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Chaplaincy in Palliative Care Settings

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Post Point of Chaplain Intervention?
Author: DenverC
Date: May 19, 2008 1:53 pm
We want our patients to receive chaplain services but are unsure about what point chaplain intervention is needed? Also, when our patients recieve chaplain services we want to make sure that they are not proselytized to. How can we do this?
Replies: order by [Date] [Author] [Subject]
Re:Point of Chaplain Intervention? (by Palgal1 on 05/19/2008)
If your chaplain is CPE trained, then proselytization should not be an issue. The role of chaplain is to listen and walk alongside patients in families in their journey. Spiritual care interventions are part of what we do in palliative medicine. After all, suffering occurs along spiritual domains as well. We had a patient in our program with "wailing of the soul" whenever she awakened from her pain medications. It took quite a bit of convincing the nurses on the ward that simply "shutting her up" was not enough. The entire interdisciplinary team got involved and her spiritual, psychological, and social issues were addressed with good results. This would not have happened with medication alone. Chaplain services are underutilized, but if you are fearful of proselytization, then it is understandable.
Re:Point of Chaplain Intervention? (by JJCASTELLO on 05/20/2008)
Since every patient, especially ones on palliative care, is in some level of spiritual distress, I believe it makes sense to get the chaplain in early in the assessment process. The reason being so the chaplain can evaluate the spiritual state of the patient and family and develop a plan of care for them. This is especially important when the issues center around ethical questions, i.e., end-of-life decisions of withdrawal/withholding life support machines and education of the patient's church's position on these matters. The chaplain is uniquely qualified to enlighten and support family members making very difficult decisions. I can assure you that proselytizing is not in the list of services chaplains provide and, I believe, is grounds for dismissal if a chaplain tried it. It would constitute harrassment of the vulnerable.
+ Re:Point of Chaplain Intervention? (by EMeyerson on 05/20/2008)
Yes- a properly CPE trained chaplain will know and understand that proselytizing is NOT the chaplain's role- actually the direct opposite. A major role of the chaplain is to remind the patient of who s/he is- not try and convince the patient of something else. And so, when providing support for the patient- whether it be spiritual or emotional (God does not always play a role for the patient or family), the chaplain is trained to provide that support- support that is essentially catered to the specific patient or family member where that specific person is at that specific moment.

I think the word "intervention" should be discarded. The chaplain must initiate his/her visit after the Palliative Care consult takes place (within that same day or the following day). If Palliative Care is alleviating suffering (physical, emotional, existential, etc.) at any stage in an illness, then a spiritual assessment must take place at that time as well. Once the chaplain is present and is understood, to the patient and the patient's support system, as part of the healing team, the chaplain becomes a resource and a support as days, weeks, months, years progress.

And so, to answer the question head on, at what point should a chaplain become involved? Ideally, day zero or one in the hospital. By involving the chaplain early in the process, this allows the patient and family to better understand the chaplain's role. We are not there only in times of death- we are there in times of life; we are there to witness, provide support, and acknowledge the struggle to live that life in the way the patient wants to live it while in the midst of illness.
-Chaplain/Rabbi E. Meyerson
+ Re:Point of Chaplain Intervention? (by ghandzo on 05/20/2008)
I certainly agree that CPE training is a fairly effective way to guard against having a chaplain who might proselytize. Another possibility is for employers to require their chaplains to sign the Common Code of Ethics for Professional Chaplains that can be found on the website of the Association of Professional Chaplains. Certainly, employers should make this a condition of employment. As to the point of intervention, I agee in theory with Rabbi Meyerson that day zero or one is best. In Palliative Care, spiritual/religious care should be a full partner and chaplains are the professionals who deliver that care. However, I am also aware that not all palliative care teams are staffed to this level. Therefore, we recommend a short spiritual screening done by the person doing the official intake for the service. Following the model proposed by George Fitchett, this screening should ask how important spiriuality and religion are to the patient or family member's coping and to what extent those mechanisms are working at the moment. The person for whom religion is important but it is not working should be referred for immediate pastoral care.

The Rev. George Handzo, BCC
Vice President
Pastoral Care Leadership & Practice
The HealthCare Chaplaincy
New York, NY
Re:Point of Chaplain Intervention? (by Tim_Ford on 05/20/2008)
CPE training will certainly minimize risk of any ethical violations coming from a multi-faith or secular environment. Most problems occur in systems that use volunteer and/or unsupervised chaplains from the community. We have committed to a full chaplain FTE to cover all palliative admissions which allows for assessment of every patient. I think this should be the standard for palliative care but recognize that most programs cannot yet commit to this financially. Meanwhile I think it is the chaplain's role to educate the nursing staff to provide a sensitive screening of spiritual needs in order to provide the most appropriate referrals to the professional chaplains. Imho - best point of insertion would be at the initial family meeting to establish goals of care.
Re:Point of Chaplain Intervention? (by ghandzo on 05/21/2008)
I agree that the gold standard should be a full spiritual assessment of any newly admitted patient by a board certified chaplain. The benefits are, not only protection against ethical violations, but having someone who is fully qualified to see the depth of spiritual issues and structure an intervention that is both respectful and effective. While many programs find it necessary for good reasons to employ community clergy in this role, it is important to be aware of some of the risks. Beside the possible lack of training, community clergy can have inherent conflicts of interest in this role. What happens if the new patient they are asked to visit as a chaplain is also a member of their congregation who may or may not want the clergy to know about their medical condition? Another interesting issue is that there is not significant agreement among professional chaplains about what constitutes a spiritual assessment. It might be helpful if others in this forum would share the basic elements of the spiritual assessment they do. Finally, it is important to maintain the distinction between a screening tool like George Fitchett's that is meant to be used by nurses and others and an assessment tool that is meant to be used by trained chaplains.

The Rev.George Handzo, BCC
Vice President
Pastoral Care Leadership & Practice
The HealthCare Chaplaincy
New York, NY
+ Re:Point of Chaplain Intervention? (by MarciP on 05/29/2008)
Hello - In our PC program, we have an interdisciplinary team that works together on appropriate referrals and interventions. A well trained chaplain knows better than to proselytize, but is a listener and (in many ways) a participant in the journey of patients and families. Chaplains should be trained to be sensitive to family and patient needs. Banging dying folks over the head with Scripture or guilt about past sins or salvation ain't the way to go -- but listening and being open to providing venues for confession, absolution, forgiveness and reconciliation can result in some incredibly holy moments.

The Rev. Marci Pounders
PCCS Chaplain, BUMC
Re:Point of Chaplain Intervention? (by cynmb on 05/29/2008)
It is important that your chaplains have clinical training and are certified through the cognate organizations mentioned. I believe the chaplain's support should be as key as the others on the team. As a trained and certified chaplain I see my contact to be one of emotional/spiritual/ psychosocial support. As part of a palliative care team, the expectation is that I visit (or one of our other chaplains)to determine the patient and family needs. I also often refer patients and their families for family and patient support, pain or symptom management and/or end-of-life decision making for care so am the first to 'visit' and encourage additional care from our team.
Re:Point of Chaplain Intervention? (by GeorgeHankinsHull on 05/29/2008)
Concerning proselytization:
The College of Pastoral Supervision & Psychotherapy (CPSP) accredits clinical pastoral education programs and certifies board certified clinical chaplains. We trust that the following would address some of the concerns about proselytization:

From the CPSP Code of Professional Ethics:
Respect:

Colleagues, students, clients, parishioners, and patients deserve our respect. Therefore, members will not proselytize nor force their own theologies on others. CPSP members will refrain from exploiting relationships or using them to their own advantage. Exploitation includes emotional, financial, sexual, and/or social gain. Records, evaluations, personal notes, and informational conversations will be kept confidential.

Competency in Pastoral Care:

The basic requirements in CPSP for certification as Board Certified
Clinical Chaplain:

1. The characterological make-up for ministry, including an ability to bond with others, an ability to give attention to others, and a tolerance for diverse religious traditions and values.

2. Basic self-understanding, so as to limit unconscious imposition of one’s own agenda on others.

3. Endorsement by a faith-group community to perform ministry.

4. 1600 hours of clinically supervised ministry or a year of Clinical Pastoral Education.

5. Continuing education and annual recertification.

6. A Master of Divinity degree or equivalent, which means three years of post-graduate academic study.
Access to Pastoral Care:

CPSP affirms the right of the of patient’s and their loved ones to have access to pastoral care that is directed in accordance with the patient's and their family's faith tradition.
CPSP affirms the right of the hospice patient to have that care provided by a religious professional from the patient's own faith tradition.

CPSP advocates that religious professionals employed by hospitals or hospice programs work cooperatively with parish clergy so as to facilitate ongoing pastoral support by community clergy.

CPSP acknowledges the patient's right to refuse the provision of pastoral services.
Pastoral Evaluation in the Clinical Pastoral Tradition:

CPSP affirms that pastoral care, in the clinical pastoral tradition, must include personal evaluation with the specific purpose of bringing the appropriate pastoral resources to bear. CPSP advocates for a dynamic process of pastoral assessment over against the use of a written instrument that requires nothing more than the recording of a patient’s answer to a predetermined set of questions. CPSP affirms the communication of the pastoral evaluation of the patient’s and family’s pastoral needs to the interdisciplinary team.

CPSP supports the patient’s right to be a partner in their treatment plan so
as to determine the goals of the care.
George Hankins Hull

CPSP Diplomate in Clinical Pastoral Supervision

http://www.cpsp.org/
Re:Point of Chaplain Intervention? (by revnenn on 05/30/2008)
Our hospital staff chaplain is assigned to the Palliative Care Team and receives notice, as does the team, with each new referral. This chaplain:
- makes an initial visit and spiritual/religious assessment
- works with team, patient's family, family clergy, etc. as needed
- meets with the Palliative Care Team Reviews; receives and offers consultation
- Provides brief memorial with the Pal Tm when a patient dies (ie, self care for team and hospital staff)
- writes condolences to family
- Builds alliances with local clergy
- Educates, connects, coordinates pastoral care
- Keeps Pastoral Care staff informed and aware of Pal Care patients
This chaplain is ACPE CPE trained and certified and has focused working with EOL and Pal Care.
Hope this helps. Chp J Nenninger, ACPE Supervisor. revnenn@erols.com; jnenninger@sibley.org
Re:Point of Chaplain Intervention? (by Chaplain_Al on 05/30/2008)
Marci writes: "In our PC program, we have an interdisciplinary team that works together on appropriate referrals and interventions."

The interdisciplinary process is key. The clinical chaplain needs to be integrated into this team. At UAMS Medical Center here in Little Rock, as a Board Certified Clinical Chaplain, I not only work as a part of the interdisciplinary team, but also coordinate our Palliative Care program. Each consult order for palliative care comes through me, and I do an initial screening for needs. I call in the members of the team, as appropriate. I offer this as a model where the chaplain is central to the palliative care team process.

At a minimum, a palliative care consult involves our palliative care physician, myself as chaplain/PC coordinator, the patient's nurse, the attending physician, and a social worker.

We also meet each week for interdisciplinary team staffing conference (IDT). Members of our IDT include physicians, a nurse, a social worker, a psychologist, and chaplains. At each IDT meeting, we staff each patient from that week including medical assessment, social assessment, and pastoral assessment. In addition, we discuss the interventions, plans, and outcomes of each case. Our IDT meetings also have an educational segment as well.

In my role as chaplain, a part of my pastoral assessment includes an evaluation of the religious/faith/spiritual resources already available to the patient and family. Many, not all but many, of our patients and families have a connection to a faith community (cf. S. Pulchalski's FICA model - C for faith Community). As chaplain, it is important that I help facilitate the role of the patient’s and/or family’s faith community and clergy to offer pastoral support and nurture. In addition, it is most always beneficial, if possible, to involve a patient’s clergy in our team process for that patient as well.

As an academic medical center, we are implementing a medical fellowship in palliative care AND a palliative care fellowship for chaplains through our CPE program. I will keep this group informed on the progress of both fellowship programs.
Re:Point of Chaplain Intervention? (by ghandzo on 05/31/2008)
The coordination of the palliative care team by the chaplain is an interesting model that is not unique to this one institution. It would be interesting to hear more input on the pluses and minuses of this model. It would certainly make palliative care in this system less medically focused. Certified chaplains are also skilled facilitators who are used to helping people be heard in a group- also a plus in this case.

The Rev. George Handzo, BCC
Vice President
Pastoral Care Leadership & Practice
The HealthCare Chaplaincy
New York, NY
Re:Point of Chaplain Intervention? (by Grapik on 12/04/2008)
The avoidance of proselytizing is an important mark and is part of the standard of a professional chaplain. In addition to CPE, which I believe should be the first screening tool, part of the hiring practice should certainly have a duties and responsibilities area that covers professional standards, such as being of service to all levels of faith, as well as no faith.

I am the FTE for our In-Patient Palliative Care team. Our interventions are done in concert with each other. Our family meetings are done as a team, with the MD, RN, LCSW, and M. Div all in the discussion. This is very helpful; since there are times the Chaplain might be the better role to introduce goals-of-care, while the LCSW might be the better role to dive into care of the spirit.

I believe that every patient should be assessed by the Chaplain, in every instance. Care and support of a person's spiritual wants and needs is core to palliative care. It might be a minimal role at times, little more than reminding the team of the humanity that we are working with, or as significant as walking with the patient along their spiritual processes.

I enjoyed the call yesterday, as it spoke of the MD as the Spiritual Generalist, able to recognize spiritual distress and refer to the Chaplain.

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