A Night in the Intensive Care Unit

What is a therapeutic stance? Formally, I can say it has to do with the relationship between two or more people in a setting where healing is a goal. (Picture how you are standing beside the bed of an elderly woman, brought to the emergency room in the middle of the night, and now expressing her fear that this unexplained pain in her abdomen may something that will kill her.) But there are many different perspectives that would take that opening definition in different directions. This is a blog where those directions are explored.

At the moment, I’m thinking about several of the patients I worked with last night during my monthly shift as the sole night chaplain on duty at a community hospital. If I was writing about these patients as a Zen priest, I could be focused on the physicality of the encounters, the deliberate use of breath and posture to ease their suffering. But I’m writing more as a hospital chaplain, trained in the use of the “therapeutic self.”

To me this phrase means that I better help a patient when I remain aware of the ways in which I am caught up in their suffering. From the perspective of many health care professions, this being “caught up” is very much to be avoided. But not for a hospital chaplain. This being “caught up” is very much part of the therapeutic relationship and that is what I want to illustrate here.

I saw two men in the intensive care unit last night, both close to brain death. Tubes and monitors all around. In one of the rooms the hospitalist on duty is carefully explaining to the family of this forty three year old man the sequence of events likely to take place over the next several hours as his skull continues to fill with blood following a fall earlier in the day. The blood at some point will put so much pressure on his brain stem that too many of the brain cells that support his breath and heartbeat will die. Determining the point of death in such circumstances seems to be an imprecise art as the patient is tested for the presence of several key reflexes. The final check, however, seems to be the delivery of pure oxygen into his lungs as the ventilator is shut off. By testing his blood in the minutes that follow, it is possible to see if his body is doing anything useful with that oxygen. If not, he is said to be dead and the ventilator is restarted in order to keep his organs in the condition needed if they are to be “harvested” for possible transplant.

All carefully expressed with care and compassion to the family. But I’m watching the family trying to figure out when in this progression of events their brother, nephew, son actually dies.

Here’s what is filling me as I watch and listen. Go back a month ago. It’s early evening and the rooms and corridors of my mother’s nursing home are still and quiet. My mother is dying, her hospice nurse earlier saying, “maybe tonight, maybe tomorrow.” I’m alone with her, singing what I can remember of “Swing Low, Sweet Chariot.” I’ve been counting her breaths ever since arriving at her bedside that morning. My brother-in-law calls to ask how she is doing so to give him some form of a quantifiable answer I say, “I’ll count her breaths for you. There’s one…” I wait for the next one. There are no more. Her nurse comes in, listens to her heart and chest and says, “I’m sorry.” It’s 8:45 pm. And she is dead. I say goodbye to my brother-in-law, not quite absorbing that her death would be so distinct. This said by a hospital chaplain who has watched many dozens of last breaths.

I’m alone, still hearing the sound of her last breath, coming as it did from far off down the arroyo she knew so well in Santa Fe and then sweeping onward, up the slopes of the Pecos Mountains to the east. A breath of air that never really had a beginning or an ending, just a puff that filled her for the moment of her lifetime and then was gone. Death was clear and certain. Clear in a way that was not to be available to that family in the ICU last night. I now carry in me this deep sense of finality and my job last night was to help this family find this as well, amidst all the tubes and monitors and impending arrival of those who check the health of the crop before harvest.

But, that isn’t all there is to know about this patient. He was born with a disability, the same one that hastened the death of his mother, and now carried by his elder brother, and one that made it easier for his father to make sure the hospital respected his son’s do-not-recusitate order.

So now, standing in this ICU room, not only am I son to my mother as she died a month ago, but I am father to my own disabled son. He is an active and healthy 22 year old, with no reason to think his disability might shorten his life span. But that doesn’t matter much at the moment. I’m joined to this patient’s father, an aged farmer who has watched a disability sweep through his family with the inevitability of a drought. The life of such a child is an extraordinary thing, each moment pregnant with the possibility of a sudden disaster but each moment also pregnant with the possibility of a glimpse of the full meaning of being alive. We could say this is actually a reasonable definition of parenthood, but somehow this awareness of the explosive potential for each moment of a disabled child’s life comes more readily to their parents. The father of this man in the ICU and I face each other, and without words we each know what the other knows.