Sunday, December 03, 2017

Fire Circle

Early in November, nearly all of my clinical pastoral education cohort got together at the house in Berkeley where one of us lives. We brought food and ate and talked and, toward the end of the evening, sitting in the dark backyard around a fire, did a circle where each person got a chance to check in.

Another day, I got together with my CPE peer Nellie for lunch at Xolo in downtown Oakland followed by a trip to a store called Sagrada Sacred Arts, tea at Crepevine, and a visit to a bookstore. A couple of days later, I had lunch at Green Chile Kitchen with Mason, one of my two peers in my first unit of CPE in the summer of 2016. That was delightful.

My next day at work, I set out to have explicitly spiritual discussions. Early in each conversation, I said, “I want to know how I can support your spiritual well-being.” My first shift or two, I felt overwhelmed by the number of patients on my three units, but since these are all units where patients stay for a long time, and since Carolina and one of the CPE students also visit people in these units, and since a “spiritual” conversation takes a much shorter time than my normal kind of conversation, I’m now wondering if I’m going to run out of patients to see.

I’m finally starting to memorize some of the questions we use for taking a basic spiritual history, and I’ve gotten in the habit of checking the charts for an entire unit before picking out patients to see, in part to see if Carolina visited the person very recently. I also notice where the person lives: is he far from home? And marital status: is she married, single, widowed, divorced? This is just a snapshot, with much more to be learned, but someone who lives in San Francisco and is married is in a different situation from someone who is widowed and has come to the hospital from far away.

At County Hospital a couple days later, I continued to tinker with my approach. Mentioning the wish to support the patient’s spiritual well-being first thing seems to constrain the conversation a bit too much, so I started by asking how the patient was coping with his or her hospitalization, and then brought up spiritual well-being soon after that.

A couple of patients just ignored that question completely. One was screaming at the top of his lungs that someone had stolen his boots and that he wanted to leave the hospital immediately. After yelling for five minutes, he apologized quietly when the boots were discovered in the closet in his room. Another patient seemed taciturn and angry at first, upset because I wouldn’t go across the street to get him a soda; later he asked me for money. But then he started telling me all about his life and his relatives and was smiling when I left. A great thing about this work is that the gratification, or lack thereof, comes immediately.

At the hospital that day, I attended a session on dealing with difficult patients, part of a series that emphasizes the emotions of health care professionals. There were four presenters, including Clementine, who supervises us chaplains. Another was a trauma surgeon, who said his own inclination is never, ever to give up. However, he said he often has a frank talk with a patient where he claims he says, “I can do this, this and this, or I can withdraw support, and then you’re going to die.” I was wincing a bit at that. I learned in my first unit of CPE that we never “withdraw care” or “withdraw support.” We transition to a different type of care. And I hope he does not announce so baldly that the patient will die. Or am I wrong to hope that?

I pictured how I might conduct such a conversation: “I can do this, that and the other procedure. The recovery will be long and difficult, and I can’t guarantee how much function you’ll get back. This is for you to weigh out. These procedures will be hard on your body, there will be pain afterward, and the recovery period may be months. At that point, you may be able to do most of the things you enjoy, or you may not. However, it is your choice whether or not to have these treatments. It is perfectly reasonable to decide not to have them, in which case we would focus on making sure you are comfortable and free of pain. Your remaining life span would then be measured, probably, in weeks to months.”

While I was embedded with the palliative care team at the Truly Wonderful Medical Center, I noticed that they always referred to life expectancy in such terms: weeks to months, days to weeks, minutes to hours.

Yes, I think I don’t like the idea of anyone saying to someone, “Your other choice is that we can withdraw care, and then you’re going to die.” I hope he doesn’t literally say that.

Anyway, one reason I mention the presentation is that there was a second doctor there who said that it can be wrenching to care for patients in very difficult situations, including because there can be disagreements among care team members. However, he said, not caring is not a good alternative, because caring is what makes this work satisfying.
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