The Partnership of Physicians and Chaplains: Why? How? When? Where?

1. The Partnership of Physicians and Chaplains: Why? How? When? Where? The Rev. George Handzo, Vice President Pastoral Care Leadership & Practice HealthCare Chaplaincy

2. Beliefs • 90% of adults believe in God • 84% of adults believe in miracles • The Harris Poll #11, February 26, 2003

3. Beliefs • 94% of people describe God as loving • 88% of people say they feel close to God • Galek, K., Flannelly, K. J., Weaver, A. J., & Vane, A. (2005). How Americans See God. Spirituality & Health, 8(3), 27.

4. Practice • 98% of adult Americans pray at least once a week • 56% say they pray every day • 85% say they read the Bible or Qur'an at least once a month • Summary of the 2002 General Social Survey conducted by the National Opinion Research Center, American Religion Data Archive www.thearda.com

5. Coping • In a study of 337 hospital patients, nearly 90% reported using religion to some degree to cope • More than 40% indicated that religion was the most important factor that kept them going • Koenig, H. G. (1998). Religious attitudes and practices of hospitalized medically ill older adults. Internal Journal of Geriatric Psychiatry, 13(4), 213-224.

6. Spiritual Support & Cancer • In a large study of advanced cancer patients: • 88% said religion was at least somewhat important • 72% said their spiritual needs were minimally or not at all supported by the medical system • Spiritual support was highly associated with QOL. (P=.0003) Balboni, et al. (2007). Religiousness and Spiritual Support Among Advanced Cancer Patients and Associations with End-of-Life Treatment Preferences and Quality of Life. Journal of Clinical Oncology, 25(5), 555-560.

7. Affiliation • In one study, only 42% of hospitalized patients could identify a spiritual counselor to whom they could turn. • Sivan, A., Fitchett, G. & Burton, L. (1996). Hospitalized Psychiatric and Medical Patients and the Clergy. Journal of Religion and Health. 36(3), 455-467.

8. The NCP Guidelines Address Eight Domains of Care • Structure and processes • Physical aspects • Psychological and psychiatric aspects • Social aspects • Spiritual, religious, and existential aspects • Cultural aspects • Imminent death • Ethical and legal aspects

9. National Consensus Project Guidelines and National Quality Forum Preferred Practices for the Spiritual Domain • National Quality Forum Preferred Practices • DOMAIN 5. • SPIRITUAL, RELIGIOUS, AND • EXISTENTIAL ASPECTS OF CARE • PREFERRED PRACTICE 20 • Develop and document a plan based on assessment of religious, spiritual, and existential concerns using a structured instrument and integrate the information obtained from the assessment into the palliative care plan. • PREFERRED PRACTICE 21 • Provide information about the availability of spiritual care services and make spiritual care available either through organizational spiritual counseling or through the patient’s own clergy relationships. • PREFERRED PRACTICE 22 • Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained and certified in palliative care. • PREFERRED PRACTICE 23 • Specialized palliative and hospice spiritual care professional should build partnerships with community clergy and provide education and counseling related to end-of-life care. • National Consensus Project Guidelines Spiritual Domain • Guideline 5.1 • Spiritual and existential dimensions are assessed and responded to based upon the best available evidence, which is skillfully and systematically applied.

10. Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., et al. (2009). Improving the quality of spiritual care as a dimension of palliative care: The report of the consensus conference. Journal of Palliative Medicine, 12(10), 885-904. DOI:10.1089=jpm.2009.0142. Puchalski,C. & Ferrell, B. (2010). Making Healthcare Whole: Integrating Spirituality into Patient Care. West Conshohocken, PA: Templeton Press. NCC: Improving Spiritual Care as a Dimension of Palliative Care

11. A Consensus Definition of Spirituality • “Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.”

12. Definition - Spiritual Care • Interventions, individual or communal, that facilitate the ability to express the integration of the body, mind, and spirit to achieve wholeness, health, and a sense of connection to self, others, and[/or] a higher power. • American Nurses Association, & Health Ministries Association. (2005). Faith and community nursing: Scope and standards of practice. Silver Spring, MD: American Nurses Association.

13. Definition - Pastoral Care • Coming out of the Christian tradition, pastoral care developed within the socially contracted context of a religious or faith community wherein the “pastor” or faith leader is the community’s designated leader who oversees the faith and welfare of the community and wherein the community submits to or acknowledges the leader’s overseeing. The faith leader’s care for his or her community is worked out within a relationship between the person’s unique needs, on the one hand, and the established norms of the faith community, as represented by the pastor, on the other. • LaRocca-Pitts, M. (2006). Agape Care: A Pastoral and Spiritual Care Continuum. PlainViews, 3(2).

14. Definitions - Chaplaincy Care • Care provided by a board certified chaplain or by a student in an accredited clinical pastoral education program. Examples of such care include emotional, spiritual, religious, pastoral, ethical, and/or existential care. • Peery, B. (2009, February 23). What’s in a Name? PlainViews, 6(2).

15. Goal of Chaplaincy Care • Helping patients discover and use their spiritual and religious resources in the service of their healing.

16. Biopsychosocial – Spiritual Model of Care Sulmasy, D.P. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist, 42(Spec 3), 24-33.

17. Transdisciplinary Teams • Transdisciplinary teams are the result of the evolution of the team approach. The transdisciplinary team model values the knowledge and skill of team members. It is dependent on effective and frequent communication among members, and it promotes efficiency in the delivery of educational or health care services. Members of the transdisciplinary team share knowledge, skills, and responsibilities across traditional disciplinary boundaries in assessment and service planning. Transdisciplinary teamwork involves a certain amount of boundary blurring between disciplines and implies cross-training and flexibility in accomplishing tasks. • Health Publications (http://findarticles.com/p/articles/mi_hb3317/is_4_24/ai_n29019726/)

18. Role on the Team • Spiritual Care Generalist • Vs. • Spiritual Care Specialist • Handzo, G. F. & Koenig, H. G. (2004). Spiritual Care: Whose Job is it Anyway? Southern Medical Journal, 97(12), 1242-1244.

19. Standards of Practice - Preamble • Chaplaincy care is grounded in initiating, developing and deepening, and bringing to an appropriate close, a mutual and empathic relationship with the patient, family and/or staff. The development of a genuine relationship is at the core of chaplaincy care and underpins, even enables, all the other dimensions of chaplaincy care to occur. It is assumed that all of the standards are addressed within the context of such relationships.

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24. Inpatient Spiritual Care Implementation Model

25. Spiritual / Religious Screening • A quick determination of whether a person is experiencing a serious spiritual/religious crisis and therefore needs an immediate referral to a professional chaplain. Good models of spiritual/religious screening employ a few, simple questions, which can be asked by any health care professional in the course of an overall screening. • Fitchett, G., & Canada, A. L. (2010). The Role of Religion/Spirituality in Coping with Cancer: Evidence, Assessment, and Intervention. In J. C. Holland (Ed.). Psycho-oncology, 2nd Edition. New York: Oxford University Press.

26. Spiritual Screening • Is religion/spirituality important to you as you cope with your illness? • How much strength/comfort do you get from your religion/spirituality right now? • Has there ever been a time when religion/spirituality was important to you?

27. Fitchett, G., & Risk, J. L. (2009). Screening for spiritual struggle. Journal of Pastoral Care and Counseling, 62(1,2), 1-12.

28. Spiritual History Taking • The process of interviewing patients, asking them questions about their lives in order to come to a better understanding of their needs and resources. The history questions are usually asked in the context of a comprehensive examination by the clinician who is primarily responsible for providing direct care or referrals to specialists, such as professional chaplains. • Fitchett, G., & Canada, A. L. (2010). The Role of Religion/Spirituality in Coping with Cancer: Evidence, Assessment, and Intervention. In J. C. Holland (Ed.). Psycho-oncology, 2nd Edition. New York: Oxford University Press.

29. Comprehensive Done in context of intake exam or during a particular visit such as breaking bad news, end of life issues, crisis Done by the clinician who is primarily responsible for providing direct care or referrals to specialists such as professional chaplains. Can be utilized by others such as volunteers but then not in the treatment context, more as opening up conversation Spiritual History © C.Puchalski

30. F Do you have a spiritual belief? Faith? Do you have spiritual beliefs that help you cope with stress/what you are going through/ in hard times? What gives your life meaning? I Are these beliefs important to you? How do they influence you in how you care for yourself? C Are you part of a spiritual or religious community? A How would you like your healthcare provider to address these issues with you? Spiritual History © C.Puchalski

31. Faith / Belief / Meaning Theme (n=73) • Appreciation of life and family 47 • Life activities, work, purpose 31 • Faith/Hope in healing 18 • Relationship with God 12 • Appreciation for life 7 • Reading Bible 5 • Agnostic 5 • Positive state of mind 5 • Religious affiliation 4 • Prayer 4 • Fate in God’s Hands 4 • Nature 4 • Borneman T., Ferrell B., Puchalski C. (2010) Evaluation of the FICA Tool for Spiritual Assessment. J. of Pain and Symptom Management. 20(2), p. 163-173.

32. Importance and Influence Theme(n=73) • Faith very important 56 • Faith helps control stress 40 • Faith factor in decisions 26 • Faith/belief helps in coping 10 • Faith not important 9 • Nature 2 • Attending church 2 • Illness is positive 1 • Borneman T., Ferrell B., Puchalski C. (2010) Evaluation of the FICA Tool for Spiritual Assessment. J. of Pain and Symptom Management. 20(2), p. 163-173.

33. Community Theme (n=73) • Family/friends 47 • Church 21 • Prayer 8 • Does not identify with community 5 • People with similar situations 4 • God 4 • Religious affiliation 3 • Medical team 1 • Borneman T., Ferrell B., Puchalski C. (2010) Evaluation of the FICA Tool for Spiritual Assessment. J. of Pain and Symptom Management. 20(2), p. 163-173.

34. Address in Care (n=73) • Important but not necessary in care 15 • Integrate into care 41 • Provider should not be involved 5 • Unsure 10 • Borneman T., Ferrell B., Puchalski C. (2010) Evaluation of the FICA Tool for Spiritual Assessment. J. of Pain and Symptom Management. 20(2), p. 163-173.

35. Spiritual Assessment • A more extensive [in-depth, on-going] process of active listening to a patient's story as it unfolds in a relationship with a professional chaplain and summarizing the needs and resources that emerge in that process. The summary includes a spiritual care plan with expected outcomes which should be communicated to the rest of the treatment team. • Fitchett, G., & Canada, A. L. (2010). The Role of Religion/Spirituality in Coping with Cancer: Evidence, Assessment, and Intervention. In J. C. Holland (Ed.). Psycho-oncology, 2nd Edition. New York: Oxford University Press.

36. Spiritual Distress • Anger at God • Abandoned by God • Punished by God • Faith Doubts • Conflict with Religious Community • Dr. Kenneth Pargament, verbal communication, 2010.

37. Spiritual Distress • When is it the primary diagnosis? • Distinguishing spiritual distress from psychological or social distress? • Is all grief spiritual? Psychological? • When is psychosis really a spiritual experience?

38. Spiritual Diagnosis Decision Pathways

39. Michael is coming to see his doctor for insomnia. Two months ago his wife told him she is thinking about divorce. They have been having some problems for a few months. They are “working things out.” This is causing him to question all the choices he has ever made in his life. His marriage and family was what gave him meaning all his life….now he is not sure what does? Spiritual crisis or depression?

40. Monica is 76 years old, and was brought to the ER by a friend from her church, who says she seems more confused. The neighbor thinks she is getting “demented or depressed.” The ER doc examines the patient and finds her to be alert and pleasant with a normal mental status exam. Monica does admit to being “down.” Lab results and head CT are normal. The ER doc calls the primary care provider who tells him that Monica has been mildly depressed on and off since she retired a second time at the age of 75. She derived meaning from her work as well as a social community. The patient says, “if I could find some work I would feel better.” Emotional, social or spiritual issue?

41. Frank is seeing his regular therapist for a visit. He is very animated at this visit because he feels something happened to him during his prayer that changed his life. He describes a vision in which God tells him that he is safe and that all things happen for a reason. Frank said God told him to think about changing his job to another one he was looking at in that involves more social ministry. After the vision Frank said he felt “God took my worrying about the future away. I know what I need to do…” Hallucination? Vision?

42. Forming a Spiritual Treatment Plan • A team activity with chaplain in the lead • What are the patient’s spiritual strengths and resources? • What are the patient’s spiritual issues/needs? (diagnosis) • What interventions will enhance the strengths and minimize the issues? • What is the role of each team member? • Simple vs. complex interventions • Interventions for each member of the team • Write up plan • Follow up

43. Compassionate presence Reflective listening/query about important life events Support patient sources of spiritual strength Open ended questions Inquiry about spiritual beliefs, values and practices Life review, listening to the patient’s story Targeted spiritual intervention Continued presence and follow up National Consensus Conference Intervention – HCP / Pt. Communication

44. Guided visualization for “meaningless pain” Progressive relaxation Breath practice or contemplation Meaning-oriented therapy Referral to spiritual care provider as indicated Narrative Medicine Dignity-conserving therapy National Consensus Conference Intervention – Simple Spiritual Therapy

45. Chaplain Dumping • Who is responsible for spiritual care? • When does the patient want to talk to the non chaplain healthcare provider?

46. Ethical Issues • Advance Directives • Medical Orders for Life Sustaining Treatment (MOLST) • DNR • Palliative Sedation

47. Joint Commission Publications http://www.jcrinc.com

48. Culture Broker • “The emerging prominent role of the clinically trained, professionally board certified chaplain working with health care organizations in completing spiritual assessments, functioning as the ‘cultural broker,’ and leading cultural and spiritual sensitivity assessments for staff and physicians can be of great value.”

49. Culture Broker “It is essential that organizations use training materials and formats that are applicable to their unique needs. With board certified chaplains on staff, the organization has educators familiar with the organization’s mission, staff, patient population, and application issues readily available.”

50. New From the Joint Commission • Advancing Effective Communication, • Cultural Competence, and • Patient- and Family-Centered Care: • A Road Map for Hospitals • http://www.jointcommission.org/PatientSafety/HLC/