Introduction

This article presents process oriented coma work in the field, including workshop setup and presentation, finances, case consultation, hands on coma communication, family participation, and community involvement. All of these can help in presenting and accomplishing coma work. Our society commonly regards those in coma as individuals in "vegetative states". Contrary to this idea, comatose people are part of a larger system of networks: family, friends, caregivers, community groups, and the community as a whole. I hope and believe the more levels coma workers can become involved on, the better the chances that patients and community can grow and accomplish what they need to. Benefits can include: improved connection with patients; processing grief and other emotions; managing difficult or dangerous patient behavior; reduction of caregiver hopelessness, depression and burnout; dispelling the common misconception that no one is "home" when comatose; and appreciation that people in coma states perform inner work useful to themselves and possibly others in the community.

I wish to express my deep admiration for Dwane Keehn, Karen Keehn, and the extended Keehn family, for their courage and tenacity in the face of daily struggles with the tragedy of traumatic brain injury. They have opened up to the world about their trials and efforts to understand those in coma. Many thanks to Alida Hilbrander, Hospice Volunteer Coordinator, and members of Shuswap Hospice for encouraging and sponsoring coma work in their community. Also much love to parents, friends, volunteers and professionals that suffer and have sacrificed parts of, or their whole lives to care for people in extremely remote states.        

Find below an attempt to share the intimacy, tragedy, patience, frustration, compassion, love, spirituality, detachment, openness, ordinariness, and excitement of working with those in withdrawn states of consciousness.

Interacting with families in the impossible situations that coma presents, has left me in awe of people's love and commitment toward each other, and their faith in the human spirit, and greater powers.

Coma and coma communication

Coma is an extremely withdrawn condition resulting from injury, lack of oxygen, disease, poisoning, metabolic changes, and/or psychological causes. "The duration of coma depends upon the extent and severity of the pathological process, the ability of the helpers to process its contents, and the psychology of the individual." (Mindell, Arnold:107-8)

I've observed that many people who sit with relatives and friends in coma, take note of patients' small cues and nonverbal reactions. They endeavor to develop communication systems that bring mutual support and growth. Regardless of patients' prognoses, I believe these efforts worthwhile for our culture and spiritual lives. The states that comatose people enter may provide new information for themselves and others. Mary Kay Blakely gives a detailed report of her experiences in a two weeklong diabetic coma. Her perceptions include information for herself, her family, caregivers and the world. [Blakely] Others recall nothing from their coma states, but change their lives dramatically upon recovery. Many do not return to normal consciousness, but even in these situations people can learn to communicate more fully. Those that do not return to cultural norms, challenge their families and communities to adapt and learn more about altered states of consciousness.

Process oriented coma communication

I want to thank Drs. Arnold and Mindell, and also teachers, students and clients of process work for the ongoing development of process oriented coma communication. Through doing process work with hundreds of comatose people, Arny developed hypotheses and techniques for supporting and communicating with these folks. Many of the techniques will be presented below, in the transcript of Dwane's work. (also see Tomandl)    

Process oriented hypotheses include the following: We look upon coma as a call to inner work. Even though severely damaged, some parts of comatose patients are "home" or present within their remote state. These parts can be communicated with. People in coma do their best under the circumstances they find themselves in, though they may have little or no awareness of what is transpiring in their inner and outer worlds. The coma worker acts like an awareness assistant, helping bring inner and outer events to greater consciousness. This aids those in remote states to process information and make decisions based on their experience. As coma communication facilitators, we trust what is in front of us and interact according to negative and positive feedback from patients. When those in coma complete their inner work, they will spontaneously emerge into more ordinary states, as far as their condition will allow.
 

Workshop setup

In the summer of 1990, five of us present coma work theory and techniques at the British Columbia Hospice/Palliative Care Association Conference in Victoria. Volunteer coordinator Alida Hilbrander attends from Shuswap Hospice, located in Salmon Arm, a rural community of 15,000 located in British Columbia's Interior. In general, hospice volunteers demonstrate keen interest and spend a great deal of time with patients. Many volunteer coordinators promote new skills that help volunteers with hands on work.

I believe coma communication work can help resolve some of the care problems for those in remote states, and their caregivers: rambunctious behavior; difficulties in day to day care; staff burnout; family hopelessness and depression. Coma work can often support and help complete difficult behaviors quickly and safely. When staff and family see how coma work can improve communication, they often become more hopeful.        

Alida organizes a workshop in Salmon Arm for May of 1992: "Relating to Loved Ones and Patients in Coma or Remote States." Alida phones two weeks before the workshop date. Fifteen people signed up. She needs forty five to make it a go. We cancel. I suggest she consider her effort as pre advertising for the next time we schedule.

Finances

I feel reticent talking about business and money matters concening coma work. In traumatic situations, I believe family and friends should not have to think of anything but their loved ones. This can be a tragic, awful time. If the coma has gone on for a long time, families may have run out of resources for therapy. Until coma communication work becomes more thoroughly included in medical insurance plans, coma workers will need to explore ways of supporting families in trauma, and themselves financially.        

On the other hand, coma work can bring different types of rewards. Clients have reached for hands from above, traveled to heaven, and shouted, 'Holy God!' They have seen visions, heard voices, sung songs, felt awe, battled oppressors, and embraced loved ones. Comatose people take me beyond my normal earthly boundaries and connect me with thoughts and emotions bigger than myself. I am grateful.   

In early 1993 two colleagues and I journey to Calgary, Alberta to give a coma workshop at the Faithful Companions of Jesus Centre. One of the participants, Karen Keehn, comes from Salmon Arm, BC. Twelve months previous her husband Dwane suffered a heart attack followed by 15-20 minutes of anoxia (oxygen deprivation). She asks us to come to Salmon Arm to work with him. Her funds are limited, so we brainstorm. Karen and Dwane's extended family will pay our travel expenses and put us up, plus an hourly rate for working with Dwane. Alida will organize a workshop again. Many of Dwane's relatives will attend to enhance their communication with him. Karen and Alida will organize additional private consultations for us. We are all encouraged. We will work with Dwane, his family, caregivers, institutions, and community.

Consultation

By way of preparation I ask Karen to send a videotape of Dwane in each of his various moods, both by himself and interacting with people. I show the tape and consult with Arnold Mindell at the spring quarter's Case Consultation Class at the Process Work Institute in Portland, Oregon.

The tape reveals a middle aged man lying in a hospital bed, head tipped back slightly, neck arched. Occasionally he moves his head from side to side. He vocalizes guttural sounds. My notes on Arny's comments (Italics) follow: 

There's a struggle in his neck. Work with the tension there. Put your hands on his neck and massage it. (When Dwane arches his neck, he pushes back or "struggles" against something.)

Put your mouth to his ear and make noises similar to his noises. He may not be hearing himself, so he would need amplification of his sounds to complete a feedback loop. (This can form one of the main reasons people get stuck in comatose states: They lack full awareness of what they are communicating. By increasing the volume of Dwane's sounds he may become more aware of his own communication. From receiving this feedback he may alter his communication behavior.) The growls are winning sounds (that have a good chance of developing into further communication). They come closest to the surface of consciousness, of all of Dwane's behavior.              

The initial anoxia (oxygen deprivation) process may still be in progress. His labored breathing indicates this. (He may be attempting to get more air.) Try giving him more oxygen.    

Parts (of his personality) are intact, even though damaged.

Check with the institution about intervening with Dwane. (Be careful to follow rules and routines and ask permission to go outside these procedures.)

Followup with Dwane and the family at least once a month. He needs a lot of ongoing attention.

Stay conservative, not making the family over optimistic. Take care to tell it how it is rather than how you think the family wants things to be. Find out how much they want to work with Dwane, since they will provide most of the hands on work.

If you maintain a general air of enthusiasm this helps the whole field (loved ones, institution, and community) which will help Dwane.
 

Background

Friday morning, June 11, 1993, Judith and I fly to Salmon Arm. On the flight we discuss how honoured we feel, to be invited to the bedside and intimate family situation of the Keehns. We plan to work with Dwane and help family members work with him. They can learn to relate with Dwane in new ways and practice techniques to continue working with him. We will videotape our first session and study it at the workshop the next day. Many of Dwane's extended family members and hospital staff that care for him will attend the workshop: relatives; friends; professional and volunteer caregivers. We will also connect with folks who support the relatives and friends. The whole setup exemplifies coma community networking.        

Karen and her daughter Vicky pick us up at the airport and we get acquainted on the hour and a half drive to Salmon Arm. We drop our bags at Karen's and head for the hospital. Karen, Vicky, Judith and I meet up with Dwane's son Darcy, daughter-in-law Cindy, and grandchildren Justin age four, and baby Cody. We hold a conference in the hospital parking lot on the shore of a little lake. Canada geese waddle by under the bright Interior sun. Then we spend two hours working with Dwane, first some history:

Heart attack

Dwane is 54 years old, and worked as a saw filer at a local lumber mill. Fifteen months previous he suffered a heart attack at 4am while sleeping. Karen reports that he yelled, "Help! I think I'm having a heart attack!" He helped sit himself up and held his chest in the heart area. He fell off the bed and stiffened his body. The ambulance arrived quickly and took Dwane to hospital. He was without adequate breathing for 15 to 20 minutes. A CT brain scan indicates diffuse brain damage.

From these details we can infer possible directions in his coma process: He wants help. He gets "attacked" in or by his heart when unconscious or sleeping. We can ask ourselves what "attack" means for Dwane, and how it might appear in his behavior? We later work with this part of his process by giving resistance to stiff and rigid muscles in his neck, feet, legs, and arms. Hypothesis: he unconsciously counterattacks or fights off the attack in these places. We give verbal feedback while working: Now I'm pushing your right foot . . . You're pushing back against my hand! . . . Great! These statements hopefully will help him become more conscious and re-establish damaged brain-muscle-auditory connections. People with severe brain damage may require hundreds or thousands of hours of this type of work.

Oxygen deprivation

Another big process involves the anoxia (oxygen deprivation). Readers, you may want to stiffen both arms and legs and stop breathing for ten or twenty seconds, to enter your own mini-version of the powerful altered state that overtakes Dwane. We encouraged him to sustain the long pauses in his breathing. When he stopped breathing, we pushed down on his chest with light pressure while reporting verbally: Now you have stopped breathing . . . Now your chest is still . . . Now you breath in . . .Now you breath out . . . Now you have stopped breathing . . . Now you hold your breath . . .  These statements and hands on work can help amplify awareness of his body sensations and movements. At first Dwane held his breath for approximately 30 seconds. After working with him for 10 minutes he shortened the pauses until he breathed at a near normal rate.  

Childhood dream

We asked Karen for any early childhood dreams or memories that Dwane might have told her. This information can provide one way to investigate what Arny Mindell calls the background dreaming process. Taking off from Jungian psychology, Arny hypothesized that early dreams and experiences demonstrate a pattern for what is transpiring in the present. The current representations of these early experiences may be occurring as body feelings or movements, relationship interactions, or interaction with the larger world.         

Karen reports a powerful dream of Dwane's:

Dwane was born on a ranch in Alberta. In his teenage years he dreamed this just once, but the feelings around it were powerful. He got caught in a gravel crusher. He could see the light in the hole at the end of the crusher tube, but couldn't get out. During the dream in his sleep, he actually lifted the wood heating stove off the floor. Apparently the red glow from the heater resembled the light in his dream.       

Knowing Dwane's early dream experience, we can work from the hypothesis that the process of the gravel crusher will reappear in his body experiences. "Crusher" implies strength. The long pauses at the bottom of his exhalations might represent the temporary stage of being crushed. The inhalation and stiffening of his neck and limbs could coincide with struggling against the crushing, or even becoming strong like the energy of the gravel crusher.   

Workshop presentation

We present the workshop that Alida and Hospice organized, Saturday, June 12. Thirty people attend, including ten members of Dwane's immediate and extended family. Their love and commitment touches us.

Agenda of lecture and discussion topics:

1)  Awakening to inner work: coma as symptomatic of a call to deep inner work, rather than only a “vegetative state” with nothing going on.

2) Ethics and feedback: all states; normal and remote; deserve encouragement, because they may help access meaningful information attempting to come into patients’ awareness.

3) Cultural bias about coma: exploring our familiarity with some altered states and becoming more familiar with others.

4) Information theory: Everything can be understood as information, and information continues to be communicated until received (Diamond). We keep investigating clients’ perseverations (repetitions) until we find how to help complete them.

5) Blank access statements: statements that refrain from projecting helper's ideas into clients. For instance: “Go ahead and experience what you're experiencing and know that will show you the way.”

6) Minimal cues: often overlooked bits of information such as twitches, sighs, coughs, swallows, eye movements, breathing patterns, groans, etc. Increasing awareness of  and encouraging these signals can form the beginnings of significant communications.

7) Relating through channels: noticing and using the way a patient perceives and express theirself: auditorally, visually, through body sensations, body movement, in relationship, with the larger world environment

8) Burnout: wanting to quit as an attempt to gain more detachment; staying in touch with and processing helpers inner reactions as a way to be present and gain distance from highly charged emotional situations.

9) Supervision of issues and difficulties that participants are encountering with patients in their workplaces or families.  

10) Metaskills: The main attitudes and beliefs that underpin the interactions we attempt with clients. Metaskills: compassion; love of human nature; patience; remaining open to mysterious occurrences; awareness of interconnections between people and with the environment; disease and accidents have meaning and are not only pathological; willingness to take seemingly small or useless events seriously. (Mindell, Amy 1992; Mindell and Mindell)  

Video study

After a lunch break we launch into the video study. The tape graphically depicts Dwane's ability to relate with the outer world, at least for short periods of time. Without intense interventions, Dwane's consciousness would probably rate 3 on the Glasgow Coma Scale. Three is the lowest rating and 15 is normal on a scale that measures consciousness by visual, verbal, and motor responses. After relatng with Dwane for an hour using process oriented coma communication techniques, he rates possibly as high as 12 for brief periods. (Ross: 31)         

Demonstrating more presence in the outer world is naturally what his loved ones want. The fact that he only surfaces to the outside environment for short intervals of time seems to indicate two things. He needs a large amount of time and coma work support, to remain inside and work on himself; and concentrated outside feedback to relate with the outer world.    

Verbatim

Find below verbatim sections from the videotape. We've been interacting with Dwane for about an hour previous. He's in a hospital room by himself which allows us to interact freely.        

Names in plain type followed by colons, indicate speakers. Commentary is also in plain type. Italics denote speech.

Stan: We're going to look at your toes here. Karen lifts the sheet from Dwane's feet. Darcy repositions the camera giving a full length body shot from the bottom of the bed.

Karen: I'm touching your foot. I'm touching your toes.

Dwane: Snort! on inhalation. He moves his toes before Karen touches them. Positive feedback.

Stan: There you go! You say toes and Dwane moves his toes!

Judith: You just did it. Your big toe on the right foot just moved. She encourages with "cheerleading", and works at raising Dwayne’s body awareness with precise feedback.

Karen: Can you do it again? Can you wiggle your toe, Dwane? (pause) I'm going to touch your toe. She touches his right big toe and it goes strongly decerebrate (extends toward his head).

Stan: Oh yeah! Right on! Great! Boy that right toe just went right up straight in the air. Wow! Look at that right big toe.

Karen: Now I'm going to touch your other one. Dwane's left toes extend before Karen touches him. Whew! Both of them! Right and left big toes.

Stan: That was great. Keep going, Karen.

Karen: Oh boy, we've really got movement.

Stan:  When you say, "We've really got movement" say the placement. Whew! And now the right big toe again.         

Much of the work with traumatic brain injury patients involves re-establishing and reinforcing the neural connections between body sensation, movement, auditory, and visual modes of communication. Countless hours of interventions like, "Now as I touch your left forearm your right leg moves, also notice what you're looking at." The helper acts as metacommunicator, a person that observes and feeds back information to the patient. 

Karen: Move your left big toe, Dwane. Can you move your left big toe? Do you want me to show you which toe, which foot? She lightly rubs his left instep. He extends his left toes.

Group: Yep, whew, gee, wow, yea! You moved your toe. You can do it. That's big time.

Karen: She takes her hands away from Dwane's feet entirely. How about your right toe. Can you move your right toe? Dwane extends his right foot about four inches.

Group: Cheers and exclamations. We all experience a tremendous thrill.

This makes the third time Dwane extended his toes after an auditory intervention, no touching. He goes on to do it twice more. At this time his awareness is close to the surface. He has some command over some of his muscle movements.

Next I push on the bottoms of his feet and Dwane pushes back strongly. I compliment him on his power. This may be the rigidity and force expressed in his heart attack experience and his childhood dream.        

Ten minutes later in the session Dwane's four year old grandson, Justin interacts with Dwane. As Justin and Karen talk about how Dwane and Justin used to wrestle and fix toys, Judith and Vicky take turns pushing on Dwane's feet. When Justin mentions "Jeep", Dwane's closed eyelids start flickering, indicating a possible inner visual process. No direct contact takes place between the two, but we can hypothesize that certain of Justin's words activate visions and possibly memories. Dwane loved Jeeps before he went into coma.  We encourage Dwane to look at what he sees.  

Justin: He's grandpa. Justin stands on a chair at the head of the bed. Nee, nee, nee, nee, nee. Hi!

Karen: Hold grandpa's hand. Karen places Justin's hand in Dwane's hand.

Justin: I don't want to. He's awful sick. Real sick. Hey grandpa!  

I feel Justin brings some much needed levity and bluntness to the session. He expresses things that the rest of us might feel shy or uncomfortable saying. "Out of the mouths of babes." Dwane does inner work here. He gives positive feedback via increased eyelid movements, even though his response may not fit hoped for reactions. Justin leaves and Karen initiates a new interaction.

Karen: Dwane, I've got a wet cloth. Do you want me to wipe your mouth? She begins gently wiping his open lips.

Dwane: Snort! He turns his head closer to her and closes his mouth. Positive feedback in that Dwane gave a strong reaction that conveys a message to us.

Karen: You like that don't you. Dwane smiles.

Stan: Look at that big smile. I'm touching your face a bit here. I touch Dwane on the upper cheek and pull slightly in the same direction that Dwane's smiling cheek muscles move. I help Dwane be more aware of how his face crinkles up. Wow, look at that, oh yes!

Karen: She continues to wipe his mouth. Open your mouth, Dwane. Do you want some moisture in your mouth? He opens wide.

Stan: Wow! Right on. Wow! He bites down and then chomps up and down. Karen pulls out the cloth. Put it back in. Watch your fingers.

Karen: Ohhhh. Boy, you're biting down on that cloth pretty good.

Stan: Let's wet this one. I had previously prepared a cloth wrapped around a tongue depressor. Peoples' jaw muscles are strong. I had been bitten fairly hard on my fingers a few months earlier by a client.

Stan: Yeah, that's quite the expression. Dwane turns his head toward Stan. Hi. He focuses his eyes on Stan's face. Hi, I'm Stan. Time to look at you, yeah.

Dwane: Snort, chomp. Broad smile.

Stan: Sure looks like you're looking at me and I'm looking at you. Right on.

Karen: She moves the moist cloth covered stick close to Dwane's mouth. Nice and wet, open your mouth. She pauses. Dwane opens his mouth and chomps and sucks on the cloth. Good, good.         

That makes twice that Dwane opened his mouth after a verbal interaction. Karen removes the stick and they make eye contact.

Dwayne: Grrraaghh, snort. I remember that Arny said Dwane’s sounds are closest to the surface of all his signals. As Karen puts her face close to his. She tries the stick again, but he focuses on her with his eyes. After another two minutes of eye contact, Dwane closes his eyes and goes back inside. His eyelids flicker. He breathes into his lower stomach and pushes with his feet.

Stan: Go ahead and see what you're seeing. . . Feel how you need to feel. . . .  Push how you need to push. I place my finger under Dwane's chin and apply slight pressure to help him go further with tipping his head back. Dwane swallows.    

Judith: Those legs are stiff all the way up to the knees! This is new muscular tension, an addition to his strength process.

Stan: If there's a thought that just came up, hang onto it. This responds to his swallow. A swallow can indicate something coming up and then the person swallows it back down. Acting as an awareness reporter here can help the person catch the thought.

Dwane stays mostly nonresponsive a couple more minutes as we work with him. Then Justin starts calling:

Justin: Grandpa, grandpa. Dwane comes back out to look at his grandchildren. Cody, the one year old, musses up Dwane's hair and Dwane smiles.

         
The video study produces good effects in the workshop. The tape helps dispel the common misconception that no one is home when someone is comatose. Participants see that Dwane can be present to some degree. Communication can go two ways if helpers track and interact in those channels the client communicates in.

Extended family visit

The next morning, Sunday, we go to the hospital to meet with Dwane and fifteen members of his large extended family. Dwane stays more interior this morning. This is disappointing. Is the time of day not as good as on Friday? Is he shy with the crowd? Is he just more introverted today? Regardless, we work with him where he is at. We support his withdrawn state. We also involve more family members that weren't present on Friday. We have to gently push people into doing interventions. Naturally, they shy away at first from this new style of interacting with someone they may consider minimally present. Persistence pays off, and several get into the swing.          

Simply gathering everyone together around the bedside proves a touching and bonding experience for the family. We wheel Dwane in his bed out onto the patio. He experiences the outdoors for the first time in fifteen months.

Young people and head injuries

The rest of the day we spend working with a young woman in Salmon Arm and a young man from Armstrong, the closest town to Salmon Arm. Both mothers had attended the workshop the day before. Both patients had been in car accidents as teenagers a few years previous and had suffered massive diffuse traumatic brain injury. Judith and I are amazed at the immense amount of effort, love, and time the families had devoted to their children. They had rebuilt their houses and drove special vehicles to accommodate special needs.

We attempt to help in two main areas. The first involves supporting parents to trust their children’s' inner work and remote states. Something goes on inside people even when communication signals remain minimal and nonverbal. The second area poses more difficulties: how to support the expression of angry and aggressive energies. Working to oppose stiffness in the muscles may help release tension left over from the impact of a violent accident. Also yelling and screaming can help.   

Elder and Alzheimer’s

Later we work with the workshop participant's mother who has Alzheimer’s/dementia. During her withdrawn states we use coma work techniques. When she comes out more and verbalizes "nonsense" sentences, we use symbolic language to communicate with her. This involves going beneath the content of her speech into what she implies. For instance: I want to go home. 

Stan: Feel all those homey feelings, see the sights, go to your favorite place in your mind and heart. She needs the experience of home, even though she can't physically go back there.

Last session and goodbyes

In the evening Dwane's mother Emma takes Alida, Karen, uncle Art and Judith and me out for a lovely dinner. We discuss followup and encourage Emma and Art to come to the hospital with us tomorrow morning.

On Monday morning, we meet Dwane and Karen, their children, Dwane's mom, Uncle Art, and hospital staff to work with Dwane. This is our last session. We have all lost some of our shyness. We get to work quickly and intensely as a team, spelling each other and attempting new and creative interventions. We work with his anoxia process when he pauses in his breathing pattern. He surfaces much more than he did on Sunday morning. This is the team of people that spends the most time with Dwane, so Judith and I feel gratified that we have a productive last session.

We say heartfelt goodbyes to Dwane and family and staff. We thank them all for giving us the opportunity to learn more about coma and communities. We express appreciation for the supportive atmosphere of this rural community. In the afternoon, Karen drives us back to the airport in Kelowna. We exchange hugs and fly home to Victoria.

Conclusion

This article has attempted to delineate some of the ways that coma work and community involvement can further growth in awareness about coma and its effect on individuals and groups. Mulling over our experiences in Salmon Arm, I wonder how coma workers can further utilize the networks already present, to facilitate those in coma and the human environment surrounding them? How can we as communities work better with coma communication, its meaning and purpose, and the essential experience of humans and humanity with deep remote states? If, dear readers, you have insights or experiences you wish to share regarding these questions, please write to us.

References and readings

Blakely, Mary Kay. Wake Me When It's Over. New York: Times Books, 1989.

Diamond, Julie. "Patterns of Communication." Manuscript available from: The Process Work Institute.

Hunter, Edna Lissett. For the Love of Mel. Calgary, AB, Canada: Melaney Hope Publishing

Society. #202--4015  17th Ave. SE, Calgary, AB, T2A 0S8, Canada, 1989.

Mindell, Amy, "Coma and Deep Body Work." Class presented at The Process Work Center of Portland: Winter quarter, 1992.

Mindell, Amy. "Training Issues in Coma Work: edges and personal freedom." The Journal of Process Oriented Psychology. Vol. 5, No. 2, Fall/Winter 1993: 33-40.

Mindell, Amy and Mindell, Arnold. "Coma, the Key to Awakening." Seminar in Seattle: Oct. 30-Nov.1, 1992.

Mindell, Arnold. Coma: Key to Awakening. Boston: Shambala, 1989.

Ross, Kay. "A Comparison of the Medical/Nursing and Process Work Approaches to Coma: a journey through the minefield of unconsciousness." The Journal of Process Oriented Psychology. Vol. 5, No. 2, Fall/Winter 1993: 23-32.

Tomandl, Stan. Coma Work and Palliative Care: An Introductory Communication Skills Manual for Supporting People Living in Coma Near Death. Victoria, Canada: White Bear Books, 1991.

Copyright 1995 by Stan Tomandl
All rights reserved.

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