We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place.

We are always looking for cases. Please send any cases that you would like considered for inclusion to: info@plainviews.org We will ensure that it is stripped of any identifiers. For further guidance about how to write up a CaseConference, please refer to the CaseConference Archives, Vol. 4, No. 3 "How to Submit a Case for CaseConference." (Click HERE)

We hope that this will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

PLEASE NOTE: Due to unanticipated continuing responses to both the case and the resolution of the case, added responses can be viewed in the archives. Click HERE.

Editor's note: this case was submitted by a chaplain seeking feedback on his/her own work. This is part of why CaseConference was created. We applaud this chaplain for stepping forward to seek consultation in this very public way and we hope others will do likewise. This is an example of how we might all improve our practice and advance best practice in our profession.

Case #18 (please see below for responses)

A code pink was called in the urgent care clinic. The chaplain responded to the call and was informed that an infant boy had died. The specialist explained to the team that the child’s death was expected, although he died much sooner than anticipated. The condition could not be treated. Another doctor asked the specialist if she was okay. She said she was fine, stating again that his death was expected.

The chaplain was directed to the grandmother and stayed with her until the nurse manager arrived to escort them to view the dead child. The grandmother had brought the child to the clinic for the first appointment with a specialist. The family had moved to the area recently. Prior to their move, their son had been diagnosed with a terminal condition.

When the parents and the grandfather arrived, the chaplain continued to be present with them. They welcomed the time to be with their child.

The specialist came into the room very briefly when the parents arrived. She offered a quick summary of what had happened and then left. The parents grieved appropriately. (Yes, they expected their child to die but not that day.) The reason for the referral to this specialist was their hope that treatment would ease their child’s pain and allow them to hold him without discomfort to him.

After the family left, the chaplain visited with some members of the staff, and later attempted to determine if a debriefing session would be called. The nurse manager, who decides if there will be a debriefing session, decided that a session was not needed (the staff had not requested one). Even with the support of the director of pastoral care, the nurse manager did not see the need for the session.

What is the chaplain’s role when he/she feels that a decision made is incorrect?

How can the chaplain ensure that staff involved are given the support needed so that they can continue to do their jobs?

What is the chaplain’s role with the specialist?

What is the chaplain’s role with the nurse manager?

Is there a systemic issue that the chaplain needs to consider and try to improve?

Case # 18 responses

My first observation is that if the chaplain sees the need for a debriefing, but the staff, the nurse manager, and the physician do not, then perhaps it is the chaplain who experienced the child's death as traumatic and not the medical staff. Certainly the death of a child is one of those events that is usually high on a critical incident list, but not every member of a team experiences the same event in the same way and what is traumatic for one staff member may not be traumatic for another staff member, what is not traumatic today may be devastating tomorrow or a month from now. The impact of this child's death may hit certain staff members later, or it may be triggered by another child's death, or it simply may not be a critical incident for this staff in this time and this place.

My second observation is that within the tools available for critical incident stress management, perhaps the chaplain chose the wrong intervention or limited him/herself to a single intervention rather than considering the many tools available in a situation like this and offering the nurse manager and the staff some options other than debriefing. A debriefing is a major intervention in terms of time, money, and emotional investment and to pursue debriefing when a staff does not want or need one is wasteful. It can also be hurtful to force debriefing on staff who do not want or need it. It isn't a matter of debriefing or nothing. Perhaps if the chaplain had offered pastoral care or a different critical incident tool -- defusing or demobilization, for instance -- the nurse manager and the rest of the staff would have been more receptive or would have seen their need in a different light. Following some other preliminary critical incident intervention or just good pastoral care, they may have welcomed a debriefing later. Certainly, they will view the chaplain in a different light if the chaplain offers what the staff needs rather than what the chaplain wants to give.

My third observation is that the chaplain still has available to him/her the gifts and interventions of pastoral care to offer that staff on an ongoing basis. The staff are denying the need for a debriefing. They may or may not need a debriefing, but they state that they do not. They may, on the other hand, welcome the pastoral support and care of a gifted chaplain.

My fourth observation is that this case refers to the medical staff -- nurses, nurse managers, specialists -- but makes no mention of the other staff who witnessed the child's death or the events surrounding the child's death -- housekeeping, clerical, administrative staff, security. A child death in any setting is shocking; a child death in an outpatient clinic is especially shocking. The other staff who were present need to be included in any critical incident response and in the chaplain's follow-up care. It is possible that their managers and directors would welcome intervention that the nurse manager does not.

My fifth observation is that the chaplain him/herself may be in need of post-critical incident intervention which his/her director can provide or arrange in order for the chaplain to return to work.

What is the chaplain's role with the nurse manager? If the nurse manager were refusing pastoral care and critical incident intervention when the staff is saying they need it, then the chaplain's role is clear. However, in this instance the staff, too, are saying they do not need an intervention at this time and are ready and able to return to work. The chaplain's role is to be sensitive to their needs, to be available when they do need intervention -- which may be the next shift, the next month, or the next child death -- and to have more than one intervention to offer. The chaplain's role is not to play pastor-knows-best.

Is there a systemic issue that the chaplain needs to consider and try to improve? That's difficult to answer on the basis of the information provided. If the critical incident policies and procedures for this setting are not clear or are not reasonable or are only honored in the breech, then there may be a need for review, for a champion in the system, or for other action. The chaplain can be an effective and appropriate advocate for those things. Perhaps the systemic issue is that the chaplain does not have the trust of the staff or the nurse manager and so any care offered will be declined; again, the chaplain's role or the director's role is clear if this is the situation. Perhaps the systemic issue is systemic w/in the chaplain, though, who desperately needs to provide pastoral care to a staff who do not want, and may or may not need, the specific care the chaplain is offering them in the moment.

Linda Brown
Staff Chaplain / Coordinator of Spiritual Health Services
Truman Medical Center - Hospital Hill
Kansas City, MO

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