Monday, January 01, 2018

A Dastardly Deed

One day I found that a wild animal had arrogantly knocked my little fan on the floor so that it could occupy the whole of the small bedside table, and thereupon was lolling—at that very moment—in a manner so casual as to border on the insulting.

Hmm, now that I look at these pictures in my own blog, I see that there is some paint missing from my swing-arm lamp. I have had that lamp for decades and it still works perfectly, whereas others I have bought more recently have all been unsatisfactory in one way or another. I will never part with that lamp!

(Click photos to enlarge.)

Tips for a Slimmer Silhouette

At County Hospital, we got a presentation on palliative and hospice care, at which we were told that most advance directives are too vague: “If I don’t have meaningful quality of life, let me die a natural death.” Better to say, “If I can’t ride my bicycle … ” or “If I can’t remember my own name … ” or “If I can’t eat … ” Whatever specifically constitutes quality of life.

We learned that hospice care is not usually done in the hospital because Medicare reimbursement for hospice is only $200 a day, whereas the cost of occupying a room at County Hospital and being cared for by a nurse is $8000 a day, and this is on a medical-surgical ward, not even in the ICU, and this is before factoring in any other care: examination by a physician, labwork, medicine, use of equipment.

Comfort care—palliative care at the very end of life—is often provided in a hospital (e.g., for an intubated patient in the ICU), but it can also be at home if the person has housing and 24-hour care, which can be from friends.

In mid-December I had lunch with Jonas. He talked about how he knows when compassion fatigue is sneaking up on him and how he handles it. He said that certain terrible memories will stay with us forever, but that most will fade, and that part of the trick is figuring out how to nudge memories to move along. As we discussed this, tears came to his eyes, and I imagined that he was remembering a certain patient of his own, perhaps a child, as he does palliative care and also works with children.

I spent a Saturday with my CPE peer Nellie in Oakland, and one Sunday, Ann, Tom, Jill and I saw Watch on the Rhine at Berkeley Rep (it was excellent), after lunch at Au Coquelet. Another day I went to visit the hospital where my chaplaincy mentor, Naima, works. She showed me around and then we chatted in her office. She said that since she usually just has one short visit with each patient, she tries to quickly assess what is causing them to suffer, using her own Buddhist understanding of what causes suffering. Once she figures out what they are pushing away, she tries to encourage them to let it in a little, or if they are clinging to something, she tries to see if there is a way they can let go. I wish I could be a fly on the wall for two or three such conversations. It would be interesting to see how she goes about this, especially in one brief visit.

It also caught my attention that she uses her own understanding of what causes suffering rather than finding out what the patient thinks is causing her suffering and what the patient’s own spiritual practice or religion or way of understanding life has to offer.

The day after visiting Naima, I attended the holiday party at my paying job, thirteen people, including our boss. I was seated across from a colleague who mentioned that he is of a certain religion that has such-and-such dietary restrictions. I asked if his wife is also of that religion and he said she is.

Our boss, who was seated at the head of the table and not next to me or my colleague, evidently had been listening carefully and said to me with a somewhat terrifying deadpan expression, “I’m curious why you asked that.” I felt like a five-year-old being scolded. I also felt a frisson of fear, and the impulse to defend myself, which I managed to resist for about 30 seconds. I could have just let her statement stand, but I succumbed to the urge to explain and said that it’s interesting to me when partners follow different diets, although, in retrospect, I’m not actually sure that’s why asked that. I guess I don’t actually know why.

Our boss reiterated that she always finds it interesting when someone asks a question like that, making it pretty clear that she thinks it’s terrible when someone asks a question like that, and then she turned to her neighbor and said, “I really think [whisper whisper whisper],” and her neighbor said, “Oh, yes. Me, too. [Whisper whisper whisper.]”

At the end of the party, which was otherwise pleasant, we took a group photo. There are two people in the group who are quite large. The boss said to one of them, “Turn sideways! Turning sideways makes you look slimmer.”

The next day, I got to wondering if it is indeed terrible to ask someone about his or her partner’s religion, even if that is directly the topic at hand, and so I texted my colleague to apologize, but he said he had not been at all offended. He also said that he’d felt uncomfortable when our boss was asking me about it, which makes two of us.

Drive-By Shooting

During a shift at County Hospital in December, I was in an elevator with two sheriffs, each of whom was stabbing repeatedly at the “close door” button on his side of the elevator. One turned and explained, “Drive-by shooting: we have to secure the car.” Walking toward the chaplain office, I saw a car parked outside with both doors flung open, and a bleeding young man being carried toward the emergency department on a stretcher.

In the chaplain office, I mentioned this to two other volunteers. One has been around for a while and instructed the other to go to the emergency department. (Which he did not do. He told me later that there’s no point—that the only people who are going to be near the patient for the first several hours are doctors and nurses.) I described the sheriffs’ behavior in the elevator but, as I took a breath to continue my anecdote, the senior volunteer said to me, “Enough. Enough.”

This was annoying: Who is she to tell me when to talk or not to talk? Aren’t we supposed to be able to debrief with each other? Maybe she was trying to finish up her charting or maybe she’d heard enough upsetting stuff for one day, which I can understand, but maybe there’s a politer way to say so. I went away fuming.

At my paying job, I encountered a patient who had very impulsively committed a horrendous act of self-injury. He was open and easy to talk to. I spent half an hour with him, hearing about how he came to do this unbelievably awful thing, about his spiritual beliefs, and his plans to move forward with his life.

Afterward, I could not rid my mind of images of the act itself, as I imagined it—it was the very first thing I thought of when I woke up the next morning—and recognized this as secondary trauma, but I wasn’t sure what to do about it. I know it is important to talk to someone, but whom?

As I walked home in the evening after having seen this patient, I found myself seeking out pleasurable sense experiences, things that seemed to affirm life: the beautiful green expanse of Dolores Park, the smell of evening settling over the shrubs, a charmingly appointed apartment lobby with an ornate daybed, lights strung in trees. It makes more and more sense why the arts are so much a part of chaplaincy. Poetry and music and dance and literature bring beauty, joy, healing, sometimes laughter. Here’s something I hadn’t expected: because people frequently bring patients flowers, and because they often end up at the nursing station, hospitals are full of flowers!

When I got home, I called my ex-CPE supervisor, Anita, and told her about my patient. She was suitably horrified and recalled that I had said it helps me to write about things that bother me, so maybe I would want to do that. She also said that she finds it helpful to use the “empty chair” technique to express herself. She said maybe I could sit opposite an empty chair and say why this patient’s story frightened me.

I hadn’t realized that it had frightened me, but once I thought about it, I concluded that fear must be at the root of what we strongly react to. At first I didn’t think I was afraid that I would take that kind of impulsive action against myself, but that possibly I feared one day getting into the state of emotional misery that preceded it: what if my happiness goes away and I can’t figure out how to get it back?

But later I could see more clearly that this patient had felt abandoned and unloved, as I have at times, and he turned his bad feelings on himself, as I have at times, so I think the fear was not due to encountering something unrecognizable but just the opposite: seeing that this patient was on a continuum I have personal experience of, so could that happen to me? In the end, it was an example of projection: assigning “irrevocable self-violence” to this other person, and then being horrified by it, as if it had nothing to do with me.

During dinner the evening after meeting this patient, I lit red candles. The last time these candles were lit, F. was here, so it had been at least 18 months. They afforded a beautiful, festive touch.

In Search of Mentors

After the trillion details involved with signing up for Obamacare and becoming a Kaiser Permanente patient, my first visit over there (early in December) was extremely smooth. My new doctor seems like a smart young snippersnapper and was easy to communicate with. Afterward, I went to Publico for a burrito and French fries.

That evening, Tom and I had dinner at an Indian restaurant with David and Lisa, who were visiting from Seattle. It was excellent to be with them, as always.

I had been thinking about asking the senior chaplain at my paying job, Jonas, to have lunch with me. To gain board certification, you have to submit, among other things, two verbatims that each use a different assessment model. I thought it would be interesting to ask Jonas what assessment models he uses, and made a note to call him.

This note joined many other little pieces of paper on my desk, the most readily visible aspect of my to-do list, but just the tip of the iceberg. Progress on everything that didn’t get done over the past 15 months
—well, now 19 monthshas been astonishingly slow. One day, my eye fell on that particular note, and I saw that it was 9:20 a.m., when Jonas might still be sitting at his desk, so I decided to carpe diem and picked up the phone.

Jonas said, “Bugwalk? That’s weird—I was just writing you an email, and I was checking the calendar to see when you’d be in next.” I have very little interaction with Jonas, so that was weird. He was there when I did my unit of CPE last summer, and once or twice sat down with me and offered very helpful advice. On the phone last month, he said we could certainly have lunch and we set a date.

The reason he was writing me an email was that he’d been surprised, and not necessarily pleasantly so, to see that I’d written in a chart note that a patient who was dying and who had lost a child to suicide did not have any spiritual needs. This suggested to Jonas that I had not read the chart notes from the palliative care team before seeing the patient, which indeed I had not.

I have a filter that shows any chaplain notes pertaining to a patient, and I do look at those, and I read at least the most recent chaplain chart note. While we were on the phone, Jonas suggested that I make a second filter, for notes from the palliative care service.

I told Jonas that I welcome his feedback—I wish to learn all I can—and that I take responsibility for my actions and that I don’t wish to blame anyone else or badmouth anyone, but I have been under the sway of our boss’s efficient workflow. However, Jonas said that is just for brief, “drive-by” visits, which was useful information; I don’t think I’ve ever heard our boss say that.

Jonas added that he can tell from perusing my chart notes that I learned a lot during my year of CPE (the case at hand notwithstanding, I guess). I appreciated his saying that, and also how tactfully he shared his concern. After we hung up, a wave of beginner’s mind swept over me. What am I trying to do as a chaplain? Why? How? And from whom will I learn, given that I’m mostly wandering around the hospital without oversight? I need to figure out how I can be mentored. With that in mind, I sent Delia, the palliative care chaplain at the Truly Wonderful Medical Center, a text asking if we can have lunch, and I also made a date to meet with Naima, my overall chaplaincy mentor.

I have a few books on my shelf that will likely be helpful, and I am going to reflect on what people seek from their spiritual practice or religion. What do I seek from mine? How does my religion meet those needs? If I were in the hospital, what kind of help might I need from a chaplain to make best use of my religion? A reminder here that a chaplain is a person who provides spiritual care or guidance for someone who is away from her usual source of spiritual care because she is away at college, or in prison, or in the military, or in the hospital, or in a hospice, or even at her corporate job; there are chaplains who serve corporate employees. On the radio the other day, I heard about a spiritual care provider who travels with a circus.

God Damn

(Click photo to enlarge.)