#BlogElul -- Inventory time

Am I ready for Elul? Time to take inventory.

Elul check list:

• Rosh Hashana cards for my Jewish families who lost someone in the past year
• handouts for holiday programs in facilities
• resources for facilities for Holy Day programs
•  DVDs of services
• list of congregations that stream services
• CDs of Holy Day music
• Shofar in the car:
•  for my Jewish patients (make sure they're all seen this month)
• for any Jewish residents in the facilities I'm in this month
• for my colleagues at IDT
•  haircut
•  new clothes 

And an unexpected memory from last year:

You wash your hands A LOT in health care. Everyone says to sing "happy birthday" while you wash then to make sure you're doing it thoroughly and for long enough. After a number of Holy Day programs and visits and music and shofar I suddenly noticed that my hand-washing music had changed. As I lathered and scrubbed, I listened and realized that my go-to tune had suddenly become "Avinu Malkeinu."

Caregiving

Five minute response to the writing prompt: "Write about a caregiving experience that moved you."

He was dying. He had been dying for a long time, but not really dying. Eating less. Drinking little. He still said a word or two. He enjoyed music. Was calmed by touch. The sun shining on his face made him smile. But he was sleeping more and more. Less responsive. Less present. And now he was really dying.

The family had all been in - children flying in from far away, his wife at his bedside. They stayed late into the night. Or early into the morning. At this point it was hard to know which. They told him it was OK to go.

Clergy visited. Prayers were said. Everyone was ready. But still he did not go. Morning came. He was still here. Again they gathered. His wife of oh-so-many years stroking his head, caressing his arm. "Oh my beautiful boy."

Families

End of life can bring out the best in families. They can come together, tell stories, hold hands, celebrate a life, and just be present. They may have lots of questions about the dying process, about medications, about what they should be doing, and about what to do next. They may need coaching, hand-holding, education, support, and guidance, but they pull together and they pull through.

Unfortunately end of life can also bring out the worst in families. They can bicker over property and money. They can argue over care and debate treatment options. They can become mired in what they want and lose sight of what the dying person wanted.

One of the saddest things I see is when a family lets their conflicts get in the way of being there with and for their loved one. It's not just a family fighting at a bedside or in the hallway, but it's the family that doesn't communicate that gets to me. For some families it's a time for healing or letting go. I see siblings going above and beyond to contact the estranged sibling or driving the streets to find the homeless sibling. They sacrifice some of their remaining time with their loved one to try and bring repair to the relationship.

And others don't.  There is so much anger in the relationship (admittedly often deserved.) The caregiver knows how to reach her siblings or his aunts and uncles or the missing grandchildren, but doesn't. As I sit with my dying patients in these circumstances, I wonder how the family members will feel when they get the call, if they get the call, that their loved one has died.

And I know I can't fix it. And I know it's not my role. And I sit with my patient and hold his hand, and play music for her, and say deathbed prayers, and try my best to be present. And I am sad for all the lost opportunities and missed chances.

"The Next Holiday is:"

I usually wear a watch that tells me the date. I don't need to do so - my work phone also tells me the date as does my personal cell phone. And most of the time I know the date. Despite this, every time I write a visit note, or sit down to write a group of notes, I look at my watch or the unit calendar for the date.

I do this even though virtually every nursing home unit I visit has some variation of the same sign, telling me the date:

Today is: Monday   May 16, 2011

The weather is: cold  rainy

The season is:  Spring

The next holiday is:  _________

It's "The next holiday is" part of the sign that amuses me. I don't know if it is dependent on the placards that come with the sign, the calendar that the staff look at, their knowledge of holidays, random chance, or just personal whims, but "the next holiday" is not always consistent.

Last month I was on one unit and "the next holiday" was Easter. I went upstairs and in another unit, in the same building, "the next holiday" was Passover. The next day I was in a different nursing home and "the next holiday" was Good Friday.

This week I have seen "the next holiday" as Armed Forces Day (May 21) and Memorial Day (May 30.) (I don't expect that I will see Shavuot, nor is any nursing home I visit counting the Omer. ) Right after Memorial Day, the signs will battle between Flag Day and Father's Day. They'll then stay consistent with The Fourth of July and then Labor Day, but come the Jewish Holy Days, Columbus Day, and various other fall holidays, "the next holiday" will again differ from place to place and unit to unit.

Perhaps this is why I need my watch. It doesn't focus on "the next holiday" but just on a number between 1 - 31. And most of the time the number it tells me really is that day's date.

Too soon

One of my patients died last week. On the face of it, there's nothing novel about that sentence. I could probably begin a posting every week with those words.

Some losses, though, are harder than others. When you share someone's life for six months, learning her history, listening to her stories, reluctantly leaving her to visit another patient; when the music she loved plays unexpectedly on your ipod and you remember her tears as she sang along, it's hard to let go.

It's also hard remembering the most recent visits. She asked, "Am I going to die?" I answered and we both had tears in our eyes. "I never thought I'd die," she said.

I've thought about that visit a lot lately. Obviously, a patient on hospice knows her prognosis, as do her nurses, her aides, her social workers and chaplains.

Any one of us can, on any day, acknowledge that one day we too will die. But her words ring so true. I know that one day I will die, but I imagine it far off in the future. And when that day comes, it will probably seem too soon to me, no matter how old I am. And I expect that, if you ask me, I too would say, as she did, "I never thought I'd die."

May her memory be a blessing.

Al hanisim

I was working this morning, driving to an on-call visit and listening to the radio. The radio program came to an end and the station began to broadcast a Sunday church service. This is usually my cue to change the station, but today I thought I'd listen. The service being broadcast was from a Unitarian Universalist church. I'm not sure why I decided to listen - perhaps because I recently lost a patient who identified as UU. I thought of him this morning when the service came on and I didn't change the channel.

At the beginning of the service, the service leader mentioned that it was Chanukah on the Jewish calendar. One of the song selections was "Light One Candle" and the congregation's educator would speak about Chanukah. That got my attention - what would she say?

She spoke about Chanukah as a holiday of light. She went on to equate the Chanukah lights to the use of light in many other religious traditions. I understood her connections - the UU religion is marked by theological diversity. I don't know who was sitting in the congregation (or listening on the radio) or their specific faith backgrounds, but listening to her talk they could link their beliefs to the message she was giving.

My problem came a little earlier in her talk. She spoke of the day's worth of oil that lasted eight days as she explained the holiday. She then went on to say, "but the oil is unimportant." Unimportant?!?! If you're focusing on light, how can that which caused the light be unimportant to the story?

Really, however, I had a bigger problem with her talk. Lights are important to Chanukah; one of the holiday's names is "Festival of Lights" ("chag urim" in Hebrew.) Lights are lovely. Lighting up the darkness on these cold winter nights is a wonderful thing. And the Chanukah lights glow even more brightly because they are lit in the days of a waning moon into the new moon. But for me Chanukah is not about lights - it's about miracles.

The prayers when we say the daily Amidah and later when we light the Chanukah menorah focus on the nisim, the miracles that God performed for our ancestors at this season. Last week, as I was preparing the reflection for our hospice Interdisciplinary Team Meeting, I was thinking about Chanukah. And I was thinking about miracles.

I believe that our lives are filled with miracles. There are the "everyday miracles" (as the Reform siddur labels the daily blessings) - the miracles of breath, of sight, of awareness, of freedom, of being created in the ways we are created. There are the miracles of love, and connection, and relationship.

There are the miracles I see in hospice work. I've viewed times when families find healing in the face of death. I've seen someone arrive at "just the right time" or somehow say exactly the right words. I've walked onto a nursing home unit and been greeted with "Thank God you are here." (And often when my presence was not on my planned weekly schedule. What was it that brought me to this place at this precise time?) 

When it comes to miracles, I know we can't stop the angel of death from coming; all of us will meet him one day. But we can push back, and there are times when we can delay his arrival.

Part of my job is to be present, to watch for the miracles, and to name them. Chanukah reminds me that miracles do exist. They existed for our ancestors at this season, and they exist for us in these days.

Chag urim sama'ach! May our days be filled with light and may we be open to and aware of the miracles that daily fill our lives.

"Tell me in small words."

I was following up on a hospice referral this week and the nursing home staff told me that there was just one problem - the patient didn't have a payer source. "What?" I said. "There's no payer source." "I'm a chaplain. Tell me in small words," I replied.  Once they finished laughing, they explained to me how this patient with an insurance company managed Medicare plan couldn't access benefits that general Medicare recipients have. It was one of several long, convoluted, and frustrating conversations I had around the issue.

Putting aside my personal feelings about this company and this issue, it occurred to me that there is a real benefit in getting and giving explanations "in small words." Hospice has a lot of jargon, as does health care in general. Those of us who work in any part of it become familiar with the lingo. At this point I can talk about "scheduled" medication vs PRN medication with the best of them. I know the medications we generally use and I usually understand what our nurses are talking about. When I have a patient in pain I know how  to talk with a nursing home med nurse.

But when talking with our nurses and, especially, when talking with patients and families, I tend to use small words. I talk about a patient being "short of breath." I don't say he has "dyspnea." I talk about someone losing weight and "appearing gaunt" rather than saying she's "cachectic." I will mention apnea to families, but I always describe what that means and talk about what they will observe when a dying person has apnea.

I've also realized that I try to describe medical end-of-life issues in concrete everyday terms. For an actively dying patient with a fever that isn't responding to medication, I talk about the "body's thermostat" which is no longer working. For other questions I may talk about the "body's electric system." It isn't necessarily how a nurse would describe end-of-life medical issues, but the metaphors are the ones that work for me in understanding what happens as the body ceases to function. They also seem to be metaphors that help families understand what is happening.

I know lots of "big words," but I am convinced that sometimes the simplest, smallest words are the best way we can communicate. I'm going to keep the sentence "tell me in small words" in mind as I work with families in the hope that by using "small words" we will better understand and communicate with each other.

Cake

We had several patients with birthdays this week. I missed the 102nd!! birthday party of one patient, but I was part of celebrations for two other patients. They were special moments, reminding us that the work we do is about life and the celebration of life. And cake.

One patient was impatient. There was too much talk, and too much time waiting for everyone to get there to sing "Happy Birthday." You shouldn't have to wait for cake. So a finger reached out and swiped off a finger-full of frosting. It doesn't matter whether you're 3 or 83 - a birthday is about the cake and the frosting (and "all the pretty girls" surrounding you.)

Our second patient was having a bad day, not in any physical pain, but in bed, kind of gloomy. The room was dim and there weren't a lot of personal belongings brightening up the space. But when we came in with a big chocolate cake and announced we were there to celebrate the birthday, we got a smile. As we sang "Happy Birthday" and applauded, our patient glowed and gave us a big smile. One bite of the cake was enough, so we left the rest of the piece by the bedside "for later."

It was a good day. There was cake and frosting; singing and celebration. And two people were reminded that they have not been forgotten, that we can still celebrate and sing and laugh together as we give thanks for the blessing of time . . . and for one more piece of cake!

TGIN (Thank God it's November!)

Was it the changing weather? The cold? The increasing hours of darkness? Was it just something that happens now and again?

I don't know what it was, but I know that in October we had death after death after death. I think that last month we had the most deaths in a single month in the three+ years I've been doing hospice work. I've had some people say: "You're doing hospice work. What did you expect?"

I know that most of my patients will die. I also know that some of them will plateau or improve and come off of hospice services. I'm used to that. I'm not used to days when 3 or 4 people die, followed by days when 2 people die, followed by days when 2 more people die. I'm not used to day after day of trying to figure out which dying patient, or which family, is more in need of my presence and support.

Hospice staff juggle lots of tasks, but sometimes information sessions, new patient assessments, and dying patients require too many balls in the air. Invariably one or another gets dropped and bounces until we are able to scoop it up and toss it back in the air.

As I look back at October, I'm not sure which makes me sadder - the deaths of patients who came on hospice service and died in a few days, patients whose names I barely remember; or the deaths of long-term patients, patients whom I got to know well, patients whose family members I know, at least as voices on the other end of the phone line. All I know is that there were too many of them.

And I'm grateful that in the midst of all this loss, I took time to take care of myself. I can't imagine what the month would have been like without healthy food, exercise, educational opportunities, time with family and colleagues, and enough sleep. I'm grateful that October also was filled with bright days with sunlight sparkling off orange, red, gold and green leaves and vivid blue skies. The crisp air, cider donuts, and time driving in the car between patients were moments of rejuvenation in a month that was altogether too dispiriting.

This week . . .

Working with hospice means that I spend my days surrounded by death and by life, often at the same time. This week I sat with a family as their mother was actively dying. I provided some education on the dying process and on pain management, I recited some prayers, but mostly I listened. The children held their mother's hand, stroked her forehead, and told stories. They laughed as they remembered family moments and as they spoke, the mother who had been lost to them by dementia over the past years became a vibrant presence in the room, even as her dying body struggled to take yet another breath.

This week I attended a wake. My Jewish sensibilities still make me uncomfortable with open caskets ("She looks so peaceful") no matter how often I've been exposed to them. And yet, going to the wake is a powerful moment of connection. It says to the family that we are haven't abandoned them. We're present for the dying, at the death or the pronouncement, and our care continues as we stay involved with the family for the year after their loved one dies. The wake also gives me the opportunity to view family dynamics and see what kind of support is present for the spouse, the child, the sibling. Knowing what kind of support is there helps us help the family.

This week I arrived at a nursing home just minutes after our patient died. The family was still present. I was able to offer our condolences, to remind them that our care and contact will continue for the next year, to give a needed hug, and to accompany them back to the bedside to offer final prayers. I hope my presence brought a measure of comfort. I know that the staff was grateful for my presence.

This week I wondered, as I often do, what rituals are there for the professional caregivers to help us when the deaths pile up around us. What does a funeral director or a chevra kadisha member do after they prepare a body for burial. How do they make a separation between their sacred work and their daily lives? I know of nurses whose custom when they get home is to strip off their work clothes, shower, wash their hair, and change into home clothes. Only then do they join their family, prepare dinner, read the mail. Others tell me they listen to specific music on their ride home to take them out of their professional caregiver role and back into their family role. I know of many personal rituals that we use to make a transition between what we do and who we are, but I wonder sometimes if we do enough to help us make the distinction.

This week I asked myself: How do I make sure that I am caring for myself and not being consumed by the care I give?

Oops

This week I was the one who broke one of the big nursing home "rules." I was the visitor who let a resident leave a locked unit.

I was covering for a colleague, visiting a dying patient in a nursing home that I don't normally cover. Although I used to be a chaplain in the building, I'm not the chaplain now so I'm not familiar with the residents; I only know the staff. As I was leaving the floor, I caught up to a gentleman who had just reached the elevator. I looked at him as I fumbled around trying to figure out how the elevator worked. (It used to have a nice covering over the "down" button so you had to use your keys or a pen through the grill to press the button. Now there is a full covering and a small metal piece on a chain that "locks" it in place. You have to pull out the metal piece, lift the cover and press the button, then close the cover and replace the metal piece. I got the metal piece out, but didn't know to lift the cover, so I was jabbing the metal piece every which way until I figured it out.)

While wondering if I was going to have to go to the nurse's station and get help with elevator instructions, I assessed the gentleman. He wore nice trousers and a long-sleeved white button-down shirt. He was shaved and his hair was combed. There was no noticeable wristband or ankle bracelet. There was minimal conversation, but we didn't know each other. Resident or family member? There was no way to tell. I've met a lot of men his age who come daily or twice a day to visit their wives on the dementia unit and he looked more put together than many of them.

So when he got into the elevator with me, I didn't ask if he was supposed to be there. (There's really no polite way - "Excuse me. Do you have dementia?" "Are you allowed off the floor?") But there must have been something, because when I got off the elevator I thought, "I should check with a staff member."

There was no need. Almost immediately a staff member assisting another resident looked at him and asked, "'Bob.' What are you doing here?" Another came and gently took his arm, "Here, let's go this way." And another, "What's 'Bob' doing off the floor?"

Today, when I again visited that nursing home, I was greeted (among other things) with, "I hear you let 'Bob' off the floor yesterday." I apologized. They laughed. I have the feeling that this happens often with 'Bob.'

In many of the nursing homes I visit there's a resident who doesn't quite seem to belong on the floor. Someone who is still walking around; someone who remembers the social graces and can provide polite chit-chat. Perhaps it's someone who is no longer safe living alone. Or a person whose family can no longer provide the amount of care they need. I've met many family members, especially spouses, who have run their own health into the ground while caring for a loved one with dementia, until the needs become too great and a nursing home or assisted living is the best option.

And I've met residents who ask me to "get me out of here." One wants me to gather up her medical records "RIGHT NOW" because she has "a medical appointment and needs the doctor to see" that she doesn't "belong on an Alzheimer's floor." Another wants me to call her lawyer. "You can see that I should be living on my own. My daughter put me here. She sold my car. She lives in the South. I have a cousin who will help me. I just need you to call." I always talk to the staff. Again and again I speak with residents (not my patients) who present well and just want my help to "go home." I know that they are no longer capable of caring for themselves (and I've asked.) I know some of the stories. And it breaks my heart that I can't help them (and that they can't remember that I can't help them, so they repeat the request the next time they see me and the next.) Some days the hardest part of my job isn't the hospice patients.

But the next time I'm waiting for the elevator (or struggling to circumvent the lock that keeps the residents in,) I'm going to take a second and a third look at those people who are waiting with me!

Again with the shofar

I had the shofar with me today. A Jewish patient who was not inclined to hear it a few weeks ago - he had other things on his mind that day, and didn't recognize the shofar - said "yes," he'd enjoy hearing it. So I let everyone around know what I would be doing and then blew a mighty "tekiya."

"You shouldn't do that when you're crossing the street," he told me. "Too many people might get hurt."

Driving down the highway . . .

It's been one of those weeks.

I've driven between 70 and 90 miles each day this week Normally I try to schedule my day so that the facilities I visit are near each other. But with Holy Days, new admissions, visits that had to be made this week, and patients who were not doing well, I was going from one end of my territory to the other - every day.

This time of the year, however, I like long car rides. I use the time for Yom Kippur preparation. Not for work - but for me. I listen to podcasts - programs like "Speaking of Faith" that either have specific High Holy Day programs or programs that are thematically linked to the Holy Days. I listen to music. The sounds of "Avinu Malchenu" and "U'nitanah Tokef" fill my car (and I turn the sound up, and sometimes hit the "repeat" button.)

As I drive I reflect on the ways I can be better and do better in the New Year. I think about my family and friends. I remember people who we lost in the old year. Often when I reach the nursing home I'm visiting, I spend a few extra minutes in the car listening to the end of a song or a section of a podcast.

Sometimes a word or phrase or musical piece reminds me of a book I recently read, or a sermon I heard, or some aspect of the holidays I've been ruminating over. I become lost in thought and the words or music become a muted background to my own thoughts. So far, and somewhat surprisingly, I've managed all this without missing my exit or getting lost.

It's been one of those weeks. But this week I've been happy to have the extra time on the road, as all the roads I've traveled have led me back to myself and forward to atonement.

Happy . . . Hanukah ? ?

One of the residents at a facility I visit is always happy to see me. "I love you, I love you," she has told me. She met me when I was her brother's hospice chaplain in the the same facility. I am grateful that she doesn't connect me with her loss or see me as a reminder of her sorrow.

Initially she recognized me by my kipah, now she recognizes me as me. Whenever she sees me, she gives me the appropriate Jewish greeting (or at least the Jewish greeting she knows.) "Happy Hanukah," she says. "Happy Hanukah." I thank her.

I saw her last week, just before Rosh HaShanah. She wished me a "Happy Hanukah."

I couldn't help noticing that the local Chabad has their hanukiya fully lit for their New Year observances. Perhaps she's right: it's always hanukah somewhere.

Tales of the shofar

The shofar's out of the cupboard and into my workplaces. So far:

My patient's eyes are open when a greet her - a rarity - perhaps due to the lunch-time visit. I greet her and mention the New Year. Her eyes close. I sound the shofar - the whole series - loudly. No reaction from her; her eyes remain closed. But the gentleman next to her turns to me and asks: "What the hell was that??!!"

I do a "service" for a nursing home with a younger population. Some sing along with "Avinu Malcheinu." Some "talk back" at me during the story (I love that!) We listen to Kol Nidre. And during the course of the service I sound the shofar. They are so appreciative. I get to go around the room afterward and everyone wants to shake my hand and wish me a "happy new year." And I shake all of their hands and wish them a "happy and blessed year" as well. It's a good thing that State isn't here to chastise me for not washing my hands in between every handshake. It may not meet universal precautions, but the moment and the touch far outweigh the benefit of trying to follow the letter of the law in this case.

I ask one of my facilities if they have any Jewish residents who would like to hear the shofar. "The only people we've ever seen in the building with a yarmulke are you and that examiner from the State. He hasn't been around lately." "Ok, thanks. I didn't think you had any Jewish residents, but I always like to ask." "What does it sound like? Will you blow it for us?" So I do.

I give the activity director of another facility a CD of High Holy Day music for her Jewish resident (not one of my patients.) "Thank you so much. I'll put it in her room. Her family will be so glad to hear you came by." So . . . out comes the shofar and with a few introductory remarks to the staff, family and patients present, I blow the shofar. The Jewish resident gives me a little smile. "Please let her family know that I also brought in the shofar so she could hear it."

My office thinks of it as good PR and outreach. I think of it as a mitzvah and my preparation for entering the Holy Days.

שנה טובה ומתוקה

May we all be blessed with a sweet and good New Year.

The unexpected . . . or what teenagers taught me about conversation

Some days hospice work bears a certain resemblance to working with teenagers. Anyone who has worked with (or had) teenagers knows that some of the best conversations you have are the ones that take place in the car. Whether it's the forced intimacy or the lack of eye contact, or just serendipity, a car ride can turn into an unexpected opportunity for sharing. Something special can take place in that moment. You can't plan for it or expect it or extend it. You can only experience it and give thanks for it.

Some days you have moments like that in hospice. Again, you can't plan it and you can't force it. And just because you had that special moment once with a patient or family, you can't expect it to happen again.

Much like moments in the car, some of these moments happen when I am not looking at my patient. This week I was sitting with a patient who does not talk a lot. He does like it, however, when the social worker or I sit quietly next to him and do our paperwork. He likes the company and the companionship.

The other day I sat next to him with a big afghan on my lap. The afghan belonged to another patient. It had been lost and then found in the laundry by a facility CNA. The yarn had broken in some places, been pulled out in others, and had open stitches that were unraveling. I had told the CNA that I would try to fix it. (Fortunately I usually carry knitting and had both a crochet hook and a yarn needle in my car.)

So I sat next to my patient and focused my attention on the yarn and the open stitches. I don't know whether it was my attention to the task, my awareness of some of his issues and concerns, or my thoughts focusing on Elul,  but as I talked with him about what I was doing it turned into one of those unplanned, special moments.

I commented that it could be a challenging task to try to fix something that had been torn or broken. "Yes," he said. I sewed some more and said, "I know I can't make this perfect, but at least I can mend some of the holes and keep it from getting worse." He agreed. Although he's not much of a talker, I realized he was very focused on my words and actions. So I continued to mend the afghan and talk about repairing the things we could, letting go of the things we couldn't, and forgiving ourselves for not being perfect. He would listen, make a tiny comment or a sound of acknowledgment. This continued until there was no more yarn to reattach.

I know that I got a great deal out of this unexpected moment and conversation. I think that he did as well, for I have an invitation to visit again . . . and to bring my knitting.

Sitting & knitting

We have a new patient. She's in her 90's. The family says she's "given up," she's "ready to go." The family is clearly not ready to let her go. They're willing to talk hospice, but they are hoping that the extra attention and services will tip her back on the side of living. I ask about volunteers. "She knits," they say. "Do you have someone who could come knit with her and maybe also pick up the stitches she drops?" "I knit," I say. "I'll see what I can do."

At my initial, and as it turns out, only, visit with the patient, she's curled up in the middle of her bed with the covers pulled up to the top of her head. She doesn't respond to my greeting or presence. So I sit down next to the bed, pull out my knitting, and knit. Eventually she says a word or two. As I sit there, a younger woman comes in. She's the daughter of another resident, a friend of my patient, a knitting companion. The younger woman and I talk about knitting. And then a voice comes from under the covers: "I think I'm dying."

Before I can even open my mouth to respond, possibly faster than the speed of light, the other woman says, "Oh no. You're not dying. You just need to eat more." My thoughts are unprintable. Eventually the other woman leaves. I continue to knit. And knit.

Finally I say, "So you think you're dying. What makes you think that?" She says, "I just don't feel well." She's silent and I knit some more.

Finally she says, "Am I dying?" I take a deep breath. "Everyone dies sooner or later . . . I think for you it will be sooner. You're not eating and you tell me that you just don't feel well." More silence. I've answered her question. I've told her what she needs to hear. She doesn't say anything else.

And a few days later she dies.

Indulging myself

I splurged last week. A small splurge, but on what appears to be a totally unnecessary purchase. I think of it, however, as an important indulgence. What kind of splurge inspired this posting? I bought a skinit for my work phone.

I could argue that I needed it to distinguish my phone from all the other phones on those rare occasions when we're all in the office, but that isn't the reason I bought it. (Although I think that was part of the reason I gave myself.) I could say it was because there was a special deal with free shipping, but if I hadn't bought one I would have not only not paid for shipping, but I would have also not paid to buy it. My real reason for buying it was that I could choose and upload my own picture.


In the past four months, we've had a number of family simchas. We've also had one very difficult, untimely loss. The picture on my skinit is a joyful, smiling photo from one of the simchas. I can't look at it without smiling. I look at it and remember how happy we all were. I look at it and I remember that the pain of our loss was also a part of the day. The photo reminds me that a month after one of the worst days in our lives, we celebrated one of the happiest.

When I see this photo as I'm working, I'm reminded that all of us have mixtures of love and loss, celebration and loneliness in our lives. It reminds me not to take my blessings for granted. It reminds me that joy may be followed by sorrow and then again, God willing, by joy. The photo helps me remember that I want to work to live, not live to work. It reminds me to turn off the phone when the day or the week is over.


The photograph is not a talisman. It won't protect me from the pain that comes with my work or the pain that comes with life. But I hope it will protect me from becoming callous or indifferent. I hope it will always make me smile. When I think about the joy the photo gives me, it is clear that this splurge was not an extravagance and not really an indulgence, but another important weapon in my battle against burnout.

Elul

One of my favorite things to do at this time of year is take my shofar with me to work. From the beginning of Elul until Yom Kippur, I have it with me. I sound it for my Jewish patients. I let the nursing homes where I work know what it is, why I have it, and that I will visit any Jewish resident so that they can hear the sounds of the shofar. In a nursing home with a younger, more alert, special needs population, the activity department and I schedule a program so that the Jewish residents can prepare for the New Year.

In a job where almost everyday provides the unexpected, I never know what to expect once I take out the shofar. I do a lot of education with staff and residents at this time of year. I never sound the shofar without making sure that everyone around me knows what I'm doing -- especially when I'm on a dementia unit.

Sometimes there are moments of serendipity, of grace. I'm in a nursing home doing a spiritual assessment on a new patient. We're meeting in a corner of the activity / dining room. The activity director, spotting my kipah, comes over to tell me that they are making "cards for the Jewish New Year." I am able to respond not only by coming over to meet the residents and talk about the meaning of the New Year, but by saying, "I have a ram's horn in the trunk of my car. May I go get it so that your residents can hear the sound of the New Year?" And while I have it, a nurse mentions a bed-bound Jewish resident down the hall and I am welcomed into her room so that she can hear the sound of the shofar. "Her family will be so happy when we let them know that you were here."

I'm visiting one of my Jewish patients. We sit in her room and I talk to her about the season. There's no response today, no eye contact, no acknowledgment that I'm present. I take out the shofar and blow it. Her head jerks up, her eyes open, and, for a moment, she's there.

Another patient, another home - my patient is a 100 + year old Holocaust survivor. We visit in front of her room, by the nurses' station where she sits each day. I take out the shofar -- Tekiah -- and the woman sitting next to her in the hallway glares at me and loudly asks, "What are you trying to do - wake the dead?"

Another survivor. Not yet my patient, but when I talk on the phone about hospice with her out-of-state son, he asks that I take in the shofar so that she can hear it. It turns out she's in a different place in her dementia. The shofar scares her. When I greet her in Hebrew or Yiddish she gets agitated and motions me to be silent. She responds to me and converses only when I greet her in Polish. Unfortunately my Polish extends only to "good morning," "how are you," and "thank you," but that doesn't stop her from taking my hand and talking to me - as long as the shofar is not in sight.

Once again it's Elul. This morning I opened my living room cabinet and took out my shofar. I don't know what the next month will bring, but I do know that for my Jewish patients it will include the sounds of the shofar as, together, we prepare to either close the Book of Life or to greet the New Year.

Again with the yarmulke . . .

This was my weekend to be on-call. There are a couple of differences in my on-call "look." Weekends on-call are the only time I wear jeans to work, although in the summer my weekend clothes are closer to my weekday work clothes. The big difference is that on Saturday on-call I don't wear a kipah. It's funny - as easy as it is to forget my kipah when it's on, I'm hyper-aware of its absence when I'm not wearing it. I almost feel as though I'm going to work naked; missing a vital part of my "uniform."

I walked into a facility yesterday to do some on-call visits. I said "hello" to a resident I often talk with on my way in and out. She looked at me and said, "You're not wearing your little . . ." and pointed to my head. "Right," I said, "my yarmulke. Well, I don't wear it when I'm working on the Sabbath." I didn't go into a lot of detail, simply explaining that Jews generally don't work on the Jewish Sabbath, so when I'm making on-call visits on the Sabbath I don't wear it.

I didn't want to get into an entire discussion on marat ayin (how things appear; not wanting to mislead a fellow Jew) and why I leave the kipah off. Although I consider myself an observant Jew, I am not a halachically observant Jew. In addition to working on some Shabbatot, there's the car I drive to the nursing home, the pen and paper I'm using to write up my visit notes, the BlackBerry that I use to check patient details, and the myriad of other non-Shabbasdik things involved in patient visits.

I leave the kipah off on Shabbat because I don't want to be a public Jew on that day. I don't want to advertise my religion. On a Shabbat on-call visit I just want to advertise the hospice presence. Of course, it's on my on-call days with no kipah, working in buildings where we have other chaplains during the week, and with staff who aren't familiar with me that I am most often mistaken for the hospice nurse. This weekend was no exception. "Yes, I think it's alright to skip a PPD on a hospice patient," I say, "but I'm not the nurse, I'm the chaplain. Let me call my nurse and get an answer to your question."

After a day on-call, disguised as "just another chaplain," it's a pleasure to put my kipah back on and enter the new work week as the Jewish chaplain.