Emily Christensen – Verbatim #2
DEMOGRAPHICS: Female, 36 years “domestic partner” with male (common-law married)
RELIGIOUS AFFILIATION: Baptist
CLINICAL DIAGNOSIS: Cancer – currently hospitalized due to infection (I had to gown up with gown, mask, and gloves)
PRESENTING PROBLEM: I went to see this patient because I was on-call and she was on the palliative care list.
Chart – patient’s cancer has spread, could no longer move legs because on her spine
Staff – doctor told me she was just told today that she is dying, and maybe has about four
months to live, except that time could be cut even shorter due to the infection
Family – She and husband are common-law married, called each other “partner”, she was
active at church but he was not, daughter is a social worker in Kansas City and busy with foster kids so they don’t want to bother her, friends have come to visit but only were told bladder infection and don’t know she can’t move her leg, she hasn’t told her husband she is dying
1. PASTORAL PLANS: I only had information that she was dying, because she was on the palliative care list, but not how long she had or how she felt about it. I did not know what her religious affiliation was, or if she wanted chaplaincy as part of her team, or if she wanted prayer or anything like that.
2. SITUATION FIRST IMPRESSIONS: On my way, I was thinking about this dying patient and saying a prayer in my heart for help to discern how best I could help her. I got the impression to be cautious, but I wasn’t sure why. Before I could ponder the context further, I was actually paged to another patient who was actively dying. I was with that patient and the family while the patient died, up through making arrangements, before I was able to slip away and head back to the dying patient I had planned on visiting. This provided a more somber context for approaching the patient, and quietened me in a way I needed as I transitioned from work to visiting patients for rounds. When I got to the room, there was a cart outside the door. I checked the sign to see what I needed, and it said gown and gloves, so I suited up. I knocked on the door and peeked in, and the doctor was with the patient with a very serious face, and the patient was crying and a man standing away from her looking out the window. The doctor raised a finger to me and gently said she would just be a few minutes, so I backed out again and waited in the hall. When the doctor came out, she told me the family has lots of questions, and that she was glad I was here, but to be careful because the patient only found out today that she has dying and that she had not let anyone tell her husband yet and so he does not know. I thanked her, and entered the patient’s room. She was half-sitting in bed, with a chemo cap on her head, and huge brown circles all around her eyes and into her sunken cheeks. Right as I began to introduce myself, she threw up on her blanket. Her husband bounced over and pulled the blanket off, and I grabbed a new blanket from a stack by the sink. He and I helped cover her up, and the patient and her husband started making jokes about vomit. He was very gregarious, and she was humoring him, but there was a tangible tension in the air. I don’t think it was between them, so much as something they both were carrying.
C = Chaplain, P = Patient, H = Husband
C1: Well, that was exciting! My name is Emily, and I am a chaplain. I came by to see if you needed anything this evening. How about some of these lovely blue sacks? (I handed her some blue sacks from by the sink in case she needed to be sick again.)
P1: Thank you so much, chaplain. I can’t hold anything down, not even Sprite.
C2: That’s rough.
P2: It is terrible, chaplain, for sure! I am so sick of being sick! This infection has got me stuck here, and I am pretty miserable.
H2: Nah, honey, you’re just pretty, with those big brown eyes!
P3: He’s not talking about the color of my eyes, chaplain. He’s making jokes about the circles under my eyes. I’m a mess.
H3: You’re not a mess. We just got you new blankets. You’re just fine.
P4: That’s right. I’m just fine, and don’t you forget it.
C4: Well, since you are just fine, I guess that means the staff here is taking care of you okay, and answering all your questions?
P5: Everybody except that short girl that was just in here, chaplain! She just sprayed me with some kind of body scent. It’s not like I am decaying in here! She keeps giving me sponge baths, and I keep telling her not to spray me, and then she sprays me with this stinky stuff that makes me throw up because I am so nauseous! It’s terrible, chaplain! I hate to be a tattle-tale, but someone has to tell her stop spraying me. If she is offended by my smell, then she can go work somewhere else.
H5: You don’t stink, I promise.
C5: I can’t smell you over here. (I took off my mask, since it was not required, and grinned at her. They both laughed.)
P6: Well, chaplain, I am glad to hear you say it, because this whole thing is just embarrassing. I would rather be home than be here. I was here a few months ago, when they found out I had just a touch of cancer. Last week I had to call 911 myself because my legs stopped working. I’m getting old, chaplain, but I am alive so I don’t mind being old.
H6: (At this, her husband quickly gathered up his things, making several lame jokes, and excusing himself because of the cold weather coming in and offering me his seat) Stay and visit with her, chaplain. She needs somebody she will talk to.
P7: (She and her husband told each other good night, and he slipped out and she started crying.) He doesn’t know, chaplain. I haven’t told him, so he doesn’t know.
C7: He doesn’t know? (I repeated what she had said to me, carefully and quietly, looking at her directly. She had dived into our connection, but I didn’t want to push yet, so I left it as an invitation to explore it further.)
P8: Well, he knows I am sick, chaplain. He knows I have cancer. He knows my legs aren’t working right, and that it’s probably because of the cancer. He doesn’t know the cancer has spread to my spine, or that this cupcake team gave me a deadline.
C8: The cupcake team?
P9: You know, chaplain, those people that came here to tell me I am going to die.
C9: The palliative care team?
P10: Yes! That’s them! Why the hell would they bring you a cupcake when they come to tell you that you are going to die?
C10: Because cupcakes are awesome.
P11: Cupcakes are way awesome.
C11: So what did the cupcake team say?
P12: Well, chaplain, hey said my cancer has spread everywhere, and that there are not a lot of choices left for me.
C12: Oh, we always have choices. It sounds like they are the ones without many choices.
P13: That’s it exactly. They don’t have any more options for how to treatment cancer, that’s what I mean. And choice are exactly what they gave me: either stay here and die, or go to some kind of nursing facility and die, or go home and die.
C13: What do you think about those choices? What do you feel?
P14: Chaplain, to confess and be honest, I chickened out. I told them it was overwhelming, and I couldn’t answer them today.
C14: Good for you!
P15: Yeah? Well, I also told on that nurse that tried to spray me with perfume. So I guess it turns out I really am a tattle tale after all.
C15: We like to call that self-advocacy.
P16: I love it. That’s what I want to be, is a self advocator, chaplain.
C16: Oh, but you can only be that if you make hard choices about what it means take good care of yourself.
P17: Yeah, I am going to have to figure this out, chaplain.
C17: Is there anyone who can help talk it out with you?
P18: My pastor knows everything about me, even how bad the cancer is, and I told him today that I am dying, and I think maybe he would be willing to help me.
C18: When can you talk with him about it?
P19: (I noticed patient was tearful, so I waited on her instead of clarifying or changing my question. She let just a few tears begin to fall, and I handed her a tissue.) I guess I need to, chaplain, but I guess maybe it’s hard because I just don’t want to say that I’m…. (patient started to say “dying”, but didn’t say the whole word) I guess it’s just that I will have to admit that I am this sick, and it just is, and there is not much I could do about it.
C19: Sometimes our choices are more about whether to go through an experience alone, or with someone who can hold our hand through it.
P20: You mean my husband? I know you’re right, chaplain, but it’s so hard, because (the patient stopped mid-sentence, and finally started crying real tears and letting them flow)… because he always said that he never wanted to lose me because if I wasn’t here (meaning alive), then he didn’t want to be alive, either. So I just worry about him. And even while I am still here, now I will just be sick and miserable the whole time, and that’s nothing to offer a good relationship.
C20: I saw a good relationship when he was feeding you banana bread and you snagged him a newspaper from the lady with the cart out there. That’s a lot of love.
P21: It is. We have a good marriage. (patient is silent for a while, and I wait. Patient then goes back to humor again as her coping skill). Well, chaplain, I guess it’s a good marriage for not being married! Ha! (she is quiet awhile then, looking out the window like she is a million miles away. I just wait.) But I am a mess, and there is nothing to offer a future when you are dying. I’m a mess, that’s what I am.
C21: Oh! I totally said that today, and you know what one of the other chaplains said to me?
C22: There’s always soap!
P23: (Patient started laughing, and laughed for a long time, then was quiet.) I guess that’s why I like church, because it’s my soap. Maybe that’s why I am sad for him, because I wish he would not swear so much or drink so much or maybe come to church sometimes.
C23: Maybe one of the things you can offer him is knowing that God has that kind of love for us, to accept us even when we are a mess.
P24: (Patient laughs and cries at the same time.) It reminds me of that song, the song we were going to sing in choir on Sunday before I got sick and missed it.
C24: What song?
P25: “Just As I Am.” It’s my favorite song.
C25: (My skin turns fire hot, while my insides turn freezing cold, and I know what’s coming. That mean old Jacob made me hum today, and now I am going to have to sing to a patient out loud to a patient who isn’t dead yet.) I know that one. It’s a classic.
P26: Will you sing it for me?
C26: I am scared to sing, and new at it. Can I sing it with you?
P27: I would love that. We will be our own choir!
C27: (Chaplain and Patient, singing):
Just as I am, without one plea,
But that thy blood was shed for me,
And that thou bidst me come to thee,
O Lamb of God, I come, I come.
P28: (crying) Thank you, chaplain. Thank you.
C28: May I say a prayer?
P29: (She nodded her consent, giving a little whisper of ) “Please”.
C29: (I said a prayer for her and her family, that they would have peace and comfort as they need it, and that they would feel the love patient has for them and that God has for them. I prayed for her to know when it was time to talk to her husband further about her illness, and for help finding words for what to say, and that he would find the help and support he needs to cope with the news. I prayed a lot of gratitude things, thinking of things from our conversation for which we could be grateful.)
P30: (still crying.) Thank you, chaplain.
C30: I sat with her for a moment, but it felt like good closure and I prepared to leave. She did ask for a Bible, and I had a New Testament with me to give her, and was sure to reassure her it was still in the package so she could know it wouldn’t make her sick. She made a joke about how much more sick could she get, and waved me goodbye. I remember to take off my gown and gloves inside the room as I stepped out.
4. THEOLOGICAL REFLECTIONS: Some explicit issues were that she had a strong faith, but her husband did not. Less explicit issues for the patient included her concerns of how to measure her worth before her husband and God, as well as concerns for whether or husband or her children would continue trying to attend church or not after she dies. As we talked, I thought of Psalm 32:7 for her, “Thou art my hiding place” because it seemed like she needed a safe place to rest before facing this next big piece that would be the end of things, and for me I thought about the following verse, “I will instruct thee and teach thee in the way which thou shalt go” because she was very witty and lively and kept me on my toes for how to respond next, and with the end of it for both of us: “I will guide thee with mine eye” as we navigated our interaction but also the issues she was addressing. I relied on this guidance throughout, to know when to mirror her humor and when to lift her up a level through encouragement and sometimes even side-confrontation.
5. SOCIOLOGICAL REFLECTIONS: This crisis was deeply affecting her relationship with her husband, because she was secret-keeping in effort to protect him. This was backfiring, though, as I think he already understood (my interpretation of the way he left the room), and so they were isolated in shared knowledge instead of united by sharing an experience.
6. PSYCHOLOGICAL REFLECTIONS: I was scared to sing, and said so, but didn’t let it stop me from trying. It actually became a pivotal moment in our experience, as she faced her fears and I faced mine. It was very powerful, and a turning point for both of us, I think. Also, I think the patient was in some denial: I think even she knew her husband knew, but they were both pretending he didn’t, and her avoidance of talking about her own death is not going to stop it from happening.
7. INCLUSIVE REFLECTIONS: My counter-transference with this patient was definitely focused on her cancer. When I first saw her, I wondered if my eyes had ever been that dark, and I so wanted to free her from that hat which I knew was so hot and scratchy. I didn’t get stuck on these issues, but just a passing curiosity because my own illness is such a blur and I don’t know. At one point she lifted her hat to scratch her bald head, and I realized that even though I hate my shaggy hair right now and still do not feel my appearance is back to normal yet, my hair really has grown so much. I hadn’t realized that until I saw her without any. I was embarrassed that I was worried about something as superficial as hair. I also wondered after the visit, like my peers in CPE class had discussed, why some of us survive and some of us don’t, or like one asked, how do we know who has to die or not, or why some lives are cut short. Other than that, though, I did not notice any strong feelings or thoughts interfering with my interaction with the patient. I think the connection I felt with the patient impacted my visit by making it far more casual in tone than any of the other visits I have had thus far, except that it was also very fitting for her personality and the way she was interacting, as if all my other patient visits have been very slow waltzes, and then she popped in with West Coast Swing.
8. ANALYSIS OF PASTORAL CARE: This patient and her husband both really relied on humor as their coping skill and interactional style; it made for an interesting visit, but it was a lot of hard work to keep it on track. I think it went okay, but I was also very aware that it could quickly go badly if I wasn’t careful. I was concerned about that during my visit, but it ended up okay and exactly what she needed, I think. It was definitely an interesting experience following the death I had just attended, and perhaps the levity lightened both of us to face more dying. The death before this patient was the first experience I had of getting there before the death happened, sitting for some time with the patient, seeing the patient die, waiting on family, and consoling family, who then also even asked for help making funeral arrangements when the nurse started asking questions. It felt like a rite of passage somehow, in the same way my first night shift felt like one, which I found to be interesting to experience that and then walk in to this patient experience where she kept calling me “chaplain” every other sentence. It almost made me laugh sometimes, except that it was also maybe the first time I really felt like that, and could feel myself shift into my new chaplain identity and be mindful of it fitting me appropriately and well. That felt good, after being anxious and not knowing and wondering what that would be like or if I would ever get there. It was a solidifying experience for me, somehow, to hear them call me chaplain and for me to believe it.
9. PASTORAL OPPORTUNITY: The one thing I wish I could have done for this patient, and would have if it had not been so late at night, would be to contact the pastor that was visiting her frequently and tell him (with her permission) of her desire to sing with the choir once again. She was shaving so many visitors, that it would be easy, I think, to organize them to come together once to sing to her or with her.
10. SPECIFIC ASSISTANCE YOU NEED: I think I chose this experience because it really felt like I was being a chaplain: I had just dealt with one death, had to put on protective gear to visit this patient, I talked with the doctor before going in, I talked with the husband after going in, and I danced with the patient right into a small moment of worship, I think. It felt powerful, and an experience of all the different aspects of what we do. I still need guidance in forming my pastoral identity, but this was a taste of it, and I really loved it.