"... that is a friend who cares."

“When we honestly ask ourselves which person in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand. The friend who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, not healing and face with us the reality of our powerlessness, that is a friend who cares.” - Henri J.M. Nouwen, The Road to Daybreak: A Spiritual Journey

Standards of Practice for Professional Chaplain in Hospice and Palliative Care—Part 3

Section 3 of the Standards of Practice is critical to growth and chaplaincy development. It would be fairly easy for a hospice Chaplain who is busy meeting the needs of his or her caseload to fall into a rut of foregoing reading and personal growth. This particular Section reminds the Chaplain that the goal is competent Chaplaincy care. There is no such thing as a one size fits all type of hospice chaplaincy. Because of the diversity in hospice chaplaincy, continuing education related to culture, religion, family dynamics, counseling, disease process, medical terminology, research processes, personal devotion and spiritual growth, and contemporary application of Chaplaincy interventions are but a few of the arenas the hospice Chaplain will find enriching and instructional. Section 3 reads as follows: Section 3: Maintaining Competent Chaplaincy Care Standard 11, Continuous Quality Improvement: The chaplain seeks and creates opportunities to enhance the quality of chaplaincy practice. Standard 12, Research: The chaplain practices evidence-based care, including ongoing evaluation of new practices, and, when appropriate, contributes to or conducts research. Standard 13, Knowledge and Continuing Education: The chaplain takes responsibility for continued professional development. The chaplain demonstrates a working knowledge of current theory and practice. There are three words in Section 3 that encompass a great deal of hospice chaplaincy and that inform my ministry. These words are: quality, practice, and responsibility. At Cornerstone Hospice, I wrote the Chaplain handbook and titled it, “Toward Excellence in Spiritual Care.” I specifically used the phrasing “toward excellence” as ‘toward’ infers movement in the direction of. Stale and obligatory chaplaincy won’t work … ever. The hospice Chaplain is committed to quality in spiritual/pastoral care. This is our calling and this calling demands the best the Chaplain can provide. ‘Practice’ suggests to me that hospice Chaplaincy is as much art as it is science. There are nuances to care such as how we listen, how we deliver care, the language we use, the demeanor we portray, the tone of voice, the facial expressions, the body language, the way we identify with patients and family members/caregivers. Practice also suggests growth in ability to deliver evidence-based care. One day the light will come on and the Chaplain recognizes that for all those years she was actually delivering evidenced-based care, it just wasn’t called that. That yes, the “expected outcome” was relief of anxiety; or reconciliation with a sibling, family, faith community; and so on as spiritual concerns were identified and outcomes established. 'Responsibility' identifies who it is that bears accountability for progress. It is the individual Chaplain who determines how far he or she will go in growth and development. I can only speak for myself when I say that there is no economic remuneration enough to cause me to read, to study, to write, to teach, to 'become' my best in hospice chaplaincy. The demands of the profession require no less than my best effort regardless of economic benefit. Not everyone shares that opinion and that is fine. Patients and families will be the direct beneficiary of any Chaplain's maturing in the profession. It seems worth it for that reason alone. Section 3 is the crux of the issue as it focuses on application of theory and practice. A Chaplain who is growing and developing chaplaincy skills is a huge benefit to any patient and family in hospice care.

Standards of Practice for Professional Chaplains in Hospice and Palliative Care Part 2

My method for commenting on this section of the Standards of Care will be to follow the Standard with comments in italics. I am grateful that this Standard has come out and was accepted recently. Further, it must be noted that the arena of chaplaincy that has grown the most in recent years has been that of hospice chaplaincy. In my opinion what will elevate hospice chaplaincy to a more credible level of recognition is the requirement of not only an MDiv. or similar Master’s degree, but also, the requirement of 4 units of Clinical Pastoral Education and Board Certification from one of the major certifying bodies. The work of the hospice Chaplain is challenging as end-of-life issues are complicated. Chaplains engage patients for up to a year or more or for just a few days. Managing the relational aspect of spiritual care requires a highly competent Chaplain. My bias is obvious. But, I don’t apologize. Patients and family caregivers need the best we can offer. The crucible of CPE and the experience of Board Certification develop mettle in the life of the Chaplain that serves patients and caregivers well in the hospice dynamic. Section 1: Chaplaincy Care with Patients and Families Standard 1, Assessment: The chaplain gathers and evaluates relevant data pertinent to the patient’s situation and/or bio-psycho-social-spiritual/religious health. Through use of the Spiritual Plan of Care, the Chaplain addresses many issues in his initial and subsequent assessments. The Chaplain identifies a Spiritual Concern then works with the patient and caregiver to negotiate what it is that they desire as an Outcome or Goal of Care. From there, the Chaplain wisely uses Interventions to attempt to meet that Outcome. This is just the beginning of the clinical aspect of hospice chaplaincy. Standard 2, Delivery of Care: The chaplain develops and implements a plan of care to promote patient well-being and continuity of care. The initial assessment creates the Plan of Care. While the Chaplain has some direction as to what the patient desires for an Outcome, she moves toward that goal at the behest of the patient. In other words the Chaplain serves the agenda of the patient, not vice versa. There will be those visits in which the patient just needs to talk … about anything else but spiritual matters … and that is ok. The entire goal is patient well-being. Counter-transference issues can cause a Chaplain to be anxious and that anxiety has a way of spilling into the pastoral encounter and, in so doing, skew the conversation away from the agenda of the patient. A Chaplain who is self-aware will carefully guard against this. There is no such thing as “I have to talk about this or that or the other” in hospice chaplaincy. A calm demeanor is what the successful Chaplain brings to the visit. Standard 3, Access to Information and Documentation of Care: The chaplain, as member of the interdisciplinary team, assesses and enters information pertinent to the patient’s medical record that is relevant to the patient’s medical, psycho-social and spiritual/religious goals of care. Gone are the days of paper documentation. The Chaplain must have computer skills. Documenting in the agency’s computer program, be it Solutions or Allscripts or another program, is simply an expectation. What is vital to the Chaplain is to memorialize not only the progress toward Outcomes, but also, observations of pain and decline. The Big MAC is a key element in observing decline. It is simple to use in concept and design. Please refer to my post published on 8/1/2014 for a review of the MAC. Standard 4, Teamwork and Collaboration: Team is an essential component of both hospice and palliative care, and the chaplain is a fully integrated member of the interdisciplinary team. The Chaplain has a seat at the table where patient issues are discussed. It is expected that the Chaplain will participate and function in a professional manner along with her colleagues. The Chaplain is expected to engage the IDT to provide support and encouragement. In my career it has been a privilege to conduct weddings, funerals, and other pastoral care support for my Teams. The influence a Chaplain can have on the IDT is invaluable. Standard 5, Ethical Practice: The chaplain will adhere to the Common Code of Ethics, which guides decision making and professional behavior. It is expected that the Chaplain holds the highest of ethical values and lives them out in his work. Standard 6, Confidentiality: The chaplain respects the confidentiality of information from all sources, including the patient/family members, medical record, interdisciplinary team members, larger health care team and local faith community members, in accordance with federal and state laws, regulations, and rules. HPPA guidelines are strict. Carelessness in handling confidential information could cost the Chaplain his/her position and include a hefty fine. Standard 7, Respect for Diversity: The chaplain models and collaborates with the organization and its interdisciplinary team in respecting and providing culturally, psycho-socially and spiritual/religiously competent patient- and family-centered care. The Chaplain is a leader in educating the IDT regarding other belief systems and how those beliefs impact the congregant at end of life. At Cornerstone Hospice, I provided education regarding “Caring for Jewish Hospice Patients” as part of our accreditation requirements. The study was embraced by the IDTs and by many other clinical staff that attended. In hospice care, a clinician for any discipline will engage patients from various ethnic, religious, and cultural backgrounds and do so without regard to those backgrounds. Time and again I have heard of the excellent care given to a patient and family and the theme is the same… “You treated us right.” It is hoped that as we progress through the Standards that we will recognize what great value the hospice Chaplain is to the IDT and the agency in total. There are high expectations, for certain, but look around, there are high expectations for the physicians, nurses, social workers, CNAs, volunteer specialist, and bereavement counselors. And, that is what makes hospice the great service that it is.

A Case for Board Certification

Having gone through 2 certification processes, I think I can make a good case for hospice Chaplains being Board Certified. What does it mean, Board Certification? In a nutshell, having Board Certification means: 1. A Chaplain has successfully completed 1,600 supervised hours of classroom and clinical work. 2. A Chaplain has presented him/herself to a Certification Committee after 2,000 hours of work as a hospice Chaplain. 3. A Chaplain has completed the grueling work of writing responses to 27 Pastoral Competencies and successfully defending those responses in front of the Committee. 4. The Board Certified Chaplain has accomplished a task that few other hospice Chaplains have attained. Does Board Certification make the Chaplain a better Chaplain than those who are not Board Certified? Not necessarily, but it does give the Chaplain a broader sense of the issues surrounding hospice and palliative care and depth of understanding of those issues. Recently, I was asked by the Special Interest Group at the Association of Professional Chaplains to complete a survey from the Joint Commission. I was to comment on their proposed Palliative Care Certification Requirements. One of the proposals had to do with the Chaplain being part of the Interdisciplinary Team. The qualifier to the Chaplain had to do with Board Certification or being Board eligible. Being Board Eligible has to do with the Chaplain completing 4 units of Clinical Pastoral Education, but not appearing before a Certification Committee. It is my deepest hope that hospice Chaplains who are Board Eligible will complete their work on the 27 Pastoral Competencies with APC or will seek Board Certification through the College of Pastoral Supervision and Psychotherapy. Both certifying bodies are extremely competent and will position the Chaplain to accomplish great things in the great work of chaplaincy. It is my opinion that it won’t be too far down the road before the Joint Commission is going to recommend that all hospice Chaplains be Board Certified. This is a new day in healthcare. Chaplains of all types in healthcare must attain the highest for the needs of patients. It is also hoped that hospice agencies will recognize the value of Board Certified Chaplains and seek to make this a requirement for Chaplain candidates.

Standards of Practice for Professional Chaplains in Hospice and Palliative Care Part 1

For the next several days we will look at the Standards of Practice for Chaplains in the hospice and palliative care setting. It is the opinion of this writer that it is timely that these Standards were compiled giving credibility to the work of the hospice Chaplain. As I review history, Standards of Practice seemed to follow some type of crisis in spiritual care or lack thereof. In the 1940’s the Rev. Russell L. Dicks gathered a committee and formulated a set of Standards for hospital Chaplains. Why was this necessary? According to his correspondence: "It has come to the attention of the American Protestant Hospital Association that the spiritual needs of many patients, both in private and public institutions, are not receiving proper attention. In some instances patients are not receiving any spiritual care, in others they are receiving altogether too much.” There was a need presented and a need met through collaborative efforts. With thankfulness, I embrace the Standards of Practice for Hospice and Palliative Care Chaplaincy (compiled by the Association of Professional Chaplains, through whom I am Board Certified). For today’s thought we will look only at the Preamble. It is rich in truth and practicality: Chaplaincy care is grounded in initiating, developing, and deepening a mutual and empathic relationship with patients, families and staff. The development of genuine relationships is at the core of chaplaincy care and underpins, even enables all the dimensions of chaplaincy care to occur. It is assumed that all of these Standards are addressed within the context of such relationships. While the fields of hospice and palliative care differ, it is recognized that both specialties of care are on a continuum that is complementary and collaborative. These Standards of Practice incorporate both the distinctions and the similarities of chaplaincy care within each specialty. The trajectory of hospice spiritual care flies high based upon the relationship the Chaplain is able to build and maintain with the patient and family. In this writer’s experience, it matters little that I share a similar faith background with the patients I am serving. What they have to see is sincerity and compassion in me. There is a beautiful word picture in the etymology of the word ‘sincere.’ Sincere is a compound Latin word: sin=without; cere=wax. The concept goes to the days and times when in the agora a dishonest merchant would attempt to sell a cracked earthenware pot by melting wax in the crack and then when the painting and finishing of the pot was complete, it looked like any other pot. The truth would come out when the pot held its first meal and dripped all over the fire when heated. For the hospice Chaplain looking all neat and professional, the sincerity will reveal itself in the confines of the crisis. "No wax" means effective chaplaincy. That’s our goal … a “no wax” chaplaincy that is effective. The actual Standards will help us define the term “effective.” More to come ….

Hospice Chaplain Ponders Lessons Learned from Survivors

There has been much attention paid to suicide these days following the untimely death of Robin Williams. Our hearts go out to his family and friends. If you or a loved one is struggling with deep depression, please call 1-800-273-8255. Please talk it out. You are special and you matter. What follows is a poignant article written about a hospice chaplain as he deals with survivors of a suicide. In Grief, Stigma on January 24, 2009 at 12:07 pm ORIGINAL COLUMN — Ted Swann, a chaplain for Burke Hospice & Palliative Care of Valdese, N.C., writes in a column for the Morganton News Herald, “In my opinion, death by suicide is the most complicated grief to deal with.” There are no goodbyes … Once, I facilitated a support group for suicide survivors … [in which] the group of six widows ITAL taught me. I was a good listener. Once they felt safe with one another they shared deep feelings, frustrations, anger and disappointments. Swann says he learned several important lessons from listening to the members of that support group: People don’t want to talk about suicide. It’s a different grief … There are at least these three reasons we don’t talk about it: The stigma — What do you feel when people whisper behind your back? … If you don’t know what to say, just be there for your friend. He/she is hurting and is an unfortunate victim … It’s too painful — It’s a sudden, violent death. There’s no gentle way to die by suicide … It is excruciatingly painful, but communication is vital … Theological beliefs — Many Christian churches, and individual members of them, are divided on this question. Personally, I want to look at all of a person’s life, not just the last 60 seconds. I accept the belief that the God of grace encompasses all of life. Swann also makes several observations about the “feelings of anger, guilt and shame” that the support group members shared with one another. Wrongly, we think, someone is responsible. This is more common with a suicide death than with other illnesses. This is an important quotation: “The other day I heard the father of a boy who had committed suicide say, ‘Everyone has a skeleton in their closet. But the person who kills themselves leaves their skeleton in another’s closet.” Each loved one wracks their mind and tears the heart questioning, “What could I have done to prevent this?” In the end, he shares his opinion: The suicide survivors, wounded healers, are the best therapists for each other. Together they work through feelings of shame and guilt. And he offers some excellent advice: A good rule to follow: As we meet people each day, let our kindness and caring be intentional. After all, we don’t know what just happened in their lives. “In response to all He has done for us let us outdo each other in being helpful and kind to each other and in doing good” (Living Bible — Hebrews 10:24). Isn’t it time we talked? I have a friend who is a whittler. The finest I’ve known. He and I made a covenant that if the time comes, we will say to each other, “Isn’t it time we talked?”

Tribute to a Hospice Nurse

When it comes to death and dying There's a special gift you share One that Angels all admire One that goes beyond just care It's a gift of deep commitment One that eases pain and fear And alleviates the sorrow When the hour of death is near Yet this gift is more than comfort More than nursing at its best For it cradles every patient Right up till their last request In this gift you give compassion Wrapped in dignity and love And in honor of your calling There's a tribute found above As a tribute to your Nursing All the care that you bestow High above this earthly planet Hangs a Hospice Nurse Rainbow And this rainbow graces Heaven A reminder of your goals "End-of-life-care" you excel at It's your gift to human souls To the soul of every patient Every brother, Mom and Dad Every household member present Every heart that's feeling sad To alleviate this sadness That engulfs a grieving heart Counseling and intervention Set your Nursing skills apart So within the skies of Heaven Bows of silver dangle high On a rainbow made of glory That makes every Angel sigh And upon each bow of silver There appears a nurse's name As an everlasting tribute For the Heavens to proclaim. © copyrighted 2007 "Angel of Mercy Collection" by E.V. Stankowski RN This poem goes great with a "Nurse Appreciation Week/Month/Day" recognition. Hospice Chaplains are the ones to bring this to pass. Bless you Chaplains!