what happenth nextht?

a day in the life of a hospital chaplain

0604: Wake up to a stirring dog, Oakley, who wakes with the light of my 6:15 alarm, which precedes the sound. By the time the gentle melody plays, we’ve usually been awake together for a few minutes, sharing a little cuddle. He licks my face and I still detect the slightest hint of puppy breath. These are the most peaceful moments of my day.

0807: Arrive at work and settle in (put my lunch in the fridge, turn on the pager, log into email…). I check on patients from the day before; two are of particular interest to me. One is a woman my mom’s age who is intubated and failing. I talked with her kids at length the day before, both of whom were struggling with her impending death.

“A week ago, she was fine.”

The second patient I look for is a very young man who was seeking medical aid in dying because he felt hopeless about his neurologic condition. He was threatening to leave against medical advice if no one would help him, and told me he would “do it himself.” This didn’t meet the threshold for SI (suidical ideation), which meant we couldn’t hold him against his will.

I’m relieved he is still hospitalized, but sorry to see that the older woman hasn’t passed yet. Her kids have no doubt been up all night, waiting for her to die. It must feel interminable.

On the other hand, these are their last moments with their mom’s earthly body...maybe they didn’t mind the sleepless night.

As I look over the palliative care dashboard, I note a name that’s familiar. I’m pretty sure I met her during my residency at a different hospital, about a year ago, when she was admitted for symptoms that turned out to be stage four breast cancer. I was alarmed at the time by her symptoms, realizing she must have known she was sick, yet had not sought medical attention despite her declining condition. Why not?

Further, given her symptoms, it was hard to imagine that her husband didn’t realize something was the matter. Why hadn’t he insisted she seek care?

Image by Sean Dimond.

I try not to ask questions like this. Questions of this nature are unproductive, rooted in blame and judgment, and imply I know what’s best. So I try hard not to go there, to allow the people I care for the dignity of their choices.

As I sit wondering if it’s the same patient, I remember back to the day I met her. Our visit was very brief. I greeted her in her hospital bed. Her wide, blank eyes took me in. Then she dismissed me. She wasn’t going to talk.

I remember the feeling of resistance in my body as I turned to leave. It’s hard, when you feel you have something to offer, not to be able to give it, or even explain how you might help. I also remember the cloud of heaviness in the room and my feeling of disappointment at seeing how closed off she was. But to try and override her “no” would be wildly disrespectful and paternalistic. So I left.

I review her chart and confirm it’s the same person: 40-year-old woman with three kids, ages 9, 12, and 16. I see she’s been admitted to the ICU and figure I’ll peek in when I get to the unit to see how she’s doing, and if she or her family might be more receptive to care.

0825: A rapid response is paged overhead and via the device clipped to my right shoulder. There is a chime, followed by the operator repeating “rapid response” and the room number, three times. A rapid response could mean the patient is showing signs of a stroke, or has fainted, or their blood pressure may have dropped, or spiked.

I don’t rush, but I make my way to the rapid, where the patient is sitting on the edge of his bed using a nebulizer, which delivers medicine to help him breathe. Several staff members are beginning to clear out of the room, so I go in and introduce myself. He tells me he’s glad I came, and asks me to pray for him as he offers me his hand. I take his hand and set my other hand on his shoulder. I pray for his healing and comfort and for his providers. I pause for a moment and he speaks his prayers—for himself, for his family, and that God will bless me. After “amen,” I open my eyes and notice his doctor has crouched down. She mouths “thank you” to me. I nod, smile, and excuse myself.

On my way back to my office I greet a staff member from housekeeping. He is an older man, with a dense thatch of bangs on top of his head. Apart from a few errant wisps he is otherwise bald, which I find unusual and charming. Feeling uplifted by the prayer with the last patient, I smile warmly at him and thank him for his service. He puts his arms out for a hug, so I hug him.

“I’m Minda,” I say, showing him my badge. “Renaldo,” he says, pointing to himself. English is not his first language, but it doesn’t matter. It’s a loving moment.

0858 Before returning to my office, I follow up on a patient I tried to see the day before but couldn’t because she was receiving care. I introduce myself and tell her I’m from Spiritual Care. This confuses her. I say instead, “I’m a chaplain.”

“Oh, a chaplain!” she says brightly. “Well, I want to know how I got here and what happens next.”

She has a daffy sort of lisp, so “what happens next” comes out as “what happenth nextht.” She is a tiny old woman and very endearing, which is useful because she has been difficult to care for. She has dementia, which makes her easily agitated and sometimes aggressive. She’s had to be restrained at times because of her behavior so she doesn’t hurt herself or a staff member. The restraints made her angrier. The care team reached a compromise: provide her with a companion who can make sure she’s safe. His company seems to help her stay calm. (Is it any wonder that a person would be more content with companionship versus left alone strapped to a bed?)

I tell the patient I don’t know how she got there or what happens next, and that I am there to offer companionship and listening. She asks me again, “What happenth nextht?”

“Well, I don’t know…it looks like you still have some breakfast you can eat.”

“What happenth nextht?”

We don’t get anywhere conversationally, but her companion and I smile at one another and continue to try and redirect or engage her. Every minute or so she repeats herself. “What happenth nextht?”

Eventually I see the word NEXT on her communication board; someone had written it for her in dry erase marker. Next to that it says CHILL, which is circled, then WATCH TV, and NAP. I point this out to her, explaining it is her plan for the day. She says, “I don’t want to nap.”

I say, “OK, maybe we can think of something else. Do you like to color? I can get you some crayons and pictures to color.”

She says no, she can’t color because her hands are numb. Her companion tells her he will help her and nods at me. I tell them I’ll go get the crayons and be back in a bit.

0929 Back in my office, I look over the palliative care list and note a few patients I want to see. I look up their charts one by one, noting demographic info, why they were admitted, whether they have family, their expected discharge date.

It’s easy to get lost in charts, though they are only nominally helpful in most cases. I can ascertain 90% of what I would read in the chart in the first few minutes of a visit, which is also an opportunity for rapport building. But my Western mind is conditioned to believe there is power in information.

There is a deeper truth. That is, chart review takes up time that I could be seeing patients. Sometimes, this is a relief. It is hard to be immersed in the hardships of strangers day in and day out. There are times I’d rather zone out on the computer, or chit chat with staff, or, frankly, clean the kitchen sink in the break room. Pretty much anything besides initiating another visit.

1013 Pry myself from my desk chair and take the crayons and coloring sheets up to the patient on 18. Her nurse is standing with two doctors outside her room, talking about her medications. I hear the word chaplain and then, “There she is…”

The group turns toward me. I hold up the coloring sheets and say, “These are for her. Not sure it will help, but it’s something.” The nurse sounds genuinely relieved when she accepts them. I convey my gratitude for her care and tell her I’m happy to come back if it would be helpful. She thanks me and suggests another patient who would appreciate a visit, in 1806.

He is a long term patient receiving treatment for metastatic prostate cancer. In the course of his care, he had a stroke. He doesn’t remember that we have met before. He accepts my offer of care but seems distant, offering little about his experience or feelings. He tells me he’s Methodist. I ask if a prayer would feel supportive, and he says yes, but he’d like to rest. I tell him I can say the prayer and then leave him to nap. He accepts this.

The exchange—my presence, our conversation, the spoken prayer—doesn’t seem to change anything. He is still not making eye contact when I say goodbye; he’s as distant as he was when I walked in.

Visits like this are fairly common. I will never know what difference they make, if any.

1015 I arrive in the CCU. A nurse sees me and says, “Are you here for 920?”

“I am,” I say, taking the cue.

The nurse who greeted me is not the nurse for the patient in 920. I have learned it’s a bad sign when the nurses on the unit are aware of a patient they aren’t assigned to. Usually, it means the circumstances are particularly difficult, and this one is no exception.

The patient is the woman I met the year before. She had been gearing up for another round of chemo and went into cardiac arrest very early that morning. From the hallway, I can see her husband sitting on the bench seat by the window. Her nurse is at her bedside and there are bags and bags of medications hangin from the IV pole, running through tubes that lead to her arms, neck, and a central line in her heart. Her hand is peeking out from the warmer that covers her, and it is blue. This is a very bad sign that indicates her heart isn’t beating sufficiently.

I sanitize my hands and knock on the doorframe. The nurse nods to me as I make my way toward the husband and introduce myself. His expression is locked and his mouth barely moves as he says hello.

Over the next fifteen minutes of conversation, I learn—among other things—that they haven’t told anyone but her parents and his sister about her cancer. I glean that his hope is for her to recover and resume treatment. I more or less conclude this man is beyond his capacity to meet the reality of the moment.

A medical resident comes in and stands at the bedside, staring at the monitor. The husband walks over, waiting for a report. I stand at the foot of the bed, a few steps back from their space. The resident says some things about pressors (used to maintain or raise blood pressure) and the neurologic exam (“her neuro exam is not encouraging”).

It’s a lot of doctor-speak, and I can see he is not processing her meaning. This young doctor may have no personal experience of significant grief, thus she does not realize that a grief-addled brain cannot track facts and figures. It cannot derive its own meanings. The husband needs her to translate, but that would mean the resident has to tell him that his wife is dying. She clearly doesn’t want to do that.

I pipe up. “Would you be surprised if she woke up and could talk with us again?”

I’m out of my lane, but the husband had been wondering aloud to me whether it’s time to bring his kids to say goodbye. I’m afraid if the doctor doesn’t tell him the truth, he will not realize the severity of her condition, and will wait too long. Based on what the doctor said and the amount of artificial life support she is receiving, I know the patient is functionally dead already.

“I would be very surprised,” the resident says.

The husband says, “I gotta get my kids here,” and starts dialing.

I step back further, observing and wondering what would be most supportive in the moment. When the husband gets a friend from work on the phone he says, “Hey man, I need your help,” and starts to cry so hard he can’t talk.

I realize the man on the other end of the call is hearing for the first time that his work buddy’s wife is sick. Not only that she is sick, but that she is dying. This thought distracts me from the immediate environment. (Can you imagine receiving that phone call?) The husband asks his friend to help get the kids from their schools and bring them to the hospital. When they hang up, I say I’m going to give him space to make the calls he needs to and that I will check in again later. I am nearly certain, based on his body language and limited engagement, that he’d prefer to do this on his own.

I walk to a computer on the critical care unit and begin charting my visits from the morning. It is best practice to chart after every visit, but that interrupts my workflow. Visiting a patient and charting the visit use different parts of my brain. I find toggling mentally between these functions as exhausting as enduring ten minutes of doctor-speak.

When I finish charting the four visits, I swing by the room of a patient who is intubated. Her husband visits virtually all day, every day, occupying the bench seat with his phone or a book or doing nothing at all. I contemplate devotion.

This husband smiles when I greet him, and I think he seems young to have dentures. He’s more chipper than one would expect for a man whose wife is in the CCU. I wonder if he’s in denial, or if glossing over his true feelings is a way of keeping them at bay. I join him in his pretense and we have a basic conversation about the good weather and preparing their garden for spring flowers. I talk to his wife, too, and tell her I look forward to visiting when she wakes up. I don’t know how he receives this, but figure he might appreciate my recognition of her personhood. It’s a kiddy pool kind of visit…warm and shallow. I need it as much as he does.

1142 I walk past the doorway of 920. The husband is on the phone. The nurse and resident are in her room talking to each other. I keep walking, right to my office. I check email and record the morning’s visits in SurveyMonkey, which my director uses to report out on our productivity. I warm my lunch and talk to the ladies in Admitting who sit just outside of my office door. One of them is 27 and wants to go into Ethics. She loves true crime and is scared of butterflies. She is exceedingly kind to the people she checks in; I am often comforted by her warmth. I doubt she has any idea what a blessing her presence is to the people she meets.

1314 I’m texting a girlfriend about a concert we’re planning to go to when my office line rings. It’s the CCU asking if I can come back. At the same time, I get a message on our paging system from the resident who is caring for the patient in 920. She, too, is asking if I can come back. “Kids are here.”

I trudge up the stairs reminding myself that the chaplain should always be the calmest person in the room. When I arrive on the unit, I can hear sobbing in the family waiting room. A moment later I see the door to 920 is closed, as is the privacy curtain. I don’t know until I enter what a different scene it is now.

The husband is joined by a man who looks older than him as well as a young boy and adolescent girl—obviously his kids. The attending physician is standing back and the resident looks frozen near the doorway. There is a respiratory therapist near the bed. The patient’s nurse is standing with her hands folded. The room is still except for the young people, who are silently crying. The air feels leaden.

There is a third doctor who shakes her head when we make eye contact. I imagine this means don’t come in here or now is not the time or something of that nature, but it’s too late. I have already interrupted the stillness. Anyway, I figure the resident who asked me to come is closer to the case than this third doctor. Her head shaking is confusing and unhelpful.

I take a spot next to the attending, who whispers to me that the patient is actively dying and asks if I want to know more. I shake my head “no” in what I hope is a subtle yet obvious gesture, not wanting to draw any more attention.

I wonder about the sobbing I heard and assume it must have been the oldest child. Moments later, he walks into the room. He goes to his sister and hugs her, and I think of my own brother. He would do something like that. The young man hugs his little brother and holds him, telling him “I’ve got you,” and, “I’ll always be here for you.” He’s crying harder than anyone and wiping his nose in the way of teenage boys. The dad puts his arm around his daughter. The older man squeezes the dad’s shoulder. The dad nods to the nurse, who begins to turn off the machines.

There is no activity when the patient dies. The difference between her life, sustained by machines, and her natural death, is imperceptible. The only change that happens is the children begin to wail. At this, the lump in my throat turns into tears I cannot hold back. Several people leave the room.

The family holds one another in a static group hug that includes the older man, who I figure must be the work friend. I think, what a bizarre day for that guy.

I can’t not think of my own son, and I feel an overwhelming need to see him. I need to look in his eyes and feel his mass and touch his little sideburns that I wish he would shave more often so he doesn’t look like such a grown up. I long to hold him and smell his breath. I need to be sure of him.

Eventually, I am the last staff member in the room, standing at the bedside of the patient, gazing upon her, tears still streaming steadily from my eyes. The patient’s family is on the other side of the bed. I tell them I don’t know what to say, but that I am very sorry for their loss.

Seeing their rapt attention (where else are they going to focus?), I try to impart something useful. I encourage them to talk to and hug her. I suggest they move slowly, draw near to one another, and to let themselves cry. I tell them that their life won’t ever be the same, but that in time, they will find their way through the grief, and they’ll find ways to remember their mom and stay connected with her.

I want to tell them, too, that life doesn’t end—only our bodies do—along with everything else I have learned about grief. But realize I have already said too much. They can’t hear me. I am a stranger, and this is not a family who is open to a stranger’s counsel. They never even told their friends that she was sick.

They will have to learn on their own. Maybe we all do.

I think to myself, I hope they don’t give up before it gets better.

1435 I’m charting the visit when there is another rapid response called on floor 15. I walk slowly, numb. When I arrive, I hear utterances of CCU, and know the patient is being transferred. Respiratory failure; they’re going to intubate.

I greet the patient’s sister as warmly as I can. When there is an opening to talk with the patient, I introduce myself to her, too. She’s on high flow oxygen and appears very anxious. She grasps for my hand, so I stay with her, holding her hand and talking with her. I tell her she’s doing a good job, which is something I have started doing lately. I figure it must really suck to be a patient, so wouldn’t it be nice to be validated in the role? You’re doing a good job. It seems to have a soothing effect, which is the point.

When the care team resumes working with the patient, I step back. The patient’s sister tells me quietly how bad she feels that her sister’s kids haven’t visited their mom. “I mean, I don’t blame them,” she says under her breath. “She can be a real bitch.”

I nod and smile faintly. “Ah, yes. Families are complicated. How kind of you to be here with her even still.”

The patient’s sister scoffs, nods, and rolls her eyes. “Well, I can’t stand for her to feel like no one loves her.”

“That’s very generous.”

I meet her eyes and she glances away, as if looking to the past and the history they share. The expression on her face suggests she remembers every offense or slight over the decades. She doesn’t look angry so much as she looks pained.

I walk slowly with the patient’s sister, back to the 9th floor where I stood moments ago with three children who just lost their mom.

When we reach the CCU, the patient asks if I’ll stay with her while she is intubated. I say yes, but turn away from the scene as soon as she is sedated. I don’t want to watch them shove a tube down her throat.

The procedure goes smoothly. I say goodbye to the patient’s sister, waiting in hallway, on my way back to my office.

1540 I grab my grapes from the fridge in the back room and wash my hands twice as long as usual. I wash my dishes from lunch and joke with the admitting ladies. Recently they’ve started coloring pictures for each other when their shifts are slow, and they’re showing off their latest works. One of them gifts me a mandala that was colored in red, green, and blue Sharpie, plus fluorescent yellow highlighter. It is, frankly, kind of ugly, but I appreciate her kindness. I tape it to the wall by my desk where she can see it through the door. I notice I have 45 minutes left in my shift, and wonder what happens next.