Reflections on the National Institute for Jewish Hospice Annual Conference

For the last four years I have had the privilege to attend this vital conference. This year’s conference was wonderful for two reasons: the content of the program and the fellowship with other conferees. I was particularly inspired by the presentation by David Kessler. His topic was “How Judaism Heals Grief: How do we heal grief? What works and what doesn’t?” Kessler has five best-selling books on grief and is an experienced hospice bereavement expert. What struck me most about him was the fact that he is an excellent communicator whose humility makes his presentation extremely compelling. Kessler posed the provocative question, “Are we destined to die as failures?” Think about it. What is said about patients who died of cancer: “It’s sad she lost her battle with cancer.” “It’s sad he/she lost …” Is that the language we as hospice spiritual care providers want to perpetuate about our patients? Let’s change the language from “she was a great painter/a stellar actress/a fantastic friend”, to “she IS a great painter/a stellar actress/a fantastic friend”. Let’s keep the present tense when talking about patients. They are not a “was” until they die. There was so much more Kessler had to say… For more information, please go to his website, www.grief.com. Rabbi Young spoke with passion and energy as he presented “From Dying Until Burial”. No one should die alone was made crystal clear. That is one of the goals at Cornerstone Hospice. Humility is the value most important to a funeral. The casket is made of wood. The wealthy and the poor are buried in the same type of casket. The money not spent on the funeral may be given to a worthy charity that helps the poor. The fellowship around the lunch table was particularly energizing. Hearing from Rabbi’s, Chaplains, and hospice administrators dealing with such topics as Medicare requirements/reimbursements, programs for and methods of care for patients, and other things hospice made the conversation instructive and inspirational. Of the four annual conferences that I’ve attended, this one was the best. I want to thank the leadership of Cornerstone Hospice and Palliative Care, Inc. for making it possible for me to attend. By making this possible we remain an “Accredited Jewish Hospice.” This sends a strong message to our Jewish patients, their families, and the Jewish community as a whole.

The Chaplain and Social Courtesies

Chaplains have a wonderful opportunity to make a positive impact and impression upon patients and their families. To do so, it takes more than skill in spiritual support or in counseling or in providing encouragement. The Chaplain that excels in social skills and common courtesy will find his or her spiritual care greatly enhanced. I had a bit different upbringing than some as from the age of 10 my Mother educated me on manners and social skills as my Father died and could not add to my Mother’s advice. Opening doors, be they to buildings or vehicles, saying “Please” and “Thank you” were just the basics. Through my career I have learned that those basics can carry one a good way, but there are many other social courtesies to learn and apply to solidify great relationships with those we serve in hospice. The list that follows is by no means exhaustive nor given in any order of importance as they are all important. Key Courtesy Tips for Chaplains  Smile! It takes more facial muscles to frown than to smile.  Pause for a moment before answering the telephone. This will allow you to shift gears and focus on the caller.  Sitting down and making eye contact while talking to patients leaves a more favorable impression than standing and you are perceived to spend more time with the patient.  Eye contact should be made 40-60% of the time in conversation. Less than that suggests you’re not paying attention… more than 60 % makes people feel uncomfortable.  “Imagine yourself in the patient’s position… how would you feel?”  “Never let a patient hear you complain.”  Show compassion.  Never blame another Team Member for something that went wrong. Apologize right away and say,” I will try to correct that for you or I will get someone who can. I’m sorry that happened to you and it will not happen again.”  Anticipate patient needs. For example, if a patient is nauseous and looks like he will vomit, either hand him a plastic basin or hold the basin for him. Another example: If a family member is carrying patient clothing or other item, hold the exterior open so they may enter the building without fumbling to get a free hand to open the door. Perhaps assist with carrying a heavy item.  Introduce yourself to the family that is entering the Hospice House and walk with them to the patient’s room.  Be friendly. Be warm. Be approachable.  Use common courtesy that you learned early in life.  Saying, “Yes/No, Ma’am” and “Yes/No Sir” is not just Southern in it origin, it is just plain good communication and courteous.  Make people feel like they matter  Go the extra mile with the patients and their families. What this looks like has many faces and facets. Being kind is fundamental to this one.  Show appreciation that the patient and family chose Cornerstone Hospice. Say something like: “Thank you for the privilege of serving you and your (loved one) here at Cornerstone.” Every time I’ve said that, the family member reflects that they are the ones grateful that we are serving them. It goes a long way to building a great relationship.  Never be too busy to meet a need. I am sure that we could make a list twice as long as this, but please accept this as a good start. Whether you visit in a patient’s home, or LTC facility, hospital or hospice house it is always proper to be mannerly. When you read the Best Practices for Chaplains in each of those localities, you will come across Chaplain Etiquette. Please be mindful and apply these guidelines for great patient and family care.

Spiritual Suffering

SPIRITUAL SUFFERING Spiritual pain can be defined as emotional distress due to spiritual and religious issues. These issues tend to fall into three categories: Theological and Religious Belief issues; Existential and Meaning issues; and, Relationship issues. Theological and Religious Belief issues are often characterized by the inability to participate any longer with the patient’s religious practice; detrimental beliefs about God, the Divine, or Transcendent One; an incongruence between beliefs and the patient’s experience in life; and conflicted beliefs about dying, death, and the afterlife. Existential and Meaning issues are characterized by a loss of a sense of meaning or a role in life which provided meaning; a feeling of hopelessness, anger, emotional pain caused by letting go of this world; a loss of dignity, control over life, feelings of inadequacy. Relationship issues are characterized by a need to seek forgiveness from God, a loved one, or some other person; a need to forgive God, a loved one, or some other person. A need to forgive self for some offense committed earlier in life is often a cause of spiritual pain, as well. For the hospice Chaplain, the above provide an understanding of the spiritual suffering patients at end-of-life experience. Building trust with the patient, providing a non-anxious presence, and listening with compassionate intensity are all skills the Chaplain must master to provide supportive spiritual care. Through my experience with patients I often wondered what they went through before they came to hospice and into my realm of care. I came to the conclusion that a hospice patient goes through a lot before they become a hospice patient. They have been ill for some time, they haven’t felt well, and to top all of this off, like a wrecking ball comes the terminal diagnosis from the physician that they have 6 months to live. The reaction of the patient to this devastating news is called “the existential slap.” In the International Journal of Palliative Nursing (November 2004,Vol. 10 Issue 11, p520) Nessa Coyle pens an article that focuses on the psychology of patients when a physician discloses the diagnosis of a life-threatening illness. The usual habit of allowing thoughts of death to remain in the background is now impossible. Death can no longer be denied. This awareness precipitates a crisis for most individuals, who are suddenly faced with addressing and most likely rearranging, their priorities in the time they now anticipate is left. The "existential slap," occurs when the reality and inevitability of one's own personal death sinks in. (Abstract to the article) Following this diagnosis a recommendation to hospice is made. In a flurry of activity the patient and family is met by an Admissions Nurse for a 3 hour meeting to enroll the patient in hospice followed by the Case Manager/Nurse, Social Worker, and Chaplain all within a 5 day Medicare mandated window. Is it any wonder that one of the key personality traits we look for in hospice Chaplains is compassion? The patient is reeling from the diagnosis of 6 months to live and is thrown into an environment they are totally new to and may never have heard of before or at least not understood. The Rev. Dr. Kathleen Rusnak references how her new patients described their reaction to the Existential Slap. The first time I heard a patient say, “When the doctor told me I had less than six months left to live, it felt like “I hit a brick wall,”-- I didn’t hear it. The second time a patient said that to me, I heard it the first time. And then I read this metaphor in a hospice nurse-practitioner’s thesis on suffering. The interviewed patient stated that she felt like she “hit a brick wall” when the doctor told her she had six months left to live. Metaphors are very powerful. They express in symbolic language the depth of raw feeling and emotions that cannot be directly expressed in words. (www.thebrickwall2.com) For now, as there is so much more to be explored in the Existential Slap, I want to do a deeper dive into what Dr. Rusnak so candidly wrote when she described her response to the patient, “I didn’t hear it.” If there is one regret I have as a Chaplain, it is that like Dr. Rusnak, I didn’t hear or at least didn’t “get” what the patient was actually trying to communicate. Could this be what Heidegger refers to as “the forgetfulness of being”? Could it be that we Chaplains are so incredibly busy that we often are thinking ahead to the next patient, the next this, the next that that we are not in the moment, but in the next moments? And, we forget. We forget that before us is a new patient who has just started the hospice journey and is about to have the most daunting experience of a lifetime that will conclude with the end of life on this planet. Which among us has died before and lived to tell about it? I’m not talking about near-death experiences. I’m speaking of the real experience of death. With that clarification, the answer is simple, none of us. Can we grasp the magnitude of what this new hospice patient is attempting to process? It’s pretty hard, isn’t it? In this article, I simply want to urge my fellow Chaplains to do whatever is necessary to be in the moment with your patients. We who are living fall prey to the “forgetfulness of being” while the patient we serve is moving rapidly to the stage of the “mindfulness of being.” Simply put, the mindfulness of being is encapsulated in the long hours of self-reflection where the patient pours over life searching for answers to these questions and more: “Who am I? What was my purpose? Did I have a purpose? Did I waste my life? Did I love? Was I greedy? Did people love me? Will I be remembered? Did I make a difference?”

IT’S ALL ABOUT THE PATIENT, RIGHT?

IN THE HOSPICE WORLD WE HAVE A SAYING, “IT’S NOT ABOUT US, IT’S ABOUT THE PATIENT.” WHO CAN ARGUE WITH THAT? WE EXIST TO SERVE PATIENTS AND THEIR FAMILIES. IT IS OUR CALLING, IT IS OUR PASSION, AND IT IS WHY WE GET UP IN THE MORNING. THERE IS NO DOUBT ABOUT THAT. BUT, UPON REFLECTION, IS IT REALLY ALL ABOUT THE PATIENT AND FAMILY? HOPEFULLY, IT IS A GOOD BIT ABOUT YOU, TOO! LET’S EXPLORE WHY. IN HOSPICE CARE, EMOTIONS AND SPIRITS GET FRAYED BY A NUMBER OF THINGS:  WHAT WE BRING WITH US TO HOSPICE: OUR OWN BOX OF ROCKS: PERSONAL ISSUES, FAMILY ISSUES, FINANCIAL ISSUES, DISAPPOINTMENTS, FAILURES, LET DOWNS, AND QUIRKS OF PERSONALITY, TO NAME SEVERAL. HOW WILL ANY OF THESE AFFECT HOW YOU DO YOUR HOSPICE WORK?  WHAT SKILL SET WE BRING TO OUR DISCIPLINE: ARE YOU NEW TO HOSPICE? HAVE YOU TRANSFERRED FROM A HOSPITAL SETTING OR A PARISH PASTORATE, OR HOME HEALTH SETTING? WHEREVER YOU SERVED BEFORE COMING TO HOSPICE YOU WILL FIND IT TO BE DIFFERENT FROM WHERE YOU ARE NOW SERVING. FOR INSTANCE, THE HOSPITAL SETTING FOR NURSES IS VERY STRUCTURED. HOSPICE SETTINGS TEND NOT TO BE STRUCTURED. FOR PASTORS, YOU CALLED THE SHOTS. YOU SET THE AGENDA. IN HOSPICE, YOU ARE PART OF A TEAM. YOU NO LONGER SET ANY AGENDA, INSTEAD, YOU FOLLOW ONE. THOSE EXAMPLES ARE FROM MY OBSERVATION AND OWN EXPERIENCE.  WHAT EXPECTATIONS DO YOU HAVE? THERE ARE SOME WHO HAVE ROMANTICIZED HOSPICE CARE. YES, IT IS A WONDERFUL AREA OF THE MEDICAL PROFESSION TO WORK IN. BUT, WHAT ARE YOUR EXPECTATIONS FROM THE COMPANY? THE TEAM? YOUR MANAGER? YOUR PATIENTS AND THEIR FAMILIES? CAN YOU DEAL WITH NOT HAVING A DESK ASSIGNED TO YOU? CAN YOU DEAL WITH NOT BEING THE LEADER? LIST YOUR EXPECTATIONS AND THEN REVIEW THEM. WHERE DID THESE EXPECTATIONS COME FROM? CAN YOU ADJUST THEM TO FIT THE HOSPICE WORLD? I THINK YOU CAN SEE FROM THE THREE PARAGRAPHS ABOVE THAT, INDEED, HOSPICE IS ABOUT YOU, TOO. WE TAKE OURSELVES WHEREVER WE GO. FOR THE SAKE OF OUR PATIENTS AND THEIR FAMILIES, LET’S COMMIT TO OURSELVES, OUR COMPANY, AND OUR PATIENT AND THEIR FAMILIES, THE GREAT MISSION STATEMENT OF DAME CICILY SAUNDERS, THE FOUNDER OF THE MODERN HOSPICE MOVEMENT: “YOU MATTER BECAUSE YOU ARE YOU, AND YOU MATTER TO THE LAST MOMENT OF YOUR LIFE. WE WILL DO ALL WE CAN; NOT ONLY TO HELP YOU DIE PEACEFULLY, BUT ALSO TO HELP YOU LIVE UNTIL YOU DIE.”

The Million Dollar Survey

Chaplains will have an impact on Medicare reimbursements with their provision of spiritual care. Since CMS is placing a high degree of importance on the new Hospice CAHPS Survey, it behooves every hospice Chaplain to look at the Survey to find out what is being evaluated by the surviving family member(s) who complete the Survey. If the results of the Surveys are not good, it could cost a hospice of our size (1,000+ patients) a 2% decrease in reimbursements or over 1 million dollars. So, what’s in that Survey that a Chaplain should be concerned about? The primary question the family will answer is #36: Support for religious or spiritual beliefs, including talking, praying, quiet time, or other ways of meeting your religious or spiritual needs. While your family member was in hospice care, how much support for your religious and spiritual beliefs did you get from the hospice team? The family will answer one of three ways: Too Little, Right Amount, Too Much. Please do not think that because the final 3 words in the question #36 end with “the hospice team” that it excuses the Chaplain from responsibility. As the Chaplain the family will be looking you for direction and effective spiritual support during their loved one’s and their journey in the hospice experience. Other than providing spiritual support for the patient that is loving, encouraging, and compassionate, how can a Chaplain positively impact the family? Particularly for facility patients (LTC, hospital, and hospice house), the family members are not always present when a Chaplain visits. However, the Chaplain has access to the Primary Care Giver’s telephone numbers. After each visit with the patient, the Chaplain will place a phone call to the PCG informing that person of the visit and will express sincere concern for the PCG by asking, “And how are you?” Chaplains, this is a million dollar survey. While we have a small part in it, it is a vital part. Do your hospice ministry and by all means, be sure to include a phone call to the PCG and document it.

Our biggest day!

Yesterday was our biggest day. Hundreds of guests logged onto Embraced. Welcome! Please use this site to enhance your understanding of hospice chaplaincy and use the concepts and best practice principles to grow professionally. Your comments are also welcome and are a source of encouragement. Blessings!

3 Pitfalls of Value Judgments--Leadership Tips

Before I attempt to assign the 3 pitfalls, let me define what a value judgment is. A value judgment is an assessment that reveals more about the values of the person making the assessment than about the reality of what is assessed. In any value judgment there is the assumption that the person making the judgment knows all the facts, which they don’t. Yet, when a person with a title makes the judgment, the person who was assessed as deficient is pigeon-holed with a reputation he or she cannot shake. That is a shame, but it is the reality. This happens for some reason a lot in hospice work as leaders and team members work through their day to day challenges. The 3 pitfalls include: 1. An unfair assessment of an IDT member’s worth based upon a snapshot of time in an IDT meeting. When a value judgment is made about that person, it is quick like the cutting of a vegetable with a razor sharp knife. A value judgment disregards what the person is going through at the time and disregards one of the key elements of an IDT meeting. That element is safety. In an IDT the Team comes to work but a team also comes to care for its own. Value judgments take that aspect of the Team off the table and relegate people to robots. Not a good thing. 2. Value judgments cultivate a shallow view of people. It takes no time at all to decide whether someone is good or bad at their field work based on a Team member having a bad day. Shallow leadership is unhealthy leadership and unhealthy leadership is damaging to the organization and leads to recurring employee turnover. 3. Value judgments create instability on the IDT. It doesn’t take long for Team members to pick up on the fact that their leader thinks little of them. Again, a value judgment neglects the outstanding work a Team member may do in the field with patients and families and focuses on a small portion of time with that worker. Morale suffers when workers believe their leader think so little of them. A key value of leadership is to know one’s Team, to know the individuals on the Team, to know the issues they face at work and elsewhere. If the worker was hired because of excellent skills then that worker must be given the opportunity to be human from time to time. To pigeon hole a worker without knowing that person is exceptionally unwise. Beware then of falling into the trap of making quick, unfounded value judgments.