind. However, Mrs. White, her personal assistant, Ms. Ferber, Sally Brown (Mrs. White's niece) Patricia Wheeler (Mrs. White's niece) and I, Mary Merlo (Mrs. White's relative) encountered issues that should be brought to your attention so that you can improve the quality of care for your rehab facility.

Sally Brown and Patricia Wheeler are familiar with Mrs. White's condition because their mother had a colostomy. I am familiar with elder care because my brother, I and an aide cared for my father 24/7 at his home when he was battling prostate cancer over a period of three years. In facilities other than the home, family members can speed the recovery of their loved ones, providing a comforting presence, especially if the patient is elderly, anxious and fearful, as was the case with Mrs. White, who felt reassured with her nieces and others present. But in addition, she found that she also needed personal attention above friends and family "visits" because the care at the rehab was less than standard for good rehabs. The following list pertains, revealing the substandard care she received.

Monday, July 25, 2011

Amy Winehouse is in a Real Rehab, Now

OK. My spirituality is showing. Forgive me atheists, religionistas who believe in a particular denominational doctrinaire of who gets to Heaven and who goes to Helllllll and Doubting Thomases who don't believe in a clarified heaven or hell and just don't know what's out there beyond this "mortal coil." I don't pretend to know either. I've never had an "after life" experience from a hospital bed, floating above my body watching while doctors "pummeled and prodded me back into life."  And God help me, I pray I never will. I would probably be annoyed that they "brought me back," if, following what St. Paul said, "To die is gain" which I do believe is so. But then in spiritual terms, he also could have meant something else by "To die is gain." He might have meant that our flesh (for those of you who are lost...your ego, your pride, your arrogance, your selfishness, your self-absorption, etc.) should die and that is gain. (something akin to what the Dali Lama probably believes as a Buddhist )  I can't tell you how many times my flesh has died, then, ego, pride, arrogance wamped down by the humility of a child. And that brings me to Amy Winehouse's death. For child-like, her death humbles me and braces down my ego, pride and arrogance of life.

The details are immaterial to me. All of what she went through in her life, the messiness of her being found. She is incredibly human. How will any of us be found dead? It will come. The readiness is all. Perhaps Amy was ready. And that is her business and none of us, no matter how the media, including my poor post, feeds off celebrity deaths, platitudes excepted will be able to elevate, decry or discredit who she is. It couldn't be done while she was alive and we were seeing her as we see those who are near and far from us, family and friends and those we do not know, we see them and do not understand who we are looking at. I will speak for myself. I do not understand and I barely am familiar with myself. But I do I live by faith because I do not have the facility or arrogance to think I really can say "for sure." And that faith allows me grace every now to posit with clear eyed rationality until something comes along to knock me off my "high horse." Science/mankind has proven few answers in the long scheme of the earth's historical record. But it's fun guessing. And what have we better to talk about while we're here?

So here is my guess about Amy and my hope for her. That she is in a real rehabilitation center, a spiritual one that can bring her peace and love and joy. That she is surrounded by those who have passed through to the other realm before her, friends and family, and that they are restoring her to herself...that she will continue to use her talent, 100% of the pyramid, we seeing only the topmost tip of it when she was here. And finally that she understand the fullness of her purpose seeing that her life was perfect, undeniable, and very real. Amy, keep on, keeping on!