Bridging with the Sacred: Reflections of an MD Chaplain
2011; Elsevier BV; Volume: 42; Issue: 1 Linguagem: Inglês
10.1016/j.jpainsymman.2011.03.014
ISSN1873-6513
Autores Tópico(s)Grief, Bereavement, and Mental Health
ResumoLife has a curious way of growing us beyond what we can imagine. After 19 years as an emergency physician, I never could have guessed I would become a chaplain. In fact, there were times during those years when I was incapable of comforting a family after giving them the news that a family member had died. I would be so overcome with emotion after 30–60 seconds of the family's grief, I would say, "I'm so sorry for your loss. I'll ask the nurse to come in and be with you." Then, I would get out of the room as quickly as possible. It is ironic. In my new career as a chaplain, for the past dozen years, I am the one called to bring comfort. I am the one to provide solace when a baby is stillborn, guidance to a husband struggling with whether to continue respiratory support for his beloved wife, or prayer for the young woman desperately awaiting a lung transplant. I also teach a required class, "Spirituality and Meaning in Medicine,"1Feldstein B. Grudzen M. Johnson A. LeBaron S. Integrating spirituality and culture with end-of-life care in medical education.Clin Gerontol. 2008; 31: 71-82Crossref Scopus (12) Google Scholar, 2Puchalski C. Larson D. Developing curricula in spirituality and medicine.Acad Med. 1998; 73: 970-974Crossref PubMed Scopus (187) Google Scholar, 3Puchalski C. Spirituality and medicine: curricula in medical education.J Cancer Educ. 2006; 21: 14-18Crossref PubMed Scopus (66) Google Scholar and an elective, the "Healer's Art" (developed by Rachel Naomi Remen, MD)4Rabow M.W. Wrubel J. Remen R.N. Authentic community as an educational strategy in professionalism: a national evaluation of the Healer's Art course.J Gen Intern Med. 2007; 221: 1422-1428Crossref Scopus (39) Google Scholar, 5Rabow M.W. Wrubel J. Remen R.N. The promise of professionalism: mission statements among a national cohort of medical students.Ann Fam Med. 2009; 7: 336-342Crossref PubMed Scopus (34) Google Scholar, 6Remen R.N. O'Donnell J. Rabow M.W. The healer's art: education in meaning and service.J Cancer Educ. 2008; 23: 65-67Crossref PubMed Scopus (21) Google Scholar to medical students at Stanford. In these classes, students and physicians share personal stories that reveal what I call "the landscape of human spiritual experience." They speak of unexpected moments of awe in nature or in the operating room, of experiencing the kindness of strangers, of deep connections with family members at life transitions such as weddings or death, as well as grief and loss, and their dream of service. Through such sharing, students and physicians discover they do not need to deny their faith and spiritual values when they practice medicine. They can have a professionalism that honors both. I have had to cultivate the same in myself as I have navigated the journey from action-oriented emergency physician to reflective chaplain. I have had to let go of my focus on "curing" or "fixing" to bring comfort, and to become someone capable of being fully present, bringing all of myself to the bedside: body, intellect, heart, and soul, as well as my training and life experiences. The lessons I have learned apply not only for me but also for any of us who aspire to bring spirituality and meaning into our lives and our work. This has required a lot of personal growth, not all of which was easy or readily embraced. Still, I am glad I overcame my reluctance and followed the call to step more deeply into this sacred dimension of healing. Many of us are responding to this call, each in our own way. I share this reflection as an example of one person's journey from the traditional role of physician into the realm of spirituality and healing, in the hope that it may be of use to you in your journey. As we each respond to this call, we help to evolve health care into something more complete, something that encompasses biopsychosocial-spiritual care.7Sulmasy D. A biopsychosocial-spiritual model for the care of patients at the end of life.Gerontologist. 2002; 42: 24-33Crossref PubMed Scopus (474) Google Scholar We all know, innately, that there is a kind of healing not found in an I.V. or prescription bottle or at the end of a scalpel. This dimension of healing is largely missing from modern medicine. And because it is, we, patients and health care professionals, suffer far more than we should. As I look back at my life now, I can see how the path to being a chaplain unfolded along two tracks: the professional and the spiritual. Each developed in its own time and in my case, came together in my 40s. The first was never in question. My father was a physician. He used to say to me: "You can be anything you want. A surgeon, a dermatologist, a family physician, even a psychiatrist. Anything you want." But Life had its own agenda. When I was 19 years old, during college, I had a mystical vision, one that would awaken my interest in faith, prayer, and spiritual community. This was my first acquaintance with the "uniqueness in me that asks to be lived."8Hillman J. The soul's code: In search of character and calling. Random House, New York, NY1996Google Scholar Over the years, even as I developed my career as an emergency physician, I studied philosophy and ethics, and sacred psychology, and experienced a variety of spiritual traditions. I had no idea then that I was training for the next phase of my career. My career in Emergency Medicine had a good 19-year run until April 1998. I had sustained an injury the August before that made it all but impossible to continue. Just four months before the injury, I had an extraordinary encounter with a patient that presaged what was to come. On that day, I took sign-out from my chief. At the time, I was a senior physician in a high-acuity Emergency Department at Kaiser-Permanente Medical Center in Santa Clara, CA; chair of the Peer Review and Quality Improvement Program; and faculty in the Stanford-Kaiser Emergency Medicine residency program. The patient, Mrs. Martinez (not her real name), was an 86-year-old Hispanic woman with a history of colon cancer and recurrent nausea, vomiting, and dehydration. She was rehydrated and about to be discharged. Her head CT scan, to rule out increased intracranial pressure, showed multiple metastases to the brain. Because I just met her and her oncologist knew her very well, I planned to let him tell her the news. When I entered her room, however, she asked me a question I could not ignore. "Doctor, what was the result of my brain test?" I sat down and told her as gently as possible: "Mrs. Martinez, the cancer has spread to your brain." She turned pale, looked away, and said it was a death sentence. I always felt there was something I could say to provide comfort, but what? I tried to reassure her that her oncologist was very experienced and would help her, but it did not faze her. Then I noticed she was wearing a cross and recalled a story Rachel Naomi Remen, MD, told of a doctor who prayed with a patient.9Remen R. My grandfather's blessings. Riverhead Books, New York, NY2000Google Scholar I knew what I had to do, although I had never done this before. "Mrs. Martinez, are you a prayerful person?" I asked. She nodded. "Would you like to have a prayer together?" "Yes," she said. I took her hand and waited for her to begin. There was silence; I sensed she was waiting for me. "O God, you who are the great healer," I began, improvising some words. To my utter surprise, she repeated them after me. Then she recited the Lord's Prayer, which I remembered from working in a Catholic hospital years before. I joined as best as I could. She concluded with a prayer in Spanish, then looked up directly into my eyes. The color had fully returned to her face; tears ran down her cheek. "Thank you, doctor," she said, with a depth of gratitude I had never experienced before. The moment brought healing for each of us. I felt profoundly privileged, indeed blessed. I had the distinct impression I was bridging two worlds: the world of science and technology on one side with the world of the sacred on the other. Although I was completely "off my map," at another level, I felt deeply satisfied that I had fulfilled my duty as a physician and healer. By duty, I think of how the French physician, Edward Livingston Trudeau, stated the goals of medicine: "to cure sometimes, to relieve often, to comfort always."10Russell J. Consoler toujours—to comfort always [editorial].J Musculoskelet Pain. 2000; 8 (Available from) (Accessed January 20, 2011)http://www.cfids-cab.org/cfs-inform/Ptsd/editorial.russell00.txtGoogle Scholar As I learned in taking care of Mrs. Martinez, doing the right thing often means addressing what really matters, stretching us beyond our roles as physicians and health care professionals, as they are currently defined, into the further realms of spirituality and meaning.11Feldstein B. A piece of my mind: toward meaning.JAMA. 2001; 286: 1291-1292Crossref PubMed Google Scholar I now see the act of bridging with the sacred as an ethical one, born of compassion, service, and healing. Several months after that prayer with Mrs. Martinez, I was helping a friend lift a dresser when I felt an excruciating pain in my low back. I came up crooked, like a three-dimensional question mark. An MRI scan later showed internal disc disruption at L4–5, L5–S1. On the night of the injury, I had a sense this was the beginning of the end of my career in Emergency Medicine; it was time to move on. But what would I do next? The answer unfolded over the next few years, punctuated by a number of telling occurrences. I was only able to work part-time. One night shift, four months after the injury, my chief pulled me aside and asked what I might do if I could not continue in Emergency Medicine. "I don't know," I said. "But whatever it is, I need to follow my heart." Mrs. Martinez came to mind and I told him the story of how I prayed with her. Just as I finished telling the story, a nurse came scurrying into the room like the rabbit in Alice in Wonderland. Her name was Mary and she was from England (where Anglican priests are called vicars)."Dr. Feldstein, Dr. Feldstein," she said, pulling on my sleeve excitedly, "I had the funniest dream about you last night. I dreamt you were a vicar wearing a yarmulke. Hee, hee, hee, hee, hee," she laughed, and darted out as quickly as she came in. (At the time I was wearing a stethoscope and white coat, not a yarmulke.) The chief and I were stunned at the synchronicity of that moment. Mary's dream, and the timing and context in which I heard it, clearly pointed to my new calling, but I did not have the capacity to understand that then. So I could only ignore the "hint." Four months later, I left Emergency Medicine on the recommendation of the spine surgeon. In the meantime, I had become a visiting scholar at the Stanford Center for Biomedical Ethics, and thought I would go into ethics. In October, I met with the vice president of the American Medical Association's Ethics Standards Division who offered me a position. During that meeting, she got this quizzical look on her face. She turned to me and asked, "Can I tell you what I see for you personally?" I nodded. "I see you coming here for a year maybe, and then I see you going into… pastoral care." She seemed as surprised as I was by what came out of her mouth. I thought to myself, "Whoever heard of a doctor going into pastoral care?" I ultimately declined the position. I went on to Israel, studied Jewish religion and ethics in Jerusalem, and returned home after a semester. In February of the following year, at the International Conference on Jewish Medical Ethics, I sat next to a rabbi at lunch. Out of the blue, he turned to me and said, "You know, you should become to chaplain!" "What?" I said. "A chaplain? Chaplains are Christian. I'm Jewish." "No," he corrected me. "Chaplains are members of any faith who provide spiritual and religious support. There are hospital chaplains, and chaplains in the military and other settings." "But I'm not a rabbi," I countered. "I'm a physician." He explained, "Most chaplains are ordained, but the rest come from other backgrounds: social work, therapy, religious studies, and education. So why not medicine?" I learned that chaplains typically have an advanced degree in theology or religious studies, then receive professional clinical training called Clinical Pastoral Education (CPE).12Association for Clinical Pastoral Education www.acpe.eduGoogle Scholar Stanford Hospital & Clinics is a nationally accredited site for CPE training. It turned out that the National Association of Jewish Chaplains, one of the professional associations of chaplains, was holding their annual meeting in the same hotel that year. I sat in on some sessions and felt at home. I was finally open to the possibility of becoming a chaplain. I became a spiritual care volunteer in the Spiritual Care Service at Stanford Hospital and had that same experience of feeling at home while visiting patients at the bedside. I enrolled in Stanford's year-long CPE residency program. That year was incredibly rich and transforming, yet emotionally challenging. I provided spiritual care to patients and families of all faiths on three hospital units, took weekly call, and was present at some 70–75 deaths. Throughout that year and over the past decade, I learned so much about the association of spirituality, religion, health, and healing; and how bringing spirituality to the bedside helps alleviate suffering.13The George Washington Institute for Spirituality and Health Spirituality and Health Online Education and Resource Center (SOERCE).www.gwish.orgGoogle Scholar I came to see how spiritual care is everyone's responsibility;14Mohrmann M.E. Medicine as ministry: Reflections on suffering, ethics, and hope. Pilgrim Press, Cleveland, OH1995Google Scholar and how, as a chaplain, I bring something essential to the health care team.15VandeCreek L. Burton L. A white paper. Professional chaplaincy: its role and importance in healthcare.J Pastoral Care. 2001; 55 (Available from) (Accessed June 1, 2011): 81-97http://www.healthcarechaplaincy.org/userimages/professional-chaplaincy-its-role-and-importance-in-healthcare.pdfPubMed Google Scholar, 16Puchalski C. Ferrell B. Virani R. et al.Improving the quality of spiritual care as a dimension of palliative care: the report of the consensus conference.J Palliat Med. 2009; 12: 885-904Crossref PubMed Scopus (859) Google Scholar, 17Feldstein B. Cowden M. Block J. The role of clergy and chaplains in healthcare.in: Serlin I. Rockefeller K. Brown S. Whole person healthcare. Vol. 2. Praeger, Westport, CT2007Google Scholar So much of what I learned applies to anyone who works with patients. One thing I learned was how to observe—and respond appropriately—to the multiple domains at play in each patient encounter, such as emotions, coping, family and social dynamics, as well as issues of spirituality, theology, ethics, and social justice. Through a process of continual reflection and refinement that is at the core of CPE training, I learned to observe my own reactions—thoughts, feelings, and images—and draw on these in formulating what to say to patients and families. I would consider how to be with them—whether to accompany, guide, bless, or advocate, or some combination of these. Over time, I became a spiritual reflective practitioner in action.18Shön D. The reflective practitioner: How professionals think in action. Basic Books Inc., New York, NY1983Google Scholar, 19Patton J. From ministry to theology: Pastoral action & reflection. Journal of Pastoral Care Publications, Inc, Decatur, GA1955Google Scholar As a chaplain who was trained as a physician, I learned to let go of reflexive tendencies to fix and problem solve, and to shift my emphasis to the patient's emotional and spiritual concerns. It was important to learn to grieve my own losses, to become less triggerable and more available for others.20Mitchell K. Anderson H. All our losses all our griefs: Resources for pastoral care. The Westminster Press, Philadelphia, PA1983Google Scholar I learned the importance of developing five key relationships to sustain myself and remain openhearted—a relationship with myself (self-acceptance), a soul friend (who you can say anything to), a therapist or spiritual counselor (to process emotions and find meaning), colleagues (who understand what you are going through), and the transcendent (through worship, prayer, meditation, reading, nature, music, art, volunteering, etc.).21Meier L. Healing the healer. Presented at: the National Association of Jewish Chaplains Conference; 1999; Burlingame, CA.Google Scholar I am discovering how, as a chaplain who is also a physician, my medical experience and knowledge facilitates trust and communication with patients and families as well as members of the team, even when they do not know my background. My familiarity with the monitors and tubes, the bedside smells and the patient's disfigurement can bring reassurance in an unspoken way. My understanding of pathophysiology and prognosis allows me to shape a realistic horizon of hope without giving medical advice. With patients and family members who are physicians, our camaraderie can allow them to open to vulnerability, meaning, and blessing, sometimes for the first time. In the classroom and on teaching rounds with medical students, my credibility as a MD chaplain facilitates learning about spirituality and healing. I now appreciate that the most important thing I bring to each bedside encounter is myself, and how my presence comforts and heals.22Taylor C. Healing presence: creating a culture that promotes spiritual care.Supportive Voice. 2006; 11(2) (Available from) (Accessed June 1, 2011)http://www.supportivecarecoalition.org/SupportiveVoice/SV_Articles/SV_Vol_11_No_2_Taylor.htmGoogle Scholar, 23Miller E.J. Cutshall S.C. The art of being a healing presence. A guide for those in caring relationships. Willogreen Publishing, Ft. Wayne, IN2001Google Scholar Before visiting a patient, I stop to prepare two things—my attention and intention. This is something I teach to all my students. This allows for greater connection and meaning. It also can open us to the sacred. It applies whether one is providing routine medical treatment or spiritual care. There are many ways different people prepare their attention and intention. I have developed a simple ritual for myself. Before I enter my patient's room, I stop. While washing (or gelling) my hands, I prepare my attention. I bring my awareness to my feet on the ground… then to my breath… and to the flow of water (or gel) over my hands, as if they are washing aside (evaporating away) my preoccupations, leaving only my best intentions. I make a blessing before I dry my hands (or as my hands are drying): I lift up my hands. May I be of service. Then I take a full breath and remind myself: What matters for you, my patient, is what matters for me. May I meet you in your world as it is for you and accompany you from there. Whatever time I have with you, may I be fully present. May I serve you with all of my life experience as well as my expertise. May I listen fully with a generous heart, without judgment, and without having to fix what cannot be fixed. May my presence allow you to connect with your source of comfort, strength, and guidance as it is for you. May I be well used. Before entering the room, I stop again… take another full breath to keep my focus… and then I knock. When I enter, I scan the room, "touch" the patient with my eyes, then with my voice, and then, as appropriate, with my hand. I cannot know who and what I will encounter when I enter the room. What stories, what emotions… will I even be welcome? I do know that my preparation can facilitate meaningful connection. It also can open the way to what may normally be unseen, which can announce itself to any of us at unexpected times, in unexpected ways, with unexplainable, sometimes extraordinary, moments of awe. Such moments can help sustain one through challenging times. My experience as a chaplain has opened my eyes to the unmeasurable in the healing encounter: the mystery I witness, the awe I experience. The following stories are examples of this mystery and awe: I visited a man in the coronary care unit, who was being evaluated for a heart transplant. He was sitting in a chair. I noticed his swollen legs and the markedly distended neck veins of someone in congestive heart failure. His breathing was labored and you could hear gurgling in his breath from the rales. He explained to me how the fluid was backing up in his lungs, making it harder for him to breathe. As a chaplain, I do not wear a MD on my name badge (to avoid any misunderstanding of my role) so he did not know my background. He was a fundamentalist Christian, and asked me to bring a Bible and suggest a passage. I did and flipped it open. Psalm 69. I read out loud: "Save me O God, for the waters have come up to my neck…." We were both stunned at the uncanny coincidence. How extraordinary that the Bible happened to open to a passage that addressed his underlying pathophysiology. Weeks later, no longer a transplant candidate, he lay dying. His wife was sad but accepting. She told me how the incident of the Bible passage brought great comfort to their family. They understood the incident as a sign they were being "watched over" and no matter what happened, everything would "be okay." During the Hanukah holiday, I visited a Jewish woman in the intensive care unit who was in end-stage liver failure and was hoping for a liver transplant. Her jaundiced eyes peered out from under a warming blanket; two trees of I.V.s on either side sustained her. I asked her if I could dedicate a Hanukah light in the hospital's menorah for her. She nodded. "What would you like it to mean?" I asked. "If only we can just get along," she whispered, asking nothing for herself. I have seen this kind of transcendent selflessness in others in dire straits, and stood in awe. Moments later, the nurse came in, excited. "We just received the news that you're going to get your transplant. Your new liver is on its way!" I marveled, thinking about the exquisite orchestration that had to occur. Someone had to agree to give the gift of life, the Emergency Medical System had to get to that person in time, the donor network had to be called, a medical team had to scramble to harvest the organ… and so on. If that is not "everyone getting along," what is? We are part of an unseen network that connects us all. One afternoon, I was offering a Jewish blessing for healing to a middle-aged Jewish woman who was about to go for an organ transplant. As is my custom, I explained the meaning of the prayer to her and asked her what she would like it to mean for her. I asked if I might take her hand, closed my eyes, and began to sing the blessing. As I sang, I had a very distinct sense—unlike anything I experienced before—of something else in the room, behind her. "Am I just imagining this?" I wondered. "Should I tell her? I don't want to impose my experience on her. On the other hand, it might have meaning for her …" So I said, "While I was singing, there was an image that came to mind. It might mean something. Then again, it might not. If you'd like, I could share it with you." "Yes, please," she said. "Well, I saw the figures of two people standing behind you," I said. "Me, too!" she said. "My father and grandfather, may they rest in peace. And now I know, no matter what happens, I am not alone." Within each of us, there is a human longing for meaningful connection. We help alleviate suffering when we create the conditions for connection with each other and what we hold sacred. The depth of that connection is made possible by our willingness to be authentic and by focusing on the quality of presence, and the attention and intention that we bring to each other. We become authentic, in part, by asking ourselves: What is the uniqueness in me that asks to be lived? Where is my heart? In this reflection, I have shared some of the stories and questions that have guided me, and some of what I have learned along the way, in the hope that they may be useful for you. Are there stories and questions that guide you? That is worthy of your reflection. Those of us who provide spiritual care help fulfill an essential dimension of caring and healing. And when we do, we stand on sacred ground between the patient and health care system,24Silberman J. Jewish spiritual care in the acute care hospital.in: Friedman D.A. Jewish pastoral care: A practical handbook from traditional and contemporary sources. 2nd ed. Jewish Lights Publishing, Woodstock, VT2005: 241Google Scholar on behalf of so much that is often overlooked—comfort, coping, meaning, hope, and mystery. I am often asked, "How can you do the work you do? How can you stand it?" For any of us who encounter and respond to suffering, the work is challenging, soul stretching, and sometimes emotionally hard to bear. Yet, this work can also be immensely gratifying in a sustaining way.As Rabbi Amy Eilberg so eloquently writes:"We walk amid a great deal of sadness, grief, and fear. We regularly encounter the face of injustice and we frequently find ourselves in the midst of trauma and conflict. It is indeed a heavy burden to carry. This demands a great deal of us. It calls on the best of our capacity for compassion. It requires us to be courageous and wise, generous and unwavering. It requires a complex dance of giving and limit setting, of opening the heart and of clear boundaries. We regularly come face-to-face with our own mortality …Nevertheless, this work also gives us great gifts. We witness much holiness and beauty. We have the privilege of being invited into the most sacred and intimate moments of another's life. We encounter extraordinary acts of love and devotion, of trust and courage. Our days contain many moments of awe."25Eilberg A. Walking in the valley of the shadow: caring of the dying and their loved ones.in: Friedman D.A. Jewish pastoral care: A practical handbook from traditional and contemporary sources. 2nd ed. Jewish Lights Publishing, Woodstock, VT2005: 396Google Scholar
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