Cindy Heine on building ethical competence

Integrating Ethics into a Health System

WWJD? We have all seen the license plates and bracelets –What Would Jesus Do? A quick, clever –though simplistic –way to reflect on actions against the standard set by Jesus. The Franciscan Missionaries of Our Lady Health System has taken a similar approach –albeit a bit more complicated application –as a means of addressing ethics within its faith-based organizations. The professional chaplain has skills in assisting patients and families to interpret their beliefs in light of necessary decisions. These skills are transferable to an organization’s ethical decision-making and are one additional way that chaplains can add value. Here is one story that may serve as an example.

Prior to the Enron and WorldCom scandals, seeing the ever-increasing pressures related to healthcare’s commercial environment, as well as the advancement of medical technology, our sponsors called for an examination of the ethics function. The Franciscan Missionaries of Our Lady Health System –FMOLHS –formed a multi-disciplinary ethics work group to take up this charge.

The efforts began with a review of current practices as well as an extensive literature review and ended with an integrated approach to ethics as well as a revised code of conduct entitled, “Principles of Organizational Ethics.”It became clear that as a faith-based organization our focus needed to be as broad as possible. Who we are as a faith-based organization needed to mold and shape our decisions, whether those decisions were being made at the bedside, boardroom, or billing office. Therefore, our efforts encompassed medical ethics as well as compliance, social responsibility, and business practice issues. We began by defining organizational ethics as who we are and how we ought to act.

This understanding was depicted in a conceptual model* and was followed by a revised code of conduct**. Having been approved at the highest levels of the organization, this approach builds ethical competence in the organization to read the signs of the times and reflect our history and tradition in the current realities. It is also believed that such an approach will allow FMOLHS to be more proactive in identifying and addressing ethical issues, thereby creating ethical standards of practice rather than being reactive to a situation or, worse yet, unaware that an issue exists.

Efforts to operationalize this approach have included annual and new hire employee education, public posting on websites, inclusion in Medical Staff by-laws, and an annual Ethics Summit designed for Executive and Governance leaders, etc. There is now cross-functional review of both traditional ethics committee information along with quality, satisfaction and compliance data being reported to the highest levels of the organization. The sharing of multiple data points allows for a more comprehensive view from which to identify trends and patterns.

There was not one particular issue or challenge that led to this approach. We were not out to fix a problem but to prevent one. It was just one more step in one health system’s efforts to follow the example of those who have gone before them in the midst of very challenging times.

* Conceptual Model

** Code of Conduct

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

Rabbi Nathan Goldberg on the next great frontier of chaplaincy

Community Chaplaincy:
Evolving Health Care Challenges

As the pressure to decrease inpatient length of stay increases, our healthcare culture confronts new challenges. Modern medicine has responded with a greater emphasis on outpatient treatment and specialized rehabilitation programs outside the confines of the traditional hospital.

Spiritual caregivers confront this problem as well. How can we serve this elusive community? Inpatient care has become more compact. Inpatient pastoral relationships are often limited to one visit –not based on need but time constraints.

One response has been reframing the chaplaincy model to a community based chaplain. This model has the potential to offer ongoing pastoral relationships where the traditional model cannot. This model also comes with numerous challenges that need to be met as the position evolves.

The strength of this model lies in its fluidity. Community chaplains have mobility. They can follow patients before and beyond the limited inpatient stay, can help design, provide, and sustain a network of community support to help care for patients in a more holistic fashion and can work with local schools to educate and support teachers and peers of the patient’s children. The chaplain can serve as a liaison to local clergy and other support professionals as changes in the patient’s condition may provide or preclude opportunities for strategic visitation.

The community chaplain may be in a better position to link the family with community resources for counseling support during and after sickness. For example, community chaplains ideally have more connections to various support and grief groups than their typical hospital based colleagues.

(Please note that as I list some of the advantages of the community based model, I come not to bury inpatient chaplaincy but to “praise”/advocate that spiritual care and concern continue beyond the confines of the medical center environment.)

While community based chaplaincy provides supplements to traditional models of chaplaincy, there are also significant challenges. While community chaplains have the potential to be “everywhere”on paper, they will be dependent on a network of other professionals for referrals. These relationships take time to build and cultivate. Additionally, these chaplains must become one of the “chosen,”so to speak, allowed access to appropriate and relevant medical records. As HIPPA becomes more prevalent and far reaching, this task becomes more time consuming. Negotiating each different community medical center’s HIPPA interpretations can become a Herculean task.

There are two other major concerns. First, who supervises the community chaplain and how? The community may provide experts from local congregations, social agencies, and medical centers to help support and supervise the chaplain. This model has the potential to help inform a greater ministerial experience as the chaplain receives input from a number of areas of expertise. However, community chaplains may find themselves in awkward situations as the various supervisors maintain a parochial vision in supervision of a community position. How can a many-voiced community give a clear message when supervising an individual community chaplain?

But the biggest challenge will be to answer the question, “Where’s the money?”Who finances community based chaplaincy?

Community chaplaincy has the potential to be the next great frontier in healthcare ministry. Its evolution is dependent on a community working together to fund and supervise such a model. As professionals caring for the spirit, I believe we need to be on the front lines of community chaplain advocacy. We must articulate our unique perspective to congregational leaders, ordained clergy, medical and administrative professionals, helping them embrace and further innovate this change in clinical spiritual ministry that is beyond the bedside.

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

Education & Research

Spiritual Development

Sharon Weissman on learning who it is about My Patient is Gone! As I near the completion of my fourth unit of CPE at St. Luke’s Hospital in Chesterfield, Missouri, I have been looking back upon my experiences providing pastoral care to patients. For many years I have been writing poetry to express deeply felt emotions about various situations that life has presented to me. I wrote this poem during my first month at the hospital. I had been visiting a man over a period of about a week and we had developed a trusting relationship within which he had shared many personal stories. One day, I went to see him and he was no longer there. This poem expresses my feelings of grief and loss. My Patient is Gone! How is this possible? Mr. K. is gone! Thank God, he’s not dead Just transferred to a different hospital To have surgery. But my needs are not being met! I wasn’t able to say goodbye and Wish him good luck. No more deep conversations or witticisms. No more deep discussions about alcoholism Or his kids, Or the problems with his wife. I have to learn that it is NOT about me. I have to try to meet the needs of other patients Who might need me as much as Mr. K. But losses are not so easily assuaged. I will grieve and move on, Hopefully………….. Sharon Weissman is in CPE training at St. Luke's Hospital in Chesterfield, Missouri. After a 30+ year career in medical/ oncology social work, she felt that her talents could be used in chaplaincy. Upon completion of her training she is hoping to serve either in a hospital or a hospice. Sharon is grateful to her supervisors and peers who encouraged her to submit her poetry. 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. Confidentiality v. Duty of Care Scene 1: Sandy, age 8, is admitted for surgery. Over a puzzle Sandy says: “Chaplain, please tell God I’m sorry for how I treat my father…I am bad. I don’t mean to be and I don’t know what I do, but he says I make him so hot he can’t help himself. Then he does things that hurt my private spots. Sometimes I cry. Afterwards he feels bad too. He cries and then buys me a present. I’m afraid God hates me for liking presents so much that I make my father hurt me to get them. Will you tell God I’m sorry? Please don’t tell anyone but God.” Scene 2: You find Sandy’s father, Fred, in the surgery waiting room. You sit down. He tells you he’s “alone in his worry.”Sandy’s mother is incarcerated. Two older siblings are emancipated and Fred doesn’t allow Sandy to see them: “bad influences –don’t respect my authority or the Lord’s.”Fred leans close and says, “Chaplain, maybe you can help. Sandy and I do things that’s probably not right. Mind you, Sandy likes it and I always get Sandy something special afterwards, but the Bible says what we do should only happen with my wife.”You ask for more specifics and then affirm that the behavior is prohibited by scripture -- and state law, and is harmful to Sandy. Fred cries and says “pray with me to stop but don’t tell no one else. I can do this on my own with the Lord and you.” Is this an ethical dilemma? Strictly speaking, yes. The duty of confidentially conflicts with the duty of care (here, protecting a vulnerable child). Clergy confidentiality, many believe, encourages people who otherwise would not, to confess their sins to God in the presence of clergy who will offer spiritual guidance to foster healing and reconciliation. Rules of testimonial evidence, statutory and case law in the United States recognize and honor clergy confidentiality. Indeed, for some, this is a cornerstone of the religious freedom enshrined in the U.S. Constitution. The duty of confidentiality is challenged by laws mandating reports of suspected child abuse. Arguably, a duty of care ethic requires clergy to examine the primacy of confidentiality in circumstances involving God’s most vulnerable persons, children (and in some instances, incapacitated adults). What would you do here? Note: 1. Both communications came in your role as chaplain. 2. No third parties were present either time. 3. Each communicator asks for secrecy. 4. Each requests intercessory prayer and assumes prayer and your involvement are “enough.” 5. In your state, clergy are permissive but not mandated reporters of child abuse; and, clergy privilege permits exclusion of testimony for information obtained during the course of “spiritual counseling or confession.”[No state’s privilege rule specifically addresses child abuse reporting –privileges apply only to court related testimony.] 6. The hospital requires all personnel to report suspected child abuse to the state. 7. Would your denominational polity inf