As professional chaplains we need to be in dialogue with each other about what we do, how we do it, and why we do it a certain way and how these practices benefit our patients. The ultimate goal of MyPractice is to build a consensus about what constitutes “good practice” and eventually establish “Standards of Practice” for chaplains. As with quality improvements in our institutions, this is an ongoing process in order to improve our practice.

To have a description of a practice that you use in your setting considered for inclusion here, write it up and send it to PlainViews for consideration. The Association of Professional Chaplain's Quality Commission’s Best Practice Committee will work with the Managing Editor of PlainViews to review submissions and select articles for publication. Your submission does not necessarily need to be cutting edge (although that’s okay, too). We want to identify “good practices” that could be recognized as standard practice.

PlainViews will highlight one article in the second issue of each month. Readers are invited to respond to the featured practice. Responses will be posted as they are received. This is a great opportunity to start a process that will move us forward in professional chaplaincy.

If you’d like to respond to MyPractice, please send a comment of no more than 400 words. You can use the e-form below (click on "hearing from you," link) or submit your commentary to the editor in the body of an e-mail (or as a Microsoft Word attachment) sent to Info@PlainViews.org. Please put the phrase “MyPractice” in your subject line.

We look forward to hearing from you.

Comment on Texas Medical Center Protocol - see below for article

What a great work to collaborate on a standard of practice for chaplains in a multi-hospital medical center! I did notice that there was not place for supporting staff after a code or a death. That is part of our practice at Presbyterian Hospital in Albuquerque, a practice which enhances spiritual and emotional support of staff, as well as contributing to staff satisfaction and employee retention.

Jenny Lannom
Manager, Pastoral Education
Presbyterian Hospital
Albuquerque, NM

Texas Medical Center Protocol for Chaplain Response to Codes

(Commentary is indented and in italics)

Notification
• Chaplain on site coverage 24/365

Full on site coverage is the norm for all Texas Medical Center Hospitals

• Automatic page through pocket pager or overhead system for all Codes

The "On Call" Chaplain is automatically paged when a Code is called as Pastoral Care is considered an essential member of the Code response team. The exception to an automatic page may be when a "silent code" is called when the medical team is already present and working with a patient. "Silent Codes" most often occur in critical care areas such as the Cardiovascular Recovery Room.

• Prompt response expected with arrival at site within 5 minutes.

The Chaplain paged to a Code is expected to respond immediately by proceeding directly to the location indicated by the page, walking quickly, at a pace that does not draw attention, and not running. In general, the Chaplain is expected to become physically present at the site within 5-10 minutes. During the night when the On Call Chaplain is awakened, he/she is expected to arrive promptly at the Code site, fully dressed according to the dress code for chaplains established by the hospital.

• Triage with site of Code notification when multiple crises.

In the event the Chaplain is already engaged in a critical situation and cannot leave to attend the Code, the Code site needs to be notified immediately of the Chaplain's delay and information obtained about the pastoral needs related to the Code. Evaluating and setting priorities are important skills for Chaplains who respond to hospital crises. In many cases, going back and forth between two, sometimes even three, concurrent crises is the challenge for pastoral care givers.

All TMC hospitals have back up systems in place for dealing with multiple crises. During week day business hours when the Pastoral Care Department full staff is present, the On Call Chaplain who receives simultaneous multiple pages notifies the Pastoral Care office and requests assistance from the "back up" chaplain. During evenings, nights, and week ends, the On Call Chaplain can call the "back up" chaplain for assistance. However, the emergency situations prompting request for assistance are usually resolved before the "back up" chaplain could arrive on scene. Therefore, advice on triage is often the need that is met by the "back up" chaplain.

Initial Actions

• Report to Code coordinator upon arrival at code site.

Identifying the RN who is overseeing the Code is essential for appropriate communication.

• Obtain status update on patient, family members, and staff.

Often the only information that can be obtained initially is whether or not family is present and what they have been told. Do not expect the Code Coordinator to provide a full briefing on the situation.

• Introduce self to family after first being certain of their knowledge of the Code in progress.

It is inappropriate for chaplains to provide the initial news or any follow up information of the Code in progress. If the family knows of the Code, the chaplain is limited to updates such as, "They are still working" or "The doctor will come to talk with you when possible." Explain to families that it is routine for chaplains to be paged during such events, that chaplain presence is for the support of families.

• Arrange for privacy for family, if possible, or facilitate their presence at the Code site according to hospital policy, moving them to an appropriate position of noninterference with medical team.

Providing a private space for families separate from a general waiting room is essential hospitality and helpful in assisting families find equilibrium. A consultation room can help contain a family from wandering about in agitation.

Some TMC hospitals have written policies that allow and/or encourage a willing family member to remain present in the room during a Code. The violent reality of Codes often aids loved ones toward quicker or greater acceptance of the patient's condition as well as gratitude that "everything possible" was done.

• Provide emotional/spiritual support and hospitality to family.

The chaplain may effectively support the family through attentive listening and asking caring questions about the patient's illness, their faith traditions, family situations, and their ways of coping. Offer to pray with them.

Secondary Actions

• If no family or significant others are present, check to make sure medical team contacts them and find out the family's response. Put in place a plan to prevent family from “stumbling upon” their loved one in another unit after the code.

It may fall to the chaplain to see that a doctor contacts the family. Coordinate this, if needed, with the Nursing Supervisor or Code Coordinator.

• When Code is prolonged the chaplain may need to facilitate communication to family. Ask Code Coordinator what information should be conveyed to family. Never convey medical updates, only the most general of information to family.

• Look for advance directives if chart is accessible.

• Observe medical staff and patients in surrounding area for distressed reactions, and provide pastoral care.

• Help facilitate transfer of roommate in coordination with RN.

• If no family or significant others are present, leave word of availability with Code Coordinator before leaving the unit.

Post Code Actions – when patient is stabilized and remains in the same room.

• Inform the family of chaplains' ongoing availability.

• Document chaplain's presence and interventions in the patient's chart (paper or electronic). Sign entry.

e.g. "Chaplain was notified and attended Code Blue. I remained with the family and patient during the code, providing emotional and spiritual support. I provided support to the staff as well, until the patient was stabilized. Made referral to unit chaplain and the on-call chaplain for follow-up."

• Document the event in the chaplain's log book for reading at Chaplaincy Department morning report the next day.

• Inform the unit chaplain of the event.

For continuity of pastoral care when relationships with patients and families have already been established, it is desirable for Unit chaplains to be notified of Codes. It is our experience that it is unrealistic to expect unit personnel to page their unit chaplain directly, so it becomes the responsibility of the On Call Chaplain receiving the automatic Code page to notify a unit chaplain during daytime availability.

• Refer to the next on-call chaplain, especially if patient remains unstable, so that family can be followed.

Post Code Actions – when patient is moved to an intensive care unit.

• Accompany family to the ICU and/or locate them in nearby waiting room, informing nurse of family's location.

• Accompany the doctor when they tell the family of the transfer.

• Check on patient’s belongings.

• Inform family of chaplain's ongoing availability.

• Document chaplain's presence and interventions in the patient's chart.

• Document the event in the chaplain's log book for reading the next day.

• Inform chaplains assigned to both the previous unit and receiving unit.

• Refer to on-call chaplain for follow up during the night.

Post Code Actions – when death occurs.

• Ask family about religious traditions pertaining to death.

• Scan room ahead of time to prepare the family for what they might see.

• Following preparations of the body completed by nursing staff, accompany family to the bedside.

• Provide unlimited time for family to grieve, either at the bedside or in a private area provided for them.

• Offer to provide prayers of commendation or obtain appropriate ministry of family's faith tradition.

• Assist with completion of paperwork for time of death, including release of body.

Responsibility for requesting autopsy belongs only to the medical staff, but the chaplain may need to facilitate the family's discussion and communicate their decision to the medical team. The Chaplain may witness signatures on these forms.

• Accompany family to exit of hospital.

• Document chaplain's presence and interventions in patient's chart and the chaplain's log book for reading the next day.

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