· Judgment and Impatience: I found to my surprise that I rarely experienced impatience with or judgment of others. I was very cognizant and tolerant of others’ beliefs and styles and didn’t run across anyone who tested me, even in trying situations. One Friday evening early in my program a dying patient’s daughter needed to speak with us and she was a distraught compulsive talker, not only repeating herself but adding tangential details to every statement and without exaggeration, we sat with her for nearly two hours. I understood her compulsion was magnified by the crisis and while I did glance at my watch periodically I didn’t lose patience. Another instance occurred when I was recently on call attending what I thought would be an extubation. The patient’s twin brother and his daughter reneged based on the patient’s indicating nonverbally that he wanted the breathing tube to remain. However, he made that decision without being told he was terminal and his treatment for sepsis and renal failure was ineffective. He would be dying within five days. They wanted him on Hospice but would not tell him and would not allow the physician in the ICU to tell him he was terminal, and even though he signed a DNR stating he didn’t want to be kept alive by artificial means, the physician said his nodding to keep the tube in overrode that document. I asked the daughter if she was being fair to her father, not giving him all the information he needed to make a sound decision, but she was adamant that he not be told how sick he was. Both the Vitas admitting nurse and I agreed that this conflicted with our ethics but I couldn’t impose myself any more than I did, and I didn’t get angry. I will admit to feeling the most frustrated with “my own people,” Jewish patients and families, who hear “chaplain” and immediately throw up a wall by saying “no thanks.” This did sometimes make me angry. It never hurt my feelings but made me angry in the sense I can be angry with my own mother who shuts a door on a conversation she is too afraid to have. For the most part, I was able to avoid judgment and impatience.
· A defined spiritual path or faith community: I have found without variation that every time I introduce myself to patients or families, I am asked one of three questions: “what denomination are you?,” “what is your church?,” and “are you Jewish?” The first two questions come from Christians who automatically assume when I say “chaplain” that I am a particular brand of Christian. The last one, obviously, comes from Jews who want to make sure I am not imposing an unwelcome faith on them. I answer them all one of three ways: “I am an interfaith minister,” “I don’t have a particular church. I’m comfortable everywhere,”or “I am Jewish but work as an interfaith minister.” Not one of those answers ever stopped me from engaging patients in conversation. The few times I was not invited in to chat further happened with Catholic families who had already called in a priest or with Jewish families who had their own rabbi, and even in those cases of people with very specific religious preferences, I would make an offer to call a priest or a rabbi if they needed. Most of the time my own practice never interfered with my work, and a couple of times, my metaphysical practice actually enhanced it. One dying patient told me how she loved Unity, which started a discussion that was right up my alley, and another one said something about Reiki, which led to the two of us doing Reiki on her mother together the day before she died. The woman was so excited over that that she told our team manager, who came looking for me shortly after, and it actually worried me because perhaps I thought I’d done something wrong. Instead, she said, ”I didn’t know you did Reiki! I wrote my thesis on the use of Reiki in nursing.” At that moment I knew that I didn’t have to seek a more mainstream religious affiliation because I am fine with my beliefs, which are fully congruent with all the principles of the Metaphysical Churches and Buddhist philosophy. If we as chaplains must meet patients where they are, then the Association of Professional Chaplains should also be able to meet me where I am, and that was the primary reason I sought a more mainstream affiliation. My path is not amorphous, I have found. I don’t need a institutional name and address to be valid.
· Dialogic engagement: This is where I did the bulk of my work and this is where I found the most success. I am surprised that I never gravitated toward sales because that field requires good talking. I guess my 35 years of classroom experience have shaped me as a good talker. I can talk to anyone about anything, and that is exactly what I did when I engaged patients and families. I was afraid to open up difficult subjects in the beginning and gradually learned to ask the questions I needed to ask and move on in the conversation so it wasn’t stultifying. One of those questions was “have you made final arrangements?” If the families had not expected the death or denied the patient’s terminal diagnosis, I feared that question would shock them, but I learned to ask it. I learned to ask a loved one directly, “how are you doing through this?” and respond effectively when he replied “How do you think I’m doing?” I answered, “I think you’re probably doing terribly,” which opened the conversation door. He looked up at me tearfully and began talking. When a patient asked me, “How would you feel if you went to the doctor and he told you that you had only two weeks to live?” and I said, “I would feel sad at first, and then scared,” and the patient said, “You could not have answered that question more perfectly!” and we had a long talk over two or three days about life, death, afterlife.
· Prayer: Because I have no formal training in religion and prayer, it was an area in which I never found comfort. Silent prayer, yes, but praying aloud and more specifically, leading others in prayer was intimidating. I did learn to do this with people of varying religions and denominations, first with my mentor, and eventually by asking the patient and/or family if they would like a prayer. The first time I did this was in January, with a Pentecostal patient. Apparently I didn’t die from it so I tried again with other patients. I did extemporaneous prayers, the Shema, the Lord’s Prayer, and in every instance the family and/or patient was appreciative no matter their particular religious background. In a few instances with an unconscious patient, I went in and prayed aloud by myself because I knew the patient would hear it.
CPE is described as an intense experience that is not for the squeamish. In fact, I know a couple of people who were unable to make it through the program, not because they couldn't handle deathbed encounters but because they couldn't handle the personal scrutiny of the weekly five hour class and additional individual supervisory hour which entails very intense probing and questioning, much like therapy. The unexpected reward of CPE is that these intimate interactions among the group and between the supervisor and student mimic the best kind of therapy, promoting self evaluation. Particularly in the beginning, even years after I’d been through therapy, subtle causes of my actions and reactions would emerge when my supervisor asked a harmless question about a step I took or avoided: “Where do you think this comes from?” It was like a pin puncturing a balloon. I’ve learned to see myself differently. As a professor teaching a subject most often met with resistance if not downright hostility from underprepared students who blame me when I identify their 12 years of deficient writing skills, I earned a reputation as being hard-line, “bitchy,” “tough,” (although good at what I do)….and had come to believe these as descriptors of my whole self, not just the narrow tube of my career. This is my most critical gift from the past seven months: CPE has allowed me to meet me .
I am not adversarial in this capacity. I am an ally, and I am compassionate and cry with patients and their families, provide support, distract them from the overwhelming pain of watching a loved one die….not hard-line or bitchy and actually quite the opposite. I have learned I am not my profession. My heart is much larger and more generous than the hand that grades the freshman essay or that withdraws the student with 6 absences and 4 missing assignments. I am learning to become more confident with who I am and present myself as such in many areas. Last term I had a confrontation with a a 48 year old student who already had a B.S. in nursing but who took my literature course for professional development credit. We got along very well, but I found that she had plagiarized her last assignment, a journal assignment, a reflection, and I took it very personally, feeling angry and betrayed. I was going to fail her in the course. I happened to get a phone call from the college Provost on another matter – she’s a former English professor who is quite familiar with hospice. She called just as I was about to explode, and I did explode to her on the phone. She said, “Lisa, don’t be so harsh. You’re a chaplain. Have you considered why she felt she had to plagiarize?” Wow. That was a CPE question. I reconsidered. I saw the student the next morning in the elevator and asked her the hard questions instead of just entering a failing grade, and I gave her the option to do the assignment over on her own because I wanted to know her feelings, her thoughts, not something she stole in its entirety from the internet. That was a growth moment for me. I also confronted my mother with some long standing issues that I’d held in for years, years, years, and I was able to express them in a non-accusatory and non-threatening manner which I believe strengthened our relationship. During CPE I never felt threatened even when I was asked probing questions or criticized for something I did or didn’t do in a verbatim (a screenplay-like reenactment of a complete patient visit). I was able to accept criticism and suggestion from the group, my supervisor, and my mentor without feeling defensive. Another byproduct of CPE has been the tempering of my volatile and sometimes hysterical nature when there is a crisis. I’m the first to “lose it” and become an emotional, worried wreck, and the last to return to a state of normalcy. That has not happened. I had a dog crisis a couple of weeks ago that could have resulted – should have resulted in a bloody death -- by veterinary and all logical standards – and I didn’t fall apart as usual (and my dog, God bless him, is fine.)
I have expanded my behavioral repertoire. I’ve never been a hugger. It is not my nature to be demonstrative with people, especially strangers, but I’ve learned that some people need hugs to be comforted and I’ve learned when to offer a hug. We recently had an actively dying patient admitted from the E/R and the extended multi-generational family was present at his bedside. His daughter, his caregiver for 30 years, was inconsolable, sobbing in her uncle’s lap for over an hour while the family stood vigil bedside and a Catholic chaplain spoke with them and led a prayer. I was there for presence and observation but about an hour later the family was assembled in the family room. The daughter was no longer sobbing but was sitting quietly. I went to her and asked if I could hug her and she was receptive. There were no words to offer at that time. I did sit with her the next day and ask her questions about her father and their life together but I knew the night before it was not a time for words. I’ve sat with a patient who revealed in the first minute that she had terminal metastasized ovarian cancer and said she was hoping her death would come soon. I probed and found her reason was fear of pain, and I was able to assuage that fear for her. We had what was probably the most authentic conversation I’ve ever had with a patient after that.
I’ve also learned to relate to patients with dementia, something I truly feared at the onset of the program. One Romanian Jewish patient who was so adorable (she reminded me of my grandmother), became animated when I came to visit her. I couldn’t understand a word she said, some in Romanian, some in Yiddish/Hebrew, some in English jibberish. But she smiled whenever I talked, and really, all I talked about was my grandmother’s cooking which she may or may not have understood, but since she was smiling and making sounds, I stayed and kept her happy. Another confused patient was so anxious, fearful, and confused, claiming that someone stole her telephone, something sinister happened to her son in South Carolina because he never showed up to visit, someth crime was about to happen to her in her room. She then tried talking on her TV remote, insisting it was a broken telephone. I just sat with her and held her hand and reassured her. I told her we had cameras monitoring the hallway outside every room and that she was safe. She kept holding my hand and said, “I wish you could stay in this room with me.” I just gave her the gift of company, which she needed. At another time I developed a relationship with two sisters who sat vigil at their mother’s bedside for two weeks. Our talks initially centered on the patient and their feelings but eventually veered into general discussion…they were so happy to have someone to relate to. We were all in the same age range, lived in the same areas earlier (we found we lived across the street from each other in Lauderhill at the same time), had the same background. When I would come in they would get so excited, and I think it’s because I was able to simultaneously provide pastoral presence and provide distraction from watching their mother slowly die. I have learned distractions are a good thing. They are not avoidance but necessary momentary respite from quite an emotional overload.
My relationship with families and patients is easy, respectful, conversational, open. Even when there is not an assessment to be made or a visit to do, if I see families in a patient’s room engaged in conversation, I’ll go in and ask them if they would like me to make a pot of coffee or if they want some tea. Often they take me up on it. One afternoon I saw a patient’s spouse sitting bedside with his head in his hands, and later I saw him standing almost lost in thought outside the room, and then I saw him wander into the family room and just stand around. I called the daughter earlier, who said although he was confused and living in an ALF, he still took the bus twice a week to go to the Hard Rock to gamble. I asked him if he would like to join me in a cup of coffee and we sat down. I asked him some simple questions and then said I’d heard he liked the Hard Rock and that was a huge opening for him….I got to hear about his years of gambling exploits and his wife’s reactions to his winnings and learned so much about the couple I wouldn’t have gotten by asking prescriptive questions. He was thrilled and relieved to have someone take an interest in him personally. Then I could ask how he was feeling with his wife being in her condition and he trusted me enough to share. My relationship with the staff is also very good…I enjoy them and I believe it’s mutual. The nurses have helped me when I have cried (after I witnessed my first death), we have laughed and shared patient stories, personal stories, argued over TV reality show stars and storylines. They have come to me when they felt a family member needed extra support, and I always felt free to go to them for patient information and advice. I will never forget the image of me walking down the hall after that first death, sobbing, with Kathleen putting her arm around me and saying she understood, or Yvonne telling me “it’s all right,” that she cries every time she suctions a patient. I have a tremendous respect for the nurses and will miss their camaraderie. I even forged a friendship or two that might continue after my unit is over. Last weekend my mentor and I had a theological discussion in the team room. We disagreed over the randomness of tragic events. I said that everything happens for a reason, that there are no random events, and she said she can’t subscribe to the fatalistic view that someone dies at a pre-appointed time, that we have free will and the universe is full of accidents. I guess I disagreed respectfully enough for one of the nurses to say, “This is one Jewish person that I really like.” I made a joke out of it. “ONE? You like only ONE Jewish person and I’m IT?” and she backtracked and said, “No, I like how accepting you are when you talk to people about religion.” I felt that was a validation of my theology in practice. I am an interfaith minister and believe many paths lead to the same source and respect them all even when I disagree with the details. I think my theology comes through in my interaction with patients and staff in this way. Spiritually, I am led by my intuition, which is connected to the Divine, so I have learned to be in the moment and nonjudgmental and go wherever the conversation takes me.
The small group is a key component of the CPE experience. We are each assigned a mentor to work with in the hospital or the field, but the shared experience combined with the weekly support and analysis we give each each week creates an early and strong bond among the interns. Five hour sessions once a week = profound intimacy. I felt very comfortable in our group of five. What I appreciated was the ability to share my opinion and my theological viewpoint without fear of judgment, which I had in the beginning. I was able to find common ground among all of us. I was careful to ask questions that didn’t threaten the other group members as well and maybe in the beginning I was too timid to confront anyone but learned to do so in a gentle way. I felt safe enough to bare my emotions and cry (but I didn’t cry as much as ONE pastor who will remain nameless!). Our group consisted of Cuban Presbyterian pastor, an orthodox Jewish woman, a Chabad rabbi, a Haitian Baptist minister, and me. The orthodox woman, who lives in a very sheltered community, awakened to a world she didn’t know before: dealing with AIDS patients, promiscuity, drug abuse, Christian prayer. Every week she came in more excited. When she shared stories of her mentor, a Buddhist, she glowed with a sense of wonder and amazement so she truly embraced the interfaith element of chaplaincy which is so important. We would meet in the parking lot after CPE class and “schmooze,” analyzing the evening’s events, and despite our differences in practice, there is much we share and as she says, “We get each other,” which is always an affirmation.
The Presbyterian pastor came in kicking and screaming admitting he was taking CPE only because he needed it for ordination. He prefaced every statement with, “I’m a Presbyterian and we believe ….” but completed the unit by volunteering to remain with the program and demonstrated a true devotion to interfaith chaplaincy. I’ve seen him laugh and cry and felt honored to be a part of both. He is truly a people person with the rare ability to draw people into his energy so that they feel both comfortable and befriended. I felt this way and I know patients have as well.
The rabbi affected me in unexpected ways. I have a deep, deep respect for the learning and knowledge of a Chabad rabbi but learning and knowledge do not necessarily complete the recipe for wisdom. I saw in him the gift of wisdom, generosity of spirit, purity of intention, non-judgmental acceptance, and an appreciation for if not the possession of the mystical. There were times he was quiet in the CPE class, particularly early on, but when he did speak it was, as the Buddhists say, “right speech.” I went at his invitation to the Chabad seder, the first traditional seder I’ve been to in over 10 years. I was even more honored that he selected a special spiritual annotated Haggadah for me. His understanding of my theology and his recognition that outside of the brick wall details of the Law, we share the same belief and principles, have helped me to see that I may not be as estranged from Judaism as I thought. I have considered my own dying and what I would want in terms of a service and prayer, and I have told him that I would like his presence and leadership at the end of my life.
This was a good and valuable ride that I'm climbing on again.