Well it’s spring... (at least in California...)
I can see it with my eyes... in the blooming of Bradford pears and the Purple plum trees... and the green green grass which has benefitted from so much rain.
But my body (and sinuses) are telling me, too.
Spring is about renewal, and planting more of what we want... but as in every life, we need to let go of that which is NOT working.

Yesterday was Ash Wednesday - the first day of ADVENT where we start to think about what renewal looks like for us. Maybe we give something up for the next 40 days... or Maybe we claim some new life-affirming habit.
But Renewal is in the air.

Like a garden, we can’t grow everything all at once. We have to weed...
What do I want to grow? What is mine to do? What’s working... and what is NOT working?
These are big Life and death questions for life as it happens...

Every human beings needs to find fresh new ground...To plant more of what is working.

Its true with us ... we need to address unfinished business - Unfinished business and unfinished relationships can have a serious negative impact on our live in the present day.

FOR those us of in Healthcare, our patients too - even when facing the EOL, need to address unfinished business... so they might be ready for whatever’s next - the great sleep, the Great Mystery...or the Maker of All Things.

These are the BIG EVERGREEN issues at EOL and just for a GOOD LIFE:

1. I Forgive you
2. I love you
3. I’m sorry and...
4. Thank you.
   

Happy Spring AND HAPPY Weeding.

Amen

Click here for a PDF Text of this offering - Use it as it works for your team. Or check out the YouTube Video.

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.

For more on breath as stress reductions see this U of M. handout:
From https://www.uofmhealth.org/health-library/uz2255

Here is the second post of our IDG Staff Reflections Series for Healthcare Teams. It is in three formats for your free use: video, audio and text. Make it work for your own team, your offerings and your IDG team's unique culture.  Use them stand along or as inspiration to prepare your own.

They are free for your use. Drop us a line.  Let us know how it worked for you.

Best blessings,

Rev. Eleesabeth Hager

We as healthcare professionals cannot do our work if we ourselves are depleted. Best practices for employee retention, good care (and MCofP for staff care) are to regularly check in and remind each other about the circle of care in which we are all participating... until it is our turn in hospice.  Right?

The lessons of Winter are in the soil, which sleeps. It composts what is no longer useful. Let go of those ideas and notions that no longer serve is good gardening.

Here is a 3 1/2 minute audio for your IDG with a word document attached for your MSW, or chaplain or Adminstrator to read.

 More will be posted to keep us resilient now and in the new year – for ourselves and our patients.

​Yesterday I had this beautiful visit with a hospice patient and her adoring adult child who had been taking care for years and before that taking care of another ... also for years.

​This serial caregiver was exhausted, overwhelmed and moving toward burnout.

I got it...because I was it. She was on the tipping point into resentment from simply being willing. Our conversation eased her off the ledge because her feelings were reasonable and common ... but they were new to her. They were troubling because love isn't suppose to feel that way but overwhelm always feels that way.

Here is my patient's Happy Valentines Day 2022 gift to you today:

​May you be be surprised by the love...that loves you back. 

L.C. decided what his deathday would be a few weeks before it happened. It wasn’t mystical.

He quoted The Gambler song to me in his last days with us on hospice. In his cheerful, reserved but upbeat way, he smiled.

“You gotta know when to fold’ em…”

This brought to my mind an Orson Welles quote about happy endings. 

“If you want a happy ending, that depends, of course, on where you stop your story.”

Our hospice patient was a meat-and-potatoes, stand-up, guy because “my grandfather raised me that way.” In the manner he had lived his life, he chose that particular day because it was well-reasoned, measured and considerate of all concerned. As few humans in history have been willing or able, he was claiming for his departure the uncertain privilege of certainty: September 4, 2021 at 9 AM PDT. He had successfully secured the paperwork to a 21st Century legislated kindness: a prescription and promise for an end-of-life cocktail now available in eight states.
 
Denial that death might ever happen to us was a modern standard before COVID-19 happened. Only when death comes near, and to the dear, do we reconsider our own exodus as plausible or even just possible. Then we may contemplate the preparation of the mundane but mindful paperwork to guide our loved ones with our wishes. Who in human history has been willing or able to put a calendar date and time to our deathday, until now? Perhaps only a few enlightened meditation gurus’ who can reportedly transition on command, or the warrior-soldiers of history who have chosen to make the ‘today is a good day to die’ determination
 
Our good man was in another category – not of choice; he was condemned. Not for crimes, but with a prognosis. He was a prisoner none-the-less with an ugly and excruciating cancer death ahead.
 
Like physicians, he also had extensive and intimate trench-warfare experience with what cancer looks like on the frontlines of love and caregiving. As a young man, he had watched too many of his own family confront and fight this debilitating and disfiguring disease. He looked death in the face and it smiled back at him in his beloved grandfather, his own brother, his mother, and brother-in-law. He was their primary caregiver as they declined into his able arms and into well-meaning but painful attempts at end-of-life (EOL) medical fixes.
 
Physicians have a higher likelihood of choosing significantly fewer EOL medical interventions in the last six months of their lives than an average patient because they have seen the limitations and the downsides of the medical model, which is, itself, a miracle. We fix the broken parts of the human body so well and in so many ways that as Atul Gawande says in Being Mortal, ‘Death is no longer a cliff but a slide to fragility.’ Medical-aid-in-dying counters that iatrogenic miracle with its own.
 
As a master carpenter, our patient too, knew about fixing the broken and making it whole. He taught many young men from Colorado to California about learning the life skills of fixing the broken, being responsible and kind. He was a builder– not a destroyer. Our good man moved his life after caregiving to San Francisco where he, eventually fell in love with an old Victorian apartment house which he bought, tended and managed for the last few decades of his life. He knew when fixing was a lost cause and when it was worth a patient restoration.
 
The Death with Dignity Cocktail or as the legislators call it Medical Aid in Dying (M.A.I.D) is about knowing when to “fold’em’. It is not an easy decision. It is one that is best grown incrementally from the inner to the outer as other important life milestones. Patients commonly undergo many more painful procedures than they actually want to because they do it for their loved ones who are bargaining for more time–either with them or with the Maker of All Things. On the frontlines of love, the good decisions are the ones that families tend to make together, listening to their infirmed one and putting their needs above their own. It is messy work. It is the work that hospice is lovingly crafted to support with doctors, nurses, aides, social workers and spiritual care & bereavement providers, like me.
 
The medical model has many miracles to its credit, but how to have a good death is most certainly not one of them. Hospice can both support the dignity of control and the respite of surrender with as much comfort as is possible. We support the whole person within the family unit. We also stand in for that family when there are none available. It is a privilege that is more than a job. It is a calling. Hospice teams support, tend and comfort. We do not hasten death, but neither do we prolong it. Hospice does not kill.
 
With M.A.I.D., we now stand by, in support, as the patient drinks the cocktail unassisted, which is usually a legislative safeguard. This creates a new experience for the hospice team. We are all willing to stand and serve our patient’s choices but how we feel about it, personally, is still being sorted. For me, I have never read a eulogy to the person I was eulogizing. I did not know what to expect. I explained my intent, that his life was very inspiring to me with its balance of a teaching legacy as well as being a maker. I did not want to embarrass him, as he seemed a quiet, reserved fellow, but I was honestly moved to write something for his deathday. I let him know, there was no obligation.
 
Many people have commented in my eight years as a hospice chaplain that it was a sadness to them that the memorialized could not hear their own memorial. Our gentleman-carpenter was no exception to this. He was appreciative and touched that I had heard him during our conversations about his life. He spoke words from his heart and said, “There are very few people in life who really listen to you. They are thinking about something else, or how they will come back at you…but they don’t listen. I do want you to read it on Saturday.” And I did. (You may read it too at www.makingspace.com/ceremony/eulogy-for-a-m.a.i.d-patient
 
It begins and ends with a Native American Prayer – A Chinook Psalter
May all that we say
and all that we do be in harmony with thee,
God within me,
God beyond me…
Maker of the Trees.
 
L. C. met the Maker of Trees in the kind of death that most people say they want: in their sleep and in their own homes. It was for me perhaps the most gratifying death to which I have attended. It wasn’t just because his affairs were in order, the pain was controlled, and that he was ready, all which denote “a good death” but it was more than that. The Mystery from which we all come, reached out and called L.C. home, and because of M.A.I.D cocktail, he was able to reach back with the dignified control of a humble surrender. It was complete; it was a well-crafted finale.
 
 
Rev. Eleesabeth M. Hager is a hospice Interfaith chaplain in the San Francisco Bay Area, the author of two books, a resiliency workshop and a monthly, which is devoted to sustainable caregiving.
 

A “Good Life” GARDEN for Blooming and Ending Well
 
When confronted with the shock of our imminent mortality in a terminal diagnosis, what makes a good life, is the same as that, which makes a good end...and you're still breathing, it's not too late to begin.

The hospice team is created to help us talk about what is difficult and find comfort:

               • medically,
               • socially and
               • spiritually.

The fact that everyone who has lived on the planet to date, has passed on (or will) does not give as much comfort as it could when faced with our own personal experience of serious illness. It is commonly outside our experience…It is new to us.
 
Americans live in an over-medicalized, fall-to-fragility, end-of-life model that tends to see death as a failure. We deny it is ours to do…until we can no longer keep up the pretense. Our collective end-of-life template is so limited, and deeply ingrained that it is hard to see our way to better–even when what we have creates more suffering than need be.
 
We’ve reached a “new normal” where people are so afraid to talk about death that they agree to interventions that shorten or ruin a patient’s remaining time.” - Atul Gatwande, Being Mortal
 
 Most people want to die at home, in our sleep, and pain-free.  We know how to do this with hospice and a team that serves us, but few achieve this ‘good death’.  Why?
 
The GARDEN as a Healthy Model for a GOOD END
There are healthier models for our own end, and with help from a team of family, friends and faith, it is not only possible but easier. 
 
As spiritual beings having an Earthly experience, gardens and their seasons are better models for a healthy “end”.  What we plant might grow beyond us, or it may not. We give it our best shot. It is a Joyous Wager in that we did what we thought best at the time. We might plant an apple tree but mistakenly it grows oranges. Rejoicing in orange juice or trying again for apples are our choices. We each have a limited number of seasons to play. Death helps us clarify what is important every day of our lives if we use it. When this reality sinks in that we do not have unlimited time on the planet, it changes us, our priorities and orientation. Death keeps time and because my life is not unlimited, it is precious.
 
How we make a good end is about our final winter, but also the potential of crafting a living legacy, which models death as part of life. Our families and culture are hungry for these embodied life-lessons, which comforts those who remain.
 
TALKING ABOUT IT: Clarity & the Five Engagements
Talking about death is our last taboo. We lose the benefit of our personal lineage of experience from who have come before us…our own family’s death experience. Dying well, like living well, is a bit of work. Why reinvent the wheel by not knowing, and not talking about it?  Your hospice team knows and can help you talk about death.
 
As a hospice chaplain, I walk with people who are on the edge of their lives.  I see death well met and kindly engaged in a dance with God, which becomes a renewable blessing to those who witness it.  I also see the opposite. To keep up pretense at the end is exhausting for the ill and their loved ones. We also lose the opportunity to make beautiful use of the time we have left:

          • to say goodbye,
          • to ask for forgiveness, or
          • to be forgiven,
          • to say that you are sorry…and
          • to offer the penultimate blessing, of an ‘I love you’. 

The simple clarity and necessity of these five engagements are life changing–for your own good end and the ripple effect into the next generation.
 
No one benefits from unfinished business.

We need all we have learned in life to effectively speak our goodbyes, embody a positive transition that will satisfy us and enrich our loved ones…with that legacy in their own life and, eventual passing.  Like water ripples in a still lake, our actions here at our own end, might be a blessing  on both how to live well…and how to die satisfied that we did and were enough.
 
Death is not a failure but a fulfillment.
A good end is easier than you might at first imagine. We have a well of wisdom for a better, braver return journey - guided by our Higher Selves, hospice and with a little help from our friends and hospice.

When we are in pain, it’s hard to think straight. 
Most people want to die at home, in our sleep, and pain-free.  Hospice knows how to do this. It has powerful medicines which are not just from the pharmacy. Its team structure is designed to act from a wholistic perspective of body, mind and spirit. The doctors, nurses, aides, psycho-social and psycho-spiritual support of social workers and hospice chaplains are generally called by the Higher to do this work ….and having said that, they (we) are fallible humans. As a hospice chaplain, I have seen good passings and could-have-been-better ones but the fruit of each hospice tree is always better than without their support.
 
Begin with hospice early.
Every end is different but it saddens me that so many people lose out on making the most of the time they have left by fear of hospice.  They lose out on chances to put themselves in the drivers seat and craft a passing that is satisfying and a gift to all who witness it.
 
A good end starts here, wherever you are and right where you are. Most of life is easier in community.  A good death is the same.  We need a faithful team of family, friends and a hospice, which understands your desires and wishes. It takes a bit of time to speak it into existence, so we need to use our time well.
 
A hospice team, which listens and serves is the best.
Hospice needs a captain to listen and guide it to act on the wishes of our client-patient. Love, miraculously, does this without anyone’s help through the many hands, which show up to serve.  However, if communication with the one who is ill is still possible, it should guide the team.  I see our job as offering back as much dignity and control in one’s own passing for as long as possible. The best hospice teams do this by listening and serving as Dr. Rachel Naomi Remen defines it because hospice, unlike the medical model, is not about fixing or really even helping:
 
Helping, fixing and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Service is a relationship between equals: … service strengthens… Fixing and helping are draining, … but service is renewing. When we serve, our work itself will renew us.
Finding a local hospice that listens, serves and fits you is worth the effort. Interview them. Interview the leadership: the director of nursing, RN/case manager. Ask how long the team has been together? Follow your heart and mind here: do you feel valued and heard?  I recommend, as a hospice chaplain, even to have conversations with the psycho-social-spiritual members, too.
 
BODY: Getting Comfortable
Hospice makes our last days comfortable. The physical medicines used are powerful and used properly lengthens the quality of life - not shortens it.  These are medical options, and adjusted as you change. Each time the team meets they are reviewed.  Speak up and say what is working and what is not. It is important to feel heard but it is also important to listen here.  Escalate until the dialog is balanced…or switch hospices. You have that right
 
MIND: Feeling Safe ENOUGH to Speak Truth
No matter what your spiritual or faith tradition, or the lack of it, we are all ultimately here on the edge of not-knowing what is next. Uncertainty rules here, which is uncomfortable at all times, but it may be particularly terrifying to the logical and rational part of our minds which have no framework or possibility for fixing this; so that piece of us, our mind, simply circles in fear.  Faith is tested. Fear is not where we want to be at our end or in our life, for that matter. Consider Einstein here:

• "The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift." ~  Albert Einstein
  
  

Acceptance is a process. Be patient. Talk to God. Pray with your faith community until you arrive to a safe enough place to make some decisions. Talk to your family and friends and to your team.  What would a good end look like for you?  Consider it. What are your goals in the time you have left? Talk to your family and begin to work backwards to achieve it.  Find the person(s) who you are comfortable talking with about where you are, what you are feeling and the person who comforts you in doing it.  Allow the comfort in.  People tend to show up whom you would not expect.  Find a safe place from which to be curious and open.  Love is at this helm.
 
SPIRIT: Wisdom of the Higher
Here, we need to remember the Higher. Your faith leads. God also accompanys our loved ones who are walking with us to the end of life, but not the end of love.  It is our human journey.  As Ram Das says, “We are all just walking each other home.”
 
Stay in the drivers seat as you are able. Speak your wishes to your loved ones. Entrust one to speak for you when you may not be able to. Choose your hospice & team.  Every human being is unique, but in death, we are all on the same return journey…Know that, no matter our plans, Love is at the helm and, at some point, we all slide over and give the car keys to God.

A few of you asked me to clarify what I said in one of my last posts in the Sustainable Chaplain:

Re-making health care to be about health, as hospice makes death about hope, is an earthquake to the medical model of fixing ....

How can death be about hope?
I am answering it here because hope is al best practice for hospice and palliative care. It is also the roots of reconciling with loss of any kind.

• Hope is NOT about putting on a happy face sticker (...over an empty gas tank dashboard indicator).
• Hope is NOT about accenting the positive...like the song in the musical
• Hope is about grounding in the truth of where we are, and asking the question:

      What is it you hope for?

Where we go from here... depends upon where we are at presently.
Most hospice teams tend to disrespect and disregard the benefits of denial. In my training for 'companioning' those in loss, I paraphrase my professor here:

                 Denial is useful and self-protective... to a degree...but don't take it away.
                                     - Dr. Alan Wolfelt, Center for Loss and Life Transitions

It takes time to gather ourselves, to approach the unknown...and death is the great unknown.  How do we live with uncertainty?

We need practice at it - to live with uncertainty. What is it, really,  but just another day of cleaning out your closets of old baggage...or vacuuming the dust bunnies.  But if you have NEVER cleaned the closets of old stories and concepts that are not longer useful to you, it's going to be a bigger job than if you did had done it regularly. It makes sense that even dust bunnies can be overwhelming when you when you have avoided and accumulated them for a lifetime.

Metaphysical dust bunnies
I am attempting lightheartedness here, but it is also true.  If you avoid all notions of EOL dust bunnies, your task at the end of your days here will be tougher. 

Why not write down what YOU want when you are no longer able to say? Why NOT make a will? Telling your loved one's what your wishes are in this tender valley of our humanity is a great gift that will lighten the load of deciding when you can no longer do it for yourself.

Why do we spend our days pretending that we will not get old, never get to our end on this good Earth? I see a direct relationship between denial at the end of life (EOL) and messy closet hygiene. Like anything, we need practice for these big milestones.  Many people do their best NOT to show up for death - anyone's death - even their own. They don't visit sick family members; they try not to visit even their own mother at the end because they 'don't want to remember her THAT way'. 

I am saying...this life is practice for our own good end.

I have seen many family members collude in this EOL denial by multiplying it by THEIR OWN denial. Or holding out 'for a miracle' until that dying breath...so there is not time to reconcile, to say goodbye, to forgive the dust bunnies of feud and disconnection which are blocking the door.

It is the door to a 'good death'. (This is not an oxymoron.)
In hospice, we say a good death is a peaceful death where the pain is controlled.  The measure of pain is TOTAL pain.  This includes emotional pain and 'spiritual' pain.  We are now back to the original question of this post:

                               How might hospice make death about hope? 

The answer here is:
• Hope meets between the possible and the probable.
• Hope is common ground
• Hope takes many forms...

The A.M.E.N. Protocol*
Many folks look for a miracle. They pray that they be spared the bitter pill of loss. It can look a lot like denial.  It may be and it may not be.  Statistically, prayer beats most miracle drugs for beneficial outcomes. As a chaplain it is important to stay engaged in this difficult, INCREMENTAL and iterative conversation. In fact, there is a palliative protocol for it. It is called the A.M.E.N. Protocol.
       • Affirm the patient's belief. (I hope with you...)
       • Meet the patient or family where they are. (I join you in hoping and praying...)
       • Educate from the role as a medical provider (...and here are some medical issues..)
     • No matter what:  assure the patient and family you are committed to them...no matter what happens...(We will be with you every step of the way...") which tends to be more doable in hospice than palliative...

It asks the question:  "For what purpose is this miracle?"
"The physician may respectfully inquire.  He or she might learn,...that a man's first grandchild will be born in a few months.  The hope may be to simply cradle that baby for a few sacred hours before succumbing to his disease. The physician, on inquiring, may learn that a mother hopes for remission to see the last of her children graduate from high school  or college.  Hope takes many forms.  'Even dying people have work to do or work to finish: relationships to enjoy or mend, goodbyes to say, lessons to teach their families.'  The only sure way to know what hope means for the individual is to inquire, respectfully and reverently."

Even if the patient (and or family) are insisting on a miracle. The miracle may be just another day to wait to see their daughter flying in from the East coast.  It is what hope looks like at the end. 

Please find the PDF for further reference. This is a brilliant and useful study.
* Cooper, Ferguson, Bodurtha, and Smith. The Sidney Kimmel Comprehensive Cancer Center, John Hopkins, Baltimore, MD. Download PDF here:

It was quite a week– The world played the part of "Goldilocks" and I was the three bowls of porridge: one was too hot, one was not hot enough...but I ended the week with it being 'enough" to just be of service.

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.