PlainViews

Rev. Jon Overvold on listening as a tool for healing the wounds of 9/11

"May Peace Prevail on Earth"

With the fifth anniversary of September 11th approaching, I wonder how we will mark the day. My thoughts go back to the memorial service held at my hospital on the second anniversary in 2003. In that service I experienced a kind of healing through the act of listening. Listening is so basic and yet powerfully sacred. The healing I experienced is best described as a renewed sense of wholeness and unity. I recall it more often now as wars continue, divisions in the world harden and weariness prevails.

A simple observance was held in a new Peace Garden on the hospital grounds. A large, wooden, sixteen-sided pole was placed in the center of the garden with the sentence "May Peace prevail on earth" in sixteen different languages. We chose the languages spoken in the countries of known origin of those who died on September 11th. On a day when words fail . . . we listened to one another. We listened to the prayers of three great faiths. We also listened to the words of a humanitarian and scientist, Louis Pasture. It was an acknowledgement that for some staff in our medical community the “sacred texts”might be in the musings of a fellow scientist. Maybe by listening to one another and by listening to our hopes for peace and hopes for a resolution to conflict we will have our own hope renewed.

One of the attending physicians read from the Qu'ran and spoke of how hard it feels to have your faith misunderstood. Everyone listened. And then in what in my tradition would be called a Pentecost experience, we listened as 16 staff read the sentence on the pole in their own language (Arabic, Swedish, German, and even Swahili.) “May peace prevail on earth.”

Listening was really all that was happening –and in a kind of liturgy that let us hear one another and take in one another's stories and traditions, a bit of the weariness eased. Healing was realized and we discovered new ways of understanding one another.

I believe the Sacred is present and working when we listen to each other and seek deeper understanding of our humanity. And isn’t that what we as chaplains offer every day in our work with people. Creating a space where someone can be heard, some weariness eased and a small piece of our world is healed.

Rev. Jon Overvold, BCC, is on staff of The HealthCare Chaplaincy and is the Director of Pastoral Care and Education at North Shore University Hospital on Long Island New York. He serves as the Association of Professional Chaplains State Representative for New York and has recently been appointed Chair of the Quality Commission for APC. He is a graduate of Luther Theological Seminary, St. Paul, MN, and ordained by the Evangelical Lutheran Church in America.

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: The European Network for Health Care Chaplains (ENHCC) held its 9th consultation in Lisbon, Portugal from May 18-21, 2006. Fifty-one representatives of chaplaincy organizations from 27 European countries gathered in a charming retreat center of the Franciscan sisters in the Lisbon hills.

The central theme was Building Bridges - Growing Hope. APC had two observers in Lisbon: Jo Schrader (APC Executive Director) and George Burn. In this article and in Part II which follows in the next issue, George Burn has a conversation about his experience in Lisbon with Anne Vandenhoeck, committee member of the ENHCC and representative for Belgium (and a member of the PlainViews Advisory Board).

ANNE:
What was an American chaplain doing at the consultation of the European Network for Health Care Chaplains in Lisbon, Portugal?

GEORGE:
After 9/11, when the world was busy building walls, I felt that I needed to do something differently. While the US was becoming isolated and the media becoming more one-sided I decided to do two things. First, I found a website entitled Principal Newspapers of the World so that I could read more international views of what was transpiring. The second thing I did was ask to join the European chaplains email network to begin to expand my knowledge of European affairs. What began as a personal journey has transformed into a bridge building effort between continents.

Two years ago when the 8th consultation was held in Dublin, Father Stavros Kofinas, the Coordinator of the European Network of Health Care Chaplaincy, made an appeal to the US chaplains listserve for funds that would help some Eastern European Chaplains attend the meeting. We were able to raise a substantial donation that enabled several people to attend that might not have otherwise. When I indicated interest in someday attending the European chaplain’s meeting, Father Kofinas extended a warm invitation to come to Lisbon. I was most honored to accept his invitation.

Anne, what do you feel it meant to the European Chaplains to have a US representative present?

ANNE:
I think it meant a lot to have both Jo Schrader and you as observers at our consultation. The theme of the gathering in Lisbon was 'Building Bridges' among the 27 represented European countries, among our respective religious traditions and theologies, with the European Community and with other chaplaincies in the world. You both represented the American chaplains and that gave us the opportunity to learn from you, in formal and informal contacts. We were very pleased that Jo Schrader gave a session on the APC and the lively discussion afterwards showed how much we had in common and what we could learn from each other. What did you learn from experiencing the European chaplains, George (except from the fact that Belgian chocolate is great and Portuguese Fado is very dramatic)?

GEORGE:
I learned a lot about the issues that Europeans face in trying to build a common network of chaplaincy across Europe. The language barrier is substantial although I was deeply impressed that the sessions were held in English and that many of the chaplains at the meeting were multilingual. Cultural and political barriers have been an issue for all of Europe, but the ENHCC has worked with high-level leaders of the European Union to establish the groundwork for chaplaincy becoming a standard for healthcare throughout the European Union. I also learned that there is a substantial divide in terms of training for chaplains in Western Europe when compared to those who have been recovering from years of Soviet domination. There are shining examples of countries that are blooming after their recent liberation, places such as Latvia, where chaplaincy training is being brought in from Western Europe and individual chaplains are being sponsored to receive training in the west at a rate of one per year. I learned, and it didn't take very long, that you are a wonderful and fun-loving people, sincere in your efforts, and loving in your hearts. I learned that I have new friends across the continent as a result of being there in person. (And yes, I admit, Belgian chocolate is to die for and I've already purchased a Fado CD).

Anne M. Vandenhoeck, a member of the PlainViews Advisory Board, is a research assistant at the Faculty of Theology, Department of Pastoral Theology, of the Catholic University of Leuven, Belgium. Her academic formation includes a master degree in Religious Studies and a master degree in Theology. A Catholic lay woman, she served as a chaplain for more than 13 years in several hospitals in Belgium and the United States. Currently she divides her time between working on a PhD, teaching Pastoral Theology and supervising theology students. She is a CPE supervisor in training. Anne is a member of the European Network of Health Care Chaplaincy.

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

In the religion of the ancient Greeks, it was believed that gods and humans were separated by language –neither could speak nor understand the language of the other, and consequently, the two groups had no way of knowing the needs, wants and/or expectations of the other. It took the gifts of the god Hermes to find a way to stand in the midst of the chaos and create a space where understanding could emerge. Hermes carried the words between Mt. Olympus and earth, interpreting the activity of humans and gods each to the other. From his name, we derive the word “hermeneutic,”the art of the interpretation of hidden meaning (as well as sacred texts).

As the director of spiritual care in a mid-size community hospital, I found myself longing for a visit from Hermes, especially when it came time to interpret the work of my department in administrative circles. It was never a matter of appreciation for the essential nature of the work; but how to uncover the “hidden meaning”of our work in the language of healthcare administration. We needed a hermeneutic of productivity.

After a bit of trial and error, our department developed a tool that has served us well for over a year.

Our “Productivity Hermeneutic”is a 3x4 inch card completed by each chaplain for each visit. There are five fields on the front of the card for documenting the following: date, shift, length of visit, location of visit, and acuity. Two additional fields capture the following: who was visited; type of visit; source of visit (i.e., referral source); and chaplain activities (e.g., prayer, reflective listening, pastoral presence, sacrament, liaison, comfort/affirmation, etc.). Except for the date, all fields are in check-box format, with a blank space for “other.”At the bottom of the card is a place for the chaplain’s initials, and a place to check whether the chaplain is weekend, weekday, volunteer or student. The back of the card is left blank and is often used by chaplains to make brief notes for documentation on the visit.

At the end of the day, the cards are gathered and data is entered into a database developed by our Information Services department. In addition to tracking the number of visits, whenever needed (e.g. monthly, quarterly) the program will produce various tables and graphs which successfully translate the work of our department into interesting and valuable reports, such as:

•Which floor/unit calls us most frequently
•What activities are most utilized by chaplains
•Average length of visits, not only in general, but by chaplain, floor/unit, etc.

Suddenly, we were speaking in a language that was clear and succinct to our administrators. Developing a tool that was “chaplain-friendly”(e.g., fast, clear, and easy to read and use and taking an average of 15-20 seconds to complete) has resulted in high compliance from the chaplains.

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

I have been blessed to be able to work and support my family in a profession that has allowed me to do what I love, listen to peoples stories.

When I began my work as a chaplain over 21 years ago, I was the only Protestant in a department that had three Jesuit priests and four Sisters; two were Sisters of Providence while the other two were a Carmelite and St. Joseph of Peace. I was on a fast learning curve, as I had not had much exposure to the Catholic faith. But how I have come to love and treasure my friendships with them all. But then I was here because of the Catholic faith for they were the sponsors of the Catholic hospital where I was privileged to work.

My first years of work were simple. Having an assigned area, I was to visit as many patients as I was able, focusing on the new ones, and the ones hospitalized the longest. The work was focused on the patients alone, but even then I found myself being asked to celebrate with staff in major events of their lives, weddings, blessings and an occasional Baptism.

In the later years my work has broadened into more disciplinary focus, being part of the development of Pathways for Open Heart Surgery, CHF, and alternative pain management options. It has been my privilege to teach several classes to nurses on issues ranging from the dying process to conflict resolution and dealing with stress in the work place. My most recent involvement has been with the development of electronic charting for our hospital, and being an advocate for spiritual care throughout the process. This has spanned a period of over a year-and-a-half working with a great team in designing the electronic record. I will retire before it is rolled out, but I know that my presence and influence will be a lasting one, and I am blessed to have been here.

But the stories of the patients have been my greatest love. Just recently I was visiting a little native lady from one of the villages in Northern Alaska. She made a lasting impression on me when she said that her father was the face on the Alaska Airlines jets that are so well known to people in Alaska, and to people who live in the destinations now served by the airlines. She was so proud of him, and pleased that he had unlimited flight privileges as a royalty. What an opportunity to share in her story.

Our department has grown. It had been a desire of mine to see a CPE program established in Alaska. Finally that has come about with a program that has had two summer units, two extended units and now a residency program, which is to start soon after I leave. This has been an answer to my prayers, and so I can leave in peace knowing that professional chaplaincy is doing well in Alaska.

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.

Louisiana’s attorney general is capitalizing on a national obsession to “blame, slander, and sue”as he second-guesses the decisions of medical personnel at New Orleans’Memorial Hospital during the Katrina crisis. PlainViews CaseConference # 11 outlines the situation.

Why are actions of a doctor and two nurses who voluntarily remained with critically ill patients of greater concern than the inaction of absent primary providers responsible for the patients who died? [1] The ethically challenging questions center not on the professionals who stayed at Memorial, but on those who left –doctors, nurses, technicians, chaplains, administrators.

What prompts some people, with or without specialized skills, to choose to assist in crises? What ethical and legal precepts support or discourage assistance?

If an adult passively watches a child drowning in shallow water, people are horrified. Most assume the adult has moral and legal duties to rescue. While the former surely exists, in most U.S. jurisdictions no legal obligation attaches absent a special relationship between child and adult.[2] Unlike France, Portugal, Spain and other European civil law countries, neither U.S. common nor statutory law requires assistance to endangered persons.[3]

Historically, helping the stranger in distress has been a religious or moral precept, not a legal imperative. In the Good Samaritan parable (Luke 10:29-37), neither priest nor Levite violated Roman law by ignoring the wounded stranger. As Jews, they transgressed the commandment –neither shalt thou stand idly by the blood of thy neighbor (Leviticus 19:16). However, they did not risk criminal sanctions because “their breach involved no action.”[4] Medieval English Common Law and its modern U.S. progeny follow the Roman model.

American “Good Samaritan statutes”do not compel action. They provide immunity from liability for voluntarily assisting someone in distress.[5] Autonomy –an individual’s right to decide whether or not to intervene –trumps beneficence. Individual rather than communal interests are preferenced.

1. Can any person, with or without specialized skills, be expected to make uniformly “perfect”decisions in highly charged, even toxic, emergency situations? If so, will prudent persons decline to volunteer assistance in high-risk environments?

2. In war zones, wider latitude of judgment is given to soldiers who “mistakenly”kill civilians than when such killings occur during peacekeeping missions.[6] Should similar latitude apply to decisions of medical personnel during systemic crises?

3. Should Good Samaritan statutes be re-written to include professionals in medical facilities during times of local/national emergency?

4. At what point are the values of patient autonomy and informed consent subsumed by safety and survival concerns of other patients or even medical providers?

5. What would it say about our national character if Thomas Aquinas' theory of "double effect"[7] were assumed to apply to the Memorial doctor's action rather than the attorney general's theory of homicide and, as a result, the prosecutions were suspended?

6. In the fourth Christian gospel, Jesus admonishes, “Let he who is perfect cast the first stone”(John 8:7). What response does your faith tradition suggest to the prosecution of those who made decisions most of us will never be forced to consider under circumstances most of us would have chosen to escape?

[1] Twenty-four of fifty-five patients who died, including those on whose deaths the prosecution focuses were patients of Life Care, a corporation separate from but using Memorial’s facilities. Life Care’s chief administrator and medical director were not at Memorial during the crisis. Memorial’s staff was caring for Life Care patients. The New York Times, 08/01/2006.
[2] A parent or other caretaker is expected to rescue a child unless to do so would cause that person’s death or serious injury.
[3] The majority of U.S. jurisdictions provide no legal duty in civil law to assist another in danger, “even though a moral obligation might exist. This is true even ‘when that aid can be rendered without danger or inconvenience’to the potential rescuer.”8 Touro Int’l L. Rev.93 (1998) [FN 11] Exceptions to the above do exist in seven relationships: (1) duty based on personal relationship (parent-child); (2) duty based on contract (physician to patient); (3) duty based on creating the risk (driver who hits jogger); (4) duty based on voluntary assumption of care (once rescue is commenced); (5) duty based on statute (hit and run accidents); (6) duty to control the conduct of others (employer to control harm to others from employees); (7) duty based on being a landowner.
[4] Kirschenbaum, Aaron J.D. The Bystander’s Duty to Rescue in Jewish Law, citing Maimonides (1135-1204) Code. www.daat.ac.il/daat/kitveyet/assia_english/kirschenbaum.htm
[5] In 1959, California legislated the first Good Samaritan law. All states followed. The intent was to encourage medical professionals to render care in emergency situations outside a hospital where limited resources and adaptation of skills would affect quality of care. Providers were immunized from resulting problems as long as: (1) the situation was outside of a hospital and a genuine emergency –loss of life or limb at stake; (2) no remuneration was expected; (3) care was given in “good faith;”and (4) once commencing assistance, personnel remained until someone comparable took over. Eventually, most states extended this legislation to non-medical providers of emergency assistance with the criteria adapted appropriately. [Ordinary negligence standards apply and may be waived for ordinary citizens whereas gross negligence standards may apply to medical personnel unprotected by Samaritan statutes]. Cf: Good Samaritan Statutes: Are Medical Volunteers Protected? Cameron DeGuerre, www.ama.org/ama/pub/category/12191.html. The medical actions at Memorial are outside Good Samaritan protection according to Louisiana’s statute LSA-R.S. 37:1731.
[6] An investigation cleared the U.S. soldiers who shot and killed the rescuer of an Italian journalist when her car sped towards a check point in Iraq in 2005.
[7] “Double effect”principle holds that actions may have both good and bad effects. If the intention is for the good effect and it outweighs the bad effect (which must be tolerable, foreseeable and unavoidable), one can engage the action. This theory supported the U.S. Supreme Court decision in 1997 which said it is acceptable to sedate a dying patient even if unconsciousness follows. The same decision prohibited physician-assisted suicide. Many medical ethicists weighing in on the Memorial prosecution argue that the drugs found in the four patients in question fit within this principle and practice. Cf. "The Fuzzy Gray Place in the Killing Zone," Denise Grady, The New York Times, Sunday, August 13, 2006, Ideas and Trends section.

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.

With the recent decision by the Louisiana Attorney General to ask a grand jury to indict a doctor and two nurses for "administering lethal doses" to patients who were under their care during the aftermath of hurricane Katrina, we thought we would invite chaplains to comment on the situation. For those of you not familiar with the situation, we will give you the "details" as they were presented in The New York Times (July 20 & 21). Since there has not been an indictment nor a trial, no "facts" are yet established. The "details" below are those that have been released to the public.

It is 4 days after Katrina. The temperature is over 100 degrees and 5 feet of water surrounds the hospital. Only one wing remains usable for patient care. Most patients have been evacuated but the most acute have been moved to the available wing and left with the staff that agreed to stay on duty. Over-heated patients are dying. Medicines are running low and there is no electricity. Machines that are being used to keep patients alive are running on batteries and the batteries are beginning to run out. There is no way to know if or when the remaining staff and patients will be evacuated. The doctor who has stayed pulls you aside and asks you to consider the alternatives she and the medical staff have for caring for these acutely ill patients in this crisis situation.

What is your role as chaplain to this doctor?”

As the chaplain, how would you approach a discussion about making the patients "comfortable," even though it might hasten their death?

What is your role with the patients? The rest of the staff? Does this particular crisis make your role different than it is under "normal" hospital conditions?

My first priority would be to assess the doctor. Is the physician in seeking an ethical consult asking indirectly for emotional spiritual and physical relief? The fatigue and stress in such a setting could well take a bitter human toll on the caregivers. The doctor may need more support for personal suffering than advice on the management of the patients' suffering. The first ethical question for me then is "Does the doctor need to be rescued?"

While as a culture we can easily understand the failure of machines and the final consumption of supplies, we are less likely to accept failure in our caregivers. Yet it is not impossible for me to imagine that the doctor can be in very real danger of failure and at some point the welfare, perhaps even the survival of the physician and staff, has to be triaged into the scenerio. Lacking clear guidelines, the immediate leadership may need to rethink the situation. Did their willingness to stay and care for these most fragile patients imply an expectation that the staff or any of its members would give the best possible care or to give it all?

To my thinking, the best possible care does not include self-destruction and the physician should not be asked to choose between the barest minimums of self care and patient welfare. The life of a patient does not take priority over the life of a doctor. Heroic measures should not include physical, emotional or spiritual martyrdom for the caregiver. And if, at the moment when the staff reaches the conclusion that euthanasia is the only remaining option for best possible care, then I believe they would have fulfilled their oaths and their obligations to their patients.

I can imagine that my response in this situation would depend in large part according to the degree to which staff are open to being companioned and the level of acuity in the remaining patient population.

I would see my role to the healthcare team as both a member of the team as it affected patient care discussions and distinct among the team, being present to help the remaining doctor and the rest of the staff name their own experience in the moment. Naturally this sort of debriefing would have to be bracketed, but enabling the team to speak to their experience could also be huge, in terms of caring for the team. Likewise, I would see my role with the patients as helping them speak to the present moment and enabling them to claim their spiritual needs and attending to these needs as best I could.

Ideally my input to the team would be in the context of some sort of consult in which a range of ethical considerations would need to be brought forward, beneficence/non-malfeasance, common good and autonomy playing a large role, but common good would seem, in some ways to be the driving ethical consideration. There are limited resources, people are dying, people are going to die but all deserve to be treated with respect and dignity. And, all deserve the best care that can be given to them as best as the situation and resources allow. There would be a natural role here for Palliative Care, including comfort care that might hasten death.

Does this particular crisis make my role different? Yes and no. None of the principles/practices are different from every day practice; however, given the situation tension and anxiety must be higher with more immediately at stake.

Andrew Schoenfield, M.Div.
Priest-Chaplain, Archdiocese of Seattle
Department of Spiritual Care
Harborview Medical Center
University of Washington Medicine

Although it is important to consider the ethical and legal questions that arise from this case, we must also consider the luxury we have of looking at this situation from a distance. In the days after Katrina
our healthcare colleagues on the Louisiana, Mississippi, and Alabama Gulf Coast faced emotional, spiritual, and physcial distress that is unimaginable to those of us who were not there. We who look at the situation from a distance can only speculate how we might react in such a situation. One would hope that our ethical judgement would remain intact or even be enhanced under such stress. But how can any of us who were not there know for sure? This uncertainty does not excuse illegal or unethical actions, but does remind each us of how easy it is to judge from a distance. We also cannot escape the questions of social justice that arise from this case. Why were people not evacuated sooner, thus leaving the healthcare community in such a situation? Were the poor and disadvantaged left to bear the brunt of the hardship? If wrongful acts were committed, do we as a society share the responsibility? What is our societal responsibility to the victims of this crisis? What is our societal responsibility to protect others from ever having to face such a situation again? Hurricanes Katrina and Rita have called us to an examination of our ethical barometer as a society.

We all are servant of the living God but was it ethical to respect the life and dignity of a person or are we acting like gods? We know when the conditions are dificult we have to make dificult decisions but the best is ask our self is it correct to kill? We all know the answer so was it an bad decision. Yes we can't play the paper of God even in bad situation we need to depend in his grace an do our best and wait for him to act and then he will show us an better way.

Pastor Samuel Santos, Gods servernt and yours.
Iglesia Evangelica Bautista de Bayamon Inc.
Bayamon PR

My role as chaplain to this doctor and also to the staff and patients in this situation should be one of emotional, spiritual and physical support. I would explain that in the medical profession as well as religious profession the roles are the same. Do no harm and respect the fact that there is only one who can make decisions about ending life and that is God.

There is no doubt that this crisis would make everyone's role different. This is a crisis situation but by its very existence, it does not allow us to make decisions about life and death. Thankfully, I was never in this situation and I hope I never will be.

The ethical considerations are the same in every circumstance. We owe every patient the best medical and spiritual care for as long as they live. If we are not the "caregiver" according to legal documents, we do not have the ethical right to disconnect any tubes or hasten death in any way. My job in this situation would be to remind everyone in the hospital that we are not God and only He makes the life and death decisions. I am there to offer spiritual and emotional support during this time of crisis.

Gene Simco
Community Chaplain
Vassar Brothers Medical Center
Poughkeepsie, New York

I lived in New Orleans for a while, and I can recall how oppressive the heat and humidity could become when both reached a peak at the same time. I was also trapped in a car one time while flash flood waters came up all around us. Eventually, we crawled out the windows and made our way in muddy waist deep water up a slope to "dryer" land. We were tired, wet and
miserable at the end of the day. Quite frankly, though the waters receded after several hours (not days, weeks or months as with Katrina), we were a little freaked out by the whole experience. When nature shows its strength, even a little, we are quickly reminded of how small and vulnerable we truly are.

In the case of decisions made during post-Katrina days, I cannot imagine how overwhelming it must have been for all involved, doctors, nurses and patients. Some patients may have actually welcomed the "hastening" measures
described in this case. Some may not have been at all aware. And, I'm a little skeptical of these kind of "postmortem" legal machinations. I lean toward thinking the doctors and nurses were truly believing they were doing the least harm given the extraordinarily painful circumstances by the critically ill in their care.

I would hope that my role as chaplain in that scenario would be to provide support and guidance to all involved. If patients were aware enough to decide with the doctor their best care, and if that meant no heroic measures, but rather receive comfort care, then the ethical issue would have been to what measure those comfort care procedures went. Hopefully,
the doses stayed within ethical range of comfort care for patients. For patients that were not aware, and no family to consult, the issue is much stickier, I agree. I think to err on the side of minimum doses to keep the patient comfortable would have been my hope. I wouldn't have known the difference between a non-lethal and lethal dose by the way. I still don't know. My counsel would have been, and would be now, to regard the patient's rights and dignity at all times. Hopefully the doctors and nurses would know what level of dose that would entail.

Q1
My role, as chaplain, would not be to play doctor. Helping the physician(s) and staff clarify their roles, options, and responsibilities through reflective listening would best example the approach I would take.
Q2
Helping keep patients comfortable with the possibility of hastening their death is a very different issue then intentionally hastening a patient’s death. It's at least normative to focus on a patient's comfort, intending their death creates a different ethical and legal dilemma.
Q3
The ethical issues I imagine to be at play might primarily concern rationing (limited resources for numerous needs through an unknown duration), justice/distribution, truth telling, beneficence, autonomy (for patient and provider) including personal value clashes (what doing the right thing really means), and resulting moral distress.
Q4
I think that balancing these ethical issues could only (if at all) be possible through discussion with the involved persons. If there is time for the physician to pull the chaplain aside, there is time to have this discussion with the larger group of those involved. I think it to be a mistake to act in isolation (taking questionable courses of action) without involving and valuing the team with their views, expertise and input.

Rev. KC Schuler, MDiv, BCC
Supervising Chaplain for ThedaCare Hospitals
Appleton and Neenah, Wisconsin

It would be important to query the doctor a little more to know more about what exactly they were asking. I think it would most likely be generated by their humanitarian concerns regarding discomfort in dying as ventilator support, medicines etc ran out.

Code status is not something the medical team as a rule should be involved in unilaterally in spite of the fact it is a doctor's order. While medical staff play a vital role because of their expertise in the medical part of the equation, patient or power of attorney wishes are equally important because they are involved in the subjective question of quality of life. At our facility these questions are worked on jointly by a multi-disciplinary team. In the absence of this, I would say that the only way code status should be changed without patient or family input would be on a case by case scenario in which the patient might be unbearably suffering (such as suffocation without adequate ventilator support). Probably many would disagree with this and I think this kind of circumstance would be rare, but we pull support on almost a daily basis if patient care is futile and patient or family is on board. For the most part, I think we are obligated to provide medical support until the very end, hoping for the helicopter!

I think the role of the chaplain here ought to be clear to those of us who do this work...

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

Requiem for a Faith is a moving visual portrait of Tibetan society, a society that is “so close to the sky, the natural occupation of its people is to pray.”Fluttering prayer flags, lavish artwork and the hypnotic chanting ceremonies of the Buddhist monks are captured in this film of Tibet as it was almost two decades ago.

World religions scholar Dr. Huston Smith provides a compelling narrative overview of the Tibetan belief system, a compassionate system that incorporates a densely populated spirit world with different methods for achieving enlightenment.

Requiem for a Faith is a window into the mystical culture of Tibetan Buddhism. Over years of isolation in the remote Himalayas, Tibet evolved into one of the most deeply religious societies known to the modern world. Chaplains will be reminded of the spirituality that becomes almost tangible when religious beliefs provide the framework for daily life.

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

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.

With these words, Chaplain Jan Knaus, one of many contributors to this volume, characterizes her vocational journey. Spiritual Caregiving in the Hospital is the result of a research and writing project done at Associated Mennonite Biblical Seminary. This project reflects their institutional commitment to contribute to the formation of healthcare chaplains through a concentration in Pastoral Care and Counseling within the Master of Divinity program. The book is divided as follows: Part I: The place of spiritual care in the hospital; Part II: The chaplain as caregiver in specific settings; Part III: Special concerns in chaplaincy ministry.

Spiritual Caregiving in the Hospital succeeds because the book is written by practitioners of the art. In the introduction the editors differentiate ‘spiritual’from ‘pastoral.’“Pastoral care is the dimension of the ministry of the church that has concern for the well-being of individuals, families, institutions, and communities. It may include various functions—guiding, nurturing, sustaining, comforting, reconciling, and healing—in diverse settings, including hospital chaplaincy…We adopt the understanding of faith as a human universal that may or may not find expression in terms of specific religious tradition and content…By spiritual, we mean the fundamental capacity to have faith, to make meaning, to create community and culture, to long for and practice love, peace and justice, and to be oriented toward wholeness.”(p. 3)

Opening ‘windows to chaplaincy ministry’is an apt metaphor for the editors’intention to allow a better view of healthcare chaplaincy by getting out of the reader’s way. Through effective use of Biblical imagery, anecdote, personal experience, case study and poetry, the editors and their contributors hold the reader’s interest without becoming pedantic. I commend a thorough reading of this book by chaplains, students and teachers of pastoral care —anyone interested in this vital discipline!

Bueckert, Leah Dawn and Schipani, Daniel S., editors. Spiritual Caregiving in the Hospital: Windows to Chaplaincy Ministry. (Kitchener, ON: Pandora Press, 2006) 263 pp.

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