Toward Meaning Chaplain Bruce D. Feldstein, MD
Stanford, Calif
JAMA. 2001;286:1291-1292.
When I came on duty at 3 PM, it seemed like the most ordinary of days. At the time I was a senior physician in a high-acuity emergency department at Kaiser-Permanente Medical Center in Santa Clara, Calif, chair of the Peer Review and Quality Improvement Program, and faculty in the Stanford-Kaiser emergency medicine residency program. I took sign-out from Dr Koscove, who told me, "I've got an 86-year-old woman, Mrs Martinez, in room 17 with nausea, vomiting, and dehydration and a history of metastatic lung cancer previously treated with chemotherapy and radiation. She was discharged from the hospital two days ago for the same thing. I controlled the nausea and vomiting with IVs and ordered a CT scan to look for brain metastases and signs of increased intracranial pressure. I told her you're taking over. You'll need to review the scan, and see if she can tolerate oral fluids, before discharging her."
I walked over and introduced myself to Mrs Martinez (not her real name) and her son. She was sitting quietly on the gurney.
"Hello, I'm Dr Feldstein. I'm taking over for Dr Koscove. I see that you're feeling better. I'll have the nurse bring you some water while I review the blood tests. If you can keep the water down and the tests are OK as I expect, then I can discharge you home to follow up tomorrow with your oncologist, Dr Post" (also it is not a real name).
At that moment the nurse interrupted. "Dr Feldstein, there's a call for you." I excused myself. The ward clerk handed me Mrs Martinez' CT result: "Multiple brain metastasis. No shift." Sobered, I put the slip in my pocket to give to Dr Koscove. It was a good pickup.
After I took the call, I asked an intern who was going into radiation oncology to look at the scan and to accompany me, since he'd be seeing patients like Mrs Martinez. We headed back to her room.
"Mrs Martinez, I'm glad to see you're keeping down the water. Your blood test results are normal. I'm going to give you a stronger medicine to control the nausea and vomiting and arrange for you to see Dr Post tomorrow."
Before I could continue, Mrs Martinez looked directly at me and asked, "Doctor, what was the result of the brain test?" I was taken aback. I had been planning to let her regular oncologist tell her the news, but she spoke with such forthrightness and courage.
I pulled up a stool next to the gurney and sat down. "Mrs Martinez, the CT scan is abnormal," I said. "It shows that the cancer has spread to the brain."
Mrs Martinez looked down. Her face became pale and stricken. I was keenly aware that this was not the kind of test result one simply tells a patient and walks out.
Gently, and after a long pause, I asked, "What is your reaction?"
"This is a death sentence," she said, looking away.
"What do you mean ‘death sentence'?" I asked.
Mrs Martinez explained. "I knew that with the cancer one day I would die, but I did not expect it so soon."
I tried to reassure her. "Mrs Martinez, Dr Post is very experienced in this situation. Tomorrow you will discuss with him the kinds of treatment that will help you." She did not seem reassured. I thought about saying "I know how you feel," but I did not know how she felt.
I then noticed her wearing a large crucifix around her neck and recalled a story about a cardiologist praying with his patient.1 I knew what I had to do. I felt very uncomfortable. I have talked about spirituality and religion with my patients on previous occasions, but the thought of explicitly praying with a patient, that was another matter. How was I to proceed?
"Are you a prayerful person?" I asked with hesitation.
Mrs Martinez nodded. "Yes."
Awkwardly I offered, "Well, then, would you like to have a prayer together?"
She immediately looked up at me. "Yes, I would."
Now what? We were from such different worlds. She was Catholic, originally from Mexico. I am Jewish, originally from Detroit and, at 43, half her age. We had only just met. She prayed to Jesus. I did not pray to Jesus. What would I say? I certainly had not been prepared in medical school for a situation like this.
I took her hands in mine. We closed our eyes. I waited for her to begin, but I soon realized she was waiting for me to begin.
I began to speak, trusting the proper words would come and she would find comfort in them.
"Oh, God, You Who are the Great Healer."
I paused for a moment, thinking of what to say next when Mrs Martinez repeated, "Oh, God, You Who are the Great Healer."
She was repeating after me! Now I had to find the right words that she could repeat.
"Who guides us through life," I said.
"Who guides us through life," she repeated.
I continued and Mrs Martinez repeated.
"In your wisdom . . . "
". . . may you guide Dr Post and all the other doctors and nurses to provide the best care."
"Provide us all with Your comfort and guidance . . . "
I brought the prayer to a close. "Thank you for hearing our prayer."
"Thank you for hearing our prayer," she echoed.
"Amen."
"Amen."
Relieved, I opened my eyes. But hers remained closed. She didn't let go of my hand and began the Lord's Prayer: "Our Father, Who art in heaven, hallowed be Thy name . . . " I joined in as best I could.
Then Mrs Martinez began to pray in Spanish to Saint Jude—the patron saint of hopeless cases, as I later learned. She finished and we both opened our eyes. Mrs Martinez appeared visibly calmer. She looked directly and deeply into my eyes. "Thank you," she said softly, a tear falling across her cheek. Her son's eyes too were filled with tears.
"Thank you," I replied. I too was tearful and filled with a profound sense of gratitude.
Mrs Martinez gave my hand a last squeeze. Our prayers had taken only a few minutes, but it seemed much, much longer. Finally, I stood to say good-bye, telling her I would arrange for her discharge.
The intern appeared stunned. "What did you think?" I later asked him. He did not seem to know what to say. "I have to admit to you," I continued, "I was not even planning to tell her the CT results, let alone pray with her. I've never prayed with a patient before, but her question required an answer and I had to take care of her reaction." We discussed how Mrs Martinez had not seemed to be reassured that Dr Post was experienced, how psychological and philosophical approaches were inadequate, and how I arrived at prayer.
Praying with Mrs Martinez felt so completely right. But was it? It truly comforted her and her son. As for me, I walked out feeling "well used," not bleak or hopeless, as I would have felt otherwise. But praying with a patient? Is it ethical? Is it legal? What if someone complained and referred it to the Peer Review and Quality Improvement Committee? Wait. I was the chair of Peer Review and Quality Improvement. Would I be reported to my own committee?
That episode was never brought up, but I could not stop thinking about it. Later, as a visiting scholar at the Stanford Center for Bioethics, I examined this case in detail under the ethical microscope with Professor Ernlé Young, ethicist and codirector.
Dr Young and I looked at it in terms of core ethical principles: to do good (beneficence), to do no harm (nonmaleficence), and to respect a patient's autonomy. We examined it in terms of the duties of truth telling (veracity), loyalty and putting the patient first (fidelity), of confidentiality and privacy. We contemplated the virtues of compassion and professionalism. We reflected on the goals of a physician to relieve pain and suffering and to provide comfort, as well as the value of the Golden Rule: "Do unto others as you would have them do unto you." A prayer that is supportive and comforting for the patient, that has his or her permission, and is mutually respectful is ethical. One that is proselytizing, coercive, and unrealistic is not.
As Professor Young discussed, the prayer was appropriate on all counts. "Your intentions were ethical," he said, "to tell the truth and to provide comfort, what physicians pledge to do. Mrs Martinez asked you specifically for the test results. You answered truthfully. You were aware how your pronouncement could provide harm and suffering and you followed the Hippocratic principle First, do no harm. Conventional medical, psychological, or philosophical explanations were insufficient or problematic, so you considered a spiritual approach. Prayer is a tremendous source of comfort for people who are prayerful. Although new for you, in the world of spiritual care, offering a prayer is as straightforward as recommending an antibiotic.
"A physician praying with a patient may not be standard practice," he went on, "but this does not make it unethical unless you do not have the permission of the patient or if you conducted your prayer in an unethical way. You identified a cue—the cross—that it would be appropriate to offer a prayer and trusted your deep intuition and judgment. You could have called a cleric if one was available, but then there is the question of timing, to make the right intervention in the right moment. You asked her first if she was a prayerful person. She said yes. Only then did you ask her if she wanted to have a prayer together. She could have said no. You found a common language. You did not tell her what faith to have and did not pray for a miracle."
I was satisfied that that as a physician, praying with Mrs Martinez was right.
In the intervening years I have become a full-time hospital chaplain at Stanford Medical Center. I am more aware than ever how human beings are spiritual beings—whether or not they are religious—concerned with meaning, hope, relationship and love, suffering, and life's mystery. Spirituality is linked to health and spiritual care is a core element of health care. Spiritual care is not something that should be left only to the chaplain.
As with so much in medicine, timing is key. There are many crucial moments that call for a spiritual presence—a listening ear, a gentle touch, a compassionate word, and sometimes a blessing or prayer. So often the physician or nurse or other health care provider is the one who is available. That is why I believe it is not only appropriate but sometimes necessary for them to provide a spiritual response.
As I learned in taking care of Mrs Martinez, doing the right thing means addressing what really matters, sometimes stretching us beyond our professional role as it is currently defined into the further realms of spirituality and meaning.
I took sign-out from Dr Koscove, who told me, "I've got an 86-year-old woman, Mrs Martinez, in room 17 with nausea, vomiting, and dehydration and a history of metastatic lung cancer previously treated with chemotherapy and radiation. She was discharged from the hospital two days ago for the same thing. I controlled the nausea and vomiting with IVs and ordered a CT scan to look for brain metastases and signs of increased intracranial pressure. I told her you're taking over. You'll need to review the scan, and see if she can tolerate oral fluids, before discharging her."
I walked over and introduced myself to Mrs Martinez (not her real name) and her son. She was sitting quietly on the gurney.
"Hello, I'm Dr Feldstein. I'm taking over for Dr Koscove. I see that you're feeling better. I'll have the nurse bring you some water while I review the blood tests. If you can keep the water down and the tests are OK as I expect, then I can discharge you home to follow up tomorrow with your oncologist, Dr Post" (also it is not a real name).
At that moment the nurse interrupted. "Dr Feldstein, there's a call for you." I excused myself. The ward clerk handed me Mrs Martinez' CT result: "Multiple brain metastasis. No shift." Sobered, I put the slip in my pocket to give to Dr Koscove. It was a good pickup.
After I took the call, I asked an intern who was going into radiation oncology to look at the scan and to accompany me, since he'd be seeing patients like Mrs Martinez. We headed back to her room.
"Mrs Martinez, I'm glad to see you're keeping down the water. Your blood test results are normal. I'm going to give you a stronger medicine to control the nausea and vomiting and arrange for you to see Dr Post tomorrow."
Before I could continue, Mrs Martinez looked directly at me and asked, "Doctor, what was the result of the brain test?" I was taken aback. I had been planning to let her regular oncologist tell her the news, but she spoke with such forthrightness and courage.
I pulled up a stool next to the gurney and sat down. "Mrs Martinez, the CT scan is abnormal," I said. "It shows that the cancer has spread to the brain."
Mrs Martinez looked down. Her face became pale and stricken. I was keenly aware that this was not the kind of test result one simply tells a patient and walks out.
Gently, and after a long pause, I asked, "What is your reaction?"
"This is a death sentence," she said, looking away.
"What do you mean ‘death sentence'?" I asked.
Mrs Martinez explained. "I knew that with the cancer one day I would die, but I did not expect it so soon."
I tried to reassure her. "Mrs Martinez, Dr Post is very experienced in this situation. Tomorrow you will discuss with him the kinds of treatment that will help you." She did not seem reassured. I thought about saying "I know how you feel," but I did not know how she felt.
I then noticed her wearing a large crucifix around her neck and recalled a story about a cardiologist praying with his patient.1 I knew what I had to do. I felt very uncomfortable. I have talked about spirituality and religion with my patients on previous occasions, but the thought of explicitly praying with a patient, that was another matter. How was I to proceed?
"Are you a prayerful person?" I asked with hesitation.
Mrs Martinez nodded. "Yes."
Awkwardly I offered, "Well, then, would you like to have a prayer together?"
She immediately looked up at me. "Yes, I would."
Now what? We were from such different worlds. She was Catholic, originally from Mexico. I am Jewish, originally from Detroit and, at 43, half her age. We had only just met. She prayed to Jesus. I did not pray to Jesus. What would I say? I certainly had not been prepared in medical school for a situation like this.
I took her hands in mine. We closed our eyes. I waited for her to begin, but I soon realized she was waiting for me to begin.
I began to speak, trusting the proper words would come and she would find comfort in them.
"Oh, God, You Who are the Great Healer."
I paused for a moment, thinking of what to say next when Mrs Martinez repeated, "Oh, God, You Who are the Great Healer."
She was repeating after me! Now I had to find the right words that she could repeat.
"Who guides us through life," I said.
"Who guides us through life," she repeated.
I continued and Mrs Martinez repeated.
"In your wisdom . . . "
". . . may you guide Dr Post and all the other doctors and nurses to provide the best care."
"Provide us all with Your comfort and guidance . . . "
I brought the prayer to a close. "Thank you for hearing our prayer."
"Thank you for hearing our prayer," she echoed.
"Amen."
"Amen."
Relieved, I opened my eyes. But hers remained closed. She didn't let go of my hand and began the Lord's Prayer: "Our Father, Who art in heaven, hallowed be Thy name . . . " I joined in as best I could.
Then Mrs Martinez began to pray in Spanish to Saint Jude—the patron saint of hopeless cases, as I later learned. She finished and we both opened our eyes. Mrs Martinez appeared visibly calmer. She looked directly and deeply into my eyes. "Thank you," she said softly, a tear falling across her cheek. Her son's eyes too were filled with tears.
"Thank you," I replied. I too was tearful and filled with a profound sense of gratitude.
Mrs Martinez gave my hand a last squeeze. Our prayers had taken only a few minutes, but it seemed much, much longer. Finally, I stood to say good-bye, telling her I would arrange for her discharge.
The intern appeared stunned. "What did you think?" I later asked him. He did not seem to know what to say. "I have to admit to you," I continued, "I was not even planning to tell her the CT results, let alone pray with her. I've never prayed with a patient before, but her question required an answer and I had to take care of her reaction." We discussed how Mrs Martinez had not seemed to be reassured that Dr Post was experienced, how psychological and philosophical approaches were inadequate, and how I arrived at prayer.
Praying with Mrs Martinez felt so completely right. But was it? It truly comforted her and her son. As for me, I walked out feeling "well used," not bleak or hopeless, as I would have felt otherwise. But praying with a patient? Is it ethical? Is it legal? What if someone complained and referred it to the Peer Review and Quality Improvement Committee? Wait. I was the chair of Peer Review and Quality Improvement. Would I be reported to my own committee?
That episode was never brought up, but I could not stop thinking about it. Later, as a visiting scholar at the Stanford Center for Bioethics, I examined this case in detail under the ethical microscope with Professor Ernlé Young, ethicist and codirector.
Dr Young and I looked at it in terms of core ethical principles: to do good (beneficence), to do no harm (nonmaleficence), and to respect a patient's autonomy. We examined it in terms of the duties of truth telling (veracity), loyalty and putting the patient first (fidelity), of confidentiality and privacy. We contemplated the virtues of compassion and professionalism. We reflected on the goals of a physician to relieve pain and suffering and to provide comfort, as well as the value of the Golden Rule: "Do unto others as you would have them do unto you." A prayer that is supportive and comforting for the patient, that has his or her permission, and is mutually respectful is ethical. One that is proselytizing, coercive, and unrealistic is not.
As Professor Young discussed, the prayer was appropriate on all counts. "Your intentions were ethical," he said, "to tell the truth and to provide comfort, what physicians pledge to do. Mrs Martinez asked you specifically for the test results. You answered truthfully. You were aware how your pronouncement could provide harm and suffering and you followed the Hippocratic principle First, do no harm. Conventional medical, psychological, or philosophical explanations were insufficient or problematic, so you considered a spiritual approach. Prayer is a tremendous source of comfort for people who are prayerful. Although new for you, in the world of spiritual care, offering a prayer is as straightforward as recommending an antibiotic.
"A physician praying with a patient may not be standard practice," he went on, "but this does not make it unethical unless you do not have the permission of the patient or if you conducted your prayer in an unethical way. You identified a cue—the cross—that it would be appropriate to offer a prayer and trusted your deep intuition and judgment. You could have called a cleric if one was available, but then there is the question of timing, to make the right intervention in the right moment. You asked her first if she was a prayerful person. She said yes. Only then did you ask her if she wanted to have a prayer together. She could have said no. You found a common language. You did not tell her what faith to have and did not pray for a miracle."
I was satisfied that that as a physician, praying with Mrs Martinez was right.
In the intervening years I have become a full-time hospital chaplain at Stanford Medical Center. I am more aware than ever how human beings are spiritual beings—whether or not they are religious—concerned with meaning, hope, relationship and love, suffering, and life's mystery. Spirituality is linked to health and spiritual care is a core element of health care. Spiritual care is not something that should be left only to the chaplain.
As with so much in medicine, timing is key. There are many crucial moments that call for a spiritual presence—a listening ear, a gentle touch, a compassionate word, and sometimes a blessing or prayer. So often the physician or nurse or other health care provider is the one who is available. That is why I believe it is not only appropriate but sometimes necessary for them to provide a spiritual response.
As I learned in taking care of Mrs Martinez, doing the right thing means addressing what really matters, sometimes stretching us beyond our professional role as it is currently defined into the further realms of spirituality and meaning.
Honda 928TA, Ariens 924 STE, Toro single stage S-620, 95 Jeep Wrangler with a 6 foot Fisher Plow, many shovels, one 14 year old boy. Craftsman 01 1000 LTX pimp Gold LT 20hp Briggs OHV V-twin. Tough as it is ugly.
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