Geoffrey Tyrrell, D. Min.

The Clinical Value of the Chaplain on the Palliative Care Team

(There were two excellent responses to this article. You can read them by clicking here.)

I recently spent a year as a Chaplain Fellow in an interdisciplinary palliative care program at the VA in Palo Alto. I joined a well-established team of very experienced and trainee clinicians who provide extraordinary care to Veterans.

I quickly saw that all disciplines on the team provided compassionate relief of suffering, and began to mull over a simple question: what is the clinical value of the chaplain on the palliative care team? I also asked myself this question: what would the team miss if they didn’t have a chaplain? I surmised that the director of the team would have to justify the expense of hiring the chaplain, so I contacted directors of palliative care teams and asked them how they valued the chaplain.

What I found was surprising. I present the results below because I have not seen such an assessment of the clinical value of a chaplain by a group outside the chaplain “tribe.” In addition, I offer some suggestions and reflections to chaplains. Perhaps chaplains and team members from other disciplines will weigh in with their thoughts as well, so that we can continue to learn from each other.

My findings represent only the views of the people with whom I spoke: ten directors of palliative care teams from around the country. It is a relatively small number and not intended to be representative of all directors. Still, the views of ten directors of palliative care teams are important, and I think chaplains could find them helpful, affirming and even painful at times.

When I presented my findings to my interdisciplinary group of Fellows, I gathered comments together by theme; I will do the same here. I do not endorse all views expressed, but want to represent the thoughts that were presented to me as best I can.

Positive Findings

Many of the directors clearly felt that chaplains address important issues that patients think about. Chaplains were seen to communicate about the patient's journey, bringing in issues of faith, quality of life and meaning. On this theme, some see chaplains as a team resource, e.g., debriefing with staff after a difficult death, or as a bridge between family and staff.

Chaplains are often relied on as the eyes and ears of the team for spiritual and emotional issues. One director said, “Without the chaplain, the team would miss a full understanding of patient's suffering.” For a director who did not have a chaplain on the team, he said, “Having a full-time chaplain on team would allow us to address the spiritual needs of patients.” For the palliative care team, “A chaplain can help frame difficult information and discussions, such as Advance Directive conversations, in ways that may be more palatable [to the patient or family.]”

In this way, chaplains are valued for the complementary data they provide, and sometimes for their advocacy. “Chaplains bring a holistic vision to the team, sometimes challenging the team,” said one director.

Another team leader proposed an interesting model for differentiating chaplains from other members of the team: “Chaplains provide a different kind of comfort from other disciplines. Clinical staff work with agony and pain. Social and community staff work with isolation and financial issues, and spiritual/holistic staff work with meaning and religion.”

Chaplains can also add their value, in the view of several directors, by: training and coordinating volunteers, assisting with fundraising, education in community, mobilizing community resources, e.g., clergy, volunteers, partnerships, and saving the time of more highly paid staff.

There were also quite a few ambivalent responses to the question. The most dramatic example was the director who said, “The chaplain is essential to address spiritual pain.” She then related an example where she had referred a patient who complained of “spiritual pain,” to the chaplain. He spent just two minutes in the room with the patient. The outcome for her was a major doubt: “Can chaplains address spiritual pain?” She clearly thought not.

To my surprise, chaplains were seen as a “cost saver,” by more than one of the directors. For example, one administrator, “needs someone to spend time with patients, and a chaplain saves the time of the nurse or MD [both of whom are paid much more].” Another administrator said, “If we had a chaplain we could free up our psychologist from bereavement tasks.”

For an administrator to see a chaplain in this light is somewhat hard for me after many years of training and education. But, I believe it reflects the reality that chaplains are paid less than other members of the team. Someone has to allocate financial resources—the director in all likelihood—and they naturally try to get the most from their budgets. If we chaplains want to be paid more in line with professionals from other disciplines with a similar level of training, which NHPCO calls for, we will have to prove our value to people such as these administrators.

A Lot of Work for Chaplains To Do

I came away with a strong sense that while many administrators value chaplains, and most see the need for spiritual care of patients and families, there is a lot of work for chaplains to do to establish our value and create trust among our colleagues of different disciplines.

Interestingly, most of the directors had not thought about the chaplain in terms of clinical value. They may have needed a chaplain to qualify for Medicare reimbursement, or, in many cases, it was a hospital policy.

Only in a minority of cases was the director passionate that the chaplain was a valued member of the team. Others had reservations: “The chaplain may be seen as a spiritual person who floats in,” according to one team leader. Another source said, “It's not clear how chaplains are going to help with problems that exist.” Another director, at the end of our conversation had a sudden insight, “I have no idea how to use the chaplain.” This RN has been a palliative care director for several years, and values having a chaplain on the team. Yet she suddenly realized as she thought about the clinical value of the chaplain, “I don’t know what your skill set is. We don’t know how chaplains are trained, or what their scope or background is… What do they have to offer?”

Note that she did not ask, “Is the chaplain endorsed?” Nor, “Is the chaplain board certified?” While these are issues that chaplains talk about in terms of demonstrating competency, accountability and professional requirements, none of the administrators referred to them. They had much more practical and relational concerns, such as: can we trust the chaplain? What does she do?

Similarly, in my fellowship program, I noted basic questions about chaplains, such as: what is the chaplain’s scope of practice?; what is your training as a chaplain and how does it rate compared to mine?; when should I refer to you (the chaplain on my palliative care team) and when to the chaplain for the floor, or to social work, or psychology? These are questions I believe the chaplain needs to address proactively, because they may not be explicit in a clinical setting.

I don’t think anyone reading this—chaplain or not—will be surprised to hear that some clinicians are wary of chaplains. I did hear directors expressing fears about chaplains. Proselytizing or advocating for one’s religion was unacceptable to them. In the same vein, I heard about chaplains with an agenda, such as seeking to prove the power of prayer rather than addressing the needs of the patients, or overstepped bounds, which created problems for an administrator.

A director at a teaching hospital reported that staff on several units, "protect patients from the chaplain." Chaplains on those units were CPE students (trainee chaplains), she said, and several experienced palliative care administrators described struggling with having CPE students on the team. Those who reported this concern ultimately chose not to work with them.

Bearing in mind the limits of this investigation, CPE supervisors might note the pointed comments of one director: “[the CPE students] are not well enough prepared. They don’t step in [when needed]. They are afraid and lack adequate supervision.” One institution includes CPE residents by having them shadow the palliative care chaplains, and this appears to work well.

Team dynamics are a critical part of palliative care because of its interdisciplinary nature. And often chaplains were literally, “not a part of the team.” Teams without a team-assigned chaplain reported difficulties which reflected the lack of consistent chaplain involvement, and were most likely to find the chaplain not available, or leaving in the middle of family meetings.

One M.D., the director of a hospice and hospital palliative care team, said, “Without a chaplain on the team, we can’t feel good about our work.” To me this is a critical message: chaplains need to be a member of the team to the same degree that other core disciplines are. If the Director is 0.5, the chaplain should be 0.5 FTE. Why? So they can be available for meetings, can follow up with families, can support the staff, and not get called away in the middle of IDT by the demands of their other commitments.

Directors who have chaplains on the team have concerns too. One feels that the chaplain may be proselytizing. Another feels, “something is missing.”

Finally, there were negative experiences that could have been unique to particular chaplains, such as making inappropriate comments, being “abrupt or insensitive,” or, “angry with the family.” This poor performance by such chaplains affects the whole team and certainly creates negative impressions of our profession.

It was recommended by three directors that the chaplain meet the patient with the whole PC team to help address issues as they come up, “rather than following up later by a referral.” Another said, “Meet the patient as a team, so that the patient gets an immediate sense of the team. Chaplain can stay behind and talk with the patient about spiritual issues that come up during the team visit.” This is a matter that depends very much on the culture of the organization or team. In my team, there was cultural resistance to the idea of joint visits. Concerns expressed included the difficulty of scheduling joint visits.

Spiritual Care can be a “Black Box”

Based on my conversations, the palliative care team wants to know more about the chaplain’s expertise and role, but there is a degree of fear/distrust of chaplaincy which is shared by many directors. Chaplains therefore need to build trust and add value to their work.

One director was quite explicit. The chaplain, “needs to tell me what they have done… tell me specific achievements, such as: how many patients you have seen; what materials you created; which community resources (such as volunteer training, clergy networking) you have developed.” To me this again points to the need for chaplains to be out ahead of the curve, informing his or her co-workers about their work, training and availability, and leading the team by being their educator and expert on spiritual matters.

One chaplain who has proven her value to administration said the way she did it was to become more visible—getting mentioned by name in letters from families to the director, and even in death notices, for example, helped.

Both her experience and my conversations tell me that a chaplain needs to be a leader in educating the team about what spiritual care is and how a chaplain can help. Through these conversations I have come to a clearer understanding of the value of speaking up for my expertise as a chaplain, assessing the spiritual needs of patients, speaking to the spirituality of patients and family with the team, and guiding the spiritual care provided by all disciplines.

These conclusions are supported by Pediatric Palliative Care Chaplain Rev. Dr. Cathie Stivers, who wrote on PlainViews,“I have assumed a leadership role on increasing the awareness and knowledge of pediatric palliative care among the TCU staff and families.”

Final Thoughts

I have come away from my program with deeper understanding and even greater respect for the clinical staff I have worked with and the compassionate spirit of care they provide. For example, many of my patients have gained relief from spiritual pain (such as misery, despair, isolation) through the skillful use of medications by MDs and nurses, which allowed them to experience greater peace. This in turn allowed them to explore spiritual terrain that they may not otherwise have been able to attend to. (This is an issue that I would like to explore further, but that’s a topic for another article. If you have any knowledge about this or helpful resources, please let me know.)

Chaplains are responding to the desire and need of other clinicians for more information, and reaching out in different forums with information, analysis, self-criticism and setting standards. For those who are looking for more information about what chaplains do, one place to start might be, “What are we doing here? Chaplains in contemporary health care,” by Martha R. Jacobs, Hastings Center Report, Nov-Dec, 2008. This article looks at chaplaincy in some depth.

NHPCO guidelines recommend the chaplain provide orientation to new team members and ongoing in-services. With that in mind, and on the basis of these conversations, I will be continuing my one-on-one conversations and offering spiritual care in-services, including at least these elements:

1. Definition of spirituality and scope of a chaplain’s practice.
2. Shared responsibility for spiritual care between the different disciplines, and how that affects team dynamics.
3. Chaplain’s expertise—chaplain education and training. When to refer to the chaplain. Vignettes/case studies.

Given the concerns expressed above, I would encourage any chaplain out there who is curious: Ask your team members what they really want or need from the chaplain. What are they afraid of when it comes to chaplaincy? You may be surprised what you find out, and will at least be better informed.

Responses:

Thank you for the timely reflections about Chaplaincy and Palliative Care. I can certainly appreciate the critical voice that I hear interwoven in the experience of so many medical folks, regarding our professionalism and service provision.

I am fortunate to have been in the group who planned and implemented the Palliative Care Program here at CMC. We have been a Team (officially) since the fall of 2004. At first, we operated under a grant from the Duke Endowment, but within a couple of years moved to the mainstream of hospital support.

From its inception, our lead Physician insisted that the team should be fully interdisciplinary and non-hierarchical. As such, each team member provides the “voice” and professional competency for his/her discipline, but all have a relatively equal voice in team and at the bedside. I realize with great humility that this concept is unique. All the team members respect each other, and our individual voices are clearly heard in every venue. We have worked hard to integrate our care, for the sake of seamless (and synergistic) care.

I enjoy the full support of MD’s and Palliative Staff. Our Director, who is also the Manager (RN) of the Medical Unit, agrees that spiritual care is vital. As the spiritual care provider, I am expected to contribute PRN to each family and patient. I am also the care-provider for the team members. In addition, when I have been in my own “difficult moments,” either personally or professionally, I have been supported and encouraged by the Team. Our intra-team care is genuine and reciprocal.

We also enjoy the presence of a linguist for team meetings. She is the current Chair of the English Department of a State University, interested in the Narrative component of our team’s interactions, with each other as well as with patients/families. Spiritual Care is often a key component of her interest, in terms of the patient/family’s way of understanding, valuing and making meaning.

I am, as a CPE Supervisor (working toward it!), quite concerned about your reflections concerning HOW the chaplains operated at the bedside, in the hospital wards, and with the team. Some of your reflections are clearly in violation of good pastoral care policy, no matter where they are rendered. We have CPE Interns on a regular basis, but they are NOT cast into these specialty roles without training and preparation. Our Volunteer Chaplains offer what the hospital refers to as “hospitality visits,” that include basic pastoral care, but volunteers also operate within strict guidelines written by my department (i.e., ME) and signed by my Vice President into Policy.

Finally, I am aware that a segment of my own hospital remains clueless as to what the clinical chaplain can and does provide for patients, families and staff. To them, I’m just the “Jesus person.” “If a patient wants to ‘get saved’ I’ll call the Chaplain.” (Or if a family situation in grief, etc., spins out of control, they call me!) It ain’t a perfect world, here, either!!!!

I have also forwarded this article to my team colleagues, in hopes that the Palliative Physician (and perhaps others) will respond to your article.

Again, thanks for your work with and writing about this subject that is so near (and dear) for me.

Best,

John E. Renfro, DMin, BCC
Director of Pastoral Services
ACPE Supervisory Candidate
Conway Medical Center
Conway, SC

I have just read Geoffrey Tyrell's article about his experience as a palliative care chaplain and the responses from palliative care directors.

I have been a palliative care chaplain for seven years and hospital chaplain for over twenty. The palliative care unit is a ten bed inpatient unit with a community team attached. I am/was paid for 10 hours per week. I have changed from direct patient interaction to working by referral and this seemed to be acceptable. I would engage patients or their families if I met in public areas. I attend the weekly ward meetings and contribute in turn to the weekly presentation by all disciplines., I have a role of interaction with staff and see this as significant. I am valued as a team member. Chaplains need, in my experience, to be highly visible, even appropriately aggressive, as we can so easily become invisible with no one to argue for us except ourselves. I am also the only CPE Supervisor in Tasmania and am careful about the students that I allow onto the Unit.

Thank you, Geoffrey for this article.

Best wishes,
Rev. Eric Cave
Pastoral Care Worker
Tasmania, Australia

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