11/1/2006 Vol. 3, No. 19

Professional Practice

Advocacy

Chaplain DW Donovan on the limits of volunteer chaplaincy

A Response to Volunteer Chaplains –Yes or No

I hope it’s not too late to add my two cents on the issue raised by Marshall Scott in his article entitled “Volunteer Chaplains –Yes or No.”(PlainViews, Vol. 3, No. 14, 8/16/2006)

The fact that I’m so far behind in my reading might suggest that additional staffing in our pastoral care department would be welcome …but I have to agree with those who have argued that such help should not come in the form of volunteer chaplains.

Chaplain Scott begins by describing a model of nursing that has evolved towards less and less hands-on care by nurses, and suggests that practitioners with a lower level of training, including volunteers, now engage in many nursing functions.

I would challenge this premise. The functions he describes, such as passing ice water and distributing literature, are not truly nursing functions. In today’s era, marked by pressure to reduce length-of-stay, patients who do not require true nursing care are sent home. Today’s nurse is a true medical professional, charged with assessing the medical needs of the patient (this is not just a role for doctors) and helping to coordinate their overall care.

While I appreciate the dedication exhibited by those who have cared for loved ones at home, I’m always a bit perturbed when they make an offhand comment that they have “earned their nursing degree”through their work at home. In that same way, years of visiting family members, even church members in the hospital, does not a chaplain make. Just as there is a gold standard in terms of education and peer review (passing one’s boards) in order to claim the title of Registered Nurse, we are moving towards that same level of professionalism in pastoral care.

I would agree that the board-certified chaplain is an advanced practitioner. However, the context of our ministry is not as an extension of church life, but can best be understood as an integral part of the healthcare team.

Considered from this perspective, the staffing of pastoral care departments must be based on the assessed needs of the patients and families. In my department, we have defined the role of the clinically trained chaplain in this way: to assess the degree to which the patient's emotional and spiritual equilibrium has been disturbed by the healthcare event and to determine what interventions would be appropriate to help the patient restore his or her equilibrium and when such interventions should be employed.

If we are serious about providing pastoral care as an integrated part of healthcare (and not everyone is, although I’m grateful to JCAHO and JCAPS for their work in this direction), then we have to ask what training is sufficient to meet the identified needs of our patients and families. Over the years, and for very good reasons, four units of Clinical Pastoral Education, together with a masters degree, has become the gold standard for chaplaincy. I am even leery of Chaplain Cathell’s suggestion (Responses to Volunteer Chaplains –TalkBack, Vol. 3 no. 15) of creating a satellite CPE program to meet the needs of patients. The entire point of a CPE program is to train ministers to be chaplains, not to provide inexpensive pastoral care coverage.

Likewise, while I’m delighted that my friend and colleague Chaplain John Stangle first came into contact with professional chaplaincy through volunteer work, there is a reason for the additional training …one needs it in order to be effective. In a similar vein, I would respond to Chaplain Ramos’invitation that we take volunteer chaplains and train them to be the best by acknowledging my own limitations: I am not a teacher. I am certainly not a CPE supervisor, and I’m not qualified (nor do I have the time) to turn volunteers into chaplains. We have a program to develop chaplains and it works very well. We need to use it, and continue to affirm the “gold standard”of competency-based board certification.

Once hired, we must live or die on our own merits. To quote my mentor, administrators are not deaf to the work we do. Given the opportunity to see truly effective pastoral care, administrators are able to see “who cooks the best vegetables.”If you yourself are in doubt, move into the literature and note how unit-based, clinically trained pastoral care can make a difference in measurable areas such as length-of-stay and patient satisfaction. You might even surprise yourself.

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

Education & Research

Daniel Coleman on acknowledging our anger

Anger As a Pathway to Holiness

The Hebrew Bible refers to anger in its various forms and expressions over 500 times.[1] Jacob is angry with his wife Rachel; Jonah is angry with G-d; Moses is angry with the people; the people are angry with Moses; Moses is angry with his nephews; Pharaoh is angry with his servants; G-d is angry with Moses; G-d is angry with Miriam and Aaron; G-d is angry with the people; Saul is angry with his son Jonathan; Jeremiah is angry with G-d; Habbakuk is angry with G-d, etc., etc.

More important than simply noting the frequency with which a concept arises in the Bible, it is necessary to examine the first occurrence of the concept or emotion. This provides a lens through which to understand and gain perspective on all future Biblical references to it.

Anger first appears in the context of Cain and Abel.[2] Cain becomes "exceedingly angry" when Abel's offering is found more acceptable than his. G-d asks him "why are you angry..." and, without waiting for a response, proceeds to tell Cain that he still has an opportunity to harness his anger, perhaps even channel it to a constructive use. Cain is apparently unable to rise to G-d's challenge: to identify and take control over his anger. Consumed by his anger, he kills Abel.

G-d and his Biblical servants appear unafraid to publicly demonstrate their anger –yet they and the teachings that we derive from their lives are not diminished. Anger –be it G-d's or ours –seems to be an inevitable part of life. Unless we believe that we are greater than our Creator, anger would seem to be something that is impossible to eradicate through piety or training of the mind, however saintly or contemplative we become. In fact, the opposite may be true. Anger is something we should welcome and cultivate.

In the aftermath of the Golden Calf betrayal, G-d self-describes as "slow to anger" [3] –not devoid of anger! As a human being charged with the responsibility of emulating G-d in my life, [4] I have 'permission' –indeed a mitzvah or an 'obligation' –to express anger at injustices perpetuated towards me (and maybe others as well).

This attribute (and the passage in general) directs us to acknowledge our anger, just as G-d does. We shouldn't feel guilty for having anger. G-d doesn't apologize or feel shame for having and expressing this emotion. Just the opposite. From these teachings, we can infer that G-d is challenging each of us to 'own' our anger and to take responsibility for it along with our other emotions, to confront our anger rather than avoid it.

With this in mind, we can interpret the question "Why are you angry?" that is sometimes directed at us as: "OK, you're angry. Now what are you going to do with that anger?" Will it be left unchecked, or can it be mastered just as we are enjoined to master every other object and emotion that G-d puts into our world? [5] Maybe we can ultimately learn to emulate Moses who selflessly employed his anger in the service of G-d,[6] or Pinchas who used his anger to defend G-d's honor.[7]

It is our responsibility to cultivate a thought-out response that emulates G-d's attribute and directive of being "slow to anger." Open discussion, recognition, and validation of the emotion, rather than avoidance, allows the parties involved to consider ways to prevent future moments of conflagration and attempt reconciliation.

[1] 5 Hebrew words are used to convey anger in the Bible: af over 200 references, chaimah 125, charah 93, ketzef 62, kaas 75.
[2] Genesis 4:3
[3] Exodus 34:6
[4] Babylonian Talmud Tractate Shabbat 133b, expounding the imperative of Imitatio Dei found in Deuteronomy 10:12 & 28:9
[5] Genesis 1:28
[6] Exodus 32:19
[7] Numbers 25:11

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Spiritual Development

Katherine Murray on having the courage to reconcile

The Family Prodigal

Recently I was called to be with the large family of a man who had died suddenly of a heart attack. He had no history of heart trouble, and although he recently had outpatient back surgery, no one expected anything other than a continuous, steady recovery. This kind of shock –the absolute ripping of the fabric of life as we expect it to be –is something I am with often. But this story had heightened color and life because of all the voices contributing. Lawrence had 14 children, ranging in age from 51 to 25, and all but two of them (and their spouses and children) were at the hospital. The waiting room overflowed into the ambulance service area; the hallways of the ER were lined with stunned and hurting relatives, each in his or her own way trying to get their minds around what was happening to them while their hearts were breaking.

Of all the siblings, there had been a family break with only one –a son, the fourth oldest, who had not seen or spoken to his family in more than seven years. The other siblings showed anger when his name was mentioned; they had been the ones who stayed close, who cared, who had a right to their grief. He walked away years ago and rejected them. One younger sister had called him from the hospital; he had said he would come. The family waited, struggled, and disbelieved he would actually show up. After they had said their goodbyes and we had made arrangements with the funeral home, they were preparing to leave. The children told their mother he wasn't coming. "He's had more than enough time to get here, hasn't he?" she asked.

I was in the room with three of the children when the mother entered with someone I hadn't seen. The son had arrived. The mother motioned him in nervously; the other children left the room. I stood with the mother and her son while she explained –in a much more lucid way than she'd previously been able to –what had happened that morning. The son sat heavily in a chair. His mother sat beside him. No words were exchanged. No touching, no comforting, just a heavy, disbelieving silence.

The son was the last to leave his father's bedside. I went and sat with him for a while. We talked about loss and about being gone and about families remembering what was most important in times of crisis. I expressed my hope for his healing with his family. He told me he hoped for that, too.

When the son was ready to go, I walked with him out to the empty waiting room. His mother had already left and, eventually, two by two the siblings and spouses had departed. In the hallway outside the waiting room, one brother remained, the fifth oldest. The two men fell into each others' arms and wept. He extended an invitation and a hope that the estranged brother would come to their mother's house that evening and go to the funeral home to help make decisions tomorrow. He said, "Mom wanted me to be sure you knew we all want you there."

Grace. Healing. Courage. Pain. Priorities.

I found myself thinking of the courage it took that son to bridge the gulf of years and upset and come to the hospital in those painful moments. I think of the hope that the family expressed –even in their cutting, disappointed, and angry comments about him –that somehow reconciliation might come.

For this family, the terrible loss of a father may have brought about the return of a lost brother. At least the people are there, and willing. I trust God –and the natural draw toward goodness in all of us –to take care of the rest.

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.

Surrogate Health Care Decision Makers

Rev. Gordon Putnam discusses the value of chaplains’asking clarifying medical questions for patients. [PlainViews, 10/18/06] Similarly, chaplains may be useful in clarifying roles of people functioning as agents for incapacitated patients.[1] Such agents most commonly hold a Durable Power of Attorney (DPA) for Heath Care [2] and often are family members or close friends of the patient. DPA’s are recognized, albeit with variations, in every state, and offer the strongest avenue for patients’health care wishes to be advocated and honored. DPAs are not limited to end-of-life issues; they serve whenever a person becomes incompetent at any stage of life by disability or illness. Wisdom suggests everyone designate a DPA while competent to choose.

When a patient becomes incapacitated (a medical determination) and has not designated a DPA, if dissension arises among relatives and/or with the medical team, a court may be asked to appoint a guardian. Relatives, close friends, or medical personnel make the request. Before acting, the court hears evidence to determine if the patient is competent (a legal determination). If the court determines the patient incompetent, a guardian is appointed. When there are significant property assets, a conservator may be appointed to oversee the estate.[3]

State probate or surrogate codes set standards for incompetency and delineate the responsibilities of guardians and conservators.[4] This discussion uses language of the Uniform Probate Code [5] (UPC) adopted by eighteen states.[6] All states use similar language and concepts.

Guardians have most of the powers and duties that a parent has toward a minor child, although guardians do not provide for patients out of the guardian’s own resources. To the extent possible, the guardian should include the patient in decision- making processes. Guardianship may be limited to health care (or other types of decisions) or may encompass all aspects of the patient’s life. It may be permanent or temporary. If the patient has a small estate and no conservator, the guardian’s authority may include managing the patient’s money and property. [The resources of the patient must never be co-mingled with those of the guardian.]

A health care guardian must follow any advance health care directives expressed by the patient when she or he had capacity. The guardian must consider the patient’s personal values when making decisions on the patient’s behalf. However, the guardian has no greater power to determine course of care than would the patient have if competent.

Appointment of a conservator may be permanent or for a “single transaction”to manage the business/financial/property affairs of a patient. If there is a guardian, the conservator must consider the guardian’s recommendations as to the best interests of the patient, but the final management decisions for which the conservator was appointed belong to the conservator.

If relatives, friends, the medical team or anyone else concerned for the patient believes either the guardian or conservator is acting outside the best interests of the patient, the court can be asked to terminate the guardian or conservator’s appointment.

DPAs for health care are a regular component of many lawyers’discussions with clients making wills and doing estate planning. Their importance should be stressed in health-care discussions between clergy and congregants –especially hospital chaplains.

[1] The Uniform Probate Code (UPC) defines incapacitated as “any person who is impaired by reason of mental illness, mental deficiency, physical illness or disability, chronic use of drugs, chronic intoxication, or other cause except minority to the extent that he [sic] lacks sufficient understanding or capacity to make or communicate reasonable decisions concerning his [sic] person.”Most states use some form of this definition. Capacity usually is discussed in conjunction with “competency”, the later which is “specific rather than global and depends not only on a person’s abilities but also on how that person’s abilities match the particular decision-making task he or she confronts.”Principles of Biomedical Ethics, Beauchamp and Childress, 2001, p.70.
[2] Also known as Health Care Proxy in some jurisdictions.
[3] The UPC sets forth the following list in order of preference for the appointment of guardians or conservators: 1. The person or organization nominated in writing by the person in need of a guardian or conservator; 2. The spouse; 3. An adult child; 4. A parent; 5. Any relative with whom the person in need…has lived with for more than six months prior to the filing of the petition; 6. A person nominated by someone who is caring for the incapacitated person or paying benefits to him or her.
[4] One must consult the Probate or Surrogacy Statues or Code of the state in which one’s facility is located. A Goggle search of the Uniform Probate Code will reveal most state sources, or call a local lawyer for statutory references.
[5] Uniform Probate Code was approved in 1969 by the National Conference of Commissioners on Uniform State Laws and the House of Delegates of the American Bar Association. The intent was to unify terms and processes among the states. Unification remains illusionary.

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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.

CaseConference #13 Resolution

In the chaplain's initial assessment, the patient focused solely on her pain issues. In the conversation, the chaplain asked the patient to identify what had successfully soothed her spirit during her life. The patient stated she had always liked classical music, to which the chaplain suggested that music might assist her in soothing her pain. The patient was doubtful at first, but agreed to try. The chaplain obtained a CD player with classical music and headphones, set it up for the patient, and then sat quietly with her. Within minutes, the patient fell asleep. The chaplain documented the intervention and updated the RN. The chaplain made additional brief contacts with the patient, first several hours later, and then the next day, to inquire how the pain was being managed. On the 3rd contact the patient –who had been managing successfully without asking for a sleep aid –told the chaplain that "she wished the music would soothe the pain in my heart, too." The chaplain invited the patient to conversation and care began to address the patient's grief at the death of her husband.

By the end of the patient's hospitalization, plans for community follow-up had been made and agreed to by the patient so that she would have ongoing grief support.

CaseConference #13

Nursing paged the chaplain to make a referral to see a 75-year-old woman recovering from back surgery performed seven days ago due to non-compliance with recovery care. The nurse explained that she had just spent 45 minutes with the patient who was insisting on receiving a sleep aid in addition to her pain medication. The patient had been seen by the pain specialist and a pain plan was in place, but she was still refusing to cooperate with nursing or participate in therapies, saying, "I just want to sleep it all through because it hurts so much." The nurse added at the end of the referral request that the patient's husband had died two weeks ago.

What is your role as chaplain in this situation?

How would you approach the patient?

How would you go about assessing this patient?

Would you raise the issue that her husband had just died?

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

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

Reviews

Sarah Masters reviews the audio series

From Fear to Fearlessness

Pema Chodron, Buddhist nun and resident teacher at Gampo Abbey, Cape Breton, Nova Scotia, teaches that the definition of an enlightened being is one who is completely fearless. Her clear and engaging discussion of the tenets of Buddhist practice in this 2-CD set serves both as a spiritual and practical introductory guide to Tibetan Buddhist beliefs and a useful educational tool for Chaplains.

Chodron describes “The Four Great Catalysts of Awakening,”which are known in Tibetan Buddhism as loving kindness, compassion, joy and equanimity. She believes that these traits are “the greatest antidotes to fear”and that if one embraces these traits through meditation one will “cultivate strength and openness in any situation.”

Pema Chodron is the renowned author of The Places That Scare You, Comfortable with Uncertainty, The Wisdom of No Escape, Start Where You Are, and the best selling When Things Fall Apart.

Completed: 2003
Running Time: 2 ½ Hours
Music: Nawang Kechog
Distributor: Sounds True

If you are interested in purchasing this audio CD series, you can do so at www.hartleyfoundation.org. Just click on “Sages of Our Age”on the homepage, then Pema Chodron for more information. The cost of the 2-CD set is $24.95.

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.

Book Review

Rabbi Dr. David J. Zucker reviews

The Blessings of a Broken Heart

“You learn as well . . . that love can overcome death, and that what is required of you in this is memory and devotion.”(Mark Halperin, Memoir from Antproof Case, p. 514)

Sherri Mandell’s alternating faces of grief and hope is found throughout this volume. The reader will experience them on nearly every page. A part of Mandell’s book recounts and relives the brutal, cruel and merciless murder of her thirteen-year-old son Koby and his friend Yosef one fine spring day in 2001.

Yet out of this terrible tragedy, she has found the courage to remake her life, to translate this deep and irreversible grief into a foundation that brings hope and comfort to women who, like herself, have had loved ones torn from their family fabric. Mandell now serves as the Director of the Koby Mandell Foundation Women’s Healing Retreats for Bereaved Mothers and Widows.

People react differently to the face of horror. Mandell finds answers in Orthodox Jewish thought, Hasidic teachings, and the path of mysticism. In one of the chapters, she explains that her son Koby has sent messages from the world beyond, indicating that he is well. She states her belief that she will see him again. In her words, “we’re all heading toward one destination. After death, we have a place waiting for us, nearer or further from God, depending on our actions in this world. . . Koby’s death makes me see my eventual death as a reunion with my son, a return to the unblemished purity of the jewel of my soul.”(pp. 78-79)

She writes about her beliefs, but she also acknowledges that there are times that she despairs. “The divided heart lives with contradiction.”(p. 191)

In some ways this is a painful book to read, and certainly it is a book about pain. Yet, Mandell is able to work through her pain, and find –or better, she is able to make –meaning in her life. Her way may not be someone else’s approach, but she shows the reader that there are paths past the darkness of despair. Though we will live our whole life with irreparable loss, and we will never forget, nonetheless, in time we can heal. In time, we can find “our own voice –our own way of responding to the world, our own way of coping with the mystery and pain of living.”(p. 163)

In explaining the title of her book, Mandell writes that it “is possible to build a new heart . . . many of us live with broken hearts. But when you touch broken hearts together, a new heart emerges, one that is more open and compassionate, able to touch others, a heart that seeks God. That is the blessing of a broken heart.”(p. 7)

Sherri Mandell, The Blessings of a Broken Heart (New Milford, CT: Toby Press, 2006), 235 pp.

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