4/19/2006 Vol. 3, No. 6

Professional Practice

Dr. Diane Bridges on preparing pastorally for the inevitable

Spiritual Care at the Heart of Pandemic Planning

With the apparent inevitability of an Avian Flu Pandemic on the horizon and the catastrophic consequences that will ensue, it is imperative that chaplains and spiritual leaders consider in advance the critical role they have to play in a preparedness plan. At our health Care Centre we have extensive and thorough preparations in the works…everything from workforce planning, supply chain management, infection control to morgue capacity etc.

This pandemic, unlike SARS (which we recently experienced at crisis levels in Toronto) is not about containment; it is about capacity. Because a pandemic could last more than a year, healthcare employees and their families will be at personal risk when the pandemic is in their community. The physical, personal, social, emotional and spiritual challenges must be addressed in order for these first responders to maximize their personal resilience and professional performance.

During a pandemic situation, a percentage of employees will show signs of anxiety and distress, confusion about what to do and outright fear for their own safety and that of their loved ones. These folks will be more vulnerable to fear mongers. Considerable personal support will be required in order for staff to keep working.

With this reality will come the need for extensive and sometimes troubling ethical decision making ranging from allocation of scarce resources to personal decisions about showing up for work. All systems will be stressed to the limits.

I sit on our hospital-wide planning committee and am confident about the expertise and foresight of all involved. What concerns me is the high level of personal angst and fear that I experience from my colleagues who struggle with their own thoughts about these realities. Certainly, while we cannot always control what happens in life we are more able to control HOW we will choose to act in times of crisis. Viktor Frankl gave us wise counsel in writing that, "Everything can be taken from a man - but the last of the human freedoms - to choose one’s attitude in any given set of circumstances, to choose one’s own way.”

In light of this awareness, I am actively engaging our staff, the faith communities, funeral directors and other community support people to begin discussions about the spiritual and psychosocial issues and resources which will be needed to support a pandemic crisis. We are all involved in an anticipatory grief process and are being challenged to dig deeply to the roots of our faith which must address the eternal questions of life, death and the meanings of suffering. At no time will spiritual care be more critical to positive outcomes than at this time.

It is incumbent upon all of us to be apprised of the pandemic planning in our areas and to be proactive in planning our own preparedness approaches…call back lists, counseling support lines, prayer groups, chat rooms etc.

With the grace of the Holy One, let us lead the way fearlessly and lovingly in the ways of faith.

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

Advocacy

Rev. Connie Madden on interconnected ministries

A Moment of Glory

The interconnected ministries of local clergy and chaplains can be a bane or a blessing. While clergy get to share life with members through their many stages of celebration and tragedy, chaplains are posed perfectly for the best moments of ministry—deaths, births, life-changing decisions, relationship climaxes, etc., which are all forged in the stress of their unique institutions. Many chaplains utilize the skills of clergy to help in their ministries while clergy see chaplains as uniquely qualified to help them with more delicate situations.

In a perfect world, the ebb and flow of these ministries should complement each other. When a patient from a certain faith family enters the chaplain’s setting, the clergy should be contacted. When a minister needs advice about helping in a complex ethical situation, the chaplain should be called. When the chaplain and clergy are both present for a patient and family, no sense of competition or threat should be present. The problem is that many chaplains and clergy simply don’t cooperate, communicate or respect each other.

While my husband serves in the pastoral role, I have seen both ends of the spectrum, having been both pastor and chaplain. My husband complains of chaplains waiting until the final hours of life to contact him, if they call at all. Now furious at the pastor, the family turns to the hero or heroine on the white horse, the chaplain, who has been present for them since the beeper called them to give prompt support. He sees the chaplain as wanting that “moment of glory”in the funeral service or in the crisis while the clergy person is blocked out.

Yet, I have been the chaplain who has attempted to involve clergy at every step, through calls or otherwise, without response. If the minister is present, they are often threatened and uncomfortable with my presence, so my unique perspective is often ignored. While this tension isn’t the norm, the often strained relationship of chaplains and clergy warrants examination on both sides.

Recently, I was called to cover a termination of life support for a patient. The family was Greek Orthodox, and although the priest was on his way, the family still wanted my prayers for their situation. After a prayer, the priest arrived, someone that I had met at a local clergy association meeting. While preparing the elements for anointing, he asked how I was and how my family was doing, while sharing his grief over this loss of a beloved church member. Then, we both entered the room as I watched him perform the ritual. While waiting for her to die, I shared how singing can be meaningful and the family eagerly sang a hymn with me, and then offered another song from their tradition in Greek. The harmony of the moment, with both ministries flowing respectfully and compassionately, embodied how powerful this cooperation can be. May the future bring better understanding, foster trust and reciprocal respect between the ministries of chaplain and clergy, such as I experienced that night.

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

Education & Research

Carol McAninch-Pritz on a win-win CPE model

Moving into Bi-lingual and Bi-cultural CPE

Banner Good Samaritan Medical Center is a large inner-city hospital in Phoenix, Arizona. Our community has a large concentration of people for whom Spanish is their first and sometimes only language. Currently, the patient population at BGSMC is between thirty-five and forty percent Hispanic. In the Emergency Department, that percentage rises to fifty-five or sixty percent. It is a significant challenge to provide adequate spiritual care in the midst of crises when our chaplains and Clinical Pastoral Education students are primarily English speaking.

In 1997, during a self-study for accreditation with the Association for Clinical Pastoral Education, we discovered that our student population was five percent Hispanic but the patient population was about thirty percent Hispanic. After exploring the reasons for the discrepancy, we discovered that most Hispanics, especially those not born in the United States, were unaware that hospital chaplaincy was a potential career. In an attempt to raise the awareness about this ministry, we requested and received a grant from Banner Health to fund scholarships and stipends for six students to enter an extended unit of CPE. We recruited students by sponsoring an invitational dinner for Hispanic denominational leaders, interested pastors and lay people. Six students entered our inaugural bi-lingual CPE program in 2000.

Early in the development of the bi-lingual CPE program, we realized that the program would have to do more than just offer the opportunity to do CPE. In consultation with Hispanic leaders, we discovered the need to develop the group through relationship-building activities before students could feel comfortable offering critique to each other. The students planned several social events and regular pot-luck lunches as a way to build their sense of community. Students found learning easier when critique was depersonalized and when their struggles with ministry were normalized. They were able to develop pastoral skills when they realized that the group’s intention was to help them find better ways to provide ministry. Students could learn without feeling as if they had to compete with each other and could maintain their social unit. We also found that some of the teaching styles we learned from the Hispanic students improved supervision with non-Hispanic students.

After the initial pilot program, we secured a three-year grant from a community agency to continue the program and eventually were able to support the bi-lingual CPE program from the hospital budget. Bi-lingual CPE is now seven years old at BGSMC. To date, thirty-five students have taken at least one unit of bi-lingual CPE and five have entered residency after an initial unit in the bi-lingual program.

Our hospital recently hired our first Hispanic chaplain as a direct result of the bi-lingual program. We now have a worship service in Spanish every Sunday evening and offer services in Spanish for special religious holidays. Patients now have the opportunity to receive spiritual care in their primary language without having to go through an interpreter. Our staff has become more culturally sensitive; and our English-only staff is learning more Spanish and can assist our Spanish-speaking patients in a limited way. Bi-lingual CPE is a great win-win blessing.

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 Virgil Fry on stories that make us who we are

A Prayer of Bittersweet Moments

Our Lord God,
How conflicted life can be—
Full of blessings and curses,
Reasons to celebrate, reasons to lament.

In bittersweet moments,
we resonate with this phrase:
“A time for everything under the sun.”

Walk with us, companion Lord,
As we relish the naming of our blessings,
As we rehearse the unspeakable joys that come
with each good and pleasant thing.

Walk with us, companion Lord,
As we reluctantly name failures and losses,
As we rehearse the suppressed pains that come
with each unwelcome and hidden thing.

For it is in remembering and listing
the pleasant and the unpleasant,
The things we brag about
and the things we bury,
That we find You
still being faithful in your love for us.

It surprises us, Lord, that Scripture
commands us to remember, to re-tell
Stories of redemption and utter defeat
of celebration and lament
of unity and division
of divinity and evil
of births and deaths.

Lead us, Immortal One,
Pillar of Cloud and Fire,
As you led the Israelite children out of bondage.
Open our eyes to your holy, healing hands
in all of the stories,
Stories that make us who we are,
and who we are becoming
In your ever-unfolding kingdom of love.

And if the oppressed one cries out to me, I will hear, for I am compassionate. Exodus 22:27

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.

Response to End-of-Life Discernment: Personal, not Political

Government's and the law's primary obligation at all levels is to promote the common good, guaranteeing protection under law for every person, especially when it is vulnerable, such as at the earliest stages of life, at the end of life, when the person is handicapped, or otherwise disadvantaged. This protection was denied Terri Schiavo. Judge Greer's final order reads that the feeding tube (basic humane care for a disabled, non-terminal person)"shall be removed." The court "intruded" to kill an American citizen. This is unprecedented in our history and reveals a departure from the guarantee of ordinary human rights which we have enjoyed until now.

Ruth Tapio
Hospital Chaplain
William Beaumont Hospital
Royal Oak, Michigan

One of the basic principles in Medical Ethics is the right of self determination and things usually stay at the level of patients and families within a healthcare facility until an impass is reached in which case the Ethics Committee is called. Sometimes we even resort to having a court appointed guardian or ask the legal system for an intervention. Most of these cases are handled locally.

When a patient is incompetent is is the right of the next of kin to provide guidance which in this case to Terri's husband.

For a situation to get this out of hand means that all of the basic levels of conflict resolution have been ignored or bypassed in some way. For a medical ethical dilemma to become politicized is more than a travesty. The case should have been sent back to a lower level for resolution with a mediator.

A last resort measure for me, in my opinion, would have been to have Terri's husband retract his right as the decision maker and allow Terri's parents to take over the responsibility, both emotionally and financially.

George Burn
DIrector of Pastoral Care
Mount Nittany Medical Center
State College, PA

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 #7 (see responses below)

A mother, father and their 12-year-old son appeared for an appointment with an ENT (ear, nose and throat) physician. The family stated that the reason for the visit was their son’s “voice box”was closed; he did not speak. They informed the physician, “The Holy Mother of our Church sent us to you, because you can open the voice box and make my son speak.”

After realizing the boy was autistic, the doctor shared the psychological and neurological nature of the condition with the family. Still the family pressed him to do a CT scan and X-ray study, saying it was foretold that the problem with the voice box would appear on the scan. The studies were ordered. Results of the study were negative, no lesions or abnormalities were apparent.

The results were reported to the family. A few days later the mother, father, the Holy Mother, and priest of the church had an appointment with the doctor. They asked to see and review the X-ray and CT results. The doctor carefully took time to explain how he had read the studies and the reports of the radiologist. He shared the films with those gathered.

The Holy Mother then pointed to a specific slice of the CT films and remarked that she was told by God that in this place he would find a “perisicula”that God would help him to remove and the boy would speak.

The physician knew of no such abnormality. He informed the family that in keeping with his medical oath to do no harm, he could not operate seeing there was no lesion, growth or visible blockage.

The doctor called the chaplain for advice on how to respect this family’s strong religious convictions without compromising his professional integrity.

What might the chaplain do to support the physician?

How could the chaplain assist the family?

Responses to CaseConference #7:

First, this doesn't sound like an issue of ethics as much as how to support a Dr and family. Secondly, the chaplain could spend time listening to the Dr explain her/his understanding of a "perisicula." According to my search through my Webster's Medical Desk Dictionary and the ever present Goggle I found no such term. What does the physician understand the HM to say? This chaplain would want to hear the physician's story that makes this case problematic. This chaplain would want to provide the supportive listening and pastoral conversation to the Dr thoroughly enough that the person wearing the title can process his/her own theological, personal, and historical story and possibly find personal healing.

Finally, after hearing the person/Dr the need for a chaplain to interact with the family may not be necessary. If the physician still want chaplain support this chaplain would arrange a meeting with the family, HM, and Priest to listen to their story. I wouldn't do much by way of convincing or explaining; I would simply state the obvious. "It is against medical practice to perform a surgical intervention when there is nothing to be gained." I am sure the group will move to another physician and another and so on at the expense of this young person. Ultimately my job will be to put the son on my prayer list, possibly never to be removed.

Rev. Roy Sanders, M.Div. B.C.C. Diplomate in CPE Supervision
Director Spiritual Health / Clinical Pastoral Education
Truman Medical Center Hospital Hill

What makes this case a matter of ethics as well as a matter of spiritual care is exactly the physician's concern about being asked to perform a procedure that he sees no medical reason to perform. I see at least two possibilities: 1) I would wonder with the physician if there might be additional tests/scans that could be done that could reveal something that cannot be seen with the scans available; or perhaps the physician could suggest that he perform scans at intervals of several weeks, in the event the "perisicula" is too small to be seen at this point. The cost of such diagnostic imaging may be prohibitive, however, and thus not a tenable solution. The physician's concern not to perform invasive surgery for no visible problem should be respected, and supported with the family.

But another tack that could be taken is: 2) to offer other doctors (psychologists), in conjunction with spiritual care providers, who may be able to address the autism, and thus "remove" the "perisicula" from the boy's voice box. It seems that a good religious history and spiritual assessment, in addition to psychological assessment, would be useful in this case.

Rev. Beth Collier, MDiv, ThD, BCC
Coordinator Chaplain
Alexian Brothers Medical Center
Elk Grove Village, IL

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 the film

Peace Is Every Step: Meditation in Action
The Life and Work of Thich Nhat Hanh

Peace Is Every Step provides an intimate portrait of the life of Thich Nhat Hanh, internationally known Vietnamese Buddhist monk, poet, and Nobel Peace Prize nominee. His main message, delivered in soft-spoken tones, concerns meditation in action, a theme that Chaplains live. “You get out of the meditation hall,”Thich Nhat Hanh says, “and that is called meditation in action. Deep looking is meditation, and deep acting is also meditation.”

Since his efforts to end the Vietnam War, which resulted in a forty-year exile from Vietnam, Thich Nhat Hanh has resided in Plum Village, France. Footage of his work in Vietnam and at his monastery in Plum Village, as well as at several retreats in the U.S., weaves a tapestry of his constant efforts at reconciliation. Thich Nhat Hanh served as Chair of the Vietnamese Peace Delegation to the Paris Peace Talks and some of the most interesting moments filmed involve his ongoing interactions with Vietnam Veterans. One of the most touching moments in the film is his visit to the Vietnam War Memorial in Washington, DC.

In Peace is Every Step, Thich Nhat Hanh reminds viewers to lead a “mindful and meaningful life…The best way to take care of the future,”he says, “is to take care of the present moment.”As Chaplains know, “There are things we can do, we all can do.”

Completed: 1998
Running Time: 52 Minutes
Director/Producer: Gaetano Maida

If you are interested in purchasing this film, 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 $24.95 for a DVD.

Book Review

Rev. George Handzo reviews

Providing Culturally and Linguistically Competent Health Care*

As any hospital chaplain knows well by now, the JCAHO has, of late, placed a heavy emphasis on cultural and linguistic competence. And with good reason. About one third of people living in the United States can be classified as racial or ethnic minorities. One third of the residents of New York City are foreign born, and that number is rising. Lack of cultural competence in health care costs money and leads to negative health outcomes - not to mention the distress caused to patients and families whose beliefs and customs are not respected or who literally can’t read the writing on the wall.

In many institutions, chaplains have rightfully been called upon to contribute to the teaching of cultural competence. While some of us have a lot of experience in this area, others of us do not.

Just recently, the publishing arm of JCAHO, Joint Commission Resources, has published a book on this subject that is a must for everyone in health care, including chaplains, who are involved in providing or teaching culturally competent care. The volume is clearly written, laid out in a user-friendly way, and practical. It contains five major chapters - Language, Health Literacy and Their Effects on the Safe Provision of Care, Overcoming Health Barriers through Cultural Competence, The Role of Community in Cultural Competence, Developing and Training Staff to Be Culturally Competent, and The Business Case for Cultural and Linguistic Competence. Additionally, there is a very helpful glossary.

While some chapters were more interesting to me than others, there was significant learning in each. The discussion of health literacy is very clear and its impact well spelled out. There are easy to use cultural assessment tools with verbatim accounts of assessment conversations. I found the discussion of the different possible foci of cultural competence training useful.

Many of you who are professional chaplains may now be expecting the seemingly inevitable line that goes something like, “Although this volume is useful for chaplains, it doesn’t discuss the role of pastoral care”. Not this time! Through the efforts of Sue Wintz, BCC, chair of the APC Commission on Quality in Pastoral Services, professional pastoral care and its role in cultural competence and competence training are described throughout this book. One example, “…board-certified chaplains are valuable resources in identifying and communicating patient/family beliefs…”.(p. 58). Also, “The professional chaplain on staff can assist the interdisciplinary team in understanding cultural, spiritual, and religious issues that emerge…”(p. 45).

Thus, this volume is not only good education for chaplains, it is, for once, a mainline resource that puts professional pastoral care squarely in the center of the institution's efforts in cultural competence. Even at $75, it is well worth the price.

Providing Culturally and Linguistically Competent Health Care, (Joint Commission Resources, 2006) 138 pp.

*This resource will be available to purchase at the APC conference in Atlanta.

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