PlainViews

Chaplain Cheryl Palmer on an invitation to make a difference

Establishing a Cystic Fibrosis Standard of Spiritual Care

Opportunity is knocking for professional chaplains to create a national spiritual care standard of care for patients living with cystic fibrosis. The national Cystic Fibrosis office has invited us to introduce the value and importance of developing spiritual care guidelines for persons living with the disease at the November 2-5, 2006 annual conference in Denver, Colorado.

So, I am sounding the call to you, my fellow chaplains, to:

work collaboratively to establish standards of care.
educate the cystic fibrosis community about the value and difference professional spiritual care makes in patients' lives.
attend national, state, regional and local cystic fibrosis meetings to promote understanding of professional chaplaincy as an integral aspect of patient care.
communicate with leadership on your cystic fibrosis teams and your lung transplant teams about the upcoming work to establish such a standard and seek their input, advise, and support.
share your expertise about what constitutes excellent spiritual care as we develop these standards of care.

One of the unique features of the cystic fibrosis community is their multidisciplinary approach to patient care: Cystic fibrosis standards of care demand the active participation of not only the physician, but also the nurse, the social worker, and the dietician.

When the annual cystic fibrosis conference is held, a whole host of professionals assemble on what is a very even playing field: It’s usual to see physicians, nurses, and others participating in workshops that might sound like they’re geared to the psycho-social side of patient care (like end-of-life care) and it’s usual to see social workers, psychologists, and others asking questions at the poster of a scientist who is trying to further solve the mysteries of the CF gene. It’s a terrific spirit that inspires team members to take whole person care seriously.

Noticeably missing is a disciplined and intentional approach to spiritual care. The good news is there is a real appreciation among the cystic fibrosis community about this aspect of patient care and these same professionals are inviting us as chaplains to develop spiritual care guidelines.

What can you do?

E-mail me clp1840@bjc.org if you or a colleague works with adults living with cystic fibrosis (include those who work on lung transplant) so that we might begin networking and collaborating, perhaps by forming a special interest group.
Join the spiritual care guidelines workgroup. We will likely link our work with the APC’s Quality Commission.
Attend the annual cystic fibrosis meeting in November (if you’re on a cystic fibrosis team, your team may be able to fund your trip).

Chaplain Cheryl Palmer, BCC, has been the manager of Spiritual Care Services at Barnes-Jewish Hospital in St. Louis, Mo since 1989. She received her education from The Southern Baptist Theological Seminary and was ordained Southern Baptist. She is currently in the process of changing her affiliation to the United Church of Christ. Cheryl has written articles for many publications and has done consulting work for hospitals and chaplains interested in learning more about outcome-oriented pastoral care giving.

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

Editor’s note: Normally, responses to articles are included in TalkBack. However, the responses to Dr. Hamdy’s article, “Spirituality and Medicine”that appeared in the last issue of PlainViews (Education & Research, June 21, Vol 3, No. 10) raises an issue of great importance to the chaplaincy profession. PlainViews encourages chaplains to write and participate in raising the level of professionalism, awareness and understanding with other disciplines that interact with chaplains. Therefore, the decision was made to include these comments in place of an article, including Dr. Hamdy’s response to the two chaplains who responded so forcefully and passionately to his article.

I appreciate that the Southern Medical Association has taken the initiative to hold a conference addressing issues of spirituality and medicine as described by Dr. Ronald Hamdy in the June 21 issue of PlainViews. Dr. Hamdy notes that "Patients often value interactions with community-based clergy and hospital chaplains saying their visits bring hope and ease difficulties." He also goes on to identify that the scope and objectives of the Spirituality/Medicine Interface program are to "promote among physicians, chaplains, counselors, students, ministerial staff affiliated with hospitals, social workers, nurses, and other health care professionals - an appreciation of the importance that spirituality and religion may have in their patients' lives."

However, upon closer look at the information on the website promoting the conference, the Spirituality/Medicine Interface Program faculty does not include a board certified professional chaplain. I wonder how the program intends to "encourage dialogue on this topic" when spiritual care professionals are not included as faculty members. This would be akin to another professional organization offering a conference on medical interventions without including a physician's expertise. As one who works with numerous healthcare agencies and disciplines in articulating the contributions of board certified professional chaplains and knows the importance of first learning my audience before attempting collaboration or providing input, I find this offering disappointing.

One additional note: if Dr. Hamdy and the Southern Medical Association were truly engaged in understanding the role of spirituality, beliefs, and values in medicine, they would be sensitive to the choice of language that is being used in this Program. The use of words such as "clergy" and "ministerial staff" indicate a Christian bias, and are not inclusive of the wide range of religious and cultural beliefs. In the same way, the linking of "spirituality/religiousness or religiosity" shows a misunderstanding of the
significant differences between the two. A board certified chaplain, if included in the planning process, would have identified these issues before the information was finalized. One only has to look at professional literature and programs of healthcare organizations, including the AMA and JCAHO, to see that professional chaplains have contributed greatly and are sought out for their expertise.

The Southern Medical Association has shown good intent to begin to engage in dialogue on this critical topic. This could have been a wonderful opportunity to engage in dialogue on ways to contribute to better patient care by attending to spiritual, religious, and cultural beliefs, values, and needs. I am saddened that board certified professional chaplains, who are the trained and nationally certified experts in spirituality and pastoral care, have not been invited to share their expertise.

Rev. Sue Wintz, M.Div., BCC
Chair, Commission on Quality in Pastoral Services
Association of Professional Chaplains
St. Joseph's Hospital and Medical Center
Phoenix, AZ

What an interesting juxtaposition of articles. On the one hand, we have an excellent article by Rozann Shackleton advocating for the need for professional chaplains to pick up the pen and enter the world of publication. Without our valuable input into the critic issues of the intersection and application of spirituality and healthcare, the field is left wide open to other professionals, such as physicians, nurses, social workers, etc., who are neither intentionally trained nor directly work in the area of spiritual care in a healthcare setting.

Then, on the other hand, we have an article, or better, advertisement by Ronald C. Hamdy, MD, for a workshop coming up in September at Emory on the intersection of spirituality and medicine sponsored by the Templeton Foundation. How exciting, we think to ourselves as all giddy we follow the links to the web page. But, low and behold, as most things on this level of sponsorship, we find all MDs, a couple of PhDs and one ThM--but no board certified chaplains!!! According to the bios for the faculty, I did not see one who directly provides spiritual care in a healthcare setting. I did read quickly, however, as my giddiness drained over the let down of once again finding that the medical-scientific community has their own agenda when addressing the issue of spirituality, which appears to be getting all the research money and then putting on showcase workshops for one another.

It sounded so good and forward thinking, Dr. Hamdy, when I first began to read. But it is the same old suffocating blanket of medicine's hegemony attempting to spread itself over an area of which few medically trained physicians and academically trained PhDs have working knowledge. This is evidenced by the "teaser" case on the web page that attempts to lure us with interest to the workshop. Baa, humbug! If you want to understand the intersection of medicine and spirituality, then engage some professionally trained and board certified chaplains as dialogue and presentation partners. Otherwise, don't pretend to offer something that is related to our work as chaplains.

Respectfully,
Mark LaRocca-Pitts, Ph.D, BCC
Staff Chaplain
Athens Regional Medical Center
Athens, GA

The over-riding goal of the conference, as stated in the Mission/Vision (page 2 of the brochure) is to "promote, among physicians and health care professionals, an appreciation of the importance that spirituality and religion may have in their patients' lives..." As such we felt it appropriate to have among the faculty physicians with expertise in this area. I hope you will agree that the credentials of Drs. Koenig, Peteet, and Curlin are outstanding and that they are very well suited to address these issues. Rather than having "professional chaplains" discuss what they may have to offer, it was felt to be of greater impact if these comments were made by the consumer, i.e., the physician who has witnessed, utilized, worked with, and come to appreciate the value of the "professional chaplain." This also would give an opportunity for the chaplains to interact with clinicians and appreciate their perceptions.

The contents of this program have been developed with significant input from "board certified chaplains". Furthermore, of the 6 faculty, 3 are MDs, 2 are theologians and one is engaged in public health. This conference is part of a large initiative launched by the Southern Medical Journal and Southern Medical Association to examine the Spirituality/Medicine Interface. An advisory board, with representation from "board certified professional chaplains," has been formed to advise on all components of the program. Indeed, at the inaugural session of the program last November, one of the three lectures was given by a professional chaplain.

The April issue of the SMJ Spirituality/Medicine Interface is entirely dedicated to chaplain education and their role in health care. Its main aim is to familiarize clinicians with the background, education, knowledge, experience and potential of chaplains who we strongly believe should be an integral part of the health care team. Alas, as we all well know this is very often not the case.

Frankly, I am disappointed. We are trying to bridge the gap between spirituality and medicine; we are trying to highlight the importance of spirituality in health and the important role chaplains have to play. I would have expected chaplains to seize the opportunity and actively get involved in the dialogue we are trying to initiate. Instead, I note with regret that you are more concerned about the choice of terms and of faculty. The interactive format of the conference with plenty of time for discussion should offer chaplains who attend the conference ample opportunities to establish their claims and correct any misconception.

The gap between spirituality and medicine cannot be bridged unless we are prepared to blunt our sensitivities, repress our prejudices and engage in a dialogue with a positive attitude. I hope that the conference in Atlanta will provide such a forum and I sincerely hope that you will attend and especially participate in this conference to clearly state your views and engage in a constructive dialogue. As this is a dialogue, no one has the "final word," nor do we wish this conference to be limited by such temporal concerns.

Ronald C. Hamdy, MD, FRCP, FACP
Editor-in-Chief, Southern Medical Journal
Professor of Medicine
Cecile Cox Quillen Chair of Geriatric Medicine
Director, Osteoporosis Center
East Tennessee State University
Johnson City, TN

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Rev. Dr. Howard W. Whitaker and Rev. Margaret C. Tuttle on the clinical implications of charting

Pastoral care is such a “soft,”value laden, narrative driven discipline that chaplain observations and interventions are often difficult to chart. However, chaplain progress notes should document pastoral care and interpret the patient’s spiritual concerns to the line staff and treatment team.

Additionally, charting helps chaplains think about the clinical implications of their role, and structure their task accordingly. The progress note can be an effective supervisory tool to track the operational and clinical performance of the chaplain staff.

THE PROBLEM
Through 2000 and much of 2004, a review of Pastoral Care progress notes in patient records at Greystone Park Psychiatric Hospital revealed insufficient charting by chaplains. The few existing notes provided little information about pastoral care that would be helpful to either the treatment team or the chaplain supervisor. Several clergy then functioning as chaplains were neither certified nor clinically trained for a psychiatric setting. They seemed unclear and defensive about their role, the role of spiritual care, and its relevance to the treatment process.

The Chaplain Supervisor did not know what the chaplains were doing. The treatment team did not know what the chaplains were doing. It was unclear that the chaplains themselves knew what they were doing.

THE SOLUTION
Writing progress notes should be reaffirmed as a core clinical skill for health care chaplains working in this psychiatric setting.

Using our hospital’s Plan, Do, Check and ACT (PDCA) quality improvement plan, we moved ahead.

A training module titled “Writing the Chaplain Progress Note”was designed and distributed to the chaplain staff in September of 2004. While competency in charting had been included in past PAR’s, it was re-emphasized on the 2004-2005 PAR’s. It was explained at the time of signing off on the new PAR’s that there would be on-going audits of charts and continuous feedback on charting performance.

Working with the Office of Quality Assurance, a scoring tool was developed which assigned a numerical value to criteria such as pastoral specificity, data, assessment, plan, brevity, and relevance to the master treatment plan. The conversion of the narrative criteria into a numeric value was an innovative and critical piece.

The first audit was done and a baseline established for each chaplain, and a composite score was established for the department. Data was collected again at 30-day intervals. Continuous feedback was given to the chaplains.

Data collection, analysis, and feedback continue at 30-day intervals. There are some preliminary observations:

The Rev. Margaret C. Tuttle is lead chaplain at Greystone Park Psychiatric Hospital.

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Violence is something that police personnel or United States armed forces in the war zones of Iraq and Afghanistan live with each day. Yet inner city urban hospital chaplains also live and minister in emotionally violent zones. The bullets, the missiles and car bombs are not direct hits. It is the destruction wrought by the bullet, the knife, the speeding car, the anger-filled shove and venomous word that opens us to become the first-hand witness of violence that cuts deep in the soul.

The Emergency Department and the Intensive Care Unit become the repositories of violent acts. They receive the trauma victims. The Chaplain heeds the call, the page to come, to minister. It can overwhelm.

In one week, I saw an 18-year-old stabbed multiple times, his aorta ripped apart by a knife-wielding crowd at 2 o’clock in the afternoon. At 6:30 that evening the surgeon and I were carrying the news of her son’s death to an immigrant mother and 13-year-old younger son alone in a foreign land. The grief overwhelmed.

I learned of a 17-year-old mortally wounded by stray gunshots in the neighborhood where he lived. Again the words, “I’m sorry for your loss”were uttered. Their world of grief was entered. It overwhelms.

A man in the ICU brutally attacked playing dominos in the park and left for dead. He was brain dead. I walked with his wife and the organ donor network support person to possibly turn this violent death into a gift of life. Yet, even inside the playing out of this resurrecting act of love in the midst of grief was more violence. Mean and angry words spoken by an estranged daughter of the deceased to her stepmother, “You pulled the plug on my father, you b---- for the insurance! He is not dead.”In her own grief and anger she was acting out. Demanding control of that which she had no control was her goal. Her own pain of a recent arrest and losing custody of her child was too much to bear; she could take no more. Lashing out was her way to cope. She could not talk through her pain. The pain overwhelmed.

A young, skilled elevator construction engineer is caught up in angry words with another on the job. He lost his balance and plummeted stories to his death. His wife, son and aging parents come in stunned shock to view a body marred beyond recognition and bid a last farewell. It overwhelms.

I see pure violence in many forms each day. I compassionately walk with the victims who bear the grief of this violence. They leave an impression on my soul. I wonder, Is this battle fatigue? Do we to suffer from the PTSD of our own urban battlefield? We do. It is Compassion Fatigue. It is real.

I thank God for the loves of my life who listen to me: A spouse who seeks to comprehend the depth of the rapid-fire pain. Daughters who pull their mother back with good humor and the innocence of youth. It is my family who helps me emotionally step from hospital to home each day; colleagues who allow me to process all the traumatic sights we share; a spiritual director who helps me to focus on the assurance of God’s love; a massage therapist whose hands rub the tension filled muscles to relax; a physical therapist and a Pilates trainer who share in keeping me strong physically.

Healing is a gift of God. As a chaplain this belief is deeply embedded in my mind and spirit, in my very being. I believe God cares for those who seek to do the will of God. God encourages chaplains to reach out and build the networks of support we need to be sustained for doing the spiritual healing we have been called to do, especially in the midst of all the violence we encounter.

As a chaplain, I need to be connected and supported to many who love and care for me. This is my strength and my salvation. This is the love of God in Christ alive for me.

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 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.

Anne Underwood is on a break for the summer. If there is a particular issue that you would like her to write about this coming fall, please send your ideas to: info@plainviews.org.

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.

Upon receipt of the emergent page, the chaplain first checked with the NyICU staff, including the MD and RN, to be updated on the baby's condition and determine a plan of care to respond. The chaplain, after talking with the parents, called the NyICU to alert the RN and MD that she was bringing the parents to the unit.

A conference was immediately held with the parents to address the miscommunication and update them as to the baby's condition, continued plan of care and possible outcomes for the baby.

The parents expressed appreciation for the immediate response of the NyICU team; their immediate anxiety was reduced, and they spent time at their son's bedside.They requested that the chaplain baptize the baby in order to utilize their religious resources, which was provided with the MD and RN both participating in the ritual. The neonatologist addressed the issues of miscommunication and boundaries with the perinatolgist as well as the NyICU policies for communication with and presence of parents.

A 27-week gestational age baby was emergently delivered and admitted to a Level 3 Nursery Intensive Care Unit in stable condition.

The unit chaplain, following the established protocol of the unit, met the parents and completed a spiritual assessment. On the third day of life, the baby exhibited changes in his condition. Tests revealed that an Intraventricular hemorrhage had occurred. However, as is typical in premature infants, the extent of the bleed was uncertain. The neonatologist updated the parents as to the changes, range of possible outcomes, and the plan to monitor the baby closely, including additional tests in two days to reassess the bleed.

The next morning the chaplain received an emergent page asking for her presence as "the parents have been informed that the baby is to be removed from life support."

Upon arrival to the mother's room, the chaplain found the parents in tears. They stated that mom's doctor had been in earlier in the morning and informed them that "something happened in the night" and that "they need to take the baby off life support." Additionally, the doctor had instructed the parents not to leave mom's room "because a neonatologist will be coming down to talk with you when it's not so busy in the NyICU." The distraught parents had been waiting for several hours. They asked if the chaplain would go to the unit and baptize the baby "in case he dies before we are allowed to go be with him."

Should the chaplain check the facts in the NyICU before responding to the page to be with the parents?

Should the chaplain advocate that the parents be allowed to be with their baby no matter how busy the NyICU?

Please check the archives below for comments made about the last CaseConference.

The power of individual charisma resonates throughout this story of an obscure monk who challenges the corrupt and all-powerful Medieval Catholic Church and unleashes forces that plunge Europe into war and chaos.

Martin Luther is a beautifully filmed documentary narrated by Liam Neeson that closely follows the transformation of Luther from a devout monk cloistered in a small German town that is dominated by the Catholic Church to a Protestant revolutionary. The film examines in detail and through expert commentary how he comes to understand that it is his own individual faith and liberty of conscience, and not the Church hierarchy, that will guarantee his salvation.

A very illustrative sidelight of Martin Luther’s influence is how he benefits from the newly invented printing press. The pamphlet criticizing papal authority that he nails to the doors of the Wittenberg Cathedral is carried from town to town and duplicated in further print runs so that, within three months, all of Europe is exposed to his 95 theses.

The camera follows Luther’s pilgrimage throughout Europe, from rural Germany to the Vatican and back as he struggles with the dawning realization that “no institution could believe or atone for you or stand between you and God.”When Luther takes the stand that the Church has no right to sell redemption and that salvation is a gift received through faith he is excommunicated and forced to defend his theses before the Holy Roman Emperor.

One individual’s epic vision of his relationship with God, which destroys the medieval concept of man’s relationship with authority, leads to the collapse of his world and the dawning of the modern age.

If you are interested in purchasing this film, you can do so at www.hartleyfoundation.org. Just click on “Masterworks”on the homepage for more information. The cost is $19.99/DVD.

Sarah Masters is the Managing Director of the Hartley Film Foundation, a non-profit foundation dedicated to cultivation, support, production and distribution of the best documentaries and audio meditations on world religions, spirituality, ethics and well-being.

Spirituality, Health, Wholeness: an introductory guide
for health care professionals

This book is a very fine compilation of multiple issues surrounding the topic of whole person care. Chapters include the titles: “Toward a Theology of Wholeness, Spirituality and Coping with Trauma; Faith, Illness and Meaning; Spiritual Care: Basic Principles; and Spiritual Care of the Dying and the Bereaved.”

I particularly liked that the book is formatted into two sections: Theory and Praxis. Each chapter begins with an introductory statement of the objectives and concludes with several guided questions as a review of the contents of the chapter. It is conceivable that, while using this text as a study guide for CPE students or hospital staff in general, competencies for working with patients around their spiritual needs could be established and tested.

The writers are thoroughly versed in, and have researched the writings within psychology, nursing, and pastoral care journals. This is not simply a reiteration of old material but a carefully prepared and fresh approach. Two writers have theology degrees. The remainder practice clinical psychology. This actually makes this book more useful and may add to its reception by physicians and other hospital staff.

Spirituality, Health, Wholeness: An introductory Guide for Health Care Professionals. Siroj Sorajjakool and Henry Lamberton, editors: Haworth Press, 2004, pp 180.

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