MA - LAB PROCEDURES [ EXAM 1 ]

Chapters 1, 2, 3, 12, & 14

Identify the members of the laboratory staff.

Phlebotomy, hematology, urinalysis, chemistry, microbiology, immunology, blood bank (immunohematology), primary testing, cytogenetics, molecular diagnostics, cryptology and histology (pathology), stat lab (emergency), ambulatory

Phlebotomy

• cross trained venipuncture as well as capillary collection, patient care, receptionist duties, sample processing, and computer work

Hematology

• studies blood cells and performs qualitative and quantitative analyses along with microscopic exams

  • Qualitative analysis are chemical analysis designed to identify the components of a substance

  • Quantitative analyses analyze a substance to determine the amount or proportions of the substance; results are released as an amount, such as grams per liter

coagulation/hemostasts

• studies blood clotting mechanisms as an aid in the diagnosis or monitoring of patient therapy

  • ex of tests: prothrombin time (PT), activated partial thromboplastin time (aPTT), D-dimer, factor VII, fibrinogen assay, heparin level, von Willebrand factor

urinalysis

• studies urine to aid in patient diagnosis to follow the course of a disease or the body’s metabolism

  • ex of tests: urinalysis, specific gravity, urine pH, urine glucose

chemistry

• preforms biochemical analysis of blood and body fluids to dtermine the status of a patient

  • ex. of tests: comprehensive metabolic panel, iron studies, renal panel, carcinoembryonic antigen (CEA), glucose, alanine aminotransferase (ALT), aspartate aminotransferase (AST), cholesterol

microbiology

• cultures samples to determine if pathogenic organisms are present in a sample and determine the organism’ sensitivity to antibiotics (culture and sensitivity)

  • ex. of tests: blood cultures, throat cultures, anaerobic cultures, urine cultures, parasite identification, stool culture, mycobacterial (tuberculosis) culture, virus cultures, fungal cultures, genital cultures, mycoplasma cultures, antibiotic susceptibility testing

immunology

• studies antigens and antibodies to determine immunity to disease or the presence of disease

  • ex. of tests: HIV testing, rubella, syphilis (rapid plasm reagin [RPR]), hepatitis testing

immunohemtaology (blood bank)

• determines compatibility of blood and blood products that are to be administered to patients

  • ex. of tests: compatibility testing, antibody screens or ABO, Rh determination

cytogenetics

• studies deficiencies related to genetic diseases

  • ex. of tets: chromosomes analysis, prenatal chromosome screening

molecule diagnostics

• uses PCR technologies to study the presence of various diseases or infections

  • ex. of tests: methicillin-resistant Staphylococcus aureus (MSRA) infections, HIV and other infectious disease

Outline the phlebotomist’s responsibilities as a member of the health care team

• represent the laboratory and the health care center, they are in contact with the patient, and they perform tasks that are critical to the patient’s diagnosis and care

• traditional role of the phlebotomist in a hospital is only one job: to collect blood samples

  • centralized: sample collection where the phlebotomist is part of the laboratory team and is dispatched to hospital units to collect blood samples

    • often results in times of no work and other times of more work than can be done in a short time

    • works well until there are a large number patients to draw and the work cannot all be completed by 0700

  • decentralized: sample collection where all members of the health care team share the responsibility to collect blood samples

    • difficult for a hospital to hire people to come in at 0430 to just draw and then go home

    • everyone who has contact with the patient needs to become multiskilled

  • hybrid phlebotomy: blend of centralized and decentralized phlebotomy

    • used to reduce the errors of decentralized phlebotomy

    • typically sends lab-based phlebotomists to the nursing units during the early morning collections and then keeps a limited number of phlebotomists available the rest of the date to help PCT with difficult collections

Describe what it means to be a professional as a phlebotomist

common sense i fear

• Phlebotomists should conduct themselves with honesty and respect, maintain professional competence, and promote ethical behavior in the healthcare system.

Electroencephalography

• record electrical activity of the brain

• help locate and access the extent of brain injury or determine if there is any brain activity

electrocardiology

• does electrocardiograms

• performed in the patient’s room

radiology

• x-ray lungs, broken bones, cardiac catheterization , CT scans, MRI, and ultrasound

• each of these techniques has become a subspecialty of radiology that still looks into the body as teh traditional x-ray did but in much more detailed and sophisticated way

pharmacy

• hospital pharmacy dispenses many types of therapeutic drugs that often are much more potent thatn a prescription taken at home

  • prescribed and monitored under controlled onditions while the patient is in the hospital

  • with results of blood samples, pharmacists can consult with the lab and the patient’s physician to provide the best treatment possible for the patient

physical therapy

• works with patients who, due to disease or injury, are no longer able to function to their full physical capacity

  • therapy may involve rebuilding deteriorated muscles after a long illness or learning to function after an amputation

• occupational therapy is related, works with patients to overcome their physical challenges so they can be productive again in their old job or function in a new job

• speech therapy is another area related to physical therapy

  • patients who have difficulty speaking or who have lost the ability to speak because of a stroke or disease are retaught how to speak

nursing

• provide direct patient care

laboratory

• provide testing of patient samples

• include a variety of locations including;

  • main laboratory, ambulatory care laboartory, stat laboartory, and surgery laboartory

environmental services

• maintains a clean facility

administration

• keeps ths hospital in compliance

food service

• provides diets to patients

gastrointestinal (GI) laboratory

• diagnoses gastrointestinal disorders

medical records

• maintain patient records

respiratory therapy

• provide therapy to evaluate lungs

administrative office

• responds to telephone cells, handles specimen collection requests, and handle some specimens

phlebotmy (sample collection)

• collects samples form patients and processes samples for testing or transport

Descrube the importance of communication and maintaining quality care with the laboartory and with other departments of the hospital

Effective communication within a laboratory and with other hospital departments is critical for maintaining high-quality patient care by ensuring accurate information is shared promptly, preventing errors, coordinating treatment plans, and ultimately leading to better patient outcomes; poor communication can result in delays, misinterpretations, and potential harm to patients.

List five patient rights and explain how these patient rights would affect a phlebotomist’s job

1. patient has the right to considerate and respectful care

   • It is important for the phlebotomist to remain calm and to show consideration and concern for each patient.

2. patient has the right to and is encouraged to obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis

   • except in emergencies whent he patient lacks descision-making capacity and teh need for treatment is urgent, the pateitn is entitled to the opportunity to discuss and requent information related tot eh specific procedures and/or treatments, the risks involved, the possible length of recuperation, and teh medically reasonable alternatives and their accompanying risks and benefits

   • patients have the right to know the identity of physicians, nurses, and other involve fin their care as well as when those involved are students, residents, or other trainees

   • patient also has the right to know the immediate and long-term financial implications of treatment choices, insofar as they are known

     • If questions are asked during the phlebotomy procedure, simply state that the physician has ordered blood to be drawn for testing and refer the patient to the physician. The phlebotomist may question the need for the test to be drawn or realize there was an error on a previous sample, and now the patient must be redrawn. Questions and concerns should not be discussed with the patient but with the phlebotomist’s supervisor or the nurse, outside the presence of the patient.

3. patient has the right to make decisions about the plan of care prior to and during teh course of treatment and to refuse a recommended treatment or plan or care to teh extent permitted by law and hospital policy and to be informed of the medical consequences of this action

   • The phlebotomist may need to explain briefly how the venipuncture is performed and that these are tests the physician has ordered.

4. patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attornery for health care) concerning treatment or designating a surrogate decision maker with teh exoectation htat the hospital will honor the intent of the directive to the extent permitted by law and hospital policy

5. patient ahs teh right to every consideration of privacy

   • Often the phlebotomist may be in the room at the time another procedure is being performed, the patient is completing personal hygiene, or the physician is examining the patient

6. patient has the right to expect that all communications and records pertaining to their care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law

   • patient has the right to expect that the shopital will emphasize the confidentiality of this information when it releases it to any other parties entitles to review information in these records

7. patient has the right to review the records pertaitning to their medical care and to habe the information explained or interpreted as necessary, exept when restricted by law

   • If the patient asks the phlebotomist to look at the chart, this request should be referred to the nurse or physician.

8. pateint ahs teh right to expect thatm within its capacity and politices, a hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services

   • The appropriate person to handle these requests is the nurse or physician. Often a patient may request a drink of water, aid in getting out of bed, and so on, from a phlebotomist. Refer these requests to the nursing staff, since the physician may have written specific orders denying the privilege because of upcoming surgery or other aspects related to that patient’s care.

9. patient has the right to ask to be informed of teh existence of business relationshupis among the hospital, educational institutions, other health care providers, or payors that may influence the patient’s treatment and care

   • A patient may request the phlebotomist’s name and title, and it is appropriate for you to give this information

10. patient has the right to concest or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement and to have those studes fully explained prior to consent

11. patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of abailable and realistic patient care options when hospital care is no longer appropriate

    • For the laboratory, this means that samples should be obtained and processed expeditiously to facilitate the care of the patient.

12. patiwent has the right to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities

    • patient has the right to be informed of abailable resources for resolving disputes, grievances, and conflicts, such as ethics committes, patient representatives, or other mechanisms available in the institution

pathologist

• physician who reads and interprets the results of lab tests or examines tissues under a microscope to diagnose and monitor disease

• experts in diagnosing such disease as cancer, dianetes, AIDS, hepatitis, and thyroid condicions

  • requires 5 years of training following a graduation from medical school to be elgible to take examinations leading to board certification as a clinical/anatomic pathologist

medical laboaratory scientist (MLS) or clinical laboratory scientist (CLS)

• holds a minimum of a baccalaureate degree and is responsible for performing a full range of lab tests, confirming teh accuracy of test results, and reporting lab findings to the pathologist and other physicians

• work in five maojr areas of the lab, blood banking, chemistry, hematology, immunology, and microbiology

medical laboratory technician (MLT)

• under tbh supervision of the medical technologist

• performs general tests

• have special training in addition to an associate degree

phlebotomy technician (PBT)

• collects blood samples to be used in many lab tests to detect and monitor treatment

• have training in addition to a high school diploma

cytotechnologist (CT)

• examines cells under the microscope to detect signs of caner in teh earliest states, when a cure is most likely

• must hold a baccalaureate degree and have special training to search out the smallest abnormalities in color, shape, or size of cells

histotechnologst (HTL)

• prepares body tissue samples for microscopic examination be the pathologist using sophisticated techniques such as immunohistochemistry

• must hold a baccalaureate degree and have special training to freeze, cut, mount, and stain the tissues, often while the patient is still in surgery, thus playing a major role in the diagnosis in malignancy

The Joint Commission

• sets standards of care to ensure quality and reliability of health care

• surveus are accepted by medicare

• lab tests must meet The Joint Commission’s accuracy standards

• laboratories must meet procedure standards

College of American Pathologists (CAP)

• proficiency samples are sent to labs by CAP for accuracy chekcs

• inspects lab procedures and lab results

• TJC accepts CAP inspections

National Accrediting Agency for Clinical Laboratory Sciences (NAACLS)

• international agency for accreditation and approval of educational programs in clinical lab sciences and related health care professions

• accreditation approved by on-site inspections of facility to ensure the program meets certain educational standards

• competencies must be met by students in order for the educational program to exist

Clinical Laboratory Standards Institutute (CLSI, formely NCCLS)

• establishes lab guidelines and procedures

• consists of reps of the lab and lab industry

• maintains uniformiety of lab procedures on a national basis

Clinical Laboratory Improvement Act of 1988 (CLIA)

• enforced by a committee of inspections

• main goal is to protect patients from recieving inaccurate results

Occupational Safety and Health Administration (OSHA)

• regulations enforced by a committee of inspectors

• establishes and enforces safety standards for employees

• can issue fines if there are violations

explain the principle of and procedures for infection control

• universal precautions - a principle to protect health care associates from infections as a result of exposure to body fluids

  • assumes that all blood and most body fluids are potentially infections

  • involved into a system called body substance isolation

    • assumes that each patient had the potential to spread disease through body substance

• standard precautions - enhancement of universal precaustions and combine many of teh basic principles of universal preacutions with techniques from BSI

  • maintain that PPE and barrier controls must be worn for contact with all body fluids, whether or not blood is visible

  • goal is to reduce the risk of trasmission of microorganisms from both recognized and unrecognized sources of inception

  • five main points:

    • wash hands when changing gloves and between patietns

    • wear glvoes when likely to touch body substances, mucous membranes, or nonintact skin and during all blood drawing

    • wear protective cover when clothing is likely to be soiled

    • wear a mask and eye protection in addition to a protective body cocver when likely to be splashed with body substances

    • place intact needle/syringe and sharps in designated sharps containers; do not bend, break, or cut needles

describe how breaking the chain of infection can stop the spread of an infection

Breaking the chain of infection stops the spread of an infection by interrupting the steps that allow a microbe to pass from one person to another.

explain the differences in teh different types of transmission of infection

• direct contact: physical transfer of infective material; from the source to susceptible host

• indirect contact: transfer of infective material via an object, such as bed linens

• droplet: droplets that travel 1 meter or less from the infected individual

• vehicle: transfer of infective material through contaminated items, such as food

• airborne: droplets that transfer on air currents, such as tuberculosis

• vector: transmission by insects, such as malaria transmitted by mosquitoes

explain how the phlebotomist can control the transmission of infection

A phlebotomist can control the transmission of infection by consistently practicing good hand hygiene, wearing gloves for every patient interaction, using sterile, single-use equipment for each blood draw, properly disposing of sharps in designated containers, disinfecting work surfaces between patients, and following appropriate procedures for skin antisepsis when collecting blood samples; effectively breaking the chain of infection through these practices.

describe the proper handwashing technique and use of personal protective equipment

1. remove all rings, watches, and so on to prevent the jewelry from harboring microorganisms

2. have disposable towels ready or use an automatic towel dispenser so that you do not have to touch the towel dispenser

3. stand back from the sink so that you and your clothing do not touch the sink

4. turn on the water with the foot pedal or with a disposable tower if not foot controlled. The temp should be lukewarm.

5. wet hands under the running water. Be careful to not touch the sides of the sink

6. Apply soap, and lather well. The lather and scrubbing action will remove dirt and dead skin. Scrub between fingers and around fingernails. Continue to scrub for at least 20 seconds. Some facilities have a specific minimum time to scrub. Use a nail stick and a brush during the first handwashing of each day or when your hands become excessively soiled

7. Rinse hands with the water flowing downward off the fingertips. This will rinse the contaminated water off the fingertips and not onto the forearms

8. Complete the washing process again if this is the first handwashing of the day

9. Dry hands and wrists with the disposable towers

10. Turn off water with the disposable towels if the sink is not foot controlled

• PPE used by the phlebotomist may include masks, goggles, face shields. gowns, and gloves

describe how the phlebotomist can reduce the spread of infection

A phlebotomist can significantly reduce the spread of infection by consistently practicing good hand hygiene, wearing gloves for every patient interaction, using sterile, single-use needles and equipment, properly disposing of sharps in designated biohazard containers, disinfecting work surfaces between patients, and following proper patient identification procedures

identify rules that promote safety of the individual and patient

• Rules that promote patient safety include following infection control protocols, practicing good hand hygiene, and maintaining clean patient rooms.

• Patient safety rules

  • Infection control: Wash hands or use hand sanitizer when entering and exiting a patient's room

  • Medication management: Take antibiotics as prescribed and report side effects

  • Cleanliness: Keep patient rooms clean

  • Fall prevention: Take precautions to prevent falls

  • Risk management: Identify and report potential risks

  • Communication: Communicate well with patients and staff

  • Learning: Learn from incidents and near misses

  • Leadership: Provide leadership and support staff

  • Involvement: Involve patients in their care

identify the differences in cleaning for phlebotomy and cleaning of hard surfaces

The key difference between cleaning for phlebotomy and cleaning hard surfaces lies in the specific focus on disinfecting living tissue (like a patient's vein) in phlebotomy using antiseptic solutions like alcohol swabs, while cleaning hard surfaces primarily involves removing dirt and debris with a general disinfectant, often requiring a longer contact time to kill microbes effectively; phlebotomy cleaning is more targeted and needs to be quick-drying to avoid patient discomfort, whereas hard surface cleaning can be more thorough and take longer depending on the surface and level of contamination.

identify policies and procedures for identifying laboratory safety

Laboratory safety policies and procedures for identifying hazards include: hazard identification through chemical safety data sheets (SDS), regular safety inspections, proper chemical labeling, employee training on hazard recognition, incident reporting, risk assessments for new experiments, and a system for reporting potential hazards; all aimed at proactively identifying and mitigating potential risks within the laboratory environment.

identify what “other potentially infectious material” is in healthcare

• semen

• vaginal secretions

• cerebrospinal fluid

• synovial fluid

• pleural fluid

• pericardial fluid

• peritoneal fluid

• amniotic fluic

• saliva encountered during dental procedures

• any body fluid that is visibly contaminated with blood

• all body fluids in situations where it is difficult or impossible to differentiate between types of body fluids

• any unfixed tissue or organ from human or nonhuman primate (living or dead)

• HIV-containing cell or tissue cultures, organ cultures, cell medium, or other solututions

explain the purpose of material safety date sheets (MSDSs)

• information sheets that must be kept on file and that indicate teh hazards of the chemicals used in each section of the lab

• chemicals used in the lab must also contain labels indicating the identity of the chemical and showing warning appropriate for employee protection

explain the phlebotomist’s responsibility for fire safety and hazard identification

hazard identification

• hazards can be identified on the container by a hazard emblem designed by teh National Fire Protection Association

• contains a diamond shaped diagram further subdivided into smaller diamonds

  • health hazards are identified on teh left

  • flammability at the top,

  • reactivity on the right

  • bottom space is used to identify other hazards or to alert fire-fighting personnel to the possible hazard of using water

• hazards are identified by color: blue for healthhazards, red for flammability, and yellow reactivity

• diamonds are identified by # on a scale of 0 to 4 to indicate the severity of the hazard

fire safety

• class A are used on class A fires and include foam, loaded-stream, and multipupose dry chemical extinguishers

  • includes those of ordinary combustible materials in teh lab, such as wood, plastics, and paper

• class B inlude fires or flammable liquids and fases— that is, elements that require blockage of oxygen from teh fire to extinguish

  • extinguishers include carbon dixoide, dry chemical, foam, and loaded-stream

• class C fires are energized electrical equipment

  • use of nonconductive media is needed to preven electrical shock when putting out such a fire

  • extinguishers include carbon dioxide and dry chemical extinguishers

• class D includes fires of combustible and reactive metals such as sodium, potassium, magnesium, and lithium

  • poses special problems bc explosion and spreading can easily occur

most fire extinguishers found in the lab are of a unicersal ABC type

RACE

• R = Rescue anyone in danger

• A = Sound the alarm

• C = Contain the fire by closing doors and/or windows

• E = Extinguish/Evacuate. Extinguish the fire if possible. If the fire is too large to extinguish, start to evacuate anyone in the fire’s path

describe the procedure for clearing a chemical splash in the eye

• Will need another person to help in holding the eye open and removing any contact lens that might be in the eye

• should be flushed with water for 15 minutes

• person must be evaluated for medical treatment by the emergency department or occupational health facility

explain the requirements for disposing of potentially infectious materials

(1) incineration,

• most common method used to dispose of infectious waste in incineration

• waste is burned to an ash, and then the ash is taken to the municipal disposal

• kills any potentially infectious organisms and makes the items within the taste unusable

• Healthcare institutions must rely on a commercial medical waste handler to dispose of the waste. will charge $$

(2) chemical treatment, and

• alternative to incineration

• consists of grinding or chopping the waste into small pellets and then treating the pellets with a disinfectant chemical to kill any infectious organisms

• ended the waste unusable, while the disinfectant permits the waste to be sent to the municipal disposal site

(3) autoclave

• can be used in small operations where only a small amount of waste is generated

• waste material is placed in the autoflave

• control tapes are placed on the biohazard bags to ensure adequacy in the sterilization

  • change color if the sterilization has reached the proper temp and pressure

• once sealed, the autoclave is injected with steam under high pressure for 15 mins to cook the waste under pressure

describe precautionary measures and actions to be taken with accidental needle punctures

• Wash the wound with soap and water.

• If soap and water aren't available, use alcohol-based hand rubs or solutions.

• If you are at work, notify your supervisor or occupational health and safety officer - you will need to fill out an accident report form.

explain teh appropriate response after an accidental biohazard exposure

• wash exposed area with soap and water

• report incident to supervisor immediately

• exposed associate must be tested for HIV and HBV if consent is given

• source individual’s blood is tested for HIV and HBV if consent is given

• if source patient refuses testing, is HIV or HBS positive, or is in a high-risk category, associate may elect to recieve prophylactic treatment

Explain what preexamination errors can occur with a sample and how these errors can affect a patient’s outcome.

occur during any of the processes that it takes to collect the sample and get to the point in which testing of the sample occurs

• most serious and potentially most dangerous preexamination error is improper patient ID

• tourniquets - reduction of fluid volume results in hemoconcentration

  • inability to circulate lowers the pH and causes potassium to be forced out of the blood cells

  • also causes an elevation in calcium and magnesium

• exercise and posture- exercise will change cell permeability, causing an increase in various analytes. hemoglobin will increase with exercise

• incorrect volume of blood in the tube

• fasting and timed samples - fasting samples after a 10- to 12- hour fast will give the best results for certain tests that are influenced by food intake

• timed samples - timed samples are collected for those analytes that follow diurnal or circadian rhythms

• hemolysis with syringe draws

• cleansing the venipuncture site with betadine or iodine solutions

  • can cause increase potassium, phosphorous, and uric acid

• incorrect order of draw

  • the order of draw for evacuated tubes will cause a carryover of additive from one tube to the next, resulting in compromised test results

Explain how exercise and stress can affect laboratory results.

• exercise and posture

  • vigorous exercise can affect the result of testing

    • patent’s cell permeability will change if they have just completed vigorous exercise

    • causes an increase in concentration of creatine kinase (CK), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), bilirubin, creatinine, and uric acid

  • stress can have a similar effect

    • WBC increase

    • patient who make an extremely tight fist or pumps the hand can increase lactate by as much as 100 percen or more

  • changes in posture cna influence lab results due to a chanfge in blood volume

    • lying down to standing will have an increase in blood pressure

List the tests that require chilling or warming and explain why these steps are necessary.

chilling of samples

• released potassium from the cells and elevates the serum potassium values. other analytes are also affected

  • ammonia

  • acid phosphatase

  • catecholamines

  • lactic acid

  • pH/blood gases

warming of samples

• tests need to be maintained at body temp

• best method of maintaining this temp is to wrap the sample in a heel warmer, or to use a plastic black that is maintained at body temp before taking it to the patient

  • tests that must be maintained at 37º C are cold agglutinins & cryoglobulin

Describe situations that would result in re-collection or rejection of a sample.

• when a test result is not consistent with previous test results, it is always recommended to redraw and run the test again

Describe methods of transporting samples.

• pneumatic tube system

  • moving samples within a building or to another building a short distance may be accomplished by a pneumatic tube system

• absorbent wrap

  • transporting samples long distances by an outside agency, requires teh sample to be wrapped

explain the laws that regulate compliance

• antikickback law

  • prohibits the knowing and willful payment or offer of any remuneration directly or indirectly in return for inducing, referring, or soliciting services, including lab testing paid for by a federal health program

• stark law

  • forbids physician from referring sample to a lab in which physician or immediate family member has financial interest

• false claims act

  • prohibits knowingly presenting false claim to gov

  • prohibits changing billing code (upcoding) to increase reimbursement

  • billing for lab tests that are not medically necessary for diagnosis and treatment

• civil monetary penalties law

  • prohibits claims for service not provided as claims

• many states have their own set of lawys

• not limited to medicare and medicaid programs

• penalties vary depending ons tate

discuss why it is essential that laboratories maintain compliance and follow these laws

• ensures that the customer is not being overcharged for testing or charged for testing that was not ordered and that unnecessary testing not being conducted

discuss the best way for a phlebotomist to avoid injury-related lawsuits

• follow established procedures and practices

• be observant of the patient

describe a situation in which a phlebotomist would need to make an ethical decision

• phlebotomist must treat patients as they would like to be treated themselves

• phlebotomist see many patients at their worst

  • may find it difficult to be ethical and professional with these patients

• phlebotomist often has to deal with dying, death, and grief for the first time