One of my patients and I were talking about faith today. He was born Catholic but no longer practices. He had told our nurse that he believed in God and would be happy to have me visit. He's not much for talking - he told me that and told me that his voice was wearing out from talking with me (and there really wasn't that much talking.) Then he asked, "Where did you get your faith?"
Wow. I needed to think about that one. Where did I get my faith? I got it in part from my parents who joined a synagogue and sent me to religious school. I got it in part because I looked around at how the world works and knew there must have been something (someone) who created it. That was about as much as I could come up with during the visit. We talked a bit more - about people whose faith teaches them that there will be a reward after this world, about my belief that what's important is not whatever comes next but what we do here. He was tired, so I asked if we could talk about this more at our next visit. He agreed.
Before I could write a visit note or even begin to process the visit, my phone rang. I was needed somewhere else -- 50 + miles away.
I love driving. It gives me time to think, to ruminate, to dream. I've been known to miss a turn I know well because I'm mentally writing a sermon (or now a blog post) while I drive. So, with 50 + miles of highway I had plenty of time to think about where I got my faith. The more I thought, the more I think that my first answer -- my synagogue -- was more true than I realized. I don't remember a lot of details about what I learned in Sunday School, but I remember some formative experiences there. In sixth or seventh grade we studied comparative religion. At the end of the course, we had to write an evaluation. I wrote that we should have had teachers or guest speakers from the different faiths, because the teacher, Mr. H., "couldn't answer all my questions." Mr. H. wrote in reply, "God Himself couldn't answer all Chana's questions." It was in my synagogue and youth group that I learned I could ask as many questions as I wanted and that there were a lot of texts that spoke to my concerns. It was in my synagogue that I found a community, teachers, rabbis, mentors. It was through the synagogue that I went on to advanced Jewish learning and had pivotal experiences, including significant time spent in Israel.
Where did I get my faith? I got it from Jewish texts, from Jewish experiences, from friends, and from my rabbis. I get it through the work I do and the people I meet. And today I was reminded that in the work I do, I get so much more than I give.
Wednesday, July 21, 2010
Monday, July 19, 2010
kipah / yarmulke
I wear a kipah when I'm at work. Some days it's just part of my work wardrobe, like my name badge. Of course, I do like to match it to my clothing or the season. It's been awfully hot lately, so I've been wearing my summer "watermelon" kipah.Whenever I wear it, someone will do a double take and ask "Is that a watermelon?"
That's not the usual response. Usually, at least initially, people say either "Why do you wear that?" or "I didn't know women could wear one of those." To the "why" question I respond that I'm a rabbi (while in my head, I hear Kol B'Seder singing "The Kipah Song" - "Kipah, yarmulke, shows the world you're a Jew.") It may seem like a simplistic answer, but on days when a facility social worker or activity staff member chases me into the elevator or out of the building "Rabbi, can I talk with you a minute," the kipah as identification serves its purpose. They know who I am. They spot me by the brightly colored, crocheted head covering. Whether it's a question about one of my patients or, more typically, a request that I visit a Jewish patient who's not on hospice, or blow shofar, or supply holiday music or readings, the kipah assures that they notice me. "I've been hoping to catch you." "I'm so glad I saw you when you walked by." In the busy nursing home world, the sight of my kipah reminds them that they had a question for me.
The "I didn't know" or the "You must be Jewish" comments lead to theological discussions or educational opportunities. I never know where those discussions will go. The timing isn't always convenient and sometimes the topic doesn't lend itself to a quick answer, but the kipah gives me the chance to have conversations that would otherwise pass by.
There's another reason for the kipah. It reminds me that I'm a rabbi, that I represent the Jewish community - sometimes to people who have never spoken to a Jew. The kipah reminds me to be aware of what I say and what I do. While I certainly don't speak for the Jewish community, a person's encounter with me may form their impression of who a Jew is or what a Jew believes or how a Jew acts. The kipah is my reminder of the responsibility that comes with my title and the work I do.
And then there are the unexpected comments, the unplanned moments, the laughter that sometimes comes my way because of the kipah. But that's another post.
That's not the usual response. Usually, at least initially, people say either "Why do you wear that?" or "I didn't know women could wear one of those." To the "why" question I respond that I'm a rabbi (while in my head, I hear Kol B'Seder singing "The Kipah Song" - "Kipah, yarmulke, shows the world you're a Jew.") It may seem like a simplistic answer, but on days when a facility social worker or activity staff member chases me into the elevator or out of the building "Rabbi, can I talk with you a minute," the kipah as identification serves its purpose. They know who I am. They spot me by the brightly colored, crocheted head covering. Whether it's a question about one of my patients or, more typically, a request that I visit a Jewish patient who's not on hospice, or blow shofar, or supply holiday music or readings, the kipah assures that they notice me. "I've been hoping to catch you." "I'm so glad I saw you when you walked by." In the busy nursing home world, the sight of my kipah reminds them that they had a question for me.
The "I didn't know" or the "You must be Jewish" comments lead to theological discussions or educational opportunities. I never know where those discussions will go. The timing isn't always convenient and sometimes the topic doesn't lend itself to a quick answer, but the kipah gives me the chance to have conversations that would otherwise pass by.
There's another reason for the kipah. It reminds me that I'm a rabbi, that I represent the Jewish community - sometimes to people who have never spoken to a Jew. The kipah reminds me to be aware of what I say and what I do. While I certainly don't speak for the Jewish community, a person's encounter with me may form their impression of who a Jew is or what a Jew believes or how a Jew acts. The kipah is my reminder of the responsibility that comes with my title and the work I do.
And then there are the unexpected comments, the unplanned moments, the laughter that sometimes comes my way because of the kipah. But that's another post.
Thursday, July 15, 2010
The State
One of the big concerns in nursing homes is the visit from The State. Periodically (I have no idea how often) the Department of Public Health (DPH) comes in and surveys the records, charts, and files. The goal of the nursing home is to have a survey with no deficiencies.
Ideally, all of us want to give good care. We want to be attentive to our patients' needs, caring in our interactions, manage pain, prevent falls, etc. And, of course, we want to document that we have done all of this without making every visit note sound like every other visit note. We want to individualize the care we give, even when our care plan forms don't always give us enough choice in our check boxes to show that we're doing so.
Some days it feels as though all we do is check off boxes and write narratives. Some days it feels as though we spend more time documenting what we do than doing what we do.
Yesterday, I was "snagged" by The State. As I was leaving a nursing home, a DPH worker stopped me to ask some questions. After telling her I was an outside provider, and thus ensuring that they knew there were hospice patients in the building, she asked a few questions about our patients. One of the things DPH looks at is coordination of care. Does the nursing home staff talk to the hospice staff? Do we collaborate on the care plan? Do we work in coordination or in competition?
While internally hoping that I had checked all the appropriate boxes on my forms and that my narratives were complete, I was pleased to be able to talk a bit about this nursing home. Not just because we do coordinate care, but because the staff in this nursing home are caring and attentive. They give superb care to some very challenging patients. It is one of my favorite places to visit. It was nice to be able to share this outside the circle of my co-workers (who feel the same way) and beyond the nursing home staff (whom we have also told how much we enjoy coming to their facility.)
Still, the next time DPH is in one of the facilities I serve, I hope I slip though the building without their notice.
Ideally, all of us want to give good care. We want to be attentive to our patients' needs, caring in our interactions, manage pain, prevent falls, etc. And, of course, we want to document that we have done all of this without making every visit note sound like every other visit note. We want to individualize the care we give, even when our care plan forms don't always give us enough choice in our check boxes to show that we're doing so.
Some days it feels as though all we do is check off boxes and write narratives. Some days it feels as though we spend more time documenting what we do than doing what we do.
Yesterday, I was "snagged" by The State. As I was leaving a nursing home, a DPH worker stopped me to ask some questions. After telling her I was an outside provider, and thus ensuring that they knew there were hospice patients in the building, she asked a few questions about our patients. One of the things DPH looks at is coordination of care. Does the nursing home staff talk to the hospice staff? Do we collaborate on the care plan? Do we work in coordination or in competition?
While internally hoping that I had checked all the appropriate boxes on my forms and that my narratives were complete, I was pleased to be able to talk a bit about this nursing home. Not just because we do coordinate care, but because the staff in this nursing home are caring and attentive. They give superb care to some very challenging patients. It is one of my favorite places to visit. It was nice to be able to share this outside the circle of my co-workers (who feel the same way) and beyond the nursing home staff (whom we have also told how much we enjoy coming to their facility.)
Still, the next time DPH is in one of the facilities I serve, I hope I slip though the building without their notice.
Tuesday, July 13, 2010
Signage
On a nursing home door:
"Door is alarmed."
It looked pretty calm to me. Perhaps the calm was a facade.
"Door is alarmed."
It looked pretty calm to me. Perhaps the calm was a facade.
Wednesday, July 7, 2010
Always good to laugh
A sign I saw today in a staff bathroom at a nameless facility:
ALL STAFF
WHEN your
Done using the
toilet Please
giggle the handle
or it will not
Stop Running.
So I giggled. The toilet did not find it amusing.
ALL STAFF
WHEN your
Done using the
toilet Please
giggle the handle
or it will not
Stop Running.
So I giggled. The toilet did not find it amusing.
Thursday, July 1, 2010
Health care
There were two articles in the New York Times last week that spoke to some of the issues I face as a chaplain. The first dealt with issues surrounding the medical decisions people make. The author writes about the use of medical resources and the ways that patients are often persuaded or pressured to make medical decisions that may not be in their long term best interests. The other reported on delerium and hallucinations in elderly hospital patients.
When I meet with families we often address the issues of medical decisions they have made before they decide on hospice. There is the gentleman whose wife persuaded him to get a feeding tube "to give him the strength to try one more" kind of treatment. The treatment didn't work and now they're tied to a feeding tube that he never really wanted and she, and the children, no longer want in place. However there's little documentation that he acquiesced to the feeding tube "just for them." Even though there's plenty of documentation that this is not a treatment he would want given his current health, the doctor is uncomfortable removing the feeding tube. As in the New York Times article, there is the women with end stage dementia and a pacemaker. Instead of viewing her slowing heart as a natural part of reaching the end of life, it's viewed as a problem that needs to be fixed. There's the patient who is a "full code" and whose children don't want a DNR (a whole issue in and of itself.) Some patients and families say that the aggressive treatment was "right at the time," but now want it stopped. Others feel that it was never right but they felt they "had no choice."
And then there is the issue of hospitalization. In addition to the hallucinations and delerium that patients often face, there is also the fact that hospitals are not always the best choice for elderly patients. Often a nursing home can provide the care that one of their residents needs without the disruption and disorientation that comes with hospitalization. For patients with dementia, the unfamiliar surroundings and staff are especially disruptive. Patients who are mobile in their own homes, whether private homes, assisted living or nursing homes, are kept in bed or in a chair because they are a "fall risk." In addition, virtually every nursing home I've visited has stories of elderly patients sent out to the hospital with intact skin who return with skin breakdown and pressure sores.
Sometimes it seems that just because we can - insert a feeding tube or a pacemaker, send a resident out for specialized treatment, try an intervention that may be helpful - we think that we should. Sometimes the best thing we can do for a patient, a parent, a friend is to do nothing medically. Sometimes the best we can do is to look at the quality of life and provide the best quality we can for however long a person has. Medical intervention is not always the answer. We need to look at the whole patient, the whole family, not just a single symptom or two. We are more than our diseases, more than "the little old lady in bed A." All too often our health care system misses the person as it focuses on the disease.
When I meet with families we often address the issues of medical decisions they have made before they decide on hospice. There is the gentleman whose wife persuaded him to get a feeding tube "to give him the strength to try one more" kind of treatment. The treatment didn't work and now they're tied to a feeding tube that he never really wanted and she, and the children, no longer want in place. However there's little documentation that he acquiesced to the feeding tube "just for them." Even though there's plenty of documentation that this is not a treatment he would want given his current health, the doctor is uncomfortable removing the feeding tube. As in the New York Times article, there is the women with end stage dementia and a pacemaker. Instead of viewing her slowing heart as a natural part of reaching the end of life, it's viewed as a problem that needs to be fixed. There's the patient who is a "full code" and whose children don't want a DNR (a whole issue in and of itself.) Some patients and families say that the aggressive treatment was "right at the time," but now want it stopped. Others feel that it was never right but they felt they "had no choice."
And then there is the issue of hospitalization. In addition to the hallucinations and delerium that patients often face, there is also the fact that hospitals are not always the best choice for elderly patients. Often a nursing home can provide the care that one of their residents needs without the disruption and disorientation that comes with hospitalization. For patients with dementia, the unfamiliar surroundings and staff are especially disruptive. Patients who are mobile in their own homes, whether private homes, assisted living or nursing homes, are kept in bed or in a chair because they are a "fall risk." In addition, virtually every nursing home I've visited has stories of elderly patients sent out to the hospital with intact skin who return with skin breakdown and pressure sores.
Sometimes it seems that just because we can - insert a feeding tube or a pacemaker, send a resident out for specialized treatment, try an intervention that may be helpful - we think that we should. Sometimes the best thing we can do for a patient, a parent, a friend is to do nothing medically. Sometimes the best we can do is to look at the quality of life and provide the best quality we can for however long a person has. Medical intervention is not always the answer. We need to look at the whole patient, the whole family, not just a single symptom or two. We are more than our diseases, more than "the little old lady in bed A." All too often our health care system misses the person as it focuses on the disease.
Wednesday, June 30, 2010
Unfinished business
Sometimes we have a patient who is declining, declining, declining, declining or actively dying, but, somehow, just keeps on going. We wait. We watch. We stand vigil. Well, really, we sit vigil.
At hospice rounds someone asks, "How is it that Mrs. S. is still with us?" or someone comments: "Mr. G. really needs to go to heaven."
We don't have an answer. As a chaplain, I get to say that matters of life and death are in God's hands, not ours. And I believe that. Because we really don't have an answer. Some people begin their process of active dying and are gone in a few hours or a day, or two. Others last and linger and fade and get more and more gaunt, but they don't die. It has nothing to do with medication. They can be on heavy doses of morphine to control their pain; they can be on minimal medication with no indications of pain.
We hold their hands. We play soothing music. We let them know that they are not alone. The family asks "when?" and "how long?" We don't have an answer. But sometimes we get a hint. Mrs. S. is talking to people we don't see. Mr. G. is apologizing for something, we don't know for what. One is calling out "I love you."
And we get a hint that there is some unfinished business; a lost connection, something that wasn't said or done, something that still holds them here while their body is doing everything it can to leave. Sometimes we help bring someone in and that is the business that is holding someone here. A lot of times, though, we don't know why someone is still here. Or "how long." So we sit vigil. And hold hands. And say "I love you." Sometimes that is enough.
At hospice rounds someone asks, "How is it that Mrs. S. is still with us?" or someone comments: "Mr. G. really needs to go to heaven."
We don't have an answer. As a chaplain, I get to say that matters of life and death are in God's hands, not ours. And I believe that. Because we really don't have an answer. Some people begin their process of active dying and are gone in a few hours or a day, or two. Others last and linger and fade and get more and more gaunt, but they don't die. It has nothing to do with medication. They can be on heavy doses of morphine to control their pain; they can be on minimal medication with no indications of pain.
We hold their hands. We play soothing music. We let them know that they are not alone. The family asks "when?" and "how long?" We don't have an answer. But sometimes we get a hint. Mrs. S. is talking to people we don't see. Mr. G. is apologizing for something, we don't know for what. One is calling out "I love you."
And we get a hint that there is some unfinished business; a lost connection, something that wasn't said or done, something that still holds them here while their body is doing everything it can to leave. Sometimes we help bring someone in and that is the business that is holding someone here. A lot of times, though, we don't know why someone is still here. Or "how long." So we sit vigil. And hold hands. And say "I love you." Sometimes that is enough.
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