Spidey Sense

One day I went to a party honoring my boss at my paying job, whose last day had been scheduled for the end of that week, but by the time party day rolled around, she had agreed to stay on for a couple of months, which was excellent news from my point of view. Celebrants included two staff chaplains, three CPE students, my boss’s boss, and several members of the Professional Advisory Group, who oversee the CPE program.

My boss received gifts and kind words, and poems were read; it was an inspiring event. We each shared a word we associate with her. Mine was “benefactor.” After I said it, we bowed to each other. The final thing on the agenda was a catered lunch. I thought I would leave at that point—I was still not feeling great—but one of the PAG members, a physician, sidled over to me and firmly instructed me to tell my boss’s boss something compelling about chaplaincy, so I told him an anecdote about a recent difficult patient where pastoral care (namely mine) had made a positive difference.

(Earlier, another PAG member asked him about his support for chaplaincy in the whole organization, well above our four campuses. He has little knowledge of this, but shared what he could. The PAG member asked again, more insistently. At this point, my boss’s boss’s arms were crossed in front of him and he was frowning. I wanted to tell the PAG member to lay off: “He doesn’t know!” To his credit, my boss’s boss said he would try to learn more about this. I joked, “In your spare time,” and he smiled at me. His responsibilities go way, way beyond spiritual care. He listed the areas in his domain, and there are an awful lot of them, so I can see why the PAG members are anxious for him to have a special feeling for chaplains. However, that he even came to our party and said directly that he is committed to spiritual care and to our CPE program says a lot. He seemed like a nice guy. I liked him.)

In the palliative care rounds meeting early the next week, I asked if someone could explain briefly how they assess for risk of complicated grief. One of the doctors gave an extremely pithy 45-second explanation, which I was able to capture probably less than half of, but she mentioned: if the survivor has a drug or alcohol problem, if she is isolated, if she had been estranged from the patient. The patient having had a long course in the ICU is a risk factor, as is sudden death, or if the survivor seems shocked, and certainly if she verbalizes that this loss is particularly destabilizing for her. “And then there’s always our spidey sense,” the doctor concluded.

During the meeting, another doctor said that a patient “had the dwindles.”

A doctor mentioned that there was going to be a family meeting for a patient both Merlin and I had visited. Invitations for chaplains to attend such meetings do not seem to be forthcoming—though, as always, one of the doctors was careful to consider for every patient we discussed whether spiritual care was needed—so I invited myself: “Would you like a chaplain to attend?” The doctor right away said that would be fine and that she’d meet me near the patient’s room.

At the meeting, a specialist I’d never seen before (he was TV handsome) explained that he had thought the patient would get better after period of intubation, but it didn’t happen that way. He said that, in the way you can be left with an ugly scar after healing from a burn, her lungs had healed wrong and would never improve. I asked if I could say something and, with the doctor’s permission, led the group in a brief moment of silence, to start to digest this news. I wish I had the nerve to make such periods a full 60 seconds, and maybe someday I will, but for this one, I contented myself with taking three breaths and then saying, “Thank you.” Really, the person who can’t tolerate the silence is me, because I think it’s torturing everyone else.

Medical options were discussed. The patient’s husband turned red in the face. He said he understood that the patient’s prognosis was very poor, but that it was just too hard to contemplate letting her go. The doctor said another option was to continue with the current treatment, but not to escalate care when a problem inevitably occurred.

The husband said he knew it was probably best to withdraw life-sustaining treatment, but that he felt weak; he just couldn’t do it. He said that part of him was still hoping for a miracle, and that, as a Catholic, he was reluctant to play God.

The doctor said that a law has been passed in California that says a doctor can decide not to provide treatment he or she knows is not helping, without fear of legal repercussions. He said he was mentioning it because it meant that the responsibility could be his rather than the husband’s. The husband could leave it to the doctor to decide on treatment. And then the doctor said something I thought was jaw-droppingly brilliant, which I have already said to a patient at least once since then and will probably say a thousand times from now on. Using the family’s language, the doctor said, “God has already made this decision.” I thought this was remarkable for two reasons. It was very kind, in that it lifted off the husband’s shoulders the burden of trying to make a life-or-death decision. And it was absolutely, completely true. Mother Nature, as always, was in charge.

Another family member agreed that it would be the same no matter what choice was made. In the end, the patient would die. The question was whether this would be after a lot more suffering, or less. What the patient would want was discussed: definitely not what she currently had. People wept. And before the meeting ended, the husband said, “All right, let’s go ahead.”

The three doctors agreed and left the room. They all seemed to understand what had been communicated, but I couldn’t figure out whether the husband had meant, “Let’s continue with the current treatment but not escalate,” or, “Let’s withdraw life-sustaining treatment.”

Fortunately, while I was charting, the palliative care doctor who had been at the meeting (the one who said I could come) came up to thank me for being there, and I had the chance to ask her how all the doctors had known what the husband meant. She said it was context—that they had for some time been discussing removing life support. That made me feel better.