Saturday, December 29, 2007
Endings and Beginnings
My hospital shift this week was difficult and emotionally draining, filled with grief: a patient who lost a beloved parent a few months ago, a patient being admitted to the hospital but frantic with worry over a spouse with advanced Alzheimer's, a patient who'd lain down to take a nap and become unresponsive, and whose CT showed disastrous bleeding in the brain.
The first patient was in the ER because of ETOH issues, and was too out of it to have a coherent conversation. I pride myself on being sympathetic even to the most difficult of our alcoholic patients, but at this particular bedside, I got worn down quickly. The patient's professions of love for me alternated with keening howls over the deceased parent, and none of my calming techniques did any good. Because what the patient needed most was probably sleep, I retreated. Over the course of the shift, I watched other staff struggling to keep their tempers with this patient. The grief was real, though, and I wished I could have found some way to offer comfort.
The second patient agonized -- "Who's going to provide the care if I'm here?" -- but then read me the riot act for breaking confidentiality when I talked to our case manager about the situation. "You shouldn't have done that, hon. I don't want social services involved! I hope you'll take this as a lesson!" Flustered, I apologized and went back to the case manager, who said cheerfully, "I forget things very easily. Don't worry about it." Then I went back to the patient, who lectured me for a few more minutes -- very kindly -- but then showed me a series of dog-eared family photographs. "Here we are hiking before the Alzheimer's really set in. I love this picture. This is how I want us to be remembered."
It was a sticky ethical situation. The patient was right that I should have asked permission before talking to the caseworker, but I also suspect that this patient wound up in the hospital at least in part from the stress of caretaking, and that the entire family probably desperately needs services (respite care, if nothing else). The patient was very invested in believing that no one else could care for the spouse, and clearly felt threatened by any offers of help that might prove otherwise; and was so distressed about the hospitalization, I'm guessing, at least in part because it would prove that other people could care for the spouse. A relative in the room told me wearily, "We've been down this road a lot of times," so I have a feeling the same scenario has played out before.
I loved looking at the family photos, but left -- with a promise to come back -- when I overheard something outside about an unresponsive patient being brought in. The charge nurse told me, "They're trying to intubate. I asked the family to go outside, because that's hard to watch. They're probably in the waiting room. Will you go talk to them?"
"If you'll come with me," I said. "Under the circumstances, they're going to panic if the first person they see is a chaplain."
She came with me, and we found the family and led them to the chapel, which is quieter and more private than the waiting room. They were, understandably, very distraught. I prayed with them. Then the case manager, the charge nurse and the doctor came in, and the doctor explained the CT results. "I've never seen someone recover from something like this," he said gently, and we all watched the family dissolve into tears and disbelief.
"This can't be happening," the spouse said, over and over. "This can't be happening." The patient was intubated now, and the family had been invited back to the bedside. We made a slow, mournful procession; the spouse walked slowly, using a cane, but didn't want a wheelchair. "This can't be happening!"
At the bedside, I watched the family cry, kiss the comatose patient, say, "I love you." The spouse was on a cellphone, trying to reach other relatives, and occasionally looked at me pleadingly, struggling for words to explain the medical situation. Narration of test results alternated with self-blame. "If only I'd -- "
"No," one or another of us would say. "There's nothing you could have done. Nothing could have prevented this. It just happened."
"We were going to the doctor today. If we'd gone to the doctor -- "
"It isn't your fault," I said, and shot a help me glance at the nurse who was checking the monitor.
"It's not your fault," the nurse agreed, to my immense relief. "Nobody could have predicted this or stopped it. Not you, not your doctor, not even us if you'd gotten here sooner. It just happened. Things like this happen."
"But why?" None of us could answer. We didn't know.
In the middle of this, a Code Blue came over the intercomm. It was upstairs, in ICU. Normally, I'd have gone, but I knew there was at least one staff chaplain on duty, and I didn't feel like I could leave this family. My shift was almost over, though, and I was exhausted: I had to go home.
I excused myself to go talk to the case manager. Could we get a staff chaplain down in the ER? "I called up there," the case manager said, "but nobody answered."
"They're probably on the code," I said. "I'll go up and see what's happening, because if a staff chaplain isn't there, they may need somebody."
I excused myself, telling the spouse that I was going to look for another chaplain. On my way out of the ER, I glanced back at the room that had held the Alzheimer's spouse. The room was empty: I'd lost the chance to keep the promise I'd made to go back, unless I wanted to go see the patient upstairs. And I was exhausted, and it was almost the end of my shift, and given what had happened, I thought the patient would only feel more betrayed if I wrote a note asking another chaplain to visit.
In CCU, I found a long-faced staff chaplain -- the only one still on duty, it turned out -- standing with a cluster of other staff outside the room, where the curtain had been drawn. The doctor had just called the code. A griefstricken relative was still next to the bed, imploring the patient not to die, even though the patient already had.
The staff chaplain looked as exhausted as I felt. "I hate to dump this on you," I said, but proceeded to dump it anyway, explaining the situation with the intubated patient. "I feel like someone should be with the family, but my shift's almost over. What should I do?"
"Go home," the staff chaplain said promptly. "You've put in your shift. You've done good work." (Ha, I thought.) "Thanks for letting me know about this; tell them I'll be there when I'm done here."
I went back down to the ER and delivered the staff chaplain's message, and the spouse thanked me. And then I went home, exceedingly glad that this was the last shift of my year. Because of travel plans, I won't be there next week or the week after.
As I left the hospital, I tried to remember shifts that had left me feeling as if I'd accomplished something. This was one of the shifts that only made me think, So, like, why exactly am I doing this? Am I helping anybody here? Am I having fun yet? I felt entirely inadequate: "like butter that has been scraped over too much bread," to quote Bilbo Baggins.
But I'll go back, because after three years, I've had enough positive visits to outweigh one awful shift. I'll go back and start a new year, and this week's patients will start their new years, learning how to live in a world rendered alien by loss. It's trite to say that every ending is also a beginning, especially when that beginning is so unwanted. But my hope for all of these patients is that they'll discover good things in that world along with the terrible ones: that in all that darkness, they'll also find friendship, and hope, and love.