This past Wednesday, I got up at 4 a.m., as usual, to meditate, see to Hammett’s needs, stretch, and have breakfast. I took the city bus to the palliative care team meeting and got a ride afterward to campus from my hospice friend who usually goes to that meeting. Back at work, I realized I didn’t have my hat. I walked to the administrative building to get the key to Jodie’s office; I had stopped to see her upon returning to campus and thought I might have left my hat there. I walked back to the building where her office is to see if my hat was in her office. It wasn’t. I walked back to the administrative building to return the key and got on the shuttle to go to the other campus.
I went to the weekly farmers’ market and to Publico to get a fish taco, with the sun blazing down on my bare face, before going into the hospital. Inside the hospital, I went to the cafeteria to eat my fish taco. I spied a couple of my peers sitting outside on the patio and went out to offer them blessings for their hands; it was Blessing of the Hands week. I went up to the student office and hung out until a didactic on the “use of self” started. After that, three peers each spent 20 minutes apiece offering wisdom: on a specific aspect of the Kabbalah, on the Jizo ceremony for dead children, and on the “Rule of Life.”
I waited for the shuttle after work for about 45 minutes, in a long, long line, and after I got on, found we were stuck in an impenetrable traffic jam. It ended up taking an hour and a half to get home; I could have walked there in an hour. Then it was time to see to more of Hammett’s needs, water my neighbor’s plants, check my email, make my to-do list for work for the next day and fall into bed, where I fell asleep right away, but then woke up 30 minutes later and lay awake for hours. This happened several nights in a row. I finally fell asleep, but after I got up to go to the bathroom, I again lay awake for a long time. And that is the story of one day in CPE.
The palliative care team meeting that day was very interesting. We ran out of dead patients to talk about, and discussed informational interviews with potential hospice patients: Giving information versus pushing hospice services. It’s hard to get people interested in hospice when two or three other services (e.g., surgery or oncology) are saying, “We can do such-and-such for you.” It’s even worse when providers say, “You can either do nothing or have treatment.” Given that choice, who would not choose treatment? Sometimes people speak of “withdrawing care,” which is a terrible phrase. We never withdraw care as such; we transition from curative care to hospice care or comfort care.
In telling people about hospice services, we might do better to say, “Let’s optimize the possibility you are going to get stronger. These are the services hospice can provide.” Also, hospice is not a one-way street; you can do a trial period. People are eligible for hospice when their life expectancy is judged to be six months or less, but most people go to hospice so late that they die a week or two after going “on service,” and so of course people associate hospice with immediate death. It’s not supposed to be what you do for a few days before you die. It’s supposed to afford up to six months of being able to do what is most meaningful and enjoyable to you at the end of your life, as possible, without having to spend time on treatment that is no longer helping, takes up however much time, costs however much money, and potentially causes suffering and makes it impossible for you to speak with your loved ones.
It was mentioned that, at our medical center, attending physicians feel uncomfortable with fellows having conversations about end of life choices without oversight. The only current requirement is that a person with metastatic cancer be asked if he or she has a durable power of attorney, which is a pretty low bar. I also learned that “case finding” is not appreciated—other doctors don’t enjoy hearing that their patients have turned up on a list of possible palliative care patients.
As mentioned, it was Blessing of the Hands week this past week. We were invited to write and submit a verse to be used for the blessing, and the verse that was chosen was lovely. (I did not submit one.) It was also very easy to memorize, so I did that, and then I went around my unit offering this brief ritual of good wishes to care team members. I would invite each person to rest his or her hands on mine, and I would speak the words of blessing, and finish by saying, “Thank you for your important work.” People seemed to really like this. We each signed up for areas in the hospital outside our actual patient units, like radiation oncology or administrative areas. In addition, I offered blessings to random people who crossed my path: a cashier in the cafeteria (who said this made her day), a couple of construction workers, several housekeepers, two young volunteers, and four of my peers. Near the operating rooms, someone at the front desk announced it over the P.A. system, and 14 people lined up to have their hands blessed. One person said afterward that it made her hands tingle; she was smiling.