PlainViews

Chaplain Joan Paddock Maxwell on hope yet to come

Garden Communion

Sometimes a patient is too sick to take anything by mouth, and yet wishes to receive Holy Communion. The various Christian traditions deal with this situation in several ways. In my own tradition, we are told to assure a patient “...that all the benefits of Communion are received, even though the Sacrament is not received in the mouth.”[1] This is called “spiritual Communion.”This practice makes sense theologically, but for a gravely ill person accustomed to ingesting the Host, words do not have the same impact as touch. Hence some have expanded this practice. Patients needing to receive “spiritually”are told that, if they wish, the consecrated wafer will be gently touched to their lips and then wrapped in linen and taken away to be returned to the earth. Patients seem to find this practice meaningful.

Last Christmas I was privileged to offer the Sacrament to patients and their guests in our ICUs. In three cases the patient received spiritually. One was a person on life support. The family was waiting for one more member of the clan to arrive before consenting to extubation. They asked that they and the patient be able to share Communion one last time.

The linen I use to keep a Host in after it has been used for spiritual Communion is a handkerchief that belonged to my grandmother, who died long ago but who was dear to me. Unfolding the handkerchief by the bedside, seeing my grandmother’s initials, and then wrapping the cloth around the Host is always a special moment for me.

The second patient was a woman I had been following for a couple of months. She had been in and out of the ICU several times. On Christmas Day she had just been readmitted, and from the deep furrows on her husband’s face it was clear that things were not going well at all. They were grateful to be able to receive together for what we all knew was their last Christmas. A second wafer for the handkerchief.

The third patient was a wild-haired man who had recently been admitted from the street. He was able to speak just enough to say that he wanted to receive but couldn’t eat. He was entirely alone, surrounded by monitors and IV poles. After he received he watched me wrap the Host in the handkerchief with the other two that were already there. “You are not alone,”I said, and he nodded, both of us aware of the Presence the Hosts symbolized.

After I completed my rounds I went home, the handkerchief and its cargo light in my pocket. It was raining and growing dark. For some reason I decided I needed to dig the hole with my fingers. I went to a garden bed near the base of an old oak tree and knelt on the soggy mulch to dig. The cold water seeped through my trousers to my bent knees. I parted the mulch and the earth opened easily to my hands. As I unfolded my grandmother’s handkerchief and looked for one last time through the raindrops at the three wafers, I prayed for the patients for whom they had served as tangible reminders of God’s loving presence in the midst of pain. When I let the wafers slip from the handkerchief into the brown earth, the rain and my own tears marked not only the sorrow of the present moment but also the hope for what is yet to come.

[1] Ministry with the Sick: Revised and Expanded Edition with rites from The Book of Common Prayer and Enriching our Worship 2 (New York: Church Publishing Incorporated, 2005), p. 9.

(Patients’identifying details have been changed to preserve their privacy.)

Chaplain Joan Paddock Maxwell, M.T.S., is the Palliative Care Chaplain at George Washington University Hospital in Washington, DC. She is endorsed by the Episcopal Church.

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

Editor’s Note: Because of the importance of the findings of Tracy Balboni's study to the profession of chaplaincy, we have chosen to post Rev. Handzo's response here and not in TalkBack. It is our hope that others will respond to Rev. Handzo's questions and concerns.

First, Mr. Jacobs is to be commended for advocating for spiritual care and making the effort to do so publicly [Vol. 4, No. 3]. It is certainly too easy to sit back and let opportunities like this be lost. His general point is well taken. In the journal editorial accompanying Tracy Balboni’s study, Betty Ferrell, a noted nurse-researcher from City of Hope points out that if anyone reported unmet need of 72% for any other dimension of patient care, “cancer care settings concerned with quality would respond.”She ends with, “The first step toward advocacy is personal action. Refer (your patients) to chaplaincy and serve as a model for other oncology professionals by including them in your plan of care…..What percentage of patients do you and your colleagues refer to chaplaincy?”

Our collective temptation might be to yell for all to hear that the answer to this problem is more professional pastoral care. Give us more certified chaplains and all this will go away! Certainly availability is part of the answer. However, the answer is clearly not so straight forward. The researchers reported:

A total of 133 patients (52%) had received visits from chaplains or other clergy. Most whites (83%), African Americans (94%), and Hispanics (100%) stated that the pastoral visit provided some comfort to a lot of comfort. Four patients (3%) reported that the visit made them uncomfortable.

In sum, about half of the patients were visited by a chaplain or clergy and the vast majority felt positively about the visit. It seems reasonable to assume that most of the rest had access to chaplains if they wanted to see them. So, as we know, patients like chaplains and even report satisfaction with our interventions. Yet, some significant number of patients who were visited and took comfort did not have all of their spiritual needs met.

The possibility this study raises for chaplains is, to quote the old QA maxim, that we are doing things right but not doing the right things right. It seems that this is not simply a quantity problem but also one of quality. Could it be that even though people like us, our service is often missing the mark? Could it be that we are incorrect about what patients need from us, or we don’t have the skills to deliver it –maybe as much as half of the time? If someone accused us of this meager level of success, could we prove otherwise?

The question the study does not ask is specifically what the unmet needs were. How can we put screening and assessment systems in place so that we can identify these spiritual needs that we may now be missing? What kind of quality assurance projects and other research do we need to discover what our patients’spiritual needs truly are?

We need to do some serious looking at these and related questions and be prepared to adjust our practice accordingly.

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

Writing The Unwanted Gift of Grief: A Ministry Approach has been a ten-year process. Hospitals seem never to give sabbaticals for writing and study, so we have to write in the morning or night hours. My moments of solitude and inspiration were usually from 4:30 to 7:30 in the morning and on weekends. Writing became a spiritual experience, transcending the moment and the demands of the day and leaving me feeling inspired and transformed.

Why did I write? “Everyone has a book on grief. I have nothing new to say!”I whispered to myself and to Jeanne, my wife. It was Jeanne who kept saying, “Your right, there is nothing new ever written, what is new is how you write it and say it.”

That insightful encouragement kept me going even as I submitted my finished manuscript to five publishers. Why did I write? Was it because of Abby, our daughter, who has Down Syndrome? Or was it because Jeanne was widowed in her mid-twenties left with an infant and a two-year-old? Or was it my divorce –a traumatic teacher? Or was it the many seminars in CPE I taught, or the congregation presentations I made, or the people who kept saying, “You must write this approach to grief! We need this in writing.”

There were so many reasons not to write. Days were already long: being a spouse, father to four children, serving as chaplain, ACPE Supervisor, a private practice of marriage and family therapy and learning to be a system executive for a 3000-bed hospital system. I told myself I was crazy but the inner voice kept nudging and calling me to write. At numerous resting places over the years, concluding that it was complete, I would send it to readers who were in the middle of the wilderness of grief. Or I ministered to a new person/family that taught me a new perspective I had not considered. Just months after I submitted the book and could not change it, we faced a tsunami and hurricanes. There is nothing in the text about these unbelievable disasters and losses. The book seemed out of date before it was printed. I cognitively and emotionally criticized myself in these moments for not seeing and including natural disaster. Yes, I am hard on myself.

So the book unfolded. Finally the past president of our hospital system became the tipping point. Dan Wilford had been through a traumatic car accident where he was badly broken physically but also broken emotionally/spiritually because his wife, Ann, had died in the crash. After some months of working together, I asked him to read my text and give me feedback. When I returned, the manuscript was dog-eared and written on. He told me how it had touched him in areas he had not considered. Dan asked, “When is this going to be published?”I responded, “I don’t know. Every time I minister to people in trauma, loss and grief, I add to and reshape it.”His next comment was the electrifying kick in the pants, “This book may be perfect in five more years but people need it now!”Isn’t it an amazing gift, that God’s voice is heard through people which become the tipping point for a decade of writing?

I did not want to write another theory book with multiple footnotes. My hope was that the narrative be born out of my story as minister and fellow struggler, to write to the person suffering and the many sojourners who walk with them whether they be professionals or the neighbor next door.

Soon after I started writing, I decide not to read another book about loss, mourning or grief. The more I read others, the more I moved to my head and convinced my heart that I had nothing to say –no words to contribute. Embracing the freedom to trust myself, I wrote out of my story, spirituality, theology and perception of the behavioral sciences.

In my writing, I compare grief to a wandering and wondering experience in the wilderness as one searching for a promised life…searching for transformation…searching for hope and healing. There were many days and months I wandered and wondered around in my body, mind and spirit searching for a word, a story, a truth that would be a hopeful voice to God’s people and a hopeful catharsis from my soul. I recently spoke to a congregation about the book and afterwards a women said, “It must be like giving birth. Through the labor and contractions a book is born.”

The Unwanted Gift of Grief: A Ministry Approach, Haworth Pastoral Press, New York, 2006, pp 192.

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

Workman had come to clear an overgrown area of our garden. Branches were cut and, in the heat of the noonday sun, I returned to find a nestling baking in the nest, which still stood on cut branches propped up against a wall in our driveway. I couldn’t take the thought of this poor bird suffering, never to know flight. I was now the predator.

I inquired about how I could humanely put the bird out of potential misery. To be strong. To do the right thing. I couldn’t leave it until it dehydrated, lost consciousness, and died slowly. I couldn’t hope for a predator to come and let nature take its course. One course in the buffet we know as the food chain. Where was a cat? Where was a hawk?

I called Audubon. What was the bird’s present condition? How long had it been away from its mother? How long had it been in the sun? Two hours. Still viable. Call Second Chance.

Minutes later propped in the backseat, an elderly mother in the front holding a puppy, I set off for the forty mile drive to an animal rehab sanctuary. It was the right thing to do.

I entered to find many hatchlings, nestlings, and various other fauna in cases with warm cotton stuffing and syringes of Gerber baby pureed foods. I was captivated by the work I was witnessing. I completed paperwork, and was informed that I could call anytime to inquire about the condition of my nestling. I walked back toward the car and collapsed in tears. Not good.

I guess I just couldn’t handle any more death, at least the death of something that didn’t have to die.

The animals in the Prague Zoo captivated Europe several years ago as the Danube River reached record flood levels. As rhinos and hippos drowned, as their keepers had no routes of escape or safe harbor for something so large and so ‘wild,’children and adults wept at the loss of familiar and exotic friends from the heights above.

There had been one hope, a favorite seal that had entertained and meant joy to zoo visitors each day. News that it had escaped –been swept away –surely it had survived. This was his element. Until days later, his carcass was discovered a hundred miles downstream as floodwaters receded. Death happened all over again. Grief seemed well out of proportion to the loss of one animal. Not to me. Not to those families who had to abandon their family members in New Orleans, or, along the Gulf Coast. These were only animals. Human lives are more important. But, not for those who were counted as members of the family. Not to Rumi, the Persian poet, who stated that the two highest spiritual disciplines are tending animals and cooking. Persons of faith get the cooking part –ministry as hospitality, and, the symbolism of the good shepherd is rich and part of vast tradition, history, and faith. However, a society that takes care of its most vulnerable –all living things –does tell us so much about what a society values, how a society practices justice, compassion, and mercy.

And, the dependency part –the vulnerable populations, the special populations that need more care, also may include populations that love us unconditionally (or as the cynic posits: just want to be fed; or folks get what they deserve; or all life is suffering; or nothing really matters). So many abandoned. So many left to fend for themselves. So many motherless children. And, it’s not okay.

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.

Abraham Lincoln advised lawyers, “Discourage litigation. Persuade your neighbors to compromise whenever you can. As a peacemaker the lawyer has superior opportunity of being a good man. There will still be business enough.”

Contrary to stereotype, most lawyers practice conflict resolution as Lincoln counseled. Frustrated lawyers frequently lament, “the practice of law would be fulfilling were it not for clients.”

As last month’s column [Vol. 4, No. 1] and the follow-up response [Vol. 4, No. 2] stressed, legal ethics require lawyers to represent their client’s best interests as articulated by the client.[1] This column is not to defend lawyers[2] but to assist readers in using lawyers wisely. Resolving conflict is a collaborative endeavor: the lawyer is the expert on the law; you are the expert on your life. The suggestions apply to professional and personal cases.

Opposing counsel routinely talk with each other and shape settlements. Before you reject or attempt to wring more out of them, remember: your lawyer is trained to spot issues and craft resolutions. More importantly, your lawyer is invested in your best interests without being mired in the present emotional murkiness of the conflict. He or she is ready to close your case and move on. Are you?

[1] The lawyer is the client’s alter, not super, ego. Only in very limited circumstances is a lawyer permitted to withdraw from an active case. What the lawyer thinks professionally or feels personally about a client’s position is irrelevant to the lawyer’s duty to represent.

[2] A 2006 Harris survey found 85% of respondents trusted doctors and 30% trusted lawyers. My read is that litigation seldom makes people happy. In a 1993 American Bar Association survey, 59% of respondents perceived lawyers “file suits that benefit themselves, not their clients.”Perception is reality. Whether true or not, individual lawyers have a duty to recognize, address and perform contrary to these negative expectations.

[3] Many lawyers offer an initial free consultation where you and they can measure mutual compatibility. Upon retention, you should receive written confirmation of fees, services to be provided and any limitations to representation or expectations particular to your case.

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.

We are always looking for cases. Please send any cases that you would like considered for inclusion to: info@plainviews.org We will ensure that it is stripped of any identifiers. For further guidance about how to write up a CaseConference, please refer to the CaseConference Archives, Vol. 4, No. 3 "How to Submit a Case for CaseConference." (Click HERE)

We hope that this 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 fourteen-year-old young lady was admitted through the emergency room to the Adolescent Psychiatric unit of a hospital after attempting suicide by an overdose of drugs.

Four months before admission, her mother had died of cancer. Since that time, the adolescent's behavior had greatly deteriorated. She was skipping school more than she was attending. Her grades had fallen from a B average to failing. She became promiscuous, started on street drugs and alcohol, became belligerent in speech and abusive emotionally and physically, and began running with a wild crowd. Her attitude towards life had greatly changed from the church-going adolescent she had been six months earlier. She appears to have lost all desire to live.
She has been living with her maternal grandparents since her mother’s death. They no longer feel they are capable of caring for her and want her placed in foster care.

She shares with the chaplain that she and her mother and had attended church constantly, asking God to heal her mother, but her mother died anyway. A few weeks before her death, the mother called her daughter into her room and said that she was angry with God for not healing her. The mother said that she decided to reject God and “follow the devil instead.”The adolescent told this to their pastor. The pastor told her that it was "too bad" and that her mother was "now in hell."

What would you advise the rest of the team in terms of how they should relate to her?

This is a complex case for everyone involved that could stir deep seeded emotions for everyone. It is obvious that the girl has attended a conservative church that believes in some strong values, such as heaven, hell, and sin. Exploring the religious dimensions of the whole family's life, (including the grandparents) and possibly other family members could be valuable in the spiritual assessment. Other family who might be supportive could be valuable. However the acute grief, the difficult adjustment to the new home, all need to be addressed. It would be interesting also on a first visit to see how the adolescent responds to the idea of "chaplain". Does it trigger anger because of what has happened with the pastor or some other response? I think targeting grief work would be the initial need and that may come through some relationship building at first. The treatment team may or may not even exam the "hell" question or the healing question. They will focus also on grief, as well as adjustment (and probably some medication issues for depression). It would serve the chaplain well to become part of the family meeting to further ongoing assessment. One might hope for a reframing of the pastor's response at some point; however the ethics of challenging religious beliefs would need to be carefully thought through.

Adolescent treatment often goes very fast in psychiatric hospitals and this adolescent probably will probably stay at the longest two weeks. If the treatment team does decide on foster care based on the family conference, the adolescent will be there possibly for a few more weeks. Contacting the church if the child wants this could be valuable or could be painful; however the church may be a support for the grandparents. One other goal in treatment or informally in conversations with the child may be conversations on the nature of addiction and the relationship to grief.

Assessment and treatment, at some level involve balancing religion (the church where she and her family has come from), theological beliefs (hell and healing), and spirituality (grief, family grief and adjustment, and her individual as wells as family spiritual help). Perhaps a referral at discharge to a Christian Counseling center (similar to her beliefs or a Pastoral counseling center could be in order as part of discharge planning. A lot to accomplish in a psychiatric healthcare system that will at best give her 2 weeks.

Dennis DuPont, M.Div., BCC
Director of Pastoral Care
Spring Grove Hospital
Catonsville Maryland

What else would you want to know before making a spiritual assessment?
I would want to know more about her relationship with her mother and her hopes for that relationship. Is she hell-bent to be reunited with mom? Is she acting out the way she feels that everyone around her sees her mother? Similarly, I would want to know more about her relationship with God and how she might understand the role of reconciliation in covenant.

What is your spiritual assessment given the information already presented?
The patient is emotionally and spiritually alienated from her social and moral groundings. Her spiritual world has collapsed and she is unable to access the resources necessary to rebuild it. She sees herself as painfully alone in an entirely unfriendly world.

What would you advise the rest of the team in terms of how they should relate to her?
Respond honestly to her questions and respect her opinions. Do not try to reform her so much as try to help her come to terms with who she is after this devastating loss. She needs to develop healthier ways to feel more in control of her life and may well have a great need for trust, because without trust she cannot begin to re-grow her faith.

What would your plan of care be?
Let her spend as much grief in as many forms as she chooses to share. Then explore her spiritual and religious resources uncritically, encouraging her to build an inventory of spiritual and moral stories from which she can begin to develop an independent theological framework, reflective of her family and church's stories, but not wholly dependent on them for validation.

Help her to reflect on the qualities of her mother's faith and how her faith might be like and unlike mom's faith. Encourage her to look for maternal figures in her world and in the stories of her faith tradition from which she can find solace and inspiration. Let her know that being angry with God is okay, and it doesn't mean that their relationship is over.

What outcomes would you expect?
I would expect her to make the first tentative moves toward experiencing an interior life independent of her mother, and to find some value in that discovery.

Inside Islam. a production of The History Channel, brings to light the striking commonalities among the sacred texts of Islam, Christianity, and Judaism and suggests that textual differences between the Bible and Koran are not highly divisive.

Chaplains would be well aware that Islam claims a direct line to Abraham via his son Ishmael, while Judaism is linked to Abraham's son Isaac. But are you aware that the Koran reveres the Old Testament prophets, that Jesus is mentioned 93 times in the Koran, or that the Koran states that it was the Archangel Gabriel who transmitted the Word of God to the Prophet Muhammad in the 7th century?

Among other interesting insights revealed in the film is the Islamic belief in the Virgin Birth and the view of Jesus as a divinely inspired prophet who was not crucified, but was lifted to heaven by Allah. Muhammad, like Jesus, was born under a brilliant star, according to the Koran.

This film covers in detail the history of Islam from the 7th century of Prophet Muhammad’s world to the present day. Inside Islam also highlights Islamic contributions to the modern world from the field of algebra to the fields of orthopedics and the first recorded treatments for mental illness.
_____________________

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.

My experience with health care bio-ethics prior to accepting a position as Pastoral Care Supervisor at Health Central, a local community hospital, was limited to occasional requests to assist families through end of life decisions, generally in the patient’s final hours. This new position included the onus of being the Chairperson of the hospital Ethics Committee. My college ethics books and even Christian ethics texts often clouded rather than clarified my thinking. Over time and thanks to Beauchamp and Childress, the Florida Bioethics Network, and a Chaplain’s blog, I began to feel more comfortable in this role. It was, though, the reading and rereading of David F. Kelly’s book Medical Care at the End of Life, A Catholic Perspective that I realized that being the chairperson of the Ethics Committee could transition to a blessing from that of an onus.

Kelly drew the concepts together for me. In simple and understandable prose he encapsulated the essence of Roman Catholic theology, doctrine and canon, American civil law, and practical health care situations dealing with the end of life dilemma. Kelly succinctly covers topics from Ordinary and Extraordinary Means, Killing and Allowing to Die, to Decisions by competent Patients and Decisions for Incompetent Patients. He comprehensively examines the issue of Advanced Directives. Kelly also covers Hydration and Nutrition, Physician Assisted Suicide and Euthanasia, and Medical Futility. What he doesn’t do is attempt to force the Roman Catholic belief system on the reader. In some cases he is not in 100% agreement with that perspective.

What Kelly does do, at least for me, is to bring a refreshingly simple and rational view of the system of ethics that he has applied in the health care setting for over thirty years. He has instilled in me the hope that I can walk through the ethical decisions with patients, families, and the committee knowing that I can contribute with my own theology and a clearer and more balanced understanding of ethics as a process.

Kelly, David F.Medical Care at the End of Life, A Catholic Perspective, Georgetown University Press: Washington, DC (2007) pp 172.

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