This one was tough

Jack (not his real name) was a lovely man in his eighties whom I met when his wife died in hospice care. I spent time with the family during her last illness and was the chaplain on duty when she died. Jack was deeply affected by her death. He adored her and had been her main caregiver for a long time, as she had some chronic health problems before her final illness. Jack would weep, openly, at her bedside, because he knew how much he'd miss her. He had adult children and grandkids too, and all of them adored him and vice versa. We all hoped he'd be OK given what a disruption as well as a loss the death of his wife would be. His wife had become the center of his life, and caring for her had occupied most of his time, and when that happens the adjustment is enormous--there are so many empty hours to fill. I was drawn to Jack immediately, because he was absolutely genuine and open-hearted. He was not afraid to show deep emotion for his wife and family, and at the same time he was very much a strong man. I just loved him, all of us who cared for his wife just loved him. He and I met up again at the quarterly memorial service the hospice provides for patients who have died in the past few months. Jack remembered me right away. He gripped my hand and wept, we hugged and talked. He was there with several family members, and it was clear that there was a lot of love in the family.

Just a couple months after his wife died, Jack came into the hospital for something that seemed pretty minor. Unfortunately, it seemed that every test he had revealed some new, ominous problem. He had operation after operation, had a heart attack during one operation, and finally had a stroke. He wanted treatment carried out until it was clear he could not get better, as his organs were failing one by one. At that point he came into the hospice inpatient unit. And there he was, the big strong stocky man with his leonine head, his big hands, his very proper VanDyke beard, dying. He remembered me and was too tired to talk. We wanted him to rest and sleep, finally free of all the tubes and monitors from the hospital. He'd put up a tremendous fight but was utterly worn out. The medical staff worked to control his pain, while family members gathered.

On Sunday afternoon I was at the nurse's station and a daughter-in-law ran toward us crying. "He just stopped breathing." I grabbed his nurse from report and we all ran to the room. As soon as I looked I knew he was for all purposes gone. The nurses waited until all reflexive breaths had stopped, and verified that his great heart had stopped beating. Then they left. The room was filled with sobbing. One thing about Jack--his sons-in-law and daughters-in-law loved him without reservation. He was their Dad too. (One son-in-law had told me the day before that Jack had been the one who taught him to be a man, just by example.) The family asked for a prayer which I led, my own voice breaking. Imagine losing both your parents in just a couple of months... I checked in on the family a couple of times in the next few hours. Busy with other emergencies, I didn't see them when they left, but I did have the chance to go see Jack one last time, as the mortuary van was driving up. I sat beside him and caressed those big hands, blew him a last kiss, and told him goodbye. He was simply a wonderful man--I'd learned that he was a combat veteran of WWII, wounded in action. He was also a quiet philanthropist. His family told me that until his last illness, when they'd had to pay some bills for him, they'd had no idea how many charities he'd supported without a word to them. He loved to give and receive hugs, and tell stories, and play cards with his friends, and he loved his family dearly. He was a rock to them, someone who was always simply there. It was tough to say goodbye.

Merry Christmas in heaven, Jack. I imagine you and your beloved wife as newlyweds again and wish you eternal joy.

Economy and Waste in Health Care

Let me start by saying that I think there are many valid points of view about what causes health care costs to be so dramatically high and to rise so dramatically fast. Doctors see different things from patients, and both may see different things from accountants who see different things from insurors and lobbyists and etc. So I fully acknowledge that even the sum total of all I see or could see from my perspective is only one viewpoint and not the whole.

However, there are things that certainly make one wonder. A new patient came into the inpatient hospice unit recently. This patient has had some serious diagnoses for quite awhile and everything kind of came together in a perfect storm a couple months ago. The patient was in and out of the hospital, in and out of intensive care. A couple weeks ago the patient, who could in layman's terms be described as "held together by chewing gum and baling wire," was discharged from the hospital to a skilled nursing facility (SNF) for "rehab." This lasted about 24 hours, whereupon the patient was returned to the hospital in critical condition and went back to ICU. And back onto a ventilator.

Now, obviously, cost is minimized when patients get the appropriate level of care in the appropriate (that is to say, cost-effective) setting. And to be sure nothing is gained by keeping a patient in a hospital who doesn't need to be there, but really? Two ambulance transfers in 24 hours? With all the coordination and paperwork and orders and etc. that are required to transfer someone to another care facility? How much money did THAT save? The patient is now in hospice, the last acute crisis having pretty much shown everyone that the prognosis is simply awful, the patient is suffering terribly, and it's time to quit with the invasive curative stuff and look for comfort.

I really am annoyed by expense that is disguised as efforts toward efficiency. Such as, holding meetings every single day to browbeat department leaders about why they are not more cost-effective. If the meetings degenerate into repetitive exhortations to "do better," and, in the industries where I've worked that tends to be the case, then they become, themselves, a huge waste of money as well as a morale-destroyer. I suppose you could call that efficiency: wasting money and ruining morale in a single meeting. I'm sure Scott Adams has explored this theme in the Dilbert strip and books.

A death early this morning, and our wild and crazy mortuary driver appeared. I warned him the deceased was a good-sized fellow, not tall but sort of stocky. He sighed. "They're all big, today," he said. He'll be more chipper in a couple more days when we have some snow and ice for him to drive through.

Oh, and here is a GOOD rant: I was present at a death of a gentleman of middle age. His mother and sister were attending him. A brother had died recently, so this mother had lost two sons in, I think, less than a year. The earlier death had happened in some sort of care facility and unfortunately a new age romantic had attended the family. The romantic had told the mother that she should not have her hands on the body of her dying son because "It would hold him back spiritually" and "She needed to let him go." She had tears in her eyes as she said, "I didn't get to hold my son..." and wondered about THIS son. Who, as it happens, had curled his fingers around my hand when I touched it. I'd transferred his hand pronto into his Mom's hand, where he continued, although profoundly unresponsive, to curl his fingers round hers. "LOOK," I said to her. "There just is not one rule for all. Your SON will tell you what he needs, and you will know. If he gets agitated when you touch him, you will know he is asking you for a little space. But, see, he is curling his fingers around your hand. It looks to me as if he LIKES having you touch him. You're his MOTHER, you know him, you stay here and do what you know will help him." He died less than thirty minutes later. With his mother and sister holding him. The way they wanted, the way he wanted, the way they didn't get to do thanks to the romantic, the last time. Blech. Now, I suppose it is possible that the previous son was agitated and the caregiver wanted to diminish the stimulation around him, that can happen. But the way it was phrased, that's mean, and I call it every bit as much abuse of power as if the caregiver had told the mother her son would go to hell if she didn't get him to say the sinner's prayer.

When we have agitated patients and they need calm, I would ask the family to try giving the patient a little space and emphasize that as a way for them to help, which is what they are yearning to do, rather than lay some sort of trip about "holding back spiritually."

Enough grumbling, time to walk Big Fuzzy!

A pretty boring post

It was soooooo cold over the weekend that my windshield washing fluid froze in its jug (and in its reservoir as well). I have purchased a jug of SERIOUS windshield washing fluid that purports to be good to minus 34 Fahrenheit. Having done so I can rest assured that the remainder of the cold season will be warmer than the weekend. Despite the windshield washing fluid fiasco, my car cooperated brilliantly, starting without fail on the first turn of the key. I big-puffy-heart my car.

This afternoon I have to assemble the bits of a holiday package for my Sole Blog Reader (well, perhaps one of two, but the one related to me). Said reader is unlikely to be reading, as I suspect he is suffering the pain of Inevitable Disappointment From The Hero. Yes: Our President-elect, though in many ways apparently of sane mind, has proposed the Superintendent of the Chicago Public Schools as his choice for Secretary of Education. This on the basis of "experience with what's really happening in the classroom." I can barely type these words; I flinch, imagining them as so many lashes in the flesh of my Sole Blog Reader. On the one hand he was warned, as I did, I believe, mention the tendency of heroes to disappoint, while rejoicing with abandon at the results of the Presidential Election. I do feel constrained as a proper chaplain to inject SOME hope into the situation by pointing out that, as the head of an even larger bureaucracy in DC, the proposed Secretary may be hindered from doing any further harm to the hearts of minds of those who actually participate in What Happens in the Classroom. Also, should the selection pass muster, the City of Chicago and its Schools will have another Superintendent, and provided the current Superintendent's name is not hard-coded into too many places in the City's new computer system, things might improve.

You think?

Oddments

The husband of a hospice patient who died a few months ago is now in the hospital himself. A granddaughter stopped by to let us know and ask if I could visit him. I went over that evening and found this lovely gentleman on a vent in the ICU. I guess he has been found to have serious heart trouble and also cancer, and has undergone a couple of serious surgeries. He has a lot going against him medically, and the stress from the loss of his wife is a huge additional factor. He really adored her and, in her last days, he alternated between trying to be strong for her and the children and grandchildren and simply weeping at the loss. His granddaughter is afraid he'll "give up." I kind of hate that language as it implies that death is a failure, and who could blame this gentleman if he just wants to be with his wife? The family, though, at least some members, are still reeling from the earlier loss and don't want to imagine losing him as well, and who could blame them either? Given all that he has been through in terms of cancer and surgeries, I don't know what his quality will look like if he survives this hospitalization, so I hope that what is best for him is what happens, and that his family will find the support they need whatever comes about. This is the second time in the last couple of months that I've visited a widowed husband in the hospital. The first one did die, which seemed understandable, as he told me that two combat tours as a paratrooper had been indescribably difficult but only a drop in the bucket compared to the difficulty of losing his beloved wife. Both of these widowed husbands have been really wonderful men, good husbands and fathers, beloved in their families. And I have loved them, too. It's hard to see them suffer...

I am especially lucky to have a couple of friends whose mere existence makes the world a far better place. I don't see them often enough due to demands of their lives and mine, but I did run into one of them earlier this week. He's a program director for a local nonprofit that provides emergency assistance to individuals and families. It was pure, pure joy to see him and talk to him--he's one of those people whose main decision point, about anything, is "What is the RIGHT thing to do?" This focus, rather than a focus on expediency or a focus on money, can put him in opposition to organizational structures at times but he is absolutely steadfast. He told me that the needs for emergency assistance in the community he serves have at least tripled in the last few months with the downturn in the economy. Sobering. On the other hand, he is one of the funniest people in the entire world and he always leaves me laughing. He has at least a couple of books in him, and I hope with all my heart he writes them!

Speaking of books, one of my classmates at seminary has published her first. I recommend it without reservation; it's Salvation on the Small Screen, and its author is Nadia who blogs at The Sarcastic Lutheran. It's for those with a healthy skepticism, an interest in theological reflection, and a stiff sense of humor. I sat in the local coffee shop laughing out loud through it, and my brother and sole blog reader also enjoyed it.

And speaking once more of books, I think our craziest mortuary driver should write one as well. Oh, the stories. SUCH stories!!!

And the reason this post is so boring is that I worked all night Thursday and my body clock is completely out of whack. I could sleep for a week, though I don't need to!

A sweet moment...

I was at a care facility and visiting an elderly lady who didn't seem to feel much like talking. She was sitting in a chair in her room. I noticed her hair was a bit tangled, and I asked her if it would be all right if I combed it. She said she'd actually like that. So I picked up her comb and started, very gently, working out the tangles in her pretty silver hair. I told her her hair was like spun silver. She was quiet for a moment, then talked about her grandmother's hair. I told her about my grandmother's hair, and about one of my aunts, whose hair turned white overnight, so the story went, when she was 24 years old. She started talking, a bit at a time, about her family, and eventually talked about the death of her father when he was very young, about how much she'd missed him and still did, about her most clear memories of him. She's well into her eighties, and that loss impacts her life to this day. I don't know if she'd have ever told me the story if I'd approached her as a "conventional chaplain," since I've been told she's a little suspicious and isn't always very talkative with strangers. How lovely to have time as two women, bound by a ritual as old as history, of gently caring for her hair and telling stories.

Back again with another note from my Advance Directives

I would like to begin regular updates. If wishes were horses, of course, beggars would ride, but let's see if I can do at least a little bit better than I have.

From the ever-increasing stack of my advance directives: If I have dementia and I am not peaceful in my dementia but rather miserable, and if I fall and break some ribs, and give myself a pneumothorax (collapsed lung), PLEASE do not put a chest tube in to reinflate the lung so I can go to a SNF for rehab. Chest tubes hurt for one thing, and if my memory is shot I won't be able to remember why it is there, and it will freak me right out everytime I see it, and so I'll probably make repeated attempts to remove it, and I'll end up in restraints. And I won't like that, not one little bit.

So: a big NO to the chest tube, a bit YES to Oodles O Drugs, aka Comfort Care.