If this is heaven...

The other night I was working a shift in the hospital. I was paged to a Code Blue. Most times when I'm paged to those the outcome is bad for the patient and family, so I was trying to get myself mentally in gear as I headed for the department that had paged me. I spotted the typical cluster of respondents--portable X-ray, lab, portable EKG, in a hallway, and joined them. The doctors and the nursing supervisor were in the room. The X-ray technician told me the patient was conscious and talking which is pretty rare. I peeked in and there were plenty of folks round the bed, starting medicines, checking monitors, and the like. The patient was on the bed, which was tilted so the head was downward, and was talking to a doctor. Usually by the time I arrive the patient has Gone to their Reward, is Resting, has Passed, is With the Lord, is In a Better Place, or has Crossed Over, effectively even if not officially. Lying head down? Talking to a doctor? If this is heaven, maybe I'm not so excited about trying to get there.

A rare good outcome; hoping things worked out for this patient.

These are the stories that linger

Not long ago I saw a patient I'd met months past, an old man with dementia and other severe health issues. I'd seen him a few times before he got better and went to a nursing home, and I loved him. He had not had a very easy life, and I imagine he hadn't always been a very easy man. His family had some conflicts and struggles too. He'd been a stubborn man, and he didn't like asking for help, and he really just wanted to be in his own home, but he needed more care than family members could provide, so he had to live in a nursing home. He came back to the hospital not long ago, his dementia by now very advanced, and his other health problems as well. There had been some sort of accident at the nursing home, a bad one. He had fractures and bruises and cuts, and lots of stitches. I was horrified when I saw his poor battered self resting in a bed. The medical staff had determined they needed to get his pain under control before even doing a full assessment of his condition, so they were waiting for medicine he'd been given to take effect. He was moaning--I got his nurse, who checked him and got more medicine. I sat beside him, trying hard not to cry. So many bruises and bandages and cuts and stitches, no wonder he was hurting so. And his breathing sounded awful. I touched his hand, and he grabbed mine and held it tightly, his face turned slightly toward me. He would doze a bit, awaken coughing, and start wailing, or maybe it was keening, again. I told him we would get him feeling better, but he just kept on keening. On a hunch, I said to him, "We'll keep you safe here. We'll protect you." THAT had an effect--he stopped keening and seemed to settle, only to wake again. I tried the reassurance several times--he always settled to the words, "We'll protect you." He was so frightened. He didn't know where he was, or why, and he was in terrible pain, and I don't know about his accident, perhaps that frightened him as well. Even a healthy old man would have been upset, and this was not a healthy man. A family member came in to be with him. We decided he was chilled, and I went to get him a warm blanket, and told the nurse I thought he was afraid. I told her the words that had calmed him and she wrote them down to use later when she needed to give him more care. Back in the room, I helped tuck the warm blanket around him, very gently so as not to hurt him more. He wasn't afraid of me, it seemed; I could touch his head, his shoulder, his battered face. I murmured more assurance to him, told him we loved him, told him once more we'd protect him. Medicine was starting to work, and he was settling. It was time for me to get out of the way so his family could be with him without interruption. I checked on him a couple times before my shift ended. He had finally been able to rest, but his breathing was even worse. The family had been called back in. Early the following morning, he died.

I couldn't get him out of my mind for days. I will never know what all transpired to bring him back to the hospital. He'd had his accident some days earlier and been taken to an emergency room for care, and apparently he'd been taken back to the nursing home to recover, and then been brought back in. I just hated seeing him so hurt, so vulnerable, so terribly frightened. This is not what he wanted or what his family wanted for him. It isn't what I would want for anyone. It isn't the way we'd want anyone to die.

We don't take the best care of our vulnerable elderly in this country and culture. They're pushed to the side by the younger generations; they aren't making money anymore; they aren't the demographic that even churches want to attract. Those who care for them in nursing homes are not well compensated. And sometimes, our vulnerable elderly end up like this poor man, broken and bruised and terrified, because their medical needs are too great for care at home. Their friends are dead or dying, their political clout is zero, and in most cases only family members are left to care about what has happened to them. They have become anonymous.

So, today, I want to make this man a tiny bit less anonymous. Sure, he was an old man with dementia who could no longer even recognize his family members. When I first met him months ago, his capabilities were already greatly diminished. Nonetheless he was full in personhood to the end. He liked music (big bands, Sinatra). He liked a good meal. He liked company--he liked having his hand held, he liked to laugh. He was a lifelong Baptist who'd been a member of a huge urban church. He liked church music and hymns. He liked the Bible, and he loved to watch religious programming on TV. He liked a kind of religion that was upbeat and gave him hope. He liked the Lord's Prayer. He had a radiant smile and wispy hair that stuck out every which way no matter how often it was combed. He liked being outdoors, watching television, and birds.

Now he is gone, and his suffering has ended. May he rest in perpetual light.

More mortuary bad fun plus best Five Wishes ever

So the mortuary drivers have learned that I am up for a good story--two younger men who work for one of the transport services told me the following one. They had been called to a home. The service for which they work always dispatches two drivers/vans to a home in case the removal is, ummmm, complex. So to speak. This was a very straightforward removal until the moment the two men were wheeling the cot and its Very Quiet Passenger down the driveway of the home, at which time a pizza delivery truck zipped up and parked. The pizza person jumped out, grabbed the pizza, turned around, and was confronted by two men in dark suits and a very unmistakable mortuary cot with a very unmistakable Dead Person thereupon. The men told me the pizza person's facial expression was absolutely priceless, and the act of stepping back while juggling the pizza and trying not to fall right down in the middle of the street took great coordination. The drivers called up to the house and found out someone alive had ordered the pizza and was prepared to pay for it, and took off about their business, but I imagine the pizza person needed a stiff drink at the end of the day at the very least.

One of the hospice patients in a care facility had completed the Five Wishes document to outline his end-of-life choices, a very good thing to do. This individual had always been fiercely independent, very bright, and very outspoken. Friends, family, and caregivers reported that his communication could be painfully blunt. Thus, a choice for having inspirational readings and beloved poems read at the bedside was eliminated with three large, FORCEFUL X's. Likewise he'd written the word "Bull***t" next to a section exhorting the family of the writer to see the writer's death as a personal growth opportunity, indicated that he didn't care at all how his family disposed of his remains and suggested the decisions be based on financial reality only, scribbled in the margin that his family could believe whatever they wanted about death, and indicated, for his thoughts about his death, "Not liking it much." This was the best such document I've ever seen, in terms of giving a glimpse of the person who wrote it. An out-of-town relative attended the death and I brought out the document for the family to think about a mortuary. This relative found such a sense of her loved one in the document that I made a special copy to send home. You don't have to be "nice and polite" to be real and worthy of love and remembrance. Through reading the wishes the relative got one last chance to "hear" the loved one, and was able to realize his essence had maintained throughout his illness, and found that comforting. As for me, I just loved that "Five Wishes." Especially the big forceful Xs crossing out everything that sounded schmaltzy or inauthentic to its author. I hope the God of humor did not greet the author with a squadron of chubby harp-playing angels sitting on a fluffy cloud.

Catching Up

It's been a while, again--this'll be kind of a random post.

Sheer joy at the inauguration of President Obama!!!!!!!! That this country is ready to have, as its representation to the world, someone who is not white, is a huge source of hope for me. Things CAN change. And, as an old romantic and an old feminist, it did my heart good to see the closeness between him and Michelle Obama. Who is everything one could dream of in a First Lady: drop-dead gorgeous, brilliant, accomplished, honest, and, with her husband, very attentive to their children.

Completion of second unit of required 4 of clinical pastoral education (CPE). Now I'm in the third. I look to a time when this will be over; it's expensive, good learning to be sure, but wearying. I need the four units to make myself at all plausible as a chaplain.

Grief as well as joy and pride as seminary classmates proceed to ordination. It's so complicated; never have I been so sure that my choice was right, but that doesn't mean I have to like the consequences. At core I do experience a call to ordination, a sense that ordination is somehow a piece of who I am. I don't know if, or how, I will find it...

Have been hanging out once per week at the Episcopal Cathedral--there is an Evening Prayer service followed by Eucharist each weeknight, and since weekends aren't feasible, I've been going there, usually Tuesdays. It's a very small group and many aren't all that friendly, one senses they are there for a time of meditative worship and soul-feeding rather than community, and that's something I understand quite well. Now I know one fellow's name--big progress! The most friendly person I've encountered is the Dean and Rector, who is sort of both CEO and pastor of the cathedral parish, and a very outgoing fellow. No doubt a politician as well, one doesn't get to be Dean and Rector of a Cathedral parish without some skills in that department, but I like his warmth and humor. He's asked me to read a couple times at service, and that feels like "coming home," and brings both deep sadness and deep joy. The services are liturgical and beautiful and I do sense the possibility that this denomination, problem-ridden as they all are, could be home. The rub? I don't know that the Colorado Diocese currently implements the procedure for endorsing lay chaplains, which I would need if not ordained, and ordination? I can't imagine that as possible, and if I could imagine it as possible, I imagine it would require many more years of preparation...

Meanwhile I have friends pursuing ordination in UCC, which does ordain for chaplaincy, and is theologically open, and etc. And its ordination process is said to be more sane than others, although not everyone agrees. I don't know much about it at all.

So much to learn, so little time!!!!

Bad fun on the night crew

So, I have a standing joke with one of the charge nurses who works night shift at the inpatient unit to which I am sometimes called. When I leave, and this nurse is charge, I always tell him I'm "off to Joe's (bar and grill, our imaginary local cheap bar)." I bring him greetings from the mythical Joe, and we talk about the price per pitcher of beer. He tells me how many pitchers I should drink for him. If we are with a patient who is up for it, we involve the patient in the joke. The other night, I had finished handling a death, and I told the charge nurse I was off to Joe's. A floor nurse, thinking I meant the nearby St. Joseph Hospital (called "Joe's" in the same way that the nearby St. Anthony Hospital is sometimes called "Holy Tony's By the Sea"), said he hadn't known I was on call for them. The charge and I corrected him. I said, "No, no, Joe's BAR AND GRILL." The charge nurse said, "We hang OUT together, at Joe's bar and grill." The floor nurse was flummoxed. Which, of course, made us more determined to be poker-faced. The charge nurse was actually getting off in an hour, so we talked about meeting up in an hour. I reminded the floor nurses I was still on call until morning and promised to stay relatively sober, and left them, laughing all the way to my car. It's hard to shock a crew of hospice nurses, especially a night crew, but hey, you have to have fun.

This particular night crew has lots of jokes. For some reason, a number of us have acquired imaginary names, with the last name "Suggs." I am "Reverend Suggs." Who knows why. I don't know that the managers quite know what to do with us, but that makes it even better. Since some of the more difficult deaths happen at nights or on weekends, when we have to lean on each other for support, shared jokes have a special importance... you really HAVE to laugh when a family wants an autopsy, and it's after hours, and there's no one there in the Pathology department of the nearest hospital to tell us what to do to arrange for the autopsy, and when we finally find the policy it doesn't say who pays to get the body to the hospital, and a family member says, "Well, we HAVE a van..." and all you can think of is the urban myth about the stolen station wagon with the deceased grandmother strapped to the luggage carrier.

(I should say that we got the body to the hospital without use of any private vehicle. The family negotiated a transport by the mortuary who was going to get their business for the final arrangements. One reason the family wanted the autopsy was because they suspected that hospice treatment, where we don't give IV fluids "just because we can," had resulted in death by starvation for their loved one. Our favorite mortuary driver arrived to transport the deceased to the hospital's morgue. He asked why the autopsy, and we explained we'd starved the patient to death, because we are just like that. He was nonplussed by the size of the body, the loved one having been a person of some stature. He complained, "I thought you starved this person to death, why's she so heavy?")

A public service announcement

Get those advance directives going! I have had an update on the law in my state, and, given that the update comes from a physician board certified in hospice and palliative care who has practiced for a long time here, it's well worth repeating.

Here's the thing: in my state, if you become incapacitated and do not either designate a medical durable power of attorney or leave advance directives, things get very complicated. What your doctors are required to do is contact those closest to you and ask them to name a party to act on your behalf. A consensus is not required, the physician explained, but an election is.

Think carefully about this. Are your closest relatives close at all? Is ANY of them a person you'd like to have acting on your behalf? Would you feel guilty imposing that responsibility on them? Or, in a darker scenario, is the one most likely to be elected the one least likely to know what you'd want? Family dynamics are complicated, I'm just saying.

And if you have no directives, no MDPOA, and no one can be found to act for you? DOCTORS will. Often, the doctors caring for you in this situation will be doctors who don't know you at all, and won't have (and shouldn't be expected to have) any idea what your values are and what you would want done for you.

Get to work on those directives. Attach them to your fridge with a magnet. Better yet, tattoo them on your body. In more than one place.

Oh coroner! My coroner! Or, the job market is bad, but still...

In the state and county where I work, the coroner's office must be notified of every death, and depending on a series of criteria, may be required to conduct a death investigation. Even for patients in hospice care, a death investigation may be required. One common reason for a death investigation is a fall or fracture in the days right before death, that precipitates the final decline. When hospice workers report the death (by paging a coroner's investigator; one is on call 7x24), the investigator may request certain information from the medical record, may come to the site to examine the body, interview the family, and review the records, and may elect to have the body transported to the coroner's facility for further investigation or autopsy. There was a death in a care facility one night, and the coroner's investigator requested transport of the body for investigation. Luckily, the family said their goodbyes and left the facility before the transport service arrived. I say luckily, because the transport service dispatched a driver who looked as if he'd been repairing a car when he got the call. He was a big burly young guy, dressed in work pants and jacket--I looked for his name in an oval patch on his jacket, but that detail was missing. He had a badly grown out crewcut, dirt under his fingernails, and bloodshot eyes. His cot squeaked badly as we walked to the room to retrieve the body. I told him he needed some WD-40, and he muttered something about a brake job. He then told me he hadn't been getting more than a few hours of sleep a night for weeks, because he'd been filling his brother's call shifts while his brother was on vacation, and that particular night (it was about 2 AM) he'd had only about an hour of sleep. "You're DRIVING?" I asked. "Yup," he said, "Hope I make it." I think if I were the deceased I'd sit right up in horror at that point, and plan to make my way to the coroner's on my own, but this deceased was apparently unconcerned and remained Very Quiet while loaded into the back of the van. I hope he made it, because you'd hate to be the family and hear that your loved one had been in an auto accident ON THE WAY TO THE MORGUE. Seriously, if I'd been a family member and this guy showed up to transport my loved one, I'd have declined permission, not that it might have done much good, since it was for the coroner's office. And, in any case the driver told me the back-up for his shift was HIS GRANDFATHER. Apparently the business is family-owned... Imagine making conversation on dates, saying you worked for your family's business DRIVING DEAD PEOPLE ON ONE HOUR OF SLEEP. This poor guy is doomed to remain single for a long, long time, I fear.

Don't even know what to name this one

I got a call once, to go to the scene of a death in the home hospice program. The home hospice program brings hospice care to a patient wherever the patient happens to reside. In this case, the patient lived in one of those retirement complexes that offers graduated levels of care, all the way from independent apartments through assisted living to a skilled nursing facility. These can be wonderful since residents don't have to completely leave their friends and support relationships when they find themselves in need of more care.

So I agreed to meet the hospice nurse at the complex. When I got there, I found a gentleman in white shirt, tie, slacks, sport jacket, wearing an ID that identified him as a chaplain from the complex itself. I hadn't known the complex had a chaplain or had called a chaplain; we introduced ourselves and the chaplain explained he lived in the apartments, was a retired pastor, and was one of the chaplains available to all the residents at the complex.

There are a number of clear advantages and wonderful possibilities about the arrangement this complex has, having retired pastors available for the spiritual needs of their fellow residents. Unfortunately, none of those advantages was in evidence in the situation I describe. This particular chaplain, while well-intentioned, was very hard of hearing, did not know the deceased or the family, and had a skill set that relied almost exclusively on saying prayers and reading Christian scripture.

The family, consisting of a heartbroken spouse and a number of supporting relatives, arrived at the scene. They'd been visiting the deceased most of the day and really had not expected death to come that evening, so they were shocked and regretful at having left, in addition to heartbroken over the death. The chaplain and I began to talk with them; it soon became apparent that the family was in no shape to cope with the repeated questions owing to the chaplain's hearing problems. (The spouse would introduce an adult child to the two of us, and the chaplain would then ask something like, "And what is the relationship between you two? Is she your daughter?") The chaplain optimistically mentioned prayers and scripture; a lot was going on at the moment but it did not escape my notice that the family, without a single exception, ignored the suggestion.

I had to meet with the hospice nurse briefly and on my return I noticed the family seemed even more restive. It devolved that the chaplain had announced he would take the family to view their loved one, and the family wasn't sure they wanted to do this at all, and REALLY didn't want to do this until one last family member arrived. I assured them there was no hurry and no rules, they could do exactly what they wanted. The chaplain interjected that now we would say prayers and read scripture. I caught a desperate glance from one family member. It seemed to say, "DO something about this man, or I can't promise I'll stay polite." I interjected that it didn't seem that prayers and scripture sounded comforting, and perhaps the family would just like to remember their loved one while waiting for that last person to arrive. The desperate one jumped on that suggestion as if it was a winning Powerball ticket, but of course the chaplain then asked, "Do you have a church?" It devolved that the family really is not religious at all. Fine by me. Finally the last relative arrived and the spouse wanted to go see the deceased. I said, "I can walk you back to the room so you can have some family time." The chaplain, perhaps not having heard, said, "I'll go with you." We marched ourselves to the room and I said, "If you need anything at all, I'll be in the lobby where we were sitting," and firmly closed the door, leaving the family inside and the chaplain and me in the hallway. I wish I'd had a brain in my head; if I had, I'd have invited him to come with me and tell me about his ministry. I didn't have a brain in my head, so he stationed himself roughly three inches from the door of the room.

Shortly after, the hospice nurse asked me to come back with her while she explained some logistics to the family. We went back, and to my horror, the room door was open and the chaplain inside. When we entered, I caught another desperate glance from the same family member who'd silently begged for help earlier... We said what we'd come to say; the chaplain was standing there with a look of impending prayers and scripture. This time I decided not to mince words. I asked the family if they'd like a little time alone, AS A FAMILY, and the desperate one leaped on the suggestion as if he'd seen a second winning Powerball ticket, and we escorted the chaplain out. This time, at last, he got the hint and decided he'd return to his own apartment, as long as the hospice nurse and I agreed to stay as long as the family might need us. We thanked him for coming, and I for one WATCHED HIM LEAVE. The nurse and I went back, I to the lobby and the nurse back to the nurse's station to handle the required procedures. The family took some time and then, assured that there was nothing at all that they needed to do, took their departure.

Encounters like this one are why a lot of folks are suspicious as can be about chaplains. A lot of folks have met "religious types" who aren't sensitive, who have a religious agenda, who insist on inserting themselves into a family in ways that are not helpful. There's a lot of baggage that goes with the word "chaplain" and all of these things are part of that baggage. To be sure there are families whose religious values match those of that chaplain who might have found his presence reassuring. Unfortunately, the family we were there to see was not such a family, and the chaplain did not have the ability to shift tactics to a different way of support. I am guessing that he also had a bit of judgment, a bit of feeling that the family "should" have religious values more like his, and a bit of hope that he could steer them in what felt to him like an appropriate direction. That might have been his job as a pastor, but it's not the work of chaplaincy, which is to be present to the family as they are, to offer what they need if you happen to have it, or find the right person if you can't do what they need. And a ministry of presence sometimes means having the sensitivity to realize that you need to get the h--l out of there and leave the family alone.