By JULIE MINDA
With their mission to provide holistic care, ministry facilities want to ensure they are meeting patients' spiritual needs at the end of life, but this can be a challenge for caregivers working with an increasingly diverse patient mix.
"The hospitals are the crossroads of the world — everyone in the neighborhood, sooner or later, will have to go to the hospital," said Sr. Annelle Fitzpatrick, CSJ, associate professor of sociology and behavioral medicine at St. John's University in New York City. She said it's important for caregivers to honor the beliefs of all patients.
Over the past decade, as the Joint Commission has been paying closer attention to health care facilities' ability to provide culturally sensitive care, ministry health care providers have been making increased efforts to ascertain and honor patients' religious needs, particularly at the end of life, ministry experts say. The Joint Commission has issued recommendations for doing this, as have the U.S. bishops in the Ethical and Religious Directives for Catholic Health Care Services.
Ministry experts say they are asking both spiritual care teams and other caregivers to attend to patients' spiritual needs at the end of life. Maureen Asper, coordinator of palliative care and faith-based nursing ministry at Holy Spirit Health System in Camp Hill, Pa., said that hospital makes this a priority because "when we meet the spiritual needs of the patient, the patient can then start to relax, and with relaxation, that leads to more peace, and even though it's difficult at the end of life, the dying process can be peaceful."
Diverse perspectives
It can be a very intimate process to get to know a person's religious point-of-view, said Asper. She explained, "In order to best serve our patients, we have to understand what's important in their lives. At the very core of every person, is their spirituality and religion. Understanding their unique being and what is important to them allows us to give this holistic care in the most healing environment."
Ministry facilities familiarize caregivers with common practices at the end of life: Hindus may chant prayers over their dying loved one. Muslims may ask for their loved one to face the direction of Mecca, and they may read the Quran. Jewish people may wish to stay with their loved one's body until the funeral director arrives. Christian patients who are dying, and their loved ones, may value hearing scripture. Catholics may ask that a priest administer the sacrament of the Anointing of the Sick.
Since nurses, certified nursing assistants, and other caregivers outside of the spiritual care team may not have the training to anticipate such preferences, ministry organizations are increasingly offering staff seminars, workshops and other training on the subject. Many also provide materials about faith and the end of life. For instance, Multicultural Coordinator Charles Horne, at Franciscan Hospice and Palliative Care in Tacoma, Wash., disseminates information electronically about various traditions to colleagues. He invites faith leaders to give presentations to staff on how their respective traditions view the end of life.
While it's helpful to know about such things, this knowledge alone is insufficient to personalize spiritual care, said David Lichter, executive director of the National Association of Catholic Chaplains. That is because "there are both such diverse belief strains within traditions and ... each person so uniquely embodies his or her tradition that one cannot make assumptions about a person's beliefs."
With faith so individualistic, "each death is so unique," said Sr. Mary Assumpta Zabaszkiewicz, CSSp, director of mission effectiveness at Jennings Center for Older Adults, a long-term care and retirement complex in Garfield Heights, Ohio.
Reflecting beliefs
To respond to such personalized expectations, staff must check in regularly with patients and their loved ones, said Mary Kienzle, director of mission integration at Holy Spirit. By asking and listening, Holy Spirit staff knew that a Jewish man and his family wanted the window open as his death approached so his soul could leave the room. The hospital prearranged with security and its engineering crew to have the sealed window opened.
Some patients' spirituality is not tied to an organized religion. In the Pacific Northwest, only about a third of people identify with a formal religion. Many people create their own brand of spirituality. Staff at Franciscan in Tacoma gently probe to determine what has meaning for their patients and then create rites and rituals in line with that. One patient dying of a brain tumor found Washington's Snoqualmie Falls significant. Her condition prevented her from returning to the falls a last time. So, the spiritual care team created a video of the falls and brought back water and stones from its shore. They created a cleansing and blessing ritual with these items.
Practical constraints
But it's not easy to respond in such a customized, creative way to an individual's idiosyncratic faith.
The hospital environment in particular can seem cold and noisy; it can be hectic, said Sr. Fitzpatrick. This is not a peaceful setting for end-of-life rituals.
And, staff in hospitals can be constrained by their busyness, said Kienzle of Holy Spirit. Sr. Margaret Washington, ASC, Holy Spirit's director of pastoral care, said staff members often share the workload to free up a colleague whose patient is dying. She said it is common for hospital staff to relocate dying patients to the end of a hall where it is quiet.
When it comes to providing spiritual care, practical constraints are present even in environments designed for those at the end of life. Kevin Henne is a chaplain with Franciscan Hospice and Palliative Care, a program that provides both inpatient and outpatient care. He said people often begin their hospice service within weeks of the end of life. Henne said, "It takes time to hear the history, to develop a rapport and to eventually hear the areas of spiritual need or distress. We'd love to have two to three months with a patient at the end of life to be able to do this work."
Interpersonal barriers
Sometimes patients resist discussing spirituality. Rev. Susan Cutshall, spiritual care supervisor with Franciscan Hospice and Palliative Care, said it can be helpful to determine why. In speaking to a person lapsed in his or her religion, it is part of a chaplains' role to find out what happened to cause the disaffection, and to discover what, if any, aspects of a faith tradition may give comfort or have value to the patient now, she said.
Patients' loved ones also may resist staff overtures to talk about the patients' spiritual needs. Asper of Holy Spirit said one patient was away from her Catholic faith most of her life but turned toward that religion in her waning days. Family members didn't understand when she asked for a priest to visit. "Their first initial response was, 'Uh oh, this is a Catholic hospital trying to jam this down my mother's throat,'" said Asper. By talking to the family members about how the woman had been changing her views on faith, Asper was able to help them understand the basis of the woman's request.
A journey
Ministry experts said it is an ongoing process to train their caregivers to navigate the complexities of dealing with faith matters.
Even during this learning process, staff may be uncomfortable with what they don't understand. Sr. Zabaszkiewicz said the Jennings long-term care facility asks staff to think about their own faith and their feelings toward other faiths. "If you look at all the major traditions, there is more similarity than diversity." For instance, she said, many religions share a common view that there is an afterlife of some kind.
Sr. Fitzpatrick agreed, "It enhances your (Catholic) identity to help people go to the other side at peace with God, whether you call God Yahweh, or Allah, or Wahegewru or HaShem. Whatever you call him or her, I think our ministry has to help people die well," she said.
The bishops' perspective on faith at the end of life
Catholic health care institutions offering care to persons in danger of death from illness, accident, advanced age, or similar condition should provide them with appropriate opportunities to prepare for death. Persons in danger of death — should be provided the spiritual support as well as the opportunity to receive the sacraments in order to prepare well for death.
Excerpted from Directive 55, from the Ethical and Religious Directives for Catholic Health Care Services
Joint Commission recommendations on faith at the end of life
- Make sure that staff are aware of any garments, religious items, or rituals important to the patient during end-of-life care
- Provide an area or space to accommodate the patient's and family's need to pray
- Note any cultural, religious or spiritual needs at the end of life in the medical record and communicate these preferences to staff
Excerpted from "Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals."
Training helps caregivers anticipate needs
Ministry health care providers want to ensure that their staff are well-prepared to assess and address patients' spiritual needs at the end of life. Some are stepping up efforts to equip caregivers to meet the needs of a diverse population.
Chaplains receive such training as part of their education and certification, but that is not always the case for other hospital staff.
It is common for Catholic health care providers to use materials from organizations including the National Association of Catholic Chaplains, Supportive Care Coalition: Pursuing Excellence in Palliative Care and the National Hospice & Palliative Care Organization to train their caregivers on what people from various faith traditions might expect at the end of life.
Some ministry providers go further with awareness-building. The Jennings Center for Older Adults in Garfield Heights, Ohio, for instance, has tailored a course for its caregivers called the Sacred Art of Living and Dying Program. The curriculum of the three-hour retreat includes teaching on spirituality at the end of life. The course challenges caregivers to view the end of life not just as a medical event, but as a spiritual event. It provides background on various traditions and an opportunity for attendees to reflect on how they view each tradition.
Holy Spirit Hospital in Camp Hill, Pa., recently offered a workshop on "Respecting Diverse Religious Traditions at End of Life" — about 70 people attended, including Holy Spirit's pastoral care team, dozens of its nurses and chaplains from around the community. Presented by the head of the NACC, the session covered why it's important to address patients' faith needs at the end of life and tips for how to do so. Presenter David Lichter, NACC executive director, provided background on major faith traditions and described the types of end-of-life requests their practitioners may have. Holy Spirit is planning additional education sessions for the future.
Franciscan Health System of Tacoma, Wash., has a multicultural coordinator — Charles Horne — who disseminates information about various traditions to colleagues and gives them access to local spiritual leaders who can explain how their congregations view the end of life.
Sr. Annelle Fitzpatrick, CSJ, is director of the Catholic Healthcare Administrative Personnel program in New York City. She has taught on the subject of faith traditions, explaining teachings and practices and describing the support that those each faith's adherents might value at the end of life. She is encouraged by ministry caregivers' growing knowledge of religious preferences that are foreign to them.
But, she cautioned, "I'm a firm believer that you can never know enough."
She recommended that such learning be an ongoing journey.
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