March, 2013 | Hank Dunn

Compassionate, informed advice about healthcare decision making

Archive for March, 2013

Gordon Cosby and my Call as a Healthcare Chaplain

Posted March 22, 2013 by kbrachle

Gordon Cosby is the man partly responsible for my 30-year career as a healthcare chaplain. Few outside a certain circle have ever heard about him or the congregation he co-founded with his wife, Mary, the Church of the Saviour (CofS). But there is a rather wide circle of folks who owe much of who we are to Gordon and Mary.

He died this week at 94.

Hundreds let homes, jobs, and traditional churches behind

I left a thriving church youth ministry in Macon, Georgia in 1978 and moved my family to Washington, DC, just so I could be part of what he and Mary started. What they had done drew scores, if not hundreds, to leave homes, jobs, and traditional churches behind. So we sold a home in Macon and put all our worldly belongings in a Ryder truck and moved here with our two kids. I worked as a carpenter for a year then for four years directed one of CofS’s ministries trying to create jobs for hard-to-employ people.

Gordon preceded me at the Southern Baptist Theological Seminary in Louisville by maybe 35 years. He served as an army chaplain with a combat unit in the Second World War. Convinced there was a better way to do church he and Mary started a congregation with just a handful people. The guiding principles were few: integrity of membership, commitment to mission, and commitment to prayer and the inner spiritual life.

Gordon was just that respected

By 1983, the job with the inner-city ministry was coming to an end and I was facing a time of unemployment. Gordon was approached by Charmaine and Robert Bainum, owners of Fairfax Nursing Center (Virginia), asking him if he could suggest someone to serve as chaplain at their nursing home. Robert knew Gordon through their joint concern for Cambodian refuges in Thailand. Gordon suggested me. I interviewed and got the half-time position. I don’t know if they interviewed anyone else.… Gordon was just that respected.

I knew precious little about healthcare. It was on-the-job training. I was ten years out of seminary and out of work. I thought I would give it a try. It turned into being a real call. After six months at half-time I asked if we could make it a full-time position. Turned out I liked it that much. They said yes and I was at the nursing center until 1996 when I moved over to hospice.

My niche found me

“Call.” It’s a big word around Church of the Saviour. It wasn’t so mysterious. What is my passion? What do I really care about? If you could find another person who shared your passion you could announce a call to start a new mission group. I witnessed the birth of many missions to serve the poor in Washington and around the world. Common folk who felt called stepped up to live out that call.

My call to healthcare chaplaincy followed my actually being hired to do the work. Details. But call it has turned out to be. It has been a passion that has broadened to helping all the deaths in this country to be more compassionate. When I introduced my second book, Light in the Shadows, to my colleagues at hospice in 1999, one of social workers commented, “Hank, you really have found your niche.” My immediate response was, “No. My niche found me.”

Sometimes call works that way.

He was the embodiment of servant leadership

As I sought ways to minister to severely demented patients on our Alzheimer’s unit I am sure Gordon’s influence was with me. He was the embodiment of servant leadership. In the early days of the jobs program at CofS, I worked with a housekeeping crew that cleaned apartments to prepare them to rent. Gordon came to visit us one day at a work site. He found me on my knees cleaning up the filth around a toilet. He laughed and commented, “Bet they never told you about this part of ministry at the Southern Baptist Seminary!” Indeed they didn’t, but I saw Gordon set tables at the Potter’s House coffee house or sit with a drug addict who was sorting out his life.

How could I “reach” the demented nursing home patient? Bible studies didn’t work and they couldn’t track my sermons at chapel. I found playing my guitar and singing the old gospel songs connected. I wasn’t very good but they didn’t seem to care. I also learned to hand feed patients. I would show up on the dementia unit at lunch time and tell the nurse, “I could help feed some people but I don’t want any spitters or chokers.” I am reminded of Jesus words, “Whenever you have done it to the least of these you have done it unto me.” Gordon lived those words.

Jim Wallis of Sojourners wrote, “Gordon Cosby taught us how to live by the Gospel and, in these last years and months, he also showed us how to die. In one of my many visits near the end of his life, Gordon said to me in his deep graveling voice, ‘I am enjoying dying.’ What a Gospel thing to say.”

How would my life have been different if Gordon had not given my name to the Bainums? I may have found my way to the bedsides of the dying. I don’t know. Don’t have to. He did and here I am thirty years later. Thanks Gordon.

Featured image photo credit Sojourners Magazine

Choosing Wisely . . . Once Again No Feeding Tube

Posted March 13, 2013 by kbrachle

What five things can physician groups agree will not help and may harm patients?

This is the question posed to physician professional organizations in an effort to help patients avoid harm. Twenty-six medical groups, from the American Academy of Allergy, Asthma & Immunology to The Society of Thoracic Surgeons, polled their members and came up with a list for each specialty. Interestingly, two different groups listed the same treatment at the top of what is to be avoided. These lists were just published last month.

Feeding tubes … the number one treatment to avoid

Both the American Geriatrics Society and American Academy of Hospice and Palliative Medicine ranked feeding tubes in advanced dementia patients as the number one treatment to avoid. Specifically, number one of both lists is, “Don’t recommend percutaneous [through the skin] feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.”

I have blogged about this before. The research is clear. For patients with advanced dementia, like end-stage Alzheimer’s, feeding tubes offer no benefits and increase the burden of living.

Often, these patients have increased difficulty eating as the disease progresses. The quantity of food they take in declines and they lose weight. They can choke and get food in their lungs that can possibly turn into aspiration pneumonia. These problems are common at the end of a long decline in this sad disease process.

Mistakenly, some medical professionals recommend a feeding tube when these expected eating difficulties arise. They might say, “Your mom is having eating difficulties and we are worried that she is going to lose weight and maybe get pneumonia. We recommend putting in a feeding tube to prevent these things from happening.” THIS IS NOT TRUE! They may even say, “You can’t let your mother starve to death. Let us put in the feeding tube.” DON’T BELIEVE THEM! There is nothing in medical research to back up what they are telling you.

Feeding tubes may be very helpful to others

I want to emphasize that what I am talking about here applies to dementia patients. Feeding tubes may be very helpful to others like some stroke patients or survivors of throat cancer. Consult with your physician to see if this research on advanced dementia and feeding tubes applies to your case.

Tube-fed advanced dementia patients do not live longer than carefully hand-fed patients. I used to tell families that putting in the feeding tube only prolonged the dying process. I WAS WRONG! In one study a group of surgeons assessed 41 advanced dementia patients who were experiencing eating difficulties. All 41 met the criteria that have, in the past, led to a recommendation for the insertion of a feeding tube. The tube was refused by 18 families. Both groups (tube-fed and hand-fed), on average, died within about the same amount of time. Putting in a feeding tube did not add one day to the life of these patients but made them more uncomfortable and actually might have caused them harm.

Tube feeding does not reduce the risk of aspiration pneumonia. In fact, some studies show that it increases the risk. These patients can be fed orally with careful hand feeding. It takes skill, time, and patience, but it can be done.

Interestingly, there is a wide difference in this country in the frequency of use of feeding tubes for severely demented patients. On average, 21% of advanced dementia patients in the United States have a feeding tube. But look at the different rates of use:

On the low side:

Wyoming only 4% use.
Montana, New Hampshire, and Maine all have 5% use.

On the high side:

Alabama has 34% use of feeding tubes for advanced dementia patients.
Hawaii has 36%.
The District of Columbia has 45% use.

How do you explain such wide use of a treatment known to offer no benefits and cause harm to the patients who get them? I say these tubes are put in for cultural, emotional, and spiritual reasons. It cannot be for medical reasons. In places where use of feeding tubes is high you may be going against the cultural norms to refuse the feeding tube. Hopefully, we can get the word out there to be compassionate to these patients in their last months and feed them by hand.

Hank Dunn

A Peaceful Death . . . Without CPR

Posted March 8, 2013 by kbrachle

Who hasn’t heard it yet? The 911 dispatcher in Bakersfield, California begging the retirement home employee to find someone to begin CPR on 87-year-old Lorraine Bayless who had collapsed in the dining room. Apparently the policy at Glenwood Gardens independent living facility is to call the rescue squad and let them care for a stricken resident. Glenwood is not a medical facility but an apartment building with extra services for the elderly. The employee on the phone with the dispatcher very calmly said repeatedly “No, we don’t have anyone here who can begin CPR.”

Much of the commentary I have heard this week condemned the employee and the policy as unethical and uncaring. I am not surprised given the false information out there that CPR saves most of those who suffer a cardiac arrest.

May I offer a few things to consider.

1) CPR is rarely successful. Only 15% of those who have resuscitation attempts in the hospital survive to be discharged. Patients who do not live independently, who have more than one or two medical problems, or have a terminal disease survive in the 0-2% range. In one study of out-of-hospital cardiac arrest only 9.4 percent of those in their 80s and 4.4 percent of those 90 and older survive.

I don’t know what diagnoses this lady had but at 87 many people have several health issues which make them unlikely to survive a CPR attempt.

2) CPR itself has risks of broken ribs and punctured lungs as well as the risk of brain damage. Half of “successfully” resuscitated patients have brain damage ranging from mild memory loss to ending up in a vegetative state. I know of at least one case where a medical facility was sued for “wrongful life” because they “successfully” resuscitated a patient against the patient and family wishes. Evidently they felt the burden of living after resuscitation was much worse than death.

3) Most 87-year-olds wish for a peaceful, quick death like Ms. Bayless had. I say this having spent years as a nursing home, hospice, and hospital chaplain and caring for my parents (along with my brother and sister) as our elders made the journey from independent living, through assisted living, to a nursing home, and finally dying under hospice care. These old, old people’s greatest fear is to become demented, incontinent, wheelchair-bound, and having to live out their days dependent on others. Ms. Bayless was still in independent living. She never had to make that final decline most of us will make.

Mrs. Bayless’s family released a statement after the media frenzy. They wrote:

“It was our beloved mother and grandmother’s wish to die naturally and without any kind of life-prolonging intervention. . . . We understand that the 911 tape of this event has caused concern, but our family knows that mom had full knowledge of the limitations of Glenwood Gardens, and is at peace. We also have no desire, nor is it the nature of our family, to seek legal recourse or try to profit from what is a lesson we can all learn from.”

Sounds like those with most to lose in this situation are quite accepting of the outcome.

CBS radio commentator, Dave Ross, observed that neither the employee nor a resident who also called 911 had any panic in their voice. He said:

“In fact at no time do you hear anyone crying for help or panicking—probably because they all know the policy. Not just the policy at Glenwood, but the policy that applies to us all—which states that at some point—life ends. If you’re lucky, it doesn’t end until you’re well into your 80’s—but it ends. We like to think we can change that by declaring an emergency and rushing to the rescue.

“In fact, one California legislator says she plans to introduce a bill so this never happens again. Unfortunately, I think outlawing natural death may be more than even the state of California can enforce.”

Hank Dunn

Emergency Preparedness

Posted March 4, 2013 by kbrachle

“Could you come to ‘labor and delivery’? We’ve had a fetal demise and the family would like a chaplain,” the nurse said. She had paged me at 5:30 AM last Monday. I told her I could be there in a half-hour.

We have a volunteer on-call chaplain program at Loudoun Hospital near Leesburg, Virginia, for just such an event. It was my turn.

The small ritual of prayer to the bedside

I entered the room and found the young mother in her bed with the father of the child sitting next to her. Her mother was in the chair next to the bed. She went into labor at 20 weeks and, of course, the baby did not survive. All in the room were very quiet. I said, “I heard you lost your baby. I am so sorry.” The mother nodded her head as she just looked down. They did not seem in the mood to talk much. I asked if they would like to have a prayer and they said, “Yes.”

It was a short visit. I offered my pastoral presence and brought the small ritual of prayer to the bedside.

I am glad to do what I can but I often am sorry that those I am called to meet did not have their own faith community to call on in such an emergency. Losing a pregnancy needs more than just a prayer. What about grief counseling? How could a faith community support this family in their loss?

This family needed more than a quick prayer

Contrast this visit to one I made a while back to the emergency room. The rescue squad was heading toward the hospital with a man who had suffered what turned out to be a fatal heart attack. The ER staff wanted a chaplain there to comfort the family. The man was in his 50s and there were two children and his wife. He had no history of heart problems and just collapsed and died.

One of the first questions I asked the family was if they had a faith community. They immediately said yes and gave me the church name and pastor’s name. I called him. He was shocked and distraught over this death of a friend and parishioner. Of course he would be right over. I stayed until he arrived.

Again, this family needed more than a quick prayer next to the dead husband and father. They had funeral plans to make then the long road of grief to follow.

America is still a very religious and spiritual nation. But more and more of our population are not connected to any faith community. Those who answer “None” on surveys asking religious preference are at an all-time high. These “nones” might consider themselves spiritual but not religious.

Spiritual needs are great yet many people have no place to turn

As a healthcare chaplain I run into these folks all the time. That is why medical facilities have staff chaplains. The spiritual needs in the midst of a health crisis are great yet many people have no place to turn. I like to think the future employment opportunities for chaplains are good given the need.

Of course, I wish more people had their own faith community to turn to. I remember in my days as a nursing home chaplain I could judge how important spiritual things were to a new patient just by reading their admission papers. The response to “religious preference” and “congregation” ran from “none” to “Christian” or “Jewish” to something like “First Methodist Church” to even including the pastor’s name and phone number. The more details I got on the form showed me someone who took their faith more seriously.

I don’t want to come across here as judging people for not going to worship somewhere. But I wish people stopped to think, “Who would I call if there were a sudden death in my family?” If the faith element is important then find a community now. Most faith communities handle crises very well. They are there when you need them. Sure, we can scurry around and find a volunteer to show up for a few minutes. But faith communities have so much more to offer.

Photo by Jonnica Hill on Unsplash