This is an AI-generated transcript from auto-generated subtitles for the video Buddhist Chaplaincy Speaker Series: A Palliative Perspective on Health Care and Living.. It likely contains inaccuracies.

Buddhist Chaplaincy Speaker Series: A Palliative Perspective on Health Care and Living.

The following talk was given by Emily Linderman at The Sati Center in Redwood City, CA on February 24, 2025. Please visit the website www.audiodharma.org for more information.

Introduction

Okay, well hello, good morning, everybody. Welcome to the Sati Center Chaplaincy Speaker Series. Today, we're very excited to have Emily Linderman with us. I'll just say a few words of intro for Emily before passing it over to her.

Reverend Emily Linderman is a queer, bi-plus, board-certified chaplain with the Association of Professional Chaplains. She is also a spiritual director, facilitator, and certified meditation teacher in the Shamatha-Vipassana¹ tradition via the Open Heart Project. She was ordained to authorized ministry by the United Church of Christ in 2020 and is a member of the Open Heart Project, an online Buddhist Sangha² with a Tibetan Vajrayana³ lineage. She holds a Master of Divinity from Seattle University School of Theology and Ministry and a Bachelor of Architecture from Ball State University in Muncie, Indiana.

Emily was born and raised in Michigan and trained as a chaplain resident, palliative care fellow, and certified educator candidate at Stanford Healthcare from 2017 to 2022. She also completed the nine-month-long UCSF-sponsored Practice-PC interprofessional continuing education in palliative care for practicing clinicians in 2019. Emily loves collaborating on an interdisciplinary team, pursuing the highest quality of full-catastrophe living for all beings, singing, laughing, baking, and creating along the way.

That's a wonderful bio, and I can't wait to hear what you've got to say, Emily. So thank you, and over to you.

Thank you, Jim, and hello all. That bio just cracks me up. I'm always relieved when we get to the baking and singing and laughing along the way part. That sounds way more familiar and how I know myself. So, nice to be with you today.

Buddhist Chaplaincy Speaker Series: A Palliative Perspective on Health Care and Living (link)

When Vanessa and I were talking about this presentation, I must have been in a really creative, lofty mood: "A Palliative Perspective on Healthcare and Living: Learnings and Laughter with a Palliative Care Chaplain." If I was going to rewrite it, it would just be "Intro to Palliative Care: Emily's Perspective." That's the bottom line of what we're getting today.

I do hope and plan to touch on an intro and overview of the palliative care specialty, touch on the specialist and generalist provider framework, and then share with you what inviting the spirit of improv into the practice of chaplaincy and life has meant for me, and how it influences how I work with teams and people, and just generally with being with other humans in this experience of living.

But before we do that, something one of my meditation teachers taught me from one of her meditation teachers is how to keep something sacred. I do really consider this conversation and time together sacred this morning. The three steps for that are: make offerings, request blessings, and dedicate the merit, which we'll do together at the end of this time.

We've made an offering right now just by showing up to this moment. The greatest thing that we can offer ourselves and each other is our presence and our awareness, our attention. If you just want to take a moment to look around the Zoom room and see that we're here together on a Saturday morning.

And to request blessings, I automatically notice I close my eyes, which you're also welcome to do if you want to. Call to mind a teacher or an ancestor or someone who's offered care to you, who has been a palliative presence in your life, who has helped to alleviate suffering for you, or someone who has generously received your care. We ask their blessing on this time together today. Thank you.

So, what comes to mind when you hear the phrase "palliative care"? Many people associate it with imminent death, dying, holistic care, easing suffering, comfort care, and letting go of curative interventions. These are all very normal associations with palliative care, and all of them are accurate. But if there's one thing I want you to take away from this presentation, it is this: palliative care and end-of-life care are not synonymous.

This is really important for us to understand, whether we're working as spiritual care providers, physicians, or just hearing about it. Maybe your physician or somebody on your care team mentions, "Have you thought about palliative care?" and you might think, "Well, we're not there yet," or "I'm not there yet," or "My loved one isn't there yet."

What palliative care is, is an interdisciplinary pursuit of the quality of life. This is from a palliative care superstar, Dr. BJ Miller. Palliative care is the interdisciplinary pursuit of quality of life. The four primary disciplines that work on several palliative care teams—not every healthcare organization can afford them—are physicians, nursing (advanced practice providers like physician assistants, nurse practitioners, clinical nurse specialists), social workers, and chaplains. Those are the primary disciplines that I get to work with on the team at Stanford Healthcare.

We are pursuing quality of life. One of the doctors that I work with uses the phrase, "Palliative care is for any age and any stage of serious illness." So who is palliative care for? It's for anyone—a patient, their loved ones, or staff—whose quality of life is impacted by serious illness. It doesn't have to be at the end of life. You don't have to wait to have access to a palliative care team.

Palliative care coordinates with Psychiatry. If you have a dual diagnosis, like an underlying mental illness alongside an oncology diagnosis, a heart condition, or a transplant, we can provide care alongside other providers. We do not focus on mental illness by itself most of the time.

Another way that we can think about the difference between palliative care and hospice is that hospice is a part of palliative care. Palliative care is like the overarching umbrella that hospice is a part of, even though palliative care was born out of the learnings of the hospice movement. The hospice movement, credited to Dame Cicely Saunders⁴ in England, was based on her understanding that caring for the whole person—their body, mind, spirit, emotions, and relationships—at the end of life could alleviate suffering. The question started to be asked, "Well, if we could do this at the end of life, why couldn't we do this earlier?"

So, the palliative care specialty can be consulted at diagnosis, when people are probably focused on disease-modifying therapy with curative or restorative intent. We work in a parallel fashion until the therapy starts to become more of a burden than a benefit, and then we transition to the part of our specialty that focuses on the end of life. Hospice is for folks who have a prognosis of generally six months or less.

Palliative care means patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. It is offered throughout the continuum of illness and involves addressing physical, intellectual, emotional, social, and spiritual needs, and facilitating patient autonomy, access to information, and choice. We are really focused on getting to know who the patient is, their freedom as a human being inside a system that can be really hard to navigate, their access to information about their own health and well-being, and what options they have, and then supporting their voice and their choices within that system.

I was listening to an NPR interview with BJ Miller where he was talking about palliative care existing in this gap that he called the "suffering gap" between what is and what we wish would be. This happens any time in life, not just in palliative care, although that is the specialty that acknowledges and tends to suffering. This gap between what is and what we wish would be teaches us what we long for and about our desires. So it's not just a place of pain; it's also a place of learning. Then we get to be creative about how to meet that need in a new way and to let go of our attachment to what life was supposed to look like and tend to that grief.

We are a consulting service. That means that people need to be working with another team, like an oncology team, a cardiology team, or a transplant team, and that team reaches out to us as an interdisciplinary team for a consultation. We specialize in eight domains of care, put together by the National Consensus Project. These domains are:

1. Structure and Process of Care
2. Physical Aspects of Care
3. Psychological and Psychiatric Aspects of Care
4. Social Aspects of Care
5. Spiritual, Religious, and Existential Aspects of Care
6. Cultural Aspects of Care
7. Care of the Patient Nearing the End of Life
8. Ethical and Legal Aspects of Care

We do all of this with the patient and their family, however they define family—loved one, chosen family, blood family, caregivers. All of those folks are at the center of the circle for us. We're caring for the patient, and we're also caring for the people who matter most to them.

Primary teams consult us for these primary things: pain and symptom management (nausea, vomiting, dyspnea, sleep disturbances, bowel regimen, anxiety), coping, goals of care conversations and family meetings, communication, collaboration, and general support. Living with a serious illness is rough, and people could use support.

Somebody asked what's the difference between being a unit chaplain versus a palliative care chaplain. I never expected in my experience to be talking so much about what people are eating or how their vomiting is going. It's not that I'm an expert in those things, but something that sets the palliative care team apart is the generalist and specialist model. A doctor, a nurse, a social worker, and a chaplain—we should all be generalists in all of these areas. We should all have a general understanding and ability to assess physical symptoms, psychological coping, social connections, cultural impacts, and their spiritual, religious, and existential world.

The difference is, when I'm talking to somebody about their nausea or their sleep, I'm assessing and then referring back to somebody on the team who can address it as a specialist. In the same way, I expect the doctors, nurses, and social workers on the team to be able to talk to their patients about their inner world and their existential distress, and they will assess and refer to me as a specialist. For those of us who are spiritual care providers, we are spiritual care specialists. What's different about working on a palliative care team is I need to have the skills of facilitating goals of care conversations, and I need to be able to assess people's symptoms and then know who to refer to while staying in my specialty role.

Palliative care asks, "What can we do and how can we be within and around what is, that cannot be changed?" This philosophy attracted me to palliative care. It's this non-dual reality of everything constantly changing, and impermanence is real. There are some diagnoses where there's not going to be a miracle that takes it away. So within the reality—which I really appreciate palliative care and Buddhism sharing this overlap of coming to terms with what is—what can we do with the time, space, resources, and relationships at hand? We think there's a lot you can do, even if we can't "fix" it or "cure" it. We can be present to the suffering and see if we can make it even just a little bit better.

This is where I want to talk about inviting the spirit of improv into the practice of chaplaincy. When I was first introduced to palliative care, I fell in love with the specialty. It was somebody talking about being truth-tellers. I fell in love with a group of people who were working together to put our minds and hearts together to really get to know somebody and understand what was important to them.

At the same time, I was taking an improv class. I'm a heady person, and I needed to get out of my head and into my body. I learned these awesome concepts: it's not about me, it's about the "we." We would play games where we would aim for average and make mistakes cheerfully. Being in a medical context can be so tense, but aiming for average felt freeing. Could I just show up to the room? Could I just tell the truth? Could I just ask some questions about who a person is?

And then, like this week, when I was talking with a patient and got her son's name wrong, I just made the mistake cheerfully and moved on. I learned about "yes, and"—to build on what people are saying and add on to that. And to accept all offers, not going in with an agenda but really paying attention to what's happening in the room right now. As a spiritual care provider, I can be a really good listener, but I also need to lean in and take some risks with people.

I was called to a consultation with a patient at the end of life, but her two siblings were disagreeing about whether she was really dying. The primary team asked if somebody from the palliative care team could come and talk to them. When I sat down, one of the siblings said to me, "What's wrong with you? Did something happen to you that you're willing to do this work?" I just laughed. It broke the ice. It is absurd. We're sitting in this room as his mom is dying, and he wants to know what happened. So I told him my story, and it just put him at ease that I answered honestly, that we laughed. It connected us.

Laughter and bringing it down to this place where both of our feet are on the ground and we're human beings dealing with our mortality—that's going to happen to all of us. Improv taught me that I don't have to make a certain outcome happen. My goal is to connect with people, to have our hearts open just a little bit more. And if our hearts open a little bit more, maybe our minds can open a little bit more, and we can detach from needing things to be exactly the way that we think they should be.

We also make our partners look good. When we work as an interdisciplinary team, sometimes I go with social workers, doctors, or nurses. I'm laughing because I'm thinking of this principle. I was with a social work colleague meeting a patient for the first time. We were learning about how her serious illness was bringing up a memory of her mother's dying. Through the course of our conversation, her heart rate started to increase to the point that a nurse came in. As things were starting to calm down, but her heart rate was still high, my colleague said, "So you were talking about your mom..." and I turned to him and said, "Do you think now's the right time to talk about that?" And we started laughing again. We enjoy each other.

Listening deeply and joyfully with our whole being is how we stay in this work, being in service to a larger story. There are no heroes in spiritual care or healthcare; we're all in it together. There's no one that's going to come in and save the day. It's not up to any of us individually.

I approach this work with the three tenants of the Zen Peacemakers project, which are attributed to Roshi Bernie Glassman⁵: not knowing, bearing witness, and compassionate action. I added "not alone." Anything in healthcare, anything in life, can be lonely. Remembering that we're not alone is the beauty of working on a team.

I want to tell the story of a patient, we'll call him Dan. He was in his 70s with a history of bipolar disorder, some religious trauma, and substance use for which he was in recovery. He also had a brain disease causing a tremor. He had an elective surgery that he hoped would make it easier for him to get around, but the surgery didn't go well. His son came to the bedside, and palliative care was consulted to help navigate goals of care. We couldn't communicate with Dan directly because of how the surgery had impacted him.

His son had a robust social support system and met several of us from the palliative care team. Ethics got involved, and the neurosurgery team was hesitant to transition to comfort care, but his son felt his father would not want to live like this. We advocated alongside them. In the end, Dan transitioned to a hospice house.

The son wrote us this incredible letter. The patient was Buddhist, and the family was Catholic. He wrote about all the different chaplains who had visited. He described his father's dying process: being rolled out under the stars at the hospice house. The son was feeling agitated, and in a moment of lucidity, the patient said to his son, "Relax, everything's going to be okay. I'm going to be okay. I just need to follow the holy man," referring to a Buddhist chaplain who had visited him. The son ended up keeping vigil for two days.

Not all cases go that way, but some of them do. And I bow to all of them, to making things just a little bit better and ensuring with our presence that people feel less alone—as a caregiver, as a patient, or as a team.

The Five Remembrances and Dedication of Merit

As we close our time together, I would love for us to speak the Five Remembrances. This is what helps me stay grounded in the practice, grounded in life, and with my own fears and anxieties. Then we'll close with the dedication of merit. If you would join me, you could put your hands together. I will speak these, but you can also speak them where you are.

I am of the nature to grow old. There is no way to escape growing old. I am of the nature to have ill health. There is no way to escape ill health. I am of the nature to die. There is no way to escape death. All that is dear to me and everyone I love are of the nature to change. There is no way to escape being separated from them. My actions are my only true belongings. I cannot escape the consequences of my actions. My actions are the ground upon which I stand.

May the fruits of our practice and this conversation be for the benefit of all beings. May our actions be for the benefit of all beings, known and unknown, seen and unseen, without one exception, including you and me.

Q&A

Question: You talk so much about working as a team. Even a non-palliative care chaplain has overlap in emotional and spiritual support. With palliative care, you have communication, advanced care planning—there's even more overlap. How do you navigate that when you're working with, say, a social worker or a psychologist?

Answer: Great question. Our practice for the day is we come together as a whole team in the morning and review our patient list and new consults. Oftentimes, when we get a request for support or goals of care, a social worker and a chaplain will go together for the initial visit. We want to save them from having the same conversation twice. Then we discern what this patient and their family need, where their distress lies, and who might be the best specialist to take the lead. If it's a lot of religious or spiritual distress, or even grief, a chaplain might take the lead. If it's more about anxiety, mental health, coping, or depression, I'll lean on my colleagues who have more training in intervening on mental health. We stay in dialogue and check in with each other. Sometimes, if a case is really heavy, we trade on and off, or one of us will take the lead on caring for the patient while the other takes the lead on caring for family members.

Question: How does that work with spiritual assessment if you have multiple spiritual care providers working together?

Answer: We all have access to each other's chart notes and communicate with each other. One of the psychiatrists on our team likes to use the word "formulation." What's our formulation about this patient and this family and what they need? It can change from day to day, week to week.

Question: Is care ever given outside of the hospital?

Answer: Yes, we have outpatient palliative care providers. Those of us on the inpatient team don't transition to outpatient, but some of the physicians do. Those are video visits; we don't go to people's homes. People can find that very beneficial, to continue to get check-ins on their symptoms and support from the interdisciplinary team, and have ongoing goals of care discussions.

Question: Can you talk about spirituality in your work?

Answer: My favorite definition of spirituality comes from a working group led by Dr. Christina Puchalski: "Spirituality is the dynamic and intrinsic aspect of humanity that refers to the ways persons seek and express ultimate meaning, purpose, and transcendence, and the ways they experience their connectedness—relationship to the moment, to self, to others, to society, to nature, and to the significant or the sacred." This definition focuses on connectedness. To be able to be present to someone else's inner world, we have to know our own. Physicians, social workers, chaplains, nurses—if we want to engage with the spirituality of another person, it starts with being engaged with our own. Then we can be aware of this connectedness between ourselves, human to human.