As professional chaplains we need to be in dialogue with each other about what we do, how we do it, and why we do it a certain way and how these practices benefit our patients. The ultimate goal of MyPractice is to build a consensus about what constitutes “good practice” and eventually establish “Standards of Practice” for chaplains. As with quality improvements in our institutions, this is an ongoing process in order to improve our practice.

To have a description of a practice that you use in your setting considered for inclusion here, write it up and send it to PlainViews for consideration. The Association of Professional Chaplain's Quality Commission’s Best Practice Committee will work with the Managing Editor of PlainViews to review submissions and select articles for publication. Your submission does not necessarily need to be cutting edge (although that’s okay, too). We want to identify “good practices” that could be recognized as standard practice.

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Response to Trauma Protocol (see below for article)

I was interested in reading Chaplain Phillips take on "Trauma Protocol" given that I had completed one of my units of CPE in the Trauma Unit. All of the protocol was on target. It's my hope that other interns will take the opportunity to read it. One point that is important for all chaplains and especially those working in trauma is self care. It's vital that the Chaplain continue to nuture and allow for their own thoughts and feeling to emerge and flow out of their own souls. For myself, connection with family and friends as well writing poetry and journaling helped me. Another realm of self care is the valued resource of our colleagues to talk through experiences. Chaplain Phillips article is a welcomed resource for Chaplain Interns newly exposed to trauma units.

Rev. Joanne Mumley
Winter Park, Fl

A Trauma Protocol for Chaplains

I began working in the Emergency Room of The Westchester Medical Center towards the end of my Clinical Pastoral Education Residency in March, 2000. I knew nothing. No one here had done this before me, so I learned by trial and error. Through these past eight years, I have learned some helpful information that may help you in your ministry in situations like these.

I am grateful for the wisdom and wise counsel of other chaplains who contributed to this article. Thanks to members of our Chaplain’s Circle group, Chaplains Anne Gentile, James Gorman and Suzanne Hope Graham. Similar gratitude for their insight and affirmation go to my two colleagues in Trauma Chaplaincy, Chaplains Angelo Betancourt and Lauren Ivory.

Emergency Room Trauma (When the patient arrives by ambulance or helicopter)

1. Before entering the Trauma room, compose and spiritually center yourself. Upon entry, be observant of all infection control procedures. (gown, glove, mask, if needed)

2. At all times, stay out of the way of the medical procedures that need to happen. Stand off to the side until it is appropriate. A good place to stand is at the head of the stretcher; you are close by and can talk calmly and quietly to the patient. Another good place is near the patient’s hand, so you can hold it.

3. Listen and observe details about the patient’s injuries. If you touch the patient, be sure not to touch anything cut, scraped, burned or broken. If there is an IV in the hand, be careful how you touch that hand, so as not to compromise the needle or fluid flow. For the same reason, make sure the arm remains straight.

4. When introducing yourself to the patient as a chaplain, remind them that you are not here to present any additional bad news. Remind them you are here to be present with them until things settle down. Be reassuring, but defer all medical questions to the Trauma team.

5. When the patient is turned and the back board removed, you can be of help by taking the board out of the room. Doing so will put you in touch with the ambulance crew who might be able to shed some light on the Trauma.

6. In the Trauma room, if appropriate, or if the documenting Nurse is too busy, ask the patient his/her name. It is more calming for the patient. Also, try to get phone numbers for family members (so have a pen handy).

7. The medical staff may ask you to call the family. If so, only provide basic information. ("There’s been an accident. Your family member is in our ER. Here is how to get to the hospital.") Give them your name and offer to meet them when they arrive. Refer medical condition questions to the medical staff.

8. Generally, it is a source of comfort for the patient and family if the patient can speak on the phone to the family. Both need to hear each other’s voices. But if the patient is in too much pain, do not encourage it.

9. When family arrive, take them to Triage area. Give them information, but be careful what you say, as they will be hanging on every word. Refer to medical staff for medical questions. Respond to family’s shock and sense of feeling out of control. Remind them that anything they are feeling, no matter how crazy it may be, is completely normal. Be prepared to listen a lot.

10. In Traumas, rumors begin and are disseminated quickly. Do not pass along any information unless it has been verified.

11. If family and friends are gathered outside the Trauma room, get them something to drink. Let them sit down, or if they need to pace, accommodate them as long as it does not interfere with patient care. Go back and forth between family and patient. Pass along any information the medical staff needs to know about the patient and any communication between patient and family. Note: if the patient is a police officer, firefighter or Emergency Medical Responder, be prepared for a large gathering of visitors. Be sure to treat them well, as you will likely encounter them in future incidents.

12. If the patient is dying in the Trauma room, coordinate with the Medical Staff as to whether or not the family can be, or wants to be, present during heroic measures.

13. Attempt to keep the crowd size and temperament manageable. If necessary, call for back-up either from other chaplains, medical staff or as a last resort, Security.

14. If the gathering becomes too unwieldy, move them to a Quiet Room, or some other place out of the way, yet still accessible. Traumas bring out the best and worst in families. Be aware of conflicts. Separate people, if necessary, in different rooms. Often, groups will move back and forth between the Quiet Room and other areas.

15. Coordinate with medical staff a timeline for when family will get to see the patient. Encourage only one or two visitors at a time, so that the patient is not overwhelmed. Brief the family on what they will see. Explain IVs, ventilators, beeping monitors. Do a cursory description of the patient’s appearance, so they will be as prepared as possible. If the Medical Staff is addressing the family, have some questions in mind that you can ask the doctors that you think the family needs to know, but which the doctors may not have addressed. (Remember, often the family is in shock. They may not know what to ask. They may think of questions later, but you can save them additional anxiety by asking the questions now.)

16. Before the family visits the patient, encourage them to vent some emotion so they will be as composed as possible. It is crucial not to upset the patient. Have two chairs set up in the room near the stretcher. Be prepared for signs of someone who may faint.

17. If the patient needs to go into surgery, go with them, either alone with the patient, separately with the family, or together, to the OR staging area. If desired by patient and family, say a prayer before surgery.

18. Take the family to the Surgical Waiting Room. Be prepared for several trips between ER and Waiting Room to escort latecomers. The family is generally in shock; they are not in the position to recall the physical layout of your hospital, so take the most direct route to the waiting room.

19. Things to tell the family In the Waiting Room:

• Recommend they appoint a spokesperson to disseminate information and suggest they minimize details about the trauma until the patient’s condition is fully understood;
• Suggest they tell only people who will be helpful to them;
• Remind them of the importance of self-care (Your loved one is going through a Trauma. You are, too. Get rest. Eat well. Avoid caffeine. Go home when you feel safer about the situation. Take a walk, etc.);
• Let them know that they will hear other people’s sad stories in the Waiting Room ("You can listen, if you want, but you are obligated only to carry your own burden, not anyone else’s");
• Suggest that they put any family conflicts aside and pull together for the patient;
• Advise them of the Chapel’s location and how to find a chaplain;
• Offer to contact their clergy;
• Offer to pray. (And be sure to ask for what would they would like you to pray.)

20. Be alert to media intrusion. If the family needs to be shielded, notify the hospital’s media relations department to issue a statement and put Security in place.

20. While the patient is in surgery, keep in touch with family, if possible. Follow up with the patient when moved from surgery to the Post Anesthesia Care Unit. Try to find out where the patient will go next. Be careful what you say on these return visits; the time will be crawling for the family. They will be desperate for news and will hang on anything you tell them. Explore their feelings. Try to address their appropriate needs. Call for back-up, if needed.

21. Follow up with the patient and family, if you can, if even for only one more visit. Then refer them on to other chaplains when the situation stabilizes.

Trauma Death Protocol

1. On a Trauma death you will be ministering to both patients and staff. If the news is fresh, and particularly if you are wearing clergy apparel, do not go into the Quiet Room with the medical staff to deliver the bad news. If they see you first, they will know it is bad news. Wait a few moments. Give the family time to hear the medical staff’s explanation. If you do not speak their language, have a translator ready.

2. If you have a Quiet Room, have it ready at all times. Have plenty of tissues on hand. Pillows or cushions are helpful, too. After the doctor has finished giving them the news, enter and be prepared for anything. Respect the innumerable ways in which people grieve. As a representative of God, they may blame you. They may even hit you. You do not have to defend or explain God. You do not have to come up with perfect words to make it alright (Obviously, there are no such words.). Just listen and be the calm within the storm. Pay attention to your own feelings; if your tears are genuine, cry with them. Whatever it is you are feeling, be authentic.

3. Notice the social cues. Do they want you with them? Do they need to be alone?

4. At some point, they will want to see the body. Coordinate with the nurses as to when this will be possible. (Give the nurses time to do what they need to do to prepare the body to be seen.)

5. If you go in with the family to see the body, brief them first as to what they will see. Note that the breathing tube must remain until the funeral director or medical examiner removes it. Gently describe visible trauma, skin discoloration, or anything else that looks different from how the family last remembers their loved one.

6. Prepare the room where the body lies. Have chairs on both sides, close to the stretcher. Be prepared for signs of family members fainting. Close the curtains and doors to ensure privacy.

7. Give them as much time as they need, unless the Trauma Room will be needed soon. In that case, the patient will be moved to another room in the ER. Coordinate with the medical staff how long they will be able to stay. Stay in the room with the body as family come and go. Ask if they need privacy; if so, stay outside the door.

8. When there is the largest gathering of family, offer a prayer (if wanted by the family). Or have a brief litany or other appropriate ritual on hand to facilitate the grief and mourning process.

9. If the medical staff offers to help you in any way, include them. They are grieving, too, so don’t forget to minister to them.

10. In conversations with family, unless urgently necessary, discourage family members from traveling long distances to come to the hospital to see the body. Waiting for late arrivals ties up the room longer and burdens the medical staff. Eventually, the body will be moved to the morgue. If you can, avoid trips to the morgue! At our hospital, these trips require a Nursing Supervisor to accompany the family. If you must go to the morgue, describe to the family in advance what they will see so it will be less of a shock.

11. When it feels appropriate, help the family begin to detach from the hospital scene so that they can go home to begin their mourning. Have the patient’s assigned nurse ready to answer any medical questions. Be prepared to answer, or refer to appropriate sources, questions about organ donation, autopsy, Medical Examiner and funeral arrangements.

12. Offer a closing prayer. Provide them free parking passes, if needed. Walk them out to their cars. Encourage them to look out for each other so that no one will be alone on the drive home or on this first night.

13. If you have connected with the family and if it seems appropriate, go to the viewing. It will mean a lot to them. Or call in two weeks to check up on them.

Withdrawal of Care Protocol

1. Be present with the family, if you sense they want you with them.

2. If they want their own clergy, try to locate that person.

3. If you are offering the prayers and other rituals, and need a translator, get one.

4. If you need back-up, call for it.

5. After withdrawal of care, no one really knows how long it will take for death to occur. People often feel obligated to stay until the end, whether or not they want to remain. Remind them that their loved one will die whenever s/he’s ready, whether or not they are present. You can offer them peace of mind by telling them you will continue to check in on their loved one, even after the family leaves.

6. Encourage the family to speak loving, affirming words and give the patient permission to go. Encourage each to make their peace with the patient.

7. Have sources available to answer questions about organ donation.

8. Stay with the family for a while. Leave when you need to see other patients. Come back later as you can.

9. Have a brief litany or healing ritual on hand. Remember that when the family allows you to be present, you are a witness to a sacred moment in their history.

10. When the timing is right, help the family with closure. Offer a prayer, blessing or benediction. Get them parking passes, if needed. Walk them to their cars.

11. If you felt connected to the family, go to the viewing. Or call in a few weeks, or write a note later. Refer them to their places of worship and any available Bereavement and Support Groups.

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