(watch the video above before you read on: it’s funny, creative and has cute doggies)

I wanted to share my most recent verbatim which I’m also using for my certification. It’s in a bit of a different format and is definitely longer than most of my posts. Read on and I hope you benefit from it. You’ll catch why I included the video at the end of the paper.

Background:

This is the second visit to Ms. F by this chaplain. The first visit with this patient had to be cut short as she has having pain in her back and did not want to talk. At that initial visit it was difficult for me to obtain much information regarding her background as she couldn’t recall much of her past and was oriented only to herself. She frequently called out “where’s my pain pill?” and I contacted the nursing station to get her pain medication. She was agitated and in distress and I tried to help calm her but this was not effective. When I asked if she wanted me to stay she said that she just wanted her pain pill. I talked with the nurses on the unit and reviewed her chart, noting that she was Presbyterian and had a history of anxiety and episodic depression. She spends most of her day in her room. She did not have any current connection to a church.

Following the first visit I spoke with her friend Rick who serves as her POA. He confirmed what I already knew and wasn’t able to add too much more. He did note her increased confusion and overall decline.

Plans:

While this visit was planned, I felt rushed and didn’t have much in mind regarding how the visit might go. I had just come from one visit and had hoped to get three more completed by the end of the afternoon. I planned to see if there was any improvement in terms of her comfort as well as to try to find out some more about her religious background and spiritual concerns. I also wanted to see where she was in terms of understanding her prognosis and acceptance of it. I did not know quite what to expect given my last visit.

Observations:

As I walk in Ms. F is sleeping in bed on her side. Her television is on, playing an old movie. She is thin and frail, gray hair, and very pale. The room feels comfortable and private. I enter and say her name a few times with no response. I move closer to the bed and say her name and she awakens. She does not turn or move during the visit, remaining on her side the entire time.

Visit:

	Interaction
C1	Hi Mrs. B, how are you today?
P1	Oh, I’m ok. Not too bad I guess.
C2	I’m Sam from Bridges. I’m the Chaplain that comes around every once and a while. It’s been a while since I saw you and I wanted to check in and see how you were.
P2	Well that’s awful nice of you.
C3	The last time I was here you were having a lot of problems with your back. How is that today?
P3	Oh my back is fine today.
C4	Really? No aches or pains or anything?
P4	(thinks) no, everything’s fine
C5	OK good. I’m glad you’re feeling better. Now let’s see if I remember right – you’re Presbyterian?
P5	Right
C6	Wow – I’m glad that I remembered. I didn’t think I would.
P6	Yes. I went to the Presbyterian church in Wilkinsburg.
C7	Oh I see – so did you like church?
P7	yes very much
C8	That’s good. I like to ask what you liked most about church.
P8	(pause) the stories
C9	The stories? Like stories from the Bible?
P9	(another pause) yes
C10	Any stories in particular?
P10	(a very long, silent pause) There’s the story…it’s of the…of the chippies…it’s…the chirp…I can’t think of the right word for it
C11	That’s ok. (silence) Well one of my favorite stories is the story of Joseph. How he was sold into slavery and left for dead, and then God used him to save not only his brothers but the whole country of Egypt. I remember Joseph said to his brothers that “you meant it for evil but God meant it for good.”
P11	oh yes yes…
C12	It helps me when I’m going through rough times to remind me that maybe those rough times are there to help me or someone else.
P12	right
C13	Have you ever had rough times like that?
P13	Loads of them. But they turn out pretty good
C14	Can you think of a time like that?
P14	(long pause) no…
C15	I see. But you know you had them.
P15	Yes
C16	And that in the end they turned out pretty good?
P16	Yep. I survived. (long pause) How’s the weather out there? Is it cold?
C17	It’s pretty cold. The sun’s out but it’s only about 16 outside.
P17	Oh my!
	(we talk for a bit about the weather)
C18	So you grew up in Wilkinsburg? What was it like back then?
P18	Oh it was very nice. We were very fortunate. It was wonderful
C19	So you have lots of good memories of there.
P19	oh yes yes…
C20	(pause) are you tired? You look pretty tired.
P20	Yes I could use a rest.
C21	Ok, do you have any concerns or worries right now?
P21	well..(long pause) no
C22	Anything little?
P22	…I’ll have to think about that…
C23	I know a lot of folks get worried about their health as they get older. They might worry about what would happen to them if they got sick and didn’t get better. Is that something you think about?
P23	no not really
C24	Ok good. I know too sometimes people feel bad because they need help. I’ve talked with people who have a really hard time because they need help and feel that they shouldn’t need help.
P24	yes that’s true
C25	do you ever feel like that?
P25	no I feel pretty good. (pause) What’s that on television?
C26	To be honest I don’t know. It looks like an old movie. I can see you’re tired. Would you like to take a rest?
P26	Yes I think so.
C27	Well I really appreciated the visit. Thanks so much for talking with me. I’ll let you get some sleep.
P27	Oh the visit was wonderful. Thank you.
C28	Is there anything else I can do for you?
P28	No
C29	Can I say a prayer for you?
P29	Most certainly
C30	I take Mrs. B’s hand and pray, mentioning the beauty of creation, God’s love for us, the security we have in Jesus, and how God always hears us when we pray.
P30	Amen. Thank you, thank you thank you!
C31	Thank you too! I hope to see you again soon.
P31	Yes please come back.

 

Analysis:

Religious concerns

Ms. F’s faith is very important to her and continues to be a source of comfort and peace. When I first visit people I usually ask their religious background, what church they attended and if they liked it. The answer to that last question helps direct me to see what aspects of their religious experience have been helpful or possibly hurtful in their lives. Her response was very positive, which leads me to believe that religion and faith played a positive role in her life. Ms. F mentioned “stories” but couldn’t say much more, though she was trying. This allowed me to open up about my own story, hopefully giving her a chance to relate and share some of her own belief related to that story. In asking about her own “rough times” she did not open up much but her emotional response was positive. Her faith has brought her through hard times and it seems that it continues to guide her today. Her acceptance of prayer at the end and overall positive response to the visit reinforces this as well.

Psychological concerns

While during this visit she seemed less impaired than on the prior visit she did have some obvious difficulty with finding words and recall (P10 for example). While her memory was impaired her emotional resonances with memorable times in her life were positive. I did note on two occasions (P16 and P25) that when I touched on potentially sad topics (getting through difficult times, her own decline) she diverted to other topics. It could be that she was consciously trying to avoid talking about negative subjects at the time, or these could have been unconscious defense mechanisms. To me it seemed like she intentionally diverted at these times, as when the talk was more positive she stayed on track with me pretty well. This may indicate some past hurt that she is trying to avoid as well as an avoidance of current existential pain: her own decline and death.

Toward the end of the visit I brought up her own decline and if she had any concerns about needing help (C24), as I find that many struggle with the change in role from caregiver to needing care and lose meaning in their life as a result. She seemed to have no concern at that time, but that is also when she deflected. I admit that I avoided approaching her own status with her as I didn’t know how capable she would be of understanding it given her confusion. These will be areas of further exploration.

Sociological concerns

While Ms. F is socially isolated both by choice (keeping to her room), her debility (she sleeps throughout the day and stays in bed) and by her life history (unmarried without children) she seems to be comfortable. It could be that she has been more comfortable being alone than with a lot of company. While I know little about her background, the fact that she is at the facility she is in shows me that her power of attorney wants her to be in a comfortable place, which may reflect on her background and upbringing. The facility is operated by the Jewish Association on Aging and integrates faith and religious practice in their continuum of care for all their residents. However the fact that she is not connected to a parish or local congregation means that she is not getting much outside religious or social support from outside the facility, and is a religious minority where she is.

Chaplain’s assessment:

This patient was chosen to visit because I had three others in the area that I could also see without much travel in-between. I also chose her because I felt that my prior visit was not that beneficial for either of us. I hoped going in that this would be better, but I was also apprehensive and wondered if it would go the same as before. Prior to visiting I felt anxious and rushed. I was already thinking and planning about where I needed to go and how long I could stay and still be able to get my other visits in. Given that my mind was elsewhere and preoccupied with my own worries rather than the patient didn’t help me going in, and also played a part in my interaction with her as well.

I decided to report this visit because there were parts that I thought went very well and others perhaps not so well. I felt our interactions were positive and she felt supported by the visit. I also felt helpful and affirmed in my support of her.

Her initial reaction to my introduction (P2) surprised me and made me feel more at ease during the visit. I had expected her to be either asleep or in pain and didn’t expect much out of the visit. Her pleasantness and happiness rubbed off on me and helped to relieve my own anxiety going in. Toward the end I felt less pressured by time to end the visit than by her own visible tiredness.

I thought several times during the visit about how to address her own knowledge of her decline. With many of the folks I see this is not an issue because either their dementia prevents them from fully grasping their terminal status or they are already aware of it. As Ms. F was so confused at my last visit I did not feel that she would grasp that she was dying, or if she did it would be a source of distress for her. While this knowledge is distressing for everyone, I rarely tell those with dementia that they are dying because the self-grieving process gets short circuited by the dementia itself. The knowledge gets forgotten but the emotional anxiety lingers without focus. I do talk about dying and death in “what-if” statements frequently in order to see their reaction to death and dying, which is what I tried to do here. From her responses I gathered that she seemed to be at peace at the time, though this is also where she diverted. I think this would be a good area to revisit. Looking back I wonder if I could have been more up front with her, but I still don’t think it would have been that helpful at the time. However this fear of saying the wrong thing, along with the fear of not saying the right thing, was in the background at different times in the visit.

I feel that Ms. F enjoyed my visit and seemed very thankful for it. This visit also gives me a good place to start to continue to explore her needs and concerns. I felt that I heard her and was a positive presence to her. I was comfortable during the pauses she had and held back from trying to fill in her own blanks with my own suggestions. I felt much more at peace, even happy, at the end of the visit because it went so much better than the last one.

Pastoral opportunities

After this visit I feel that I can more comfortably talk with Ms. F about her own decline and will look to find ways to find out her feelings about it, as much as she is able to. I feel it may be hit-and-miss though given her condition, but it gives me much more groundwork concerning where her spirit is and areas where I can possibly provide listening and reflection.

I continue to visit Ms. F monthly but will visit more often as needs arise or as time allows.

Conclusion

One of my favorite bands has a song called “White Knuckles”, with the phrase “maybe it’s not so bad” featured in the chorus over and over agian. This visit made me think of that song. I entered in to the visit expecting things to not go well. I felt anxious and worried, with my mind everywhere else except where I was and what I was doing. This has been a feature of mine for some time, one I am working to understand and let go of.

This is true not only for my job but for my life in general. I can dwell on the negative and live there for quite some time. I’m learning that things are rarely as bad as I think they are. Spiritually this is a lack of graciousness to myself. I’m often more kind to others than I am to me. Even in writing this report, I was anxious to start off with and quickly began picking apart my visit to find all the bad things and to try not to leave anything out. I realize that if I were to do that then this report would be as long as a book and incredibly boring. So just as with this visit I’m going to continue to try to do my best and learn where I can do better.