Sunday, March 26, 2017

Empty Chair

I have lately read two books. One was Dying Well: Peace and Possibilities at the End of Life, by Ira Byock, M.D. He says that reconciliation tasks include saying to someone, “Please forgive me, I forgive you, thank you, I love you, goodbye.” He says that if we aren’t able to be with someone in person to say these things, we can sit (or lie) opposite an empty chair and pretend the person is seated there and that we are addressing him or her directly. The idea is to complete relationships as best we can and free our minds of worries or resentments.

He says that a common fear near end of life is of being in pain, but he says that pain (and shortness of breath, which can be very frightening) can always be alleviated.

Something I learned that I was not aware of at all was that starvation and infection are relatively peaceful ways to die. When someone is dying, eating can become a burden. It can be a relief not to have to eat and not to have to digest and eliminate what is eaten, but for his or her loved ones, this can appear cruel: “She’s not going to die of starvation, is she?!” To this, Dr. Byock might mentally reply, “What would you prefer she die of?” That is, the person is going to die of something, and, as he mentions a handful of times, there are ways to die that are much less pleasant than starvation or infection, so it is perfectly reasonable for a dying person to choose to stop eating or to decide not to take antibiotics to treat an infection.

The other book I have just finished is Being with Dying: Cultivating Fearlessness and Compassion in the Presence of Death, by Joan Halifax, which I also really liked.

She writes about “giving no fear”—behaving in such a way that others don’t have to be afraid of us, and facing our own difficulties so that we ourselves are less afraid and have less fear with which to infect others. She writes about two Zen images related to giving no fear: the iron man, who demonstrates resoluteness, resilience and durability, and the wooden puppet, who compassionately responds to the needs around her automatically and instinctively. Halifax’s shorthand for the two together is “strong back, soft front,” and she writes that both the iron man and the wooden puppet can practice what she calls “radical optimism,” because they are free of expectations about what the outcome should be.

At the end of each chapter, she offers a meditation. One I particularly liked is called “Contemplating Our Priorities.” She asks the reader to imagine herself as an old person on her deathbed and asks several questions, including, “What goals would you like to have achieved by this stage of your life?” and “What do you want your life to be like when you are an old person?” Next she asks the reader to imagine herself as ten years older and on her deathbed, then five years older and dying. What if the reader will die in one year? “What can you do at this moment to support your peaceful death?” What if death is a month away, next week, tonight? 


I found this contemplation so powerful that I rushed into my closet, unearthed my old stereo receiver (a gift from my father 35 years ago) and my stereo speakers, and placed an ad on Craigslist to give them away free. In a couple of hours, they were gone. I’ve meant to do this for about two years. With death looming, there was no more time to waste! Seriously, I do plan to return to this contemplation and go through it in detail, to see what other changes I might need to make right now.

Floppy

A couple of weekends ago, I had lunch at Au Coquelet with Ann and Tom and then we went to Berkeley Rep to see Hand of God, which we all loved. Raucous and mesmerizing. It was a brilliantly sunny afternoon and I had some time to pass before going to the monthly potluck at Thomas House, so before heading home, Tom and I sat outside a café in Berkeley, reading and having refreshments. The potluck was nice, as always.

A few days later, I was on call at the other campus and visited a baby who has been in the hospital her entire life and whose parents come to the hospital to see her very rarely. She had a mask over her whole face, so it was hard to see her features, but I was instantly charmed by the loose, almost floppy way she moved her arms and legs. I put my hand near her and at first, every time her hand bumped into mine, she moved her hand away, but after a while, she allowed her hand to rest on mine, which made me cry.

We had a didactic earlier that day on narrative spiritual assessment, which appealed to me right away. In this assessment model, you just talk to the patient and try to get a sense of the four Cs: crisis, connection, “care gate,” and care plan. We learned that there are five types of crises:

—Disruption. The person’s normal life pattern is disrupted / stopped / slowed down. Hospitalization itself is a disruption.
—Discomfort. Acute and/or chronic pain.
—Disfigurement. Loss or anticipated loss of body image.
—Disability. Diminished capabilities or potential loss of independence.
—Death concerns for oneself or a loved one.

Connection has to do with support system and spiritual or other resources. Is person connected, unconnected (never had spiritual resources), or disconnected (used to have resources but doesn’t now)? If the latter, what happened?

The “care gate” is our potential opportunity to assist, which may become obvious once we learn more about what the crisis is and what types of resources the person has or lacks. The care plan might include prayer or meditation, presence, scripture or sacred writings, counseling, listening, or sacraments, rites or rituals.

I subsequently read an excellent article by James Michael Lewis called “Pastoral Assessment in Hospital Ministry: A Conversational Approach.” He says a good assessment model provides practical information, doesn’t interfere with conversation, and can be used when there will be only a single visit with the patient. My favorite two sentences: “A plan … is not always a document projecting future actions. It is simply what the chaplain intentionally chooses to do.”

My new interpersonal relations group has met twice so far. At our first meeting, we shared our fears in regard to being in this group with each other, and so were off to a roaring start. After our second meeting, Anita, our supervisor, sent us a note that started, “You all brought it!”

Somewhere along in there, I went to a noontime presentation on the “second victim”—how caregivers can be affected by adverse patient outcomes. The presenter came from a hospital in Missouri. At the end of her talk, she mentioned two harrowing incidents from our own hospital, both of which I had responded to as a chaplain.

At the end, I discovered that Delia was there. I mentioned to her that I had responded to both incidents and she said vaguely, “Yes, we can really be affected by our work.” I was expecting more of a “Wow, really?” and went away counseling myself that Delia is not my mother or my therapist, and that I should avoid burdening her with undue requests for attention.

We are all now doing our mid-year consultations, to which we invite a peer, one of our supervisors, a member of our professional advisory group, and a mentor of our own, which could be a member of our sangha or congregation. Flatteringly, I was invited to be the peer participant for two of my fellow students and have attended one so far. It was a wonderful experience, mainly because I heard great things from the professional advisory group member and the person’s own mentor, both of whom were Buddhist.

One said we can ask ourselves, “What risk do I need to take to cease the doing [as opposed to being]? What is the place of rest in this situation?” She went on to say that the role of the chaplain is subversive: to remain present and not to be swept away—not to be tied to doing. “Do I really need to do something? How can I be of this situation?”

The week after we saw Hand of God, Tom and Ann and I returned to Berkeley for another tasty lunch at Au Coquelet and to see Roe, about Roe v. Wade, which was also excellent.

Self-Portraits


(Click photos to enlarge.)

Saturday, March 11, 2017

Overfunctioning

Thursday afternoon I went to interview with Delia, Jodie (my supervisor from Unit One), and a doctor and a social worker from the palliative care service. We talked for about 25 minutes. When I left, Delia gave me a warm hug. Later Jodie saw me and Monica and said, smiling, that we could both expect good news. The next morning we got an email of congratulations which said I will be the palliative care chaplain intern in Unit Three and Monica will do it in Unit Four. We had discussed between ourselves which units we preferred, and this is what we wanted. I like the idea of doing this right away, because then I can use what I learn in my final unit, and also because I’m impatient.

Jodie said we are probably going to like the pace, since the palliative care service has 20 patients or fewer total. And they stay for days or weeks, so I will get a break of a couple of months from the sense of a torrent of patients constantly rushing toward and past me. Properly, I should start this next Monday, but Delia is away the week after that, so I’m going to start on March 27. I wish I didn’t have to miss the two weeks, but it’s not the end of the world.

I’ve had extremely good luck when it comes to getting a full night of sleep while on call, but Thursday night was horrible. I was paged four different times between midnight and 5 a.m., one of which was a Code Blue, and then there were two more Code Blues the next morning, about 7:30 and 9:00. One patient—at 3:47 a.m., if I may mention it—wanted to discuss an annoying symptom she’s having. But she was a very dear person, so I wasn’t mad at her.

I think a lot of people don’t realize that we work a 24-hour shift when we’re on call. They probably assume that we have day shifts and night shifts just like they do. We can gently educate people one-on-one as the occasion arises, but staff members come and go constantly, and we don’t want to do mass emails on the subject, since we do want people to use spiritual care services.

So that was a horrible night in terms of sleep. Fortunately, Friday was pretty quiet. I went to see my friend from the soup kitchen, who finally had been released from the ICU and was that day on a neurological unit. I had decided that morning that I was clearly overfunctioning in regard to her, and I sent Sam, who is the chaplain for the neurological unit, a note saying that maybe I would just visit a couple of times a week and otherwise leave her in his capable hands.

As it turned out, she was sent to rehab today, or at least that was the plan. I was there when the nurse told her that only one place had accepted her. She is often belligerent and stubborn, and when she heard which hospital she’d be going to for rehab, she said, “Oh, no. Definitely not. They tried to kill me there!” I told her that if she wants to be independent and autonomous again, going to rehab is a crucial step, and this was her one option. I hope and trust that someone was able to talk her into being transported over there today.

She clearly didn’t understand that this meant she wouldn’t be seeing me again—schlepping over to another hospital to see her when I rarely even have time to have a burrito with a friend would definitely be overfunctioning—and I didn’t have the heart to state it baldly, though it’s likely she would have forgotten it right away, anyway. I told her I’ll call the other hospital in a few days to see how she’s doing. I hope she’ll be all right. She was a difficult person to get along with even before receiving a serious brain injury.

This morning I got up after a refreshing 11 hours and 10 minutes of sleep. It was a beautiful summery day here, well deserved after an astronomical amount of rain and weeks of unseasonably chilly weather. I went to Sam’s ordination as a Zen priest at the Hartford Street Zen Center. A whole bunch of his friends showed up, and the ceremony was very nice
long but leavened by the abbot’s droll sense of humor. It was moving to see Sam in his robes. 

I introduced myself to about 20 people, one of whom turned out to be a palliative care doctor at the Truly Wonderful Medical Center, so I will probably encounter her at work one of these days. Two of my fellow students were there, two of our supervisors, a staff chaplain, and one of our admins, with her partner. My friend Karen was also there, and afterward she and I took a walk, went to a couple of Tibetan shops in the Castro, and had lunch at a Chinese place on 18th St.

Thursday, March 09, 2017

Obvious Slacker

At the morning meeting on Monday, one of our supervisors announced that only two people had passed the palliative care test and would be offered interviews: Monica and myself. Since there are two slots and two candidates, this seems promising. (The interview is later today. I am on call, so I get to go in late, just in time for the interview.) Another person who had taken the test was in the room, so both Monica and I received the news in a low-key manner, to avoid rubbing salt in his wounds.

After the meeting, one of my peers said, “I can’t tell if you’re happy about this news or not.” I told her that of course I’m not like, “Spending all day every day with people with life-limiting illnesses! That sounds great!” But I did really enjoy being a hospice volunteer. Also, the palliative care chaplain, Delia, has given us several presentations on palliative care, and more than once, she has smiled a mysterious half-smile and said, “It’s really great to work in palliative care.” I would like to find out why.
 

Also, several weeks ago, I was visiting a palliative care patient just 29 years old (on the weekend, when Delia and our per diem palliative care chaplain are not around) and realized I had no idea what to say to him. I felt completely confounded as to how to proceed, and then it suddenly came to me: this is my work.

Shortly after the Monday morning meeting, I saw an email from the manager of the spiritual care department saying that I and the chaplain who took over when my shift ended both had done a great job at the other campus the day before and that one of the directors of that hospital had mentioned both of us by name. Our own debriefing session was scheduled for Tuesday morning, and Jodie suggested it would be good for me to attend for my own sake and she also thought it would be educational. She said it would be something I could take forward into my chaplaincy.

I said I would like to do that, but I had also been invited to give a campus tour on Tuesday morning to our new intern and new supervisor in training, and I was really looking forward to doing that. Jodie said they would push the tour back so that I could do both! Gifts seemed to be raining down on me from all directions.
 

I see Delia (of course not her real name) now and then in the hospital, but not very often, being as my units are ortho/spine—few end-of-life situations. My colleagues who are assigned to ICUs see much more of her. I greet her with a sunny smile whenever I encounter her, but had no idea if she knew who I was. That very day, I entered an elevator to find her there and said hello, and she smiled at me and said something that made it clear she does know who I am.

On Tuesday morning, I reported to the other campus to go to the debriefing session, which was attended by even more people: 40 in the room, and nearly 10 on the phone. It was interesting to see how Sarah, the manager of spiritual care, facilitated the meeting. I took the hospital shuttle back to my own campus afterward and led the aforementioned tour. The new supervisor in training is a very sweet fellow, and I also really like our new peer, Jake, who radiates joy and enthusiasm. Several of us had lunch with our two new people in the cafeteria.

That afternoon, I visited a guy who tried various arguments to get me to go buy him a bottle of scotch, including mentioning a chaplain he knew when he was in the marines who kept a bottle for his own enjoyment and that of his visitors. “Now, that was a good chaplain,” said the patient. When I finally said point blank that I was not going to do this, he said witheringly, “Yeah—I could tell from the moment you walked in that you’re the kind of person who does just the minimum.”

Tiny, Perfect, Alive Baby

I woke up Sunday morning feeling wonderfully refreshed, even though my cell phone alarm hadn’t gone off yet. I felt so awake that I considered getting out of bed early, and then there was another Code Blue, which ended my deliberations. When I looked at my phone to see what time it was, for the tally sheet we have to fill out, I saw that it was 9 a.m., hence the great feeling of refreshment. My phone’s battery had died in the night.

I don’t think I’ve had even one Code Blue during an on-call shift at this campus before, let alone two. This one occurred in labor and delivery and the subject was a woman younger than 35 who had been transferred from a hospital in Reno. I was sent to provide support to her husband, who appeared at least externally to be calm and also not at all inclined to talk to me, so I just sat quietly next to him. I strongly suspected that if I told him I could stay or go, he would tell me to go, so I didn’t give him the option, though if he had said of his own accord that he’d like to be alone, I would of course have gone.

From time to time, a doctor came with an update. We learned that the baby had been surgically delivered and, though premature, seemed to be doing well. After a while, the baby was transferred to the infant care nursery and we went to see her. She was beautiful. Tiny but perfect. The nurses said that she was a good size for her age.

Then we were called back to labor and delivery and shown into an empty patient room, a bad sign; we had been sitting in the hallway earlier. The news got worse and worse, and then one doctor said they were running out of options because there were two things wrong with the mother, and treating one exacerbated the other. The father became visibly very dismayed, and then the doctors providing the update suddenly ran out of the room.

After a few minutes, a doctor came back in and told the father that his wife had passed away. Three of us sat with him, all touching him. One doctor, in reaching for the father’s knee, rested her arm on my knee, so I put my hand on her back, and the four of us just sat there, one joined physical unit, three of us silent, one crying and shaking.

After awhile, the father was taken to see his wife. I followed him into the operating room, which was in tremendous disarray, smelling of blood and with blood everywhere, including on the shoes of several members of the care team, several of whom were in tears. When the father left the room, so did all but three care team members, including myself. I offered a brief prayer for the now-gone mother.

In the hallway, there were two groups of eight or ten nurses apiece, visibly upset. The spiritual care department offers a debriefing session after Code Blues, and I also got a call right then saying the nurses planned to do a debriefing of their own at the end of their shift that day, and wanted a chaplain to attend. That occurred after my shift was over, but I learned the next day that 40 staff members had attended.

Malevolent Co-Worker Wishes Chaplain a Peaceful On-Call Shift

I arrived last Saturday at the other campus for an on-call shift, my first in three weeks. The departing chaplain was Monica, the person in my group in the first half of the year with whom I had the most difficulties. (We are in different groups now.) I arrived quite early and told her she should feel free to run along, but she ended up staying until the end of her shift and we had a good talk.

Later she sent me a nice email saying she had enjoyed our talk and thanking me for my honesty and willingness to discuss interpersonal issues. Before she left work, she wished me a peaceful on-call shift, and I considered saying, “Please say, ‘May your on-call be just what you need,’” but I decided just to accept her wish, which was a big mistake, if you’re superstitious in the way that I now definitely am.

I considered not doing rounds, since no one was there to see whether I did it or not—some of our supervisors expect us to do this; others don’t care—but then decided to do what I would do if someone were watching, and visited the nine units we’re supposed to visit. I was not requested to see any patient, and I got in bed at about 9:15.

An hour later, there was a Code Blue, so I got up and got dressed and made my way to the unit where an adult patient was being resuscitated. From my spot outside his door, I could see his bare leg and a beefy doctor forcefully doing CPR, which caused the patient to make a horrible noise with each compression. After a while, I could see the patient
s face and it occurred to me that he was not unlike my father in appearance: slender, with white hair and a neatly trimmed white beard.

I had felt quite exhausted ever since getting out of bed, and after I made the connection with my father, I had to sit down immediately. I wrote here previously about sometimes finding it extremely difficult to listen to a patient’s medical tale. This has not happened in the past couple of months, so maybe I have gotten past that difficulty and maybe what happened Saturday night was the next challenge. Fortunately, there was a chair nearby in the hallway, so I drifted over to it in a serene, chaplain-like manner and sat down as if I just happened to be sitting down rather than as if I were going to collapse if I didn’t. Every time I stood up, I felt extremely weak and shaky and had to sit down again.

Eventually, they transferred the patient to the ICU, and since his wife hadn’t come in, I decided to return to bed. As I walked back to the on-call room, I wondered where the adult ICU even is, and then I realized it is actually right next to the on-call room. It’s a sleepy unit that often has no patients at all, or maybe one or two, with a couple of nurses sitting quietly around. Quite a contrast from my own campus, where there are six ICUs with 16 beds apiece, usually with every bed occupied and numerous personnel undertaking considerable activity. Since it was right there, I stopped by the patient’s room. He was still being worked on, but by fewer people, and his wife still wasn’t there, so then I did go to bed.

Sun

(Click photo to enlarge.)

Saturday, March 04, 2017

Treasure Trove

On Tuesday, the famous cancer patient’s DPOA (durable power of attorney) was discussing her care with the doctors, one of whom estimated that the end could be three to five days away, so I was quite shocked when I saw Wednesday morning that she was gone. Such a short time ago, we were having long, delightful conversations, and she was utterly, fully alive.

That day, I went to see the woman from the soup kitchen, as I do every day. I arrived just as the social worker as leaving and found my friend worrying about her benefits and where she will live. Before I left, I encouraged her to rest and to focus on her body for now—to offer love and care to it, at which she rolled her eyes.

“Did you just roll your eyes at me?”

She nodded and smiled a smile of great satisfaction.

“OK, good. That tells me you’re feeling a little better.”

Her doctor told me he is hoping to get her out of the ICU and into another unit where she can start to do physical therapy. He said that every day she is in the ICU, she loses five percent of her body mass—I imagine this is true of anyone—and that her chances of leaving the ICU alive diminish.

That was also Ash Wednesday, when we got to go around “imposing” ashes on those who wished to receive them. When the woman at the front desk for the operating rooms saw the little container in my hand, she immediately made an announcement over the public address system and staff members lined up for this brief ritual. It was touching to see the trusting look in people’s eyes as I dipped my thumb in the ashes and made a cross on the person’s forehead, while saying, “Remember that you are dust, and to dust you shall return.” You can also say, “Turn toward God, and believe the Good News.”

One woman in the waiting room wanted ashes and also instructed her small grandson to approach me, but he looked terrified and backed away. “You don’t have to,” I assured him. “We have freedom of religion in this country.” In the course of the day, serving as an
extraordinary minister,” I offered ashes to 36 people, both patients and staff.

Imposing ashes was so satisfying that I briefly considering becoming a priest, but then I remembered that you don’t get to smear ashes on people every day even if you’re a priest, and also that ladies can’t be priests. On my way home, I saw someone on the bus with black stuff on her forehead and thought, “Ha! I know what that means.” I never would have even noticed it before, or if I had, I would have been mystified.

On Thursday, Anita pulled me aside to discuss a chart note I’d made about the woman from the soup kitchen. It was for the visit where she was fretting about her benefits, during which she’d insisted on writing down her social security number for me, even though I kept telling her I’m not a social worker and also that her SSN was already in her chart. But, lo and behold, the SSN in her chart was different, so I put the one she gave me in my chart note, which turns out to be prohibited because the charting system is insufficiently secure. Also, Anita thought my note sounded more like a social worker note than a chaplain note.

I felt a little defensive at first, but it all came out all right. Anita watched me delete the note, which made me feel like a five year old, but then I was instructed to put the note back, just minus the SSN, and the managers said it was not a question of being in trouble, just an educational thing, and that there was no need for me to apologize to the social worker, but that it would be good if I spoke with her in person to clarify about the SSN. I did that, and she asked me to send it to her in a secure email, so that information actually was welcome, just not in the charting system.

I asked about one other thing I’d put in the chart—was that OK? The manager of the spiritual care department thanked me for asking and told me how she would have handled that piece of information. I thanked her and said I would add that to my treasure trove of learning for the day. (Only to quote other members of the care team in my note if it pertains to spiritual care for the patient.)

I also did joint visits with a peer on Thursday because my supervisor, Anita, told her that I’m particularly good at reflecting back what I hear and that she should observe me in action. That was flattering. However, I thought my peer also did a great job in her visits. She created a very nice, relaxed, leisurely mood in the room, and I thought she did a perfectly fine job of reflecting what she was hearing. When I told her that, she said she had made a point of doing it because I was watching.

We had no classes or groups this week, just seeing patient after patient, so I tried to be relaxed and unhurried and reminded myself repeatedly to be present in just this moment. Nonetheless, I was exhausted at the end of every day, which reminded me that Sayadaw U Tejaniya says if you’re getting tired while being mindful, you’re doing something wrong. You’re using too much energy. Next week, I will see if I can make my attention lighter, more buoyant, less focused.

First Visitor

We found out last Monday who will be in what groups in Unit Three, and who the supervisors will be. My supervisor will be Anita, the same as in Unit Two. She was a co-supervisor of my group in Unit One, so I know her well and am happy she will be my supervisor, though either of the other two would have been fine, as well.

As for the group, alas, I have been separated from all four of the people I’ve been with since the program began in September. I particularly wanted to continue to be with Tony, but he is in another group. Also in my group is one of the young chaplains from the other campus, a woman from my own campus, my friend Sam and the new guy—the intern who is coming to take the place of our colleague who had to leave due to health issues. As the week wore on, I got more used to this idea and realized I’m looking forward to reading and learning from the verbatims of four new people. Also, Sam has an excellent sense of humor, which will be fun.

I went to the ICU on Monday to see the woman from the soup kitchen again. She smiled and seemed pleased to see me. She didn’t remember I had visited her on Friday. She said three times during our short chat, “You’re my first visitor.” I told her that I’d noticed in her chart that they had made contact with her father and brother—had they come to see her? She said no, then yes, then, “You’re my first visitor.” I told her if she can think of anyone from the soup kitchen she would want to come visit, I will let that person know where she is. Presumably this would not be a HIPAA violation, since it would be at the patient’s request. I assume that being homeless goes hand in hand with not having a robust network that quickly learns you’re in the hospital.

I am still hoping to get one of the palliative care slots. They had said that the five people who got the highest test scores would be interviewed. It sounds like only five people took the test, so I was thinking all of us would be interviewed, and that it didn’t matter that, from the sound of it, I may have gotten the highest score. Others have said they didn’t have as much time to study as they hoped, or that they didn’t read all the articles, or that they found the test challenging.

However, Jodie, one of our supervisors, told me she thinks a high score actually would be helpful, since it demonstrates mastery of the material, and then I found out that one of my colleagues had been told that his score was not high enough for him to continue in the process. Ouch. Also, they didn’t say anything about having to get a certain score. But, given that, and given that one of the people who took the test is going to move to the children’s hospital, my chances look increasingly good.

But if that doesn’t happen, I will continue in orthopedics and do my best to throw my heart and soul into that. I talked to a woman this past week who described a horrible experience she had while in the hospital: she woke up while intubated. I asked if I could sit down, and she ended up telling me an astonishing story about her ex-husband. Everyone in the hospital has something on her mind and a story to tell, whether she has had joint surgery or is dying of cancer.