Saturday, April 22, 2017

Dazzlingly Lovely Flower

The next morning, a physician said something to me in the palliative care rounds meeting that initially was quite jolting. He said, “I’m not comfortable with you as a chaplain.” I spoke up for myself in what I thought was an appropriate manner, and the physician clarified that he was merely saying that, while Delia was on vacation, he felt unequal to the task of mentoring me, since he is not a chaplain. I saw that I had projected onto him, which I acknowledged in the moment, and the interaction ended in a relaxed, agreeable mood.

However, possibly that very day, I accompanied the palliative care team to visit a woman in the ICU, and after we left, her relative joined us outside the room to share some bad news he had gotten about another family member. I said I’d be happy to return to offer emotional support. He broke in to say excitedly that he had been hoping emotional support was available, but instead of letting him talk, I finished what I was saying: I talked over him. As with visiting the wrong patient, I felt embarrassed afterward and again feared that the palliative care team will think I’m incompetent. I comforted myself by remembering how our new supervisor asked me to do joint visits with him. He said, “I heard you’re the all-star chaplain, and also that you’re good with the charting system.” Nice to think someone is saying good things about me.

One day at work, I went to a very interesting panel discussion about how care team members respond emotionally to patient requests to exercise the End of Life Options Act.

It has now been four months since F. left me, and the pain has abated noticeably. Particularly since starting the palliative care rotation, I’ve hardly had time to think about him, but it does occur to me that the relationship itself, like a person, was subject to sickness, old age and death. I think of us as having been a dazzlingly lovely flower that bloomed for a whole year, but then wilted, became ugly, fell. No one thought this was going to be a good relationship, including me, but it exceeded expectations. My mother said once or twice, “That worked out better than I thought it was going to.”

This past week, the palliative care team visited a woman, not much older than I am, who is dying and terrified. She loves God, but wonders where he is. The physician in our group talked to her at length, in Spanish, about end of life choices. I would never have been able to conduct this conversation myself in Spanish, but could understand pretty much everything the doctor said (less so the patient). After we’d been with the patient for about 30 minutes and the meeting was maybe winding down, I asked the physician to ask the patient what she would say to her own child if her child expressed that she was scared and felt God had abandoned her. The conversation ended up going in a different direction, but I think that might have been an interesting question. Or maybe it would have been too theoretical and too complicated for someone feeling so frightened. However, just saying, “Of course God loves you!” seems useless, which none of us did say.

One day, I went to a meeting with a palliative care doctor, a patient’s wife and his grown children. The situation was quite dire, and the wife periodically wept. Meanwhile, one of the children talked and talked, throwing out possible plans and ideas. After about an hour, the imbalance between the grief at one end of the table and the verbalizing at the other seemed so glaring that I asked if we could just sit together silently for a few moments. I said, “Maybe we can take a few moments to notice how it feels to be having this conversation about your husband, and your father.” We did that, and then the meeting drew swiftly to a close.

The doctor said afterward that he had been trying to think of how to end the meeting, and that he never would have thought of doing something like that. He said, “Just like that: poof! The meeting ended.” I liked that the idea arose very naturally, as if on its own. That makes me feel I can trust my intuition.

Late this past week, a woman from Zen Hospice came to the hospital, which I guess she does every now and then. She attended rounds and thought a certain patient sounded like a great candidate for the hospice. After rounds, she and I went to see the patient together. She did all the talking and I observed. She described what Zen Hospice is like and what services are available there, and finally asked the patient, “Does that sound like somewhere you would like to go?” The patient said he did want to go there, and the woman said she would go start the paperwork; he could go the very next day.

But the very next day, he was dead. I couldn’t believe it, but then realized he had spent his last day thinking he was going to go somewhere wonderful, and maybe that is just what he did.

A Trip to the Morgue

A couple of weeks ago, I noticed there was a mourning dove sitting on a nest on the fire escape outside my living room window (my living room being the same as my bedroom, office, gentlewoman’s cave and workout area). I saw there were two eggs on the nest after the mother (or father) for whatever reason flew away. The parent had not been gone for more than two seconds when a large black crow landed and began to pluck at the edge of the nest with its beak. I shooed it away, and it was lucky I was watching at that exact moment because, according to my father, the crow would have eaten the eggs. He said birds will even eat the young hatched children of other birds. After several days during which a parent was present every time I looked out the window, the baby birds hatched, and a time or two I saw their scrubby little bodies peeking out from under their parent.

At work that week, I saw a note from one of the palliative care social workers saying that a certain younger patient does not want chaplain visits and had asked Delia to leave his room. I was pleased to be able to report that I had had a perfectly civil, if short, visit with him. I said that he said he is being visited by his wife. His wife? He was not known to be married. Why, yes, his wife, coming from such-and-such Bay Area town. Bay Area? This patient lives in another state. When I was asked during rounds meeting to describe the patient, it finally became clear that we were talking about two different people. I said I would delete my chart note and figure out how I had come to see (and chart on) the wrong patient. To make such a blatant screw-up was rather embarrassing, though the social worker assured me that she has done something similar, and that everyone has.

Right after the meeting, I went to that patient’s room and immediately understood what had happened. As I approached the room, noting the descending room numbers, I saw personal protective equipment on the door of what was likely to be the correct room, based on the number of the room next door. Or was it personal protective equipment? Maybe it was the equipment those who clean the room are supposed to use if the patient is receiving chemotherapy.

Fortunately, just then a nurse popped into view and I asked her. She explained, and I turned and went into—the wrong room. I sent a note to the palliative care team saying I’d figured out what had happened and had removed my chart note. I got a note back from the social worker later that afternoon saying, “Just wanted to let you know that we are so very appreciative of your presence this week. We completely trust your instincts, skill and wisdom as a chaplain. I can imagine that today was quite difficult. [The other social worker] let me know about the morgue experience.  Hoping we can check in tomorrow. Sending hugs.”

As for the morgue experience, I got a call saying that the family of a deceased palliative care patient wanted him to have a blessing. The staff member who normally brings the body into the viewing room was not available—would I mind doing this in “the cooler”? I said I would not mind, though my true feeling was that there was nothing I would less rather do. Anita offered to come with me, but I decided to be brave.

A young woman let me into the necropsy room. Beyond her, I could see a man poking at something red and pulpy lying on a table, evidently an autopsy in progress, something I had had an active desire never to see. The young woman opened the door to the freezer, where there were five or six bodies wrapped in white bags. She offered to bring my fellow into the room outside the freezer (or perhaps not a freezer as such; a cold room), where her co-worker was, but I also actually didn’t feel like seeing the face of the frozen dead person, so I said, “No, that’s fine,” and I stood in the doorway of the freezer and offered a blessing to the patient of interest, as well as to the others in the room, while I was at it. I wondered if I should make the gesture of touching his head through the bag, but did not want to and did not.

Before I left, I asked the young woman, “Is your co-worker working on a head?”

“Yes,” she said. “A fetus.”

I then called Jodie, one of our supervisors, to see if I’d cheated by not having the man brought out and uncovered. “No!” she assured me. She said the family just wanted a chaplain to be near their loved one and offer a blessing. I told her about the autopsy and she was sympathetic. She asked if I’d ever seen one before, and she said she has seen two. She said I should feel free to come by to debrief further if I wanted.

That afternoon, when I got home from work, I went to the window to admire my birds and saw that the nest was empty. When I turned on my computer, I saw a note from the manager of my apartment building saying it had come to her attention that nasty, poopy birds were nesting on the fire escape, and might she go through my apartment to deal with the situation?

I was upset. I cried. I didn’t think she would harm baby birds, but I suspected she might have shooed the parents away long enough for the crow to get them. But it turned out that she does know you cannot disturb nesting birds, and she said that when she went through my neighbor’s place to get to the fire escape, the nest was already empty. Maybe a big aggressive bird scared the parents away and ate the children. I was relieved when I learned that, though a tragedy had occurred, we had not caused it.

That first night, the parents were clearly in distress. They flew around close to the nest, and periodically, one of them stood on the nest and looked down as if somehow the babies would reappear. I kept looking, too, thinking maybe somehow they would come back.


(Click photo to enlarge.)

Sunday, April 09, 2017

Aid in Dying

We visited a patient last week who is fairly young, has metastatic cancer (“mets,” as it is written in charts) and wants to exercise her rights under the End of Life Options Act. It is my understanding that those working in palliative care do not particularly want to be associated with the suicide of patients and, further, that they believe that in many cases, when someone wants to do this, it is a quality of life issue, such as untreated pain, depression, or anxiety.

So I was touched when our social worker answered affirmatively, saying she would bring more information. In the course of a long and unhurried conversation, it emerged that the patient is dealing with a lot of pain, and that when she is not in pain, she does not feel like using the aid-in-dying medicine. It was neat to see the textbook come to life, or so I thought until I mentioned this to the social worker the next day and she reminded me that actually, what the patient said was that when she’s not in pain, she doesn’t feel like slitting her wrists. She always feels like obtaining and taking the end-of-life medication (which is morphine plus a sedative; 30 pills, give or take) because she wants to be in charge of when the end of her life comes. I was not listening carefully enough. The reason the social worker was supportive is that, most of all, palliative care providers want the patient to get what she wants, when possible.

We also visited a fairly young couple who wanted advice on talking to their two sons about the wife’s cancer. I felt sad about this young woman whose death is likely not too far off, but worse for the partner who will be left behind. It seemed at first that he didn’t want to talk to us, but by the end of the visit, he (and his wife) seemed grateful for Delia’s assistance.

Mid-week, during a time when Delia wasn’t around, I got to go to a care providers’ meeting for a patient whose sister has been at her bedside nearly 24 hours a day. (I know both of them from the soup kitchen; this is not the same as the woman I was mentioning a couple of weeks ago whom I also knew from there.) There was a geriatrician at the meeting who spoke passionately about changing this blind patient’s medication so that she doesn’t sleep 22 hours in a row and about engaging her other senses. Since the patient likes to put things in her mouth (in fact, when she is not sedated, she likes to bite anyone who comes close enough, and tried to tear out her IV with her teeth), this doctor suggested she could be given a necklace meant for toddlers, which is safe to chew on.

Someone asked where you’d get a thing like that and the doctor said, “I was looking on Amazon—it should be at my house when I get home tonight.” Awww! I was extremely touched by this doctor’s refusal to give up on this patient and ordering the thing from Amazon herself. Someone from psychiatry talked about making sure to keep the patient’s blinds open during the day and to have her room dark at night, to get her internal circadian clock working properly again. I’d heard a palliative care doctor speak about this patient as being terminal, which she may well be, but I was touched by this geriatrician’s approach and felt relieved that she is part of the patient’s team.

Delia had told me early in the week that she would be in on Friday at 1 p.m. because she had a presentation to give downtown. On Wednesday or Thursday, she invited me to come to the presentation, so on Friday, I got to report to the Fairmont Hotel and attend a panel discussion on palliative care. I was seated next to a retired plastic surgeon who told me that he mainly worked on congenital birth defects, including covering up exposed bones. He said he liked it because he could actually see what he’d accomplished, in contrast to operating on an internal organ.

This Can’t Be Good for My Very-Close Veins


Last Sunday, I was on call at my own campus. There had been emails going around about a particularly difficult patient (one I never saw) who finally had to be told that she would get one chaplain visit per day and no more, to be administered in the late morning. That didn’t stop her from calling one of my peers at 1:30 in the morning, though she had received a visit earlier that day. That peer hadn’t carefully read the emails about this patient, and got dressed and went to see her. Fortunately, she had been discharged by last Sunday, so I was surprised (and displeased) to get a call from her saying that she was wondering where the daily chaplain phone call she had been promised was! I said that we don’t offer services to people who are no longer in the hospital (indeed we don’t, as was confirmed later; we can barely see all of those who are in the hospital), but she was adamant and we ended up being on the phone for 20 minutes, during which I had to keep saying silently to myself, “This person is suffering, this person is suffering.” (Weirdly, during this conversation, the patient asked, “What are you—about 54 years old?” That is exactly how old I am.)

I got a pretty good night’s sleep that night and arose at 6 a.m. to offer prayers for a patient coming in for surgery, per previous arrangement. The patient said she has strong faith in God and so wasn’t worried on her own account, but she wanted to make sure that Someone would be guiding the hands of her surgeon. She was wearing fuzzy jammies and her bedroom slippers.

I suppose I went to the teaching session that morning and to rounds and to visit a patient or two with the team or with Delia; I can’t remember. My notes indicate that there was nothing to do in the afternoon and that I felt extremely exhausted. I have peers who now and then go to the library and spend a whole morning or afternoon reading. I have never done this, until Monday. I read for awhile and then fell asleep in one of the many comfortable chairs in the library, waking myself up with gentle snoring. Paradoxically, what is making me so tired is having less to do. I used to see lots and lots of patients and spend virtually no time talking about them (except of course for discussing with my peers those patients of particular interest to us: very colorful, ill-behaved, or in particularly sad or harrowing circumstances).

Now it’s almost exactly the opposite. Rounds take an hour each morning, and then the team decides who to see, and then new information comes in via one channel or another, and all of the care team members have to hear the new information and give their opinions. Having to coordinate with one or more family members also attenuates the schedule. We might end up seeing two or three patients in a whole day, and currently, that will usually be the team seeing the patient and me observing, or Delia seeing the patient and me observing, though she has also sent me off to see patients on my own, which most often means talking to the patient’s family.

Also, I used to quite often sit down in a patient’s room. To encourage care providers not to stand over patients, which does not exactly communicate that the provider has plenty of time to speak with the patient and is interested in what she is saying, there is a sturdy folding chair behind the door of nearly every patient room in the hospital. (If it’s not there, it has migrated into another room.) But now I’m standing around for 30 or 45 minutes at a time, like a police officer doing crowd control, because if there is one team member who is going to get to sit down, it’s not going to be me. Tiring.

Being one to leap to conclusions, I was thinking by the end of Monday that maybe I would not enjoy being a palliative care chaplain, though I recognize I have barely begun this period of training. The next morning, I felt very unenthusiastic about the whole thing. When Delia asked how I like palliative care so far, I didn’t say that I hate it. Instead I tactfully observed that the ratio of time spent talking about patients as opposed to talking to them is nearly the opposite of what I was doing before. She said this isn’t unique to palliative care—that doctors discuss their patients all the time, and that usually chaplains do work with a team, though it depends. She mentioned a certain hospital where the chaplains just get a list of people to see and don’t discuss cases with a team, which she characterized as “lonely.”

She asked that day, “Are you tech-y?” and enlisted my aid sending videos to someone, which she was having trouble doing from her phone. Being able to help was satisfying. Every now and then it occurs to me that I actually kind of like sitting in front of a computer all day, as I did in my former job.


(Click photo to enlarge.)

Sunday, April 02, 2017

Relational Thinking

Friday was the last day at the Truly Wonderful Medical Center of the fellow who led all the teaching sessions last week. I really like him a lot—he is bright, funny, kind. I wished him good luck at the hospital where he will go next, and he thanked me and said that next year, he is going to San Francisco General. He said, “It’s a nice place. It could use someone like you.” That made me feel good.

That afternoon I was in the elevator with just one other hospital employee, who noted my badge and said, “You’re lucky to have that job.” I introduced myself, and after we stepped off the elevator, he added that he had just been “short” with someone and felt bad about it. He was thinking that he wished he could apologize to the person; he said it made him feel better when a chaplain got on the elevator with him.

Delia had sent me to see several patients on my own earlier in the week. On Friday, she shadowed me for the first time, and I forgot to do the one thing she specifically told me to do, which was to introduce her. There were a lot of people in the room, and while I was shaking hands with them, Delia quietly sat down on a chair a few feet behind me and I forgot all about her.

One of the palliative care social workers mentioned unpleasant interactions she’d had with a case manager, who also had gone in and riled up a family. Someone made an observation about analytic versus relational thinking: The former practiced at the expense of the latter may hurt relationships and needlessly upset people and/or force other care team members to spend precious time repairing relationships. In this case, a doctor ended up having to calm the patient and the family down. Yet another way of saying, “Don’t be a jerk.”

I visited a patient who was intubated, sedated and unable to communicate, and another, and another, and another. Much of the contact in palliative care is with other members of the care team and with the family members of the patient, less with the patient him- or herself.

On Friday night, I did the important monthly self-care practice of eating an entire pepperoni pizza, and then I slept for 12 hours. Saturday was a gorgeous, sunny, warm day. I went to Rainbow and did stuff for work. In the evening, several of us went to the beautiful four-story loft of a peer for a potluck dinner and to watch the movie Griefwalker. (She said excitedly during the movie,
“For so long I have wanted friends I can do this kind of thing with.”) Afterward, she generously gave us rides home. I was squished into the back seat with Sam and our peer’s daughter’s baby seat. When I put on my seat belt, Sam shrieked, “Stop touching my butt!”

Medical School in Twenty Minutes a Day

On Tuesday, I went for the first time to the presentation a palliative care fellow does every morning at 8:40 a.m. This one was on pain management. The other two attendees were the fellow’s medical students, and the pace was very fast. I was scribbling notes and found it fascinating. I am going to get to go to medical school twenty minutes at a time for the next couple of months! This I did not expect. Delia also told me on Monday that I will need to learn a lot about medicine.

I didn’t go to rounds on Tuesday because I was having my own mid-year consultation, which was fantastic. It was my own supervisor, Anita; my dear friend Jack (who I see for bodywork and who I have known for 30 years; he is a longtime Buddhist meditator, as well); one of my young peers from the other campus, Nicholas, who is now also in my own small group; and a member of our professional advisory group I’d never met before but who I liked very much immediately. He is a psychologist who has been affiliated with the hospital for 40 years. He was delightful, and the whole meeting was very warm and friendly. I enjoyed it.

At the beginning, I stepped out of the room while they framed the discussion, and at the end, I stepped out again while they compiled a list of my strengths and of my opportunities for growth, which Anita then read aloud to me. There were more of the former than the latter. I felt that I was treated very generously, and Anita seemed pleased with how I had presented myself.

In the afternoon, our whole group of students went to a church across town for a half-day retreat. The church recently had their stained-glass windows cleaned and they were gorgeous. We had a delicious Mediterranean lunch, and colored mandalas (yep) (I’m chuckling), and then had 90 minutes of free time. I walked with one of our supervisors in the Presidio, where we saw an Andy Goldsworthy artwork made of tree trunks. It was a lovely, sunny, clear day. After the supervisor needed to turn back, I found a bench and read my New Yorker.

I remember once at the end of a meditation retreat Jack Kornfield asking us to make eye contact with another person but not to do the “deep soul stare.” When we reconvened at the end of the day on Tuesday, they asked us to do the deep soul stare. Each of us got a chance to stand opposite every other person and look into that person’s eyes and connect for a good long minute or two. Once upon a time I would have found that excruciating, but it seemed easy this week. Actually, it was nice, and very nice in the case of certain people.

On Wednesday, I went to the teaching session and to rounds, and visited three patients with one of the palliative care doctors. I got in two fights with Sam—we have a strong sibling dynamic—and resolved two fights with Sam. He suggested that maybe we should sit down with Anita, and I said I was willing to do that, but also that I think we have sufficient communication skills to continue processing our fights, and he decided that he agreed. He said, “We got this.”

That day we also had didactics on grief (led by Delia, using poetry) and on medical ethics, led by Paul, the director of the spiritual care department.

On Thursday I observed while Delia visited some patients and was startled by the complete change in her personality. She tends to be quiet and to take in many minutes of input before she comments, so I was surprised to see how warmly affectionate she became with patients, touching them freely. I plan to ask her about this: was that always an aspect of her personality? Did she consciously work to develop it, or did it just sort of happen over many years of being a palliative care chaplain?

Chair Assignment

I began the palliative care rotation last Monday. I hadn’t gotten any instructions—Delia, the palliative care chaplain, was away the prior week—so I went to morning meeting as usual and then, per Jodie’s instructions, just went to the palliative care office, where I found Delia sitting with a doctor and a social worker for morning rounds. The doctor did most of the talking. It took her an hour to discuss 11 or 12 patients. I was surprised we could spend so long on so few patients, but I appreciated getting a good understanding of each person’s situation.

Delia explained to me that, at this hospital, palliative care is a consult service and only gets involved when the patient’s attending doctor or primary care team requests it. The doctor who was in our rounds meeting is the attending doctor for palliative care services itself. The palliative care patients are divided into two groups, and each group has a fellow—an M.D. who is training to be a palliative care physician, who rotates between the two groups. There are four palliative care fellows total, and each one comes with a clump of medical students.

After rounds, the four of us agreed to meet in a certain ICU at 11 a.m. I arrived 10 minutes early and then everyone else didn’t get there until quarter after, so that was a lot of standing around, but then, chaplains do a good deal of standing around.

We went to a patient’s room but he had visitors, so several care team members discussed his case and then Delia and I went back to the office, where she said she wants this rotation to be more leisurely than what I normally do, with time for reading and reflection. She said that on some days, she will tell me to go home early. She said I’m welcome to go through her files anytime I want and to make copies of anything that interests me, and I’m welcome to rummage through her books and borrow anything I like. On the other hand, she also told me not to sit in her chair nor to sit in one of the four comfortable chairs for the rounds meeting unless the whole group is four people or fewer.

I said, “Oh, chaplains don’t sit in those chairs.” 

She said, “No, you don’t sit in those chairs.” Got it! She also said not to leave so much as a toothbrush in the office overnight, which she shares with two palliative care social workers, but I can leave my backpack there during the day if I want.

At this point, it was noon. I told her I was going to participate in a peer’s mid-year consultation from 12:30 to 2. She said to rejoin her at 3, which should give me time to have lunch, research the spiritual beliefs of a certain obscure ethnic group, go visit a patient of that group, and, time permitting, a second patient.

We get 30 minutes for lunch and two 15-minute breaks, but we can configure this as desired, so I don’t usually take breaks and instead have an hour-long lunch. I couldn’t figure out how I was going to have my lunch and do all that other stuff in the allotted time. Delia said she eats at her desk and sometimes doesn’t eat, which alarmed me a little, partly because one of her specialties is self-care and avoiding burnout. but mainly because I have no intention of ever skipping lunch.

I went to my colleague’s consultation and then back to the student office where something lucky happened: the two people who were in there happened to know all about the topic I was supposed to research. In 90 seconds, they explained the key points of this group’s spiritual beliefs, saving me 20 minutes on the computer. I ate and went to see the patient, who was unresponsive, anyway, and then to see the other patient, who was not interested in speaking with a chaplain, and then charted both visits.

When Delia later asked me what I’d learned, I was able to report that I’d learned this, that and the other and seen both patients. She reviewed one of my chart notes and gave me feedback. She said she wants palliative care notes to be listed as such; my notes are listed as spiritual care. I could easily be changed in the system to be a part of the palliative care group, but I’m not in fact a palliative care chaplain, and also, when I’m on call, I would need my notes to display as spiritual care notes. Therefore, Delia said just to tell her what I do and she’ll do the charting. I felt a slight pang that I might not have any chart notes to show for these next two months, but I don’t really care that much. Also, she might get sick of this chore and think of some way for me to do it.


(Click photo to enlarge.)