Tuesday, July 29, 2014

What do patients expect of Chaplains and other hospice IDT members?

“What do patients expect of Chaplains?” This question was posed to me at a volunteer training event. At first, I thought it was a simple question to answer and because I was the speaker fielding questions, I proposed a few simple answers: kindness, respect, listening skills, no preaching, and expertise in matters religious and spiritual. I felt those were too simple, so I did a little exploration. From the Family Satisfaction Surveys in the Deyta reports, I analyzed the Positive Comments to find out more information. The Negative Comments gave no insight. Keep in mind, the family members received the Family Satisfaction Survey within a month of the death of their loved one. Here is a list of descriptors family caregivers used to describe their experience with hospice. The List—You will notice that I pulled together quite a number of descriptors as they were very similar in meaning. 1. By far, the number of times the following words were used were the most frequent: loving, nurturing, kind, respectful, considerate, warm, understanding, great help, gentle, comforting, sensitive, thoughtful, humane, patient, companionship, soothing, sent by God. Without question these attributes of the hospice team were valued far more than any of our expertise or clinical skill. These people had the expectation that we conveyed to them that were important to us, that they mattered. 2. Coming in second place in numbers of times used were these words: great, marvelous, wonderful, awesome, best, super, terrific, outstanding, incredible, exceptional, excellent. All of us like to hear these words said of us, but think about it...these words are filled with approbation and energy! We met all of their expectations and in the midst of their grief they were able to find the words to express their positive emotions. 3. A very distant third were words used to describe clinical skills: expertise, professional, knowledgeable, skilled, informative. My sense is that it was assumed that the physicians and nurses, social workers, chaplains, home health aides, volunteer specialists, and bereavement counselors were all well trained and could do their jobs. It wasn’t the skills that mattered most it was how they went about using their skills that did. So, how do these positive words inform your hospice chaplaincy? Will you do something differently than you have been as a result? If so, what? What did you gain from this?

Monday, July 28, 2014

Reducing Hospital Readmissions

I completed reading an article by Rev. Malcolm Marler, Director of Pastoral Care, University of Alabama Medical Center, titled Support Teams Network Aims to Reduce Hospital Readmissions. You can find this article in the Summer 2014 edition of Caring for the Human Spirit Magazine. His contention is that to reduce hospital readmissions “we need to partner with the community, train lay people. It’s one piece of a big jigsaw puzzle that is today’s health care system.” While not every patient that is readmitted to the hospital is a hospice patient, it needs to be heard that hospice does a great job limiting readmissions due to excellent care of hospice patients. Our patients are urged to call the hospice telephone number in the middle of the night if they sense they need to go to the hospital. A nurse will go to the patient’s home to provide medical care. One of the goals of hospice is to keep readmissions down as hospitals have to pick up the tab if the patient is readmitted within 30 days. Yes, the new health care system is a big jigsaw puzzle. Hospitals and hospices are working diligently to navigate through the turbulent waters of today’s healthcare system. Where does the hospice Chaplain fit in this issue? There are three actions the hospice Chaplain can take in helping reduce readmissions: 1. Listen to the patient and caregiver for their history in seeking medical care. Where have they sought treatment prior to hospice? Pass these findings on to the IDT members. 2. Re-enforce education on the hospice model of care. The nurse and social worker more than likely have educated the patient and caregiver about how to handle after hours medical crises. 3. Observe decline. If the patient has declined significantly since the last visit, alert the nurse. The nurse may or may not know of the recent indications of decline. The Chaplain is a vital set of eyes and ears for the medical team. Regarding decline, I have taught our Chaplains at Cornerstone Hospice and Palliative Care, Inc., The Big MAC. In the next blog post I will share what that is all about. Until then, thanks for all you do to provide excellent spiritual care!

Thursday, July 24, 2014

Voices of the Dying

The dying need to be heard. Our western culture is very uncomfortable with the concept of death and with the dying. Listen to these voices. How do they inform your chaplaincy? “Death will soon remove this bitter cup from my lips. I will be free of this life, my family will be free of this hopeless misery.” “Death is in this house, in the air, in this room. Each day it is closer to this bed, to me.” “To talk about death may be very difficult or even impossible for you. You have so much to carry. I wish I could spare you the painful horror of watching me die.” “What will it be like when it comes?” “You should rest before dinner.” “Rest from what? Rest for what?” “When I am gone, the air will fill the space where my body used to be.” “I love that woman with all my heart.” “Why don’t you look at me when you do talk? Has the cancer so ravaged my body that it is unbearable to look at?” Selah ...

Wednesday, July 23, 2014

“The new Chaplain culture …”

In reading Hospice Chaplains Take Up Bedside Counseling, an older article in the New York Times by Paul Vitello, published on October 28, 2008, I came upon this passage: “The new demand [for Chaplains] has contributed to a steep rise in the number of chaplains of all kinds, said Josephine Schrader, executive director of the Association for Professional Chaplains, the largest certification body in the country. The increase includes traditional chaplains like those who serve police and fire departments, but the vast majority of recruits in the last 10 years — an estimated 3,000 chaplains, representing a 50 percent jump, she said — are working in hospice care. They are in some ways a different breed. “The new chaplain culture is more professional and secular.” I was doing well with the article until the comment, “more … secular.” I’m not sure I know exactly what that is intended to mean. If it means that the hospice chaplain can speak intelligently about a multitude of issues that are not religious, but secular, Ok. If it means that the hospice chaplain is conversant about the medical jargon swirling about the hospice patient, Ok. If it refers to the hospice chaplain being a skilled listener and not a rhetorician during a pastoral care visit, Ok. But, if by secular is meant the antithesis of spiritual then it’s not Ok. By spiritual I mean sensitivity to sacred ideals and practices. Most of the patients I have served desire the sacred act of prayer. The dying are very interested in spiritual matters. They might not be Christian in their faith practice and belief, but they are interested enough in their personal spirituality to ask for a spiritual leader of their faith to assist them on their final journey. In my work, I have provided spiritual care for patients from every American-based religious denomination, Eastern religious systems, atheists, Jewish persons, agnostics, and others that are spiritual, but not religious. How can a hospice chaplain do that? There is only one way … by being oneself. I am who I am. I don’t parade my faith in my visits. I don’t seek to proselytize, convert or otherwise evangelize. I seek to accept, to provide support and encouragement, to listen to the story of each patient, to know them as persons. As I look to my personal hero for spiritual care, Jesus Christ, I try to emulate His broadness of appeal to persons of all walks of life and value them as He did. My experience has been that the question of "Where will I spend eternity?" comes up without any prompting by me. In those sacred moments, if the patient so desires we discuss the issue. If the patient desires a spiritual guide from his or her faith community, I contact that person. Otherwise, we try to sort things out with the patient. So, in the final analysis, I still don’t know what was meant by ‘secular’, I just know what I do and who I am. That’s enough for me.

Friday, July 18, 2014

Fostering hope in caregivers

Caregivers shoulder physical, financial, emotional, and spiritual issues that for most would be back-breaking. How many of us in hospice chaplaincy haven’t witnessed the exhaustion of the caregiver of an AD/dementia patient? or of the Parkinson patient? or ALS patient? That is not to exclude the stress and mental, emotional, and spiritual exhaustion caregivers of COPD, cardiac, or cancer patient’s experience. It is in the purview of the Chaplain to foster hope in the caregiver. How? “Previous research conducted by Benzein and Berg [Benzein E, Berg A. The level of and relation between hope, hopelessness and fatigue in patients and family members in palliative care. Palliative Med. 2005;19(3):234–240.] noted that family members of patients in palliative care had significantly lower hope than the patients, indicating that the family members' suffering may be greater than the patients. One reason for the lower level of hope noted by Benzein and Berg was that the needs of family members of patients in palliative care were insufficiently met, especially in regard to information and communication from healthcare professionals. Caregivers in the study by Perreault et al [Perreault A, Fothergill-Bourbonnais F, Fiset V. The experience of family members caring for a dying loved one. Int J Palliat Nurs. 2004;10(3):133–143.] also identified the lack of support from healthcare professional as a factor that negatively affected their caregiving experience. Thus, it was postulated that encouragement and support offered by healthcare professionals can provide family caregivers with the strength, confidence, and comfort necessary to participate in the caregiving process, which can ultimately foster hope and lead to a positive experience for both the family caregivers and their loved one.[Benzein and Berg] Similar findings were noted by family caregivers in the current study, indicating that physical support, informational support, and reassurance offered by healthcare professionals and other supportive individuals were necessary to maintain hope during the caregiving experience.” [The Lived Experience of Hope in Family Caregivers Caring for a Terminally Ill Loved One, Sara S. Revier, RN, ACNS-BC, Sonja J. Meiers, PhD, RN, Kaye A. Herth, PhD, RN, FAAN,Journal of Hospice and Palliative Nursing. 2012;14(6):438-446.] (emphasis mine) Each Chaplain will have to decide how this information informs their approach to spiritual care, but there are several huge targets at which to aim one’s care: informational support, encouragement, and reassurance. While it seems that these three arenas of support require a good bit of talking, they also require a good bit of listening. I can recall listening to the exhausted pleas for help of the daughter of one of the dementia patients as she was at the end of her patience and emotional strength after what seemed to be several sleepless nights. She needed to be heard more than she needed to be talked to. I did, however, give the nurse a call to explain some of the issues she was having with her mother and have her provide education on those matters. The daughter just needed to talk it out. For this woman, prayer inspired new hope even in her most exhausted moments. It provided a sacred break in her world. I am convinced that hospice Chaplains have the background in pastoral care to provide for the needs of caregivers. Thank you for all you do in your work!

Wednesday, July 16, 2014

The Message of Illness from the Patient’s Perspective

I read a sign that went something like this: “Remember, dealing with death is an everyday thing for us, but for our patients it is their first time.” Do we know what the patient has been through? What is a ‘day-in-the-life-of’ our patient? What have been this patient’s experiences in the healthcare system? What do we really know about this patient? How do the previous questions inform your chaplaincy? I ask because in too many conversations with chaplains I get a queasy feeling that a one size fits all approach to spiritual is being used. That simply won’t cut if for excellence in spiritual care. Please listen carefully to the results of a compelling study conducted by Julia Overturf Johnson, BSN, MA, Daniel P. Sulmasy, OFM, MD, PhD, and Marie T. Nolan, PhD, RN titled, “Patients’ Experiences of Being a Burden on Family in Terminal Illness”, found in The Journal of Hospice and Palliative Nursing. September 2007; 9(5): 264–269. “An under-recognized aspect of care burden at the end of life is how dying persons experience and manage the fear of being a burden on their families. This burden can have emotional, physical, social, and financial aspects. Patients with terminal illnesses face grief and fear not only for their own future but also for their families’ future. These concerns over how their illness will affect their loved ones may influence how they seek care, what decisions they make about their care, and even how they experience dying. The purpose of this study was to further explore the concept of fear of being a burden on family from the perspective of the person in the terminal stage of illness.” My experiences as a field Chaplain attest to the validity of this finding. I recall a nursing home patient with a short while to live shared with me that she would be glad when her life ended so that she would no longer be a burden to her daughter. We explored those feelings a bit. My sense was her statement was not couched in terms of self-pity or depressed mood, but out of a sense of reality. Her daughter’s life was negatively impacted by her illness and the sooner her life could end the better. She was ready to die she said. In another case, the emotions of a husband erupted when he learned that his wife could no longer care for him at home and the option his wife had was to place him in a facility. His worst fears were realized. He was so great a burden that he was “put away.” How do these two episodes in real life inform a Chaplain’s spiritual caregiving? To the patient? To the caregiver? Herein lies another attribute that sets the hospice chaplaincy apart. The hospice chaplain develops a trusting relationship with the patient and family so these fears can find a place in conversation. And, in finding that place they are not diminished, marginalized, or ignored (perhaps a better word would be ‘missed’) by the attentively listening Chaplain. The Chaplain hears the pain, the wounded-ness, the grief the patient is expressing and applies soothing spiritual counsel to the wound. It takes skilled listening, mature understanding, and wise words to assist these persons through their journey of feeling like a burden.

Monday, July 14, 2014

Staying Spiritually Grounded

The demands of the hospice chaplaincy require a Chaplain to stay spiritually grounded. Crisis is the daily event for the Chaplain. Absorbing the pain of others, providing a presence of calmness and serenity in the face of chaos; assisting family members by listening to their pain, guilt, and sorrow; and, navigating the politic of a facility, ALF, or hospital takes its toll on the Chaplain. One might say that the ‘emotional cup’ of a hospice chaplain gets filled every day. Herein lies the absolute necessity of spiritual grounding. If I might digress to capture a thought that begs for expression … Many hospice chaplains come into the field from the parish pastorate. The reasons for this vary, but it can be said that there are those whose experiences with the local church were less than pleasant. For the Chaplain, as well as, the lay person, spiritual pain inflicts deep wounds that cry out for healing. As I review the 25 years I served as a Senior Pastor, I reflect upon the harshness of some church members, the judgmental-ism of church leaders, and the unfortunate surprise announcement that a family was changing their membership to another congregation. These type of events can and do leave a parish pastor in pain. On a very personal note, I recall a meeting with the deacons of the church I served when my marriage collapsed and divorce was pending. The meeting was called with the intent of electing new deacons to serve the spiritual needs of the church. Three men, however, had a different agenda. For an hour, they publicly flogged me emotionally, used the Bible as a brick bat, and when I failed to take the bait to respond in anger at them one of them wagged his finger in my face and declared, “You ought to be ashamed!” That whole scene was unbelievably painful. For the sake of clarity, this group was informed months previous that my marriage was in a shambles and I sought their prayers. When a pastor’s marriage fails it is a trauma to the lay leadership and the church as a whole. I do commend the general membership of that particular congregation as they allowed me to serve them for over a year and a half following the divorce. Those three men who co-opted the meeting soon left for membership in another congregation. It’s been over 10 years since the marriage break-up. God has healed the wounds. I have remarried and have a wonderful marriage and great life. Through those years, I have had the opportunities to fill in for pastors who were on vacation and even serve a church of nearly two years as a bi-vocational pastor. Some Chaplains will not serve in any capacity in a church. The wounds are just too deep and there are too many trigger points to remind them of the past. In knowing the amazing pastoral care skills these men and women possess, I can say with confidence that the church lost many skilled leaders. For me as a hospice Chaplain, these painful experiences inform me that the flashbacks are real and need to be dealt with. Stuffing pain is never a wise action. I believe the Bible says very clearly “let no bitter root grow up to cause trouble and defile many” (Hebrews 12:15). Bitterness and hospice chaplaincy are totally incompatible. Being spiritually grounded then reaches backward to bring healing to the past. There are present realities that lend credence to spiritual grounding. Connecting with a family whose child is dying of Hurler’s Disease, with a woman whose husband of 48 years has lost his personality and body functions to late stage dementia, with a teenager who has just been thrown into emotional confusion by the untimely death of his father … each of these scenarios call for a chaplain whose spirituality is healthy and strong. Where does the Chaplain get this spiritual grounding? This question will have many answers. Some would say through attendance at a house of worship. Others would say, through daily reflection from Holy Scripture or other sacred writings. Still others would suggest through fellowship with a spiritual director. And others would not say, but affirm their grounding is solid. Wherever the Chaplain finds spiritual grounding is secondary to the fact that this is a vital need in the Chaplain’s life. What are your thoughts? How do you find spiritual grounding?

Thursday, July 10, 2014

What sets Hospice Chaplaincy apart?

From the outset, I want to say that I love hospice chaplaincy. Here are two observations I believe set hospice chaplaincy apart from other types of chaplaincy work: 1. Hospice chaplaincy is a calling few can fulfill. Is this a prideful statement? Not at all. It is a statement of truth. I have seen chaplains come and go. The work is simply not for them. Dealing with death, uplifting the sorrowful, and working within the confines of a care team are not necessarily great fits for many minister-types. It is a daily grind to meet all the requirements of Medicare and the local hospice agency all the while providing compassionate and heart-felt care for patients and their families. Working with a patient toward a good death, providing wise counsel to hurting family members, and being the active presence in their world that many times has dissolved into chaos all require a unique calling. Hospice chaplaincy is not the pastorate. Hospice chaplaincy is not a counseling ministry. Hospice chaplaincy is not social work. Hospice chaplaincy is not something that a local parish pastor just takes up. The demands of the patients at end-of-life require spiritual care skills that have been honed to a sharp edge through education and praxis. A one-size-fits-all approach to patients is an embarrassment to the work of the hospice chaplain. One with a calling to hospice chaplaincy will never be satisfied with 4 units of CPE, but will expand his or her horizons of spiritual care through continued study and research, through writing, through speaking engagements, through a contagious attitude which inspires colleagues and others. The hospice chaplaincy does not require Board Certification, but should. Every calling in a ministry setting should serve as a motivation to gain as much knowledge, insight, and skill as possible to do the work with excellence. Frankly, as I review my journey of hospice chaplaincy service, I sensed and even heard others in healthcare settings denigrate and marginalize the hospice chaplaincy because of the low requirements for CPE and Board Certification. I hear the other side of the coin from hospice chaplains who are really good at what they do, state that they would have no problem with obtaining 4 units of CPE and even Board Certification but for one thing. That one thing is financial compensation for the Board Certification. Let’s face it, CPE and Board Certification require much time, effort, money, and in most cases, agony of soul. Yet, in most hospice HR job postings, there is a requirement of only 1 unit of CPE and a few years of ministry experience. That needs to change; however, in the environment that hospice now finds itself, the salary scale will not change any time soon. The reasons for that are another story, but suffice it to say that hospices across the country are going through spasms of financial turmoil unseen in the short history of hospice in America. So, in my way of thinking, I value the calling and as an expression of commitment to that calling, I will continue to educate myself, obtain certifications I believe serve the hospice agency well, and will work tirelessly to educate and motivate my colleagues. 2. Hospice chaplaincy requires excellent people skills. One of the challenges I have had to work through is the cynical, raised-eyebrow-looks due to my faith background being Southern Baptist. To some this conjures up an image of a fire and brimstone preacher with veins sticking out in his neck and forehead and maniacal look on his face, and, also, an attitude of spiritual of condemnation and judgmental-ism. I must say that even in the credentialing process I bumped up against this. That was a very disappointing experience. Whatever background the hospice chaplain is from and whatever challenges he or she may experience one thing is crystal clear; the hospice chaplain must have excellent people skills. The hospice chaplain is not the keeper of the faith, the corrector of the faithful, or the critical eye of the wayward patient or family member (as judged by the chaplain). The hospice chaplain must navigate the maze of belief systems different from his or her own; work through prejudices of family members; actively listen for the question behind the question or the pain behind the rage; creatively attempt to communicate spirituality to patients whose minds have succumbed to the ravages of dementia; function extremely well in the clinical environment; humbly ask for clarification of medical terms, social work terms; seek to position the chaplaincy as a vital contribution to the care team; and, do all this and much more, with grace and skill. The chaplain’s persona can be gregarious, sanguine, introspective, quiet, or any combination of such. Concern for the staff, the patient, the patient’s family, the IDT, the many persons that cross the path of the chaplain and, of course, competence in people skills are key components that will bring the chaplain success in his or her work. Thank you to my Hospice Chaplain colleagues who have paid and are paying the price to provide excellence in spiritual care to the patients they serve. I continue to respect and admire your work.

Tuesday, July 8, 2014

Keeping on the right path … The Safety-net of Healthy Boundaries

It is required of a hospice Chaplain to function in a manner that respects the physical, emotional, and spiritual boundaries of others. Len Sperry, MD, PhD, in his book, Sex, Priestly Ministry, and the Church, 2003, page 10 gives a vivid definition of boundaries: “Boundaries are norms, rules or codes that characterize an individual’s personal space or environment and his or her sense of security and safety. Healthy boundaries provide a nurturing and safe physical, emotional, sexual and spiritual environment for individuals.” Drawing from an earlier blog, “Pastoral Formation: From Theory to Action,” I noted Bowlby’s Safe Haven. Healthy boundaries create the safe haven. Violations of boundaries lay waste a healthy pastoral relationship. The key enemies of healthy boundaries are pride, overconfidence, and embarrassment. Pride believes the Chaplain is above even having boundaries because chaplaincy suggests a high degree of integrity and the Chaplain certainly must be a person of that level of integrity and would never have a problem with boundaries. Overconfidence is the twin of pride. It speaks of arrogance, “I can handle it;” “Rules are legalistic. I live in grace;” “Rules drown my creativity;” etc. Embarrassment cries out, “My God, what have I done? I can’t tell anyone. I’ll be fired. My reputation is ruined. I’m done. I can’t tell anyone, they’ll hate me…” Firm boundaries must be set around the issue of sexuality, for sure; however, the necessity of boundaries includes other areas, such as: borrowing or lending of money from a patient or patient family member; abuse of pastoral authority/power; violations of confidential discussions (unless it involves self-injury or injury to others) to name a few. The issue of pastoral authority or power plays into the discussion of boundaries. When a Chaplain, the one in a position of power, interacts with a patient who is subject to that power or position, then the person with power should honor and support the boundaries of the other person. In hospice care we often talk about the patient being in charge of the Plan of Care. If that is the case, then respecting the boundaries the patient sets is the norm. Respecting these boundaries and keeping true to one’s own boundary set lends dignity to the pastoral care relationship. How all of this functions in the hospice setting can be seen in the following events:  Spiritual Boundaries: I was called upon to visit a patient who was a follower of Wicca. I gained insight into the sensitivity she possessed regarding her faith. Her brother denigrated her beliefs. She took that as a personal attack. Therefore, I sought to respect her faith choice by not challenging it and by allowing her to express how Wicca benefited her. I focused on her story and what she considered were her greatest spiritual needs. This has been my pattern in all spiritual care encounters. The patients I provided care for do not need a Chaplain to condemn, judge, or otherwise marginalize their belief system at this most vulnerable time in their lives.  Physical Boundaries: Respecting the physical boundaries of the patients I serve is evidenced in three ways: I respect the patient’s space. I do not carelessly touch any patient. Personal space is much like a bubble encircling the patient in a three foot radius. As interested as I am in the story the patient is telling, or as closely as I need to get to hear the hoarse whisper of a patient, I respect that radius.  Emotional Boundaries: Patients in hospice care are vulnerable emotionally. It was my privilege to serve a patient who felt safe enough with me to share her story of childhood abuse at the hands of several of her male neighbors. She lost dignity and a blow to her personhood through those violent acts. Creating sacred space through active listening and a safe haven for her to unpack the pain of decades of self-loathing were the only goals I had in providing spiritual care. There was never any prying or leading questions which would have violated her personhood. After all of the pain tumbled out, this patient needed the assurance that her sharing this dark portion of her past was safe with me. Together we negotiated how we would proceed. She gave me permission to refer her to our counseling staff so that her emotional wounds might find treatment. In the weeks that followed, she received emotional care from counselors trained in this type of abuse. I noticed a marked improvement in her emotionally and spiritually. It was agreed that the counselors would counsel and I would provide spiritual care. Again, another boundary was respected. This is simply how it must be. There are general guidelines for a hospice Chaplain that will hold him or her in good stead: 1. The Chaplain is always responsible to safeguard the relationship. 2. The Chaplain must always act and talk in such a way as to prevent harm to the other. 3. The Chaplain is not a surrogate: not a father, not a mother, not a spouse, not a child, not a therapist, not an accountant, not a lawyer. 4. Be sensitive and honest with yourself about your sexuality and personal needs. 5. Be responsible for proper self-care. Give adequate attention to your spiritual, emotional and physical well-being. 6. The Holy Writings or Scriptures to which you adhere do not justify, minimize or rationalize misconduct. 7. Consider every pastoral relationship like a body of water - don’t get in over your head. Drowning in poor judgment is still drowning.

Thursday, July 3, 2014

Spiritual Care Crises: Who do I see first?

One thing the hospice Chaplain will soon discover is that handling crises is part the work of spiritual care. Whether the Chaplain visits patients in their home, facility, or hospice house managing crises will test the mettle of the Chaplain. Wisdom and information are two key elements in the process of triaging patients and their families. It would not be unusual for the Chaplain to receive emails or phone calls from the Case Manager Nurse informing the Chaplain that a certain patient has transitioned to actively dying and the family needs the Chaplain by their side … NOW. Add to that emails and calls from other CMs and even family members and the Chaplain’s day is now filled with crises. The Chaplain must then prioritize and triage based upon the following: acuity and intensity. Regarding acuity, the following questions seem to assist the Chaplain to develop a triage list of priority: What do I already know about the patient? When did I last see this patient? What is happening with the patient? family? What did I glean from my collaboration with the Nurse? Is this a difficult case that requires quick response? The concept of intensity is subjective, but that does not marginalize or minimize its importance. What did the Chaplain understand from the tone of the conversation with the Nurse? with the family member? When the Chaplain asked questions for clarity as to the acuity level (the Chaplain would never use that word with the family member) what was the response? At this point the Chaplain has enough information to make a decision on where on his/her visitation list this patient/family in crisis will fall. As the Chaplain works through the crises it will be naïve to think that a day filled with crisis will not tax the Chaplain emotionally and spiritually. At this point, the idea of self-care takes front and center stage in the Chaplain’s life. Many Chaplains come into the hospice environment from the parish pastorate. Often in the parish scene a pastor will not practice healthy self-care because of the demands of the congregation or their disdain for the pastor having need for self-care. Unpacking emotions with a colleague or manager is always a good first step. Some IDT’s have a debriefing session to support one another. Chaplains and other IDT members who follow the sage advice that reads, “We must care for one another. If we don’t take care of one another, how can we take care of our patients and families?” Hospice is built upon compassion, understanding, patience, support, encouragement and many other such concepts. We need one another in the IDT. There is no room for a “lone-ranger” attitude. The “lone ranger” will soon burn out. Triaging based upon the acuity and intensity will assist the Chaplain to develop a strategy to meet both patient and family crisis. Self-care will prevent attrition of the staff and build a deep bond of trust and strength within the IDT. Do you have examples of how you were overwhelmed with crises and how you handled it? Together, we can offer great ideas to support one another.

Wednesday, July 2, 2014

Pastoral Reflection: Being Who I Am Without Repelling Others

Articulating a theology of spiritual care requires significant reflection on one’s own belief system and a sense of fearlessness to put word to paper and declare, “This is who I am.” A caveat to that declaration is to be sure that who you are and how you carry out who you are is not offensive, pedantic, or filled with counter-transference issues. What follows is my personal theology of spiritual care. My theology of spiritual care is rooted in my understanding of the doctrine of the Holy Spirit. In John 14:6, Jesus states: ‘And I will ask the Father, and he will give you another Counselor to be with you forever …’ (New International Version) The Greek word translated Counselor is παρακλητον “and it literally means God at hand, One by our side, One that we can call upon in every emergency, One that we call upon, or call to us, One ever within call. In this connection the Holy Spirit is represented to us as the present and all sufficient God.” (The Holy Spirit, pg. 78, A.B. Simpson) The Holy Spirit’s work is seen as “practical efficiency and sufficiency for every occasion and emergency that arises.” (Simpson, p. 78) Simpson’s conclusion that the Parakleet involves Himself in the emergencies of life informs my work as a hospice Chaplain in that I am a vessel to bring God at hand and that I am called to the side of a patient. The functions of the Holy Spirit as they apply to my work as a Chaplain involve comfort, counsel, and companionship.  Comfort: As I understand comfort in the hospice setting, it is the absence of feeling alone in the battle against life-limiting illness and suggests there is someone alongside the patient and family as they face the illness. It is my privilege to be that person that comes to the side of the patient and family. I assist the patient and family by providing spiritual care and by providing comforting rituals or finding religious leaders who will do likewise. Involving a Rabbi, a Vietnamese Buddhist monk, a Catholic priest, a Hindu religious leader, or a local pastor are actions I take to assist the patient to receive comfort in their religious belief system. Providing effective and timely interventions (active listening, prayer, Scripture reading, to name a few) assists the patient and/or family members to find comfort in their crisis. Often, just showing up and “sitting in the dust” (imagery from the book of Job) with the patient provides comfort. I hasten to say I recognize the danger that “religious language and practices provide [Chaplains] with a readily available means of escaping the demands of serious dialogue, and retreating into the religious authority role.” (Benner, Strategic Pastoral Counseling, p. 38) Instead, I carefully employ interventions which avoid churchy and empty religious buzz words and seek to engage the patient in meaningful dialogue.  Counsel: My understanding of giving counsel is to explore with the patient the deeper issues of life, such as, meaning, forgiveness, relatedness, and hope. (The American Book of Dying, 2005) Many hospice patients I served and serve ask difficult questions in their quest for inner peace: Who am I? Does my life still have meaning? Who is it that I need to forgive or who needs to forgive me? How am I relating to myself, my family, my God? What is my hope? Do I feel hopeful, hopeless? For instance, I served a father who was estranged from his two adult children. He brought up the fact that he and his children were alienated due to his neglectful and selfish lifestyle when they were young. While he understood how they felt and why, he was deeply moved to reach out to them before his illness claimed his life to seek their forgiveness. He pondered how he could express to them his desire for forgiveness and decided the best way to contact them was to send a letter. When I came back for the next visit I found him at his kitchen table writing letters to his children. He asked if I would proof read the letters. What he wrote literally brought me to tears. This patient owned all that he had done, how wrong he was, how badly he felt about it, and sought their forgiveness. [While he did not place this request in the letters, he told me that he wanted two things: forgiveness from his children and to see his grandchildren.] He sent the letters later that day. My next contact with him was at the Emergency Room at Lakeland Regional Medical Center. When I approached his bed, he looked at me and said that he knew he was dying, but it was OK. His children had responded positively by forgiving him and bringing his grandchildren to see him. He said it was a moment that he had longed for. To be a part of such an experience of reconciliation was very moving and fulfilling.  Companionship: Accepting each patient as they are forms the basis of companionship. My interaction with a follower of Wicca is an example of this. At first, she felt very hesitant to allow me to visit with her. However, during the visit she must have sensed my purpose in visiting with her was to provide support and encouragement rather than judgment and condemnation. In one conversation she contrasted my approach with that of the members of her church when she was a youngster. These persons condemned her father because he didn’t attend church and informed her that he went to hell when he died. The spiritual pain and damage of those words led the patient to embark on a spiritual quest to find a religious system that did not preach the doctrine of hell. She discovered Wicca and embraced it because she felt safe in its teachings. Thankfully, she felt safe with me as I provided spiritual care. It is never the position of the hospice Chaplain to condemn or judge any patient. My faith system informs my chaplaincy as I try to model the compassion and kindness of Jesus before my patients and families. I am convinced that when a hospice Chaplain develops his or her theology of spiritual care that it become the compass for their chaplaincy. It, indeed, becomes who we are in our interactions. I would like to hear from you as you state your theology of spiritual care.

Tuesday, July 1, 2014

Pastoral Formation: From Theory to Action

Theory is great. Action informed by theory is even better. In the Clinical Pastoral Education classroom environment ideas on how human developmental theory applies to chaplaincy can get very tiresome. Applying this knowledge in the field, however, is very energizing! This essay will include both theory and its application. In the course of my CPE research I discovered the works of John Bowlby, Carl Rogers and Harvey Chochinov provide a basis for my understanding of human development theory. The writing of Ira Byock, a hospice physician, provide an almost devotional aspect to this study. So as not to totally bore the reader, I will briefly state a focus of each of the theorists. Bowlby’s writing is exceptionally challenging to read, but he informs my ministry in that he suggests the Safe Haven. Since relationships are the foundation of hospice chaplaincy, I find it fundamental to establish a Safe Haven for those that I serve. There has to be a place of safety, a relationship of safety for the hospice patient. A lot is going on in the heart and soul of a hospice patient that is longing to come out. Consider the inner suffering of a patient I served who bottled up 64 years of pain caused by sexual abuse at the hands of 3 men when she was but a child. She swore herself to silence until decades worth of pain gushed forth during a pastoral encounter with her. She felt the relationship with this Chaplain a safe haven to unload this heavy baggage. I can’t state it enough that hospice chaplaincy is based upon relationships. The Chaplain must be adept at creating ‘instant’ relationship by his or her demeanor characterized by kindness, sincerity, heart-felt concern, non-judgmental and non-condemning terminology and body language that affirms genuine care. Carl Rogers is well known for his person-centered approach. His belief in the importance of empathically understanding a client's emotional experience and reflecting it back in a way that orders and distills it informs my work daily. Patients (persons in general) need to feel heard. Rabbi Maurice Lamm adds his thoughts regarding empathy, “Do not tell me you have empathy, show me you have empathy. Empathy is not something you talk about, it is something you do.” Rogers wrote in Experiences in Communication, “I hear the words, the thoughts, the feeling tones, the personal meaning, even the meaning that is below the conscious intent of the speaker. Sometimes too, in a message which superficially is not very important, I hear a deep human cry that lies buried and unknown far below the surface of the person. So, I have learned to ask myself, can I hear the sounds and sense the shape of this other person's inner world? Can I resonate to what he is saying so deeply that I sense the meanings he is afraid of, yet would like to communicate, as well as those he knows?” The Chaplain, of all persons on the Interdisciplinary Team, must be the one to express and consistently express empathy to the hospice patient’s plight and suffering. Chochinov is of particular interest to me as he developed a theory of care called Dignity Therapy. Dignity Therapy assists a patient tell the story of their life. The Chaplain works with the patient listening to the stories that matter most about their life. As the patient tells these stories, the Chaplain either records or takes copious amounts of notes to capture the patient’s stories. The stories are transcribed, presented to the patient for editing, until the document is completed. This legacy document is then passed on to the family at the patient’s death. “I didn’t that!” “Really? Wow!” “I didn’t know he felt that way about me. I love him more now.” These are some of the reactions of loved ones who read these legacy documents. Again, hospice chaplaincy has much to do with relationships. Ira Byock writes in The Four Things That Matter Most, “Please forgive me. I forgive you. Thank you. I love you. These four simple statements are powerful tools for improving your relationships and your life. As a doctor caring for seriously ill patients for nearly 15 years of emergency medicine practice and more than 25 years in hospice and palliative care, I have taught hundreds of patients who were facing life’s end, when suffering can be profound, to say the Four Things. But the Four Things apply at any time. Comprising just eleven words, these four short sentences carry the core wisdom of what people who are dying have taught me about what matters most in life.” It has been a humbling and rewarding experience of mine to work with fathers, husbands and others to right relational wrongs and to pass from this world into eternity with inner peace. So, there you have it, from theory to reality. Clinical Pastoral Education provides many skills for the hospice Chaplain to use in providing excellent spiritual care.