12/7/2005 Vol. 2, No. 21

Professional Practice

The Rev. Beth Newton Watson on relationship-centered care

Relationship-Centered Care in a Sanctuary of Healing

Clarian West Medical Center opened its doors to patients on December 14, 2004. At the heart of its operating principles is a commitment on the part of its board of directors, administrators, physicians, and staff to be a Sanctuary of Healing for everyone who comes through the door.

Each of us has a different experience of Sanctuary: a hall in which worship takes place, a safe relationship, a room of our own, a place out in nature. It may be the holy ground created with a burning bush or a still, small voice. We have laid Relationship-Centered Care as part of the foundation of our Sanctuary of Healing. Relationship-Centered Care contributes to rapid recovery from illness, and comforts those who will experience a different kind of healing. It focuses on what exists between people, how you and I can create a sacred space together in which both of us can experience a kind of healing.

We staff want to be healed ourselves as we work to heal others. Although we may not manage it all simultaneously, what is good for our patients is also good for us. Relationship-Centered Care is meant to help us all be good stewards of our healing energies and potential, of the gift of life. Those of us who are caring for others are not to be used up and destroyed in the process. A hospital that values healthy relationships (for ourselves, with our colleagues, and with our patients) supports the health of all who come through the door.

We discover that healthy relationships established at the administrative level positively affect decisions made at that level and elsewhere. People do not always arrive on the job with extensive knowledge about what makes a healthy relationship possible. We learn together how to build covenant work relationships, listen for essential information, reward excellence, acknowledge feelings, and confront in times of disagreement. We are co-creating a culture in which we can integrate who we are as individuals, what we believe in as caregivers and patients, and our skills as people who want to be healed and heal others. Increasingly, in that integrated space, we are discovering the soul of our hospital.

We prayed for our hospital in the early days, when we thought it needed some healing of its own. Patients, families and staff write their prayer concerns in a prayer log in the chapel, and those who come in read and pray for one another’s concerns. At a weekly healing service staff and patients name the concerns of their hearts. An interdisciplinary team meets daily to discuss how to balance the medical, emotional and spiritual needs of the patients with the standards of medical practice and the realities of the economy. We send one another on the staff letters of consolation when we hear of sadness. We have a chaplain designated for the staff. We broadcast email the compliments we receive. We begin every meeting with the remembrance of things that work right. We gather to confront one another in times of disagreement, and mediate conflict. As staff we have apologized and forgiven one another.

I have learned that the quickest way to establish Relationship-Centered Care is to be--in my behavior and in my conversation--inviting of relationship. I don’t have to be strong or perfect. I do need to “show up, pay attention, speak the truth in love, and accept the consequences.”I must choose life, my own and the life of healthy relationships with others, in order to be facilitating Relationship-Centered Care in a Sanctuary of Healing.

Do you have thoughts about professional practice you’d like to share with your colleagues? Send an e-mail info@PlainViews.org.

Advocacy

Rabbi Dr. David J. Zucker on appropriate chaplain boundaries

More than the Songs that We Sing

Some years ago there was a song lyric which said, “You’ll know who I am by the song that I sing.”While we could understand this to mean, “You will know who I am by what I say,”a more practical approach might be that we would know others by what they actually do. As we know, in the real world there is theory, and then there is the actual practice. Often, in the language of chaplaincy, we suggest that there may be a difference between people’s Espoused Theology and their Operational Theology. The first is what people say they believe, the second is how they act. At times, there may be some cognitive dissonance between the two.

Just how do we really know the inner qualities of others? Further, if we are to evaluate people by their acts, what criteria should we consider?

In a very insightful statement found in the Talmud, we learn that we can detect people’s character through several items: what they drink, their generosity, and their tendency toward anger (Babylonian Talmud ‘Eruvin 65b). In its original language, these terms reflect a play-on-words for in Hebrew they all sound very similar: koso, kiso, and ka-aso (literally one’s cup, one’s pocket, and one’s anger, respectively). Another marker suggested is to judge people by their laughter (ts’hako).

These standards continue to be relevant in the contemporary world. To know one’s limits with drink, and to choose to control one’s anger, deal with inward behaviors. Helping others by giving to those in need, and being ready to laugh at the humorous parts of life, never mind laughing at oneself, affects outward relationship with others.

When we take the time to look at our own lives as chaplains, what are the answers to those categories? Do we remain within appropriate boundaries when it comes to drink (or whatever we imbibe or ingest?) and do we remain in appropriate boundaries with our anger? Or, are these boundaries more porous than they really should be? Likewise, in terms of our relationships with others, at work or at home, are we generous with our time, and our charitable giving, as well as with our laughter?

The sage Hillel remarked, “If I am not for myself, who will be?”and then he added, “If not now, when?”If we need to modify our behaviors, it could begin today, if we set our minds to it. There is always room for us to grow: let us be guarded with our cup and our anger, and generous with our pocketbook and our laughter. If so, then we will be, and we will be experienced as people who live their lives guided by both goodness and kindness, and we will be deserving of praise.

Do you have thoughts about advocacy you’d like to share with your colleagues? Send an e-mail to info@PlainViews.org.

Education & Research

Dr. Diane Bridges on a seasonal way to help those who grieve

Holiday Grief

Anniversaries, birthdays and holiday times are especially poignant for those experiencing the loss of a loved one.

The anticipation of the event can be as stressful as the occasion itself and some people may even experience physical illness as the day or time approaches. Family and friends may try to be helpful, but often they too dread the event.

The Christmas season, which seems to begin early November and carry on until the New Year, is an especially difficult time for those who recently experienced a loved one’s death. I have found in my practice that while I cannot realistically respond to all the calls I receive during this time, I can offer excellent assistance through bereavement seminars which I conduct at the hospital.

Fairly early, prior to the event, a local funeral home distributes invitations to those recently experiencing a loss. Advertising is also done on the radio, in local churches and in the press. People R.S.V.P. and are encouraged to come with friends or family members.

The setting is informal, with people sitting at round tables. Guests are greeted at the door and coffee and tea are available.

The first task is to be welcoming and affirmative, reassuring and caring. Another presenter and I outline what the flow of the presentation will be and assure people that questions and comments are welcome at any time.

The tasks of grieving are outlined simply and clearly, as are the variables which affect the intensity and length of a person’s grief.

The manifestations of normal grief –feelings, physical sensations and thoughts –are outlined and discussed as well as behaviours which seem unnatural and stressful.

Reassurance is then offered in describing the recovery period and offering helpful guidelines such as:
•Accept your emotions
•Express your feelings
•Try not to use drugs or alcohol to escape your grief
•Don’t expect miracles overnight
•Reach out to friends and family when you need them
•Avoid hasty decisions
•Be good to yourself

Questions and discussions are entertained throughout the presentation and following a break time.

Guidelines for handling grief are offered.

A candlelight service in memory of the deceased is then conducted. Each person lights a candle in memory of the deceased and passes the light to the one sitting next to them saying: “Peace to you in memory of George”(or something similar).

At the conclusion of the evening, the presenters are available to comfort and advise individuals as needed. Written materials are available to take home and a list is provided for those who might like to gather to start a self-help group in the future.

While this bereavement seminar does not take away the pain of the holiday season, it does offer comfort and hope that may help to alleviate some of the grief. Just knowing that there are so many like yourself in the same room experiencing similar emotions helps to heal the isolated feeling of being “so alone”during the festive season.

Do you have thoughts about education & research you’d like to share with your colleagues? Send an e-mail to info@PlainViews.org.

Spiritual Development

Chaplain Ed Horvat on sharing traditions

Lord Ganesha and St. Nicholas

My wife and I are fortunate to live in a town with a massage therapy school. We ended a busy week by scheduling couples massage with two students who are biological brothers, Joey and Bobby. They will graduate soon, so we avail ourselves of their talents while we can more easily afford their services. These guys are blessed and gifted healers.

An hour later, speechless and reduced to puddles of flesh and bone, my wife and I try to muster movement. Eventually we float out through the doors of the school, contemplating dinner. We consider our options and decide on the Café of India, as the soft sitar music, atmosphere, and fragrant foods will prolong our trance.

Following a leisurely meal and conversation over three refills of Masala Tea, Sushil, one of the owners, joins us and asks about the origins of Santa Claus. We relay stories and legends about St. Nicholas. Inquisitive ourselves, we ask about Hindu traditions from our hosts at the café, so it was fun to reciprocate!

Once home, the icon of St. Nick on my bedside table greeted me. It was a gift given to those of us who attended Nick’s feast day service on December 6. The description on the back reveals that Nick is, among other things, the patron saint of merchants. I returned to the café and presented the icon to Sushil, passing the gift forward. An image of Ganesha, the Hindu deity invoked at new beginnings, is present in the café and has truly blessed their business. We shared beliefs about the spiritual patronage and protection of Ganesha and Nicholas.

Joey and Bobby. Kevin and Sushil. Lord Ganesha and St. Nicholas. There are many ways to touch and be touched; to heal, connect, pass along, and bring peace to one another. We all have work to do, renewing life, letting the spirit flow through and among us, deepening relationships, building community.

Do you have thoughts about spiritual development you’d like to share with your colleagues? Send an e-mail of any length to info@PlainViews.org.

EthicsWalk

EthicsWalk addresses spiritual care as an ethical enterprise. It explores why relationships between spiritual care providers and those they serve need protection, and examines what that protection entails. PlainViews invites our readers to share their responses to each EthicsWalk column, which will be published in the following issue.

If you’d like to respond to EthicsWalk, please send a comment of no more than 100 words. You can use the e-form below (click on "hearing from you," link) or submit your commentary to the editors in the body of an e-mail (or as a Microsoft Word attachment) sent to Info@PlainViews.org. Please put the phrase “EthicsWalk” in your subject line.

We look forward to hearing from you.

The Gift of Declining Presents

Should spiritual care providers accept gifts from those served?[1] Would Eid al-Fitr, Christmas, Hanukkah, and Kwanzaa pose exceptions to general prohibition? Are these questions, considered in CaseConference #2, those of Scrooge or professional ethics? Reader responses to the CaseConference are wise. Similar ones end this column.

Chaplaincy Ethics Codes are silent about gifts. Institutional policies fill the gap but often don’t clarify the humane reasoning. Most professional and industrial Codes of Ethics and Advisory Opinions prohibit or narrowly restrict the giving or receipt of gifts. Concerns about actual or perceived bribery or extortion[2] drive many.

Government regulations covering holidays, as well as other times of year,[3] prohibit employees from making gifts to supervisors or donations to causes on behalf of superiors. All are prohibited from accepting gifts (over $10) from anyone with whom the employer does business.

What constitutes a “gift?”[4] American poet Ralph Waldo Emerson wrote, “The only true gift is a portion of thyself, Thou must bleed for me.”As noted in last month’s column, too many recipients of health services in the U.S. are involuntarily “bleeding”to pay their providers. Should gifts, albeit voluntary, be added in?

Like most transactions between professionals and persons served, gifts are seldom a private matter. Implications abound for third parties. Hearing my Pilates teacher rave about presents from other students last week, I winced and questioned silently the possible implications (for her attention) of my practice of no gifts for professionals who enhance my life (as distinguished from people who provide newspaper, mail, and trash services). She didn’t solicit gifts, but she did accept. What does that mean for me, the non-gift giver?

If the gift has “no value”does it matter? A “no value gift”is an oxymoron for people of faith who recognize that “value”attaches by the act of giving, not purchase price. The “why”of giving is always different. The potential for real or perceived favoritism or “special closeness”is always alive. Below are suggestions for receiving the “giving”but refusing the present.

1. Follow your institution’s policy. Most prohibit anything other than hospitality tokens: cookies made by family members, bouquets patients can’t take home.

2. While declining presents, take time to thank persons for the gifts their lives provide. Help patients recognize how their life blesses others regardless of their state of diminished health.

3. In rare instances, accept a gift on behalf of the Spiritual Care Department. Specify the money or item is going to the institution (check with your supervisor or ethics committee).[5]

4. If patients persist in personalizing it, the gift might be in your honor.

5. If #1 –4 are pastorally impossible or not supported by your institution and you accept a gift, clarify how it will be used at the time you accept: “Our hospital library will appreciate this book.”[6] “I will sign this check over to Katrina relief efforts.”If the gift could have value (sentimental or monetary) to family, consult family first. If donor and family are alienated, your task is facilitating reconciliation, not brokering heirlooms.[7]

6. Substitute “spiritual care providers”for “physician”in this title from a medical journal and ponder its message: “Should Physicians Accept Gifts from Their Patients? No: gifts debase the true value of care.”[8]

This holiday season, remember to thank your colleagues and honor yourself for the gifts each of your lives bestows.

[1]“Ethics Walk,” PlainViews, 12/01/04 (vol. 1, no. 21) suggested that accepting gifts from people served is a boundary issue. One reader’s response to CaseConference #2 elaborates this point well.
[2] Bribery refers to influence on decisions or actions subsequent to and based on a gift; extortion implies a gift is required in order to obtain a favorable decision or action. Both may be reflected in individual’s increasingly lavish gifts to doormen, maitre d’s and private school teachers in large U.S. cities!
[3] For example, CFR Part 2635, Subparts B,C, & H, December 2004 “Summary of Holiday Season Gift Rules.”Such rules are the basis for the highly publicized ethics cases before several state and federal government bodies.
[4] Economists, philosophers, sociologists, anthropologists, ethicists, scholars of religion and law, have published tomes on “the gift”and “ethics of gifts in friendship and business”through out history. A delightful compendium of such is The Question of the Gift: Essays across disciplines, edited by Mark Osteen. Routledge, 2002.
[5] To avoid potential legal consequences, no contribution/gift over $250 should be negotiated or accepted by you even if you are not the direct beneficiary. The donor’s lawyer or the institution’s Planned Giving professionals should handle the transaction. Never accept or arrange for gifts of money or items of value from people receiving government assistance or in bankruptcy.
[6] Caution: If you accept one family Bible how do you decline others? How many does your institution want?
[7] I am indebted to a conversation with Rabbi David Zucker for this discussion.
[8] Weijer C. “Should Physicians Accept Gifts from Their Patients? No: gifts debase the true value of care.”Western Journal of Medicine, 2001:175:3.

CaseConference

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. Please send any cases that you would like considered for inclusion to: info@plainviews.org

We hope that this new addition 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.

Case Conference #2 Resolution

The chaplain returned to the patient’s treatment area. She thanked her for the gift and told her how much the gesture meant to her, but that she wouldn’t be able to accept the earrings. Chaplain and patient talked about their relationship and the patient’s anxieties about entering a new phase of treatment. The chaplain assured she would continue to be available to the patient.

The following work day the chaplain spoke with the patient’s regular nurse, who asked if they could speak in private. The nurse told the chaplain the patient had tried to give her some earrings (the nurse wasn’t aware of the interaction between patient and chaplain). She hadn’t accepted them. The nurse then expressed concern about the patient’s financial and emotional state.

The chaplain inquired about whether there had been an interdisciplinary team conference for this patient. According to the nurse, none had taken place. The chaplain initiated one, and it occurred the following week.

What emerged during this conversation was a more complete picture of the challenges facing this patient and the emotional/mental, financial, and physical challenges team members had tried to address. It became clear that the care team had been ‘split’. As the meeting progressed, trust was built between providers and a consistent care plan emerged. The chaplain has a deeper appreciation for honoring administrative policy and functioning as an interdisciplinary team, ideally before crisis occurs.

CaseConference #2

A chaplain was referred to a patient by a surgeon. The patient had just delivered her third child when she was diagnosed with breast cancer. Surgery and chemotherapy followed. Over the next three years the chaplain visited with the patient and her family whenever the patient was at the Outpatient Clinic, offering prayer support, referrals to support services, etc.

One day the chaplain visited the patient. The patient reminded her this was her last chemotherapy session and she wanted to give the chaplain a gift of a pair of earrings “in appreciation for all you’ve done for me. I genuinely love you and am so grateful you’ve been there.”The chaplain indicated that she was touched by the gesture, but wouldn’t be able to accept them. The chaplain was aware of an institutional policy against the giving of gifts to staff by patients.

The patient began to cry and became very emotional, stating, “I didn’t mean anything bad by it. I don’t want to get you in trouble. You’ve just meant so much to me and my family and I wanted to show you how much I appreciate it.”

The chaplain then received the earrings, and thanked the patient. She then contacted her supervisor, who made inquiries with the administration regarding the specifics of the policy and whether there were any exception clauses. The chaplain wanted to honor the institution’s policies, but also wondered if refusing the gift would create harm in the patient. Administration answered that there were not acceptable exceptions to the policy, and the chaplain would need to return the earrings.

Could the chaplain have handled this differently so that the patient would not have been as upset? Is there ever a time that a gift can or should be accepted? Should patients be informed in some way that the hospital has a policy of "no gifts to staff" so that this would not even become an issue?

Please check below for comments made about the last CaseConference.

Send your comments about CaseConference to info@PlainViews.org.

Reviews

Clicking here will take you to the Book Review

Macky Alston reviews the film:

The Perennial Philosophy

Some would say that though the liturgy changes, the language differs, and the emphasis varies, at their core, the world's great religions are strikingly similar. It is these similarities that are examined in The Perennial Philosophy, a term coined by Aldous Huxley to describe the common ground of the great world religious traditions. Chaplains may find the film useful when ministering to those individuals who view their religions through a narrow lens, disregarding the commonalities so vital to a multifaith society.

In this thought-provoking film produced in the mid-80s, writer and director Elda Hartley takes the viewer on a global spiritual journey woven together with words from sacred texts and renowned spiritual teachers who articulate with poetry and power the commonalities between Buddhism, Christianity, Hinduism, Islam, Judaism and Taoism.

Completed: 1985
Running Time: 30 Minutes
Producer: Elda Hartley

If you are interested in purchasing this film, it is available at www.hartleyfoundation.org. Just click on “Hartley Classics”on the homepage for more information. The cost is $19.95/VHS.

Book Review

The Rev. Charles J. Lopez, Jr. reviews:

Holy Listening: The Art of Spiritual Direction

Alan Jones, Rector at Grace Cathedral, San Francisco, writes in the preface, that “all along we’ve had a spiritual life and we didn’t know it.”Margaret Guenther, says Jones, recognizes “God’s amazing work in us and among us in the ordinariness of human existence.”

Spiritual direction, writes Guenther, is about “holy listening,”waiting, attentiveness and presence. Her perspective is as a woman, a mother, a teacher and an Episcopalian priest. Hospitality or welcoming the stranger is at the core of spiritual direction when getting started with a directee. She emphasizes that the true director is the Holy Spirit. Furthermore, she underscores the notion that spiritual direction is neither psychotherapy nor is it pastoral counseling nor is it a deep personal friendship, but frequently, it shares some of the raw material found in each.

One major difference between spiritual direction and psychotherapy is that “the director must be willing to be known”…“but known in her vulnerability and limitations as a child of God.”

The spiritual director is simultaneously a learner and a teacher of discernment. The first step in discernment is perception and the second is judgment with a heavy emphasis on the “value of the present moment.”In short, the director must be capable of discernment as well as being fully present with the directee.

The imagery of midwifery and the increasing role of women as spiritual directors and participants in spiritual direction is enlightening and insightful. Women finding and trusting their voice is important in this ministry.

Guenther’s book is useful by reinforcing the role of spiritual director as listener, teacher, and midwife. The example of silently saying the Jesus Prayer - “Lord Jesus Christ, have mercy on me, a sinner,”is important when there are times of silence with the directee. Self-awareness is part of the foundation for the spiritual director. Keeping a personal journal, having one’s own spiritual director, and making a retreat will help keep the director sharp.

Guenther uses gender appropriate images of midwifery. As a male, I sense no challenge from Guenther. Midwifery draws me out of my comfort zone to experience a new image for the process of spiritual direction. As one becomes involved in spiritual direction, the director is able to encourage the directee to move ahead by giving birth to something that is new and not yet known. Although, every person living on this earth has had a birthing, the only possible exception might be with those who have been cloned, Guenther provides an earthy description of moving forward and trusting the Spirit. The image of midwifery is interesting because even in the birth of the world God brought order out of chaos. She provides voice for struggling women and also men. The epilogue reminds us that even Eli encouraged Samuel to say, “speak, Lord, for your servant is listening.”(1 Samuel 3: 1ff)

Holy Listening: The Art of Spiritual Direction. Margaret Guenther, (Cambridge, Massachusetts: Cowley Publications, 1992) 1-56101-056-1,146 pp.