Sunday, February 26, 2017

Enchilada Miracle Cure

Last weekend Tom and I went to see La La Land. I was expecting it to totally blow me away, but it didn’t, I think mainly because of the cinematography, which seemed murky. Also, it seemed kind of sad: the romance didn’t work out. But it was fun to watch Emma Stone. She is darling.

On Tuesday, we had our end-of-unit party. We ate pizza and played Two Truths and a Lie and the smart phone game Heads Up! We each wrote on one side of a card what we are grateful for about our departing colleague and on the other side a good wish for her, and then all the cards were strung together into something like a Tibetan prayer flag.

As mentioned, I was reading a number of articles preparatory to taking a test, part of the whole process of applying for a palliative care internship. One of my peers said she had found the test very difficult; she wasn’t even sure she had passed it. I was surprised, since it is a multiple-choice test. Later I asked her if the test had required knowing the names of the articles and their authors. She said it indeed had, and added something like, “Great—now you’re probably going to pass it after I failed it.”

It seemed unfair not to share this knowledge with two others who plan to take the test, so I told them when we were in a car together later that afternoon. But my conscience increasingly nagged at me: if I passed the test due to what my colleague shared with me, and she failed it, that would be extremely unfair.

I decided that I needed a clean conscience more than I needed a good score on the test, and resolved to proceed as if my colleague hadn’t given me those details; I also resolved never again to solicit such information. But what about those other two people?! What if I virtuously didn’t use what I learned, and they did, and they both passed the test and I failed it?

I sent a note to the first colleague apologizing for having asked her and letting her know I was going to prepare as I’d planned to before our conversation, and I sent a note to the other two saying I wasn’t going to use the information and that I didn’t want an unfair advantage over anyone. One of them wrote back and said he commended my ethics, but he sees being able to pick up knowledge on the fly and make good use of it as an asset, not a liability, which I took to mean he would certainly be using what I’d told him. As it turns out, the test seemed very easy. Evidently, what I did to prepare was perfect.

I also am going to have a short phone interview Monday afternoon regarding moving to the children’s hospital, though I’m pretty sure I don’t actually want to leave my current campus and peers, nor the staff members I have built relationships with. Also, the other campus has way fewer patients and, by all accounts, life there is rather cushy in some respects (though certainly not when it comes to the loss of young patients). This is my only opportunity to do a year of clinical pastoral education at this prestigious institution, and I don’t want to spend half the day staring into space.

Apparently, everyone at my campus feels the same way, so I heard that our supervisors are considering an arrangement where no one would move over there entirely, but just spend some time there each week. If I don’t get one of the palliative care slots, I would be very interested in that.

On Wednesday and Thursday, we presented our final self-evaluations for the unit. Our supervisors treated us to Mediterranean food. Several of us emailed our self-evaluations to the whole group, and thus I saw beforehand what one of my peers had written about me, and was bothered by it. The morning of presentation day, I asked Tony if he had some time, and we went to a classroom with a beautiful view of the ocean and Marin County and talked it over.

I couldn’t decide between rebutting what she said, which actually seemed inaccurate, and just saying “Thank you.” Tony read the objectionable paragraph to me, which helped me see that it was actually mostly positive, and that the parts that had wounded me were a minority of the whole thing. They were also accurate, not in regard to the verbatim discussion my peer cited, but overall. And we are explicitly instructed to offer critique to each other, so here it was. Tony had also found his critique from this same peer difficult, so discussing this and sharing our feelings with each other ended up being tremendously helpful.

When my peer read her feedback for me aloud that afternoon, I said, “Thank you.” At the end of the afternoon, we recruited someone to take a picture of the five of us plus our supervisors. I hardly recognize myself in this picture. I don’t know what has changed, but something has. Probably CPE has aged me about 20 years. Also, I think I need new glasses, preferably with progressive lenses. About 50 times a day, I have to move my glasses so I can make a note on my patient list.

The famous cancer patient I mentioned is back in the hospital and appears gravely ill. On Friday afternoon, I was on my way to see her and was rather unnerved when I glanced into another room in the ICU and saw someone I know very well, also someone who neatly brings both Carlos and F. strongly to mind. She is a guest of the soup kitchen where I met F., and she was also a friend of Carlos’s. In fact, she was one of the last people to see him alive. Several hours before he died, she arrived in the palliative care unit at Zuckerberg San Francisco General Hospital with a big bag of Mexican food, which she hoped might be evocative or comforting for Carlos. Actually, I think she expected it to bring him back from death’s door, but it didn’t do that.


This is from two years ago

(Click photo to enlarge.)

Sunday, February 19, 2017

Rich and Educational

Last Sunday evening I went to the Thomas House potluck. I brought a little stack of Puffs with Lotion with me because I assumed that remembering F. would make me cry on the way in and out, but there weren’t any tears at all. It was great to see my soup kitchen friends. My walking friend gave a few of us rides home afterward. A year or so ago, I was in his car with a couple of people who really made me laugh, and last weekend, the same people were in the car and again made me crack up. It was the best laugh I’d had in weeks.

Last week at work we had didactics on assessing palliative care patients, treating Jehovah’s Witnesses (whose religion prohibits them from receiving whole blood transfusions), and working with patients with clinical depression. We also had a second session on transference, the psychological kind. Chaplains are frequently on the receiving end of this, and of course may fall into countertransference ourselves. These are exactly the same: mentally superimposing someone else on top of the actual person we are with and reacting accordingly, but when the care receiver / patient / client does this, it’s called transference and when the caregiver / chaplain / therapist does it, it’s called countertransference.

Tuesday was Valentine’s Day, and would also have been F.’s and my second anniversary. I was tempted to text him after work, but made it to the end of the evening without doing that.

I saw a patient this week whose wife left him in quite a cruel way after he became ill. He cried several times during our talk, and said he was thinking of reconnecting with his faith. I was impressed that in the midst of such a staggering amount of loss, he was able to come up with some sort of constructive plan for continuing with his life. The next day, he was sitting up in a chair and said he would be going home that afternoon. He was smiling, and I saw that someone had brought him colorful balloons.

A Code Blue occurred on my own unit Friday afternoon while I happened to be there. The patient was a man with Down Syndrome, who was soon stabilized. After a while, every member of the care team left the room and the patient was alone, so I went in, and the patient stuck his hand out to take mine. I sat next to him holding his hand for half an hour. He said two or three times, “I don’t want to die.”

This week we had our final session of presenting verbatims and last interpersonal relations group. The unit officially ends next week, when we will share our end-of-unit self-evaluations (not to be confused with our mid-unit self-evaluations) and have a party. I have arranged to take the test for the palliative care rotation next Wednesday. My statement of motivation is almost done.

There is a lot happening right now, including that one of my peers has developed health problems and has to leave the program. She works at the children’s hospital, so one person from my campus will move over there to take her place, and we’re going to get a brand-new intern who will do the second half of the year with us. So now besides the possibility of doing the palliative care training, there is the possibility of moving to the other campus for the rest of the year to work in the birth center and infant care nursery. I sent an email to see if it’s possible to apply for both or if they would prefer that we make up our minds up front and proceed down one path or the other.

In the past month, three interns who are doing an extended (part-time) unit of clinical pastoral education through June have joined us, and recently were able to start taking on-call shifts (so we like them very much, though we would, anyway; they’re all great people). It is our habit to say to each other before an on-call shift, “May your on-call be just what you need.” A co-worker once overheard me receiving this wish from our peer who is a rabbi and asked, “Educational, right?”

“No, no!” I said, before God could hear the rabbi’s prayer. “Restful.”

As it happens, that was a restful night, so the rabbi now has a reputation for magically effective prayers, and so we understood him to be undertaking a mild act of hazing when he said to one of the new students, “May your on-call be rich and educational.” Oh, no! Our colleague ended up getting two hours of sleep, partly due to getting a call at 3:30 a.m. from a patient who had had a nightmare—whose partner was right in her room!

So this is now a joke among us. One student who was pretending to be displeased with another said, “May your afternoon be rich and educational.”

More than one of us is a believer in the healing properties of oregano, but whereas I use it the way a normal, well-adjusted adult does—by applying the oil to my throat when illness threatens—one of our younger students eats huge quantities of the dried herb, and another drinks oregano tea. I think she may have influenced someone who is susceptible to peer pressure, because when we were recently together as a whole group, a foul miasma of oregano hung over the proceedings (oreganic miasma?).

Sunday, February 12, 2017

Full of Possibility

In case you don’t happen to be reading eight articles about palliative care, here’s a brief overview. Palliative care is often confused with hospice or with comfort care, but while a given patient might be receiving all of them, they refer to three different things. Comfort care is in turn sometimes wrongly characterized as withdrawal of care, but we were instructed never to put such a phrase in any patient’s chart. (Let alone say anything about “pulling the plug” on a patient, which one of my young colleagues actually did write in a chart. Come to think of it, it was not long after that that we had the didactic on charting, so the two were probably not unrelated.)

Anyway, we never withdraw care. Patients might “transition from cure (or curative care) to comfort care” or they might “transition from intensive interventions to comfort care.” “Compassionate extubation” might occur, or “withdrawal of interventions.” We might, per the patient or his or her decision-maker, “allow for natural death.” Comfort care is focused exclusively on making sure the patient is clean and warm and free from pain and discomfort.

Many patients on comfort care might indeed be hospice patients—people with terminal illnesses who are expected to die within six months. Curative care is no longer provided, a do-not-resuscitate order is almost always in place, and the focus is on helping the patient to live as full a life as possible.

And certainly a hospice patient on comfort care might also be receiving palliative care, which focuses on relieving suffering and providing the best possible quality of life for the patient, who might have a terminal illness and be expected to die within six months but who also might have a condition that can’t be medically cured regardless of life expectancy. Sometimes people begin receiving palliative care immediately after diagnosis, long before becoming a hospice patient.

Quoting from “Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference,” from The Journal of Palliative Medicine, Volume 12, Number 10, “Healing is distinguished from cure in this context. It refers to the ability of a person to find solace, comfort, connection, meaning, and purpose in the midst of suffering, disarray, and pain. The care is rooted in … the recognition that, although a person’s life may be limited … it remains full of possibility.”

That means that even though I might never see F. again, my life remains full of possibility! I felt happy when I read that, and I generally feel happy today because the sun is out, and I got my laundry done, and also my weekly trip to Rainbow, and my periodic giant delivery from Pet Food Express, and later I’m going to the Thomas House potluck.

My shopping list now says “IOS” all over it—buy this thing if on sale. I’m also planning ahead in order to take advantage of various discounts Rainbow offers if you spend a certain amount in a couple of different departments, one being bath and body. Today I got to buy, among other things, six bottles of fluoride rinse, so I certainly felt happy about that.

I also bought chocolate! I have not eaten sweets in more than five years—an even more remarkable feat these days, as the student table at work is always groaning under the load of doughnuts, cookies, candy, cake and pastries. (Actually, I am not at all tempted.) I read in the AARP magazine this week about the health benefits of chocolate, and at Rainbow, I got a bar of Pacari Raw Organic Chocolate, 100% Cacao, socially responsible, no sweetener at all. The only ingredient is cacao. I thought it would taste just like baking chocolate—bitter—but it somehow is not bitter, and it does that nice chocolate melting thing, so life is good.

If you want to read just one extremely excellent article about palliative care, read
“Letting Go: What should medicine do when it can’t save your life?” by Atul Gawande in the August 2, 2010, issue of The New Yorker. I had read this before and it is also one of the eight assigned articles. It is superb.

Saturday, February 11, 2017


I was on call at the other campus starting on Friday. Today was the first day it hasn’t rained in what seems like weeks. It was nice and clear and I was stuck inside the entire day, because the phone that is used to contact the on-call chaplain doesn’t work outside the building, but I still enjoyed looking out the window at the blue sky.

It was a quiet evening last night, greatly aided by the fact that I didn’t do any of the rounding we’re supposed to do. Am I going to become one of those chaplains who sits in the office eating doughnuts instead of seeing patients? I was forced to see two patients today, and felt somewhat joyful after seeing one of them, a young woman with an eating disorder. We talked for quite a while.

Tom and I were thinking of going to another movie next weekend, but I decided I can’t, because I have to do palliative care reading, and write my end-of-unit self-evaluation, and prepare for my mid-year consultation, not to mention other assigned reading that is piling up, and some reading I was going to do of my own accord to better understand the group dynamics model one of our supervisors favors.

I was also going to go to the Thomas House potluck tomorrow evening for the first time in months, and then decided not to do that, either, for the same reasons, or so I thought. Then I realized it’s because going somewhere with someone other than F. doesn’t sound fun. He and I used to go to the potlucks together. I can still clearly remember the last one we attended and something he said while he was there. Nothing major, just something that sticks in my mind, in the voice I’ll probably never hear again.

Nor will I ever do anything with him again (unless a whole set of small miracles occurs), and I guess I can’t not ever go anywhere again because I don’t get to go with him, so I called Tom back and said I would like to go to the movie, and I might even go to the potluck. Though I really do have palliative care reading to do.

Death Doula

I saw one of the doctors at the student health service a week ago and was pleased to learn that my blood pressure is nice and low, and my resting pulse is 53. Since I was there to discuss a tiny but nagging pain in my abdomen, I was also pleased to learn that pancreatic cancer doesn’t normally present with pain. I liked this doctor, who said minor things tend to get better and major things tend to get worse, so we made an appointment for a month from now, just in case, and I’m going to keep a log. Whatever this was already seems to be lessening.

It is a well-known fact that doing a year of clinical pastoral education causes a 20-pound weight gain, so I was also happy to discover that, at the halfway mark, I have lost 3.5 pounds. Since I should have gained 10 pounds by now, this means I have lost 13.5 pounds. (Right?)

In the past week, Tom and I went to see Hidden Figures, which I enjoyed, and my friend Karen, having come by free tickets, treated me to the San Francisco Symphony’s Lunar New Year concert, preceded by pizza on Hayes St.

I’ve been kind of down lately. I think three units of clinical pastoral education in a row is catching up with me. I’m still allowing nine hours nightly for sleeping, which is normally enough, and my schedule doesn’t allow for any more than that, but every morning, I feel as if I could easily sleep for three more hours.

During units three and four, one lucky student apiece will get to do a palliative care rotation and be mentored by TWMC’s main palliative care chaplain. This was mentioned at the beginning of the program, and I immediately assumed I would want to do this, with my background as a hospice volunteer. We learned in the past week that in order to apply, we would have a giant pile of reading to do, and then take a test based on the reading. The first five people to take the test would be invited for an interview. Stress ensued, as we were now in direct competition with each other. One of our three peers whose first language is not English expressed discouragement—she said it takes her twice as long to read in English—and another person for whom English is a second language said he would not bother to apply at all.

I guess enough people complained that our supervisors decided to revamp the process, and now we simply have a deadline for finishing the reading and taking the test, and the five people with the highest test scores will be the ones to interview. I mention all of this in part because I think my gloom started right around the time this was announced.

I spent an hour with Patricia (the chaplain who led the enneagram session) this past week and she said she thought I’d be an excellent hospice chaplain. I mentioned that I’m thinking of pairing that with being a bereavement counselor and she said those fit nicely together, and if I have an entrepreneurial streak (which I really don’t), I might think about being a death doula in private practice. A doula provides physical and emotional support during and after childbirth. A death doula would accompany a person who’d gotten a terminal diagnosis. I could totally see myself doing that.

I mentioned that once CPE is over, I’m planning to do the two-year program at Upaya Zen Center (in New Mexico, where it’s sunny!) and I hope to work two days a week as a chaplain. Upaya requires volunteering, so I thought I would do the Sojourn chaplaincy training at Zuckerberg San Francisco General Hospital and volunteer there, but Patricia mentioned the Zen Hospice Project, lately enjoying a higher profile due to an article in The New York Times Magazine about B.J. Miller (“One Man’s Quest to Change the Way We Die”). (Also probably now thousands of people want to marry B.J. Miller, who is extremely attractive.) (One of my peers used to work at Zen Hospice and can text B.J. Miller at will.)

Patricia said the Sojourn program is excellent, but noted that the Zen Hospice Project has a national reputation, and the lights in my grasping little brain lit up: ZHP will look great on my resume! Doing the palliative care rotation ditto! But right after that conversation is when I started to feel gloomy, and more so when I heard about having to do hours of speed reading in order to try to beat my colleagues to the finish line. I was very glad when I found out that won’t be necessary, but I still feel that something is not right here. Do I actually want to be a palliative care chaplain, let alone a death doula? Or even a chaplain at all?

However, one of our supervisors pointed out that we can be accepted into the palliative care rotation but decide not to do it, and it seems silly to close that door prematurely, so I am planning to do the reading (much of it the kind of dense academic stuff I normally avoid) and to take the test, and we’ll see. We have already had a couple of sessions on palliative care and will have at least a couple more, so it’s not like we’re not going to learn something about this. If my test score is not among the top five, at least I will have learned something by doing all that reading. We have to write a one-page statement of interest in the training, as well, so I’m also working on that.

Tough Row to Hoe

At work I saw a patient who took a seemingly minor fall nearly a year ago which caused a spinal cord injury and changed him from a strong, healthy person to one who hobbles about with a cane and is treated like an invalid. He asked several times why God was angry at him: if God is in charge of everything and I have a terrible situation, God must have done this to me on purpose. I am hardly a master of theology or theodicy (sticking up for God even though he does bad stuff to nice people), but my approach to this was to find out how he would treat a friend who was dealing with difficulties. It turned out the patient doesn’t have any, but he does have children, so I asked him to imagine how he would comfort a tiny child who had fallen and skinned her knee, and tears came to his eyes.

I returned to that idea a couple of times during our long visit, and toward the end, I led him in a guided meditation starting with mindfulness of the body, followed by loving-kindness (metta) for himself, and concluding with a bit of gratitude practice: cultivating the prosocial emotions that build resilience and are protective against debilitating stress. He became teary again during the loving-kindness part, as people often do.

Just before leaving, I again mentioned the idea that perhaps God loves him very much and is in fact sending kindness and comfort, just as he would have offered to his own young child. To my surprise, the patient smiled and said gently, “Well, maybe I’m supposed to learn something from this.” And then, sounding almost jovial, “He’s certainly given me a tough row to hoe.”

The next day, I encountered a patient with terrible abdominal pain and tried my first guided meditation aimed at coping with pain. I did the same thing as described above, except that after mindfulness of the body and before loving-kindness, I asked the patient to let his attention rest on the painful area. He winced, so I said, “I see your wince. Let your attention move out to the edge of the painful area, to the border between where it’s painful and where it stops being painful.” This idea came from my own hours spent sitting with physical pain on meditation retreats. I suggested that he cultivate a sense of allowing the sensations he was noticing to be present and explained that it is natural for us to resist pain, but that pushing it away makes the whole experience more miserable.

Then I asked him to identify a part of his body that didn’t hurt—a foot or hand—and let his attention rest there. After a bit, I asked him to notice the edge of his pain again, and then the pain-free area again. I borrowed this from Somatic Experiencing, which I took a class on at the Zen Center. Then we went on with loving-kindness and gratitude.

For gratitude practice, I might say, “Thinking now of something we’re grateful for, even just a small thing. Maybe your nurse smiling at you or a pleasant conversation with your nurse, or maybe something delicious you had for breakfast. Remembering that pleasant moment and noticing how it feels in your body to remember this.”

At the end of the meditation, I thought the patient was going to say, “My abdomen still is killing me, but I feel a little more relaxed.” But he said, “That was really nice!” and when I asked how his pain was, he announced that it was gone! I’m sure it was back soon enough, but I’m glad he had some moments of relief. The whole meditation took less than ten minutes, and consisted of simple steps the patient can easily do on his own if he feels like it.

Another day, a nurse asked me to see a patient in an overflow pre-op area that I didn't even know existed. The patient was deaf and a sign language interpreter was present. The patient understood the interpreter so readily and responded verbally, in perfectly smooth English, so quickly that I could hardly believe she was deaf. I stopped by the front desk to get the patient's record number so I could chart the visit. The woman who works there, who is a character and who often makes me smile, checked to see if I could access a system that tracks surgeries and we found that I could.

Poking around there later, I noticed two patients whose records were adjacent to each other and who had the same last name: what are the odds? But then I took a closer look and saw that one was donating a kidney and the other receiving one.

I also saw a man of less than retirement age who came down with a mild case of flu and was dead less than two weeks later, his final few days spent in the ICU, with his children and wife at his side.


(Click photo to enlarge.)