Cornerstone Hospice & Palliative Care, Inc. becomes a CPE Center

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
rbehers@cshospice.org

The Clinical Use of Prayer, Part 3

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.

 

The Clinical Use of Prayer, Part 2

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. 
     

The Clinical Use of Prayer in Hospice

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 Abandoned
   
   
  What 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. 

The Documentation Template We Use at Cornerstone Hospice

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…

Observations

1. 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.
2. 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.

Decline

                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

1. Spiritual concern(s)—Transfer VERBATIM from the General Tab in the Assessment
2. Goals and Expected Outcomes—Transfer VERBATIM from the Care Plan Charting Tab
3. Intervention(s)-Transfer VERBATIM                from the Care Plan Charting Tab
   Response 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—

More on Outcome Oriented Chaplaincy...

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 rbehers@cshospice.org 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.

 

 

Laying the Foundation for Excellent Spiritual Care

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:

1. 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.
2. 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)
3. 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.