Unbefriended

In the palliative care rounds meeting at County Hospital, we discussed an “unbefriended” patient who needed to fill out an Advance Health Care Directive. Such a patient may be a homeless person, which means she doesn’t have two friends to witness her form, and she also might not have the $20 it costs to have the form notarized if you can’t come up with two witnesses. Seems kind of unfair that some people have enough friends and also enough money, and other people don’t have any of either.

I spent part of the day with a palliative care fellow named George, who I thought had impeccable reflective listening skills, and was also a master of gaining consent. “Would it be all right if I summarize what we’ve talked about?”

I noticed, again, that for the physicians, the day can be one long interruption: The physician starts task A only to be interrupted by task B which in turn is interrupted by task C and so forth all day long. I asked George if it seems that way to him, and if there comes a moment at 5:30 p.m. when what you started out to do at 9:30 a.m. pops back into your mind, and he said it is exactly like that. On top of that, a huge number of personalities and viewpoints must be accommodated beyond those of the palliative care team: the patient, the patient’s family, the bedside nurses, the primary care team, specialists, administrators, insurance people, people at other facilities.

In the course of the day, we visited a patient who wanted to leave the hospital against medical advice, clarified the wishes of a patient whose speech was extremely difficult to understand and helped him fill out a POLST form, and discussed with the weeping husband of a dying patient what he might see as she approached her final moments. (On a more mundane note, I asked the husband if he felt chilly in that room, because I did. The poor man was wearing several layers of clothing and agreed that it was cold. Turning up the thermostat was one thing we could do to help.)

When the fellow and I came out of one room, I was surprised to find that he felt disappointed by his effort. I told him that I thought his reflective listening was excellent and that I thought he’d done a great job. It’s surprising how often these physicians who are so extremely intelligent and so well educated see themselves as somehow failing. Perhaps spending years in a very competitive environment encourages harsh self-judgment.

At the end of the day, our nurse hugged me goodbye for the first time. Maybe she had just known me for enough weeks at that point, but it might also have been because she was present, along with a dying patient and her son, when I prayed for the patient. Chaplains are the only clinicians who are seen to pray in the hospital, and it often seems to be really appreciated by other clinicians.

At my paying job, it occurred to me that one would do well never to review the chart note of anyone whose specialty is listed as “Wound Care.” I suspect that if I saw the actual wound, I wouldn’t keel over, but for some reason, seeing a photograph is horrible.

Mid-February was our last team meeting at my paying job with my boss present. Around that time, I had brunch with a peer from Clinical Pastoral Education who was assigned to the transplant unit. I mentioned my idea that people who get transplants feel guilty because someone else has died that they might live, but he said he had never encountered that. He said mainly people are thrilled that they have gone from being ill to suddenly being well. However, it can also happen that people who fail a blood test, even if it’s something that doesn’t pertain to their illness, are dropped from the transplant list. This is a death sentence, and these people are enraged. He said he encountered this maybe four times during our yearlong internship.

Also around that time, I attended Schwartz Rounds at County Hospital. The topic was diversity, equity and inclusion. Panelists included an African American pediatrician, who told about an unpleasant experience she had visiting the ED at Kaiser, where she felt she was treated in a dismissive way. A European American doctor told a story about realizing he was responding to an African American patient and family from a place of bias. He was able to realize this in the moment and align with the family, which allowed him to learn that some of his assumptions were not correct.

The pediatrician said that a person who encounters evident bias may tend to get angry and act out, or to go silent. She advised trying to connect to the offending doctor on a human level (“as one would do with a serial killer”). She pointed out that when we act instinctually, we’re likely to do something wrong. We need to pause and act with intention (to avoid acting from our unconscious biases). She said we can call out our colleagues: “This interaction seems disrespectful to me. Can we go back to it in a different way?” The European American doctor described having been called out by a medical student: not in line with hierarchy. It may be difficult for people with more power in a given system to hear feedback from people with less power.