Pamela

It always amazes me when someone feels the need to "straighten you out" like that. Too many people think there is only one right way to deal with anything -- their way. I am sorry for the pain this caused. You don't have to justify yourself to anyone. I'm glad you brought this to us openly. When a person is dealing with the things you are, being "witch slapped" could have knocked you to the ground emotionally. I'm proud of you that you bounced back with fight. Hang in there. You're a wonderful mother and your kids know it. By the way, I went through the lung cancer fight with my father. Being the daughter is NOT the same thing as being the one with cancer. I watched my dad and I read all the posts here and I feel admiration and deep compassion for what you endure daily. I suspect I would not be nearly as strong as you, Beth. You amaze me. Pam

This is really a good topic. My Dad went through a period when he was just plain mean. We were all doing everything we could -- and making significant sacrifices to do it -- and he was saying mean things to us. I've thought about it, and I think it's the loss of control and, of course, the fear. Suddenly your mom has been plunged into the great unknown, and she can't make it go away. It messes with her mind and her self image. She's been a certain way all her life, and now she's someone she doesn't know anymore. We found with Dad that the best thing we could do was treat him the way we would have before he was diagnosed with cancer. My younger brother was very good at it. Dad snapped at him once, and Jeff just looked at him and calmly said, "Don't jump on me. I love you and I'm going to be there for you, but I'm not going take your crap." Dad calmed down and was much easier to deal with. I came to the conclusion early in the battle that I would not expect anything from Dad, that I would just accept whatever he did or didn't do. I decided that I wanted to practice unconditional love and giving openly without any expectations from Dad one way or the other. My sister-in-law asked me once, "Didn't he hurt your feelings when he said that?" The question actually surprised me, and I told her, "There is nothing Dad could do or say that would hurt my feelings. This battle is about him, not me." That sounds sickeningly noble, doesn't it? Reading it kinda makes me feel silly, but I meant it. I couldn't take the cancer away and I couldn't make my life go back to what it was before cancer, but I wanted to give my Dad the very best I had while I still had him. I'm glad I did. It's uncharted territory for you and your mother, so it may take awhile for things to settle into your "new normal." My heart is with you. Pam

I have had that experience, too. I remember one occasion at a Luby's seeing a woman who looked like my mom and was even dressed like Mom would dress. That was 8 or 9 years ago, and I still remember the warmth and affection I felt for that woman. I had to resist the urge to walk over and hug her. All in all, it was a pleasant experience. It reminded me how special and wonderful Mom was and how blessed I was to be her daughter. Pam

Yesterday I had to go to a hospital here in town to pick up paperwork for my son. I thought it would be a quick errand and didn't give it much thought until I walked through the front doors. Then I couldn't believe my emotional reaction. I immediately felt tears stinging my eyes. It was like a flashback to all the long hours we spent with my Dad in the hospital last year. The familiar emotions of that time -- fear, heartache, helplessness, hope -- overwhelmed me. I wanted to run out the door. I know the staff I dealt with wondered why there were tears in my eyes, but I couldn't help it and I couldn't explain without breaking down. Perhaps the most surprising feeling was the longing to be back there again. I wanted desperately for my Dad to still be alive, to still be sitting next to his bed or waiting with him for some test or other. Anything, even the intense stress, would be better than Dad being gone. I guess this was just another step in the grieving process. More to come. I'm NOT looking forward to Father's Day. Pam

I, too, understand what you are feeling. Dad died in August 2004, and I still vividly remember how I felt at the time. I can't add anything to the previous posts except my own heartfelt sympathy and caring. Pam

Elaine, Your soul shows in your postings, and I am so, so sorry that you have to go through this horrible experience. I do not have cancer and I have never been seriously ill, so what I say may have no credibility. I know as a family member that I wanted desperately to talk to my Dad openly and honestly about what was happening to him. I most certainly did not think less of him when he was weak and suffering. I wanted to know what he was feeling, his fears, his thoughts about his life and what it all meant to him. I wanted him to cry with me and laugh with me and allow me the privilege of giving back some of the strength he gave to me all my life. I wanted to share old memories and be a part of the experience with him in a real way. But Dad was so accustomed to being strong (and silent) that he bottled it all up. Maybe he was afraid if he talked about it, it would overwhelm him. I don't know. I don't know how old your kids are, but they may be waiting for you to make the first move and show your vulnerability. They may be wanting to ask questions and share the tough stuff with you. They may be holding back because they don't want to make this harder on you. You will know your kids better than anyone else, so you may have a sense about that. Just rambling thoughts. You are so eloquent in your postings and I am learning from you. Pam

I appreciate your asking this question. My brothers and I did a lot of research during our father's battle with lung cancer. When reading stories of the dying process, I realized that there were many instances when death occurred shortly after morphine was administered. So I started reading and asking questions about morphine. What I learned was that morphine represses, or sedates, the respiratory system. One doctor told me that morphine helps with "air hunger," when the patient breathes as deeply as possible but still doesn't feel like he's getting enough air. He basically explained what I had concluded, that the morphine doesn't open up the air passages or allow the lungs to inflate better or improve breathing at all. It just slows everything down so that the patient isn't aware of the air hunger. My brothers and I were fortunate, I suppose, because we had in-depth discussions about this issue before Dad reached the stage when we had to make a decision. We made our decisions believing that by administering regular doses of morphine, we could be hastening his death by sedating his respiratory system to the point that he didn't have the strength to breath. We also came to the conclusion that the first priority in Dad's dying process was managing his pain -- while trying to balance pain management with mental clarity. We staggered morphine with hydrocodone, experimented with dosages, and watched Dad for signals that he was feeling pain. We only administered enough pain medicine to keep him comfortable, but not enough to keep him confused and sedated all the time. That was quite a balancing act the last 2-3 weeks, but Dad experienced very little pain, and we are grateful for that. At the same time, we were able to have some clear communication with Dad, and one of my brothers in particular is extremely grateful for that. Doctors, nurses, hospice, every medical professional we saw for the last 5 months of Dad's life wanted him to be on morphine every 8 hours -- even though Dad told them very clearly that he was not in pain, and he was not having difficulty breathing. In fact, Dad had very little problems with his breathing, right up to the end. It was such a curious thing to us that morphine was being recommended so strongly to "proactively" manage pain that Dad would have at some point in the future. After a rather horrifying experience giving Dad all 12 medicines that were prescribed "proactively," we stopped all medications unless, and until, there was a clear need for them. Without writing a book (sorry this is so long), I will say that I have concluded that morphine is prescribed and recommended as much as it is because the medical professionals are trying to be compassionate. I think they know that morphine could well shorten a dying person's life, but, as Di puts it, that may be a good thing for that patient. Of course, it would be a rare hospice nurse or oncologist who would even infer such a thing for fear of being accused of euthanasia. I personally gave Dad his first dose of morphine to manage pain that was distressing him terribly, and my hand was shaking when I did it. He immediately went into a mental fog that lasted until we brought the pain back under control and switched back to hydrocodone. No pain, mental clarity was better, breathing was fine. At the end, one of my brothers made the decision to give Dad a dose of morphine for reasons that are unclear to the rest of us, and Dad died 30 minutes later. It didn't matter, of course, because Dad was certainly dying and if the morphine shortened his life, it was only by hours. Sharyn, I will repeat what others have said. You did not kill your father. Cancer killed your father. If the medications provided your father with more comfort and peace, but may have shortened his life by hours or days, isn't that a choice you would have knowingly made? Whatever you did, you did with the greatest of love, and you could not have saved your father no matter what you did or didn't do. Please do not feel guilty. I suppose my greatest concern is that medical professionals know, or suspect, that morphine hastens death by a small measure, but they do not give that information to care givers so that they can make conscious, informed decisions. On the other hand, I may be completely wrong. I may never know. Just food for thought. I hope no one is offended by this. Pam

KC, I wish with all my heart I could help you. I was not there when my father died in August of this year, partly because I live 1,000 miles away and partly because I did not believe he could really die. After all, Dad was strong, he had been around my whole life, and I couldn't imagine him actually, truly, irrevocably dying. Not my father. My head knew he was dying, but my heart kept saying, "no way." I believe that guilt is the most terrible and destruction of all the emotions of grief. Try very hard to see yourself through your father's eyes. He loved you. If he had thought that watching him die would tear you apart, would he have asked you to stay? No, he wouldn't. If he is watching you from across the chasm today, would he be concerned that you didn't stay to the end, or would he be worried sick about how his death has affected you? I think he would be devastated to know he has caused such desperation and guilt. He would not want that for you. Life is so short, as his death proves, and any father would want his daughter to find peace and joy. I don't know your father, but I am a parent, and so are you. If you were the one dying and your daughter did exactly what you did, what would you want for her? Would she even have to ask for forgiveness? KC, please be kind to yourself. Your life matters. Your health matters. You are a valuable person. You are a kind and compassionate woman, so give some of that kindness and compassion to yourself. You deserve it! Pam

Heather, it's desperately sad, isn't it? There are so many emotions that wash over you in waves, and it's hard to keep your balance and sort through everything. Please take some time to prepare yourself. I would recommend the book, "Final Gifts." And there is a very good website www.crossingthecreek.com that will help as you near the end. It's horribly painful to contemplate, but you will be grateful later that you did the homework. Life is precious. Your mother is a wondrous, unique person, and now is all you have with her. Right now you have the privilege and honor of walking with her on her final journey. These remaining days will bring an awesome and profound experience that will change you forever. Cherish each moment, each breath, each smile. You may have months; you may only have weeks or days. With Dad, his personality slowly slipped away. There were periods when he was Dad, but most of the last few weeks he was in a distant, private world. We just continued to love him, talk to him, care for him, grieve for him. When we realized that Dad's fight was ending, I made it a point to pay attention to everything. Dad was going somewhere we had never been, but somewhere I will go someday. I wanted to be there for him, to be his daughter all the way to the end. I also wanted to learn from him, as I had all my life. It has changed me profoundly. Heather, I know you will bravely face this challenging experience because you understand that your mother is worth the pain and grief. It is desperately sad, and desperately painful, but you will do what you have to do. If you need us, we are here. My heart is with you. Pam

I understand. My dad went to the hospital for a CT scan on New Year's Eve last year, and I can't believe the difference in my physical health since then. I've gained some weight, I have a hard time sleeping, I'm having stomach spasms and nausea. I went to the doctor recently for chest pains, and he said it's stress. It's difficult to find the mental energy to focus on your own health, I know, when it takes everything you've got just to make it through the day. But everyone is right, you matter and your health matters. The best way you can honor your dad is to love and take care of his daughter. Hang in there. Be good to yourself. Pam

While I wouldn't wish lung cancer on my worst enemy, I hope these people receive a wake-up call of some kind soon. As prevalent as lung cancer is, it is likely that at some point they will have a family member or loved one dealing with this nightmare. Wonder how they'll feel then? Maybe they'll have troubling sleeping when they finally realize how cold-hearted they have been . . . Pam

Susan, I can feel your anguish, and I am so sorry you are in this situation. When my dad was diagnosed with lung cancer, my first angry reaction was, "Well, what did you expect when you smoked for 65 years?" At one point, Dad sat on the side of his hospital bed, looked forlornly at us and said, "I guess I killed myself, didn't I?" Broke our hearts. I quickly learned that lung cancer is enough to fight all by itself without adding regret, recriminations and blame. As lung cancer spread through Dad's body, it no longer mattered what caused it. All that mattered was the fight for more time. Your mother is most likely beating herself up right now, as well as dealing with almost overwhelming fear. Fear of pain, fear of sickness, fear of the treatment, fear of the unknown, fear of death. I'm sure you already recognize that your anger isn't about blaming her. It's the helpless anger of watching your mother go through something terrible and not being able to stop it. It's fear. From someone who lost a parent to lung cancer recently, focus on loving each other and finding something to enjoy every day with the hope that those days become years. My best to you and your mother. Pam

Joni, I ache for you. I haven't been where you are, but I have been through a time when my whole world disintegrated overnight. The phrase that best described it was "the dark night of the soul." I remember the pain that blotted out everything else. I remember mornings lying in bed and thinking, "How in the world am I going to find the strength to stand up?" When I finally talked myself into standing up, I felt overwhelmed by the idea of taking a shower and dressing. I had to talk to myself each step just to do basic things. Nothing came effortlessless, nothing. Be assured that you are doing all the right things. Your life will get better. Unfortunately, sometimes in life you have to do what you are doing -- just keep moving and endure the unendurable. Nothing helps much, and nothing makes it go away. You have times -- sometimes only brief moments -- when there is relief, then the pain comes back. But day by day, step by step, you will get through this. You will laugh easily again. You will feel contentment again. You will sing along with the radio again. You will look forward to things again. I'm so sorry you have to go through this. Pam

Don, Reading your posts reminded me of my youngest brother's grief when our mother died in 1993. He was a successful attorney, but after Mom died he quit his job and was unemployed by choice for almost 3 years. He had frequent, vivid dreams of Mom and reached the place where distinguishing dream from memory from reality became difficult for him. In our case, Mom died suddenly of heart failure. My brother had been the one helping Mom with doctor's appointments and decisions about treatment for her heart problems. He spent months reliving every decision, every conversation. He was sure that if he had done things differently, Mom would have lived. He felt like he had "betrayed" Mom by not doing more. Of course, none of that was true. He was an attentive, loving, conscientious son, and Mom adored him. Mom's heart was diseased, and nothing was going to save her. Nothing was going to make her okay. It took my brother years to come to terms with that. I believe that my brother focused on "what ifs" and "if onlys" and the guilt because that made him feel like he was doing something, figuring something out. That was easier for him than dealing with the gaping hole in his heart, the crushing grief of knowing that Mom was gone, and the sense of loss that overwhelmed him. My brother tried counseling and anti-depressants, and that helped some. Ultimately, I think he had to go through his own grief journey to be able to incorporate the loss into his life and continue to function. Don, one thing I beg of you: If at any point you feel hopeless or have any thoughts of "joining Mom" or "what's the use" or "life isn't worth it", etc., GET HELP!! Don't wait, and don't give in. The darkness of depression can fool you, and you can't let it suck you in. I believe that somewhere your mother is watching you, and sending her love, support, and comfort. As a mother, I can guarantee you that SHE WANTS YOU TO GO ON AND BE HAPPY. Stay with us. You'll get through this and life will be good again. Someday you will think of your mother and feel only love, tenderness, gratitude and joy. Pam

Joni, Just wanted to say that Alex is also lucky to have you as a mother. I know you didn't get a choice about being where you are right now, but you did get to choose HOW to go through it. I read every post from you because you inspire me. After I read what you write, many times I will call my husband to tell him that I love him. Or I'll send an e-mail to my son or daughter to ask what's happening in their lives. Or I'll spend extra time with my granddaughter playing and hugging her. It may not mean a lot to you, given the horrific heartache you're suffering, but you've made a difference in my life. Thank you. Pam

I can see both sides of this issue, I think. Anger is normal and unavoidable. Taking it out on someone is also normal. What I saw was an attack that goes beyond just "a bad day" or a hurt person lashing out from their pain. It was mean-spirited and very, very hurtful. I don't think that kind of behavior is acceptable, especially when it's directed at another lung cancer survivor who's suffering. Jack, I admire your attitude, and I admire your heart. Maybe there is a balance between "ganging up" on someone who's lashed out in anger and just letting it go. Since you are a kind-hearted, compassionate person who deeply loves a lung cancer survivor, I would honestly appreciate hearing how you believe the situation with BoBennett should have been handled. Let's say that he attacked Cheryl in the same way he attacked Snowflake and you were given the sole responsibility of responding to him, what would you have said? Or would you have said anything? Please, I'm being real here. I want to learn from your perspective and compassion. If you're rather reply by PM, that's great, too. Thanks. Pam

I know what you're feeling. I live 1,000 miles from where Dad lived. Thank goodness I had understanding employers, a supportive husband, and finances that allowed me to make one trip a month and spend several days. Dad was being cared for very well by a wife who loved him, but I wanted to be there as much for me as for him. I was there for diagnosis and for all the major medical events, and I will always be grateful for that. I don't feel guilty about not being there every day because I know Dad was okay with it. He understood, knew he was loved, and didn't feel abandoned. It's hard to explain, but I feel like I missed something precious by not being a part of the day-to-day care, by not being there when he died. The worst part was when he reached the point where he couldn't speak clearly and his hearing was almost gone, so telephone wasn't even a way to reach him. I kept telling my stepmother to let Dad know that even though we weren't there, we weren't just going on like it wasn't happening. He was in my heart and thoughts all day every day. Minnie, I know you're struggling with your situation. I hesitate to say anything because it's certainly none of my business, but if you have a viable option of being with your mother, you might want to seriously consider that. It was not an option for me because of children and commitments, and I have many, many regrets -- or maybe more like longings for things I wished I'd been able to share with Dad. Listen to your heart, and you'll know the answer. Don't be motivated by guilt or what someone else thinks or says. Do what is right for you -- either staying or going. But don't ignore the urgings of your heart either way. Unfortunately, you don't get "do-overs." It will be important later that you are at peace with your choice. Curtis wrote once that after Becky died he realized that his life was less stressful but that he missed being in the "fight." Now I know what he meant. For 8 months every day was committed to researching, praying, trying to make sure everything was being done right, trying to find ways to help Dad. My first day back at work after Dad died, I had the feeling I was forgetting something. I kept checking to make sure I had my purse, car keys, lunch, and then I realized that I wasn't carrying Dad anymore. I wasn't carrying the burden of lung cancer anymore. It hurt. Sorry for rambling. Hope I didn't say anything wrong. Pam

I understand exactly what you mean. My mother died 11 years ago. After Dad died last month, we started going through accumulated junk, and I came across old clothes of Mom's that Dad had stored for some reason. I felt an intense wave of emotion and just stood still for awhile enjoying memory flashes of Mom wearing that blouse. I could hear her laugh, I could feel her hug, I could smell her unique smell. I closed my eyes and it felt like she was standing right next to me. Although there were tears running down my face, I felt joy at that connection to Mom. Still miss her intensely. Still love her with all my heart. Still carry her with me every day. Enjoy those bittersweet moments. As Curtis said, soon those moments and that comb will be a wonderful touchstone for you. Pam

First, thanks for caring. If you've got THAT, everything else can be worked out. When my Dad was told his diagnosis, all 4 of his children were there. The statistics of "6 months to a year" were quite a blow. My Dad was 77, and we all had the strong impression that the oncologist felt Dad's situation was hopeless. He basically dropped the bomb, said he was sorry, asked if Dad had questions, then walked out when Dad said he didn't. He virtually ignored all of us. Throughout Dad's treatment, we had doctors repeatedly emphasize that "it doesn't matter what we do, nothing will change the outcome." When Dad had a lung infection, we had one doctor actually ask why we were fighting so hard to keep Dad alive since "even if he gets better now, he's going to die from the lung cancer anyway." We kept having to repeat that we were fully informed about lung cancer(after extensive research), and we fully understood Dad's situation. We weren't in denial and we weren't looking for a cure. We couldn't make them understand that for Dad it wasn't about the eventual "outcome." It was about grabbing quality time for him -- every hour, every day, every week, every month we could. The essence of life isn't in the years, it's in the hours that make the days that make the weeks that make the months that make the years. You start with the preciousness of every hour. Dad sensed early on that the doctors didn't have any hope for him. After the initial diagnosis, Dad wouldn't ask questions, didn't listen when the doctors tried to explain a procedure, and basically closed out any discussion of the disease. His children, however, wanted to know everything, and we took over. As you can see from the responses to this thread, there are no rules that fit each situation. We had only one doctor spend time with Dad to ask his goals for possible treatment. She was very compassionate, and she explained that his goals made a difference in the type of treatment. Dad told her that he just wanted to feel as well as he could for whatever time he had left so that he could enjoy one more fishing trip. I'm crying as I'm writing this because he never got that fishing trip, primarily because the other doctors working with Dad never understood, never understood, never understood. They just plugged him into their little "do this for Stage IV NSCLC with brain mets" program, and prescribed away. If it kills him, so what? He's going to die anyway. My opinion? The best thing you do for any patient and family is listen. Listen with your ears and your heart. Listen to the silences. Look into the patient's eyes and see, really see, that person. Pay attention to what questions are asked, and what questions are avoided. Connect. Ignore the statistical "eventual outcome," and believe in the value of one more day. If you don't have time for that, your schedule is too full. Quantity of patients seen each day isn't nearly as important as the quality of time spent with each patient. You are in a wonderful, beautiful, horrifying, terrible situation. Every day you deal with people who are enduring perhaps the worst thing that has ever happened to them. Because it is an incredibly emotional and vulnerable situation, you will likely have a significant impact -- positive or negative -- on each and every person you see. You can't go wrong by allowing yourself to truly care about each one. Good luck, and God Bless! Pam

I only know about Texas because that's where Dad was treated. In Texas it is a law that a patient is allowed to receive ALL medical records, including the doctors' notes. They are allowed to charge minimal fees for copying, etc., but most of the ones we dealt with didn't charge. One thing we learned is that doctors' notes are permanent and cannot be deleted from the record. You have to go to the doctor and convince them to add an additional note correcting the previous note. That can be difficult, given the egos of some of the doctors. At two different hospitals we had conflicts between doctors in Dad's permanent medical record, which caused problems when those records were forwarded to the rehab hospital and to hospice. At M. D. Anderson we had a conflict between a palliative care doctor and a neuro-oncologist. You would think that a palliative care doctor would yield to the superior education and experience of a neuro-oncologist when discussing a brain lesion, but the palliative care doctor was a real jerk (I chose a nice word instead of the one I wanted to use). My brothers and I have been thinking about putting together a booklet for newly-diagnosed cancer patients and family members. It's such a confusing and emotional time right after diagnosis, and there is so much to learn. We learned too much AFTER it was too late to prevent problems. That's why I think this forum is so wonderful. It's a place where you can learn from others' experiences. The issue of medical records wasn't something I even considered at diagnosis, yet it became crucial as we progressed. Our situation may have been different from others because Dad was from a very small town, so he was diagnosed at one hospital, had a second opinion at another hospital, and was treated by a totally different (very small) cancer treatment center. Then when we hit a roadblock with the cancer treatment center, he was also treated at M. D. Anderson, a totally different hospital. Pam

Amen! This is VERY important. We found things in Dad's medical reports that caused us problems with Medicare, etc., and were able to get additional notes to correct. Pam

This is a very interesting thread to me. My brothers and I learned the hard way about being an advocate for our father. We went into this thing believing that the doctors and nurses would do their best, that we should trust their knowledge and experience. We ended this experience disillusioned and more than a little bitter about it. In fact, at my Dad's funeral, my oldest brother gave a "blessing" to the health care professionals who helped Dad get to where he was. It was a very angry rant that pretty much stunned everyone there, but certainly gave food for thought. My question is the one I had all along. How do you forcefully, assertively stand up for your loved one without alienating the healthcare workers? I was always worried that if we ticked off the doctors and nurses caring for Dad that they wouldn't fight as hard for him when he needed them. We noticed that their "favorite" patients at the hospital were attended to first. Do you need to maintain that kind of "kiss their butts" perspective or is it better to let them know that you're not taking their crap? Pam

Tammy, I'm sorry. That's all I can think to say. I'm so very sorry. Pam

Denise, I hope it doesn't sound strange, but you were truly blessed to have had that last week with your mother. The way she prepared for the end was a gift of love that will comfort you in the weeks and months of grief you're now facing. Thanks for sharing the experience. Your mom must have been a very special and loving woman, and I'm sorry she had to leave you. Pam

It's been almost two weeks since Dad died. Right after he died, I had to "take care of business", help with planning the funeral, get my kids to Texas, go through Dad's things, etc., etc. We were getting on the plane to come home that Sunday night, and my 3-year-old granddaughter started throwing up. Her symptoms were bad enough that we decided to take her to the emergency room. Within a couple of hours she was already dehydrated, running a temperature of 102, and not responsive when we talked to her -- that quickly! Turns out she had a virus and a bladder infection. Anyway, I got back in town on Monday, worked 12-hour days to catch up at work, left for a trade show on Thursday, worked long hours all weekend and finally got back late Sunday night. So now life is returning to "normal" and the grief is starting to rise to the surface. It's so odd to me that everyone around me -- family, friends, co-workers -- assume I'll just shrug this off and go on like it didn't happen. On the outside, that's what I'm doing. No one knows that I am hurting inside. Sometimes I have a smile on my face, talking business or sharing pleasantries, and I want to scream, "MY DAD DIED. IT HURTS! HOW CAN YOU EXPECT ME TO ACT LIKE NOTHING HAPPENED?!?" But I just keep smiling and taking care of business. Tomorrow is Dad's birthday. He would have been 78. I remember looking into his puppy-dog brown eyes for the last time, telling him that I love him and that I'd be back to see him on his birthday. No one here understands, but I know you guys do, so I'll tell you. My dad died. It hurts. It hurts a lot. Life goes on, and I'll go on, but I'm going on with a broken heart. Pam