Bonus rounds
Nothing left to prove
Nothing more worthy of doing
than serving as God’s hands
Down here in this mess

Bearing witness to the unwinding
of the lives we have built
and the lives we have known

Embracing the new lives
God ushers into our presence
That we might tend to their souls
And they to ours

Honoring the beauty we behold
Grieving the pain we cannot evade
Seeking to touch with love
all that has been touched by fear

Awaiting our time of rest
in God’s welcoming arms

As I begin writing this, I am in transition from 2+ weeks in southern Italy to life back home.  The transition has been delightfully gradual.  One last quiet day at our place nestled in farmland, then saying good-bye to rural Italy.  One last afternoon and evening in frenetic Naples, where we began our sojourn, greeting it like an old friend, then saying good-bye to urban Italy as well.  Catching myself saying “grazie” to a restaurant server at London-Heathrow.  The flight map now tells me we will land in Portland in 7 hours.  As much as we have enjoyed this time away, shared with lifelong friends, Diane and I are looking forward to returning to the familiar surroundings and routines of home.

And then what?  What are we coming back to?  What remains for us to do?  The central goals of our lives—to raise a family, to accomplish meaningful work, to build loving relationships with family and friends—are mostly in the rear-view mirror now.  Even though I feel incredibly blessed that these dreams have come true, we have always oriented ourselves toward goals in the future, and I often find it disorienting to have no big goals in front of me.

Four years ago this month, on an even longer flight home—from Kenya, where Diane and I had served on a medical mission—these same thoughts arose for me, fresher and more urgent than they are today.  And from these thoughts arose the poem that opens this post.  I have tweaked it over the years, but the urge to do so has diminished.  It keeps calling me back, though, and it anchors me at times like this.  It helps me to let go of ambition and accomplishment, for what lies beyond them is far richer—unimpeded engagement with the fabric of life itself, in the warp and weft of each moment.

The poem also reminds me that, even if I have endured my share of losses, my season of letting go is only just beginning.  I see this in the increasing infirmities of family and friends, in the activities we once shared that are no longer feasible.  I see it in my own body, in the fact that the decades have imperceptibly shaved two inches from my height.  I still have the strength for ambitious travel and backpacking, but I am growing more at peace with the notion that I may never again see the backwaters of Kerala or the summit of a Cascade volcano.  I see in some of my patients a weariness so deep that death appears to them like a long-promised rest, and I no longer struggle to imagine feeling such a weariness myself.

Yet every day I wake up to find abundant life all around me.  Whether tending to a grandchild, listening to an elderly patient, or sharing a meal with Diane or another loved one, there is so much in each day that feeds my soul even as I seek to feed the souls of others.  This is what I am returning home to now.  It is what remains.  It is what I hope to do for as long as my body and mind are able.  And it is as satisfying as any ambition I have ever had.

Our administrative assistant stopped me as I was returning to our office.  “Short Stay called with an unusual request.  They have a patient who’s done with surgery but doesn’t want to leave until she speaks with a chaplain.”  I checked and learned that Carmen, in her late 30s, just had a D&C in follow-up to a miscarriage a month earlier.  I headed right down …

I find Carmen lying on a gurney in a small curtained-off space, still in her surgery gown, with a blanket pulled up to her neck.  I take a seat by her side.

“Greetings, Carmen,” I begin.  “Thanks for inviting me to be with you today.  What would you like me to know about you, so that I can be of help to you?”

“Well, I’m Roman Catholic, and that’s very important to me, though I don’t attend church as often as I should—maybe once a month.  What about you?”

“I was raised Catholic, though I’ve been a Quaker in my adult life.  Still, we read the same Bible and follow the same Jesus.”

This seems to put her at ease, and she begins.  “I’m here because I had a miscarriage a month ago and I never stopped bleeding.  It’s just really hard … I’ve been reliving that day again.”  She begins tearing up.

“That’s a huge loss, and I can understand how your procedure today would bring it up all over again.”

“What’s even harder for me right now is feelings of guilt I’ve been having over poor decisions I made a long time ago … I think I’m still dealing with those decisions today.”

“That guilt sounds like a big burden to carry.  Is there anything more you want to say about it?”

She looks away. “I got pregnant and had a baby when I was very young.  I raised him myself, and he’s been the greatest joy of my life, but he’s all grown up.  Now I’ve finally found a good man—Victor—and we want to have a child together, but I keep having miscarriages.  I think maybe it’s because of the decisions I made when I was younger.”

“So … you think that maybe in some way you are being punished for becoming pregnant when you were a teen …?”  Carmen nods vigorously, and tears flow abundantly.  I offer my hand, which she takes, and we sit quietly for a bit.

“Tell me, Carmen,” I finally say, “do you think the Jesus you know from the Bible would punish you today for mistakes you made as a teen?”  Carmen shakes her head no.  “I don’t think so either,” I continue.  “In fact, Jesus says many times that he didn’t come to condemn, that what he really wants for us is new life.”

Carmen visibly flushes with relief.  Her tears continue to flow, but her breathing becomes more relaxed.  We sit in silence again, and soon a look of peace graces her face.

“I’m not a Catholic priest,” I say at last, “so I can’t offer you confession, but let me ask you this:  if you feel clear that Jesus would offer you forgiveness, do you think you can offer forgiveness to yourself?”

Carmen draws a deep breath, then nods and offers a shy smile.  “Yes, that feels right.  It feels so good to get this off my chest.”  We sit for another minute, then she says, “Do you think you could say a prayer?”

“That’s my job!” I say.  “Dear God … thank you for your presence with Carmen and me today.  Thank you for the gift of Jesus, who reminds us of your unconditional love and your desire for us to be healed.  Please help Carmen to accept your forgiveness and to forgive herself.  You have blessed Carmen with a beautiful son, and you have heard of her longing for a child with her husband, Victor.  Help them to know that, whether they are able to have a child or not, you are always with them and will accompany them for the rest of their days.  In the name of the Father, the Son, and the Holy Ghost.  Amen.”

I watch as Carmen makes the sign of the cross, then looks up and smiles broadly. 

“Thank you so much for listening!  I feel like now I can go out and be a better version of myself for my husband.”

◊

My relationship with Christianity is complicated, to say the least, but over time I have found a place of peace.  As a chaplain, though, I watch people struggle with the blessings and burdens of their faith—or lack of faith—every day.  My hope is that, by listening and offering reflection, I can help them untangle a small piece of the knot, so that they might feel less torment and more comfort going forward.  It was a blessing to be invited to do this work with Carmen.

My own upbringing exposed me to some of the best and some of the worst of Catholicism.  My mother’s parents were Irish immigrants, and she embodied what I consider the best of Catholicism.  Still, in middle school I pushed back hard against doctrines and practices that I abhor to this day.  My mother debated me at length about faith, to see for herself what kind of foundation I had formed, then she finally said, “You can leave the church, but I hope you keep searching for a faith to call your own.  I have never mistaken the Catholic Church for Jesus Christ, and I hope you don’t either.  Don’t throw the baby out with the bath water.”  I’m forever grateful for that guidance.

For me, the life and teachings of Jesus are the core of Christian practice.  This might seem obvious, but I never cease to be amazed—and troubled—by how often they get overshadowed by the doctrines and practices of Christian churches, Catholic and Protestant alike.  I listen to many good people like Carmen who suffer from guilt over past actions, a sense of moral inadequacy, and the expectation of punishment that they think they deserve.  I understand where those who instill such beliefs find biblical justification for their doctrines, but in doing so I see them ignoring the “good news” at the heart of the faith.  I can’t help but see this as losing sight of the forest for the trees—or the baby for the bath water—and it breaks my heart every time.

These misguided doctrines—and the behaviors of so many leaders of Christian institutions—have been leading people to disassociate from religious faith and institutions for several decades now.  I did so, too, as a young adult, but the life and spirit of Jesus, and the wisdom that Christianity shares with so many other faith traditions, keep drawing me back to study and practice.  More important for chaplaincy, these teachings provide context for building bridges with many patients I see, whether those like Carmen who are still engaged in institutional religion, or those who have left, or those who have never paid it any attention.  The goal is not proselytizing, but rather helping the patient to use the best parts of their own faith or spiritual identity to do the work of healing themselves.

At one point I asked Carmen if she’d ever had any of this conversation with someone from her church; she replied “no,” and left me to imagine why that might not have felt safe.  I don’t know why she decided to have it with a chaplain who could not offer her the sacraments of her church, but I’m glad she did.  I have no idea if she will ever seek out a Catholic priest for the sacrament of reconciliation, but I hope our conversation strengthened her relationship with God.  As a Quaker, I don’t believe we need a mediator in that relationship, but I do think the company of fellow believers is a great asset in one’s faith journey.  I hope Carmen can find that in the faith tradition that means so much to her.

In awe of the complexity of motherhood, and with admiration for all who pursue this path …

My pager buzzed as I was leaving the chaplain’s office.  “Patient in 935 could benefit from a chaplain visit.”  I see that Dean, age 39, has been admitted for fever and difficulty breathing; he’s COVID-negative, but has an underlying disease that makes his health precarious.  No one is at the nursing station, so I head into his room.  Dean is sitting up in bed.

“Greetings, I’m chaplain Greg.  I’m making rounds and offering conversation, company, or whatever folks might want …”

“Chaplain, huh?”  Dean pauses, staring straight at me.  “I suppose they told you about my sister.”

“Not a thing.  What would you like me to know?”

“Right after I got into this room they put through a call from the Medical Examiner,” he says in a flat monotone.  “They just found my sister dead in a homeless camp in Seattle.”

“Oh, Dean, I’m so sorry.  What was her name?”

“Clara.  They said it looked like she hanged herself.  They found a notebook with her stuff where she’d written that she was done with humans.”

“That’s so hard … how are you doing?”

“I’m OK.  We weren’t close.  I haven’t heard from her since my wedding day in 2010.  I tried to get her to come and she said she would, but she didn’t.  Later she called and said I probably got some nice gifts and she needed money.  I told her no and she hung up on me, and that was the last time we spoke.”

Dean’s tone remains unemotional but his eyes connect intensely with mine.

“Do you have other siblings or family?”

“She’s it.  Three years younger.  My parents are not good people.  When I was a kid, they grew weed in the basement and cooked meth in the living room.”  Dean proceeds, in a matter-of-fact way, to narrate a litany of abuse and neglect.  He concludes, “I’ve seen a lot of things I wish I could unsee.”

“Are your parents still alive?”

“They are, though they split when I was 10.  They move around, I never know where they are.  I need to notify them about Clara … I’m not looking forward to that at all.”

Dean hands me his phone.  It displays an obituary, with a picture of an old man sitting by a lake, fishing.  “That’s my grandpa.  He and my grandma never turned their backs on me, no matter what my parents said about me.  I would ride my bike for miles just to be with them, to get away.”

Dean takes his phone back, fiddles for a minute, hands it back to me with a picture of a young couple.  “Your wedding day,” I say with a smile.  “Yep,” he affirms, “and now we have two great kids.”  More pictures follow, displaying the life Dean has built for himself as a handyman in rural Washington.

I return the next day to find Dean in street clothes.  His RN enters after me, tells him his discharge orders are complete, and asks him to coordinate a pickup time with his wife.  “You call her,” he replies, “I don’t need to get in the middle.”  The nurse, a bit flustered, agrees and exits quickly.  Dean flashes me a wry smile.

“Looks like you’re feeling better.”

“Yeah, but …”  He pulls out his phone.  “I’ve texted both of my parents, telling them I have important news.”  Dean shows me a text containing two dates, which I infer correctly are Clara’s dates of birth and death.  “I thought that might get their attention, but neither of them has replied, so I guess it’s up to me to figure out what to do with her ashes.”  He’s clearly thought about this a lot since our first visit; he’s committed to honoring Clara’s life, and to giving his parents their best shot at doing the same.

Dean then asks, with sincere interest, how my work has gone since we last spoke.  I say I’ve seen the whole spectrum, from an old man all alone in the world returning to the streets (Gideon), to a man my age with advanced cancer, surrounded by family and friends, making plans for his final weeks of life.  “So often it comes down to having good people in your life,” I conclude.

“I agree.  I’ve seen a lot, and I consider myself fortunate.  We don’t have much money, but money doesn’t do it.  I’ve seen people with lots of money and the hardest hearts, and I’ve known people with nothing at all who will give you the shirt off their backs.  I’m not religious, but religion doesn’t do it, either.  Some of those religious types are so busy being holy they don’t have time for people in need.”

Just then Dean’s phone buzzes with a text message.  He looks at it and grins, then hands it over to me.

“Your nurse says I can come get you.  I’m jumping in the car right now.  I so f***ing love you! ❤️❤️❤️“

◊

Few things inspire me more than stories of resiliency like Dean’s.  The childhood he related to me was horrific by any standard, but not uncommon, especially among people whose lives have been marked by prison, addiction, or homelessness (e.g., Hector).  What’s remarkable, but also not that uncommon, is Dean’s escape from this life.  But it wasn’t easy …

Dean struggled with addiction and homelessness in his teens, though by his own account he’s been clean and sober for 20 years, and living a stable family life for a dozen.  He seems to have sensed early on that he needed to get away from home, and he did so as soon as he could; living on the streets as a teen rarely goes well, but somehow he escaped that, too.  Dean’s demeanor was low-key and laconic, but I quickly sensed a core of steel that could push through the most difficult obstacles.

Dean’s grandparents were positive influences—they often are in stories like these—but they don’t seem to have intervened actively, just offered a place of refuge.  There may have been others along the way—a teacher, a coach, a social worker—but Dean never made any such mention.

And then there’s Clara …  I can only wonder about the factors that propelled her life and Dean’s to such different outcomes.  This kind of divergence in families is hardly rare, of course, though their situation seems particularly stark.  I didn’t sense that Dean was uncaring towards Clara, more that he was simply a pragmatic survivor who knew his boundaries and knew he had to maintain them with Clara, too.

What rises for me when I think about Dean and Clara is mystery, humility, and grace.  My own life gives me at best an inkling of what it would have been like to grow up in their family of origin.  I have no idea whether I would have been reduced to ashes like Clara, or risen from the ashes like Dean.  I celebrate Dean’s resiliency as an example of what the human spirit is capable of, but I do not condemn Clara, or the many like her, who cannot find a way forward after such a traumatic childhood.  There, but for the grace of God, I might have gone. 

My sense is that Dean understands that, too, and lives each day with deep gratitude for the life he has been granted.  And that, for me, is truly inspirational.

Prior to meeting Gideon a week ago, I’d read in his chart that he was 79 years old, his address was a shelter, and he had no known contacts.  He’d been hospitalized for pneumonia, and he’d begun to respond to treatment.  When I entered his room that day, he welcomed me and muted the TV, but continued to gaze at it throughout our conversation, looking at me only briefly.  Still, he was courteous in an old-school way, and he spoke thoughtfully of growing up in the deep South, his tour of duty in Vietnam just before things heated up, and going to college on the GI Bill.  But he did not offer anything about the 55 years since then leading up to his present situation.

Yesterday Gideon was referred for spiritual care by a provider concerned by his despondency over being discharged back to the shelter.  Gideon had asked her about eligibility for Oregon’s Death With Dignity Act; she’d told him he does not qualify, having no terminal illness.  In response to her follow up, however, he denied suicidal ideation.  Unable to offer Gideon better options, the provider hoped a chaplain could somehow help lift his spirits.

When I enter Gideon’s room, he is dressed in rumpled street clothes, sitting in his bedside chair, holding a small, grimy knapsack containing all his worldly belongings in his lap.  At first he doesn’t recognize me, then recalls our time together.  I pull up a chair and sit facing him.

“They’re telling me I’m well enough to leave now,” he begins.

“Are you feeling better?” I ask.

“Couldn’t feel worse,” he replies.  “The minute I walk out onto those streets I’m a dead man.  It’s cold and raining and I can just now barely walk.  I’m an old man, I won’t last long.  I wish they’d just off me here and now.”

“I’m so sorry, Gideon.”

“They tell me they’ll pay for a ride back to the shelter.  They don’t get what it’s like to live there.  There, I’m just a rat among rats, living like vermin.”

“I saw the social worker’s note about all the places they’ve looked for you, but nothing’s come through.”

“So why are you here?  What have you got to offer me?”

I draw in my breath.  “All I have to offer you is compassion and prayers … but I realize that might not seem like much help in your situation.”

“Not your fault.  I just can’t believe there’s nothing better out there for a person like me.”

“Honestly, I can’t believe there isn’t either.  I’m so sorry.”

I extend my hand, and he takes it.  We hold hands together for a moment of silence.

“I appreciate your coming by to see me,” Gideon says in closing.  “I appreciate all you are doing to show kindness to us humans out there.  It means a lot.”

An hour later Gideon’s name is erased from the board at the nursing station, and his room is empty …

◊

It is the morning of Easter Sunday as I write this.  For most Christians, Easter represents the triumph of hope over despair.  At this very moment, I’m not feeling it.  Elder Chaplain is committed to the notion of practicing hope amid loss.  Today, practice feels hard.  Today, instead of hope, I mostly feel anger.

I’m angry at the multiplicity of factors causing homelessness crises all across our nation.  I’m angry at the economic polarization that makes the comfortable more comfortable (and I count myself among those) while increasing numbers are pushed farther to the margins, out of even the most basic housing.  Homelessness is caused by more than simple economics, but it’s a powerful contributing factor.

I’m angry at the collapse of our mental health system. Like many my age, I was appalled by the depiction of institutional mental health care in One Flew Over the Cuckoo’s Nest, but I believe we have over-corrected.  My brother-in-law suffered a head injury in his 20s that caused lifelong mental health problems; without a supportive family keeping him connected to care, and ultimately getting him committed to a safe, caring locked group home, he surely would have spent his last decades living like Gideon.  Oregon, like many other states, has far too few institutional settings that can provide the care and housing my brother-in-law received in Pennsylvania.  We must find a better balance.

I’m angry at the scourge of drugs, especially meth and opioids, that I see destroying the lives of so many patients—rich and poor, urban and rural.  Two weeks ago I visited with Charles, a patient who had been living on the streets with “polysubstance abuse.”  Chart notes stated he was abusive to staff early in his stay, but he’d been off drugs a few days when I saw him.  “You know,” Charles began, “I’m actually a good person when I’m clean”—and you could see that he was.  “But,” he continued, “I can’t find a place to live where I can stay clean—I can’t do it on the streets or in a shelter.”  Charles was likely discharged just as Gideon was, and is back to being a less good person than he is capable of.  This scourge has many sources—the Sacklers and McKinsey peddling Oxycontin, the drug cartels peddling everything, American moralism pushing criminal punishment for the illness of addiction—but we need to do better.

I’m angry at our political system and the people it puts in power.  I’m angry at the states that refuse to expand Medicaid, which at least gives low-income folks a fighting chance.  The voters in Oregon passed well-intentioned legislation to fund addiction services and supportive housing, but the bureaucrats in charge of these programs have failed to put most of this money to use.  Now our legislature is considering a bill to require hospitals to domicile any patients who cannot be discharged to housing, as if the hospitals have a place to house all of the Gideons passing through their doors.  I would love for any legislator in favor of this bill to spend a day in our shoes and then explain how this would work.  Hospitals must play a key role in this crisis, but we need better ideas than this.

Perhaps more than anything, I’m angry at those who fail to see the humanity in people like Gideon and Charles—while owning that I often fail at this myself.  Many of those we see living under bridges and in tents have made, and continue to make, poor choices, to be sure, but almost all come from deeply traumatized upbringings that remind me of the privileges I carry into the world.  These are the people Jesus found worthy of his time and care, but not his judgment; that was reserved for those who crossed to the other side of the road to avoid them.  I am grateful to work for a hospital named Good Samaritan, and people like Gideon remind me of the work I need to do to live up to that name.

As Holy Week comes to an end, I take note that the first thing Jesus did after entering Jerusalem on a donkey was go to the temple and overturn the tables of the money changers.  This angry outburst likely hastened his execution, but the gospels tell us it gave hope to the blind, the lame, and the children.  I conclude that, in order to celebrate the triumph of hope over despair, it may be necessary to first give vent to anger at the injustices causing that despair.  I am grateful to Gideon for getting me in touch with that anger, and for encouraging me to keep trying to show kindness to all the humans out there.  And I am grateful to you, my readers, for accompanying me through it all.

Frank had lived a varied and sometimes difficult life by the time he landed in the hospital with a mild stroke.  Like many middle-aged men, several factors contributed to his poor cardiovascular health, but his prognosis was decent.  However, he experienced a major heart attack soon after arriving, and despite valiant efforts he suffered severe anoxic brain injury before circulation could be restored.  Now lying in the ICU in a persistent vegetative state, decisions needed to be made regarding whether to continue life support via ventilator and feeding tubes.  But by whom?

As elsewhere, Oregon law defines this responsibility.  Frank had no advance directive, which would have specified his wishes.  He had no spouse, either, so the law defaulted to his five biological children.  Frank lived with his eldest, Samantha, who had visited him twice in the hospital, while Karen had been by his bedside for hours each day.  The two women were several years apart, born from different mothers, and the tension between them was palpable.  His other three children were estranged from Frank to varying degrees, but after some effort they were located and engaged.

A “goals of care” conference has been called to seek a decision.  I join several others gathered in person, including Samantha, Karen, and Karen’s sister Abigail, along with Dr. Jonas from palliative care, Frank’s ICU nurse, and others.  Joining by phone are a neurologist and other specialists consulting on Frank’s case, as well as the other two siblings, who do not live locally.

Dr. Jonas convenes the group and reviews Frank’s case, noting his status has not changed in days and there is no basis to believe it will.  The neurologist reviews the EEG data and other tests and offers a concurring assessment.  Frank’s ICU nurse summarizes her bedside observations, and also concurs.

Samantha, the eldest, is armed with internet research.  She grills the team with detailed questions and cites cases in the literature of “miraculous” recoveries from similar injuries.  The doctors acknowledge Frank’s chances of recovery are not absolute zero, but very, very small.  They do not oppose allowing a few more days, but they gently press the family for a timeline to make a decision.  Karen jumps in.

“I can’t believe Dad would ever have wanted to live like this.  You all know him, he’s so strong and proud, he would hate the thought of being helpless like he is in there.”

“He’s been living with me for the past three years,” Samantha retorts.  “Who are you to speak for what he would have wanted?  You’re saying you want to give up on him?”

This argument devolves rapidly, and Dr. Jonas steps in to engage the other siblings.  Abigail quickly sides with Karen, as does Stephanie on the phone.  Frank’s only son refuses to express a viewpoint.

“This is ridiculous,” Samantha explodes.  “You guys haven’t come by to see Dad the whole time he’s been living with me.  You might be willing to give up on him, but I’m not.”  She turns to Dr. Jonas.  “So what happens now?”

Dr. Jonas pauses to restore calm, then proceeds.  “Our goal is to reach a consensus, but it’s not always possible.  If a consensus can’t be reached, the law specifies that the views of the majority prevail.  I know it may not seem fair, but it’s the law.”

Samantha scans the faces of her half-sisters in the room.  She screams, “I can’t believe you all are doing this to Dad,” and bolts from the room in tears.

After a few moments to gather ourselves, the remaining children are polled to affirm their wishes.  Frank is removed from life support later that day and dies shortly thereafter.

◊

This is not the way anyone wants a life to end.  I wish I could say this case was unusual but it’s not, except for the level of animosity between family members.  I have participated in similar “goals of care” conferences where family members love and trust one another, but still agonize and disagree over this excruciating question:  What would Dad (or whoever) have wanted?

Few requests feel more daunting than deciding the fate of a loved one without their input.  As this story indicates, it places a tremendous burden on caregivers as well.  The advance directive seeks to relieve these burdens by giving a person the opportunity to speak for themselves while they still have capacity to do so.  Unfortunately, many people refuse or procrastinate on completing the form while healthy, and then, like Frank, experience an unexpectedly sudden decline.

Modern medical technology can be remarkably effective at saving a patient’s life, but it often cannot restore or stop the decline of that patient’s quality of life.  Each of us faces an increasing likelihood that we (or a loved one) will need to deal with the questions addressed by an advance directive: 

• Who do I want to make decisions for me if I am not able?  As Frank’s case reveals, the law will decide for you if you don’t decide for yourself.
• What constitutes an acceptable quality of life for me?  Is it important to me to be able to recognize and communicate with loved ones, or simply that I not be in interminable pain?  These are questions Frank’s children could only guess at.
• What interventions am I willing to undergo to sustain my life?  Respirators, IV fluids, feeding tubes, and kidney dialysis can all play a critical role in treating disease and restoring or maintaining quality of life, but they can also sustain a life that many consider not worth living.

Nobody likes preparing a will, either, yet doing so is now common practice.  Why should we be any less diligent about specifying what happens to us while we are still alive than what happens to our stuff when we are dead?  In both cases our loved ones will be impacted by our failure to express our wishes.  In my view, if you have need for a will, then you need an advance directive, too.

Last week I sat with a woman in her 40s with advanced endometrial cancer, along with a beloved niece.  She had just been told she had six months or less to live, and she requested help in completing an advance directive.  Still in shock, she responded numbly to questions about name and address, but perked up as she spoke by phone to her sister and brother, who agreed to serve as health care representatives if she became incapacitated.  She reviewed several crisis scenarios, in each case choosing “I want to be kept comfortable and be allowed to die naturally.”  She grew more expansive as she responded to prompts about what she values in her life, her spiritual beliefs, and her preferred places of care.

At one point she said to me, “I used to think choosing anything other than all possible life-prolonging measures was committing suicide, which as a Catholic I consider a sin.  I now see that it’s not—it’s still leaving God in control.”  She continued, “This was hard, but I’m glad we did it.  I feel good having these things written down.  I’m so relieved that I won’t be burdening my sister and brother with having to make these decisions for me—how awful that would be for them.”  I affirmed that she was giving all of her loved ones a wonderful gift.

If you would like to learn more about advance directives, please click here to view the Oregon form, or search online for an equivalent form for your location.

In January I sent a note to Elder Chaplain subscribers soliciting their personal experiences of the topics shared in this blog. I have since had some wonderful conversations with a few of you, and this column is the fruit of one of them.

When Kevin moved to Los Angeles in the 1980s, fresh out of college, he struggled to make connections and build a new life while working a mundane job in a bank.  Before long, though, he met Marcia, a travel agent in her early 50s who offered him warm friendship and soon became his favorite customer.  On the surface they had little in common, but Marcia’s fun, upbeat enthusiasm and zest for life was exactly what Kevin needed.

A few years later Kevin left LA to attend grad school.  His subsequent work and life took him many other places, but Marcia remained an anchoring presence.  They talked regularly by phone, and from time to time Marcia bailed Kevin out of travel jams.  Kevin visited California often and relocated there more than once, where Marcia became a fixture at many parties and celebrations that Kevin hosted.

When COVID hit, Kevin was no longer able to travel to California.  Cognizant of Marcia’s advancing years and realizing how much time had passed since he’d last spoken to her, he recently called only to find her number was no longer active.  Panicked, Kevin tried unsuccessfully to contact Marcia through several family members. As her 93^rd birthday was approaching, he mailed a card to her last known address and, a few days later, was joyful to receive a phone call from Marcia.

She began, “I’m not doing so good, baby.  I don’t know that you’re gonna want to see me in this state.” Kevin replied, “I’m flying out to California right away.  You’re still one of my dearest friends.” 

Right after this, Kevin learned from Marcia’s son that she was rapidly declining and her family was trying to find her an assisted living placement.  By the time Kevin arrived in LA two weeks later, Marcia had moved directly to residential hospice. The setting was wonderful and her caregivers were attentive and kindhearted, but Marcia had continued to decline and was asleep most of the time.

Kevin began, undeterred.  “Marcia, I know you’re in there and can hear me, so I’m just going to talk.  You don’t need to respond at all, I just want you to hear what I have to say.”  He recounted many high points of their 40-year relationship, and how much her friendship and constancy meant to him.  He told her she had always reminded him that, despite life’s hardships, it was important to bring a sense of joy and fun to every moment in life.

With that, Marcia opened her eyes briefly, smiled, and said “Ya gotta have fun, baby.”  Marcia died two days later.

Kevin called to share this story with me the evening that Marcia died.  He was not yet aware of her death, though he said, “I wouldn’t be surprised if she has passed by now.”  He just needed to talk about his extraordinary friend and he knew I would want to listen to his story.  Indeed I did.

Being present with someone who has begun actively dying is never easy, but Kevin’s instincts were spot on.  Research tells us that hearing is the last sense to go, so one should always act as if the patient is fully aware and listening, even if we receive no confirmation.  Kevin may have spoken out of his own need for expression, but what a gift he provided to Marcia!  I can imagine nothing more meaningful to receive on my own deathbed than a visit from a cherished friend to express what our relationship has meant to them.  And what a tremendous reward for Kevin to know that his words were received and appreciated.  This is end-of-life accompaniment at its finest.

Still, Kevin felt a some guilt for having lost touch with Marcia during COVID.  It’s easy after losing someone close to think of opportunities for connection that went unfulfilled.  I find it hard myself to reflect on anyone I have loved and lost without thinking of times I wished I’d shown up better, things I wished we’d shared but never did.  Kevin demonstrated how much he valued their friendship through the lengths he went to re-establish connection with Marcia and to share a final visit.  We are never the perfect friends we wish we could be, but I hope Kevin finds peace and acceptance that he was a very good friend indeed to Marcia.  I know I am grateful to count him as a friend myself.

While searching the internet for Marcia’s contact information, Kevin made an upsetting discovery:  Marcia’s husband had been murdered a few years before Kevin met her, leaving her to finish raising her children on her own.  Kevin asked me how he could have known her all these years without learning this—if she felt that close to him, wouldn’t she have told him?  I shared something I’ve had to learn as a chaplain:  trust a person to disclose what they wish to disclose.  Just because a relationship isn’t transparent doesn’t mean it isn’t close–think of all that is not disclosed between parent and child, even when they are close.  We set boundaries to serve our purposes in all our relationships. 

Perhaps, we speculated together, Marcia didn’t want to burden Kevin, and their relationship, with the knowledge of this traumatic event, especially given how young Kevin was when they met.  Perhaps spending time with Kevin was her “happy place” where this event did not intrude, and she wanted to keep it that way.  Perhaps one of the things she treasured in their relationship was that Kevin’s company offered a space where, in keeping with her motto, she could always have fun.

I received a request for consult one evening for Robert, a 90-year-old man with many health issues.  His wife, Rosemary, was coming to terms with the likelihood of his imminent death, and she was asking practical questions around what she would need to do in the aftermath.  For many reasons, providing guidance in these matters falls to the Spiritual Care team.

I meet Rosemary outside of Robert’s room.  To my surprise, she looks much younger than I’d expected, somewhere in her 60s.  She seems fairly composed and confirms my understanding of her situation, so I suggest a quiet place just outside the nursing unit where we can talk.

She pauses for a moment, then says, “Do you suppose you could do a prayer in the room with Robert?  He’s not really a prayer person and neither am I, but it just seems like a good thing to do.”  I agree.

We enter his room, taking places on opposite sides of his bed.  Robert appears to be in a deep sleep; he hasn’t moved or spoken all day.  Rosemary announces in a loud voice, “Robert, I’ve got the chaplain here.  I thought it would be nice if he said a prayer.”  We each take one of his hands, then I take Rosemary’s and offer prayers for peace and comfort.  We leave Robert’s room and take our seats outside the nursing unit.  Rosemary seems visibly moved.

“Did you notice how firmly Robert took your hand?  We’ve been married 25 years and I’ve never seen him hold a man’s hand like that.  He rarely even holds mine that way …  He was more responsive than I’ve seen him today—I think your prayer really touched him.  I could feel him relax as you prayed—he seems to be at peace.  Maybe prayer matters more to him than I thought.”

Just then Robert’s nurse and a palliative care doctor approach.  We have an impromptu “goals of care” conference, with the doctor stating that Robert appears to be moving into actively dying.  Rosemary gradually accepts their recommendation to move Robert to “comfort measures only.”  After addressing a few more details, they leave us to resume our conversation.

“Robert has been incredibly healthy until the past 18 months or so.  He’s had a few hospitalizations since then, but each time he’s fought hard and pulled out.  I guess I thought he’d pull out this time, too …”  We sit together quietly while her words hang in the air.

“I mean, with our age difference, we talked openly about the fact that he would surely go first, and I would still have a lot of life ahead of me.  So it looks like that’s where we have finally arrived …?”

“It just might be,” I reply.  Again, we sit quietly for a bit.

“I have to ask you this,” Rosemary resumes again.  “Is it OK that I’m feeling a sense of happiness?  I always thought I’d feel distraught when Robert died but I’m not feeling that at all.”

“I think it’s important to pay attention to whatever it is you are feeling.  Can you say more?”

“Well, Robert and I talked a lot about what end of life might look like for him—that he might get dementia, or a long, painful illness.  Instead, we’ve had a lot of healthy years together, and now a short time of illness.  If this is what the end looks like for him, it seems good compared to the scenarios we’d contemplated.  I’m happy for him, and happy for me.”

“That all feels healthy to me.  Given that never dying isn’t an option, what you’re experiencing seems good in the spectrum of things.  Navigating end of life is one of the most difficult tests we face, and it seems that, with your help, Robert is going to do it well.  I think that’s definitely something to celebrate.”

Robert died around 4:00 am the following morning.

◊

As a chaplain, I pay special attention when someone begins a question with “Is it OK …”  I see it as a sign they are feeling strong but conflicting emotions.  Patients and family members often regard chaplains (among others) as possessing the power to tell them what is and isn’t OK to feel.  As in this story, they can usually answer their question for themselves once given a safe space to express their feelings.  The chaplain’s job is often just to create the safe space.

One root of the problem, I think, is that many of our cultural traditions and religious institutions claim a moral authority that weakens our trust in the validity of our own feelings.  This can lead us to think we “should” feel a certain way about a situation (like an imminent death), when we might not feel that way at all.  In these situations, we often downplay our emotions and look to authority figures (religious, family, friends) to tell us how we should feel.  But our feelings simply are what they are, and they resist being reshaped by what someone else tells us they should be.  Instead, we end up in internal conflict.

Our raw emotions often aren’t the best guide for how we should act, of course, but I think it’s essential to listen for what they might be telling us.  They provide important data!  (In Quakerism, we say, “listen for how the Spirit may be moving within you.”)  Conventional wisdom may hold that happiness at the time of a loved one’s death is a sign of a hardened heart, but once Rosemary explored her feelings she could see they stemmed from a deep love of Robert and a mature understanding of mortality.  It was not only OK, it was beautiful, and I think Robert would have smiled to see her arrive at this place.

Rosemary didn’t need me to tell her this (nor could I have), she seemed only to need permission to look inside and find that truth for herself.  To paraphrase the Wizard of Oz, she had the power within her all along.

“Hi, my name is Greg, I’m one of the chaplains here, and I have come by to offer conversation …”

I have just entered the dimly lit room of Hector, a man in his 50s with a nasty abscess.  As I speak these words he comes into focus:  a shaved head, heavily tattooed arms, staring out the window.  He is visibly agitated, rubbing his eyes with his forearm, sniffing.  He neither accepts nor declines my offer.

“… or company, or whatever you might want.”

After more silent agitation, he begins without looking toward me.  “Everything is so f***ed up right now, I have no idea what to do.  My girlfriend, if that’s what she is, dragged me up here from Arizona—said things would be better here.  But I don’t know anybody here, and now I’m stuck in here and she doesn’t care.  She was supposed to come by today but she’s not, she’s going off to get high with friends.”

“I’m so sorry, Hector.  That’s really hard.”  I sink slowly into the chair beside his bed.

“I want to get out of here and go back to Arizona, but she’s got my wallet and I don’t have any money.  If I go back I’m facing 10 years, but I’m thinking maybe prison’s better than being here, at least there I know what’s what.”

I nod silently, offer a sympathetic grunt.  I am truly at a loss for words.

“I’m trying to get clean after nearly OD’ing and she said she’d help but she’s started using again.  Every time I try to say anything to her about that she just pins it all back on me.  Everything is my fault.”

“You’re trying to get clean, and that’s hard to do when the person you’re with is using.”

Hector looks toward me for the first time.  “Exactly.”  He looks away again.  “I’m clean all right—I’ve been in here for two weeks—but now all these feelings are coming up that I’ve never let myself feel before and I can’t stand it, it hurts so bad.  All I want to do is use again to make the pain go away.”

“I’m sorry, Hector.  That sounds awful.”

“We were trying to get help at a shelter here. They told me all I need to do is put my faith in Jesus, to trust God and God will take my pain away.  How the hell is that supposed to work?  I’ve tried reading the Bible like they told me but I can’t find anything in there that helps me.”

“Sometimes people use the Bible in ways that they think are helpful but actually aren’t helpful.”

Hector turns toward me again.  “Not helpful at all.  When I OD’ed I called my grandmother and all she had to say was that the Bible says suicide is a sin.  That didn’t help anything.  It’s true, I suppose, that using heroin is like trying to commit suicide.  But I was born addicted …”

“From your birth mother?”

Hector nods, then turns away.  “Got put up for adoption.  My adoptive parents were pretty good to me but we never had any money.  So I started stealing stuff to make money.  My mom died when I was 14 and my dad when I was 15 so I joined a gang to have someplace where I felt like I belonged.  I went into prison when I was 19 and that’s where I’ve spent most of my life.”

“That’s a hard life, Hector.”

He looks toward me and nods again.  Just then a doctor enters, and we both know our time is up.

“I just appreciate you listening, letting me say all this instead of keeping it bottled up like I usually do.  I hate feeling like this, I hate that I’m crying like this.  But I can’t tell you how much it means for you to come and listen to me.”

◊

I only made it 10 steps from Hector’s door before I needed to take a seat and try to absorb this conversation.  I have listened many times to people raised (or still growing up) in difficult circumstances, but this one struck especially deeply.  The excerpts above only begin to capture Hector’s rage, his sense of betrayal by everyone in his life, the way his pain pierced him to his very core—and his beautiful spirit.  Like so many patients I see, I left his room wanting more—not so much to learn more personal history, but to experience his humanity more fully.  Sadly, this was our only visit.

Approaching Hector’s bed, though, as I settled in to his physical presence and recognized the evident gap in our life circumstances, my main thought was, “What could I possibly say to this person that might establish a connection?”  The answer: “Not much—just listen well.”  Not everyone wants to speak, but everyone wants to be listened to if there is no agenda other than to become known by another person. 

It’s hard to imagine who Hector might have ever spoken to before in this way.  Not his peers or jailers, for whom vulnerability is a sign of weakness to be despised or exploited.  Not the people at the shelter, who saw him as a chance to save a soul for Jesus.  It drove home for me again how universally we desire simply be known, respected, and loved as the human beings we are at our core.

Albert King’s blues classic “Born Under a Bad Sign” begins:

Born under a bad sign, I been down since I began to crawl

If it wasn’t for bad luck, I wouldn’t have no luck at all

Like many people, I often reflect on why I was born into my time, place, and family.  I’ve had my challenges, but relatively speaking I won the lottery.  Hector did not.  One theme that ran throughout our conversation, though never explicitly stated, was, “I’m trying to be a good person.  What did I do to deserve this?”  I don’t think he did anything, but that doesn’t really answer his question.

I don’t believe I deserved or earned my good fortune, which leads me to a place of gratitude for God’s grace.  But what is the counterpart for misfortune?  How does one forge a trusting relationship with one’s creator when born into such grim circumstances?  I don’t have any answers to these questions, either.

I know that many who are born into such circumstances nevertheless do form faith.  I wonder about the experiences and/or environmental factors that make such faith possible.  I wonder how someone in Hector’s situation could come to believe in a loving God that wants the best for him.  I see God’s light burning beautifully within Hector, in spite of all his suffering, but I wonder what it would take for him to see it and believe in it himself.

Despite not having answers to these questions, this is the work to which I most feel called.  Maybe a lack of answers is an essential prerequisite to doing this work well.

Gordon is in his 80s, with advanced metastatic cancer. He has moved to “comfort measures only,” but he retains a razor-sharp mind.  He was an engineer by trade but is a scientist by disposition:  he asks thought-provoking questions and follows the evidence where it leads him—including, in his case, to Christian faith.  In our first conversation, after sharing a story of a vision of heaven, he said, “Some people might call me crazy for believing in something like this.  Do you?”  I said, “If that is your experience, who am I or anyone else to argue with it?”  He replied, “It’s my truth.”

During that first conversation, Gordon spoke lovingly of his developmentally disabled daughter.  He had taken care of her for several years after his wife died, then helped her transition to the group home where she now lives.  He also briefly mentioned a son.  I knew from social work notes that his son had misappropriated funds intended for his daughter, and that Gordon had recently assigned power of attorney to a trusted niece to recover these assets and oversee care for his daughter.  I saw no opening to ask Gordon about this, and he did not go there, so I honored the dictum to “trust the patient to say what they need.”

When I look in on Gordon a few days later, he tells me he is in “incredible pain” and that he had just received morphine.  I return that afternoon to find him lying flat in bed, eyes only slightly open, but eager to resume with his theological questions.  We discuss a few, then the conversation takes a turn.

“You know how Catholics say that the only way a confession can be effective is if you confess to a priest?  What do the Protestants say?  Does a confession have to be made to another person?”

“There’s many kinds of Protestants, and I’m no expert.  But my personal belief as a Christian is no—I know of nothing in the Bible that says confession can’t be made directly to God.”  He nods.  “Still, some people find it meaningful to also share with another person.  Is there something on your heart?”

He stares off silently for several moments.  “No, there’s nothing I can do about it at this point anyway.”  He lifts his arms off his chest, slowly runs one hand over his other arm, then switches hands and repeats.  “I’m getting really old now.  My arms are so weak.  I can’t move my legs at all.  I’m in pain a lot of the time.  I’ve even lost my sense of humor.”  He smiles noticeably.

“I’m not buying that part about the sense of humor—you couldn’t hide that smile.”  He smiles again.  “But I hear you on the rest—I can see that it is true.”

“It is so much work just to stay alive right now.  But I need to do so until I’m sure my daughter’s money is returned to her, until I know she has what she needs to live on.  That’s what’s keeping me working at staying alive.”

“What are you hearing about how that is going?”

“I talked to my niece today, she said it is very close to getting done.”

“That’s good news—I’m sure that will be a relief to you.”  He nods.  His energy is dissipating, so I move to close.  “Gordon, when we spoke the first time, you told me about your daughter’s vision of heaven, and the comfort that it gave you about your own life after death.  Is that still comforting for you?”

“Yes, very.”

So we closed with a time of prayer:  honoring Gordon’s loving care for his daughter, asking for strength to conclude his unfinished business, for peace to accept what he cannot change, for the fulfillment of his vision of heaven—and with a shared smile, wishing God luck in answering all of his questions.

◊

I learned early in my adult life that, within limits, the human will to live can push back the moment of death.  I was 20 and working on a project 2000 miles from home when my mother was diagnosed with lung cancer and given six months to live.  My mom and I shared long phone calls over the few weeks it took to complete my project; I left to drive home the day it concluded.  Taking turns with my brother, also living on the west coast, we drove straight through in less than 48 hours.  Upon arrival we learned our mother’s health had deteriorated right after our departure, and, we were told, “she’s holding on by a thread, just waiting for you two to arrive.”  We hurried into her bedroom and said our good-byes.  She died that afternoon.

Stories like this are common in the literature, and in my experience.  The theme that runs through these stories is “unfinished business.”  Many people, upon receiving a diagnosis that sets clear limits on their longevity, are encouraged to “put their affairs in order.”  This means different things to different people, of course, and is easier said than done.  Not all items on a person’s “bucket list” can be checked off.  Difficult family conflicts, built up over many years, may be impossible to resolve in the time allowed.  As time grows shorter priorities often change.  If a desire seen as truly essential seems within reach, people like Gordon and my mother will put great effort into staying alive, and if it is accomplished will then let go and pass quickly.

But what about affairs that cannot be put in order, especially ruptured relationships that cannot be repaired?  I never learned the story of how Gordon’s relationship with his son broke down—the series of events that led to him battling his son in court while on his deathbed—but it had to have been painful.  I can only speculate, but Gordon may have felt remorse over some of his own actions that contributed to this situation, and in his questions about confession he may have been seeking a way to find forgiveness.  I take no umbrage that Gordon didn’t choose to share his thoughts with me, but I hope he felt clear to take it up directly with the God he loved so much.

A lifetime is never enough time to take care of all of our unfinished business.  The sooner we get started, while time seems abundant, the less we will have to put in order when time is short. But it is still not enough—there are likely always matters about which we feel, “there’s nothing I can do about it at this point.”  We need to make peace with the knowledge that some of our most cherished hopes will remain unfulfilled when we die, and find a way to be reconciled with ourselves, and with our creator, for the work we could not manage to complete.

Photo by Martin Lostak

Most days at my hospital the Spiritual Care team receives requests for prayer prior to a surgical procedure—some major, some minor. After experiences like the one I related in Once a Parent, Always a Parent, I now make it standard practice to offer prayer for anyone accompanying the patient, knowing that the waiting can be as difficult and anxiety-inducing as having surgery oneself.

My friend Elissa Altman, a wonderful and widely published writer, wrote a reflection last spring that captures the experience of waiting for a loved one in surgery with gritty accuracy, honesty, and vulnerability. I have been looking forward to sharing it with you all ever since, and it now feels like the time is right. With no further ado, here is the link to her essay, published in the prestigious Orion magazine. I encourage you to explore Elissa’s writing more deeply—you will be well rewarded.

Inside the Waiting (click to view essay on the Orion magazine website)