Medical Examiner

“This Has Made My Job Hell”

A chaplain at an NYC hospital explains what COVID-19 has changed, and how she holds onto her faith.

Doctors stand at the foot of a bed and put their hands on a patient's body. Across from the, a person holds open a heavy book.
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Rabbi Kara Tav is the manager of spiritual care services and a palliative care chaplain at a hospital in New York City. Her Facebook feed in recent weeks has been an almost unbearable portal into the suffering she lives with each day. The pandemic was real to her long before many of us saw its effects. The hospital chaplains who minister to the sick and dying in the COVID-19 era are witness to special kinds of suffering and solitude. I reached out to Tav in the hope that she could share some of her story. Our conversation has been lightly edited for clarity.

Dahlia Lithwick: I have a pretty cartoonish idea of what chaplains do. Can you tell me what your days looked like before the COVID-19 era? How are chaplaincies organized? What proportion of patients seek spiritual care?

Kara Tav: In health care chaplaincy (as opposed to university chaplaincy or prison chaplaincy or any other kind), I am called a multifaith chaplain. While I was in rabbinical school, I did additional training to become a chaplain. The additional training is very hands-on. I did 7,400-hour units of clinical pastoral education, working in hospitals with multifaith groups. (Basically we were like one of those jokes: A rabbi and a priest and an imam walked into a bar … ) We use an action-reflection model to learn skills—each of us would minister to patients in hospital and then write up our visits (with pseudonyms) as a type of script to review with our supervisor and our group, i.e.:

CHAPLAIN: Hello, Mr. Schwartz, how are you doing? I am [X], your chaplain. I wonder if you would like a visit?

MR. SCHWARTZ: What the hell is a chaplain? I thought those were guys who came to read you your last rites!

We would bring these scripts back to the group and read them together, each of us playing a role from the script. Then we would receive feedback during the reading: “Why did you ignore that question?” “I like that prayer.” “How dare that doctor interrupt you?” “What will you do differently next time?” And so on.

In addition to the verbatim, we had intensive group therapy during which the supervisor tried to help us learn about what we personally bring “into the room” and how to “park that outside,” and then later, we learned psychology, some medical terminology and whatnot, educational theory. We visited patients, ran spirituality groups, ministered to staff and families and each other. It was brutal. After this, a chaplain does 2,000 hours of additional work (about two years) in hospital before becoming board-certified, which completes the process.

A chaplain offers nonmedical care for the patient, staff, and family. It is much like Father Mulcahy on M*A*S*H, actually. He dealt with the socio-religio-cultural needs of everyone. The entire camp became his flock. I have met ultra-Orthodox men in lockdown psychiatric units who wanted to confess that they didn’t believe in God, and Muslim families who wanted to bury their loved ones in Pakistan but were afraid to ask their nurse to help them because, well, America. I love to advocate for the patient, the staff, the neediest. Love to. This is the second time I have worked as a director of a department. I like the combination of management/mentoring and direct service.

And suddenly you are doing this work behind a mask? Behind a Zoom screen? With families over the phone? I’m guessing none of this is how you ever wanted to do this work?

No. I hate the phone. I never want to communicate without eye contact or body language. Not about such things as life and death and ethical dilemmas. The mask isn’t new—many patients have infection precautions and you have to “suit up” to go in. That takes practice, but like all things, you learn it. Donning and doffing is a skill like any other.

You’ve been posting about ethical challenges, and I am wondering what they are and how they get resolved in the world of chaplaincy.

It depends on the times and the hospital system. Generally, ethical dilemmas in hospital are around agency or proxy. As in, does a patient have agency to make their own medical decisions (even if they are weird or unwise medically) or questions about who has proxy to make decisions for the patient? There are issues about transgender patient rites to be called by, treated as, put in units with people of their correct gender, etc. Advocacy. A chaplain’s theological voice adds to the hospital’s business and medical voice, to round out the decision-making, and force it to say about patients as real people.

Right now, or leading up to where we are now (keeping in mind that I’ve only been at this hospital for six weeks—yes, started a job at the outset of a pandemic), I was deeply concerned about the institution having a policy so that doctors would feel supported when triaging patients for resources. I was starting to hear docs talk about resources running low and how to behave if that happened. There was terror behind their eyes. And then things changed daily. The system fell back on the policy they wrote around the SARS epidemic that they really didn’t need. And now, our docs have to make very difficult decisions without a lot of guidance. There is an excellent ethics doc with whom I work, but things move very, very, very quickly. He takes calls all day and all night. He calls me once a day and once a night to check in or to tell me what’s happening.

And then there are the other nonsexy decisions about resuscitation. If an 88-year-old woman with COPD is on a respirator and coding her will definitively put a team of five young, healthy docs and two or three young, healthy nurses at serious risk of death, but her son says he wants her resuscitated, do you have to do it? He’s her proxy. It’s the law. But the chances that the intervention will save her is .000000000001. … These are not easy calls to make. How can I help? I can tell the docs that the universe decides who lives and who dies, not them.

What are the other ways in which the coronavirus has made your job harder?

This has made my job hell. Normally my job is to listen, to comfort, to pray for healing.
Now my job is to pray for a swift and merciful death for most of my patients. I hold weeping, sweaty-faced nurses through gloves and masks, to whom I promise their work is meaningful and changing lives. I promise them that it’s OK to feel bone-tired, that everyone’s living with nightmares that they’re going to get sick. I have spent this morning making condolence calls (30 deaths over the weekend—we normally have five).

A hard question: You write about how different faiths demand different end-of-life rituals. How do you manage that in a time of such need and also such scarcity?

Well, we do our best. We know as much as we can about different traditions and we also have distributed a blessing for medical or other staff to offer when no chaplain is available to honor a death.

Another hard question: Does any of this affect the way you think about God?

Well, there’s a short answer and a long answer to that question.

The short answer is: absolutely not!

The long answer is that my understanding of God is best summed up by my understanding God not as causing our misfortunes but having created a world of inflexible laws. I do not believe that the painful things that happen to us are punishments for our misbehavior, nor are they in any way part of some grand design on God’s part. Tragedy is not God’s will, so we need not feel hurt or betrayed by God when tragedy strikes. God can be present to help us overcome it, precisely because we can tell ourselves that God is as outraged by it as we are. I was strongly critiqued for holding this theology throughout rabbinical school, for its simplicity. But Harold Kushner’s ideas (that I have represented weakly … sorry) were a foundational comfort to me in my earliest tragic experience and have been consistently dependable. I can’t believe in a God that gives 2-year-olds cancer or kills thousands of fishermen at sea. I just can’t imagine God wanting to destroy God’s own image, God’s own creations. My God is all compassionate, never judging.

The patients dying alone, sometimes not speaking English. This is the stuff of nightmares. You have written so powerfully about the aloneness in death.

Dahlia, dying is something no one can do with us. We all die alone. Being “with someone” (as in, physically present when they die) is an idea we love because it gives us closure and peace. It is about us, not the patient. The patient is dying. That is their work alone. But not having the closure you want is very hard and sad and a frightening thought.

There is a recurring theme in what you write, about how desperately we all need to listen. I wonder what you are listening for and also what you hear?

One of my best CPE supervisors taught me that a chaplain “hears differently.” A chaplain hears behind the words and into the heart. I don’t know exactly how to describe it, but it’s true. I was in a family meeting that was very contentious in my first week at this hospital. I visited this very sick woman who hasn’t opened her eyes in several days, whose family is up in arms about how to proceed with her care for her. I witnessed her open her eyes and says in the meekest whisper of a voice: “I want to get off this merry-go-round. I want to go home.” Everyone was shouting about whether she should go home to her daughter’s house or to a nursing home. … I sat in this family meeting in which everyone around the table was arguing and the doctor had lost her cool and the pulmonologist was trying to quiet everyone, and I asked if I could speak. I say, maybe she was asking to go home and we should grant her that wish. Maybe we should “let God’s will on Earth be done on Earth as it is in heaven” (that’s from the Lord’s Prayer). And let her go—hand’s gesture skyward—home. That kind of hearing seems like a no-brainer, but really it is about being not invested in outcome or knowledge or being right. It’s about hearing the patient’s heart.