When I started this hospice chaplaincy blog, I had no idea this would happen. There is so little written for the hospice Chaplain to assist and focus on the great work that is done with the dying and their families.
Today, I announce that we now have had 10,000 page views. That is significant. My hope is that this educational blog has assisted at least one Chaplain.
I am humbled and thankful.
If there is something that you found here that informed your chaplaincy please email me at firstname.lastname@example.org or leave a Comment.
Again, thank you, Readers. You are the reason I keep on writing.
Saturday, July 30, 2016
Wednesday, July 27, 2016
It is a distinct privilege to announce that in the Fall, Cornerstone Hospice & Palliative Care, Inc. will be offering CPE.
For more information, please contact me at:
Rich Behers, DMin BCC CFHPC
For more information, please contact me at:
Rich Behers, DMin BCC CFHPC
Prayer of the Abandoned
Hospice Chaplains can recount that many of their patients ask the questions, “Why this?” “Why me?” “Why now?” Some feel abandoned by God. Consider the words of Jesus Christ, God’s Son: “My God, my God, why have you forsaken me?” (Matthew 27:46) For that patient that thinks the heavens are as brass and his prayers go no higher than the ceiling, “I call all day, my God, but you never answer.” (Psalm 22:2) These words of Jesus and the Psalmist are poignant and profound. Allow your Biblical knowledge to come to your aid by remembering the painful experience of Elijah or the tears of Jeremiah as he was lowered into the well, “Then took they Jeremiah, and cast him into the dungeon of Malchiah the son of Hammelech, that was in the court of the prison: and they let down Jeremiah with cords. And in the dungeon there was no water, but mire: so Jeremiah sunk in the mire” (Jeremiah 38:6). In the midst of their feelings of forsakenness and abandonment their feelings of aloneness in their struggle with their disease drives them to silence in their suffering not daring to pray. The emotions are too raw and their words too pointed. They feel that if they told God what they were thinking that the wrath they believe he is pouring out on them would get worse. This is where the skilled Chaplain provides great comfort.
The Chaplain can place a name on this experience: “the dark night of the soul” (St. John of the Cross). David, the Psalmist, cried out, “How long will you hide your face from me?” (Psalm 13:1)
Before I proceed… Herein is one significant benefit of Clinical Pastoral Education. As the Chaplain you bring your spiritual beliefs and experiences with you to every patient. This means your successes and failures, your spiritual highs and lows, your prayer blessings and prayers unanswered, and your own set of beliefs about prayer which could cause you to stumble and utterly fail in discussing prayer with your patient. The emotionally intelligent, emotionally elite Chaplain will not let his/her own journey in life trip up the process of spiritual support with the patient feeling abandoned by God.
Keep in mind, the physical, emotional, and spiritual drain of the disease process can leave a patient feeling exhausted. Exhaustion is not good for spiritual strength. Show the patient the reality of life by reading to them the struggles of David, the man after God’s own heart: “O God of my praise, Do not be silent!” (Psalm 109:1 NASB); “But I, O Lord, have cried out to You for help, And in the morning my prayer comes before You.
O Lord, why do You reject my soul? Why do You hide Your face from me?” (Psalm 88:13-14 NASB) Unless you are not honest with yourself, you have experienced your own dark night of the soul. Your suffering patient needs your strengthening hand and loving heart. Keep in mind there are always miserable comforters that judge and condemn the suffering much like Eliphaz, Bildad, and Zophar, Job’s ‘friends’. [visit my blog, embracedbytheheartofhospice.blogspot.com for the article Horrid and Cruel Counselors] Encourage your patient to attempt to pray and be honest with God about her feelings of abandonment and aloneness. You can be of great help.
Prayer of Personal Need
- Positive Qualities
- Some hospice patients have lost connection to the Divine. The Chaplain, in bringing up the topic of prayer, may unearth resentment, anger, disappointment, or other spiritually based issues that prevent the patient from engaging in prayer. Just the mere mention of prayer will open doors of discussion of faith and hope. Of course, the Chaplain has to be skillful in how he/she introduces the subject. When a relationship of trust has developed, I have found that most topics are open for discussion. Keep in mind the words of John Chapman, “Pray as you can, not as you can’t.” That is a comforting and encouraging message.
- In educating the patient about Prayer of Personal Need, the Chaplain keeps things simple. Think of your own theological training at the beginning of your faith journey. God received us just as we were and He accepts our prayers just as they are. The matter of prayer has been made exceptionally difficult when it needs to be made exceptionally simple. For a patient at the end of life making prayer simple is a worthy goal. The patient has a lifetime of spiritual disappointments and perhaps thinks prayer is too complicated. Now is not the time to get all theological and difficult about prayer. Prayer that is generated out of personal need does not concern itself with formalities, formulas, or worn out clichés; instead, it is pure in its cry of pain and sorrow seeking the intervention of a loving God for strength for not just the day, but for every minute in the day. The seasoned hospice Chaplain will understand the last phrase of the sentence clearly. The journey of the hospice patient can be very draining and dark. Prayer of personal need can provide light for the weary soul.
- Prayer of personal need simply starts by talking to God about what is happening. The patient starts where she is and pours out her heart to God. We talk a good bit about sacred space in hospice. Through the Chaplain’s discussion with the patient about prayer, the patient’s room can become a cathedral of hope.
Prayer for the Chaplain is often used at the conclusion of a visit. It might be a novel concept to make prayer a topic of conversation with your patients.
This shift from prayer as a benediction to the visit to a topic of conversation with very specific Goals/Expected Outcomes will provide benefits of inner peace, comfort, and confidence in approaching God, The Transcendent One, or the Divine depending on the patient’s faith understanding. Using prayer in a clinical fashion will require a Chaplain to cognitively and experientially know the various types of prayer; to develop a clinical methodology to present a type of prayer; and, express a contemplative patience with the patient as he or she journeys through the end of life attempting to connect with God.
The Objective in Using Prayer in a Clinical Manner
The objective in using prayer in a clinical manner is to provide the patient with a coping strategy to strengthen his or her spiritual connection to the Transcendent and to cathartically vent negative emotions and replace them with a more positive affect toward the Divine.
The Common Types of Prayers in Hospice
The following are types of prayers useful for hospice chaplain:
- Prayer of Personal Need
- Prayer of the AbandonedWhat do these prayers look like? In the next few posts I will provide insight on the Prayer of Personal Need and Prayer of the Abandoned.
Wednesday, July 13, 2016
The Documentation Template is a guide that I developed for Chaplains to present their patient in a very professional manner. Please review it as I have included instructions along the way. Yes, we have a piece called the Big MAC. The Big MAC documents the Chaplain's observations of decline. These observations are crucial to highlight that the patient is not getting better, but is, indeed, in a state of decline. I am happy to answer your questions about this template. I can assure you it accomplishes much. One of Team Managers stated that when she wants to know what is happening with a patient she goes to the Chaplain's Clinical Note. Here it is:
Template for Spiritual Care Documentation
Patient information—Pt. presented as a 78 year old, Euro-American male, diagnosed with Alzheimer's Disease, was found in his room seated in his wheelchair.
Purpose of the visit—Not about the task of visiting to keep up with POC, but to deepen the spiritual care relationship…
- Pain level/scale: VAS-is only for those lucid PainAD-ONLY for dementia patients FLACC-ONLY for those who cannot respond because of being in a deep sleep or for some reason cannot speak. This is NOT for dementia patients. This is not an essay question. Simply write: 0-10, 1-10, 2-10, etc. and name the scale.
- Safety issues: You may write this as simple as: No safety issues observed; or, you can state what the safety issues are and how you addressed this with the patient.
Mobility-State HOW the patient ambulates if at all
ADL’s-State as much about the ADL’s as possible: Pt only eating half of her meals/ pt requests assistance with bathing/ pt now taking long naps during the day/
Communication-HOW is pt speaking? With exertion, not making sense, etc.
Plan of Care
- Spiritual concern(s)—Transfer VERBATIM from the General Tab in the Assessment
- Goals and Expected Outcomes—Transfer VERBATIM from the Care Plan Charting Tab
- Intervention(s)-Transfer VERBATIM from the Care Plan Charting TabResponse of the patient/family—Use the verbiage from the Users’ Guide where possible Collaboration—Use the following language: Chaplain collaborated with ______________ about the patient. Subsequent visit—
Tuesday, July 12, 2016
The Outcomes Oriented Chaplaincy model has three components: assessment, goals/expected outcomes, and interventions. As a reference point, the Standards of Practice for Professional Chaplains in Hospice and Palliative Care assist the Chaplain in describing the assessment concept. “Assessment is a fundamental process of chaplaincy practice. Provision of effective care requires that chaplains assess and reassess patient needs, and modify plans of care accordingly.”
In the pastoral encounter with the patient and/or family member(s) it is predicted that a Spiritual Concern(s) would surface. Arthur Lucas provides guidance for the Chaplain as he suggests the importance of identifying a person’s needs, hopes, and resources. (VandeCreek, L., & Lucas, A. (2001). The Discipline for Pastoral Care Giving. Binghamton:Haworth Press). These concerns or singular concern form(s) the kernel of the assessment. It is at this point that the Chaplain would gain insight from the patient to identify their desire to meet that spiritual concern. The Goal/Expected Outcome defines where the Chaplain’s journey with the patient will proceed. The patient’s hopes and resources provide energy, direction, impetus and motivation to touch and attempt to fulfill the goal…or not. This process requires two key pastoral care skills: reflective listening and skilled verbal communication. Never should a Chaplain come across as stiff and robotic, but, rather, with a non-anxious demeanor reflect to the patient a sense of ease. The Chaplain would then use his/her pastoral care skill to employ fitting interventions to meet that goal or expected outcome. Such Interventions are found in the Spiritual Care Algorithm that we employ at Cornerstone Hospice. The Algorithm provides a comprehensive approach to identify the Spiritual Concern, the potential Goals/Expected Outcomes and Pastoral Interventions. If you would like a copy of this tool, please email me at email@example.com and I will forward you a copy. It was my privilege to present this at the Healthcare Chaplaincy Network annual conference in San Diego in April of 2016.
The Spiritual Plan of Care is a fluid document expected to change from time to time during the Chaplain’s journeying with the patient. We use the patient recertification date as a prompt for the Chaplain to update the Plan of Care. CMS requires the Plan of Care be updated. It is incompetent spiritual care to allow a Plan of Care to languish without being updated.
I urge you to read The Discipline for Pastoral Care Giving by VandeCreek and Lucas. This will provide you with additional resources to enhance your spiritual care and skill at developing an effective plan of care. Feel free to contact me for the Algorithms for Spiritual Care, Users’ Guide, and Documentation Template.
Monday, July 11, 2016
In the dynamic and ever-changing world of hospice, it is vital for the hospice chaplain to understand the issues that dominate the healthcare world. Hospice has moved from a movement to an industry. The founding of hospice came as a response to human suffering by Dame Cicely Saunders in London, England, in 1967. From then until 2008, hospice enjoyed an environment of a movement mentality. As Medicare turned its attention to evaluating and assessing the work of organized hospice agencies things began to change. Reimbursement rates began to be tied to certain indicators. Quality improvement based upon outcomes began popping up across the country. Some hospices underwent cataclysmic changes in care given to long-term patients. Many hospices downsized because funding sources dried up. Expectations were put forth and accountability was monitored for every discipline, including spiritual care providers. Into this sometimes chaotic milieu Outcome Oriented Chaplaincy found its place.
The principles upon which OOC is founded are as follows:
- Accountability—This is the foundational principle of OOC. Hospice Chaplains are no longer volunteers, but highly educated and experienced spiritual caregivers. Many are Board Certified. Others have a minimum of 3 units of Clinical Pastoral Education. Hospice Chaplains are professionals in every sense of the word. As such, these professional Chaplains are held accountable for their work. A Clinical Team Manager should be able to look at a Chaplains Spiritual Plan of Care, read his or her Clinical Notes, and discuss patient care issues and come away from each experience with a sense that this Chaplain is providing excellent spiritual support for that patient. Formulating a Spiritual Plan of Care in collaboration with the patient and family, writing a Clinical Note with all of its components, and verbally expressing the needs of the patients in an IDT setting or private meeting with a CM or other IDT members are all part of the accountability process.
- Best practice—This principle focuses on the persons a hospice Chaplain serves. “Best practice refers to a technique, method, or process that is more effective at delivering a particular outcome or a better outcome than another technique, method, or process. Best practices are demonstrated by becoming more efficient or more effective. They reflect a means of exceeding the minimal standard of practice.” (Association of Professional Chaplains, Standards of Practice for Professional Chaplains in Hospice and Palliative Care)
- Collaboration—This principle focuses on how a Hospice Chaplain interacts with other healthcare professionals. Included in this pool of professionals are: The Inter-disciplinary Team, healthcare professionals in hospitals and other facilities, and those in the community at large. This principle underscores the value and broad frame of reference the Hospice Chaplain brings to the healthcare environment. Further, as part of the Clinical Note, it is expected the Chaplain will document any interaction with other IDT members or healthcare professionals who interact with the patient.
Thursday, July 7, 2016
One of the most frequent interventions a Chaplain writes about is Pastoral Presence. Just what is involved in Pastoral Presence? It sounds sort of nebulous, doesn’t it? May I suggest a few ideas on how you convey ‘presence’…
Pastoral Presence means:
- Being compassionate and empathetic
- Being respectful and non-judgmental
- Being genuine and authentic
- Being trustworthy
- Being fully present with the patient
- Valuing the worth of the patient
- Maintaining boundaries
- Being emotionally honestPart of your professional growth and development will be to figure out the “how” on these ideas. Become a student of body language. Learn what you are saying with how you sit, how your face communicates, how your arms communicate. I can promise you that being present is not just sitting there hoping the patient will stop talking, or if the patient is not communicative looking at your watch to see if you stayed long enough to claim a visit. Being engaged with the patient in ‘presence’ is the goal. Making that deep inner connection is another way of describing presence. Your thoughts?
Wednesday, July 6, 2016
If I could teach one skill to new Chaplains it would be the skill of listening. Many Chaplains come into hospice from the pastorate where they do most of the talking. Hospice is just the opposite. Chaplains must be skilled listeners. May we learn from these two Masters of life skills: Stephen Covey and Carl Rogers.
“Most people do not listen with the intent to understand; they listen with the intent to reply,” (Stephen Covey). Isn’t that the truth? The hospice Chaplain listens for the soul’s deep meaning and not to engage in a debate about death, religious beliefs, or some other subject of interest to the Chaplain. The patient has the stage or the caregiver has the stage. The Chaplain listens with the intent to understand.
Carl Rogers gives us instruction through these statements on empathetic listening: “We think we listen, but very rarely do we listen with real understanding, true empathy. Yet listening of this very special kind is one of the most potent forces for change that I know.” In Experiences in Communication, Rogers goes on to say “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?” Are those not questions we need ask ourselves as Chaplains?
There is much to be said about empathetic listening. Let’s start with the basics: Empathetic listening helps people feel heard and not alone. What is the cry of the heart that is fearful, anxious, distracted? Is it not for someone to listen with interest? with concern? with compassion? Secondly, empathetic listening involves many skills and components: relaxed yet engaged body posture; eye contact (when culturally appropriate), reassuring touch (when culturally appropriate), listening beyond or beneath the literal words said by a person to the deeper emotions, meaning, and needs. What may seem contradictory, empathetic listening may also ask you to laugh, be joyous, and not focus on illness, pain, or dying. After all, it is the patient or caregiver we are listening to. They are our focus. And the results? In this day of outcomes oriented chaplaincy we need to be clear on the benefits of empathetic listening: Fear, anxiety, despair, and even physical pain frequently diminish when the person feels heard, understood, and accepted. Personhood, self-worth, and dignity are affirmed. Feelings of isolation decrease. Persons find their own answers in the new milieu of affirmation.
Chaplain Friend, learn this skill and all the others will come naturally.
Tuesday, July 5, 2016
Let me be very clear…What I am about to share with you is not found in the book, Final Gifts. This is but one of several experiences I witnessed that were absolutely shocking, but very real.
It’s been my opportunity to serve as Chaplain to those who either fired their previous Chaplain or were so vulgar that the previous Chaplain stepped out of the picture and I stepped in. I am not intimidated by vulgar language as I see that more as a defense mechanism to try to ward off the Chaplain. People need unconditional love, particularly at end of life. To one patient, who told me to the get the h--- out of his room when I simply knocked on the door of his room at a long term care facility, I simply said, “You’re having a hard time with someone who really cares for you, aren’t you?” He harrumphed and told me to come in. It was one of the best visits I ever enjoyed with a patient as he opened up. He told me he was trying to “bully” me as I was a minister and he wasn’t fond of ministers. Well, it seemed like it all worked out quite splendidly!
Yes, there have been patients at the end of life who died in a shocking manner. I recall a woman who was portrayed to me as one of the meanest people on earth. Since I try to meet people with a blank slate and let them design a portrait of themselves, I tucked those prejudicial statements away and went in to meet her. She wanted to know who I was and what I was doing. After get past that hurdle, I invited her to tell me her story. It seemed that she was successful enough, but something (or several things) apparently went horribly wrong in her life. She went from wealth to pauper status. She was alone in life. Family? Yes, she had family, but they were estranged, very estranged. She just had a Guardian to handle her affairs, however meager they were. She sort of boasted that people said she was mean. It sounded like she relished that reputation. Regarding any type of faith community she embraced, she told me she had none and that had no use for God. The manner in which she said that indicated the subject was not open for discussion. I saw her a few times before she died. The day of her death is one I will never forget. The Guardian called me and asked that I come to the facility. It seemed like the patient was dying. When I arrived, the Guardian was nervous and suggested I pray. I told her that I could pray for her but the patient absolutely forbad me praying for her. It was shortly after I prayed for comfort for the Guardian, that the patient came out of her interlude between life and death and jerked up and looked at us with the face of terror. She then lay back down and died. “What just happened? What did we just see? Did she see something that was so terrifying…?” Those were the questions of the Guardian to me. I am not person’s judge. That look has lingered in my mind for years. It is in stark contrast to the many deaths I’ve attended when someone of faith died. That was the most shocking death I have ever witnessed. Have you had a similar experience?
For those who look askance at these “hospice stories”, let me quote from “Final Gifts”:
We found no common cause for what we were seeing and hearing. Our patients had many different illnesses—varieties of cancer, different heart or lung diseases, birth defects, neurological ailments, AIDS. In some cases, their brain oxygen, body fluid, and body salt levels had been documented as normal. Their medications varied widely, some were taking no drugs at all, others many. In short, there was no apparent physiological explanation for their communication patterns.” (Final Gifts, page 29).
I recognize there are some who would say these nearing death experiences are nothing more that the devil appearing as an angel of light. There are yet others who would attribute these experiences to demon activity. Others, to delirium. All I know is that most all of the patients I served that had these experiences were professing believers. It seems difficult for some to recognize the mercy of God at the most vulnerable time in a person’s life and simply discard the experience as not worthy of serious consideration. Ok, whatever floats your boat.
I received a call from a patient of mine who asked that I come over as she had something to talk to me about. When I arrived her husband led me to their bed room where she was spending her last days. I moved the chair close to the bed so I could hear her weakened voice. She related two episodes to me and asked what I thought. The first occurred one evening when the house was quiet and the lights out. She was lying in bed awake. What caught her eye was the visage of her Mother standing in the doorway to her room. They had a conversation. I asked how she felt about the entire episode. She stated it was incredibly peace-giving. Then, she told me of another experience… She was turning to her left side when she noticed the visage of her long deceased daughter standing next to the bed with her hand on the nightstand. Again, her response was a feeling of deep peace and comfort. She wanted to know my opinion. I told her that I believed God is a good God who provided His children what they needed in the face of impending death. It was obvious that these experiences provided comfort and peace and she was ready to step into Heaven shortly. Her faith was a vibrant faith and she passed into life eternal quietly, peacefully a few days later.
In speaking to a hospice nurse colleague of mine about what I am writing, she said that these experiences happened frequently with patients she served. It was not a matter of medication or anything else. She noted that those who were believers had a very peaceful death, while those who weren’t seemed to have a very hard death. More on that in the next article.
If you have been a hospice Chaplain very long, there is little doubt one of your patients shared with you something like this: “Chaplain, I had a visitor earlier today. I would like to tell you about it.” That has happened in my chaplaincy practice on numerous occasions. Let me share a couple of those experience.
On one occasion I was making rounds at the hospice house. Some patients were alone and sleeping. Their family members used this time as a break from the vigil they were providing. In one room the daughter of the patient was seated on the couch. While her mother appeared resting, she and I talked about the healthy relationship she had with her Mother. We then went to the bedside and spoke briefly to the patient and I was asked to provide a prayer. After the prayer I spoke a blessing of peace and left the room. Perhaps 15 minutes had passed. There was a page for me to report to the front desk. The patient’s daughter was there. She seemed rather shaken by what she had experienced after I left her Mother’s room. We sat down in the lobby and I listened as she told me what her Mother said. “Mom asked me who the little girl was who was holding your hand as you left the room. I told her that there wasn’t a little girl who held your hand. She said that ‘Yes, there was. She was 5 years old with dark hair. She looked at me as she was leaving the room and smiled.’ Chaplain, help me understand what happened.” Now that was a tall order to try to explain what seemed to be the unexplainable. I asked about the daughter’s siblings. Do you have sisters? She said she had a sister who lives in another state. She also stated that she had one other sister who died at a young age…when she was 5 years old. As she recalled that experience of her little sister’s death, the words “when she was 5 years old” came out as it she realized for herself what had just happened in her Mother’s hospice house room. “Chaplain, you don’t think that that was her, do you?” “It just may have been,” I said. Holding the hand of a servant of God as they called me, then turning and smiling at the patient were powerful symbols of life eternal which brought comfort and peace to both the patient and her sister. I spoke to the patient about this and she stated that there was no doubt in her mind that this was her little daughter. Holding my hand then smiling at the patient were so symbolic to the patient. She was more peaceful than ever.
At this point, I need to make a clear statement to newer Chaplains. You will discover that this world is far more spiritual than it is physical. Death is much more a spiritual experience than it is a physical experience. Your chaplaincy will be wonderfully informed as you hear these type of stories from your patients. In the next article I will share about a patient that contacted me about what she saw.
I am reading a most informative book, Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. If you are not familiar with this work, please get a copy. Much of what you experience as a hospice Chaplain will be affirmed. Also, your commitment to active listening will be challenged and deepened.
There are so many nearing death experiences that patients I served allowed me to know about that have provided encouragement and comfort, not just to me, but more especially to their loved ones. I recall Jim (name changed). He and I had a very deep conversation in his hospice journey. His wife, Jane (name changed), was not at all prepared for his death as she was very dependent upon him. This troubled Jim and he made that clear to me. I took mental note of this as it might be needed in upcoming days.
A few weeks from that conversation, I received a call from our hospice nurse. She asked if I could come over to Jim and Jane’s home as Jim appeared to be actively dying. I immediately went and when I arrived, Jane greeted me with tears streaming down her face and with the question, “What am I going to do without Jimmy?” We walked together to his bedside. It appeared that Jim’s remaining time was short. However, he did not die that day or the next or the next. There was something that kept him alive if only barely.
I was called back to Jim’s bedside one evening. It appeared that once again he had taken a turn for the worse. Yet, he refused to die. I asked to see Jane and her daughter who was now there to support her Mom. I told them of the conversation Jim and I had had a few weeks earlier. Jim, in my opinion, needed to hear from Jane that she would be ok after he died. They hadn’t had that conversation prior to him moving to active dying. I asked Jane if she could to tell Jim she would be ok. Jane’s daughter stood by her Mom and I was present with both of them as Jane spoke loving words to Jim and letting him know that she would be ok and that she would be moving in with her daughter. The finances would be taken care and for him not to worry. Within 5 minutes Jim died. After Jane told Jim these words, his body relaxed and his breathing no longer was labored. He passed peacefully knowing Jane would be ok.
Jane took advantage of our bereavement care and she was, indeed, on a path to comfort and inner peace. This experience informed my chaplaincy by showing me that love for a surviving spouse can be so powerful that the dying can refuse to die until they know their loved one will be ok. I am sure you have stories like this. I would like to hear them. Use the Comment section and we will publish your stories.