I thought I’d throw in a sample verbatim that I presented in CPE a few weeks ago. These are presented in class and are a pretty significant part of what we do. After a patient visit we write it up similarly to what you see below, although there are a lot of different ways to do it. The main reason is to have the group look at what you did, ask questions, and look at the visit from a number of different angles. Plus, the writing down of the visit and reflecting back on it afterward is very helpful in your own education. I don’t write up every visit obviously, and while I used to look to try and find the “perfect visit” you can pretty much find something interesting in every visit you do.
Names and places have been changed obviously. This references the Association of Professional Chaplains’ Common Standards, available here. And pardon the weird formatting but I’m not fixing it on Monday morning.
Rev. Samuel Blair
Highland Dr. VA Medical Center, Pittsburgh PA
Supervisor: Rev. Eugene Reddel
CPE Unit 3, Level II
Field Placement: Gateway Hospice, Pittsburgh PA
Reason for Presentation: This visit deals with a lot of loss on the part of the patient, which he seemed to have a hard time verbalizing. I did not sense a lot of openness from him to explore deeper issues, so I chose not to. However I would like the group to explore areas that I could have touched on and didn’t, and also to see about next steps with him to use in further visits.
- Date of Visit: 8/5/11
- Length: about 45 minutes
- Location: a personal care home in rural Butler county
- Patient: Rich is 87 years old and is on hospice for “adult failure to thrive”. He has no significant medical condition besides a recent broken hip, however he has lost a significant amount of weight (33# in past year) and some confusion. He was a heavy machine operator, lower income. A year ago he was living independently with his spouse. Apparently there was some sort of violent
altercation with his grandson resulting in his being committed for psychiatric
treatment for about 7 months at a skilled facility. He then came to this facility. He has no funds to speak of, and the facility is apparently caring for him pro bono. He has an active death wish and has talked about suicide but stated that
he won’t because he’s “too chicken”. He also lacks the means to take his life,
however staff feel his poor intake is evidence of his wanting to starve himself
to death. Our social worker has contracted with him that if he feels suicidal that he is to tell us. His wife has not visited him and I was told that she lives with the grandson. I don’t hear anything about children, so I do not know if they are dead or simply uninvolved. They do not visit and she
also has filed a PFA on him, which is odd given that he can’t leave the
facility. The relationship between the grandson, the wife and the patient seems very odd from what I know, and it seems as if the grandson has taken on a surrogate husband role. The only visitors he has are his niece and
nephew. He has never been religious and doesn’t speak much of faith or spiritual issues according to them. I spoke with the niece prior to this visit
who stated that she feels he may be at a point of spiritual breakthrough,
though this may be their own perception of what he needs.
Prior to Visit: This is only my second time visiting Rich. I had seen him not long ago, but he asked the social worker during her last visit if I could come again and that he “needed to see the chaplain”. Given that he might be suicidal I thought that an increased presence would be beneficial as well. I know that loss and grief is a primary concern going in, as he has lost most everything he had before and is morning the loss of himself in death as well. When I arrive Rich is seated in a wheelchair in his room with a lunch tray, which has a piece of fish and some other things which I can see he has only picked at. He has a lap blanket covering himself, his hair is wild, and he is unshaven. He appears pale and thin. In the past when I saw Rich he was in bed, so I’m glad he’s up. His roommate is also in the room watching TV.
C1: Hey Rich – how are you?
P1: No good. No good at all.
C2: What’s wrong? (I sit down on his bed next to him)
P2: This. (he motions to his plate in front of him) I can’t eat it. No appetite. No taste. And when I do eat it just comes right back up. It’s like it gets stuck or something. I can drink a little bit but that’s it. But even that comes out my nose. (big sigh) I dunno. Hey you’re the chaplain right?
C3: Yeah, I saw you before and Marcie said you wanted to see me.
P3: Yeah! The Chaplain! That’s what I need! (making a lot of eye contact)
C4: Well good! How can I help you? What did you want to see me about?
P4: (sighs again) I dunno. I’m just so tired anymore. And I can’t eat. No appetite. (looks down)
C5: Does your throat feel tight? (I feel puzzled and confused. This isn’t where I
thought he would go.)
P5: No it just won’t go down.
C6: Hm– but you can drink ok? (I’m out of my pastoral mode and into diagnostic mode)
P6: Sometimes. I drink milk and that’s about it. (He takes a glass of milk and tries to take a big quick gulp, and chokes a bit on it.) See?
C7: It looks like you’re trying to drink too fast. Try to slow down. (I see that
part of his issue might be trying to hard not only at eating and drinking but at everything – and he can’t do it which makes him depressed.)
P7: Yeah. (pauses, silence)
C8: Would you want to go outside? It’s not too bad out yet. (I think a change
of scenery, as well as an outward focus and less stressful environment, could be helpful. I feel back in pastoral mode.)
P8: I don’t know. I like to go outside but I’m so tired anymore.
C9: Well I can push you.
P9: I don’t know. It might do me some good, but I don’t…(he trails off)
C10: Just give it a try. If you get tired we can come back in.
I get him a pair of pants and help him get his hair brushed down. I take him outside in his wheelchair. Along the way he talks about going outside so he is obviously looking forward to it. Once outside he talks about the other residents who are outside and especially about fishing. We sit on a large deck with some other residents. There is a small lake at the facility with some fish in it that he likes to go to. He starts to talk about his home.
P11: …I got to drive by there last week.
C11: Really? I heard that your niece and nephew took you. How was that?
P12: It was ok. At least I got to see the outside of the place. Last time I went in the place was a wreck. Everything emptied out, drawers all opened up, there was $100 in my nightstand and that was gone. I was hoping to be able to go back there but
they say I can’t live there on my own. I thought maybe my granddaughters could stay there and then I could stay in part of it, but they don’t want to do that. I can’t even rent it, my wife doesn’t want me to.
C12: Where is your wife?
P13: She’s at a home too. She doesn’t come see me either. Neither does my grandson.
C13: That’s really too bad.
P14: The only people that see me are my niece and nephew. (long pause) I don’t
know. I’m going to be 90 next week. I don’t know what will happen after that. We’ll see if I make it to next week.
C14: Well when next week comes we’ll have to have a party for you. I’m glad your
niece and nephew visit. That shows that they care for you. And I’ll come and see you too if you think that would help.
P15: Well we’ll see. We probably should go back in now.
C15: Sure. I’ll take you in.
I wheel him back inside. He’s quieter now.
C16: It was very good to see you Rich. I’ll try and see you more often.
P16: Good to see you too (smiling; I take his hand and he shakes it firmly). Good to
see you. Thanks for coming.
C17: Anything else I can do for you? (this is my way of seeing how open he is to prayer)
P17: No, not really.
C18: Ok. I’ll keep in you in my prayers this week. I hope you get to feeling better.
P18: Thank you. Thanks very much.
I went in to the visit expecting more of a formal “pastoral” visit, given that he had specifically asked for a chaplain. This was also confirmed for me in P3. Given his desire to die I expected him to have questions about God and faith, perhaps express fear of dying, confess, want to accept Christ – I wasn’t sure. However when I opened up the door to conversation, religious discussion was not on his mind. This surprised me,
and I felt myself switching from a pastoral to more of a diagnostic role in order to see what was happening. I wondered for a minute during the conversation why he had wanted a chaplain. I realized that he probably didn’t even know what to ask, and that he may just have needed pastoral presence in his life. He asked for me because I had shown up before. I decided not to press too hard in terms of his suicidal thoughts, religious themes or theological questions as I felt it would be better to let him bring them up. I felt that taking Rich outside would change the situation, make him feel a bit more free and open, and help him to talk about his losses and inner experience. I also wanted to show him acceptance and companionship as I felt that he probably expected to be rejected, just as he has been rejected by his family and probably feels rejected by God as well.
I also came in to this visit with a bit of uneasiness, because I was not sure exactly how much religious power he was going to give me. I’ve been more comfortable in my role as chaplain than I have in my prior role as a more formal minister, and even much
less so as an evangelist. I wonder if he is going to expect me to be an evangelist or confessor of some sort. In terms of my own authority provided to me by my position, it pushes my comfort boundaries because I’m not comfortable pushing people or confronting them to make decisions. I feel that building the relationship and
witnessing through that relationship is more beneficial in this situation. I could have gone in with the intent to witness to him, given his terminal prognosis and need for an understanding of Christ. But I took the path that seemed the most natural.
Relationally I think he may see me as a son. I know very little of his family except to know that they aren’t involved in his life. He sees himself as alone, though he seems to
interact with the other residents there, especially some of the men and his roommate. He seems helpless and hopeless. His abandonment defines him. Our social worker stated that she has been frustrated talking with him in that whenever she has tried to point out positives to him he ignores them and remains fixated on his losses. She expressed this as “he just doesn’t want to do anything for himself”. I believe he doesn’t because he doesn’t see any reason to do anything for himself – his “self” is gone. He has lost everything that has given him meaning in the past. I’m not sure what he holds on to or what is keeping him going. It may be that this reaching out to others and trying to rebuild relationships in the time he has left (which he thinks is short) is his purpose right now. This desire to connect with me is evidence of that.
Presence was very important to him. The fact that I visited him before, however
briefly, was an important starting point. The fact that he sought out that presence again shows he trusts me and that he felt supported while I was there.
While I felt sadness, I overall felt peace during the visit. Moving the visit outside helped me as well, as I tend to feel less pressure and more comfortable with silence when I’m outside. I also switched from a more active role to a more passive role. This opened him up quite a bit I believe, as he moved more from the negatives of his present to more positive aspects – fishing, going outside, and the other residents. He also visited with me much longer than I expected. My first visit with him was rather short, as have most of his other visits with our staff. I feel that he trusts me and I feel that I need to reinforce that trust.
Spiritually I felt as if I were an incarnational presence to Rich. I don’t know what spiritual or religious questions he has, but I know that he needed more of a presence in his life at that time. He may be dealing with a lot of guilt and shame from this event that ended up in his being committed, and I’m sure that he feels that life isn’t just or right. Being gracious to him will, I hope, make him more open to forgiving himself and releasing the shame that makes him want to die.