Saturday, August 18, 2018

End of Life Options

Earlier this year, a new person moved into my apartment building who demonstrated some behavior that I have judgments about: she told an outright lie in order to gain occupancy, which I think I mentioned here. I gave her a little lecture in my mind, and then quite a few more. I came to think of her as a bad person. She proved to be a major door slammer, and every time I heard her door slam—about eight times a day—my lack of charity grew. Months passed without my laying eyes on her, though her front door is close to mine. When the day finally came that I encountered her, I walked past her as if we were two strangers in the corridor of a downtown office building. It didn’t feel good, and I resolved that the next time I saw her, I would make eye contact and say hello.

More recently, I was entering the front door of our building, my bicycle panniers loaded with groceries. My neighbor came up behind me and said, in a very sweet voice, “I can hold the door for you.” She held the door, and I barely looked over my shoulder—I didn’t even see her face—and mumbled, “Thank you.”

Moments later, I felt heartsick. I had taken one fact about a person—she told a lie—and used it to make her into a non-person who could be treated accordingly. Thanks to studying the precepts for school, I was unable to stand the results of my own actions for more than 15 minutes, and went to knock on her door. She didn’t answer, so I sent her the email below. I reflected that while she took an action I deplore, I don’t know why she did that, and I still don’t know much else about her. It was a powerful reminder to be aware of what information I am taking in and what conclusions I am drawing, which may be entirely wrong, and also a reminder not to tell and retell myself judgmental stories about someone else. 

Dear [Neighbor],

Thank you for helping me with the door today.

I have not been friendly to you the time or two we have encountered each other—in fact, I have been rude, and I’m sorry. Please forgive me. You may rely on my being a better neighbor henceforth.

(I knocked on your door a couple of times today, as I would rather have spoken in person, but found you not home.)

As long as I’m writing, I would be appreciative if it would be possible for you to close your door a bit more gently when you go in and out. :-) Please let me know if there’s anything I’m doing that’s bugging you.


I got a really nice note back from her, in which she said she would try to do better with the door. For a few days, it actually did seem a little quieter, but soon she was back to her normal ways. It bothered me less, though, because I had at least said something.

At work, I made a second visit to a patient who is very sad and discouraged, not sure if he wants to be here. I’m trying to develop ways of allowing lots of silence without it seeming really odd. One question that has perplexed me: where do I rest my gaze during these moments? Staring into the patient’s eyes is obviously not good, and looking just past his or head seems nearly as bad. I can imagine the patient asking in the first case, “Why are you staring at me?” and in the latter, “What on earth are you looking at?”

With this patient, I chose a spot on the floor fairly close to the edge of his bed and pretended it was a TV that we were watching together. I took five leisurely breaths; out of the corner of my eye, I could see the patient look at me once or twice, probably wondering what was going on. After five breaths, I looked at him and half-smiled, letting him know I was still with him, and then I looked back at my spot and took five more breaths. During this time, I was conscious of my own discomfort and strong wish to break the silence by, if necessary, veering off into a social conversation. However, I made it to the end of the second five breaths without saying anything, and then the patient suddenly said something about a big decision he is trying to make, the first I’d heard of it.

This patient has the means of taking his own life available at home, which he mentioned several times during our first visit. Every time he said it, he looked at me with a fearful, semi-daring expression that I couldn’t quite interpret. Does he think suicide is terrible? Did he assume I think suicide is terrible? Did he think he was saying something extremely shocking? Was he afraid I would yell at him? 

He mentioned it again in our second visit. I mentally weighed my dislike of giving a lecture—really, imparting any information whatsoever that hasn’t been asked for—with the possible helpfulness of what I might say about this, and decided to offer my views, which are based in tenets of palliative care. I said, “I think that can be a reasonable choice in some situations. I think we want to make sure first that symptoms such as pain, anxiety or depression are being well addressed. It’s also important for people to know that they will be supported and cared for as time passes.” This seemed to make the patient relax a bit; he let out sort of a sigh. Many times, when a patient wishes to exercise his rights under the End of Life Options Act, it is because he has symptoms that are not being properly managed, or he fears that his needs will overwhelm others and he will end up being abandoned or not cared for. Most particularly, depression is correlated with patients wanting to end their own lives.

Saturday, August 04, 2018

Just Too Hard

At County Hospital, I started one day by holding a baby whose nurse said he was withdrawing from drugs, quite a handsome little fellow. After baby holding, I reported to the chaplain office, where Clementine asked if I would like to back up the palliative care chaplain while she was away for a month, which of course I said I would be happy to do. She immediately dispatched me to see one palliative care patient and to attend the family meeting of another. Until that day, I had been asked to see only one or two palliative care patients the whole time I’ve been volunteering there. I offered guided meditation for pain to the first patient; she said afterward that it had been helpful and relaxing.

The family meeting was 90 minutes long and involved the patient herself, three family members in the room, two on speakerphone, me, and two doctors. As at the Truly Wonderful Medical Center, I was very impressed with the leisureliness with which the doctors conducted this meeting, allowing time for everyone to say everything he or she wanted to say, no matter at what length and no matter how far off topic. The doctors were generously affirming of positive sentiments: “That is beautiful! Wonderful!”

I had been told before the meeting that the patient didn’t really want any more treatment, but that the family was insisting on it. The doctors let the relatives express all of their hopes for the patient’s recovery, and then one doctor very gently, in an almost offhand manner, said that doctors take an oath not to cause harm, and have to consider how patients experience the treatment that is offered. “We want to do what is right, and what is best. Sometimes what that is is not clear. And it can change over time.”

One family member said he had initially felt strongly that the patient should proceed with treatment, but now had decided he would support whatever the patient wanted to do. However, another family member was exceedingly forceful in expressing that the patient must continue with treatment. This person leapt up to kiss the patient’s face over and over and was so emphatic that the patient, who could barely speak, eventually said—she was the last person invited to speak—that she wanted to continue with treatment.

The doctors expressed that sometimes a patient will continue treatment because that is what his or her family wants, but maybe the time comes “when it’s just too hard.” This particular patient often refuses medication or other treatments when none of her family members is around, but the insistent relative said this will not be a problem because, since there are several family members in the vicinity, there is no reason someone can’t be at the hospital every minute of every day. At this, another relative pointed out that many of the family members are elderly or have health problems of their own; the doctors validated that trying to be on the scene constantly would be very difficult.

But no matter. It was decided that the patient would continue with debilitating interventions, by her own wish, and the doctors seemed perfectly at peace with that. At the end, I asked the family if they would like a prayer, and they said they would. I murmured to the doctors, “I’ll offer a prayer after you leave.” I figured that, after 90 minutes in the room, the doctors probably had 20 new text messages apiece and little interest in hearing a prayer. Clementine said later that that was the right call. Half an hour after the meeting ended, I was near that patient’s room again and, needless to say, no family members were present. It just is not realistic for most families to staff a hospital room 24 hours a day, potentially for weeks or even months.

The final thing I did that day was to lead the weekly half-hour meditation, which happens in the chapel. Two patients and two staff members attended. One of my favorite things about volunteering at this hospital is never knowing what the day will bring.

While with a patient at my paying job, I had a brainstorm and asked, “In all this, what is the emotional terrain like?” We have a series of questions we’re supposed to get answered, perhaps chief of which is to determine if the person—uh, let me look at that piece of paper—ah! We’re supposed to find out if the person considers herself spiritual or religious. This is very awkward to ask when you’ve known someone for just two minutes.

When I asked the patient about emotional terrain, he readily told me about feeling sad and discouraged after surgery, wondering if he should even go on. Then I asked about his “human landscape” and he told me about his family and friends, and then, without my having said a word about it, he told me about his spiritual beliefs. I didn’t bother to write these questions down on the multi-page cheat sheet I carry around. I have probably made 400 pages of typed notes since starting to learn about chaplaincy, but all that matters is what I’m able to remember in the moment, which is very little, but hopefully will grow over time.

We’re also supposed to put as many exact quotes as possible in chart notes. Some of my peers have one long quote after the next in their chart notes; I often find I can’t recall a single sentence, though my boss said, in that case, quoting a word or two is fine. I would like to have much better recall, so I have a new goal of remembering just one sentence spoken by each patient, word for word.

Friday, August 03, 2018

Or Maybe The Disgruntled Disinterred

I am in the process of renewing my passport, so I can get a REAL ID (like next year when the lines at DMV are less than six hours long), and went to Walgreens to have a photo taken. I could not believe how terrible I looked in this picture. If I could find four other people of similar appearance, we could start a band called The Peevish Cadavers.

Recently I sat with a patient in the emergency department at County Hospital, consciously leaving plenty of silence. She told me that earlier that day, she had felt short of breath, so she had come to the hospital. We fell into a rhythm of silence, another detail or two emerging, then more silence. Suddenly she said, “They found a mass on my lung. I may have cancer.” I’m not sure she would shared that if there had not been plenty of space in the room.

I have noticed that in some visits, I can fall into helping to fill every moment with words, even if that means having a social conversation (“Did you hear The Peevish Cadavers are playing at Cow Palace soon?”). I am sure this is due to some discomfort of my own that I can’t tolerate, maybe even just the discomfort associated with silence. Wishing to change my own state, I talk, and maybe the person does not end up telling me about the mass in her lung or the recent loss of a loved one.

Very often, a patient will describe her situation to me and then say, “But I’m grateful! I’m getting good care, and others have it much worse than I do.” I increasingly find this poignant. While I appreciate and even applaud the impulse to practice gratitude even at the grimmest of moments, and while it is likely factually true that others have more serious prognoses, I think the patient is saying, “I don’t deserve your care and love, and I am ashamed to be seen asking for these things.”

I appreciated this in Reb Anderson’s book Being Upright: Zen Meditation and the Bodhisattva Precepts: “We must be careful not to use the immense suffering of others as an excuse to avoid awareness of our own pain. In fact, if we refuse to listen to our own suffering, we will not really be able to listen to the pain of others.” I would like to find skillful ways of introducing this perspective when I hear a patient say that others are the ones truly deserving of tenderness.

I called Emily in hospice late in June and ended up feeling kind of distressed after she described various difficulties she is having. She said that she is woken up each day at 6 a.m. so her diaper can be checked; getting up so early makes the days very long. A few hours later, she is bathed, which she said causes a good deal of physical discomfort. She is down to zero limbs that are free of pain, but when she expresses this to the aides who are bathing her, they say they have to do it that way or risk injury to themselves. Emily said she doesn’t want anyone else to suffer, either, so she tries not to complain too forcefully. I wonder if a sponge bath every other day would be sufficient, since she is not exactly working up a big sweat on a regular basis.

She said that when she was out on the back deck—a lovely place, as I recall—another patient asked if it would be all right if she smoked. Emily didn’t want to say no; she said she understands what it’s like to crave a cigarette. The smoking patient was joined by a smoking staff member, with the result that Emily found herself craving a cigarette, too. I have mixed feelings about that one. She is proud of having quit smoking a few months ago (because she couldn’t smoke in the hospital), but at this point, it probably doesn’t really matter that much if she smokes.

Finally, she said that workers at the hospice, when they see her crying, tell her, “Don’t cry!” I asked if they seem to mean well, or if they are just being unkind. She said it seems like the latter. This made me angry. Why is it bad to cry when you feel sad? Emily said, “Maybe they have difficulty with their own feelings.” That would be my exact analysis. She begged me not to mention any of this to the staff. She doesn’t want to be perceived as a troublemaker.

I felt bad for her after we hung up, and also chagrined that I had inadvertently told her a lie when I said that hospice was a nice place. It is not proving to be very hospitable from her perspective.

Wednesday, August 01, 2018


The day Clementine at the County Hospital told me about the eight upsetting things that had happened, I came home and told all of them to my mother on the phone, who said afterward, half joking, “I needed to know all of that.” Of course, she didn’t need to know any of it, and it’s not fair of me to dump that kind of stuff on her. I remembered one of my CPE supervisors saying she doesn’t tell her husband what happens at work: “He isn’t trained to deal with trauma.” Neither is my mother, so the next time I talked to her, I apologized and said I won’t tell her disturbing stuff from work anymore. She said, “Well, you can’t keep it bottled up! It’s OK to tell me.”

That was very kind of her, but caused me to start thinking about the bottling-up thing. Is it bad to keep stuff “bottled up”? My boss at work told me that listening to someone spew out a story they have told many times before does not necessarily constitute quality spiritual care. The person may just become even more anxious in the retelling. She said that she has noticed that when she obsessively retells a story of her own, she can feel increased anxiety. Even my therapist, for goodness’ sake, lately said that revisiting an upsetting story isn’t necessarily therapeutic. I’m perfectly capable of insisting on telling a story whether she thinks it’s therapeutic or not, but what if she is right? What genuinely is helpful in this regard, for me and for my patients?

I decided that spewing forth a story is the verbal equivalent of being lost in thought and that I wouldn’t do it anymore: I wouldn’t tell my mother and I wouldn’t tell anyone else. And within a couple of days, I felt exhausted and sick of the whole chaplain thing. It even crossed my mind that maybe I would actually rather sit in front of a computer at a bank, a very rare occurrence these days. Clearly I was no longer on the right track. I thought of that childhood game where the other participants tell you if you are getting warmer or colder. I was getting colder.

I decided that I need an appropriate confidante, but who? I decided it should be another chaplain, maybe one of my colleagues. I was paged that night to the emergency department at one of our campuses to say a prayer for a patient who, not yet 60, had died very unexpectedly, alone in his office. The next morning, doing turnover, I mentioned this to two colleagues, though there was nothing either of them needed to do about it. They both were kindly supportive. One reminded me to practice self-care as I integrated this experience. That was really nice of them. We encounter death so often, it in some ways comes to seem like no big deal, but it actually is. Maybe the colleague who said I should remember to take care of myself would be a good confidante, or, at the least, I should remember to tell my team what I’ve lately encountered and ask how things are going for them, so we can support each other. After my exchange with my colleagues, my enthusiasm for chaplaincy magically returned.

Wednesday, July 25, 2018

I Get by With a Little Help from My Friends

Maybe a month ago, a nurse at work instructed me not to chart at her unit’s nursing station. I was immediately indignant. My very first CPE supervisor told me to chart at the nursing station. This is part of integrating myself into the units I serve, which is potentially all of them. She also said, as a rule, not to ask a patient’s nurse for permission to visit the patient, but to remember that I am also a member of the care team.

Later that day, I mentioned this to my boss, who also seemed immediately indignant. Her initial response was to tell me to go ahead and chart at the nursing station, but later she said to discuss the matter with the nursing supervisor, so I wasn’t sure how to proceed, but, being myself, was inclining toward announcing, “I’m a care team member and I’ll chart where any other care team member charts.”

The unit where this happened is not one I’m assigned to, so I sent my colleague who is the unit chaplain a note asking what her experience has been and if she had any insights that would be helpful.

Perhaps it was that same night that I got a page after hours asking for a priest. I called the church that is supposed to handle after-hours requests and got what they call in the corporate world a significant amount of pushback. It was possible that the need would end up being the following morning, so I called the priest who is one of our staff chaplains, and left him a message saying he might be needed first thing next morning at a particular campus.

It did end up working out that way, so I left our staff chaplain a message about an hour before our normal start time (actually 90 minutes before, because I temporarily forgot what our normal start time is) asking him to report directly to the ICU in question, if possible. I then texted him apologizing for having phoned him both after and before hours. He texted back saying he would go straight to the ICU to meet the patient’s need, and also that I should tell our boss about what had happened. But what had happened?

I asked what he was talking about: the other priest not having wanted to come to the hospital at night? My having called him outside of normal working hours? Both? He hastily backed off, saying I should do whatever I thought was appropriate, which left me, as with the nurse not wanting me to chart at the nursing station, confused about what to do next.

I went ahead and sent a note to our boss, copying our priest, outlining the entire sequence of events, and ended by saying that my purpose in sending this email was to let our boss know that there is some difficulty getting the priest from that particular church to come after hours. I also said I would welcome some direction as to when it’s OK to call our own priest.

The next time I was in the office, I saw that there had been no response whatsoever from 1) my boss; 2) our staff priest; or 3) my colleague in regard to where to chart on her unit. Now I was starting to fume. This was a Sunday morning. Soon the office phone rang: our staff priest. When he asked how I was, I grumbled that I had done what he had asked me to do—tell our boss something or other—and then neither of them had responded!

He said that he and our boss had continued the email exchange without me, which was fine, since my goal was not necessarily to send and receive email but to have the information I need in order to do my job. As to that, our priest explained that outside priests often have a lot on their plates, and that we should be understanding of that, and that if necessary, it’s OK to call him, our own priest, and it is certainly fine to call him with information he might need first thing the following morning. That was basically what I needed to know. (Although now that I’m writing this, I realize I still don’t understand why he wanted me to say anything at all to our boss.)

As long as I was on the phone with him, I asked what he does if he is discouraged from charting in a certain area. He said, “I might be understood as a coward,” but said he just saves his charting up and does it in his own office. That was helpful in that it made me feel there was no dishonor in not going to war with my colleagues.

Later that day, I also discovered that my fellow chaplain actually had sent a response to my question. It wasn’t in my inbox in the messaging system; it appeared as a comment on my original note. Fortunately, I enjoy reviewing messages I have sent so I can appreciate my own sparkling prose for a second or third time; that’s the only reason I saw her response, which was that if the nurse asks her politely to go chart somewhere else, she doesn’t mind doing that, but if the nurse is rude, I should discuss it with the nursing manager. She has told me in the past that those exact nurses are among the unfriendliest she has encountered.

At this point, I felt fine about not insisting on charting at the nursing station, and relieved that I wasn’t obligated to get into a fight about it. My colleagues, who both had initially annoyed me, ended up saving me.

Thursday, July 12, 2018

Inspect Ladder Before Use

The aluminum ladder whose leg suddenly gave way, resulting in grievous injuries for an esteemed relative. (The thinking now is that a wooden or fiberglass ladder might be safer in that it might make a creaking noise or something before failing.)

(Click photo to enlarge.)

Monday, July 09, 2018

Schwing Schwing Schwing Schwing

(Or is it just shwing?) This refers to Wayne’s World 2, featuring Aerosmith, one of the movies I watched with my mother while visiting Ypsilanti early in June. We also saw Miss Sloane (we both liked it a lot), The Florida Project, Into the Wild (for the second time), Wonder Woman, Nightcrawler, Boyhood, Get Out, Assault on Wall Street, and probably several other movies I’m forgetting. I got caught up on my MSNBC and Rachel Maddow, and enjoyed spending time with my parents and the cat that hangs around their place a lot, Jack. I had lunch with Ginny at Café Zola and with Amy at Seva. My sister came over three times, and I had lunch with my uncle and his wife at Haab’s, in downtown Ypsilanti. As for Wayne’s World 2, that was my mother’s idea. She normally dislikes comedies, but thought it would be good to have some familiarity with a work that is so well-known. I enjoyed it. I appreciated the main characters’ enthusiasm and joie de vivre.

The evening I returned home, I went to the first of six Feldenkrais classes I’m taking through Kaiser. The next day I got my annual performance review at work, which was glowing. My boss’s accompanying remarks were less so. For instance, the written review said my chart notes are great, and provide helpful information to other team members. In person, she said, “Actually, what I don’t like about your chart notes is … ” I thought that was a perfect way of handling it, in that my official review is something I can feel fantastic about, and I also got concrete information about areas where I can improve. (She also said that Jonas, before he left, said I have an “incredible” ability to connect with patients.)

When I went to County Hospital for the first time after being in Michigan, Clementine—looking a bit dazed—told me about no fewer than eight traumatic and/or disturbing incidents that had occurred at or affected the hospital in the prior couple of weeks, including two “gnarly” murders. One of the many ramifications of these things is that security is tighter, which means homeless people are less welcome to sit around in the cafeteria all day, and not at all welcome to sleep in the elevators overnight, as some of them normally do, so besides all the various kinds of misery, there has even been a loss of housing for a small group of people.

It was a fine day of learning for me. One of my fellow chaplains there is extraordinarily insightful. During our brief daily team meeting, we were talking about patients who ask us questions about ourselves. This person said, “I think that a patient who does this is trying to erase herself, so I need to leave a big space in which she can reappear.” That dazzled all of us.

My own learnings of the day:

1) I spent most of the morning, after holding babies, in the more acute psych unit, where I saw just two patients. One of them has problems with demons, and during our rather long talk, she said, “Oh! A demon just came out of me and went into you.” I paused and said, “I didn’t feel any demon come into me. It didn’t come into me. Maybe it dissipated into the air.” The patient said, “No, it came back into me,” and her face twisted in pain.

I happened to mention this to Clementine later, and was glad of that, because it caused me to remember that we’re not supposed to validate delusions. (Nor are we supposed to say, “What?! Are you crazy? There’s no such thing as demons!”) She said it was good that I had denied that the demon had come into me, but when I suggested that maybe it had gone into the air, I was validating the patient’s delusion. She advised me not to engage one way or the other about demons or other delusions, but to listen for the feelings. How does a person full of vengeful demons feel? Probably scared.

(Though Clementine said that once medication makes the demons go away, some patients can actually feel lonely for them, because demons aren’t always in a bad mood.)

2) This same patient asked about my religion and I said I am Buddhist. With non-psych patients, this is almost never a big deal. (I can recall only two patients who made it clear they didn’t like it; one went to work right away trying to convince me to accept Jesus as my savior.) This psych patient reacted favorably at first, but when I ran into her later, she spitefully accused me of stealing a Bible from her, and then said, with near-palpable malevolence, “Just because you’re Buddhist doesn’t mean you have to persecute me!”

From this I concluded it might be wise to be less forthcoming with psych patients.

3) I brought the other psych patient a copy of Our Daily Bread, which has two staples in the binding, and stopped by the front desk to see if they would like to remove the staples, which they did want to do to prevent the recipient or some other patient from removing the staples, straightening them, and using them as weapons. No one at County Hospital had told me to do this; we learned this during CPE. I mentioned this at our chaplain team meeting, and it appeared to be new information for some, so that was a reinforcement of learning for me and maybe something new for others.

4) Finally, in the ED I visited a patient who was handcuffed to her bed, with a police officer stationed outside. That morning, she had been a free woman, and now she was going to jail, and she was upset. I asked what had happened, and at some point, after I’d heard a few details, the police officer interrupted to say he didn’t think we should be discussing it. The patient got indignant and asked why not, but the police officer was quite right; I was chagrined that I hadn’t figured that out myself. I said, “You’re right, we shouldn’t be talking about this.” To the patient I said, “My thinking was that maybe it would make you feel better to say what happened.”

“It did make me feel better!”, said the patient. “I should be able to talk about whatever I want to talk about.”

“Fine,” said the police officer. “You can talk about whatever you want to talk about, but she shouldn’t ask you about it.”

When I left, I thanked the police officer and will not do that ever again. Then I felt kind of paranoid, worried that I’d get in trouble over it, but figured I wouldn’t. (I didn’t.) There’s just too much constantly going on there for everyone to follow up on every detail.

In the evening, Tom, Ann Marie and I went to see the first half of Angels in America at Berkeley Rep, thanks to Ann. Tom took me out beforehand for Thai food, for my birthday. The play was superb. The person playing the part of the angel, the nurse, and one or two other roles was the niece of my friend Carlos who died of a brain tumor in 2013. She is also a playwright, and, as we saw, a splendid actor. I couldn’t take my eyes off her, in part because I was trying to figure out if I could see any resemblance to Carlos, and at moments, I thought I could fleetingly see his face in hers. Lisa Ramirez is her name. I remember Carlos talking about going to see her performances and about how proud he was of her.

Saturday, July 07, 2018


While I was at County Hospital one day late in May, I got a text from Clementine saying that the ED was on lockdown and could I go check it out? I texted back, “Do you want me to enter the ED?” I wasn’t sure if she wanted me to go in and conduct a hostage negotiation or what. Presumably she didn’t intend for me to get my head blown off, so I wasn’t sure exactly what she wanted me to do. I didn’t hear back from her, and when I got near the ED, nothing appeared to be amiss.

I went in and saw sheriffs taking a barricade away from one of the entrances, and a staff member said the lockdown was all clear. Later I mentioned it to one of my fellow volunteers, and she said, “Yeah, that happens all the time.”

I told Clementine about having attended the training on psychological first aid, and she invited me to join the hospital’s disaster response team, or MCI (Multiple Casualty Incident) team, which I agreed to do.

Up on one of the units, a nurse told me that one of her patients seemed silent and withdrawn, and she asked if I would visit him. The patient was sitting up on the edge of his bed, and he did indeed seem to be downcast. I asked if I could sit down and then I just sat there quietly for some time. After a while, I said, “You seem kind of sad.” He nodded his head just slightly. I added, “It looks like you’re feeling kind of discouraged,” and he nodded at that, too. Then he started talking—about his disappointment that the Warriors had lost their game the previous night. Sounding stunned, he said, “I didn’t think that was going to happen.”

However, as the very leisurely visit unfolded, he shared about some physical symptoms he was having that he hadn’t told his nurse about. He said that, where he’s from, if you say you need help with anything, people lose respect for you. While I was there, he pushed his nurse call button and told her about his symptoms. It wasn’t necessary for me to tell him to do that. It was necessary for him to hear himself say aloud that he was in pain and that it’s hard for him to let people know he is having difficulties.

After that, I thought, OK, I think I’ve got it! There is nothing I can fix. The idea is to sit there, with patience and stillness, until whatever the wound is comes into view. I went off to see other patients thinking that I would do the exact same thing, and then of course found that what had worked in one visit had little utility in any other. Nonetheless, I like the idea of being quiet and patient, waiting for things to emerge on their own: whatever is bothering the patient, and also her resources and wholeness.

One evening, just after I turned off the light to go to sleep: beep beep beep! My work pager going off. I called the pager operator, who put me through to a nurse who said that a patient’s mother wanted to speak to a chaplain on the phone. My enthusiasm was whole-hearted, since the alternative was getting up, getting dressed again, and taking a cab back to work. “I would love to talk to her on the phone!”

Thursday, July 05, 2018

Chaplain Tries to Poison Fledgling Priest

A week or so after Mason’s graduation from divinity school, I returned to Berkeley to have breakfast with him before he moved back to New Mexico to serve his own church as a priest. I had checked online to see how far it is from his hometown to Santa Fe and it appeared to be more than four hours by car: too far for a day trip. I told myself that, realistically, this would probably be the last time I would see him, and to let go, let go, let go. I have a quote somewhere about how what we humans need practice in is letting go, because we’re already experts at holding on.

We met at the Sunny Side Café, near UC Berkeley, and after we ate took a walk on campus. I gave him a card congratulating him for receiving his M.Div. and a couple of small gifts, including a polished piece of malachite. (I learned later that malachite is poisonous and that you shouldn’t carry it around in your pocket. He told me he plans to keep it as a reminder that Chaplain Bugwalk tried to poison him.) I asked how long it would take him to drive to Santa Fe and was pleased when he said the trip is just two and a half hours. There is a Monday in August when I can be in Santa Fe but not at school, and it turns out that Monday will be Mason’s day off, so we have plans to meet. Mason suggested that we go to all the museums where, as a Native person, he gets in for free.

Back in the city that day, I attended a training on psychological first aid, such as one might have to render after an earthquake or other mass casualty event. One thing you can do to help someone feel calmer is to ask her to name five things she sees around her, five things she hears, and five sensations she feels in her body, then four of each of those things (not the same ones as before), and then three, two, and one. When the trainer had us do this, it was pretty hard to hear that many different sounds, but overall, this did seem to have a relaxing effect.

Her number-one recommendation for helping lesson people’s anxiety was to ask them to breathe into their diaphragms for a count of four, and then to exhale for a count of four, and to repeat this for a while. Another very useful thing the trainer shared was to say to a survivor, “Hi, I’m Bugwalk. I’m here to help. What’s your name?” and extend my hand. If the person says her name and extends her hand to shake mine, I have just learned several things: the person’s name, that she isn’t hard of hearing, that she speaks at least some English, that she is willing to engage with me both verbally and non-verbally, that she doesn’t have an injury that prevents her from moving her arm and perhaps that she is not in overwhelming physical pain.

The trainer said not to say, “Everything will be OK,” because it might not be, and to use a survivor’s name often, because people are very alert to the sound of their own names, so this might help keep the person we are talking to from getting lost in anxiety.

Most of the people in the room were nurses and social workers, most working in one hospital or another. Next to me was a fellow chaplain volunteer from County Hospital. She told me she is from Mackinac Island, a charming place in Northern Michigan and not one I had realized you can be from; I thought it shut down in the winter. At least last time I was there, about 45 years ago, there were no cars. You could get around by foot, horse-drawn carriage and bicycle, and also eat fudge. (It appears this is still correct. Wikipedia says motorized vehicles, except for emergencies, have been prohibited there since 1898. You can get there only by boat or plane; if it’s winter, you can also go over an ice bridge on a snowmobile.)

Back at home after the training, I gave Emily a call and asked the person who transferred the call to make sure she put the phone to her good ear.

“Do you have the phone up to your left ear?” I asked her.


“That’s funny that you didn’t say ‘right.’”

“Correct.” She really is rather charming.

She said things were going better: She was visited by two of her friends, and another called her on the phone, and she likes the head nurse, and she had a good conversation with a volunteer, who had a helpful suggestion. When Emily feels upset, she likes to go for a walk. She told me that the volunteer said that, when she feels this urge, maybe she can imagine she is walking, and move her feet in bed. Surprisingly, this worked.

I found among my meditation-related clippings this account of something said by Suzuki Roshi during a sesshin; I misquoted it in an earlier post: “Suzuki Roshi began his talk by saying slowly, ‘The problems you are now experiencing’—we were sure he was going to say go away—‘will continue for the rest of your life.’ The way he said it, we all laughed.” I don’t have the name of the person who wrote this, and will be glad to add it if it comes my way.

Wednesday, July 04, 2018

Am I Dying?

One day we had a five-hour staff retreat at work starting with Mediterranean food for lunch. In the course of the afternoon, my boss mentioned that when Jonas left, among other things, we lost the person who trains others how to use the electronic charting system. I’m pretty good with that system and my former computer job often involved training other people, so at the end of the day, I offered my services and she said that before Jonas left, he told her I’m good with the computer, so she would take me up on that.

She also said she would like me to apply for a part-time job when one becomes available (this would be a step up from my current per diem position), that I have a lot to offer, that I’m a good team member, and that I’m doing a great job. I was flabbergasted. I told her that her words meant a lot to me, and that I’m happy at this hospital, both very true. I had been worried that she was secretly fuming about how much time I take off work, between school and vacations, so that was another reason I was relieved and delighted to find out she is glad to have me around: she’s not trying to figure out how to trade me for a per diem who doesn’t take so much time off.

In mid-May, I went to see Mason, my peer from my first unit of Clinical Pastoral Education, receive his M.Div. degree in Berkeley. It was an inspiring ceremony, and Mason got one of three special awards. Quite a number of his family members came from New Mexico to see him graduate.

When I got home, I called Emily in hospice, and this time I did much better when she asked me a tough question: “Bugwalk, am I dying?”

I said, “Well, a person goes to hospice when a doctor believes she has six months to live or less.”

“Which doctor?!”

“I imagine it was one of the doctors you saw at the hospital.”

“Oh. Yeah. I didn’t get along with that guy. I don’t think he liked me.”

I thought of saying I hope a doctor wouldn’t send a patient to hospice because he didn’t care for her personality, but in case she wasn’t already thinking that—though she probably was—I decided not to introduce that idea.

Then an interesting thing happened, which was that she changed the subject. A bit later, she returned to it, saying she felt frightened, and asking what she should do. And then she changed the subject again. That was a powerful learning experience: I don’t have to be afraid of telling people the truth, because a natural defense mechanism such as denial or avoidance will come to the fore when needed. These get a bad rap but are perfectly reasonable means of self-protection.

One Saturday, Sam and I met in the Castro for Thai food, and the following day Ann, Jill, Tom and I had lunch at Au Coquelet and went to Berkeley Rep to see Heidi Schreck’s play What the Constitution Means to Me. I enjoyed it. Each member of the audience was given a copy of The Constitution of the United States of America. I probably will never read it, but I feel like a better person now that I own a copy.

The next time I called Emily, I found that she was still distraught about finding herself in hospice. I managed to convey to her that, when she declined to take medication, her doctors likely interpreted that she didn’t want treatment and accordingly sent her to hospice. She said, “Oh. Well. I still don’t want to take medication.”

“Then you might be in the best place!” I shrieked. It can be kind of a maddening experience to talk to her on the phone because I have to bellow into the receiver, and she still misses thirty percent of what I say.

“What do you mean by that?”

“How do you think things would go if you were back at home?”

“That’s a good question.” I can’t remember what she said after that, but I was relieved that she is sure she doesn’t want to take medication, because that does mean she probably is in the right place. I was also kind of surprised by that. I sort of expected her to say, “What?! In that case, of course I want medication!”

When Sam and I had lunch the prior Saturday, we were dangerously near where Emily is. In fact, we walked over to look at it, because Sam had never been there. It’s quite a lovely place, on a very pleasant block. But having learned by calling Emily that I shouldn’t have done so, I knew better than to initiate in-person visits. That would not be sustainable on my end, and I would disappoint her. Having said that, I have asked the staff there to let me know when she is within a couple of hours of dying, as best they can tell. If I can, I will go over there and hold her hand.

Saturday, June 30, 2018

Husband Needed ASAP

Despite what I had said to Emily earlier, I actually was tempted to go over to the hospice to visit her after work or on the weekend, recognized that as the impulse to overfunction, and remembered the conversation I had with my very first Clinical Pastoral Education supervisor in a similar situation. She asked if the patient had asked me to stay in touch with her. Well, no, she had not. My supervisor asked how it might play out if I did go visit the patient in her new facility, and I could immediately see that it would likely end in disappointment for the patient. I might visit every weekend for a couple of months, but sooner or later, I would have other things to do. I saw that it was not feasible or appropriate to try to prolong the relationship with even this one patient, let alone every patient I particularly like, which is a lot of them.

This impulse to overfunction is also about the mistaken notion that the patient really needs me. The patient might really like me and might even miss me, but there are (one hopes) many people who will care for her in her new home, and my hanging on could stall the development of important new relationships.

After I got home from work, I felt disoriented, as if a bomblet had gone off in my psyche. I had a wave of thoughts: “Maybe I should get married. Maybe I should move in with a roommate. I’m going to start eating sugar again. Chocolate-chip cookies!” Translation: Being closely connected to people, always a good thing, might prevent my ending up alone and terrified when it’s time to go to hospice. And: life is short, so eat cookies.

I quickly dispatched with the latter: not good self-care. And then with the former. Being connected with people is good, but what was happening here was that Emily’s fear had triggered mine, and I was going to have to deal with that, and also remember that end of life happens a million different ways and that I’ll just have to see how it is when I get there. I think I read in When Professionals Weep a clinician’s observation that most people who know they are going to die are able to make some sort of peace with it before it happens. I found myself thinking, and sincerely meaning it, “Gosh, wouldn’t it be lucky if I got cancer while I still have mental clarity and enough money?”

The next day, I no longer felt upset. (Joan Halifax in Standing at the Edge writes that “open awareness meditation seems to reduce our tendency to get [mentally] stuck, thus enhancing greater emotional pliancy.”) However, in the course of the morning, forgetting everything I had reminded myself about the perils of overfunctioning, I telephoned the hospice and spoke with Emily. I also spoke with someone who works there and said I thought Emily would love to be visited by a volunteer. When I spoke with Emily, she sounded fairly calm, though she had gotten the upsetting news that she can’t go visit her friends any more. She said that I had been there at the worst time—when they came to take her from the hospital—and she thanked me. When I asked if she still felt scared, she said, “Yes.” I told her I had asked for a volunteer to visit her and she said that would be good.

So that conversation was OK. She was of course glad to hear from me and I was relieved to hear that she seemed calmer, but now it was unclear what should happen next. Should I call her every day? Every couple of days? Weekly? I concluded that it had been a mistake to call, and that I should have known better. There was a very natural stopping point for our relationship—when the ambulance door closed—and I should have honored and respected that.

Friday, June 29, 2018

Moving Day

When I worked a couple of days later, I went back to see the patient who was on her way to hospice. I will call her Emily. We had quite a long visit, during which I asked if she’d like to do a writing project. She liked that idea, so I asked her questions about her life, including what the most wonderful parts have been, and wrote down her answers. At the end of the visit, I said that we could continue another day, but a nurse who had just come in said, “She won’t be here. She’s leaving at 3 p.m.” This was news to both me and Emily.

I asked, “Where is she going?” or maybe Emily asked, “Where am I going?” and the nurse named the hospice where I used to volunteer, but didn’t say the word “hospice.” That is, pretending the place is called Number One Hospice, the nurse said, “She’s going to Number One.” I told Emily that I’ve spent a lot of time there, and that it’s very nice. Of course, her anxiety level shot up, because one of the main things bothering her was realizing that she was no longer in charge of her life. I told Emily that, if I could, I’d come back before 3 p.m.

I returned about 2:30 and found Emily weeping and terrified. Another care team member came in and said soothingly to her, “You’re going to go to this really nice place for a little while,” and all but winked at me. I was outraged. After this person left, Emily said, “I’m never going home again, right?” I said, “That’s right. Probably. All kinds of miraculous things happen in this world and sometimes people go to hospice and then feel much better and go home, but if you’re thinking that you will not go home again, I think that is probably correct.”

Later she asked, “Hospice means end of life, right?” I confirmed that, but in a wordy, probably kind of confusing way. I couldn’t quite bring myself to be direct because it seems like a terrible thing to learn that you will die in the foreseeable future. That is, it was likely my stuff, and indeed, by this point, I’d abandoned my usual practice of mostly listening and was somewhat urgently trying to reassure Emily: It’s a lovely place, there will be nice people there, everything will be OK. She said over and over, “This is exactly what I was afraid would happen. This was my worst fear, and now it’s happening.”

I did also acknowledge and validate her sorrow and terror, and I did say, “This will take some getting used to,” which I stole from the trailer of the new palliative care documentary End Game, which I hadn’t yet seen. (I have now; it’s good.) Those were the better things I did, I think. I also held her hand, and I was there. I asked a few times, “How are things right this moment?” and every time I asked that, there was no answer, but I got the feeling she was realizing that things were actually OK in any given moment.

She asked, “Will I see you after I leave the hospital?” and I had to say no, that the relationship must end when the patient leaves the hospital.

When the transport guys—two nice young men—came in the room with the gurney, I felt a wave of terror. At this point, I was pretty much psychologically merged with Emily and had crested the peak of empathy and toppled over to the other side, into empathic distress, as Joan Halifax describes in her new book, Standing at the Edge: Finding Freedom Where Fear and Courage Meet. She hammers home the distinction between empathy and compassion, which at first seemed like a picky sort of point, but might end up being one of the most important things I learned from her book.

I rode the elevator down to the first floor with Emily and the two transport workers, and watched her be loaded into an ambulance, and after the door closed, I wept briefly. I told one of my co-workers about it and he offered some wise words. I appreciated his kind intention, but what the offering of wise words basically conveys is, “I can’t stand feeling what has arisen in me as I hear your words and I need it go away right now.” I didn’t blame him. It’s extremely hard to say nothing when someone tells you what he or she is upset about. I couldn’t do it with Emily in our final half hour together in the hospital. It is something I hope to get much better at.

Thursday, June 28, 2018

A Surprise One-Way Trip to Hospice

One day at work, a nurse called me (that is, paged the on-call chaplain) on behalf of a patient whose death was expected soon and who was all alone. Her family had requested that she be dressed, when dying, in her own clothes, but they hadn’t brought the clothes, and they also didn’t bring themselves, even on her last day.

I told the nurse, “I’m going to sit with her for a while, but I’m going to read my magazine while I sit with her—I’ll be back.” I went and got my New Yorker and sat next to the patient for an hour or so, periodically reassuring her that she was not alone and that she was loved. She was in a coma, and even if she hadn’t been, she didn’t speak English, but I hoped the sound of a human voice might be reassuring. She had one eye frozen open.

I stayed until I had to go to another campus to respond to a call there. While I was at the other campus, I was paged on behalf of a patient just a few doors down from the dying patient. It wasn’t an emergency, but since there was no chaplain scheduled to be at my own hospital the next day, I decided to go back there and see this patient, plus another for whom there was a non-urgent request, plus I would check in on the dying patient.

I found the dying patient evidently not breathing and having turned a yellowish color, and went to tell a nurse, who called a doctor, who came and pronounced her dead. I’ve never before been the first person to discover that a patient is dead. While I was waiting for the doctor and saying a few words to the patient, I had the odd experience of feeling strong goosebumps on both of my shins.

I went then to see one of the other patients, one whose nurse had told me she was going to hospice and was very upset about it. Accordingly, I brought along a CareNote on this subject. (From their website, slightly edited: “These compact booklets offer strength, help and healing for those who are hurting. CareNotes provide a wealth of emotional, recovery, health, grief and eldercare support and information. These wellness-oriented booklets address real-life emotional, psychological and spiritual needs.”) I don’t think I’ve ever given anyone a CareNote before, but we have a vast selection of them, I restock the meditation room with them regularly, and my co-worker hands them out all the time, so I thought I would follow suit. They use the word “God,” but aren’t associated with any particular religion.

Good thing I didn’t hand the patient this helpful item first thing because she did not know she might be going to hospice, and was very upset when the word was mentioned. From now on, when someone tells me a patient is going to hospice, I’ll ask if the patient is aware of that fact. She and I ended up having a long conversation, during which I stressed that she is in charge of making choices on her own behalf, and when we parted, she asked me to come back, so I guess recovery from that fairly serious misstep was achieved. I cravenly didn’t allude to it in my chart note, but I did come clean with her nurse, who didn’t seem perturbed.

I added, “She doesn’t know she’s going to hospice.”

The nurse said, “Well, she’s refusing care,” which I guess means the patient is therefore going to hospice.

That wasn’t my only misstep of the day. The other was that, when I first encountered the dying patient, I was kind of shocked by how young she looked, and asked her nurse—in front of her—how old she was. Later, outside the room, I apologized to the nurse and told him I do know that such a patient very well may be able to hear and understand what is said around her. (Though this patient, as mentioned, fortunately didn’t speak English.) He said, “No problem.” I’m not sure why I said that in front of her. Maybe, for some reason, I suddenly had a particular need to be seen as a kindly person who is bothered by an untimely death (which of course I am and was).

At County Hospital, I visited a patient who was missing quite a selection of body parts. After we’d talked for a while, I asked what had happened, and he said that years ago he had sepsis (a damaging immune reaction to an infection) and was given pressors (medication to elevate blood pressure, which may be given during sepsis if intravenous fluid replacement is not enough to maintain blood pressure), and this was the result.

Thursday, May 31, 2018

Space for Wondering

I recently read a wonderful book: When Professionals Weep: Emotional and Countertransference Responses in Palliative and End-of-Life Care, Edited by Renee S. Katz and Therese A. Johnson.

In this book, I learned that those working in palliative and end-of-life care, being human, are subject to a range of emotional responses based on our own histories, social locations, and many other factors, and that when we are not aware of what in the relationship with a patient or family member is arising from our side, there is the potential to offer care that isn’t actually helpful or may even be harmful. In sum, we have to know what our stuff is so we don’t unconsciously visit it upon others, and we have to be familiar with how our own defenses typically manifest so we can spot them when they arise: e.g., feeling judgmental, becoming sleepy, avoiding certain patients, zoning out, keeping a conversation at a social level, feeling the urge to “be helpful” or deliver a quick fix.

I was interested to learn about parallel process: how the dynamics between a caregiver and her supervisor may mimic and thus afford valuable clues to the relationship between the patient and the caregiver. I learned that patients may pick up caregiver opinions without the caregiver realizing it. For instance, a patient who says she would like to utilize the End of Life Options Act to choose the time of her own death may have picked up her physician’s unstated feeling that her situation is hopeless. Conversely, it can also happen that a patient may indirectly cause a caregiver to feel what she is feeling. There is an anecdote in the book about a seemingly placid cancer patient who suddenly leaves a series of hateful, aggressive voice mails for one of her providers. The provider feels attacked and traumatized—and then realizes that her patient also feels attacked and traumatized as she faces the end of her life.

I learned that patients who want to choose the time of their own deaths may be trying to communicate fears about becoming more dependent on others and how they will respond or fail to respond. “When patients feel safe in the knowledge that it is the doctor’s role to gain an understanding of their distress … they may be more forthcoming with their deeply held fears and concerns.”

At the end of many chapters is a “Countertransference Tool Box” offering exercises and questions to help the reader become aware of and deal with potential pitfalls. Individual or group therapy may be helpful, and mindfulness and loving-kindness practices are explicitly recommended. “Being kind to oneself and feeling free to have fun and joy is not a frivolity in this field but a necessity without which one cannot fulfill one’s professional obligations or one’s professional contract.”

In her chapter, Bev Osband describes how a major loss—she lost a child in an accident—can trigger an uncomfortable sense of vulnerability, which we sometimes defend against by feeling guilty. “Guilt of this sort exacts a toll and at some point becomes paralyzing. Yet, relinquishing it means nothing feels safe.” After many years of grieving, she recognized the working of something she labeled “fate,” which delivers both bad and good experiences. (For me, this resonates deeply with Buddhist ideas of causes and conditions, impersonally unfolding, and of the Eight Worldly Winds.) “That is not to say that I no longer feel anguish at having lost my daughter. … What has become possible, though, is a sense of greater spaciousness for wondering, for reflecting, and for making meaning.”

Readers are encouraged to consider their own attitudes about death and end of life in order to become aware of unprocessed emotions as well as what they have learned about how to cope with bereavement. Accordingly, I considered my earliest experiences with death. When I was about four, a puppy that I had brought home perhaps only days earlier—I have almost no memories of him—escaped from our yard and was killed by a car.

His body was kept from my sight and, as I recall, there was no discussion of his death and no ritual. It didn’t seem sad—it seemed horrible, the dead body evidently a ghastly thing a child must not see, the whole thing somehow shameful. This may have arisen from the guilt my parents, who are as a rule highly responsible, likely felt about this innocent creature’s traumatic death. Writing about this allowed tears finally to come, 50 years later.

My next encounter with death was when my father’s mother died of cancer when I was five. I remember my father weeping—he was just 29 years old—an arresting sight I would not see again for at least a decade. This death seemed sad, due to my father’s tears, and also alarming, for the same reason, and even frightening, a feeling that arose from my not being permitted to attend the funeral. I don’t remember wanting to; I just remember understanding that a funeral was not a proper place for a child. I think I picked up the idea that one might see something horrendous, specifically a dead body. I know my grandmother either did not want to discuss her impending death or was not permitted to know how serious her condition was, or both, which I think must also have contributed to the air of shame and dread that surrounded this death, as I remember it.

Both of these experiences point to the importance of ritual, of openly discussing death, of making room for sorrow, and of finding ways to include and to accompany all who are bereaved.

Once we have become educated about the ways countertransference may manifest in our work, our most powerful tool is mindfulness, which allows noticing our emotions and reactions and provides the space in which we can consider, as Roshi says, what truly will serve. I typically practice this with patients by noticing my posture and whether there is a sense of ease and physical comfort or not. Via mindfulness, we can also remember to slow down, which allows for inspiration or intuition to arise. (Roshi: “A wise person slows the process down.”)

Wednesday, May 30, 2018

Fish and Chips Burrito

I had lunch with one of the staff chaplains at the hospital where I did CPE. Our time together was delightful. I picked up a fish and chips burrito at Publico beforehand. This remarkable item has battered, fried fish inside it, along with French fries, queso, and chipotle crema. It takes about two days to digest, but is totally worth it. Afterward, I went to University of the Pacific for a second intake appointment. The dentist I had selected is just a second-year student and these appointments are usually conducted by third-year students, so I met with another fellow, with my own young dentist observing. The other fellow did not do an exam; that would have happened at yet another appointment. But he looked into my mouth for two seconds and said, “You’re going to need a lot of fillings!”

For a second, I was completely disoriented: What do you mean, I need a lot of fillings? I don’t need any fillings. He said that some of my fillings are worn and that if decay gets under them, that is a big problem. I’m sure that’s true, but I’m also sure that if there were any real danger, my former dentist would have replaced these fillings already. It’s not like I’ve been avoiding dental care. I’ve seen a dentist at least twice a year for about 50 years. Soon this person added that I also would need “a couple of crowns,” and somewhere along in there, my trust in University of the Pacific faded. I expressed my concern, and my young dentist tried to offer reassurance, saying that we would know more after the actual exam.

I really don’t want every single tooth in my head to get a filling or crown because that’s what the students at UoP need to practice. Mother Nature gives one just so many teeth, and I don’t want them treated aggressively. Nay, I would like them treated in a diffident, retiring, even avoidant manner. I called my former dentist and she looked at my X-rays while we were on the phone and said she doesn’t see anything that needs immediate attention and that metal fillings can last for 30 or 40 years and should be hung onto for as long as possible. I decided to stick with her and left my erstwhile new dentist a very nice voice mail saying that I had changed my mind (I explained why) and expressing my sincere good wishes toward him. I got an equally nice voice mail back from him.

Monday, May 21, 2018

Learning to Tolerate Peace

Early in May, I went down to University of the Pacific to sign up as a new patient. When I left, there were some students dressed as tubes of toothpaste standing around on the sidewalk outside.

The next day, I went to the NICU to hold babies for the first time. The volunteer who trained me had clued me in that the official gowns volunteers are supposed to wear are made of plastic and can cause a lot of sweating, but that there is another kind of disposable gown that is acceptable. She showed me where to find those, so when I reported to work, I went and put on one of the latter. Even so, I felt very warm.

A nurse arranged pillows in a comfortable chair and I put a small blanket fresh from a heated cabinet on my shoulder and sat down and she handed me my first baby, a little girl who soon fell asleep. It proved to be very relaxing to hold a baby—boring, actually, but then, peace can be boring, so it’s good to learn to enjoy boring things. I had to struggle to stay awake, and hoped there is some sort of protective instinct that would keep me from dropping the baby on the floor if I did nod off. Before the baby fell asleep, it was fun to watch her constantly changing facial expressions, and after she was asleep, it was satisfying to know that I was providing a safe, comfortable place for this tiny being to rest. I held her for about half an hour and then it was time for her to have some kind of procedure.

Next I held a baby boy dressed in a little onesie styled to look like a tuxedo. The nurse told me that he was frequently “desatting”—desaturating: having the oxygen in his blood drop too low—and that when that happened, he would turn purple in the face, and then I should do something to wake him up a bit: pat him on the stomach or tickle his feet. But if it went on too long, I should get a nurse. This was the second and last baby of the morning. On the whole, the experience was very agreeable. The only thing I didn’t like is that the front of my work shirt got totally wrinkled.

I went and rounded in the ED, which was surprisingly busy at 10 in the morning, and talked to 18 people. I had lunch in the cafeteria and then it was time for the daily huddle, a brief chaplain team meeting that takes place on one of the hospital units. At the end, Clementine asked someone to offer a prayer or blessing or do an interpretive dance, etc., so I began an interpretive dance, and the other five people in the circle silently joined me. We were in a hallway outside several patient rooms, and someone standing in a doorway watched us dance, a patient or family member. Clementine thanked me for being the first person ever to do an interpretive dance at the end of huddle.

Next it was off to a medical unit to see several people, and when I ran out of steam, at about 3:30, I walked home. In the evening, Karen V. and I went to an Eritrean restaurant on Irving St. The cuisine seems to be identical to Ethiopian, including the injera, but this particular place was way cheaper than the Ethiopian place in my neighborhood, and the food was just as good, and the staff were very friendly. Then to Tart to Tart for tea.

One weekend, my ex-CPE supervisor Anita and I got together. She had never been to North Beach, so we met on Market St. and took the bus there, passing through Chinatown, which she also had never seen. I showed her the park and the big church, and we went to Liguria, a focaccia place that David and Lisa used to go to when they lived in that neighborhood, and we had a tasty brunch at Pinocchio.

At work, I asked another chaplain about the family I had visited at night. The patient was unavailable for conversation, so I mostly spoke with a young family member, and therefore my chart note was mostly about this family member, whose stories I felt afforded a good lens into the family, which has many challenges. Though chaplains explicitly care for family members as well as patients (and also for staff members), I did feel it was a little odd to write a long chart note about someone other than the patient and wondered if others would also question that choice.

However, my colleague said that my chart note proved to be valuable to other care team members, and was relied upon by them as they considered their interactions with this family. My colleague said my note was the best thing that could have happened for the family member, who is just a child and on the receiving end of some extremely toxic dynamics.

Back in the corporate world, I would have said, “Could I ask you a favor? If you have time, could you tell our boss that?” I would want my boss to know I’d done a good job. But just as I was opening my mouth to do that, I decided against it. Part of me does feel it’s unseemly to toot one’s own horn (though I do it all the time right in this blog, including in the paragraph prior to this one), and it also shouldn’t really be necessary: if I’m doing a good job, that will inevitably become known, just as everyone knows when someone is doing a bad job. Also, I have in the past gotten surprising and not necessarily pleasing results after telling my boss something I did that I thought was great, so maybe less is more in this regard.

Friday, May 18, 2018

Boogie Fever

Late in April, there was a staff meeting at my paying job. It was fun, with frequent laughter. My relationship with my boss now seems quite genial and even playful at moments, which I am glad about.

A day or two later, I went to County Hospital for volunteer appreciation day. It was held outside—the weather was lovely—and there were beautiful decorations, fruit salad and ice cream, a certificate and gifts for each volunteer, and a raffle (tickets were free) to give away 15 or so hospital hoodies. There was a photo booth where you could put on a funny hat and pose with your own group of volunteers and get an immediate print of the picture. The playlist was right up my alley, 80s funk, like “Boogie Fever,” by the Sylvers, which still is in my vinyl collection.

I met a fellow chaplain I’d never met before, one who has been volunteering since 1991 and who worked at this hospital as a nurse starting in the 1960s. I noticed she was moving to the music a little, so I asked if she’d like to dance, and the two of us got up and danced in front of the whole crowd of maybe 100 people.

After sending the NICU person at County Hospital an email saying I’d like to be trained to hold babies, I started knocking on her door every time I passed it, and at the very end of April, she finally answered it and took me right into the NICU and introduced me to one of their baby holders, who spent an hour training me. The volunteer said, “See that blue thing? It’s an IV stand. Don’t kick it.” She also shared that she has learned that when a nurse is listening to a patient’s heartbeat using a stethoscope, that is not a good time to ask a question.

This NICU is quite small, maybe 12 beds total. The good news is that most babies in this unit will get well and go home. At the hospital where I did CPE, they have nursery after nursery for ill babies, plus a pediatric ICU and a pediatric cardiac ICU. They get the very sickest babies, and deaths are not uncommon.

One day I went in a Zipcar up to see Carol-Joy in Novato. We had breakfast at Toast, and then she introduced me to her delightful neighbor, Joan, who graciously invited us in for a bit. I think Joan would not mind me mentioning that in recent years she threw herself a “fun-eral”—a funeral where the guest of honor is still alive and gets to have fun hearing all the nice things her friends have to say about her. If I recall correctly, Carol-Joy said that Joan had a coffin for the occasion. Carol-Joy and I played cards all afternoon and then had dinner at a restaurant in San Rafael called LaVier.

The next day, I worked and it was the rare day when I was there at the same time as my colleague. I still felt a little annoyed about this and that minor thing, but when she started to talk about the various stresses in her life, I suddenly felt much more sympathetic. She said that on her way to work, she had seen a car accident and had seen a dead man, prior to the arrival of first responders. That must have been awful. We had lunch together and exchanged chaplain tips. She asked how often I end up having to work while on standby in the evening, and I said, “I don’t want to jinx myself, but not very often,” and I knocked on wood.

That very evening, just as I was about to turn off my bedside light, the pager started beeping. It was a request from a doctor to go to the campus that is farthest from my apartment building to support a family that was likely on the verge of losing a child who had been perfectly healthy not 12 hours earlier. I spent about three and a half hours with the family—by the time I got home and finished charting, it was 2:30 a.m.—and had a very good talk with another young family member, who said, “My family and I never sit and talk like this.” The parents work menial jobs and I saw that one of them was limping terribly. I could see a bit of how the various pressures in this family play out, the fundamental problem being that they are people of color, immigrants with little money who live in America. It bothers me terribly, and to think that the President of the United States goes out of his way to make it worse.

Monday, May 14, 2018

This Is My Toothbrush

While I was at school for sesshin, as always, we had a daily work period, during which I cleaned bathrooms, an absolute pleasure when the alternative is sitting perfectly still on a hard folding chair. We had every kind of weather. The day we arrived, it was brilliantly sunny and 84 degrees. In the course of the week, there was a ferocious windstorm and dust storm that blew a skylight off the top of the zendo so that leaves came in. It rained briefly and heavily one morning. It snowed! One night when it was terribly windy, a roommate of mine who is very tiny put her arm through mine as we staggered in the dark back to our sleeping quarters.

The week was billed as being about the Song of the Jewel Mirror Samadhi, a Zen poem, and each day the teacher leading the sesshin gave a talk about some aspect of this. My favorite two lines in the translation we were using, of which there are many:

Complications are auspicious
Do not resist them

I liked this teacher. When he gave his first talk, he pointed out a scroll he had caused to have hung in the zendo and said, “My talk might not be that good, but I have exquisite taste in scrolls.” Another day he talked about noticing that he was feeling tense while brushing his teeth and how he counseled himself, “This is my toothbrush. These are my teeth. Everything’s cool.”

The two things he said that had the profoundest impact on me were the following. Paraphrasing, he said something like, “We want the entire web of causes and conditions from beginningless time to be different so that our karma will be different so that our elbow won’t itch!” When you put it that way, it does seem ridiculous to object to this or that thing that has arisen, but we—I—do it constantly, about the very smallest things. Pondering this, I got a sense of this vast web mixing, churning, ebbing, flowing, drifting, flowering, becoming. What has arisen in this moment, how could it be otherwise? There is nothing whatsoever to be done about what is already here. The good news is that there is also a vast array of possible responses.

The other thing was the idea of being lazy and of being a fool, like Ryokan, Zen’s “Great Fool”: not having to have a full set of detailed plans, not having to react to every little thing. Going along, just this, just this. How much time I waste thinking about some task I have to do in the future, reviewing a plan which I have reviewed literally 50 times before, and which is also already written down somewhere. So unnecessary. So many moments of life missed. But how splendid that in this very moment, I can be awake again. There is nothing preventing it. I found myself returning to the foundational practice of noting: “Thinking, thinking.” Seeing what is happening is all that is needed. It is not a struggle to achieve any particular state of mind. Awareness itself is the purifying force.

As the days passed, the mind’s reactions became more subtle: zoning out, thinking instead of perceiving, noticing that I was waiting for the pain in my shoulder to go away so my real life could begin. Reminding myself that this is my real life, just this. Noticing my view that if there is any kind of suffering, something must be wrong, which is not true. Feeling that I should have more control over matters, which is also not true.

And then four full days of sitting were over, and it was Sunday morning, and instead of oryoki and instead of two hours of sitting, walking and service, we had one hour, followed by a “convivial breakfast” in the dining room, and what a delicious breakfast it was. Roasted potatoes with a hint of chipotle, fried eggs, homemade muffins, some kind of sweet whipped butter, slices of pink pineapple. Seated next to a young resident, I had eggs and potatoes and was thrown into a dilemma: I had planned to have two slabs of pepperoni pizza after I got back to the sunport, but now I wasn’t sure whether to eat too much potatoes and eggs or too much pizza. (Answer: both!) Tasty problem, and nice chat with the resident, who said she didn’t know my name, so every time she saw me, such as during walking meditation, she said to herself, “There’s [certain movie star],” so I thought she was a very nice young lady indeed.

And then looking at Rebecca’s actual face, after all those hours of silently sitting, eating and walking side by side. Big hug. Plans to get together with the other two Bay Area chaplaincy students to work on sewing our rakusus for jukai ceremony a year from now. Rebecca lives here in San Francisco. As we sat down next to each other in a large circle in the zendo for a closing session of council, I whispered to her, “Let’s be friends,” and she smiled and nodded back.

When it was my turn to speak, I said that I would be taking away two things:

—How could it be otherwise?

—Complications are auspicious.

Back to the sunport, shuttle driver tailgating alarmingly at 75 miles an hour, pizza not quite as good as I had imagined; it was fantastic last time. Minor freakout two minutes before boarding when I notice I am in a back row of the tiny plane. Didn’t I have a seat right near the front? Can I make it all the way back to my seat without succumbing to panic? Though, remember: the farther you are from the front door, the closer you are to the back door. Pleasant surprise: It was still just 12 rows of four seats, but it was a different model plane that seemed much less cramped. Horrendous turbulence leaving Albuquerque. Congenial fellow sitting to me.

Another great thing about my five-day sesshin was that I didn’t hear one single word about Donald Trump the whole time.

Saturday, May 12, 2018

Companionable Walking

Getting back to my room during sesshin entailed walking up a gravel driveway, rather treacherous near the top, and then walking on a paved public road for about 70 paces, and then down another rather treacherous gravel driveway. The walk took about six minutes and was done many times in the course of the five days. Near the front door of our house was a basket with orange safety vests, umbrellas, and nifty flashlights powered entirely by hand cranks. At night, those of us staying in this house walked together and often did the same even during the day, in companionable silence.

Rebecca and I very often walked together. In the morning, we usually left the house together, and during the day we often went back and forth together. Sometimes one of us would wait for the other after leaving the zendo, even though it was broad daylight, so we could walk as a pair. On one nature walk, we had to cross a little brook by stepping from rock to rock. Rebecca saw my look of hesitation when there was a larger step to take. Just as I was considering putting my foot on something with a little water flowing over it so as to take a smaller step, she reached out her hand to assist me. On the first day, I had a very cathartic cry about F. and walked from our house back to the zendo after lunch sobbing and gasping for breath, with Rebecca walking silently behind me. (There was a break after every meal.)

And then of course, we were sitting right next to each other in the zendo for four straight days, and we ate 12 oryoki meals side by side. At the end, there is a complicated process of cleaning bowls and wrapping them back up. Rebecca did this slowly, purposely letting me copy her. At the very end, if you do this right, one corner of your cloth napkin is sticking up at a jaunty angle.

During the one-day sits I did at SFZC, I found these meals excruciating and horrible, and the first two on the first day of sesshin similarly enraged me (while I was still in victim-and-oppressor mode). At lunch, I willfully tied my napkin up completely wrong, and the aforementioned tears came not long after that. After I finished crying about F. and felt cleansed, I decided to make a sincere effort in regard to oryoki, as well as everything else, and things steadily improved. After a day or two, I was able to get my napkin to stick up in the preferred manner and I felt great about it; I hoped the servers were noticing when they came to get our tables at end of the meal. They probably did notice, since every little detail looms much larger when everything is so still and quiet. Doing speed eating never got to be fun, but generally I did actually enjoy those meals, and of course eating itself was appreciated, since I was always starving at breakfast and lunch; a little less so at dinner, due to my afternoon snack.

I thought about how much nicer it is to go on retreat at Spirit Rock, where you can spend half the day napping if you feel like it and nothing bad happens if you arrive late for a sitting or leave early. At school, we were instructed to follow the schedule exactly. At Spirit Rock, people sometimes whip out their notebook and write something down while meditating. At school, we were asked not to blow our noses in the zendo or even to sniffle. If necessary, you can dab discreetly with a hankie or tissue so that snot doesn’t actually drip off your face, but that’s it. It was almost perfectly silent. Once or twice, one of our teachers gently said, “Please be still, and quiet.”

(Sam once grumbled to me that, “During sesshin, my nose sniffled, and someone told me to be quiet!” I thought it was cute that he attributed the action to his nose rather than to himself.)

Of course, the mind is the mind. Even at Spirit Rock, you can end up in a snit, as I have many, many times. You can learn by watching the mind in any circumstances. It doesn’t have to be dead silent, but I appreciated the silence, and it doesn’t have to be kind of uncomfortable, but I think maybe there’s something to be said for that, in that it may accelerate learning. There is a lot of chanting throughout the day. In the morning, we chanted about our “ancient, twisted karma”: “I now fully atone.” That gave a nice sense of purpose: I am doing this for a good reason. I don’t know that I think we are literally atoning for past karma, though maybe we are, but I do think it builds character, or at least understanding, to willingly encounter what is less pleasant.

And I was sitting on a chair! With my hands comfortably on my thighs, literally the only person in the zendo without her hands in the prescribed position. I had received permission to do this when I was there in March, so I just went ahead and did it in April, too. Nonetheless, I was in a certain amount of physical pain. I can’t imagine what the people around me, sitting on zafus and with their hands in mudra, were going through, though I can tell you the air was redolent of Tiger Balm, and I often saw people rocking forward on their cushions and then jerking awake.

And then day one was over! I assured myself that if I could do one day, I could do three more. On the second day, blaming and complaining were gone and instead I found myself welcoming the chance to learn about the mind. “This sucks and here is who is to blame,” gave way to, “I got this. I can do this. This is my life! Am I awake?” I was extremely sleepy during the first two-hour period of sitting and walking and service, and then it suddenly completely cleared up, like a wispy cloud blown away in a stiff breeze. I was getting nowhere near enough sleep any night, but after the second morning, I rarely felt tired again. (Though after I got home, I had to sleep for about a hundred extra hours over the course of two weeks, far more than the sleep I missed while on sesshin, so this was not actual extra energy being generated, just some sort of retreat phenomenon.)

Wednesday, May 09, 2018

New Mexico Speed Eating Contest

The third week of April, I went back to school in New Mexico for a five-day sesshin, which is required each of the two years of the chaplaincy program. I’ve done three one-day sits at the San Francisco Zen Center, which were all horrible, so I was sure a five-day sesshin was going to monumentally suck.

It began on a Tuesday night and ended Sunday morning, so it was really just four full days of sitting in the zendo. Besides sitting, activities included kinhin (walking meditation, mostly super slow but sometimes brisk), service (drumming, bell ringing, incense lighting, bowing and chanting), and highly ritualized oryoki meals.

I was assigned to sleep in a room with three other people in a gorgeous house with four bedrooms of various sizes, three bathrooms, a huge open kitchen, a big living room with a comfortable couch and several capacious chairs, and a good-sized dining room with a massive window looking out onto a grassy field and the piney mountains beyond. All three of my roommates had smartphones in evidence to a greater or lesser degree throughout our time there, and one even brought a laptop. We were in silence, but relations seemed congenial. One of my roommates was someone who is in my chaplaincy cohort. Besides us four, there was a lone person staying on the other side of the house.

The first sitting of the day began at six a.m., with an optional sit at five a.m. On the first full day, I was extremely sleepy and kept finding that, without my having intended it, my eyelids had clamped shut. Over and over, I forced them open and tried to stay awake. My shoulder began to hurt, and I observed my tendency to list complaints, at the very least, and if possible to find someone to blame: an oppressor, with myself the victim.

There were about 40 people at this sesshin, roughly half residents of the Zen center and half visitors like myself. About 35 sat on cushions, and five, including me, on chairs. I was seated next to a woman who was also using a chair. She is in my chaplaincy cohort, and works at the hospital where I did my year of Clinical Pastoral Education. She also turned out to be the person staying at the other end of the house where I was staying. I will call her Rebecca.

After two hours of sitting, walking and service, it was time for oryoki breakfast, our first such meal of 12. Each of us was assigned three nested plastic bowls with a cloth napkin, a wiping cloth, and a little cloth envelope containing chopsticks, a wooden spoon, and a wooden spatula. Those of us sitting on chairs were each brought a small wooden tray table. When the person with my table arrived, we bowed to each other, and then the person set the table down and I put my oryoki set on the table, and we bowed to each other again, and the server withdrew.

I didn’t count, but a day of sesshin must entail bowing a hundred times, including many during each meal. Each aspect of oryoki is done in a precise manner, preferably silently and preferably with everyone doing the same thing at the same time. You must unwrap your bowls and set everything out just so. Each implement, however tiny, must be handled with two hands. There is chanting. Then the servers bring out the first dish and serve the two teachers, and then they go around to two people at a time. This is happening on both sides of the zendo simultaneously.

The server arrives before you and your partner with the first dish. Facing Rebecca and me, the server would bow and we would bow back. Then the server would sink to his or her knees on the wooden floor and Rebecca would lean over with her largest bowl while I kept my hands together in front of my face, in bowing position. There are particular hand gestures to indicate if you want a lot more food, a little more, none at all of a particular thing, or when you’ve received enough. After Rebecca received her first dish, I would bend over and receive mine, and then the server would rise to his or her feet, while holding a heavy pot of food with both hands, and then we would bow to each other again, and the server would move on to the next two people.

All the servers but one were men. I learned at the end of the sesshin that each was wearing thick knee pads, though you could hear the alarming sound of cracking joints now and then as these hard-working people, all residents of the Zen center, sank to their knees and got up again over and over, always holding something in their hands, often something heavy, so that they could not use their hands to help them get up from the floor.

So. At this point there was food in one bowl. The whole procedure was then repeated for the second bowl, and the third, and then the condiment was delivered: gomasio, a mixture of toasted sesame seeds and salt. When the server arrived with a tray containing several little bowls of gomasio, Rebecca and I would bow to him, and then he would kneel down and Rebecca would take one of the little bowls off the tray, the server would rise to his feet, we would bow to him, and then Rebecca would put gomasio on her food while I kept my hands in bowing position. Then she would turn gravely toward me and we would bow to each other—but no eye contact—while she handed me the gomasio, and then she would keep her hands in bowing position while I used the gomasio, and then I would attempt to set the little bowl down on the corner of my tray table without the tiny spoon clinking against the edge of the bowl and without the bowl clattering against the wooden table. Sometimes both noises occurred, sometimes just one, or, with enough careful attention, neither. Then Rebecca and I would bow again toward our meals, everyone else in the zendo ideally doing the same.

Then it was time for chanting and a couple of ritual gestures and, finally, time to eat! This must be done absolutely as fast as possible, so that you don’t end up being the last person to finish. Almost invariably, the thing in the smallest bowl was crunchy and took a long time to eat, so if you were the last person, you had to sit there with your every loud chomp being the only sound in the room,

Obviously, this is undesirable, so I shoveled in every meal as quickly as possible, adding more and more food before swallowing, and never was I the last person eating. A time or two, I feared I might choke, and certainly you don’t have time to appreciate what you are eating, which in the first two bowls is mainly gloppy stuff: oatmeal, rice, quinoa, vegetable soup, boiled or pureed fruit. In the smallest bowl, we usually got salad or other vegetables. The salads were often creative and beautiful, and everything was quite delicious. It was kind of a shame to have to gulp it down, and I also was sure digestion would be impossible with so much unchewed food going down the hatch, but that did not prove to be the case at all, maybe it because it wasn’t very much food. Even the largest bowl is pretty small.

The sound of stomachs growling was not uncommon. Apparently, at the San Francisco Zen Center, snacking food is put away during sesshin, but here everything was generously just as always in the kitchen: mixed nuts, candied ginger, dried prunes, a selection of crackers and breads, fresh fruit, butter, peanut butter, almond butter and sometimes hard-boiled eggs were always available, along with filtered water and a selection of teas. I know people worked really hard to prepare and serve those meals, so it seemed rude to rush to the kitchen right after a meal to eat something else, so I never did that. However, each afternoon we had a nature walk, and beforehand, there was a bit of free time, so every day at that time, I went and had a piece of cinnamon-raisin toast and some nuts.

Monday, May 07, 2018

Outstanding Chaplaining, or At Least Quite a Bit of Chaplaining

Fifteen minutes before I arrived at work one day last month, I noticed that the on-call pager had gotten a page. After I punched in, Carolina, who was coming off call, told me there was a seriously ill patient at another campus for whom there was going to be a family meeting. A chaplain’s presence at the meeting was desired, so I headed over there and ended up spending nine and a half hours with the family, which I thought was outstanding chaplaining, but I know my boss would think the opposite, so I didn’t draw it to her attention, though of course I recorded everything accurately in my stats.

Probably 30 times I have said to a family in a similar situation that I am happy to stay if needed and they have said, “No, you can go. We’re fine.” If you average those with my long, long visit that day in April, it comes out to be a reasonable amount of time per visit.

It ended up being so long because the patient, in the course of the day, had about 30 visitors, and it took many hours before the family decided about going to comfort care. I’d gotten it in my mind that I was supposed to be there until they made a decision, and a key family member didn’t arrive until about 5 p.m., so the decision—which was to go to comfort care—was not made until after that.

At that point, it seemed reasonable that I would stay until the patient actually went on comfort care, which was a couple of hours later, and having stayed until that point, and knowing the patient was not going to live long after this transition, it seemed right to stay until the patient died, which did happen almost immediately, and having stayed until the patient died, I thought it would be only proper to support the family in their grief, to help explain the sequence of events after a death, and to offer condolences as people left, and that’s how it got to be nine and a half hours.

(The sequence of events after a death is that the patient’s body is placed in the morgue, where it can remain free of charge for at least several days while the family decides what they are going to do. Typically, they make arrangements with a funeral home, and then the funeral home arranges to fetch the patient’s body from the hospital.)

Much of those nine and a half hours, I was standing, because there were only three chairs in the room. At school, we are learning how our meditation practice and adherence to Buddhist precepts (ethical conduct) can be applied to chaplaincy, but that day, with my sesshin at school beginning two days later, I consciously did the reverse. As I stood there and stood there and stood there, I told myself, “Just this moment,” and recognized that I was strengthening qualities I would need for sesshin: endurance, patience, determination.

I learned a couple of interesting things that day, including where to see oxygen saturation on the bedside monitor. A nurse told me that a patient with low blood pressure might be given pressors (medication to boost blood pressure, such as epinephrine), and that usually such a patient is not given painkillers because they depress the blood pressure, working against the pressors. When an intubated patient in this situation is transitioned to comfort care, the nurse might then start giving painkillers, so that the patient doesn’t feel uncomfortable during the actual extubation and when back to breathing on his or her own; being short of breath is unpleasant. After the patient has been receiving painkillers for a while, such as fentanyl, then the extubation can occur, and after that, the pressors can be turned off, in which case such a patient will likely die within minutes.

There was a young doctor attending to the patient who had so many visitors. I liked how he took a very leisurely approach, coming every couple of hours to see what the family was thinking, answering questions, not rushing them in any way.