PlainViews

Rev. Priscilla H. Howick on an effective multidisciplinary forum

The Schwartz Center Rounds

Compassion fatigue, secondary post traumatic stress, moral distress, soul sadness, and empathic strain are all terms used to describe the soul weariness that can accompany working with people in crisis. How do healthcare providers deal with the continued stress and strain of caring for patients in our current complex medical environment? At Mayo Clinic Jacksonville, we have discovered a wonderful program that does just that –provides care for the clinical staffs who are on the front line of patient care. The Schwartz Center Rounds are a multidisciplinary forum where clinical caregivers can discuss their experiences, thoughts and feelings around specific healthcare topics. The intent is that caregivers will be better equipped to provide compassionate care for patients and better able to maintain their own sense of well-being by gaining insight into themselves, co-workers, and difficult situations.

The Kenneth B. Schwartz Center, whose mission is dedicated to promote compassionate care and strengthen the relationship between patients and caregivers, began the rounds at Massachusetts General Hospital in Boston in 1997. Currently the rounds are offered in more than 100 sites. The rounds begin with a brief case presentation by 2-3 clinicians from different disciplines. The remainder of the hour is used for staff to discuss their own experiences related to the topic. A facilitator helps ensure the process stays on track. In addition, we are able to provide a healthy lunch (thanks to the support of The Schwartz Center) and continuing education credits.

The Schwartz Center Rounds came to Mayo Jacksonville through our Palliative Care Consultative Service in partnership with Chaplain Services. We have had nine rounds to date with 40 to 50 staff attending. We have discussed topics such as, “The Difficult Patient –The Difficult Family”; “Finding Closure When a Patient Dies”; “Putting Compassion to the Test: Chronic Patients and their Complex Issues"; and "Religion and Culture: When World Views Collide." The response from staff has been overwhelmingly positive. One staff said, “It’s very helpful to hear co-workers questions and feelings about the problem raised. I always learn a great deal from these discussions.”

One of the benefits of the rounds is improved communication among patients and caregivers. Improved communication can lead to an increase in patient satisfaction, a decrease in medical errors, and fewer medical malpractice suits. The rounds have also improved communication among team members, helping staff to remember the human dimensions of healthcare.

The Schwartz Center Rounds are an effective multidisciplinary forum that gives caregivers knowledge and understanding about the non-clinical aspects of patient care and explores the human dimension of healthcare that is so easily lost in our high-tech clinical settings. Most importantly, the staff feels supported and less isolated in dealing with difficult situations.

Further information about The Schwartz Center Rounds can be found at www.theschwartzcenter.org.

Since September 1990, Rev. Priscilla H. Howick has served as the chaplain coordinator for Mayo Clinic Jacksonville. Priscilla has a masters of divinity in Pastoral Care and Counseling from The Southern Baptist Theological Seminary and a bachelors of Business Administration from the University of Florida. She is board certified by The Association of Professional Chaplains and endorsed by The Cooperative Baptist Fellowship.

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I pray

with patients, their families

and other Carers,

all of us broken and dying

caring

for the broken

the dying

each other

praying

for strength

for grace

and altogether

we hear

not just words
but the Word.

Encouraging a caring environment within which persons are enveloped freshly in the deepest of coping and healing energies no matter “what’s going down”–this is what we are all about. Out of what begins as common sense “do unto others,”can emerge a new trustfulness, a new sense of belonging, a new hope in one’s Higher Power. It is this simple and it is this important.

And so, we work directly with patients, residents and families. One patient, conveying that he was still very angry said, "Strange. I feel more alive now than ever. Nothing's changed - disease will worsen. Yet everything has changed. If I hadn't let myself open up.......(and with a look up, he continued) I'm still very mad at things but, hey, thanks to BOTH of YOU!" Went by his room later and he was sound asleep –first time in days.

We work effectively as part of a committed and supportive care team. So we support staff. One day someone said, “When you’re around, ‘Chap,’I just feel different.”Someone else said, “Thanks for that. I’d forgotten what we are all about.”

We mentor in the deep dimensions of healing –the work of all of us. In a Care Planning Conference, a person said, “Your questions help us to see ‘a person’and her deeper suffering behind the disease.”

Because all pastoral caring is rooted in a “contagious care climate,”we seek to be its facilitators. A visitor to Chapel Worship told me, “A good wind blows through this place.”

On an anniversary of his death in our AIDS Unit, Mr. A's widow hosted a gathering in the hospital of his many friends. "Why here?" I asked. "Because," she said "this is where he felt supported and loved. You were family to him."

What are our pastoral care tools? Ourselves, our own journey, companionship, pastoral conversations with patients, family, and staff, prayer, worship, healing touch, and spiritual assessment.

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As a pastoral educator with a commitment to strengthen and nurture multiethnic-multicultural communities, I often find myself remembering Dr. King’s timeless “I have a dream speech.”He said, “I still have a dream this morning: one day all of God’s black children will be respected like the white children. I still have a dream this morning: that one day the lion and the lamb will lie down together, and every man will sit under his own vine and fig tree and none shall be afraid. I still have a dream this morning: that all men everywhere will recognize that out of one blood God made all men to dwell upon the face of the earth.”King’s dream definitely addresses the dream of immigrants who are becoming Americans.

The demographics of the United States are constantly changing, with immigrants on the increase. These changes challenge us to a new level of learning and challenge us to become persons and neighbors who truly value inclusion, respect, and social justice. As culture is an elastic and dynamic concept, therefore, a life that is well-lived today cannot be static, but requires continual learning, re-learning and un-learning of race, culture, language and diversity.

We need to learn from our neighbors from diverse backgrounds and take every opportunity to expand our cultural experiences, which can only lead to the development of our compassion in becoming good and helpful neighbors. Cultural diversity is taking on a broader meaning –to see and evaluate situations from a global perspective. This includes socio-cultural experiences of people of different countries, languages (and accent), genders, social classes, religious and spiritual beliefs, sexual orientations, ages, physical and mental abilities and more.

In encountering our neighbors who are culturally dissimilar, or when we are staying in an unfamiliar culture, our identities undergo turmoil and transformation that involves a sense of emotional vulnerability. Emotional vulnerability is part of an inevitable identity change process. With mindful vulnerability, we can listen with greater thoughtfulness and see things through fresh lenses. We discover courage and curiosity to ask ourselves questions, “Who am I and who are you in this neighborhood?”“How do I define myself as a good neighbor to you?”; “How do I define you as a good neighbor to me?”

King’s dream is a dream that passionately calls us to accountability in establishing a community of neighbors that live with each other with respect and equality yet without being afraid because of shared humanity and dignity.

King’s dream is challenged and illuminated in the novel House of Sand and Fog by Andre Dubus III. Dubus highlights the compelling truth of how tragedies happen when people fail to become good neighbors.

bell hooks, author of All About Love, teaches us to nurture our neighbors on the foundation of loving-kindness. To express her conviction, paradoxically, hooks writes provocative social and cultural criticism that stretches our minds and to think beyond set paradigms. Like King, hooks claims that loving our neighbors means loving with the intention to end domination, to promote peace and justice and therefore become a true neighborhood with hope.

May the life, dream and vision of Dr. King be remembered, echoed and embraced so our hope of a true neighborhood will be renewed one more time!

I want to dedicate this piece of reflection to my son Ariel-Joseph. His passion for cultures and justice for peoples compelled him to leave the United States for Japan to study “Cultural Comparatives.”A portion of his application essay to Sophia University, Tokyo, inspires me greatly: “A translator/interpreter of cultures and languages is not limited to the local community, but its impacts reach a global scale...If there were ever a role essential to quelling all strife and wars, it would be the translator (of cultures and languages), no less. People underestimate the power of words. A single utterance can change a thousand lives. Language is not just a skill, it is an art. It is also my dream, which is my burden and my blessing.”

National Association of Social Workers: NASW Cultural Competence in Social Work Practice, 2005.

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It is easy for me to be the rabbi, spiritual leader of my congregation during the “good times.”Celebrating an upcoming marriage, a wedding, a birth or bar/bat mitzvah, etc., doesn’t require any great amount of training. Nor do these life cycle events present any real challenge to me personally. What does present a real challenge is walking with a family in crisis. Whether it is a medical challenge such as cancer or a spiritual crisis resulting from a multitude of curves that life has thrown in our way, the lessons and experience learned from CPE have always guided me and helped me to be a more effective rabbi.

I am not frightened to walk into a hospital room without knowing what my congregant will ask of me. In truth, it is liberating to know that I don’t have to speak for G-d. “Why is G-d doing this to me?”doesn’t necessitate my pondering some grand universal plan and trying to explain it to a person suffering. Formulating a pastoral care plan doesn’t require any prophetic skills. It does require that I remain “in the room”and at times be able to sit in silence and allow my congregants to say what is true for them, even if it means questioning G-d’s will or very existence. It isn’t necessary for me to have the answers to their questions. Just being there for them is often more than sufficient.

I have grown as a result of CPE and my work as a chaplain. I no longer get upset over “minor things.”After spending time with a hospice patient, a traffic jam meant that I got to listen a little longer to the CD in my car stereo. Rather than getting frustrated, I figured it was G-d’s way of giving me time to decompress!

Most importantly, CPE has taught me to remember who the patient is. I can “walk with them in their suffering,”knowing that it is their suffering and not mine. I leave their room a little richer for the time that I’ve been with them, grateful to G-d for the blessings in my own life!

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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.

A 49-year-old man collapses on a basketball court, where he is playing with his friends. EMS arrives and is able to restart his heart. He is transported to the ED. Once there, his heart again stops and he is revived again. His wife arrives and is able to be with him for a few minutes before his heart stops again. They are unable to revive him the third time.

The chaplain is called when the patient is brought in and meets the wife when she arrives. The chaplain stays with the wife and, when it becomes apparent that her husband cannot be revived, walks her to the family room so that she can sit in private and begin to consider the consequences of her husband's death.

After several minutes, the wife turns to the chaplain and says the following: "My two children are both in college several hours from here. They need to come home but I am afraid to tell them that their father died because they will not be able to drive here safely. What should I tell them?"

Continue the conversation further and reflect before making a call. I would validate her feelings and wisdom. It is hard to tell such news by phone. It is just as hard to tell it in person.

I generally think people deserve the truth. Maybe the children will use the drive time to begin their processing of this tragedy and have some of their tears in private.

Even knowing Dad is deceased they may want to hurry to be with their mother. She recognizes they may not drive responsibly. This is a reminder of how little control we have over others in the situation.

Disbelief and sorrow will roll in quickly. Consider calling the college and asking for a chaplain, counselor or friend to go and be with the student so they are not alone when they get the call. That person will be there for comfort, can help guide them in packing and focusing.

I would offer her a prayer before the call. I would pray about the needs of each of them. I would pray for peace, safety and comfort as God guides them, cries with them and receives the husband home again.

My sister-in-law was on the other side of the state at a convention when her husband was killed by a bull. She learned the news on the phone. Other women who went with her, drove her back. She had company, she had tears, she had disbelief. But she knew her husband was already dead and nothing could have changed by her being there. Her daughter (34) handled all decisions until her mother arrived five hours later.

I would begin by agreeing with the wife. Yes, she did need to have her children with her, and yes, she has every reason to be concerned about their safety as they drive back from college. However, I do not think that they would drive any more safely if they believe that their father is alive but in grave danger. In fact, they may be even more inclined to rush back recklessly. Better, I would counsel, that you tell them the truth, tell them of your need for their presence as well as your fear for their safety. then ask them to meet you at a time that would allow them to collect themselves and drive with more composure. I might suggest meeting 3 hours after the call at the mother's home for example. Other options might include encouraging the children to ride together, asking a friend or nearby relative to do the driving, or to take public transportation.

The desire to not tell the kids is very understandable and typical in the earliest moments of grief, and feeling anxiety about her children who are distant is also an appropriate reaction. Blending these responses however does nothing to improve the situation and in fact may heighten the situation's emotional volatility for everyone. As her chaplain, I would work to help her separate these two critical feelings and to address each one in a complimentary order.

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

Mere Christianity, read by Geoffrey Howard, is adapted from C.S. Lewis’s BBC radio chats, which were broadcast midway through World War II while he was a literary professor at Oxford.

Eventually, the BBC broadcast transcripts appeared in book form and became what many consider to be the most popular of Lewis’s nonfiction works. In this audio series, the man considered by many to be the most influential Christian writer of his day sets out to “explain and defend the belief that has been common to nearly all Christians at all times.”

Mere Christianity in particular is well-suited to an audio format because the text was originally written in conversational style for radio. The title Mere Christianity indicates the intention of Clive Staples Lewis (1898-1963), an Anglican, to describe common ground among Christians of different denominations and, at the beginning of the series, Lewis describes as well the common ground of all religions, instructive for chaplains ministering to individuals of different faiths.

C.S. Lewis’s major contributions to literary criticism, children’s literature, fantasy literature and popular theology include more than thirty books, among them The Chronicles of Narnia series, Out of the Silent Planet, The Four Loves, and The Screwtape Letters.

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

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.

Not only does this volume provide a thorough study of current Roman Catholic healthcare ethics, it does so in contrast to secular ethics, highlighting their similarities, differences and interrelationship. An easy read, Kelly’s text provides examples necessary to grasp the highly theoretical and nuanced layers of meaning-laden and overlapping principles used in ethics and ethical decision making. Readers will gain an overall grasp of ethical principles and their application to ethical decision making and the theological (and, by contrast, philosophical and secular) basis for both. It is a must read for anyone providing patient care. While intended to have special relevance for Catholic ethical issues, this work explicates ethics so thoroughly as to provide general relevance.

Ethics, Kelly points out, is both theoretical and applied. He has divided his work into three parts: 1) the theological and theoretical bases for ethics, 2) the various methods used to arrive at ethical decisions and 3) the application of ethics in real time to contemporary healthcare issues. All of these are famed in terms of Catholic moral teaching and secular practice. The three parts build on one another, but each chapter in each section can be taken as an independent resource. This relationship of the parts to the whole makes the book a great desktop resource for chaplains, social workers, physicians and ethicists serving in acute or long term healthcare, either as members of an ethics committee (there’s a whole chapter dealing with the role of ethics committees) or compassionate, well-informed healthcare decision facilitators.

Kelly’s mission is stated in the introduction as “…hoping that this book might serve as a textbook for students and a resource for practitioners.”Building on history and tradition, Kelly takes the reader –neophyte or veteran –on a journey from early teachings on Catholic moral theology through the Judeo-Christian traditions regarding care of the sick past philosophical theories regarding choice and morality right up into today’s healthcare with all of its ambiguities, contradictions and differences with and exceptions to the religious roots from which it sprung. In an effort to put ethics as principle and practice into context for every reader and practitioner, Mr. Kelly has done a masterful job of separating and subsequently reweaving the strands of history, theology, technology and practice that currently comprise the fabric of our healthcare environment.

The word Catholic in the title rightly predicts Mr. Kelly’s especial attention to those moral and religious issues unique to the Roman Catholic tradition. He gives careful explication to the foundation for and application to ethical practice with regard to stem cell research, in vitro fertilization, birth control, withholding and withdrawing life support, artificial nutrition and hydration and related subjects frequently debated and just as frequently misunderstood or misappropriated. Kelly’s application of foundational Catholic moral teachings to contemporary health care topics comes across as both ethically principled and hermeneutically sound.

Contemporary Catholic Health Care Ethics is successful as both textbook and resource, and will prove faithful to its users, whether as “pickup”guide, refresher course or first introduction to the subject of health care ethics in today’s medical arena. The title may well have read catholic with a small “c”–and maybe that’s what was intended.

Kelly, David F. Contemporary Catholic Health Care Ethics, Georgetown University Press (November 30, 2004) pp 336.

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