PlainViews

Rev. Timothy Madison on organ donation from a different perspective

A Community Hospital’s First DCD Case

The practice of Organ Donation following Cardiac Death (DCD) is nothing new. It was a new event, however, for my community hospital in rural southern Illinois. I serve there in my seventh year as the first Chaplain and as a one-person department.

Definitions:

DCD –A method for procuring organ donations when the patient cannot be declared brain dead. Before extubation from life support, the patient is located in an area where he or she can quickly be taken to surgery upon pronouncement as dead. In my case, the patient was transferred into a surgical suite before extubation.

OPO –The Organ Procurement Organization is responsible for family consent, logistics, and expenses related to a DCD. A three-person team arrived at the hospital to fulfill these duties once the donor family had expressed verbal interest in the procedure. They stayed in contact with the family throughout the process, even attending the memorial service.

Designated Requestor –The OPO trains hospital staff to approach families regarding their interest in organ donation. In this case, the OPO asked me, as the Designated Requestor known by the family, to present the option of organ donation. The OPO did so after first making a preliminary determination that the patient was a potential donor and that the patient had signed up as an organ donor on a state-run web site.

Process Highlights:

Hours 0-2 –The patient’s family decides to extubate and allow natural death. The OPO is notified by nursing. The OPO asks me to make a first approach. The family expresses a strong desire to pursue organ donation, due to the patient’s prior expressed wishes. I provide anticipatory grief ministry to the family and notify nursing, administration, and the hospital surgical staff that a DCD may occur. Many logistical questions are raised with each notification. I reminded each party of the DCD “dry run”we held several weeks earlier and deferred detail questions to the OPO.

Hours 3-28 –Delay after delay occurs. The family is notified of three different times for extubation, only to have those times postponed. The delays were due to the multi-step OPO procedure of donor evaluation and recipient identification, the transport of a donation surgical team to our remote site, and planning around the already heavy hospital surgical schedule. Despite my frustration with the delays, the family responded with determination to fulfill the patient’s wishes “as long as it takes,”utilizing the time to continue their bedside grieving. The OPO used this time to educate the family and hospital staff about the actual procedure of a DCD. Some hospital surgical staff voiced resistance to participation, which was resolved by recruiting an all-volunteer team. Two physicians voiced opposition to a DCD. I joined the effort to explain that a DCD did not involve assisted suicide. Their opposition vanished when they understood that they would not have to participate. Per our hospital policy, a medical resident would be in the surgical suite to pronounce death.

Hours 29-30 –After a prayer, the family and I put on our “scrubs”and joined the patient in surgery. Extubation occurred and I provided grief ministry amid monitor beeps, tears, “above the neck”touching, and old memories. After 15 minutes, the patient died peacefully. Departure was awkward, but the family responded quickly when prompted to leave surgery. They were accompanied to a nearby room where they debriefed and received more OPO information. After changing clothes, the family departed, exhausted but appreciative. I followed up with participating staff the next day.

What went well?

•A determined, highly motivated family
•The presence of a well-trained health care Chaplain
•Quick educational responses to resistance
•The recruitment of a volunteer team in surgery
•The history of a “dry run”

Improvements?

•More medical staff education about DCDs
•Better preparation of the family regarding the length of the process
•Involve the pronouncing medical resident with the family before meeting in surgery
•Removal of an ice chest marked “liver”from the family’s path into surgery

Power is a strange thing. Without it nothing would be accomplished. As hospital chaplains, we deal almost every day with the loss of power: loss of power in a limb due to a stroke; or loss of power to make one’s own decisions due to mental decline, dementia or Alzheimer’s; or, the loss of power to effect any change in the impending death of a family member. There is a corollary between health and power and sickness, disease and the loss of power.

Power is also at work in hospital settings through the power of the system. Hospitals must exercise power in caring for the physical and psychological needs of its patients through its agents who determine when and how health care is delivered to those in need. The power or lack thereof is determined by the policies established, budgetary limitations, and finite human resources that are available.

On April 3, 1887, John Dalberg wrote in a letter to Bishop Mandell Creighton: “Power tends to corrupt, and absolute power corrupts absolutely. Great men are almost always bad men.”This quote has been cited often, for there is the ring of truth to it. Most of us have experienced this abuse of power by someone who has power over us. It may have been a parent, a teacher or employer; it may have been a spouse or a spiritual leader. Of course, it would be rare that we ourselves haven’t abused our power, however limited our power might be. It seems our nature to use power to harm instead of to heal.

This is also true when it comes to spiritual power. There is a special power that those in spiritual leadership within their religious tradition, or in positions like mine as a chaplain, possess. Some people I visit are separated from the spiritual foundations upon which they grew. Curious about why this separation has taken place, conversations sometimes reveal a soul wound that is in need of some attention. I have heard stories of spiritual leaders who used their power to destroy, who used their powers to condemn, who used their powers to judge, and in so doing inflicted wounds that have not healed over many years.

When the abuse of spiritual power occurs, it is not necessarily intentional and malicious. This potential exists when those in leadership forget that they hold their office for the purpose of serving God and God’s people. One of the things we must do to guard ourselves against abuse is to be aware of it and to identify it. The following characteristics are common in a spiritually abusive leader:

1. Power positioning –The spiritual leader constantly reminds those who are under his care that he/she is the authority.
2. Unquestioned authority –The spiritual leader labels anyone who questions his/her teaching or authority as rebellious.
3. Secrecy –Church leaders broker information and maintain levels of secrecy for the purpose of maintaining control.
4. An elitist attitude –A spiritual leader insists that only those who agree with him/her on everything are true and refuses to acknowledge anyone else as being able to truly know God.
5. An emphasis on performance –A spiritual leader measures spiritual vitality by self established standards of performance and codes of behavior are imposed over all areas of life.
6. Motivation by fear –Spiritual leaders use fear of falling into the hands of the devil or fear of falling under the wrath of God to maintain control of their followers.
7. Painful exit –A person cannot leave the group on good terms. Any decision to leave results in excommunication or some other public humiliation and ridicule and censure.

People’s spiritual lives have crumbled as this abuse leaves them alienated from God and leads them to believe that God is on the side of the abuser. Spiritual abuse can happen in any congregation, for power as a bent towards corruption.

Many “unchurched”share stories of experiencing spiritual abuse. They don’t call it that, but there are many victims and the tragedy is that the damage often leaves them forever outside a caring congregation. When people have a belief system but live outside a community of faith, it may be that they find a faith community so terrifying that they can not bring themselves to come back.

I pray that God will give us wisdom as we minister to these wounded souls. I also pray that we will be ever diligent not to abuse the spiritual power that is invested in our position as chaplains.

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

The Rev. A. Meigs Ross, Director of the Center for Clinical Pastoral Education at The HealthCare Chaplaincy, NYC, presents a compelling “Case for Peer Consultation Groups”(PlainViews Vol. 3, No. 20, November 15, 2006).

Chaplain Ross framed her article in terms of her work as a supervisor working with supervisors. We agree with Ross’s conclusions, and here we offer our practical experience over a number of years in a Chaplains/Pastoral Caregivers Peer Support Group.

Like Ross, several years ago we recognized the need for an ongoing “Peer Support/Consultation Group.”We formed just such an entity that draws its membership from southern Wyoming and north-central Colorado. We term ourselves the WY-CO Peer Support/Consultation Group.

Our cluster of chaplains purposely is diverse. Membership includes Roman Catholic (female and male), Jewish, Methodist (female and male), Episcopalian, UCC, and Baptist (female and male) members. Members includes Directors of Pastoral/Spiritual Care, Hospital, Long Term Care, Hospice, Congregational, VA, Administration/Teaching, Pain Assessment and Management.

We strive to avoid sharing the same religious judicatory. We do not allow coworkers from the same institution, nor do we allow a situation where someone is actively supervising/being supervised by someone else in the group.

Geographical separation is an important feature. We are not in competition for the same economic dollars. This means we can be honest and direct with each other.

We meet in a neutral facility, where none of us serves professionally. Consequently, we are not available for direct call. We have learned the importance of psychologically leaving one’s own campus.

Our experience over ten years is that personal chemistry is important. You have to “fit in”with the group; and they with you. (If you don’t “fit”, find a new group.) The presence of both men and women is essential. It prevents male/female bashing; men and women see things differently. Diversity in age is important. Not only is there a mentoring aspect, but the younger and the more mature see and approach life issues differently providing valuable exchange and dialogue.

The group can be educational (i.e. didactics) but this is not its primary purpose. We each regularly present a verbatim. More importantly, we provide peer support and consultation on professional and personal matters.

Over the years, we have grown in friendship. More important, we all have learned that this is a safe place to vent and lament, grow and groan. Depending on the moment, we serve each other as a rod to prod, or a staff upon which to lean and draw comfort. As we are there for each other, so we know that even when we walk in deep darkness others are there for us, and so we do not fear.

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

In nearly nine years of hospital chaplaincy, I’ve come to expect deeper attachments with certain patients and families than with others. Recently, while working a weekend shift and covering our entire hospital I experienced one such attachment.

I was paged by nursing staff and asked to read the Bible to Lucille, the lady in 5613. The nurse shared that she was extremely busy and didn’t have the time that Lucille demanded of her. Upon arriving at the room I noticed that Lucille was asleep. I went to the nursing station and inquired of the nurse and she told me to go ahead and wake her because she would be disappointed if she missed an opportunity to hear "God’s Word."

I went back and knocked on the open door and slowly Lucille’s eyes opened. Before I could even introduce myself she blurted out, “Sit down and read the Bible to me.”I asked if she had a favorite book or passage and she said she wanted to hear me read Colossians. So I started in chapter one and, as I read, this frail 91-year-old sat up in bed and listened intently to every word coming out of my mouth. It seemed as though she was feasting on her daily bread. After reading two of the four chapters in Colossians I was paged to attend to another matter. I excused myself and told Lucille that I was working the following day and hoped to see her again.

On the drive home that evening and until I came to work the next day, Lucille was on my mind. Hoping that I’m a blessing or of some comfort to patients is often a desired goal, but realizing that they are often the ones blessing and comforting me often becomes the deeper reality. That short encounter with Lucille brought me such blessing.

Arriving the next morning at Lucille’s room I was in for quite a shock. Her room was empty. My heart literally fell to the floor. Knowing that Lucille had not died during the night (we keep a log of such happenings in our office), I tracked down the nurse and found she had transferred to another floor. Thank you, God! She had not gone back to the nursing home. I needed to be blessed by Lucille at least one more time!

Upon arriving at her new room we once again skipped small talk and went right back to where we had left off the day before. Once again, Lucille sat up in bed and gobbled up her daily bread. Even when I came to Paul’s urging in chapter 3 for us to put to death whatever is earthly, Lucille seemed transformed.

Right after I had finished the last line of chapter four and the book was done, a visitor came in the room. Lucille’s great niece and her family had come to bless their aunt by their presence. I thanked Lucille for letting me read to her these two days and excused myself. As I exited the room I mentioned to the niece how much Lucille loved to listen to Scripture. The niece said that she had always been that way.

Upon further reflection I know now that Lucille reminded me of my last living grandparent, Grandma Tourville, and how she had loved God’s Word too. She died over a year ago at the age of 92. You see, it’s okay and even normal for chaplains to get attached to those we care for.

Kenny Rogers was singing about a different Lucille with different circumstances than my Lucille, but I echo his #1 hit as well: You Picked a Fine Time to Leave Me, Lucille.

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.

Recently, I facilitated a discussion of a contentious mental retardation (MR) issue for which there is no clear law in the particular state. Two clergy-ethicists, two MR program directors and six lawyers participated. The lawyers worked for MR agencies whose policies reflected both ends of the opinion spectrum.

The course of the discussion astounded the non-lawyers and delighted the lawyers who appreciated an opportunity to engage as concerned MR experts rather than advocates. The facilitation plan is outlined below with hope it can be adapted to other health care situations.

1. The lawyers and I met first to establish commonalities [differences were clear]. I asked each: “Why do you work in MR?”Each spoke of family members or friends affected by MR. Personal commitment embodied in professional dedication was their commonality.

2. They were asked to phrase contentious topics as questions. They then identified the common denominator of each as public guardians’use of coercion to implement their preferences for medication, residency, association with friends or relatives, and sexual expression of patient-wards.[1]

3. A second meeting was scheduled, to include members of the respective ethics advisory panels, and delve into the differences articulated.

4. I chose, “Does the Public Guardian’s Office have authority to use physical coercion, when other reasonable means have failed, to force a ward to comply with the guardian’s residential recommendations?”as the focus question.

5. The second meeting opened with my summarizing the commonalities and concerns and outlining the process to follow. No one knew in advance the focus question or process:
•I asked the Public Advocate (PA) and Public Guardian (PG) each to take five minutes to articulate the other’s view on the focus question.
•I summarized what I’d heard and invited the actual PA and PG to correct or add to my interpretation but make no commentary. (There were very few additions and both were impressed and heartened by the precision of the other’s presentation.[2])
•The agency attorneys were invited to offer any perspective particular to their agency if not already articulated. The purpose was to get all views on the table without advocacy or comment.
•I then listed what I heard as points for discussion, asked for consensus and, after a few modifications, opened the discussion to everyone present.

What was scheduled as a two-hour meeting went three –they skipped lunch to have an extra hour because so many ideas were fermenting. A palpable sprit d’corps permeated the room. No “position”prevailed, but consensus was reached to cooperate to clarify the law by bringing a test case. The loosing side would appeal –forcing the state supreme court to rectify the ambiguity. Additionally, everyone pledged to combine resources to lobby the legislature to change the evidentiary standard of proof in competency and guardianship cases.[3]

Establishing personal connectedness, being challenged to articulate “the other”perspective and structuring discussion free of positional posturing and advocacy often permits creative responses to the commonalities imbedded in our differences.

[[1] The common law concept of parens patriae grounds the view of those accepting physical coercion when other reasonable measures have failed. Those opposing it in any instance cite First Amendment rights and Supreme Court cases implying a penumbra of privacy regarding where and with whom one chooses to live. Each legal foundation is legitimate. The former emphasizes patient and community safety; the latter, patient autonomy.

[2] In couple’s therapy, a common technique is for each person to state his or her view and then have the other person summarize what they’ve heard. In facilitating professional differences, I find it more useful to have each party articulate what they would say if in the other’s position and then I play back the comments. This format forces each to move out of his or her own advocacy stance and into the others’. My summarizing what’s been said permits the critique to be directed at me rather than the “other person.”I re-shape whatever is said into positive statements to maximize cooperative dialogue.

[3] Like many states, the one here uses the lowest standard, “preponderance”rather than the higher “clear and convincing”which everyone agreed would strengthen patient opportunity to maintain appropriate autonomy.

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.

The chaplain, after hearing the teen's stories, went to the staff and informed them that the "facts" were not making sense and that there might be more to it. One of the doctors and the chaplain went and talked with the two teenagers explaining to them that without accurate information, their friend could not be treated in the best manner. The doctor told them that there was a possibility that their friend might die unless they found out what really happened so that he could be treated for the underlying cause of his unconsciousness. The teenagers started crying. The chaplain assured them that it was best to tell the doctor exactly what happened so that their friend could be treated appropriately. The two teens then told the doctor and chaplain what really happened, including the patient getting into a fight with another friend who punched him. He fell and hit his head on a concrete pavement. They confirmed that he (and they) had been drinking at one of the teens' houses, and what it was they had been drinking. A cat scan revealed swelling in the brain and a traumatic brain injury. The teenager subsequently died, having never regained consciousness.

The chaplain did not reveal to the police what the teenagers had told the doctors, assuming that they would find out the truth when the teenagers stories did not mesh. The police did eventually get the "real" story; the teenager who punched the patient was eventually arrested for assault and when the patient died, was charged with murder. The owners of the house where the teenagers had been drinking were also arrested for allowing access to alcohol to minors.

A group of teenagers appear at the ED with a friend who is unconscious. The police, having been called by the ED, arrive shortly thereafter. Over the course of the next several hours, each teen is interviewed by the police as they try to figure out what happened. The unconscious 17-year-old has alcohol in his blood, indicating that he had been drinking. The ED staff are having a difficult time stabilizing and rousing the teen. He appears to have a head injury as well as a high content of alcohol in his blood. The chaplain has been called to the ED to help with the family of the injured teenager. At one point, the chaplain sits with two of the teenagers who have yet to be interviewed by the police. They begin to tell the chaplain about “what happened.”The story they tell is somewhat unbelievable –and the “facts”change as they tell their story.

If the staff believes that the truth of what happened to this injured teen might save his life, what is the chaplain’s role with the other teens?

What if the two teens have knowledge that could benefit the injured teen but don’t want to reveal it? They are keeping information from medical staff because it might cause a problem for them. Who is the chaplain protecting?

What is the chaplain’s obligation to these two teenagers? Should the chaplain let the teens know that telling the truth would be in their best interests or just listen to them?

What is the chaplain’s responsibility vis-à-vis telling the police about his/her "suspicion”that the teens are not telling the truth?

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

“One of the most startling developments of the late twentieth century has been the emergence in every major religious tradition of a militant piety,”Karen Armstrong says in her introduction to this 6-hour audio series.

In The Battle for God, Armstrong, a theologian and former nun and author of the best-selling A History of God, describes in a vivid and empathetic way the conditions that give rise to fundamentalism. She also takes an in-depth look at how fundamentalism in Christianity, Judaism and Islam conforms to the same basic pattern of “embattled religiosity against western secular modernity,”an excellent reminder to US chaplains ministering to a pluralistic culture.

Armstrong focuses on Protestant fundamentalism in the United States, Jewish fundamentalism in Israel, and Muslim fundamentalism in both Egypt and Iran, so that she can delineate the major differences between the Sunni and Shiite divisions in Islam. Armstrong also notes the existence of fundamentalist factions in Buddhism and Hinduism, among others.

An illustration of fundamentalism as this “dread of modernity brought on by a …religious fear of annihilation,”comes to life in Armstrong’s description of the fundamentalism that arose as the result of the exile of Jews and Moors from Spain in 1492. This series is particularly interesting because the author speaks not only to the spiritual factors but also to the geographical, culture and economic factors attributable to the rise of fundamentalism over the centuries.

She contends that “fundamentalist movements are complex, innovative and modern rather than throwbacks to the past,”and calls on all individuals to defuse an escalating conflict in this world by trying to “understand the pain and perception of the other side.”

Completed: 2000
Running Time: 6 Hours / 5-CD set
Publisher: HarperAudio, Harper Collins Publishers

If you are interested in purchasing this 5-CD set, you can do so at www.hartleyfoundation.org. Just click on “Masterworks”on the homepage for more information. The cost of the film series is $29.95 for a 5-CD set.

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.

Professional chaplains working in health care organizations need a strong working knowledge of several branches of ethics: clinical ethics at the bedside; organizational ethics within an institution or network; social ethics reflecting the organization’s relationship to its community; and professional ethics describing the duties of chaplains as professional caregivers. Chaplains who serve on ethics committees or IRB's have a further obligation to explore the issues these entities are responsible for, addressing on behalf of individual patients and the system in general, and to understand the relevant guidelines, laws, regulations, and other rules that may apply to specific situations, such research on human subjects or the termination of life-sustaining treatment.

One in five hospitals in the United States are “Catholic,”in that they are sponsored by Roman Catholic religious orders or are part of networks affiliated with Catholic institutions. In these hospitals, ethical decision making –whether at the bedside; in determining organizational, social, and professional priorities; or with respect to the language and tools used –is typically conducted with some reference to the Catholic moral theological tradition, and to guidelines such as the “Ethical and Religious Directives for Catholic Health Care Services,”published by the National Conference of Catholic Bishops.

Chaplains who work in hospitals that are part of Catholic health care systems may or may not be Catholic themselves, and, even if Catholic, may not be familiar with their own tradition’s scholarship on health care ethics. Ashley and O’Rourke’s Ethics of Health Care may be useful to chaplains working in Catholic hospitals who want a basic, “textbook”understanding of Catholic teachings relevant to the care of the sick and the ethical dilemmas that arise in this context.

This is not the book for the reader seeking a critical perspective on these teachings, and there is an unfortunate tendency on the part of the authors to use straw-man arguments against “secular”groups or positions, and to make assertions without citing sources. (Some assertions, such as the claim that condoms should be considered “questionable”as a method of contraception “because they are often found ineffective,”with no data cited, are especially troubling in terms of the responsible handling of scientific data in a textbook.)

With these caveats in mind, the professional chaplain who wishes to grasp the basics of Catholic health care ethics, and, in particular, the theological reference points for clinical ethicists and ethics committees in Catholic hospitals, may find this book a helpful primer. The authors’attention to the profession of chaplaincy and the spiritual care of Catholic (and non-Catholic) patients is engrossing: this brief section at the beginning of the book’s last chapter would be an excellent discussion piece for a pastoral care department, CPE program, or ethics committee in a Catholic hospital.

Ashley, Benedict M., O.P., and Kevin D. O’Rourke, O.P., Ethics of Health Care: An Introductory Textbook, 3rd Edition (Georgetown, 2002), pp 260.

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