Touch me in the morning. (Or not.)

me and my patient holding hands, 2010

Touch me in the morning
Then just walk away
We don't have tomorrow
But we had yesterday

Wasn't it me who said that
Nothing good's gonna last forever?
And wasn't it me who said
Let's just be glad for the time together?
It must've been hard to tell me
That you've given all you had to give
I can understand you're feeling that way
Everybody's got their life to live. 

~ from Diana Ross' "Touch Me in the Morning"

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When I enter a patient's room or approach their bed, the first thing I do--almost always-- is reach for their hand. For me, there's just something about that first point of contact through touch that seems to get things off on the right footing.

My style of touching patients is one that fits my personality. In general, I am more affectionate than not, so nothing about touching the hand of a person has to be forced or calculated. Sitting next to a patient on their bed (with their permission, of course) or reaching for their hands again at some other point in our encounter often happens, too. Again, part of that has to do with the fact that I believe touch is important. But a substantial bit is simply wrapped into my M.O. in general.

I'm reflecting on this this morning because a fellow health care provider asked me my thoughts on it recently. This friend had experienced an awkward interaction with a patient and, though it wasn't their intention, the patient was offended. He even likened this gentle interaction to being "patted like some kind of dog." That humble provider immediately apologized and told the patient that these words would be taken to heart.

And before anyone casts any judgments, it's best to agree that we weren't there. It's also fair to say that I know for sure that patting the patient "like some kind of dog" was not the intent behind that interaction.

So that moved us to this question of touching other human beings in the clinical setting. What is cool? What isn't?

Lord knows that I'm not an expert on the topic but since I am a "toucher" I gave this all some thought. I'm very interested to hear yours, too. I know my friend who had that experience would be as well.

I believe that "touching" patients and people has far more to do with just physical contact. It involves eye contact, instincts and even subtle things like variations in the intonation of the voice. My handshakes start out formally. In those first few moments, I do my best to make an assessment of what is and isn't okay with that patient.

There are some people who immediately cover my hand with their own which prompts me to do the same. Before I know it, we're in one of those cozy four-hand handshakes that quickly becomes the equivalent of being offered a warm blanket or some hot cocoa when entering someone's home. This might be the person who pats the side of their hospital bed and welcomes me into their personal space. Or even the one that gets a big hug from me as they're being discharged.

But then there are other patients who, though equally wonderful human beings, just aren't so keen on all the touchy-feeliness. My friend Psonya (pronounced Sonya) has said more than once to me that she is no big fan of being hugged. Though that's usually said in jest, I do often think of her and that preference in the context of my patients. Because Psonya happens to be quite warm and welcoming to others -- just not all up in her personal space. (That doesn't mean that as my friend and not my patient that she won't get hugged by me anyway.)

So the point? Wait, what was my point? Oh. The point I'm making is that there are people and patients who won't be too happy with hand pats and being tucked under covers before you leave their rooms. But that doesn't mean that they're cold or aloof. It just means that this isn't how they roll.

More than anything you just have to pay attention. Watch their body language, facial expressions and reactions to the things you're doing and saying. Sometimes it seems like things are all chummy but then a ripple of discontent might roll over the patient's face that tells you too back off of the whole "overly familiar" thing. That's when you autocorrect yourself and go back to the formal default.

I'll say that again. Formality is the default. If you're socially awkward, a not-so-spot-on judge of situations, or simply not one who feels natural in touching other human beings that you don't know well, formality is the safest default of all. But don't forget your other components of touch -- eye contact, facial expressions, and voice intonation.

At least that's my opinion.

Then there's the type of touch. Hands seem to be the safest and least likely to lead to offense. I'd be lying if I told you that I hadn't touched the face of a dying or critically ill patient or that I hadn't ever patted tears off of cheeks. And yes, I've even sat right beside one of my F.P.s in her hospital bed while listening to Sam Cooke on my iPod and dissecting whether his raspy voice came from just soul, cigarettes or both. I've pulled socks back onto cold feet and even scratched more backs than I am willing to admit. But all of these broaches across those personal-space barriers were done with close attention.

Now. To my friend who asked that question:

Do I always get it right? Nope. Just two weeks ago I was caring for a patient in the hospital who was dying. Her family was there every single day for every single moment I cared for her and after lots of hoops and confusion we arranged a discharge plan that worked best for this patient and her loved ones. In this instance, that was home hospice. The interactions with the family and the patient had been so tender, so sweet. The patient was so weak that I often took her hand and held it throughout our encounters without much physical reciprocity but her eyes and facial expressions seemed to appreciate it.

So what happened? I took this to mean that the family was in a similar place. But this family had some cultural mores that I hadn't given enough thought to observing. As they left, I knew that I'd not see her again. I knew that. So I squeezed her hand and she gave me a weak smile with eyes at half mast. Then I approached the sister who'd been standing vigil for that whole week and gave her a hug. And the minute I put my arms around her, I knew that this was not the best idea.

Her body stiffened and her right shoulder slightly guarded her from allowing me to get to close. I immediately took that cue and went back to the formal default. I shook her hand and those of the other family members, too. Then I simply stood and watched them disappear down the hall in their soft and brightly hued fabrics from their African homeland. I winced at my ignorance and the lumpiness of that last moment.

So no. I don't always get it right. But I try to pay attention and learn from the things that happen.

And perhaps a pat upon the head could be perceived the wrong way by someone. I will think of that the next time I bring my hand near the head of a bedridden patriarch, keeping that lesson on a post-it note in my head for later.

Because all of these interactions are lessons. Lessons in better ways to humanize what is often cold and concrete. The science is what it is. But the human beings are each different and ever-changing. They are individuals who want their doctors and caregivers to just stick to the facts on some days, to hug them like they mean it on other days, to play rock, paper and scissors early in the morning sometimes, or maybe, depending on the day, to just get them an ice cold Sprite from the soda machine.

That part isn't science. That part is human.

So we strive to connect those dots. The human ones to the science ones to the formal ones to the familiar ones. And on some days, if we just keep paying attention, we'll get it right.

That's all I got today. Weigh in, alright?

***
Happy Thursday.

Now playing on my mental iPod. . . . Ms. Diana Ross sings it like the diva that she is!