Friday, January 04, 2019

River Rock

Right before Christmas was my fifth time attending palliative care rounds at County Hospital. It is becoming clear that how my day will go depends greatly on who the attending is. This attending was, on the one hand, very mindful of my presence and that I needed to be given something to do. She did not forget about me in the slightest. On the other hand, what she thought I should do did not include visiting patients with the rest of the group. She gave me a list of four patients she thought I should see on my own.

When I asked, in a low-key manner, if I should come along on a certain group visit, she said she feels it’s better for patients on comfort care, as some of these were, to get little “doses” of care throughout the day so that they feel connected to their care team, so I went around on my own and saw three of the four patients. The fourth had several care team members in his room, but he smiled merrily at me through the little window in his door. The next time I checked back, the situation was the same; this time the patient waved as if I were his best friend. I’m sorry I didn’t get to talk to him.

I didn’t learn anything new about palliative care on this day. However, I was done by 2:45 p.m. and could go to the bathroom any time I wanted, so I guess it’s fine that the experience varies. The prior week, I did not have the opportunity to go to the bathroom the entire day, let alone drink any water. On that day, I scribbled page after page of notes. On this day, I hardly took any.

Besides the three palliative care patients, I was asked to see another patient whose nurse felt he could use a visit. I found him to be extremely labile. He got really, really angry several times during our visit, but only briefly; he was able to calm himself quickly. He also proved to have the unfortunate habit of blaming others for nearly all his problems, though he did talk honestly about his own drug use.

He said he would like a Bible, so I went down to the chaplain office to get one. We have newly relocated to the bowels of the building, far from the light of day. I took the Bible to the patient and said I hoped his eyes were good; the print was microscopic. The patient replied, “My eyes are terrible,” so off I went in search of reading glasses, which I could not find, but I did find a pleasing little mesh bag with fragrant sage in it, so I decided to take him that instead, to make him feel better about not being able to read his new Bible. Then I got a text from Clementine, the boss of the volunteer chaplains, saying she had reading glasses in the office. I thought this meant the chaplain office, so I schlepped down there again, but she meant her office, in a completely different area of the hospital, so I went there and told her my plan in regard to the sage.

She did have some reading glasses and she also said not to give patients sage unless it actually is meaningful to them. She said it is meaningful in her tradition, which suggested that she might not look favorably on the casual handing out of sage. Anyway, she had something better. She has collected some rocks from the tops of mountains and some rocks from rivers. As it happens, this patient had talked about wanting to go live next to a river, so Clementine gave me a river rock to give him. Perfect! Then it was back to the basement to put the sage back where I found it, and up to the patient’s room to give him the reading glasses and the rock. He was taking a shower, so I asked his nurse to pass on the glasses and the rock, and to tell him it was a river rock.

If It's in The Way, It Is The Way

Rounding the home stretch toward Christmas, I went on a tour of the gorgeous new hospital where I will soon perform my paying job, assuming the new boss doesn’t fire me first thing. This hospital is huge—it is 11 stories high and takes up an entire city block—and has 274 beds. There is extra space available so that it can be built out to accommodate 355 patients if needed. Every patient room is a private room except for one lone room in the ED that is for less acute patients; it looks like as many as four patients could be in there. On the units other than the ED, every patient room is also on the perimeter of the building and has a view.

You might like to know that every ICU room has a dialysis hookup, so a patient who needs dialysis doesn’t have to be transported elsewhere. There is a rooftop garden open to the public; it has an expanse of greenery where water is collected to be used for the cooling system. (There are several other roof spaces with gardens growing on them and water being collected, but only one is open to the public.) Last but not least, along the longest hallway in the hospital are 13 operating rooms: an entire city block of ORs.

This hospital looks a lot like the same system’s new hospital that opened earlier in the year not far from where I live. (Anytime my boss neglected to specify what hospital I should report to, which was most of the time, I assigned myself to go there.) One thing I love about that hospital is that there are tons of computers with reasonable ergonomics where anyone can chart. 

The ergonomics at the hospital where I work right this minute are horrible. No workstation is really comfortable. There are all sorts of ad hoc charting stations, one worse than the next in terms of what would happen to your back if you used it all day, and then there are a million of these workstations that can be raised or lowered for standing or seated use. The problem here is that you can’t change the distance between the screen and the keyboard, so you have a choice of having the keyboard at eye level and your hands way too high, or having your hands where you want them and the screen way too low, so I’m excited that I will (I hope) be moving to the new hospital, which I assume will be like the one in my neighborhood in regard to computers, since it looks the same in many other respects.

After the new hospital opens, over the course of one weekend, all of the patients at two of our current four campuses will move there, along with all of the care team members. Our admin said there will be one ambulance after the other driving across town for 48 straight hours. That should be quite a sight to see.


I keep finding myself in a frenzy over how much stuff I have to do in the coming year, and thinking about how great it will be when school is done and when the monthly palliative care class is done, when every single minute is not scheduled. I picture myself sitting in my comfortable chair reading a magazine and drinking a cup of tea. What a lovely, leisurely life it will be!

This is a mistake. It is a mistake to locate peace and happiness in the future, because there is no such thing as the future. If peace and happiness are to be experienced, it has to be in this moment, because that’s the only moment that exists or ever will. This is not to say that one shouldn’t adjust one’s obligations. That might be necessary, but I was also remembering what one of the teachers in my palliative care class said: it’s not a matter of more time or less time, but of more or less attention.

Theoretically, one can relax in any situation, and I guess it is my practice to continue to learn how to do this. What keeps happening is that I get my schedule carefully designed—for the year, for the month, for the week, for the hour, for the next five minutes—and then I have to call IT, or the phone rings with an unignorable call, or the smell that indicates a giant new deposit of cat poop in the tub wafts toward me, and then I’m stressed out. I find myself irritable and rushing so I can get back to my nice, orderly schedule, as if having to call IT is not my real life, but rather an interruption in my life to be completed as quickly as possible. This easily leads to an irritable mood, and it is another mistake: this, too, is my life.

As Eugene Cash says, “If it’s in the way, it is the way.”

This and Then That

I visited a patient in the ICU who was moaning and writhing; she mumbled that she was in “excruciating” pain. Her nurse observed that the liver and pancreas work closely together, so if one is impaired, the other may be, too. Apparently pancreas problems are painful, and liver problems, as I know from personal experience with mono-related hepatitis, can cause dreadful thirst, among other things. However, drinking water exacerbates the pain in the pancreas (I hope this analysis is semi-correct), and while I was charting, I could hear the patient, who had insisted on sipping water, now howling. There was nothing I could do about her pain, but I figured I could keep her company, so I went back into her room and said, “May I take your hand?” and I sat for 15 or 20 minutes holding her hand, until she thanked me and murmured that she was going to try to sleep.

A couple of days before, rounding in the cardiac ICU, I introduced myself to a large, muscular fellow who, when I asked him how his spirits were (a new question I was testing that day), yelled angrily, “My spirits are great! I’m a believer!” I could see his wife across the small room smiling indulgently at him. I didn’t prolong the visit and decided not to visit this patient again, since he hadn’t seemed to enjoy our first encounter, but two days later, when I was passing his room, he yelled, “Chaplain! Hey! Can you come in and pray for me?”

During the prayer, I peeked at him and saw he was in tears. After the prayer, he spoke for 20 minutes or so about his fears and regrets. The next day, as I was getting ready to print out a list of patients to see, I heard the patient screaming and swearing and saw that he was having a conversation with four or five physicians. He was clearly in emotional distress, which is my department, so I hastily logged off the computer and politely made my way past the doctors to stand next to the patient, who was cursing and bellowing that he was going to do this and was not going to do that, and he didn’t give a f*ck what anyone else thought. Glaring at the doctors, he finished by saying he was going to leave the hospital against medical advice. The physician leading the discussion finally said, “Fine,” and left the room with the other doctors.

I spent the next 90 minutes with the patient, listening while he talked about his worries, various traumas he has suffered, and what will happen if this happens and what will happen if that happens. Now and then, I inserted a reality check: “Are you sure that’s true?” I also asked if there was any way he could upgrade his main demand to a strong preference. After a while, I asked, “What does the soberest and wisest part of you think you should do?” He said, “That part of me thinks I should stay in the hospital.” I observed, in a low-key manner and not at length, that when we consider how this and then that might happen, or that and then this, a lot of energy is draining away, since we don’t have any idea what will actually happen. “Maybe it’s best to take it one day at a time,” the patient agreed.

By the end of the visit, he said he was not going to leave AMA, and that he was going to stay in the hospital for at least the rest of the day, and he seemed to be at peace with the idea of being in the hospital for the next week. I applauded his ability to pause and consider the best course of action, his ability to be honest with himself and others, and his integrity, all of which had come through clearly.

Hoping to impress the palliative care team, I wrote a long, long chart note that mentioned all my wonderful interventions, which were far more numerous than usual. On our second visit, the patient had mentioned various treatment options. During the third visit, he often seemed sunk in pessimism, which to me did not seem warranted.

The next time I worked, I looked at the patient’s chart and was dismayed when I saw that his view of his prognosis was the simple truth. Where the talk about various options came from, I don’t know. Now hoping that no one had seen my idiotic chart note, I hastened to edit it. What I had thought were efforts to orient the patient to reality were actually efforts to instill hope where there was little basis for it.

I visited the patient that day. He spoke about being at peace with his own death: “If it’s my time, it’s my time.” He was happy when I arrived: “I told people you were going to come and see me today.” And he easily said goodbye when the visit ended, as casually as if we’d see each other again the next day, when in fact it was our last visit, or would have been if I were a little bit more adept at dealing with my own countertransference.

At the end of the day I went to see him for truly the last time, in the new unit he’d been moved to prior to discharge. He didn’t need to see me. I needed to see him. What did I want from him? Not anything in particular. I think it was my own stuff about death that made it hard for me to let go. I had become attached to this person, and I just didn’t want him to die.

His new room had an incredible 90-degree view, and as we sat together for a final hour, the sun began to set. It was an incredible sunset. It was as if nature was trying to tell me—I don’t think he needed to hear it—“Everything dies. Everything dies. But it is stunningly beautiful while it’s here.” At every stage of vanishing, the sunset was lovely in a new way.

Wednesday, January 02, 2019

Long, Long Day (Part Two)

In three of the meetings that constituted family meetings that day, family members immediately said they were comfortable with the patient going to comfort care, or with no further heroic measures being undertaken. In one case, the patient’s husband explained the tremendous effort he had made over several years to help the patient heal. He had finally reached the point where he had accepted that the patient wasn’t ever going to be again she had been, and he agreed that, the next time the patient gets an infection, antibiotics can be administered, but if they don’t work, aggressive care won’t be offered. He signed a POLST form at the end of the meeting.

Another family agreed that the patient should go to comfort care, but her father said it was important to him that someone be there at the time of death. The attending gently explained that patients very typically die when no one else is present, and so the only way to ensure this is for the family to conduct an around-the-clock vigil, which is challenging to do, and even then, the patient might die when the family member steps out for just a moment.

This was also the day of the monthly palliative care lunch meeting. I’m not exactly sure yet who is invited, but in the room were eight women and one man. I arrived late, at the point when someone was offering a reflection, and then each person had the opportunity to check in, during which at least four people wept. It is wonderful that it is treated as normal that people have emotions and express them. When I did my check-in, I made sure to include something gloomy (something real, of course), because it kind of seemed it might not be proper to shriek, “My life is perfect! I’m doing great!”

Yet another thing that happened on that day was the chaplain holiday party, at which there were also check-ins, with the prompt, “What do you like most about the holidays and what do you like least?” Personally, I like everything about the holidays. I love going to be with my family at Thanksgiving. I enjoy the beautiful holiday lights I see around town, I like receiving cheerful Christmas cards with photographs of my relatives, and I really like going to Sacramento to be with Tom’s family, so I could not come up with any gripes about the holidays, though it occurred to me later that it might have been more sensitive to say that what I don’t like about the holidays is knowing that it’s a lousy, dark time for a lot of people.

I am generally trying to be an observer on these days and not to make anything take longer; it is already clear that no physician appreciates the wasting of time. The attending on this day said she rarely leaves the hospital before 7:30 or 8 p.m., and that she is regularly on a rotation that involves having to be at the hospital every single day for two weeks. However, I also want to contribute and to help other care team members understand what chaplains do. In the meeting where the husband talked about having come to accept that his wife is going to die, I thought that was worth delving into a little, to give the husband a chance to reflect on it, per the idea that what we focus on increases.

I asked, “How did you come to this place of acceptance?” and we listened as the husband explained in more detail how this came about. After we left the room, another physician who had been present said she thought that had been a good question. (The attending, however, was silent. That may have just seemed like a waste of time to her.)

The fourth family meeting of the day was supposed to start at 3, but it started at more like 3:30, and involved nine family members, most of whom don’t speak English, so an interpreter was present, which makes the meeting take twice as long. This is not at all begrudged (or not too begrudged, I trust), but it is a fact. In this case, despite the patient’s evident suffering, the family was hoping for a miracle and showed no sign of rethinking this over the course of nearly an hour.

Then, after we’d been talking for all that time, a tenth family member arrived and glared at the doctors, saying she hoped they were planning to do everything possible for the patient and not “give up on” her. “Give up on” is an oft-used phrase in palliative care, by family members. I could see how a clinician could start to feel weary at this point, or irritated. The attending did speak directly about suffering being prolonged, and she also said clearly that the patient was dying, but she did not yell, “The patient is suffering! She is never coming back! You are being very selfish!” The family wanted all interventions to continue, so the discussion eventually turned to surgery to insert a feeding tube. About then, I decided to excuse myself, since I still had charting to do.

I cannot believe how much I am learning from this one-day-a-week internship, from rounds, from the various palliative care team members, from getting to see so many interactions with patients, from getting to go to family meetings. This is a superb education. I am incredibly lucky.

As I walked home in the dark, I reflected that the qualities most needed in family meetings are patience—lots and lots of it—and beginner’s mind. That attending has been in that very family meeting five hundred times, and she has never been in it. Zen has the idea of “meeting the stranger.” The attending has heard those words and sentiments over and over—but not from these people. For them it is new and terrible. It is devastating and frightening. They can hear the doctor say, “The patient is suffering,” but all they can really hear is the cry of their own heart: “Please don’t leave me! Please don’t go.”

Long, Long Day (Part One)

In mid-December I attended palliative care rounds at County Hospital for the fourth time. While palliative care is not the same as hospice care, many palliative care patients do end up in hospice, so there was some interesting discussion about various hospices in this area. I learned that the one where Emily was does not take insurance. Patients have to pay, but there is a sliding scale. I learned that the nurse on the team thinks a certain hospice is way better than another; it turned out that everyone in the group thinks that.

We discussed a situation where one family member of a patient had, on his own initiative, switched the
patient’s code status from DNAR back to Full Code, which seemed certain to result in intra-family conflict. It was observed that family members who are local tend to be more accepting of the patient going to comfort care (i.e., death is close at hand) while family members who live far away are less so, though it can also work the other way. A local family member who sees the patient very often might have a hard time letting go, even if the patient is suffering. Generally it is more palatable to family members to not escalate care—to not put the patient on a ventilator—than to remove care: to take the patient off a ventilator.

In the course of that day, I went with the attending to three family meetings, to the psych unit to discuss a patient with a doctor there, and also to see a patient in the emergency room whose son was present. Since the latter patient couldn’t speak, that was kind of a family meeting, too. I have learned in the monthly class I’m taking that every palliative care clinician should be able to conduct a basic assessment in eight realms, including spiritual care, so I was interested to see the attending gamely ask patients, “Is faith or religion important to you?” At the end of our leisurely visit with the patient in the emergency room and his son, the attending filled out a POLST form right on the spot, one in English and one in Spanish, for the son to take home for family discussion. 

POLST originally stood for Physician Orders for Life-Sustaining Treatment; the name may vary slightly now from place to place. A POLST form tends to be more effective than an Advance Directive, mainly because it carries the authority of being a physician’s orders. Also, the care team may not be aware that an Advance Directive exists, or it may not be possible to locate it, or it can even be reviewed and then ignored. It is typical to fill out a POLST form when a new understanding about care has been arrived at, for instance, when a family decides that the patient will no longer be Full Code.

The attending on this day explained to another doctor that usually the POLST form is introduced at the end of a conversation, to record the new understanding, rather than used as the basis of a conversation, though it can sometimes be used that way, as well. She said it is generally not a good idea to drag anyone in detail through the form, explaining what each option means, even though it is just a two-page form with almost everything that needs to be filled out on the first page. The attending said it’s less overwhelming for the doctor to summarize for the decision maker and conclude by saying, “Looks like this option reflects what we have been discussing.” Once the form is complete, it should preferably be printed on “ultra pink” stock and placed in the front of the patient’s chart.

In addition to the above visits, the palliative care nurse, Megan, and the unit coordinator and I went to do an assessment on a new palliative care consult (a patient whose doctor had just requested that she see the palliative care team). Megan explained to us about various types of heart problems and about how people at end of life can have fever and become septic, and she said that when your kidneys stop making urine, your time is short. It’s worth jiggling the tube that carries urine from the patient to the thing that collects it, because the tube can get twisted or bent, and when it is straightened out, a gush of urine can suddenly appear.

She said to observe if the muscles near the neck are visibly working—the person may be straining to breathe. Also see if the patient appears to be frowning, which might be a sign of pain, but it also might be the way that person’s face normally looks; might have to ask family members or friends about this.

I was completely delighted with all of this medical knowledge being imparted so freely, and was frantically scribbling notes as Megan generously shared what her years in the field have taught her. Besides being a great teacher, she is a uniquely gifted healer. When one patient said he was feeling warm, she whipped out a beautiful gold-colored Chinese fan and began fanning the patient. I loved that—she is probably the only nurse in the whole country with a gold-colored Chinese fan at the ready, a nice reminder that care comes in many forms and that no two healers are alike.

Tuesday, January 01, 2019

Plenty of Time

Back at work again after the change of units, it dawned on me that if I followed my boss’s instructions, I was never going to get to visit any patient on the oncology unit. My orders are to do initial visits in the ICUs on the three days of the week that I work, while Merlin does the same the three days of the week he works that I don’t. In the first week, I never succeeded in making it to the third, less intensive ICU, let alone to the oncology unit. (There is a nurse in the least-intensive ICU who was there when I was doing CPE who made it clear she hated me; she’s still there, which adds to my less enthusiastic feeling about that unit.) I started to write my boss an email asking for her help in prioritizing, but then I deleted it: I can figure this out.

I decided to quietly give myself new orders. Accordingly, I decided to spend the first day I work each week in the oncology unit. Then I can spend the next day doing initial visits in the ICUs, and on the last day, maybe by afternoon I will have done all of the ICU initial visits and can get back to the oncology unit for a bit. That should leave things in the ICUs in good shape for Merlin.

Many patients in the ICU are unconscious and intubated and unavailable for conversation. Some are awake but in horrible pain. Of the talking that I do there, probably half is with family members rather than patients. I am continuing to practice my Spanish. I talked to a Spanish-speaking patient who was able to go home from the ICU soon after our visit. His nurse said it happens so rarely that a person goes home from the ICU that she had to remind herself of the procedures. It’s not that patients don’t leave the ICU; most do, but they go to another unit in the hospital or to a skilled nursing facility or to a rehab rather than home.

I was exhausted after work. I am taking the bus to work, and, to save time, I’m taking a cab home after every shift: $60 a week. Over the past year, a week that contained two paying shifts seemed burdensome. One shift a week was perfect, and when there was a stretch of two weeks with no shifts, that was even better. Now I have signed up for three a week—why did I do this to myself? I’m going to stick with it (unless the new boss lays me off) for at least a year, because the project I’m doing for school partly depends on the experiences I’ll have at work.

Last year was kind of easy: one day at County Hospital per week, and one or two days at my paying job, maximum. The year before, doing CPE, was hard. So maybe the thing now is a hard year alternating with an easier year. It may also be that this seems particularly hard right now because it’s new and there are various little learning curves all happening at once, and perhaps also because I keep saying to myself, “I’m exhausted! There is no way I’m going to get enough sleep. Why did I do this to myself? I’m going to end up burned out and miserable.” Maybe those aren’t the best affirmations.

There is plenty of time.

I am getting enough sleep.

I can do this.

It also helps to think of those who work 90 hours a week at two or three different minimum wage jobs, who can’t even take a day off to go to the doctor because they have families to support and can’t forego even a few hours’ pay. My situation is luxurious by comparison and complaining is unseemly. Also, I chose this. I can unchoose it at any time.

It was mentioned at palliative care rounds that the mother of a seriously ill patient had been mentioning that she (the mother) might commit suicide. I shared that with the patient’s nurse and she looked so shocked that I wondered if I had done the wrong thing, so I texted one of the palliative care doctors to see if this is OK to do and she said it is, that it helps for other care team members to know what to keep an eye out for.

In the rounds meeting, one of the doctors said of a patient, “His lifestyle doesn’t match his goals,” which I thought was a delicate way of putting it.

Mid-December, I spent one morning being shadowed by a medical resident. She had a calm, friendly presence, and I could see that the patients liked her right away. Afterward, I sent her an email recommending that she read Being Mortal, by Atul Gawande.

And I’m Keeping Mine

At the end of the week, I went to palliative care rounds at County Hospital. (If it’s starting to seem that this blog is about just one thing, there’s a good reason for that. My life is about just one thing at the moment.) The first two times I attended, so did the head of the spiritual care department, Robert, who is the main palliative care chaplain, but on this day, he told the team he was going to go answer his email and that I would spend my day with them.

The attending physician—there are five total—is someone I really like, whom I met during CPE, when I got to spend a quarter of the year with the palliative care team at that hospital. I think of him fairly often, because I told him back then that I had started to say to myself that if I got laid off from my corporate job, I was going to be a hospital chaplain, “and they kept their end of the bargain.”

“And you’re keeping yours,” he replied, which had never occurred to me! Now every time I tell that story, I end by saying, “And I’m keeping mine,” and I think of this lovely man.

During rounds, it was mentioned that a certain family had been receptive to the idea that life support for a gravely ill patient might not be God’s plan. Very often, people say, “We want him kept on life support. It’s not for us to determine God’s plan.” You could just as easily say, “We don’t want life support. It’s not for us to determine God’s plan,” but about 99 percent of the time, life support is considered to be
God’s plan (because people don’t want their loved one to die).

Also, “We don’t want life support” has kind of an unappealing ring to it. In the monthly palliative care class I’m taking, the first speaker talked about how when a doctor asks a family, “Do you want us to do everything?”, of course the family answers in the affirmative. The speaker joked that no one ever says, “No … for my mom, half will be enough. My mom’s a quitter.”

But the word “everything” means something different to the doctor and to the family. To the family, it means everything that will be helpful. To the doctor, it means everything: ventilator, tube feeling, chest compressions, another futile round of chemotherapy with horrible side effects. So it was nice to hear that at least one family was open to the idea that all the interventions might actually be interfering with God’s plan.

At school in New Mexico several months ago, one presenter talked about how a single person who is calm can change the dynamic of a whole group. I was thinking about that at rounds and trying to be that person, because at least a couple of people were speaking extremely rapidly. As always, the table was covered with food: doughnuts, hard candy, grapes. The attending mentioned the difference between an interdisciplinary team and a transdisciplinary team. In the former, roles don’t overlap. In the latter, they do.

Someone mentioned how a non-palliative care clinician had said in a family meeting, “The longer he lives, the more pain he’ll have.” Everyone at rounds cringed. Apparently the better thing to say is, “We are interested in starting to focus more on comfort.”

I found what this attending had to say about patients quite interesting. Somehow it seemed more oriented toward the emotional and personal and involved fewer numbers. At the end of the meeting, he briskly listed several patients and said he’d like to see them all before lunch, if possible, and we set off as a group. As we wended our way from unit to unit, we were twice stopped by nurses who wanted to express their concerns about a (non-palliative care) patient.

We visited four patients, two in one of the four ICUs, and two elsewhere. The ICUs at County Hospital are in a new building and are airy and pleasant, much nicer than at my paying job. One of the people we visited was an elderly man who was in a positively merry mood despite his grim situation. Two of his siblings were in the room, and they were also very smiley. I decided it was time for me to make some sort of contribution, so after the doctor and nurse had spoken with the patient—doing a “symptom check-in”—I asked if I could ask a question. I said to the patient, “You seem to be in very good spirits. What helps you maintain your good mood?” The patient said it’s because he is grateful for the care he is receiving, and because he trusts his team to help him.

After we left, the nurse said, “That was a good question. I’m going to try to remember that.”

Sunnily Positive

The next day, Merlin and I went to palliative care rounds together, my first time attending. These rounds happen weekly in a comfortable conference room where everyone can sit down, and  since there is no one in the room but ourselves, the speaker doesn’t have to lower her voice and it’s easy to hear every word. Merlin kindly made sure I got added to the group text list and he and I were also added to a master list of palliative care patients in the electronic charting system. Each week, one of us will copy the new patients from that list to the lists of palliative care patients our own department maintains, one for each campus.

It isn’t only Merlin and I who see palliative care patients, and, conversely, all the patients he and I see won’t be palliative care patients, since we have the ICUs, oncology and transplant to cover between us. Every chaplain is asked to see whatever palliative care patients are on his or her units. If we hear of someone during rounds who particularly needs attention, we let the chaplain for that unit know.

At palliative care rounds, I met a doctor whose name I have been hearing since my first unit of CPE. I was surprised to see how young and relaxed she looks. I’m not sure what to call her. I’ve noticed that my boss at my paying job would call the doctor named Anne Smith “Dr. Smith.” At County Hospital, the head of the spiritual care department would call the same doctor “Dr. Anne,” which is kind of charming. For myself, if she has introduced herself to me as “Anne Smith,” I’m inclined to call her “Anne,” but I don’t want to overstep. Maybe it’s knowledge common to everyone but me that even if a doctor introduces herself with both her names, you’re not supposed to call her by her given name.

After palliative care rounds, I went to the rest of ICU rounds and felt tired afterward. Merlin and I met and discussed the ICU patients. The idea is that I will do initial visits on my three work days and Merlin will do them on the three days when he is there and I’m not. On the days I do initial visits, he will do follow-ups and vice versa. I was surprised when he asked if we should divide up the initial visits: why would we do that? The Enneagram One was a little vexed: the arrangement couldn’t be clearer; why muddy it up? But then I realized that I might actually not get through all the initial visits, and if he wanted to help, why not? It was kind of him to offer.

I spent the rest of the day doing these initial visits and basically did get to all of them; here and there a person was asleep with no family in the room, or there were care team members in the room doing something. I did not get to set foot in the oncology unit, but I did run into my friend who is a nurse in that unit.

I put some energy into finding a place to sit down to chart. They are in short supply in the ICUs. I often chart standing up, but I also often sit down while visiting with a patient, which rarely happens in the ICU. The rooms are small and may not have a chair, or if there is a chair, there may well be a family member already sitting in it. Formerly, I used to sit around at the beginning of the day answering my email and so forth, but now I have to get to rounds, so a good amount of sitting has been eliminated from my day.

At the end of the day, I decided to go ahead and chart in the cardiac ICU nursing station, sitting on a chair. It had occurred to me that every single bedside nurse in the ICU has his or her own computer, plus a chair, so there shouldn’t be too much competition for what now struck me as the most desirable spot in the whole hospital: an actual place to sit down in front of a computer! No one objected to my charting there. A few female nurses gathered nearby and were joking with each other; they made me laugh, and then one of them addressed me directly. It was nice to feel included.

At the end of the day, it was dark and starting to rain and I could see the cab I’d requested parked three-quarters of a block away. I was exhausted and irritable and wondering why I had even agreed to add two day shifts weekly to my one on-call shift, though it was this that afforded the opportunity to serve as a palliative care chaplain and help cover some of our most challenging units.

Being irritable is a sign that I’m stressed out, as I imagine is true of most people. When I get extremely stressed out, I get dizzy. Toward the end of CPE, there were several days when I was awfully dizzy and even fell once or twice, after which I consulted a doctor. I felt a little bit of this dizziness my first two days on my new units, which was good, because it made it clear that I had been right not to apply for the full-time job. Just in case, I also used one of my breaks on the second day to talk to my friend Martine on the phone, and she agreed that not applying for the job was the right decision, and she was sunnily positive that everything will work out fine, which I also usually believe. I guess the concern is that the new boss will fire me because I’m a per diem, but Martine pointed out that if my current boss loves me, probably the new boss will, too.

I met Charlie at Pancho Villa for a burrito after work and then we went to Howie’s. A sangha member who has cerebral palsy gave the talk, about disability and what we take for granted.

The Works of God

A day early in December was my first time visiting my new units at my paying job, including the medical-surgical ICU. It is a cramped, airless place, with very few places to chart unless you are a bedside nurse or the charge nurse. I now understand even more why nurses are always thinking about their next vacation, and why many of them like to spend their time off in nature: somewhere quiet, fresh, seemingly untouched by man. I remember a hospital priest saying he liked to spend his weekends contemplating the works of God rather than the works of man.

Before work a couple of days later, I told myself to stop scratching a chronically itchy spot in the middle of my upper back lest it trigger a horrible autoimmune response that might rage out of control. Later that very day, I heard about someone who started out with psoriasis and was dead of cancer six months later.

My co-palliative care chaplain, Merlin, was busy with a family situation, so I attended rounds in the three ICUs, which happen consecutively. For some reason, standing while talking to a patient rarely makes me feel tired, whereas standing in a rounds meeting makes me feel exhausted after about two minutes. I think it’s because most of the details are not directly pertinent to my endeavor, and also, I can’t quite hear half of what is said, since the speaker is trying to be somewhat discreet. Her words probably reach the three people closest to her with reasonable clarity, less so everyone else, so I spend most of the meeting straining to hear and wishing I could sit down. Afterward, I feel totally enervated. Too bad these meetings happen first thing in the morning.

Merlin and I met after rounds and divided up the ICU patients who seemed to need a visit, per what I picked up at rounds (e.g., “combative,” “thinking of leaving against medical advice”), and then it was lunchtime. I had packed my lunch, as always, but, as never, forgot to bring it, so Merlin and I had lunch in the cafeteria. We went through the food line separately but, when we were seated, found we had ordered almost exactly the same thing.

At the end of the day, I had a one-on-one meeting with my boss, maybe our third of the year, and our last. She asked if I would like to be the electronic health record guru once she’s gone, training new people in charting. I leapt at that opportunity: sounds fun. She also asked if I would consider applying for one of the two full-time chaplain positions open at the time, but I said I really cannot while I’m in school and volunteering at County Hospital. Volunteering is required by school, but just 100 hours total, and I have already exceeded that. However, working with the palliative care interdisciplinary team at County Hospital is a huge honor and superb educational opportunity. Also, I just like it there.

I took a cab home—time is of the essence now that I work four days a week—and was asked by the cab driver what I do. I said I’m a hospital chaplain and he said, “Huh! I was thinking you were a nun.” I asked why he thought that and expected him to say my modest attire or no-nonsense hairdo, but he said, “The mood.” Very flattering.

I’m glad I still was emitting a nun-like vibe even while brooding about the conversation with my boss, which I started to do right after I left her office. It is possible that the new boss will get rid of us per diems in favor of full-time people, and I can all too readily picture myself six months from now unemployed and asking myself why on earth I turned down a full-time job in my new field. If I had decided to take the job, I could have explained the situation to County Hospital and of course they would have understood. Working full-time while going to school would be challenging, but it would only be for another year.

I knocked on Tom’s door when I got home and asked what he thought. At first, he seemed to think I should apologize to County Hospital and take the job, but then he agreed that working full-time while going to school would just be too much, and that other opportunities will come along.

Too Calm

After I got back from school late in November, I was home for one day and then went to Michigan for Thanksgiving, which was pleasant, as always, including lunch with Ginny at Café Zola and lunch with Amy at Seva. My parents and I reclined in front of the TV and watched Rachel Maddow. They made a wonderful Thanksgiving dinner; my sister came over to help eat it.

The flight back home was nearly unceasingly turbulent; the flight attendants had to spend a good deal of the trip sitting down. I did not enjoy it. I poked the arm of the woman next to me, who was watching a movie. She took off her headphones and looked at me kindly. I said, “I’m scared,” and she said, “Oh, I know. I don’t like turbulence, either. Hopefully it will smooth out.”

I found out that my boss at my paying job had decided that two people would share palliative care, a second-year Clinical Pastoral Education resident I’ll call Merlin, and me. Merlin and I were assigned to cover three ICUs together and to attend the weekly palliative care rounds meeting. He was also assigned to cover the transplant unit and I was assigned to the oncology unit. One of the ICUs is the medical-surgical ICU, where almost every after-hours call for chaplain care originates. All of these units are at a different campus from where I’ve been going.

In the laundromat one day, I saw a fellow I have seen around my neighborhood literally for decades, often running in Dolores Park. I decided the time had come: “My name’s Bugwalk.” He told me his name and we started chatting. Later a woman who lives in the building next to mine came by and tapped on the window. “Oh, there’s Molly,” said Doug; we both know her. After Doug was gone, a Latin woman came in. I wanted to introduce myself to her, as part of building the kinds of connections that social media is destroying, but at first feared she would think it was weird. Finally, I decided to be brave and told her my name and she immediately told me hers, and we talked in a friendly manner until I left. We spoke mostly in Spanish; I told her my Spanish is terrible and that I need to practice.

She asked what church I go to, so I told her I’m Buddhist, and asked if she is Catholic. She said she is, and that she goes to Mission Dolores. I told her that one of the priests there is a friend of mine, and she said she knows and likes him. So: two new friends in one trip to the laundromat, and it turned out that both of them and I have a mutual friend.

At County Hospital palliative care rounds one day at the end of November were the attending physician, a social worker, a nurse, two chaplains, and another nurse who is interested in learning more about palliative care. A couple of people had brought their breakfast along to eat at the meeting. One person was having an egg sandwich with cheese and bacon on white bread, which was the healthiest item of food in sight. Another person brought cookies, cheese puffs, and homemade macaroni and cheese to share. In the center of the table was a bag of candy. There appears to be a lot of comfort eating.

The meeting was led by an attending I was meeting for the first time. He asked how I came to be there, but seemed to tune out before I finished telling him. He was very generous in explaining the details of how certain illnesses typically progress, even drawing us diagrams of the heart and of an individual cell to explain how “membrane potential” works. I listened closely and took a lot of notes—free medical school, an hour at a time!—and after awhile, I noticed that he was making eye contact with me and directing some of his remarks to me. I suppose most teachers appreciate an interested student.

Emotions appear to be welcome at this meeting. The nurse wept when she shared about a patient who died just a week after his diagnosis and hospitalization, and about the shock and sorrow the patient’s grandson was experiencing.

After rounds, Robert, the main palliative care chaplain, and I went to see a patient in the ICU, where many palliative care patients are to be found. The patient appeared to be unresponsive, but when Robert gently asked her if she was feeling uncomfortable, she said, in a small voice that she was, and when Robert asked if she could say what type of discomfort she was having, she said, “I want to be out of this body.” Afterward, we spoke with Clementine, who supervises the volunteer chaplains, and she observed that there is such a thing as being too calm; she has seen chaplains wrongly assume that a patient won’t be able to communicate and not try to do any sort of assessment.

Though Robert is a chaplain, he asked the patient a question about her physical pain. In the monthly palliative care class I’m taking, we were told that every palliative care clinician, including spiritual care clinicians, should be able to perform a basic assessment in eight domains: Structure and processes of care (including how patient understands her prognosis); physical aspects of care; psychological and psychiatric aspects of care; social aspects of care; spiritual aspects of care, religious and existential aspects of care; cultural aspects; care of the imminently dying patient; and ethical and legal aspects of care.