Something to think about from Dear Abby

Dear Abby: During Mom's and Dad's funerals, I was dismayed at the degree of tension and bickering among us. I am now dealing with an incurable illness that will shorten my life considerably. I have no desire to put my husband through a funeral hosting a family who never liked him. I prefer to be cremated, and a handwritten letter be sent to each of my siblings after the fact. Is this selfish? I don't want people saying things they don't sincerely mean. I didn't have a happy childhood, and my siblings contributed to that. My letter will not be accusatory, nor will it rake up long-ago hurts. I just want them to know that my husband has carried out my wishes and they should not blame him for doing so. Any thoughts? -- KEEPING IT SIMPLE

Empathetic Listening

It was the annual conference of the National Institute for Jewish Hospice in 2013. I sat there in rapt attention as Rabbi Maurice Lamm gave the opening address. His speech started out like this: “My Friends, do not tell me you have empathy. Show me you have empathy. Empathy is something you do, not something you talk about.” What a powerful statement! 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. Ah, the worth of the hospice Chaplain! Amazing ministry it is!

My Inheritance

Hospice Chaplains are instrumental in working with patients who, at the end of their lives, recognize that there are those they need to forgive or who need forgiveness. As I review my own work as a Chaplain, this was a common theme. From seeking forgiveness from family members to seeking forgiveness from a neighbor, these encounters are usually blended with regret and then relief when forgiveness is granted. I came across an inspiring story on sunnyskyz.com written by Joseph J. Mazzella, on August 5, 2014, that highlights the concept of forgiveness, love and faith. The title of the piece is “My Inheritance.” I turned on the television as I made my breakfast this morning. The commentator was going on and on about a family's bitter fight over a dead celebrity's estate. I shook my head and turned off the TV. I went back to my breakfast and ate in silence. I thought of my own inheritance. Mom, Dad, and Nana are all in Heaven now. They didn't leave me any mansions, millions, stock, bonds, planes, or yachts. What they left me was far more valuable. My Nana left me a recipe for homemade spaghetti sauce that fills the stomach and comforts the soul. My Dad left me his short stature and thinning hair so I wouldn't take my appearance too seriously. My Mom left me her slightly crooked chin, unique smile, and love of laughter. My Nana left me her hugs and kisses and the desire to share them often. My Dad left me his silent strength in the face of trouble so I could grow better during the hard times of life. My Mom left me her love of reading and the encouragement to write as well. All three of them gave me the gift of forgiveness when I messed up. They gave me their love and support to become who I wanted to be. They gave me a love of animals, an awe of nature, a reverence for life, and an appreciation of family. They all showed me too a courage and faith when facing death. They left me all this and so much more. A thousand books couldn't contain it all. That is my inheritance and I wouldn't trade it for a hundred billion dollars. My Mom, Dad, and Nana also helped me to open my heart to an even greater inheritance, the inheritance that our Heavenly Father gives us all. We are all born with a heart made for loving, a soul built for kindness, and a mind designed for goodness. We are all called to share this inheritance too with everyone everywhere. God loves us all. We are all His Children. We are heirs to Heaven and we are here to bring Heaven to Earth. May we all do so. Perhaps you have a story from you hospice chaplaincy that highlights forgiveness, love, and faith. We would all love to hear it.

Pediatric Hospice Spiritual Care

I selected the topic of pediatric hospice care for today’s blog post because it caused me to reflect on my beliefs, my faith, my values, and my self-care. Pediatric hospice care, for me, is the most challenging, yet most rewarding specialty in hospice. “Most Americans think of hospices as facilities offering inpatient care to terminally ill adults. ‘But hospice is really a philosophy of care given in all sorts of different settings: the home, the hospital, a nursing home,’ says Pediatric Hospice Nurse Sue Huff, a veteran pediatric nurse who since 1998 has headed one of the country's leading children's hospice programs, Essential Care, in Cheektowaga, N.Y. ‘It's a philosophy of holistic care that takes a patient, whether a child or an adult, and treats not only the medical aspect of their life-threatening illness but everything about them as a person, including how they want to live with what time they have.’” (People, November 13, 2000 Vol.54 No. 20, “Comforts of Home”) My thoughts travel to the young couple whose child was born with a condition that would take her life within a month. My visits with them were filled with listening and loving them as they journeyed with their little one. Holding their baby was an honor. When the child went to heaven, they were resolute, yet very disappointed. Hopes and dreams for their daughter were dashed. Then, there was the spunky 4 year old who had a disease I cannot pronounce let alone write. All I know is that the disease covered her body with painful blisters. Mom and Dad needed me as much as “Spunky” (name changed). They were transplants to Florida from the north. Life for them was difficult, not only because of the terminal illness of their little one, but also, due to long-lasting unemployment and an inability to navigate “the system.” During one visit, Spunky had a question for me her Dad said. She nestled next to me on the couch, looked me square in the eye and asked, “Why did God allow me to have this disease?” How could I possibly answer this question? I reflected the question to her, “That’s a big question, what do you think?” Her answer flowed in childlike simplicity, “Oh, that’s an easy question … It’s to show God’s love.” My response? Let’s put it this way … I was glad my next visit took me 45 minutes to get to. I needed that time to process what she said and the way she said it. There are many more pediatric stories from my experience, but they all pretty much inform my chaplaincy in that focused listening, heart and soul, gentleness of manner and wisdom beyond my abilities are required of me… and then some. Feelings of inadequacy, even failure, were frequent. Those were my issues to resolve through debriefing with a trusted friend. Pediatric hospice chaplaincy tested my mettle. If you have pediatric hospice stories, our group would be blessed to hear them. Feel free to share them.

Chaplain, take care ... of yourself!

The dreaded topic of self-care will take some time and space for reading and reflection. In CPE we heard: ‘Love yourself as much as those you spend your time and energy and health on. All things in moderation or you will pay the price.’ Self-care is a matter that is taken seriously in the APC Pastoral Competencies for Board Certification. This competency reads as follows: ‘Attend to one’s own physical, emotional and spiritual well-being.’ If you have high blood pressure, what are you doing about it? If you have Type II Diabetes, how are you managing it? Are you eating a healthy diet? exercising? If not, why not? You are a key person. Emotionally/spiritually... is there resentment, unforgiveness, anger, passive-aggressive behaviors? All of these are huge barriers to patient and family spiritual care. To put it as clearly as I can, your family needs you and your career needs you, not perfect, but healthy. It was a good read when I came across the story/testimonial of Chaplain Rev. R. Michael Stuart, HR, M.Div., M.A., BCC, Spiritual Care Manager of Home Care and Hospice of Western New York, Inc. I found his journey compelling. You might, as well. A few months ago a lawyer friend of mine posed the question, “What’s the difference between self care and self abuse? He likes to play the devil’s advocate and tease but as I thought about it, he asked a very good question. I say that because I have personally experienced both in my attempts to take care of myself in my work as a chaplain. I believe there is a fine line between self care and self abuse. For example, in my own case I have used alcohol, tobacco, and comfort foods in excess. I have worked too much in unhealthy stressful environments and didn’t pay enough attention to achieving a healthy balance. I didn’t stop to listen to myself and spend time in prayer and meditation. My psychiatrist at the VA says that I have always been busy doing. A few years ago I began to address self abuse and work towards healthy self care. I began to explore my leaning towards a commitment to the contemplative life and contemplative prayer which works for me. It took a painful second flare up of pancreatitis and a diagnosis of Type II Diabetes to help me move towards a healthy self care. When chaplains contemplate self care it needs to be defined. In the competencies of the Association of Professional Chaplains; Section II: Identity and Conduct, it states, “Attend to one’s physical, emotional, and spiritual wellbeing.” In the critical juncture for candidates being considered for board certification, a Certification Committee makes the decision if the candidate is ready. One of the questions which the candidate must answer to the satisfaction of the committee is this one addressing self care. Now it is one thing to be able to articulate how one will take care of oneself in professional chaplaincy but another to actually practice a healthy self care. Stated succinctly in Chaplaincy Today, “Self care is about health and wholeness, being well spiritually, emotionally, physically, and mentally—for the purpose of renewal and personal and professional growth.” I will use myself as an example of a professional chaplain who has practiced both self abuse and self care in my ministry. When I was asked to be your speaker on the subject of self care, I accepted knowing that maybe I could be helpful to some of you who are still early in your chaplaincy work. The first thing I did was to e-mail a good friend, mentor, and former chaplain colleague I worked with at St. Charles Medical Center. He is the senior chaplain with over 25 years of experience. He is a year younger than myself and board certified through National Association of Catholic Chaplains. I asked him to reflect on how we struggled to stay healthy in a very stressful work environment. Since my departure, I asked if our department had developed any policies or practices regarding self care of chaplains. He said no which is not unusual for spiritual care departments. But that doesn’t mean that self care shouldn’t be intentionally encouraged by institutions employing chaplains. What he did write came out of his CPE experience. He responded to my question saying, “Sounds like an enneagram 2! Timing for this talk should be good for you though with the tending to self your docs have demanded. CPE gave us ‘Love yourself as much as those you spend your time and energy and health on. All things in moderation or you will pay the price. The five rules of homework for chaplains are: (1) Don’t drink more than you should; (2)Don’t eat more (or types of food) than you should, (3) Keep your prayer life up; (4)Make sure you get all the sleep you need; (5) Always have someone you can really talk to. Someone who will let you yell, cuss, and/or cry and forget all about it.’ He was that person for me. He concluded, ‘As we have experienced – fall short in any one of those categories and you pay the price.” Of course, I know these rules and so does he. But I have broken them and paid the price; loss of health, inability to focus on those who I am called to serve; inability to continue my ministry, and to inability to maintain healthy relationships. I appreciate his transparency. It renews my resolve to live healthy physically, emotionally, and spiritually. My battle with weight still wages, but I am winning at this point. My challenge to stay balanced emotionally with all of the pulls and tugs on my time and energy is something I am aware of. Going to the gym four or five times a week helps me rid myself of excess adrenalin and gives new strength for my work. Keep myself centered spiritually through my spiritual disciplines gives me focus. I have crashed and burned more than once in each of these key areas. That is why I highlight for all hospice Chaplains the need to be self-aware and resolve to take care of your body, soul, and mind. Your comments and testimonials are welcome.

Attitude

My son recently wrote a letter to a number of his colleagues encouraging them to press on in their work at the hospital he worked at. He has since taken a new position in Atlanta (he is a highly skilled paramedic who served out troops in Afghanistan). I was intrigued by the following event in John Maxwell’s life. As you read, think of how this kernel of truth informs your life and work as a Chaplain or other hospice professional. It was a beautiful day in San Diego, and my friend Paul wanted to take me for a ride in his airplane. Being new to Southern California, I decided to see our home territory from a different perspective. We sat in the cockpit as Paul completed his instrument checks. Everything was A–Okay, so Paul revved the engines and we headed down the runway. As the plane lifted off, I noticed the nose was higher than the rest of the airplane. I also noticed that while the countryside was truly magnificent, Paul continually watched the instrument panel. “All those gadgets,” I began, “what do they tell you? I notice you keep looking at that one instrument more than the others. What is it?” “That’s the attitude indicator,” he replied. “How can a plane have an attitude?” I asked. “In flying, the attitude of the airplane is what we call the position of the aircraft in relation to the horizon.” By now my curiosity had been aroused, so I asked him to explain more. “When the airplane is climbing,” he said, “it has a nose–high or positive attitude because the nose of the airplane is pointed above the horizon.” “So,” I jumped in, “when the aircraft is diving, you would call that a nose–down or a negative attitude.” “That’s right,” my instructor continued. “Pilots are concerned about attitude of the airplane because that indicates its performance.” Paul, sensing I was an eager student, continued, “Since the performance of the airplane depends on its attitude, it is necessary to change the attitude in order to change the performance.” That conversation triggered my thinking concerning people’s attitudes. Doesn’t an individual’s attitude dictate his performance? Does he have an “attitude indicator” that continually evaluates his perspective and achievements in life? What happens when the attitude is dictating undesirable results? How can the attitude be changed? And, if the attitude changes, what are the ramifications to other people around him? - John Maxwell

SPECIAL Clinical Post: Pain and Decline

Chaplains and Their Clinical “Observations” Chaplains are not licensed to assess; therefore, they observe and document using the term “observed”. There are two critical areas that a Chaplain must excel in when it comes to making these clinical observations: Pain and Decline. It has been stated by various leaders in hospice that a Chaplain’s documentation has saved that particular hospice money when charts were reviewed by Palmetto or other Medicare intermediary. The latest requirement of Chaplains is to state which pain scale they used: VAS scale, FLACC scale, or PainAD. Pain Scales The VAS or Visual Analogue Scale is a simple 0-10 scale highlighted by ‘smiley faces’ and ‘sad faces’ for the adult patient. The FLACC or Face, Leg, Activity, Cry, Consolability Scale is a broad-based scale used to observe pain levels in infants and children up to 7 years of age and for adults that are non-communicative (but not dementia patients). It bases its scoring upon 5 areas of observation as posited in its title. Based on the scoring, a Chaplain can document a pain level. The PainAD or Pain Assessment in Advanced Dementia is used to observe and document pain levels in dementia patients. The Chaplain must document using the verbiage similar to this: “Patient states her pain is 3/10 on the VAS Scale.” Observations of Decline The Clinical Chaplain observes indications of decline and documents these observations so that the patient’s chart will reveal a history of decline. The means that I instruct our Chaplains to use is called The Big MAC. The title is easy to remember and easy to teach as most Westerners remember the McDonald’s commercial about The Big Mac. With so much information to be included in the Chaplain documentation, it helps for a Chaplain to have a simple reminder that decline must be documented. The Big MAC includes the following: M—Mobility: How does the patient ambulate? Wheelchair, walker, cane, holding onto the wall, needs assistance? When documenting your observations of decline, note any difference in the manner the patient ambulates from your prior visit. A—Activities of Daily Living: The patient and/or family member(s) may assist you with this observation. Areas of ADL’s to observe or gain information regarding include: eating, sleeping, bathing, incontinence, transferring, toileting. Helpful questions include: How much is patient eating? What amount compared to last visit? Has food been pureed? How is appetite? How is patient sleeping? All night? Partial night? Napping for long stretches during the day? Up at night, sleeping during the day? How many hours of sleep, day or night? Is patient bathing him/herself? Assistance needed? If so, contact Nurse to meet this need. C—Communication: Is there any difference in the manner in which the patient speaks? Is the patient short of breath compared to your last visit? Is the patient struggling to remember words, gets mixed up, repeats the same phrase, has troubled making sense? (all compared to your last visit with patient) Since both of these matters of documentation are proprietary to Cornerstone Hospice and Palliative Care, Inc. I request that my colleagues in leadership positions in spiritual care in other hospices please seek permission before adopting these in your hospice. Please contact me through this blog site and we will assist you. Thank you.