Go Gentle

"Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light."

Thus says the poet about facing death.

It was about four o'clock in the morning when the telephone rang, and a nurse from the emergency room asked if I could come down to the cubicle where a woman was going to pass away very soon. 

She was 89 years old and was lying on her back, her face turned toward the right where the young male nurse who had phoned was standing with his hand on her shoulder. On her left, another nurse was softly stroking her hair. At the foot of the gurney were two or three others, one of whom had grown up in my church and had become a nurse as a second career (but not before getting what appeared to be a bazillion tattoos). The cubicle was quiet; the beeping function of the cardiac monitor had been silenced.

She had been a hospice patient for two years and was reaching the end of her journey. Her nearby family was away at the seashore, and another daughter, the one most concerned about her, lives three or four states away; there was no way any of them could get to the hospital in time. "Don't worry," the young male nurse had told them. "We'll take very good care of her. We'll treat her like family."

"This is my first patient death," the young man told me. "It's a good first death to have," responded a colleague. There were perhaps a half a dozen of us, standing quietly around the patient, listening to her gentle, slowing breathing. 

We joined hands -- with the one nurse still stroking her hair and the other with his hand on her shoulder -- and I offered a prayer. I thanked God for her life and for all that she had meant to her family. I thanked God for the care she had received this night and for the adoptive family surrounding her. I spoke of our assurance that God had created her and would receive her into his arms at the end. I prayed for comfort and for mercy.

When I finished, the patient was still and the tattooed nurse from my church listened for a heartbeat; there was none.The "first death" nurse said, "You know, I haven't sorted out what I believe about life and death and an afterlife. But she took her last breath in the middle of your prayer. That has to mean something." 

They thanked me for coming down; I thanked them for calling me. It had been a privilege to be among them, this adoptive family. The patient went gentle into that good night; there was no need to rage against the dying of the light.

Changed. Forever.

Most of us have those moments, the one where our lives are forever changed. If we don't have them ourselves, we know someone who has.

When it is us, we cope, we slowly adjust, we reimagine and reinvent our lives. When it is our friend, we support, we bring food, we futilely try to "make it better."

One of the dimensions of my job as a hospital chaplain is being exposed to these moments for others, people I never knew before. And with this exposure comes absorption of some of their pain.

My most recent shift was fraught with such experiences.

Early in the evening I was with six men who had gathered to remove life support from their brother/uncle. Four of them had flown to my city from Texas, and all of them bore a strong resemblance to Javier Bardem's character in "No Country For Old Men." All of our mothers told us that "appearances can be deceiving" and "don't judge a book by its cover," but I was unprepared for the incongruity of how gentle, loving, and tender these brothers/nephews were, eagerly holding hands all around while we prayed for God's mercy.

A lovely, too-old-to-still-be-driving octogenarian mistook the accelerator for the brake pedal, causing a five-vehicle accident and most likely her husband's death.

A pedestrian hit by a car as he crossed the street to the train station on his way home suffered a massive skull fracture and intracranial hemorrhage; his wife and son live so far away that he had already been taken to surgery by the time they arrived. "But I had just spoken to him!" she said over and over, trying to take back time. It will be days before the heavily-sedated patient will be allowed to attempt to wake up; and only then will he will be able to be assessed for brain function, for mental capacity. And during that time the family will spend hours driving to spend hours at the bedside, waiting without any idea of the outcome. "This will be a long process," the resident said and I noticed she didn't use the word "recovery."

All of these lives changed in a moment.

And perhaps the saddest story is the one about the man of -- oh, how do we phrase this? -- limited intellect who called 911 for his bedridden mom who had stopped breathing. The two of them lived alone together in an unhealthy environment. What will become of poor "Ben," now that she is gone?

Changed in a moment.

Forever.

How Can I Let Her Go?

I was awakened by the beeper at about four o'clock in the morning. It was a Code.

When I got to the patient's room, there were family members huddled outside the door, clasping their hands and sobbing. The Code was going on, and before very long, a pulse returned.

The patient had only been admitted to the hospital twelve hours earlier. She had end stage renal disease and several other problems. She needed dialysis. Complications had ensued in the dialysis unit and she was sent to a critical care floor. The need for dialysis was complicating her other problems.

The family members were the patient's daughter, the patient's aunt, and the patient's niece. The daughter is an only child and there was no mention of a husband.

The resident spoke kindly but frankly to the daughter. The patient was very, very sick. She needed dialysis, but her blood pressure was probably too low and heart rate too slow for her to sustain the procedure. In all likelihood, the resident said, once dialysis was started, it would just be a matter of time until the patient Coded again.

The daughter's wedding day is November 1.

A terribly sad situation.

The patient was only in her mid-fifties, but she had been abusing her body with alcohol for a long time,

It was agreed that a slower form of dialysis would be attempted. Pressors were given, and the patient was prepared. I prayed with the family and left.

Oddly, I was able to fall back to sleep, but not for long. At 6:15 the beeper announced another Code and I grimaced when I saw the room number.

The fiancé has joined the family by now and was holding the patient's daughter as she sobbed, "She's my mom. How can I let her go?"

The nurse and the resident spoke at length with the daughter. In time she came to a place where she understood that her mother's body was simply giving out. Her lungs were filling with fluid, her need for dialysis was overwhelming, and the pressors would only help for so long. Her liver was cirrhotic as well; the patient was shutting down.

At the mention of the liver, the daughter became more focused. "What will you write is the cause of death?" she asked. "Will it be cirrhosis?" The resident said that it would be end stage renal disease, and the daughter was relieved. It was important that liver cirrhosis not be the cause of her mother's death.

Born Too Soon

While each hospital encounter is unique, there are situations that are similar.

But I've never experienced anything remotely like this one.

A nurse from Labor and Delivery phoned. She sounded upset. Her patient, we'll call her Ruthie, had delivered a 22-3/7-week baby boy about two hours earlier. The baby was alive, but would not be for long. And Ruthie would have nothing to do with him. She didn't want to see, much less hold him. She would not talk about burial or cremation arrangements. She would  not talk about her baby. She just wanted to go home. The man with her was of the same mind. The couple were in their thirties, and "weren't from around here." Neither, in fact, is a citizen of this country.

The nurse couldn't stand the thought of the baby's being all alone, dying, and going to the morgue. She was staying with the baby and loving him. She wanted to know what would happen to the baby and whether there was anything I could do.

Mindful of my boss's instructions not to hesitate to contact the nursing supervisor if I found myself in an untenable situation, I went to find her. The sadness of the situation was shocking to her, as well. She spoke with the sweet nurse and made began the process of contacting social work to assist with making the infant a ward of the county. As we talked, my role became clear to me.

I went up to the delivery floor and sought out the nurse. She told me that the doctor was with the baby, and together we went in. He was very, very tiny, and his breaths were not close together. He was under a warming lamp and wearing a little green knitted hat. The doctor had her hand on him. I asked them to join me in prayer and thanked God for creating this beautiful child, and asked God to receive him back into his loving arms. I made the sign of the cross on his forehead and blessed him. He would not live much longer.

The parents would have nothing to do with me. They did not want to be consoled and they did not want to plan and they did not want to talk. They wanted to be left alone.

Born too soon to a mom who wanted him so much that she got all mixed up when nature failed her, this baby will be with me for a long time.

It was a terribly sad situation. This brief little life was supported by a loving and gentle doctor, a caring nurse, and a chaplain called in desperation.

His parents didn't even give him a name. But as I stood there with my finger on his tiny forehead, I thought about my own firstborn and knew that he wouldn't mind sharing his name. I will think of him as Thomas.

"Not Very Smart"

It turns out that her daughter is a nurse on another floor, and that daughter is the one who requested that I visit the patient.

She was 80 years old, but I would have guessed her to be 75. She was sitting in the chair, supported by pillows, with an oxygen cannula helping her to breathe. I pulled over another chair and settled in for a chat.

I have to say that I straightaway I liked her. A lot.

I began, as often I do, by asking what had brought her to the hospital. She replied that it was her breathing.

And then she got to the point. "I'm a twin, you know." I hadn't known. Her fraternal twin sister had been "the smart one." "I'm not very smart," she told me. "But my sister was smart." The sister had died at 39. My patient had now lived twice as long. We talked about the special bond of twins (my own mother was a twin); my patient will always miss her sister. She thinks of her every day.

She rambled on. She'd been in the hospital for pretty many days, not exactly certain. And she didn't know when she'd be going home. The diabetes was the problem, she said. She had it and didn't know anything about it. "I don't WANT to know about it. I'm not smart enough to understand it." I was taken aback. This was the second reference to not being smart. She lives alone, and people were worried about that in connection with the inadequately managed diabetes. I inquired about perhaps attending a patient information class on the subject, but, no, she didn't want to do that. Her daughter, the nurse, understood the diabetes and would take care of it. Her daughter was very smart, she said, "not like me."

Our conversation wandered around and soon the beeper shrieked and I needed to leave. We said a prayer together, and I said I would ask Sister to stop and see her on Monday, and off I went.

All the way down the hall(s) she stayed in my mind. I conjectured that her parents had been the ones who had given her this terrible message, the self image of stupidity. We tend to believe what our parents tell us about ourselves. I wondered what they would think, how they would feel, if they knew that 75 years or so after receiving that message, after marrying, keeping a household running, raising a family, helping at least one child through college, after all of that, she still believed what they had said.

Six Years

I spent a lot of last night in the Emergency Room.

As a hospital chaplain.

There were many Level II traumas, sometimes two at a time, and the staff was hopping.

Around 3:45 as I was dragging myself towards the elevator, hoping to get a few hours of sleep, it dawned on me: It was the Friday of Memorial Day Weekend. And I was in the Emergency Room. Again.

Six years ago, on the Friday of Memorial Day Weekend, I was in the Emergency Room, too. This time as a worried wife of a man experiencing a heart attack.

So I turned away from the elevator and went back to the triage area. I told them of my realization. And I thanked them for saving my husband's life.

A blog friend is celebrating her wedding anniversary today. That made me think that Joe and I are also celebrating an anniversary. We've had a wonderful married life of 47 years. But these last six have been something special. We had a reminder that nothing lasts for ever, not even us. And we spend more time together, go out separately less, and thoroughly enjoy the quiet times with each other.

I know that this weekend we are remembering those we lost, and that is as it should be. But it's also okay to remember one we didn't lose. And be thankful to those who made that true.

A Quiet Shift

In my role as a "casual" employee, I work as a chaplain in the local hospital only two or three times each month. But each shift is twenty-four hours long. I usually get a few hours of sleep during the night.

No two shifts are alike. Sometimes I can hardly catch my breath between answering the telephone, responding to the beeper, attending the Codes. Sometimes there is a more even pace, and I have time to do purposeful rounding, visiting the nursing stations in search of referrals.

While I relish the busy times, the dramatic times, I also like the opposite. It is something about the difference between hopping from a major trauma to attend a death and then respond to a Code vs. having the time to sit for an extended time with a patient, not having to think about what other work needs to be done.

A recent shift was one of the quieter ones. I picked up the referrals from the chaplain I was relieving and noted with interest that there were two requests for Advance Directives. As I was walking to the on-call room to deposit my tote bag, I was stopped by a member of the Palliative Care Team -- she was glad she had seen me because she had a patient who wanted an Advance Directive. And no sooner had I reached the on-call room than the phone rang -- yet another request! It seemed odd that all at once so many people would be wanting to put their ducks in a row.

I printed out four copies and headed to the patient nearest the office. There was a large family gathered and the nurse had indicated to me that they were most impatient and that they were difficult and demanding. The patient himself was very, very sick, barely responsive. I felt a fleeting concern that there might be some railroading going on, and decided to spend some time getting to know the family a little bit. Before long, my little twinge was gone away. Because the patient was so very sick, I asked one of the men in the room to give me the information that I would need for the Durable Power of Attorney. I filled out the form and then went to find a second witness; then we roused the patient and I asked him to confirm the wishes that were expressed on the form. It was clear that he understood and that the information was correct. He made a mark on the page, it was witnessed, and I had the document put in his chart. I told the family I thought the patient was fortunate to have such a large family who loved him.

I had a call to visit another patient and when I got to the room for another of the Advance Directive patients, I learned that he had been discharged. The third patient was sleeping, so I handed that request off to my replacement. The fourth was a young woman with a trach who was also very, very sick. She could barely respond to my questions, but she was determined to arrange for her daughter to be "the decider" in the event she got sicker and could no longer make her own decisions.

I had a call from a nurse whose patient unexpectedly had to go have a cardiac catheterization and was upset and crying. I was glad that I had no other pressing demands because I was able to sit with her until Transportation came to move her to the cath lab. She was unclear about exactly what the procedure involved -- it had all come about so suddenly. Knowing it wasn't my place to attempt to explain a medical procedure, I spoke briefly from my own experience, telling her that my husband had undergone a STAT catheterization six years ago and that he had reported it was not uncomfortable and, in fact, had been interesting. The patient just needed someone to be with her, someone to let her talk. She had been packing her suitcase to take to a southern state to attend her granddaughter's college graduation -- the first one in the family -- when the chest pain began and radiated down her left arm. She was smart enough to know she needed to come to the hospital rather than to North Carolina. We talked about disappointments, and about taking good care of ourselves. Because my shift was so long, I was able to catch up with her post procedure and I was glad of that.

A nurse from the ER phoned for me to come down and gave me a room number. The lady in the bed was an Alzheimer's patient, and her husband was in the room with her. He was crying. He had just received a call on his cell phone that their grandson, a man in his late twenties, had hung himself. This was the second grandchild they had lost. The man -- who became my patient -- was overwhelmed with sadness. The care of his wife was his responsibility, mainly, and as I well knew, was demanding. They had been in the ER for six hours at this point and she was scheduled to be admitted to the Observation Unit; he said he would have to stay there with her. Otherwise, she would become too agitated. He was overwhelmed. I spent a good half-hour with him, just listening, and supporting him. I was worried about how he was going to get any rest (he told me he was diabetic and had to be careful about eating right). Then came word that the wife did not need to go for observation; she was stable enough to be cared for at home, and with great relief, they left.

I spent some time with a family who had decided to remove life support from their father; they were just waiting for their brother to arrive before this would be activated. Their very elderly and frail mother was at home, unable to endure the being present. They talked about their dad, what a vibrant man he had been, how he would detest being kept alive in his present condition but they had permitted it when they still had some reasonable hope that he would get better. We prayed together and I went on my way after telling them that if they wanted me to return after brother's arrival, to just call.

It was a quiet shift. No really major traumas. No Codes. No drama. Just simple pastoral care, listening, supporting, validating, praying. It was good.