4/5/2006 Vol. 3, No. 5

Professional Practice

Megory Anderson on being present with the dying

Sacred Dying

Susan was right in the middle of her CPE training when she got the word that her mother was dying. “I thought I would be ready for this,”she told me, “but even being here at the hospital all summer long, I’m not sure I can do this. I don’t feel ready. I don’t know what to do.”

My work in Sacred Dying has been to help guide people through the dying process. As a culture, we often marginalize the dying, leaving them to fend for themselves. Our healthcare practitioners provide medical care, of course, but spiritual care for the dying is an art we have somehow forgotten.

Our dying remind us of this in their call for a “good death,”and our spiritual caregivers challenge us, too.

As I travel across the country, one of the common cries I hear from clergy and chaplains is: “I wasn’t taught how to do this! Give me some tools!”

More and more, our seminaries are recognizing the fact that we have a large generation of people who are elderly and dying, and our boomers are also aging. It is time to focus on the spiritual care of the dying.

There are tools out there, with people and organizations who address this need with dedication and wisdom. Hospice. God bless Hospice workers and volunteers. There are good books out there illustrating practices of numerous faith traditions. I remember one very sincere woman who tried reading her dying mother portions from The Tibetan Book of Living and Dying. That book is a classic, and filled with incredible wisdom and insight, but the poor Methodist mother from Kansas City couldn’t quite get her head around the Buddhist concept of phow and reincarnation. Perhaps we might look within our own traditions for the rites and prayers handed down throughout history.

What are three things we can do as we are called on to be with the dying, either in the role of chaplain or even as a friend or family member?

First of all, and more than anything else, know that the experience of dying is a sacred transition, and one of the most important experiences we will ever go through. Being a witness to that, and helping guide the person through that transition, is holy work.

1) Learn the art of sacred presence. More often than not, the dying want someone with them who can sit quietly and “hold”the space for them.
2) Create a sacred environment. Use music, candles, or items that have special meaning for the person dying.
3) Use ritual. Oftentimes, the clinical psycho-social model of engagement is not satisfactory. Nor does the brief visit with a perfunctory prayer meet the genuine needs of someone imminently facing the reality of death. Rituals have the potential for transcending words and emotions.

As we learn to honor the dying, to recognize their spiritual and emotional needs, we ourselves participate in something greater. Being present with the dying has changed my life, and I hope that each of you will gain extraordinary measure in your own ministries as you face death and those who are dying.

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

Advocacy

Rev. Priscilla L. Denham on visual pastoral care

Different Perspectives on the Same Conversation

Perhaps our spoken words are never received as clearly as we hope they will be. So many layers of culture, history, emotions, stereotypes, etc. are between any speaker and listener in any conversation. Twenty years ago, Maxine Glaz wrote an article citing an interaction with me. Though she used no identifying information, she kindly showed me the draft to be sure I would not feel offended or exposed by the way she presented me. I was startled to see how two persons could have markedly different perspectives on a conversation. I was not offended. I didn’t even recognize myself.

On reading the February 15, 2006 issue of PlainViews (“Do Clothes Make the Chaplain," Sandra Katz), I had a similar experience. Had my name not been used, I would not have recognized myself as the speaker. Though I’ve had numerous discussions about the implications of garb for women and men chaplains, I don’t remember this specific conversation. The tone of the attributions and the idea conveyed that I think one should wear a collar or kippah “to establish and assert authority”leaves me feeling misrepresented.

Only twice (totaling five years) out of 25 years of chaplaincy did I wear a clerical collar daily. The first time was when I was also the Shock/Trauma ICU chaplain at Hermann Hospital (Houston). People came here after being scraped up off the highway or taped together after a construction accident/ shooting/knifing. No one ever planned to be there. Families were invariably disoriented in the first days they visited. Patients were unconscious or (when momentarily awake) in tremendous pain and drugged. So I wore a collar so they—without having to read a name tag, hear through bandages, sort through religious/hospital terminology, or struggle with a drugged memory—could know what my role was when I approached them. My two male colleagues, a Methodist minister and a Catholic priest with different clinical assignments, did not wear collars.

My second stint of clerical collar wearing was in Philadelphia as the University Chaplain at Hahnemann. One day I wore a collar for a memorial service. A Catholic head nurse, a Jewish administrator, and a Pentecostal security guard all expressed happiness at seeing my collar as “a sign of religion”in the halls. Because of huge ethical issues emanating from a business consolidation of hospitals, I realized any religious symbolism was seen as a small ray of hope and right ethics. Thereafter, I wore a collar every day. It was regularly affirmed by students and employees, including our Wicca EMTs and our Buddhist and Muslim students.

The principle meaning is not, for me, authority, but identity. The meaning of religious symbol –kippah or clerical collar –is identity, hopefully, not for the wearer, but for observers who may be trying to cross a language/drug/memory barrier that a recognizable religious symbol can help them transcend. The power is not political, but spiritual. Regardless of whether a patient/family likes religion or accords any authority to it, the identification allows the conversation to begin with the patient knowing what role (out of the multiple possible roles) the person walking into the room is claiming.

I was given advice (repeatedly) on how to dress “with Authority”: wear tailored clothing. As one with only two suits and a wardrobe mostly floral or funky, I chose to earn my authority through competence, not garb. My choice to wear a collar was based on pastoral considerations.

I was uncomfortable with the “you need to…”language being attributed to me. Perhaps pressures at Hahnemann brought this out, perhaps I was attempting to say something specific to her, maybe it was just bad supervision (surely situational), but - whatever I said - that is the way she heard me. I comfort myself that she spelled my name right, she remembered we discussed an issue important to her eight years later, and (apparently) the supervision led her (whether through guidance or oppositional struggle) to her own thinking and determination of action…I hold on to the thought, “If you can’t be a good example, you can at least be a horrible lesson.”

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

Education & Research

The Rev. Dan Dixson on the problem with heightened expectations

Moral Distress in Clinical Staff

A Pediatric ICU nurse comes to the chaplain to talk about a three-year-old boy on a ventilator. He has little hope for survival. The nurse states that she and others are feeling badly about the painful procedures to which they must subject this boy. They do not believe they can “torture”him any longer and often go home in tears.

An ICU nurse comes to the chaplain stating that the family of an 82-year-old man cannot bring themselves to offer him comfort care or even a DNR. The treatment that the patient receives causes him incredible pain. The nurse does not feel that she can morally care for this patient any longer due to the painful but futile nature of the care being provided. She states that it goes against everything she believes.

These cases demonstrate the kinds of issues that can lead to significant moral distress in clinical staff who provide care for seriously ill patients. Moral distress generally is seen in situations where a person must go against one’s own principled beliefs because of imposed constraints. In the setting of nursing care, those constraints often come from a physician, a patient’s family, or the hospital administration. When one knows the right course of action but is required to follow a different course in the care of a patient, or when patient care is endangered by staffing situations, moral distress may sometimes result and can become professionally and emotionally debilitating.

Symptoms of moral distress may include fatigue, fear, frustration, depression, withdrawal, blaming, feelings of victimization, as well as a sense of loss of personal and professional integrity. It is one of the reasons given for nurses leaving critical care nursing or nursing altogether.

With the increasing improvement of life-sustaining procedures comes a sense of heightened expectations on the part of patients and family for good clinical outcomes to nearly every serious illness. Add to that the nursing shortages and organizational changes to increase efficiency in the hospitals and you have a recipe for moral distress.

The hospital chaplain, who serves both patients and staff, is in a unique position to assist in the identification and prevention of moral distress. There are a number of things that might be done by chaplains to address this issue, including:

- Encourage and take part in frequent patient care conferences that bring together an interdisciplinary team to discuss a patient’s situation and treatment plan.
- Build rapport with nurses and give them a safe place to talk about such issues.
- Be available to verify that patients and families are hearing the entire message that the medical team is giving to them about conditions and options.
- Be an active proponent of the Medical Ethics Committee process.
- Make sure that critical care nurse managers and directors are aware of the Position Statement on Moral Distress created by the American Association of Critical Care Nurses (www.aacn.org).

The role of chaplain places us at the forefront of these issues. We cannot change the fact that there will always be hard cases involving hard decisions. Through education and advocacy, however, we can help create an environment where such cases do not have to destroy the integrity or career of some of our finest nurses.

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

Spiritual Development

Chaplain Darren C. Tourville on cleansing the soul

Experiencing Lent as a Time for Growth

As children, many of us dreamed about what we would want to be as adults. Fireman, teacher, nurse, professional baseball player, etc…For some of us the vision changed often, but for others the dream remained. I don’t know about you personally, but every time I see a St. Louis Cardinal baseball game I envision the crowd cheering for me instead of Mr. Pujols (some dreams die slowly). This leads me to vocational choice #2—Trashman. I’ve always been fascinated with trash and its removal. I guess that is the obsessive compulsive side of me.

Where I grew up as a child we had a trash service that came by the house once a week and carried our filth away. I always took it as an honor to get the trash and put it out by the street and would hurry off the school bus to get the can and put it back in the garage. There was a certain sense of accomplishment in knowing our house was clean. (And yes, even today if you ask my wife I still have some of those obsessive qualities when it comes to trash and its removal).

Why would I use this reflection to talk about trash you ask? Simply put, we all have trash that affects us and we can’t get rid of it on our own. Like the people in Max Lucado’s The Next Door Savior, we all carry our bags of trash around daily burdened with the weight. Sure we ask God to take it from us, but often in our humanity we take it right back. We need a “Divine Trashman”who will take our filth to the dump for burial. Once it’s taken and dealt with it is remembered no more.

This Lenten season at its best is a time for introspection and change. May we as professional caregivers not forget our need for this type of cleansing. May we hear God say of our trash, “May I have it? And may you never feel it again.”

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.

End-of-Life Discernment: Personal, not Political

On the first anniversary of Terri Schiavo’s death, Boston Globe columnist Ellen Goodman[1] noted that people feel today pretty much the same about end of life issues as they did a year ago.[2] There is not a red state-blue state divide. Republican and Democratic law-makers have not kept Schiavo’s tragedy alive to cultivate votes.[3]

When confronting decisions about death and dying, most people want to rely on personal faith and ethics rather than public policy or laws. They want to be companioned by spiritual care providers not lawyers and legislators.

That being said, spiritual care providers need to be vigilant that government does not intrude on the privacy of prayerful and personal decision-making. Neither political expediency nor the provider’s own beliefs should exploit a patient’s, or designated surrogate’s, when appropriate, considered choices for end-of-life options.

Beneficent spiritual care requires a patient’s wishes be explored, articulated, and honored. The codes of ethics of the professional chaplaincy organizations emphasize the chaplain’s role in supporting patient autonomy in decision-making.

Political interference from Florida’s governor, legislature, the U.S. Congress, and President in Terri Schiavo’s case illustrates why privacy for patient and surrogate decision making cannot be taken for granted. Zealous religious leaders and opportunistic politicians can maneuver unwarranted governmental interference, especially when families are vulnerable to the attention.

Unlike the Schiavo situation, the federal government seldom if ever intervenes in matters of family law or medical decisions legitimate under relevant state statutes. Federal jurisprudence traditionally recognizes such areas properly governed by laws responsive to the opinions and needs of each state’s voters.

In recent years, attempts have increased to assert federal influence. In 2001 then Attorney General John Ashcroft sought to use the Controlled Substance Act (CSA) to thwart Oregon’s citizen approved Death With Dignity Act (ODWDA). He issued an Interpretative Rule [addressing the CSA] to de register pharmacists and physicians who dispensed or prescribed controlled substances to assist suicide under the terms of ODWDA. The Ninth Circuit invalidated the Rule.

On appeal, the Supreme Court held in a 6-3 decision January 2006: “The CSA does not allow the Attorney General to prohibit doctors from prescribing regulated drugs for use in physician-assisted suicide under state law permitting the procedure.”[4] Writing for the majority, Justice Kennedy quoted an earlier decision acknowledging, “Americans are engaged in an earnest and profound debate about the morality, legality, and practicality of physician-assisted suicide.”[5] He continued, “The dispute before us is in part a product of this political and moral debate, but its resolution requires an inquiry familiar to the courts: interpreting a federal statute to determine whether Executive action is authorized by, or otherwise consistent with, the enactment.”[6]

Chef Justice Roberts, Justices Scalia, and Thomas dissented, arguing “if the term “legitimate medical purpose”has any meaning, it surely excludes the prescription of drugs to produce death.”They seemed more concerned with achieving a particular substantive result (prohibiting physician-assisted suicide) than upholding the “usual constitutional balance between the States and the Federal Government.”[7]

The question becomes, will end of life medical options be characterized by uniform Federal laws, a mosaic of particularized state statutes, or respect for personal privacy to discern one’s own ethical choices?

I welcome any comments you might want to submit in response to these articles.

[1] “End-of-life issues being settled quietly,”Ellen Goodman, Portland Press Herald, editorial page, March 31, 2006.
[2] Id. Goodman reports that 63 percent a year ago thought Schiavo’s feeding tube should be removed and the number remains the same today. A Field Poll released March 15 showed “70% of adults in California believe terminally ill patients have the right to ask for and receive life-ending medication,”according to an article by Tom Chorneua at SFGate.com. The Field Poll has measured Californians attitudes toward euthanasia eight times since 1979 at which time 64% favored it. The 2006 Poll showed 65% of Protestants and 64% of Catholics support euthanasia but 76% self-identified born-again Christians oppose legalizing the option.
[3] Id. Goodman reports that “49 bills have been filed in 23 state legislatures seeking law that would leave any patient without a living will…on life support.”She observes that all “have stalled or been watered down.”
[4] Gonzales, Attorney General, et al. v. Oregon et.al, __U.S. __ (2006) (No. 04-623, January 17, 2006). The majority said CSA’s purpose is limited to preventing conventional drug abuse and excludes the Attorney General from medical policy decisions.
[5] Washington v. Glucksberg, 521 U.S. 702,735 (1997).
[6] Gonzales, p. 1.
[7] Oregon v. Ashcroft, 368 F. 3d 1118 (2004) cited in Gonzales. The Ninth Circuit noted that “by making a medical procedure authorized under Oregon law a federal offense, the Interpretive Rule altered the usual constitutional balance…”

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 #6 Resolution

The Chaplain submitted this because of his awareness that he had no knowledge of the concept of or illustrations of examples of forgiveness within Islamic literature and theology. He was relying upon Christian stories. Beyond that, there was the psychiatric issue of narcissistic personality and the notion that the patient was choosing to be the arbiter of his own destiny...that is that he could determine who God would forgive and not forgive.

Like many encounters with our patients, we will never know how this turned out since the patient was discharged to his family and flown back to his country the next day.

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

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

Reviews

Sarah Masters reviews two audio CDs

Blessed and Raise Your Voice!

Any Chaplain seeking inspiration might want to tune into two very uplifting gospel CDs, each having a unique way of uncovering spiritual truth: Blessed, performed by the Soweto Gospel Choir and Raise Your Voice by Sweet Honey in the Rock.

Southern African gospel music incorporates vocals with background drums and Blessed reflects that tradition along with the Western church styles of music absorbed by the African culture. Members of diverse backgrounds form the Soweto Gospel Choir, and the listener will hear uplifting music sung in Zhosa, Zulu, Sotho and English. The choir won the prestigious Australian Performing Arts Award in 2003 and has supported music legends from Bono to the Eurythmics.

Raise Your Voice! is a compilation of two live concerts performed by Sweet Honey in the Rock, a Grammy Award-winning African-American female a cappella ensemble. The six women who form the group perform moving renditions steeped in the sacred music of the black church. From “In the Morning When I Rise”to “Old Ship of Zion,”Raise Your Voice! captures the magic that flows between Sweet Honey and the Rock and the audience and the tremendous on-stage presence and energy of this group.

Blessed
Completed: 2005
Running Time: 50 Minutes
Shanachie Entertainment Corp.

Raise Your Voice!
Completed: 2005
Running Time: 70 Minutes
EarthBeat! Records

If you are interested in purchasing this film, you can do so at www.hartleyfoundation.org. Just click on “Sacred Sounds”on the homepage for more information. The cost for Blessed is $19.98 /CD and the cost for Raise Your Voice! is $16.98/CD.

Book Review

Nancy Berlinger, PhD, reviews

Theological Bioethics: Participation, Justice, Change

Theology is a troublesome word for chaplains. Like denominational clergy, chaplains are products of theological training and ministerial formation, but unlike these clergy, chaplains must “forget”their denominationalism if they are to succeed in multifaith ministry to patients, families, and staff in health care organizations. Chaplains must be prepared to respond to tough theological questions, while being mindful that their own theological language and symbols are not universal and may not translate well. They may try to steer clear of “theology”altogether, particularly if they work in institutions where the role of chaplaincy is not well defined, or is reduced to “meeting religious needs.”

Lisa Cahill, one of the nation’s most distinguished Catholic theologians, reminds us that theology is “a process of reflection on religious experience,”and that religious experience has much more to do with stories, symbols, and rituals than with abstract principles. In Theological Bioethics, she focuses on how religious experience –the real beliefs and real practices of real people –intersects with the decisions we make about health care, and the systems we create to deliver, improve, or deny health care within communities and across societies. Chaplains work inside these systems, and Cahill’s book will be of special interest to those in Catholic health care systems, or who are affiliated with the Catholic Health Association (CHA), the Community of Sant’Egidio, and other organizations whose work in health care is informed by Catholic teachings on social justice. Her clear discussions of traditional and influential Catholic tools for moral reasoning, such as the principle of double effect, and how these tools may be most authentically and productively applied to contemporary problems in health care, will be of interest to any chaplain involved in the teaching or practice of clinical ethics.

Her takeaway message applies to all chaplains (and to all religious ethicists working in health care, for that matter). As we have cast our professional lot with the organized delivery of health care, we have a moral obligation to work –really work –to improve care and access to care, globally as well as locally. For Cahill, there is no divide between activists and the rest of us. As her book’s subtitle suggests, theological bioethics means participating in the lives of the sick by acknowledging and attending to their spiritual needs, but it also means seeking justice, by working from our own faith commitments to change the conditions that perpetuate suffering.

Lisa Sowle Cahill, Theological Bioethics: Participation, Justice, Change (Georgetown University Press, 2005); 310 pp.

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