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The World is Naturally Lean

Working in modern North American health care, we hear more and more about reducing waste and working efficiently as an important way to both reduce cost and improve patient satisfaction. For instance, reducing the notoriously long times patients often have to wait for service in a hospital’s Emergency Department both increases the number of patients the hospital serves with a given amount of resources and makes patients and families happy. And happy patients return to the hospital the next time they need emergency care.

 One of the major systems for accomplishing this transformation is called “Lean”. Although many of the people who developed Lean were from the US, the philosophy took root in post World War II Japan because the US manufacturing community rejected it as unnecessary and undoable. Thus arose the long domination of Japanese manufacturing. Fortunately for the US economy, US companies like GE and Motorola eventually “got it” and Lean is now even fully visible in Detroit.

 One of the resistances to Lean or any other waste reduction and efficiency enhancing philosophy is that we in developed countries are so used to being wasteful that it seems completely natural to us. We find it much easier to dispose of unused material rather than find uses for it, to build vast product distribution networks which add to cost and resource usage rather than produce and use local products, and to tolerate and accept a certain amount of error in any system as inevitable rather than embrace the idea that systems can be error proofed. For someone like me who has lived in a first world country all of his life, it is easy to accept the idea that waste is just a natural part of the way the world is.

 A recent visit to Tanzania in East Africa reminded me that the natural world is, in fact, structured to minimize waste and to use all resources fully. The ubiquitous acacia tree is a good example. The tops of the trees are reserved for the baboons that eat the blossoms and fruit. The next lower level provides food for the giraffe that can reach very high but cannot conveniently reach lower branches. Elephants feed on the next lowest level which is too low for the giraffe but too high for the taller antelope who enjoy the next lowest level. Finally, the lowest branches provide food for the tiny Dik Dik, the region’s shortest antelope. No part of the tree goes unused but also the tree is not totally consumed so that it produces food again the following season. When branches and trees do die, they provide the most common source of firewood and even building material. They do not accumulate on the forest floor and provide fuel for fires.

 The carnivores have a similar system. The lions get to eat any dead animal first but male lions are territorial so the “meal” is restricted to the pride whose territory the dead animal is on. Also, the lions will only eat if they are hungry- unlike many humans- so there is often much left over. The hyenas and jackals go next. Finally, the vultures and other birds that are well suited to picking at hard to reach tissue clean up. At the end, nothing edible goes uneaten and every group has a chance at the table.  

The lesson for me is that at least much of the natural world is naturally Lean.  Just maybe finding ways to eliminate waste is the way the world was created to be.


The Different Ways of Dying in the Emergency Department.

In every hospital that I know about that has an Emergency Department (ED), the vast majority of the deaths in the institution are either in the ED or in the ICU. Further, many of the people who die in the ICU come in through the ED on the verge of dying. They are sent to the ICU, not because their lives will be prolonged by aggressive care but because the ED staff, including the chaplain, is not trained or positioned to either recognize or deal appropriately with the fact that this patient is on a trajectory which is going to lead to their imminent death. Since the process is not set up to allow the patient to die in the ED and the patient needs aggressive care to stay alive even for a short period of time, the ICU is the only option. Thus, the dying patient spends the last moments of their life hooked up to lots of machines which may even be hastening their dying and in a lot more discomfort that necessary.

Now, Dr. Garrett Chan from the Emergency Department Clinical Decision Unit at Stanford Hospital has published a very helpful article that identifies seven trajectories of approaching death in the ED: 1. Dead on arrival; 2. Prehospital resuscitation with subsequent ED death; 3. Prehospital resuscitation with survival until admission; 4. Terminally ill and comes to the ED; 5. Frail and hovering near death; 6. Alive and interactive on arrival, but arrests in the ED; and 7. Potentially preventable death by omission or commission. His conclusion is that recognition of these trajectories will help clinicians to “be more astute in their recognition of the clinical situation and react appropriately, will help identify the transitions to the EOL phase, and will help to explore the possibilities open to the patient, family and clinicians.

While a good deal of the recognition of these trajectories relies on medical information, the chaplain, because he or she will not always be intensely involved with one or two patients, can have a perfect vantage point to observe one of these trajectories unfolding and help the staff and the family recognize the clinical reality and catalyze the appropriate discussion of goals of care.


Chan GK. (2011) Trajectories of Approaching Death in the Emergency Department: Clinician Narratives of Patient Transitions at the End of Life. J. of Pain and Symptom Management.  42(6), 864-881. 


New Books of Interest

New books of real interest to the field of spiritual care and professional chaplaincy are rare.  So it is rare indeed to see four books come out in such quick succession all of which are must reads for everyone involved in spiritual and chaplaincy care.

Dr. Harvey Chochinov, Canadian psychiatrist and palliative care doctor, has published in book form his excellent work on dignity therapy (Dignity Therapy: Final Words for Final Days, Oxford Press). Dignity therapy formalizes a kind of legacy work not unrelated to what many chaplains have long done in the form of life review or ethical will. It is founded on the proposition that people at the end of life generally want to tell their stories and have those stories valued and preserved.  Chaplains should not be put off by the fact that this work is advertized as “therapy” and a “psychological intervention”. It is spiritual care. This is must reading for all members of a palliative care or hospice team.

Chaplaincy practice has long lacked a solid theoretical base. It has also been ambivalent about claiming “hope” as an outcome lest we seem to promote denial and a flight from dealing with reality. I was only recently introduced to the work of Steve Nolan, a chaplain at Princess Alice Hospice in the UK who has published a very helpful book, Spiritual Care at the End of Life: The Chaplain as a Hopeful Presence (Jessica Kingsley Publishers). Steve’s work lays out a very well explicated theory of the role of chaplaincy in being with the dying that is focused around hope. Whether you agree with Steve or not, this book will help you think more deeply and systematically about your chaplaincy practice.

Dr. Ira Byock has been maybe the most tireless advocate for the idea that dying, while inevitable, does not have to the horror that it is for many people in America today. Now he has gifted us with another book (The Best Care Possible, Penguin Group) which highlights both Dr. Byock's immense wisdom and experience  and his deep compassion and caring for those who are suffering and dying. As he says, "Dying is hard, but it doesn't have to be this hard." Be sure to read the Introduction thoughtfully. It alone is worth the price of the book.  

Finally, Rabbi Stephen Roberts, well known to many of us as a leader in our field, has edited a much needed and thorough volume, Professional Spiritual and Pastoral Care: A Practical Clergy and Chaplain’s Handbook (Skylight Paths). The book provides a wealth of material on both the foundations and current best practices in health care chaplaincy, much of it not in print anywhere else. This book should be on every health care chaplain’s shelf as a reference. (Note- while I made several contributions to this book, I have no financial interest in it.)

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