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.

Sunday, May 06, 2018

Power to the Peeple

In mid-April I went to Jonas’s goodbye party: lunch, and a chance for each of us to say what he has meant to us and to thank him. Carolina was there and gave me a big hug; I rarely get to see her in person.

I’d been thinking about what my fellow County Hospital chaplain said about there being obstacles at every turn when she did the training program I am now doing. When I got a chance to ask her about that, she said the program somehow figures out what you don’t want probed into and probes into it; she used the phrase “karma accelerator.” Encountering four things from bad dreams within 24 hours the first time I traveled there is kind of striking.

She had some practical advice, including to write the papers in reverse: to start with the application of whatever it is to chaplaincy and work backward from there. I would never have thought of that. She also said not to freak out when my proposal for my thesis gets negative feedback; apparently that is traditional. She noted that you spend nearly two years developing a vast concept of chaplaincy, and then have to compress it to a laser point for your final project, also a very helpful observation.

While speaking that day with a patient who had been in a car accident, my hand gently came to rest on some object or other that was in front of me. When I finally looked down, I saw it was the patient’s plastic pee bottle. (Carlos thought this was such a great device that he had one for his bedroom, so he wouldn’t have to get up in the middle of the night to go to the bathroom. He called it Power to the Peeple.)

One day I watched the trailer for End Game, a Netflix documentary about Zen Hospice and palliative care services at the Truly Wonderful Medical Center which features BJ Miller. It looks excellent. Sam and I might be in it; we were at a palliative care meeting one day when they were filming for this, though the camera was mostly aimed at BJ Miller. (End Game should be available on Netflix by now.)

TWMC offers a year-long training in palliative care that meets just one day a month. When I had lunch with Delia not too long ago, she encouraged me to do it. I wasn’t really that interested, partly because it didn’t necessarily seem like a good idea to add anything else to my schedule. I feel chronically tired, despite sleeping at least nine hours a night, sometimes ten, sometimes eleven. But that is OK. I accept that as cost of doing something that is really important to me. At the same time, I don’t want to be a burned-out over-functioner, and I decided not to apply for the class.

The day I watched the End Game trailer, I also happened to receive an email from someone who did the class last year and who said it was excellent, so I emailed the coordinator to ask if it was too late to apply. She said it would be fine to apply—the notice for the class says that spiritual care professionals are particularly encouraged—so I went ahead and did that, and now am waiting to hear if they will give me a scholarship.

Saturday, May 05, 2018

Farewell to Number Eighteen

And now a few words about #18. In December, I was eating something with raspberries in it, and biting down on one of those treacherous hard little seeds, I felt a sudden sharp pain and was sure the crown had come off that tooth, but it hadn’t. Early in January, I went to see my dentist. She couldn’t see anything amiss via X-ray and there were no deep pockets, which can indicate a fracture. There was also no swelling of the gum. She hypothesized that the ancient root canal had failed and that there was a little infection. She tried adjusting the bite so there would be less pressure on the tooth. This cost $162.90.

Adjusting the bite didn’t help, so two weeks later, I went to see a fancy Union Square endodontist, who also did X-rays and also didn’t see anything amiss and also adjusted the bite, which cost $228.95. He said that if it was still bothering me in two weeks, he could redo the root canal, for $2600. I said that if it came to that, I was just going to have the tooth pulled and that under no circumstances was I going to spend $2600 for a root canal. (I don’t currently have dental insurance.)

That bite adjustment actually did help for a while, but then the pain came back. This made my dentist pretty sure that it was a case of the root canal failing—that there was an infection in there gradually pushing the tooth up. After that, I just stopped chewing on that side and hoped the whole thing would magically go away, but it didn’t.

I asked my dentist if I could go to the dental school at University of the Pacific to have the root canal redone or tooth extracted, and she said that would be fine. I was thinking they would start a root canal and maybe in the course of that discover that the tooth was fractured and extract it. If that happened, my dentist said it would be fine to live without this tooth and not to get an implant, and I resolved to do that, though I felt kind of sorry for myself, starting to become a toothless little old lady at just 55.

Mid-April I finally had the chance to get over there. Optimistically, I had a massage scheduled for 11 a.m., but when I called the clinic a couple of days beforehand to see how long I should plan to be there, they said, “All day.” I arrived just before 8 a.m. and ended up being fifth in line for the emergency clinic. At 10 a.m. or so, I saw an extremely nice young second-year dental student.

With the oversight of a supervising dentist, he determined that he also did not see deep pockets or anything amiss on the X-ray, and the thought continued to be that it was probably a failed root canal. But then the supervising dentist—also an affable fellow—spotted a tiny hole in the gum, inserted a skinny piece of gutta percha, had the student do another X-ray, and said he was now sure it was a fracture.

It was time to see an endodontist, which is a whole process, but it turned out that the person being seen in the bay right next to mine also needed to see an endodontist, and this had already been initiated, so very soon, he came in, warned me that what he was going to do was going to hurt—it most certainly did—and easily located the deep pockets that meant the tooth was broken (and which neither my dentist nor the endodontist had been able to do). I was referred to oral surgery and went to pay my bill for the services already received: the examination and four or so X-rays. This cost $76!

The supervising dentist said I will probably be fine without an implant for #18—that #19 does 60 percent of the work of chewing, and that an implant that far back is more likely to fail, since it’s closer to the hinge point. However, he also said their implants are very attractively priced, so students can have a chance to do them. I asked what he would do if it were his tooth, and he said he would get the implant, but that’s because it would be absolutely free. He said if it were his wife’s tooth, he would tell her, “Honey, I’d love you just as much without that tooth.”

By then, I had decided that my future dental care will be received at University of the Pacific and said, “This is my new dentist,” by which I meant the whole building, but the young man who had done my exam said, “Really?” and looked very pleased, so right on the spot, I decided that he’s my new dentist. He walked me over to oral surgery, where they said if I came back at 2 p.m. and if someone canceled, I could have the tooth extracted that day.

I went to an Indian restaurant not too far from where F. lives—he didn’t walk by; the food was delicious—and then back to the clinic. At some point, the woman said there had not been any cancelations and she didn’t want to make me wait any more. I said I had been warned it was going to take all day, and that I didn’t mind waiting longer, and she said if I was willing to wait until 5 p.m., they would definitely get me in (that is, get it out), so I continued to sit in the waiting room.

About 4 p.m., I was called and two other young fellows did the extraction, with a venerable oral surgeon standing nearby reminding them not to damage the implant next door. I get a little panicky when I get local anesthesia for that kind of thing—I get worried I won’t be able to swallow—so there were some unpleasant moments in that regard, but the extraction itself was very quick and seemed like it went much more smoothly than when #19 was extracted (pursuant to being replaced with an implant). I’m too lazy to go look up what that extraction cost (even with dental insurance), but I’m sure it was more than $117, which is what the extraction of #18 cost. Less than $200 for eight and a half hours of quality dental care!

Plus one of the fledgling oral surgeons did something very charming. He said, “Do you want to see the tooth?” I don’t think I’ve ever had a dental care professional make that kind of offer. “Sure!” I said, and he showed me the bloody tooth, cracked neatly from top to bottom, exposing the root canal material put inside probably 20 years ago.

Thursday, May 03, 2018

Wet Fleck

At my paying job, a handful of new chaplain positions have been posted, one full time and two per diems. I heard from two of my CPE peers about their potential interest in these jobs, one of whom has since talked with my boss on the phone. When I was hired, it was for one on-call shift per week, which soon became two, which is one too many. Ever since getting back from school in March, I have felt exhausted, and would love to return to working just once per week. I’m not going to bring it up, but if it is offered, I will accept with alacrity.

For school, we are required to meet with a spiritual director monthly. They said this can be a spiritual director per se, but it can also be our therapist. I see my therapist monthly just in case, but nothing in particular has been coming up, and when I saw her in March, she said she wondered if she’s actually doing me any good. I skimmed the write-up on what we’re supposed to discuss with our spiritual director and decided it wouldn’t be fair to try to force my sessions with my therapist to conform to that when she is already having doubts about the fruitfulness of our time together. I know a woman who is an actual spiritual director and who is a delightful person, so I decided to call her up and maybe just to see my therapist as needed instead of monthly, so as to not pay both a mental health professional and a spiritual health professional.

But I made a copy of the write-up for me and my therapist to discuss, and when I finally read it a bit more closely—not word for word, of course—life is short—I saw that it actually does dovetail nicely with stuff one might discuss in therapy, and my therapist said, when I saw her early in April, that she liked the idea of having some sort of explicit plan.

There is a palliative care patient on one of my units I had not visited once because he speaks Cantonese, and 100 percent of the time, Cantonese- and Mandarin-speaking patients don’t want spiritual care. Lining up an interpreter to confirm that fact can seem like too much work, so I had never laid eyes on this fellow, who has been in the hospital for months. I decided to go see him, and when I finally reviewed his chart, I saw that his family rarely comes to visit him and that it seems to other care team members that he is terribly lonely.

I found him lying in bed with his eyes closed, looking somewhat like a sad little egg, but when I spoke quietly to him, he opened his eyes right away and looked steadily at me as I chatted away in English. His expression didn’t hint at any emotion in particular. The energy emanating from him was extremely quiet and peaceful.

The next time I worked, I called an interpreter in the morning and left a message saying that I know this patient doesn’t want spiritual care, and I understand that he is hard of hearing and also confused, but I felt that I should at least try to talk with him. At the appointed hour, I went to his room and found him in the same posture as before. Again, he opened his eyes right away, and I started talking to him, saying that I knew he couldn’t understand me, but an interpreter was on her way. I said, “Do you speak any English?” He said something in response, but his voice was so quiet, I couldn’t get what it was. He had to repeat it five times and I had to put my ear four inches from his face before I understood: “A little bit.”

The interpreter came and I told the patient that I’m the chaplain for the unit and that I wanted to say hello to him. I asked if everything is OK and he said, via the interpreter, that it is. I asked if there’s anything he’s worried about, and he said there isn’t. I asked if he considers himself to be spiritual or religious and he said he does not. I said I want to make sure he doesn’t feel lonely or alone. He had been looking steadily at the interpreter until this point, but when I said that, he turned his head and looked warmly at me. I asked if it would be all right if I came to visit him once or twice a week, though the interpreter won’t usually be there. He said yes to that.

As we left, the patient’s roommate said, “That was nice. I couldn’t help but overhear. That was really nice.” The interpreter was also looking at me with a very kindly expression, and I felt good about the whole thing. I’m going to ask the interpreter if she can teach me how to say in Cantonese, “Just saying hello. I hope your day is going well.”

Later in the day, there was a request in the electronic charting system to go see a patient on the medical-surgical floor. Since my colleague whose unit that is (the one who moved my desk) wasn’t working that day, I went and found a patient facing end of life and in immense distress—crying and afraid. Her mouth was full of some kind of gunk and she was coughing. To understand what she was saying, I had to bend over her, bracing myself for a wet fleck of something or other to land on my face or my glasses (though better my glasses than my eyeball). I noticed my own distress arising, and found myself offering more words than I usually do, which was due to my own discomfort.

This patient was not religious, but had a quirky set of things that are meaningful to her. When I asked what she takes refuge in, she immediately named a TV show and described a particular episode. Maybe the best thing I did in that visit, which was about 50 minutes long, was to ask if I could put my hand on the patient’s hand—she said yes—and then if I could put my other hand on her forehead, which I hoped might be comforting; that was all right with her, too.

I felt sad when I left her, and as if something profound had happened. I will need to do some self-examination to become more aware of my attitudes towards death and end of life so that I’m not projecting onto others my own sense that it’s terrible to die and to say goodbye to the people we love most. (But isn’t it, sort of?)