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.