Tuesday, May 21, 2019

It’s Been Seventeen Minutes Since Breakfast—Isn’t It Time for a Snack?

Yep! Work on my thesis for school has begun. Thanks to my faulty memory, I can recall writing only one research paper prior to this one. I probably remember that paper because it was traumatic for everyone involved, including my parents. I nearly dropped out of college over it, or maybe I did drop out of college over it. Who can remember? It was on the causes of homosexuality, a topic of interest to me at the time.

This one is about spiritual care as an essential aspect of palliative care, a topic of interest to me now. You don’t have to read it
—if you read this blog, you are reading it. It’s not a research paper per se, but an ethnography, largely based on my experiences at County Hospital and at my paying job. However, there will also be academic sections drawn from pertinent papers and books.

Fortunately, I happened to encounter one of the students from the cohort prior to mine on the plane when I went to school in March, and she mentioned that she had used Word’s template for an APA style paper for her thesis (File—New from Template—APA Style Paper). This has already made my life a lot easier, and is going to save me a zillion hours.

I am allocating one day a week to work on this. The first day, I found myself immediately stuck trying to write the abstract, but then I found something online that said to write the abstract last, not first. I decided to just start writing up the notes I have taken, a task about which I feel confident, and by the end of the day, I had 13 pages out of 60 (excluding reference list and appendices) written. By chance, I had a telephone meeting with my mentor that day, our second in a year. She applauded my going ahead with what seemed obvious to do, and she advised me not to let myself feel stuck for too long—I can get help from her, or my mentor group, or the wonderful woman who is in charge of helping my entire cohort with our papers.

On my second day of working on my paper, I decided to make at least one citation and corresponding entry in the references list, and I compiled information on citing books, articles, websites, and personal communications. Some of these people who write about this stuff online are quite droll.

I did succeed in making one citation and matching reference, and then I got back to doing the fun part. At the end of the day, I had 30 pages written, which meant it was going extremely well or that I was doing something extremely wrong.

Eating the Schedule

I’ve been thinking it would be nice to have a polished piece of turquoise to carry around in my pocket to remind me of Santa Fe and school; I’d like to buy it there, but so far I haven’t come upon such a thing. Someone suggested a certain store, but someone else said to first visit the Native Americans who sit at the edge of the Plaza to sell various wares. I had a bit of extra time on my way back to the airport—this was the Tuesday after Easter—so I walked over there. A vendor told me that the Santo Domingos sell loose stones, but that they weren’t there because they were still dancing for Easter.

My shuttle driver was one I’d had before, and he is one of my favorites because he doesn’t tailgate. I told him about how all of his colleagues tailgate and about how he is the rare exception. I said none of them seem to have heard the thing about allowing one car length per 10 miles of speed. He said no one does that—that if you leave enough space for a car to squeeze in between you and the vehicle ahead of you, you can be sure someone will do it. (I guess that’s bad.) He said leaving a courteous amount of space causes you to be seen as weak.

He told me that ABQ is second-windiest major airport in the whole country to fly into or out of, because of the wind over the mountains and the Rio Grande; he said Denver is the windiest. As we drove along I-25, we could see clouds to the left and right, almost as if we were on a plane, because of the altitude.

During sesshin, one of our teachers talked about how oryoki helps us to treat everything with care: the cup, the doorknob, the book. I found myself doing this once I returned home, and noticed how pleasing it is compared with rushing around doing things carelessly.

Back at work, I found myself consciously asking myself, “What else is here?” and noticing more about people: their posture, their facial expressions, what they were doing with their hands.

It had gotten to be a bad habit of mine to sit in front of the computer in the morning for an unduly long time before going off to see patients, which has often made me feel guilty. After returning home, I decided to “eat the schedule,” as they say in Zen: to do what absolutely needed to be done on the computer, and then get going to my units. (To eat the schedule is to follow it precisely. I don’t have a precise schedule to follow at work, but if I did, nowhere on it would it say to goldbrick for 90 minutes in the morning.) So far I have found that, instead of being exhausted, applying energy seems to generate more energy. It feels good to know I’m doing what I’m supposed to be doing, and to be able to report at the end of the day that I saw 17 patients instead of seven.

Another thing I changed was to start sorting my patient list by length of hospitalization rather than room number, which leads to much more walking around the unit, which I think is good. I start with the people who have been there longest.

One morning, Hammett inspected his breakfast briefly and walked away lowing mournfully to himself. I think he was thinking, “I can’t believe that person gave me cat food to eat.”

At County Hospital in palliative care rounds, the current fellow (physician) talked about hoping family members could “entertain some preparedness around the end,” which I thought was a nice way of putting it. We discussed an Asian family where all the children except the oldest were at peace with not pursuing aggressive treatment for their parent; someone in our meeting said there may be a cultural expectation that the oldest son in an Asian family will make sure all treatment options are tried. It was also mentioned that if a patient is on chronic opioids for pain management, that may cause him or her not to be considered for an organ transplant, though this may be an arbitrary criterion, and maybe not fair.

Tuesday, May 14, 2019

Gassho-Less Gomashio

In mid-April I went back to school for the sesshin (silent meditation retreat) we are required to do each year. This one was seven days. On the plane, I was sitting in the last row, which might be safer, but any sense of security was somewhat eroded by being able to hear every word the flight attendants said to each other, which turned out to be about how much they hate turbulence! One said, “It lasted for thirty minutes. I was in the galley praying.”

Arriving in Albuquerque, I thought of something a teacher said in a dharma talk last year: “We want the entire web of causes and conditions from beginningless time to be different so our elbow won’t itch.” I want everything from beginningless time to be different so the air won’t be bumpy, but the truth is, the air is bumpy, and tensing up doesn’t make it less so. This time, I thought, “So it is. If these actually are my last few minutes of life, how do I want to spend them? Can I relax in this situation of turbulence?” I decided to spend them listing the things I am grateful for, the things I love. (I also reminded myself, “I will not infect others with fear.”)

The next day, sitting on my cushion in the zendo, I wondered why I have to think it’s my final five minutes of life in order to devote myself wholeheartedly to gratitude practice, or to metta, or to accepting what is. What’s stopping me from doing that even if I have years to live?

Also, I realized that I probably haven’t been taking refuge in dharma literally enough. I think of dharma as the truth—how things actually are; what a lovely idea!—but I then don’t recognize the pain in my shoulder or turbulence while flying as instances of how things actually are and instead categorize them as aberrances or interruptions of some sort.

Last year, I sat on a folding chair with no cushion, which got to be painful after a day or two, so I spent some time in the intervening year trying to find the right cushion for sesshin. The custom sewing person at a meditation supplies place agreed to make me a cushion, which turned out to be perfect. That part of my anatomy was free from pain.

Despite not getting anywhere near enough sleep during sesshin, I made a point of getting up early enough to stretch for 20 minutes or so before the first sit (which began at 6 a.m.), and so there were only two or three sits where I had significant physical pain, and I noticed that I could tune into the vibrating or pulsing nature of the pain immediately, which has sometimes in the past taken days to notice. When I can feel that something is pulsing, it means that it’s “Worse, worse, worse” but also and equally “Better, better, better.”

In the morning on the second to the last full day of sesshin, after many, many neutral to unpleasant moments of sitting, there was suddenly a light, buoyant feeling in my body, which once again reminded me that the suffering is not in the sensations but in the effort to ward them off. Once the mind has softened enough to accommodate whatever is happening, the suffering is gone. Naturally, as soon as I had this experience, I expected to have it at every sit for the remainder of the sesshin, and of course did not. Nonetheless, it was such a powerfully expansive experience that it completely made up for everything else.

As always, accepting what is was a challenge. As I traveled to school in a shuttle, the driver pointed out a controlled burn ahead, deliberately set to decrease the possibility of wildfire. This burn plunged us into about 18 hours of thick smoke, much worse than anything I’ve encountered in San Francisco the past couple of years, which sends me running for an N-95 mask and firing up my HEPA air filter. I was glad when the smoke cleared the following day, and chagrined when I returned the house where I was staying to find it full of smoke: incense lit by fellow students. Thankfully, one of our teachers said he would ask them to refrain, but by then, others in the house had warmed to the idea of burning incense, and I had to ask two other people to stop. One of them was a 15-year-old who was there with his mother. One evening, someone did laundry late at night and the washer malfunctioned, making a terrible noise and setting off a repeating beeping signal. I got up to ask the launderer (the 15-year-old’s mother) please to do laundry before sleeping hours.

When I met with one of the teachers for a practice discussion, I said that I was feeling miserable: tired, cold, and like a bad person for so frequently finding myself incapable of not telling another person not to do something. I confess that part of me seriously thought my teacher was going to say, “You are a bad person! Stop telling people what to do!” Instead, he kindly observed that I was also treating myself with unkindness, and gently advised trying on grandmotherly mind. In regard to feeling miserable, he reminded me about Frank Ostaseski’s advice to ask ourselves, “What else is here?”

That was really helpful. I had started the sesshin using the sensations in my feet as my anchor. That was right for that time. But later, it began to feel too constricted, and it seemed to exclude noticing emotions—to be a form of aversion—so then it was right to open up to the rest of my body, and to emotions. And then at some point, that was too much stimulation, and it was right to ask myself what else was here and to let my attention rest on more neutral areas in my body. It was a good reminder about upaya—that what is best changes from moment to moment. (That word means
“skillful means.”)
As for my misbehaving fellow yogis, I wrote the 15-year-old a note saying I hoped I hadn’t made him feel bad. After he read the first two words, he threw his arms around me and gave me a long, long hug. His mother was entirely kind and apologetic about the laundry noise. The other incense burner gave me a card at the end of sesshin apologizing for not always being careful about the rules and saying she hopes to do better. Instead of people hating me because I asked them not to do this or that, I was showered with love. It was a humbling, powerful experience of sangha.

For logistical reasons, we had our oryoki meals in the dining room instead of in the zendo. We sat in groups of five or six at tables, which went surprisingly smoothly, and afforded a nice family feeling. Last year, I particularly hated oryoki, I think due to the constant feeling I was doing something wrong (and partly because of the fear I would choke on a piece of spinach). This year, with more familiarity and with the family seating, I found the meals quite enjoyable.

The person sitting across from me got about ninety-nine percent of it wrong, often seeming petulant, and often failing to bow to me when she was “supposed” to (never mind holding her hands in gassho while I was applying gomashio to my food; in vain did our table leader, a resident at the center, try to get her to do that). One day, our leader was trying to help her tie up her bowls for the umpteenth time, and I saw that the end of her cloth was pointing toward herself rather than away, which meant her bow would fail. I reached to gently tug the tip of her napkin into workable position, and she whisper-snarled at me, “He’s my teacher!” After the end of sesshin, someone else who had sat at that table said she had felt challenged by this person’s attitude. I was pleased to be able to say, honestly, that she really didn’t bother me. I could see she was doing the best she could on all fronts, and obviously her behavior was not about me. While she might conceivably have appreciated my trying to help her get her bow right, it was also true that my help was unsolicited, so I didn’t take it to heart.

This same person was sitting next to me in the zendo and was a perfect neighbor. She rarely moved a muscle, she was utterly silent, and she did not emanate any kind of displeasing smell (e.g., laundry detergent). When I thanked her at the end, she just gave me a strange look and didn’t respond. At the closing council, when I asked for forgiveness from anyone I had harmed, I noticed she was smiling a little smile and got the feeling she was thinking, “I’m glad you apologized for all the terrible things you did to me!” Who knows what she was actually thinking? People are funny, aren’t they? Thinking of her, I smile. In the end, the sesshin was about people: the ones I liked, the one or two I didn’t, the ones who annoyed me, the ones I annoyed, and the qualities of forgiveness and generosity that ultimately enfolded us all.


I was paged to visit a patient who had been placed on comfort care the night before. Her nurse said various interventions were being turned off. I found the patient lying in bed with no visitors present. The room was pleasant and sunny, with a colorful vase of flowers. I assumed the patient would be unable to speak and thought I would just sit quietly with her for a bit; maybe her family would turn up. But when I spoke quietly to her, she opened her eyes and looked right at me.

She said that she was Christian and would like a prayer for a peaceful passing and to see her husband again in heaven. I was surprised, impressed and moved; I felt I might cry after I left the room. People almost always want prayers for healing, including when they are right at death’s door. I don’t think I’ve ever heard anyone ask for prayers for a peaceful death, or any other kind of death. I did pray for that explicitly, and that she and her husband will be happy together in heaven for eternity, and I gave thanks for her life. Afterward she murmured, “That was nice.”

Crane Tree

The day after the hospital move, Tom and I went to see Metamorphoses at Berkeley Rep, preceded by lunch at Au Coquelet. It was really wonderful—inventive, beautiful, hilarious at moments, touching—and also rather moistening if you were sitting in the first or second row, as we were. Afterward, we chatted with a woman with a visual impairment who said that her seeing eye dog got freaked out when she was splashed with water and went to sit with two ladies in the row behind her owner.

On Ash Wednesday, always a hectic day for chaplains, I met the interim director at my paying job and also our new full-time staff chaplain. I asked the new chaplain, Felicia, if she would like to have lunch, and four of us chaplains ended up lunching together. Felicia is cheerful and energetic and has been a great addition to our group. (Although it gave me a pang to see a new full-time chaplain start while I languish as a per diem. My former boss asked me to apply for a full-time or .8 job, but I felt that, with school still underway, I could not.)

I got a book: Dream Work: Techniques for Discovering the Creative Power in Dreams, by Jeremy Taylor, who has written several books about dreams. I gather he advocates using every form of dream interpretation—considering dreams from a variety of perspectives, even including the Freudian one, to see what might be discovered.

I actually figured something out about a recent dream, in which I was in the backseat of a car being driven by my grandfather. Someone honked aggressively at us, but, knowing my grandfather to be quick to anger, I was sure he would defend us. Instead, he got out of the car and strolled off, not even locking all the doors. I always sort of know I’m dreaming, so I wasn’t afraid, but I was mystified that he had left me vulnerable to attack. I realized that this is about the part of myself that is quick to get angry and to mount a vigorous defense: maybe not always needed.

In mid-March, I went to Santa Fe for a week or so at school. SuperShuttle drove off without me, so I had to take a cab to the airport. Two of my fellow students were on the same flight, and one of them switched her seat to join me. She gave me a lot of helpful tips about the thesis we are writing in this second year. She had rented a car, so the other student and I decided to drive with her instead of taking the shuttles we’d reserved. How much it cost me to get to school that day, besides the airfare and $30 to check a suitcase: $21.06 for SuperShuttle, $43.65 for a cab, $20 cab tip (purposely large to restore my own good mood), and the $40 I chipped in for the rental car.

But it was worth it. (SuperShuttle did give me a refund later.) We had a fun drive together, stopping at Annapurna’s in Albuquerque for lunch. While we were at school, we had a chance to discuss our project proposals with the person who is in charge of helping us with our theses. We were not officially going to get feedback until a month later, but during our meeting, she told me to go ahead and start writing, meaning my proposal was approved.

Toward the end of the week, my cohort did final preparation for jukai, an inspiring ceremony in which we received the precepts. The day beforehand, our teachers led a session on the meaning of jukai. My cohort had begun a scholarship fund in honor of Roshi’s recently departed teacher, Bernie Glassman, and had raised nearly $10,000. We designated someone to present this to her. While we were at school, someone had the idea of us each folding a paper crane and writing a note to Roshi on it; someone went and found a beautiful branch to attach the cranes to. Someone else said we should learn a song to sing to Roshi, and so on and so forth. So on this day beforehand, Roshi came into the room to hear us singing the song, and she saw the crane tree, which was indeed a gorgeous thing, and then we told her about the scholarship. She was bowled over.

When I began this program, jukai had zero meaning for me, but by the time I did all the work to get ready for it, it had immense meaning. It was a really wonderful day. We meditated for an hour or so that morning in another temple on the property, and then the “Band of Joy” came to escort us to the zendo, where our family and friends and the cohort of chaplains after ours were in the audience.

I didn’t want to make anyone feel that they had to schlep to Santa Fe, so I invited only one friend who lives right there, but wasn’t sure if she would make it, per health issues. I told her it was fine if she didn’t come, or if she came and stayed for five minutes and then left. The ceremony was about 75 minutes long, and I was touched when I saw afterward that she was there, and had sat through the whole thing. We went up front in groups of three or four, and I feel that in those moments when Roshi was speaking to me, she truly became my teacher. It was a great week at school. It was fantastic to see my fellow students. I also had a good work assignment: grounds (i.e., making compost heaps), under the direction of a particularly delightful resident.

The Story of No Pizza

The first Saturday in March was the day of the long-awaited move of patients to the brand-new hospital at my paying job, a long-planned and staggeringly complex operation. I rode my bike to work for the first time in quite a while, despite the pouring rain. The new hospital has a lovely, secure bike room with lots of racks in it, plus a large number of racks outside the room for visitors.

The hospital provided free pastries and coffee for staff in the morning, and box lunches, but what I was really looking forward to was the pizza that was to be delivered at 5 p.m. While I was waiting for that, I went to every floor to look around. I noticed that, looking west, the view is of four churches. I went to the ICU and saw some of my newly arrived patients, including one who had just suffered such a horrendous family tragedy that she didn’t even know about it, because her husband had decided it was best not to tell her. (I believe she died without ever learning what had happened.) I offered the husband condolences. His first words were, “God is with me.”

The patient move seemed to go smoothly except for one patient who refused to leave his room at the old hospital. Last I heard that day, they had succeeded in getting him down to the emergency department, so I’m sure success was achieved in the end. I had seen chart notes warning that this or that patient was likely to die during transport, but none did.

There was only one glaring problem that day, to my knowledge. At 5 p.m., I rushed to the cafeteria along with lots of other staff members, only to see the same old pile of box lunches: no pizza. Someone said they had seen a huge amount of pizza being delivered, and we could all smell it, but they had stationed some guy in the cafeteria to explain to us that the pizza was only for “certain areas.” I was really kind of irate. It seemed wrong that they would tell us that staff would be getting pizza and then not provide it. It occurred to me that maybe the ICU was one of those certain areas, but I went back up there and it wasn’t. My mother sympathized. “It’s different than if they had said that at 5 p.m. there would be a salad bar.”

It was irritating to picture management on TV saying how great the move went—which it did, and they did go on TV to say so—while screwing people who worked hard to help make it happen. It was also kind of mystifying. How could this outfit successfully move more than a hundred patients, some of them at death’s door, across town without the slightest mishap and yet be incapable of causing pizza cooked by some outside entity to appear in the cafeteria?

Fuming, I set off for the parking garage. Before I could open a door on the ground floor where I needed to use my badge, someone on the other side opened it: the CEO of the hospital, Dr. Wrigley Bodacious (not his real name). I started toward the bike room, passing employees who were asking, “Where’s the pizza? Where’s the pizza?” Then I thought, “Wait a minute!” and I turned around to go have a word with Wrigley, who I’d never seen in person before. I walked back up to the lobby, where a security guard said that he had just stepped into an elevator, successfully eluding me.

At home, I gave Tom a call. He normally takes absolutely everything in stride, but even he was shaken: “That’s not right. People don’t forget a thing like that.” I came upon yet another flyer announcing the pizza delivery, which also had on it the number of the Command Center, so I called them. The guy there said he heard something had gone wrong with the delivery, but that they had pizza in such-and-such room if I wanted to come and get some.

The next day, I saw six or seven self-congratulatory emails from the move team, and replied to one of them expressing my disappointment about the pizza, and that’s the end of the story of the no pizza, as they did not reply. I hoped they would make this right in due time, but reckoned I would not be surprised if they didn’t, and to date, they have not.

Tuesday, May 07, 2019

The Funny One

I have been thinking lately about turning toward what is uncomfortable, the discomfort being sensations in my own body. (Where else could it be?) One place I am encountering an edge is in non-professional listening. There are people I find it incredibly difficult to listen to, and I think the same thing happens for some physicians, who listen to a patient in a leisurely, highly attentive manner for an hour, and then visibly tune out when I’m telling them something and get past the three-second mark (even if I’m answering a question they asked me).

I see that physicians work incredibly long hours and then often have families to tend to, so I know they need to make effective use of every half-second. I suppose it is a testament to their training and character that they can listen so beautifully to patients, and not a failing that they can’t do it with every person who happens to say something to them in the course of a day. As for myself, I aspire to listen to everyone in the same way, which means aspiring to bear the discomfort of fully attending to something I think is boring or irritating—but not always succeeding.

Clementine periodically trains a new crop of chaplain volunteers, and there are three new folks who go to County Hospital the same day I do who are quite young; at least one of them is just 20 years old. I heard one of them telling another about a visit to a room with two patients in it: “They’re both talkers. Like, talker talkers.”

At my paying job, I encountered a nurse in the ICU who had just switched to the day shift. He is a formidable mimic and was really making me laugh. Using a German accent, he said something about “German dancing—just using the arms,” and demonstrated, punching his fists into the air. I said, “You’re very funny,” and he said, “Some nurses are smart—I’m the funny one.”

At the very end of the day, I heard a physician saying to a patient right behind me in the ICU, “A chaplain is a good person to talk about that kind of thing with.” Then I noticed the physician had put a consult order in for a chaplain to see this patient, so I went to see her (as opposed to leaving because it was the end of the day). I knew from her chart that she had was having a recurrence of cancer. It turned out that she wanted me to facilitate a family discussion. I was excited to have the chance to run my own family meeting after seeing so many of them at County Hospital, and discovered that it was way more challenging than I expected: I found myself sharing words of wisdom in a way I rarely do speaking one-on-one with a patient. I think I was feeling pressure to drive toward a certain outcome, and so I didn’t just let things unfold naturally. I think it was basically fine, and I think the family was appreciative, but it highlighted that I’m really a very new palliative care clinician.

Late in February, I was paged to return to the hospital to offer a prayer for a patient in the ICU. I was fried when I got home and pondered the idea that I could end up having to return to the hospital twice the same night, which so far has never happened (and didn’t happen that night). I didn’t get anywhere near enough sleep and, the next morning, felt like my head was packed in cotton. I considered not going to County Hospital, but soldiered on.

I made it through the day. I didn’t attend any family meetings. I went with the team to see two or three patients, and I saw one non-palliative care patient and her son. The patient was reaching end of life and her son was quite upset. The patient herself, who had a dazzling smile, seemed almost jovial. I sat with a dead patient and her longtime partner for quite a while. (She said his final words to her were,
“You look so pretty.”)
My monthly palliative care class was about prognostication. We learned that fewer than two percent of patients and their families base their decisions solely on what their doctors say. Lived experience is given much more weight. (However, doctors are generally pretty accurate when it comes to predicting how much time a patient has left.) (Partly because they never say, “Thirteen minutes.” They say “Days to weeks” or “Weeks to months.)

The goal is to give people enough information that they have a sense of control, without overwhelming them, which makes it difficult for them to process what they are hearing and retain executive function. Therefore, communication may unfold over multiple conversations, in which clinicians try to discover where the patient or family member is in their understanding and to join with the person in her hopes and fears, and to make recommendations that are in line with the patient’s goals. It’s important to try to flow with what arises and to remain allied with the patient or family member; arousing resistance in the other person makes everything harder. It is important to remain attentive to the other person’s emotions and agenda.

Hoping along with another person is something we can always do, even if what they hope for is unlikely to happen. “I hope so much that that will happen. And I’m worried that we’re in a different place.” One might say both of these things in the same conversation, or split up into two conversations.

We had a guest instructor that day who said her two words are “wish” and “worry.” She said it can be good just to say, “I wish for that outcome” or “I wish things were different,” and then stop talking. Or, “I’m worried,” and stop talking, and see what the other person says.

Medical tidbits: A person can be sedated enough that she doesn’t realize her airway is obstructed enough to end her life. Medication that relieves nausea also lowers blood pressure, which may not be desired.

That day’s speaker, a physician, shared this quote, from Douglas V. Steere, a Quaker ecumenist (born in Michigan, near the tip of the thumb): “To ‘listen’ another's soul into a condition of disclosure and discovery may be almost the greatest service that any human being ever performs for another.”

The speaker offered a note to his fellow physicians re nurses: “Be nice to nurses. They keep your patients alive.”

During my internship, I had a patient who had survived with metastatic cancer for an extraordinarily long time. She is now gone, so what a lovely surprise to see a photograph of her in the speaker’s slide show, wearing lipstick and a big smile. The quote from her: “Everything takes longer than you think it should, thought it would, except your life.”

Thursday, May 02, 2019

The Collective Brain

The next time I was at County Hospital, the attending was Thomas, who was a palliative care fellow when I was doing Clinical Pastoral Education (mentioned in the previous post). He is really great—so smart and enthusiastic.

After rounds, we went to meet with two family members of a dying patient. Thomas and George, the fellow, explained what they might notice as end of life approached. There might be pauses in the patient’s breathing of as long as 30 or more seconds. At other times, the patient’s breaths might be short and rapid. Neither of these are believed to be uncomfortable for the patient. However, they should call the nurse if short, rapid breaths went on for a long time, as the patient might be in pain. Ditto if the patient was having to use her neck, chest or abdomen muscles to breathe—if she appeared to be struggling to breathe.

Wet breathing sounds can also be heard as death nears, caused by saliva in the patient’s throat. We all have this and mostly swallow it throughout the day without noticing it. When a person becomes unable to swallow, then saliva collects in the throat and the wet sounds are heard. As with short periods of rapid breathing or pauses in breathing, this is not believed to cause the patient distress. However, the nurse should be summoned if wet breathing is accompanied by grimacing or frowning or other obvious signs of distress.

Thomas said he would guess that the patient had hours to days to live, maybe three days, though he said this is hard to estimate. He said he would also not be surprised if the patient died that very day, while if it looked like she might live longer than a week, she might need to leave the hospital. George emphasized that if the patient did end up being moved, it would be only to a place where the same level and type of care would be available, and Thomas added that if it seemed that transferring the patient would jeopardize her well-being in any way, then she would certainly stay right where she was.

After Thomas and George were done sharing this information, and knowing that these family members hoped to be with their loved one when she died, I remembered what Helen said about how patients may choose a solitary moment to sneak off, and shared that. Afterward, I asked Thomas and George if it had been OK that I added that, and they said, “Of course!” So perhaps another role of the chaplain is simply to be part of the collective brain, another person to help remember things.

We visited a patient with a large cancerous mass who was very weak, almost unable to speak. His most fervent wish was to return to his hometown on the other side of the country, where family members had agreed to take him in, but the patient’s physical ability to make this trip seemed very questionable. The physicians and RN talked to the patient about what kind of care he might pursue in his home state, if he’s able to get there, and the topic of hospice was introduced.

The patient closed his eyes, and I got the strong sense that he was suddenly in grief, perhaps thinking that he wanted to go home to live, not to die. I said gently, “I noticed that you closed your eyes when we mentioned hospice. Are you feeling sad?” The patient nodded, and I saw the light bulb go on over Megan’s head, the nurse on the palliative care team. She asked the patient if he would like to know more about the philosophy of hospice care, and after we had left the room, she thanked me for picking up on the patient’s sorrow. I in turn thanked her for taking it from there, and seeking to give the patient information that might allay his distress.

At various times since starting to be a chaplain, I have worried that, as a person who naturally leads with my head, I am not sufficiently empathic, not sufficiently conversant with emotions. I am relieved that this is a skill that can be developed. As I make a point of trying to tune in to what others are feeling, listening for essence rather than information, I see this capability getting stronger.

I’m still pretty new on the palliative care team, and so I’m mostly silent in meetings, though I also try to be brave when I’m pretty sure something I might contribute would be appropriate, and if I get a strong intuition, I act on it.

Another patient we saw that day was also very weak. George asked her something like, “Do you want to do this or do you want to do that?” She stared at him. I whispered, “Maybe ask a yes-no question, so she doesn’t have to work so hard.”

“I know,” said George. “I’m trying to think of one.”

I made a suggestion and George asked the patient that and she gave a clear answer. Again, after we left the room, I received thanks. This team makes a point of noticing and appreciating the contributions of others.

Bony Mets

At County Hospital in mid-February at palliative care rounds, we discussed how patients often confuse metastases to the bone (“bony mets”) with primary bone cancer and think they’re getting the wrong treatment because it’s not what the Internet says should be done for bone cancer.

We had four family meetings scheduled that day. Before one of them, the palliative care fellow at the time, George, mentioned that hospice is both a service and a philosophy of care. He reassured the family of one patient that hospice is attached to the patient, not to a particular location. Wherever the patient ends up, she can get hospice care. Before another meeting later, he told a couple of other physicians that there are generally two things to be decided: what type of care will be provided, and where it will occur. You can uncouple these and tackle one or the other in a given meeting.

When we arrived for a meeting in the afternoon and counted how many chairs were needed, the patient’s family said, “We don’t need chairs,” and that’s how we ended up standing for 90 minutes around a sleeping patient’s bed. A non-palliative care physician started this meeting by saying, “So, what are your goals of care?” He was obviously trying to do the right thing, but I’ve never heard a palliative care provider say anything like that. Quite often, they start by saying something like, “Can you tell us what you understand about your mother’s condition?” Then they might ask if any changes have been observed recently. They ask permission before giving bad news: “We have received your mother’s test results. Do you want to hear about the findings?”

This particular family had gone around and around in prior meetings, and this conversation also went in circles for a while, but eventually it was understood by all in the room that there was nothing that could be done to restore the patient’s health, and also that it would be impossible for her family to care for her at home. We discussed a certain place she might go, and, at 75 minutes in, it was sounding like this was an option the family would be all right with. During the final 15 minutes, one family member after the other thanked us profusely, which was very sweet, though I must say my feet were really killing me by then.

Helen told me in the afternoon that they were going to meet with George to offer him a job at County Hospital after his fellowship ends. I was delighted for him. He is a really sweet person and a wonderful communicator, a master of reflective listening. It occurred to me that another of the palliative care attendings at County Hospital was also a fellow when I first met him, and I thought he was totally fantastic, too.

Around then, I got together with fellow students from my school in Santa Fe; we do this every couple of months. Carol-Joy came to town and we had breakfast at Santaneca and then spent the afternoon playing cards, and Charlie and I also went to Santaneca.

Any Direction Is Fine

I lately read Alice Robb’s Why We Dream: The Transformative Power of Our Nightly Journey. She whips through a huge amount of research pertaining to various aspects of dreams. I learned that we can dream in non-REM sleep, such as when we’re first falling asleep or near the time we wake in the morning. She also writes that the emotional tone of our dreams tends to improve as the night goes on. We might experience anxiety in earlier dreams and joy or pleasure in later ones. It bodes well when we take action in our dreams as opposed to passively observing.

I was most interested in the chapter on lucid dreaming, of course. The one trait shared by successful lucid dreamers is good dream recall, which can easily be improved by keeping a dream journal, which can be handwritten, typed, or voice recordings. Inspired, I put a pad and pencil underneath both of my pillows for capturing notes during the night. The first morning, I recorded a vague couple of snippets. About four days later, I had a long dream in which, in part, I found myself on a beautifully maintained country estate, so perfect it was like a movie set, with the landscaping largely in shades of gold.

I came upon four people and said, “I’m sorry to interrupt you.” They glared at me, and I realized that all four—men and women—were wearing identical gold-colored wigs that featured pony tails. I forged ahead: “What direction is Stadium from here?” I meant a street in Ann Arbor. One of the people told me the answer, but in such a way that I suspected he might intentionally be leading me astray.

However, I then realized I was dreaming, which meant it didn’t matter if the person had given me the right answer or not. I could walk in any direction and enjoy it, because the destination didn’t matter.

Formerly, I tried to follow Stephen LaBerge’s advice, which is that when you awaken in the night after a dream, you should replay the dream until you have it memorized, and then picture yourself back in that dream becoming lucid, affirming over and over as you fall back to sleep, “Next time I’m dreaming, I will realize I’m dreaming.” The reason this did not work for me is that I literally could never—not once—remember to do it. I would wake up, remember my dream, maybe picture myself once becoming lucid in that dream, and the next thing I knew, I’d be waking up after some other dream.

Alice Robb finally convinced me of the necessity for frequent “reality testing.” This is investigating, during the day, whether one is asleep or awake. It’s best to do it 10 or 12 times a day, or more, perhaps every time you pass through a doorway. There are several ways of doing this. You can count your fingers to see if there are five. In a dream, there usually won’t be, or if there are, if you count them a second time, there will definitely be more than five. (Why not fewer than five? Things in dreams invariably proliferate.)

You can see if it’s possible to push a finger on one hand through the palm of the other hand. If you can’t, you’re awake. You can read some text and then read it again. If you’re asleep and dreaming, it won’t be the same the second time. You can look at basically anything and then look at it again to see if it’s the same or if it has morphed. Alice Robb also writes about meditating before bed. I have been meditating in the morning for a long time, but decided to start doing it at bedtime instead, since becoming a proficient lucid dreamer is pretty much the one and only thing on my list of life goals.