In these IDG reflections, in the middle of our healthcare workday,
my intention is to offer useful pointers and effective methods to remember the circle of care… which we are a part of… and to midwife that wholistic care into the present moment - no matter what is in front of us.
They are a better remembering… to what we already know but as human beings we forget. We are better and healthcare is better when we care for ourselves, as much as we do our patients…. (or how about this... as we care for our patients on our good days...) because it can be quite challenging in these trenches of caring.
One of my basic tools are the Buddhist concepts of the NEAR ENEMIES. This balance a spiritual-secular check list… because we live on the edge of worlds in hospice and palliative care… and even in healthcare. Life is uncertain. We are better able to meet it when WE are balanced.
If we don’t recognize these near enemies, it will deaden us… our lives and our care.
There are several Near Enemies but I will review four.
1. Loving kindness and attachment
2. Empathy and pity
3. Sympathetic joy and comparison
4. Equanimity and indifference
If we don’t recognize this near enemies, it will deaden us… our lives and our care.
I end with a Native American Prayer… which is deeply interwoven with nature…
May all that I say
and all that I do
be in harmony with thee.
God within us,
God beyond us,
Maker of the Trees.
Blessings on your day, week, patients and your own good self,
Garden of Change IDG 3 min. Self-Sustaining Staff Reflections WWW.GardenofChange.Org
Offering head, heart, body, & spirit staff-care for healthcare workers in disciplined 3 min reflections… because what we do is hard. Each day we work on the edge of the medical model and walk with our patients to the edge of the Great Mystery. It takes daily self-sustaining practices to stay the course.
Garden of Change also offers branded bereavement mailings for mandates by MCoP/CMS 13 month aftercare.
The mind and body connection was newly documented last month in an article from NATURE.
How we move has an impact on how we feel... and how we feel is going to have an impact on how we move.
• Breathe in: calming your body.
• Breathe out: smiling
The motor cortex was found to be interwoven: with body-controlling mechanisms connected to organs, connected to your to-do lists. The data says that if stand up straight, you'll feel better… (Does that sound like a good mother?)
Textbooks previously showed an unbroken ribbon of cortex, with segments devoted to specific muscle groups, like the tongue or a toe. But scientists were seeing areas between these segments that were not in textbooks, and these areas were not controlling muscles. It's a checkerboard pattern. Specific body parts-like your fingers and your hand, were integrated essentially in the whole-body action.
The interleaved system probably helps explain the mysterious connection between what's going on in our bodies and what's going on in brain areas involved in thoughts and emotions. The region that controls your finger is connected to a region that has something to do with like, what am I going to do today…
This very non-linear connectivity gives us real power over our reactions of stress to any situation before us… If how we feel is related to how we move and how we move is related to how we feel…then we have a powerful tool for feeling better… now.
We are connected in mystery and a miracle.
Here is Thich Nhat Hahn’s directions again for mindful breathing. You have to breathe anyway…. so it takes no longer to breathe mindfully:
• Breathe in: think of calming your body.
• Breathe out: actually smiling
When I do this, I find that smiling is viral… it spreads throughout my body. It changes me and … that changes the room.
Garden of Change IDG 3 min. Self-Sustaining Staff Reflections WWW.GardenofChange.Org
Offering head, heart & body staff-care for healthcare workers in disciplined 3 min reflections… because what we do is hard. Each day we work on the edge of the medical model and walk with our pt to the edge of the Great Mystery. It takes daily self-sustaining practices to stay the course.
Garden of Change offers branded bereavement mailings for mandates by MCoP/CMS 13 month aftercare.
Breath as Medicine
Breath is medicine for better health, life and better patient care. This three minute reflection sets the tone for your IDG meeting, to be thoughtful amid the secular pressures of EOL and palliative pain management, and that we, the healthcare staff and leadership, are part of the circle of care.
It ends with a short Hafiz poem about breath and music.
As a working chaplain, who supports several hospices at this point, I have many 'congregations' so to speak. My standard intro is this:
"I support people of any faith or no faith and all the rivers which run between those two."
I have come to think of my congregation as singular but this week has teased that idea apart for me.
First visit: too, too Christian
I visited a patient who was new to me; he was from a patriarchal culture and a faith tradition (and country...) which is not known for its progressive views on women. He was not likely to be of a Christian faith, but I guessed wrong as did not respond to my greeting of Al Salame Mehaham. He was reported by the team to be energetically "in denial" about his illness, and his prognosis. He was alone in this country without his family. He had already declined a Spiritual Care visit with me over the phone and had refused the medical social worker as well.
If spiritual support is not wanted, it is, of course, his right to decline. I usually seek to refer a patient to their own local clergy to be of support, if possible.
However, declining chaplaincy blinds the team.
Communication can be more difficult. Much of a chaplain's scope is about communication and being an advocate to the medical team for the patient's and family's views and preferences.
- What is getting in the way of whole person care?
- What might support it?
This patient was declining and the case manager made an appointment for me to show up the next morning with little explanation. I was happy to have the opportunity to support his man. I prepared with appropriate books, liturgy from his faith tradition - the Koran, (and the Bible just in case...) with a trinket which was not iconic: a river rock with Love engraved, and my secret weapon - homemade candied orange peels. Gifts are a universal offering of support and a way in - to develop a relationship of care and trust.
It was a first step, which usually works.
Upon entry, the patient was confused; he did not seem to understand. It was unclear if the confusion was dementia from his disease or his command of English language. What was seen by the team as unhappiness, and perhaps depression seemed to be a defensive stance against this confusion. By happenstance an Arabic-speaking neighbor stopped by and translated, which improved everything. Providence, for sure was at work. It was also clear that he was not enthusiastic to talk to me, as a woman, as a "Christian" which was his view of who he saw. However, when this neighbor translated my offering of the homemade, candied orange peels as "like life we take the bitter with the sweet...I am here to see what we might do to make this day a little sweeter for you.", the gentleman's eyes twinkled and there was a small breakthough.
I asked him if he was Muslim. He agreed that he was. I asked if I could I reach out to a local Imam for him, he said no but then he was inspired to lead his own prayer in Arabic which was part song and part words.
It was beautiful and it was enough. He left our palliative care to hospice care soon after and I did not see him again. Sometimes all you can do is begin...and it may be enough.
Sometimes the bedside vigil happens - but less than you might imagine. The conditions of hospice are chaotic. We pretend we are in control, and we are of some things, but life happens. Today, the IDG (or IDT) team communication was well oiled and functioning as it should be. And we had time to respond appropriately, which is mostly out of our control.
Previously, this patient had several ups and downs as it typical of the end of life. Last week, when she came onto our service, she was talking about getting back to her old neighborhood and house...I thought she might make it, too, which does happens.
The Catholic Faith Tradition and the Sacrament of the Anointing of the Sick
As a devout Catholic who went to mass three times a week, there was a question that I immediately looked for an opportunity to weave into our beginning conversation. This is tricky–because she does not know me. We do not yet have a relationship of trust. But when an opening did present itself, last week she was very clear with me that she did NOT want a priest to visit. A eucharistic lay minister to give her communion was good but no priest.
When any patient comes onto hospice service, as a clinical chaplain, Medicare asks us to open the subject, as gracefully as possible, of any spiritual anxiety they may have. It is a beginning point to help them explore their inner landscapes. Have they made peace with this condition they are in? Or are they still wrestling and resisting ? The questions are more important than the answers...and that they know the chaplain or the medical social worker is able and trustworthy to speak with them, should they wish.
Family is not always easy for the patient to talk with for so many reasons. I am Switzerland and an interfaith chaplain. I respect all faith traditions. Either I don't have a dog in all the religious diversity and contentions or they are ALL my dogs. The answer probably doesn't matter because it is the same result. I respect them as voices of the Holy One of Many Names.
The relief that some patients have in having the conversation is what matters.
Essential Chaplain Superpowers: a Bluetooth Speaker and iPhone
I studied while in seminary with a wise and eloquent Dominican Nun. I know a lot but am quite humble and without assumptions to be complete support. Generally speaking, this is a healthy assumption for all. However, I speak a dialect of fluent 'Catholic" with the help of my Bose Bluetooth Speaker and iPhone superpowers.
The patient was non-verbal at the point I arrived. It was going to be a couple of hours until his people arrived so I called up YouTube and put on a high mass which lasted for an hour and a half. It was amazing. The patient seemed to like it - not because he said so (he was non-verbal but not unresponsive...). I explained who I was and what I was about to do and checked in with him regularly.
I wiped his face with a wet cloth and sat with him.
Questions of Readiness or Denial?
But to respect the Catholic faith, the question of 'would you like a blessing from a priest?' is an essential one. The phrasing is a 'softball' way of asking if they want an Anointing of the Sick sacrament. A 'yes' can be an admission of readiness to pass from this life or not. The answer is always illuminating of their process. (Are they in denial? Are they hoping for a miracle? Do they really want to try and cure this illness...which at least one of their doctors has already recommended to them as an unwise use of their hope?)
The conversation about spiritual anxiety or spiritual readiness is an important conversation for all patients, but there are different ways to gently inquire of a patient who is not Catholic. But, that is another post.
It is not common to be asked to perform a ceremony in hospice, but when a chaplain is there are many things to address before you say yes. I performed a wedding last week and it was amazing but only after I had done my homework.
First the your IDG (IDT) team must be consulted...
Hospice runs on our interdisciplinary teams. Each of us have a point of view and we need them all here. Your medical social worker (MSW) might have insight as to what the underlying psycho-social situation is. Money and inheritance issues can complicate the simple loving decision to want be married. Doctor, MSW, Case Manager (CM), and aides may have deeper (and different) insights into the possible complications and motivations which may or may not be achieved by a wedding.
Review your hospice's policy and procedures
Ask your administrator to sign off on the wedding. Do they have any concerns or written policies which they can offer as guidance? This can be tricky ground, but better for those who have tread it before you.
Find out more about what the bride and grooms want or need.
What are their expectations about ...the surviving spouses needs. If it is social security they are out of luck. It takes a year or year and a half before widow's or widower's benefits may be bestowed. If the spouse dies before that time period, the surviving spouse does not receive benefits.
Why now? The question's answer is not always obvious.
Logistics: Can both parties actually ambulate... for the license?
The good news here, (and not well known) is that most county registrars who deal with marriage have a process where a sick bride or groom may not attend to the license.
The ceremony can come to them but there is a bit of paperwork to do to get them there. In addition to all the usual marriage license paperwork and information, you will need:
- Affidavit of Inability to Appear and Request for Issuance of a Marriage License which is usually notarized.
- The hospice medical director (aka doctor) letter affirming that patient is unable to appear due to infirmity on hospice stationary.
- Whatever else your County decides it wants. Hence the research needed to be done by your team.
A wedding ceremony in hospice can be a beautiful moment...
It can be a place to say I love you, to resolve important issues, to say a good bye and to have comfort from pain while you do.
Statistically people live longer in hospice with a terminal illness and with a better quality of life. And sometimes they live long enough to get hitched. Amen.
13 Month MCofP Bereavement
Accidental Workplace Death And Grief
Annual Remembrance Ideas
Anointing Of The Sick And Hospice
Catholic Hospice Questions
Hospice Annual Celebrations
Hospice Spiritual Care
IDG Hospice Staff Reflections
IDG Pallative Care Staff Reflections
Medicare Hospice Required Bereavement
Mourning And Grieving