BY: KARIN "TEDDI" TOMSIC
Ms. Tomsic is director, Pastoral Care and Mission, St. Joseph's Manor,
Trumbull, CT.
"Nursing homes," I once heard it said, "are built on a mountain of unexpressed
grief." The speaker was referring not only to the grief of a resident facing
debilitation and death but also to the grief of the resident's family and professional
caregivers. The speaker went on to describe the psychological walls that people
build to protect themselves in such an atmosphere. Staff turnover, difficulties
in hiring and assimilating new employees, troubled relationships between staff
members and residents and their families — all such problems are at least partly
caused by unexpressed grief.
It is easy to understand the grief of residents and their families. Most people
enter long-term care because of debilitating illness or injury. Frequently such
people have outlived a spouse or family caregiver and are now losing home, routine,
and everything familiar. Their family members often feel guilty about placing
their loved one in a long-term care (LTC) facility. That guilt is sometimes
expressed as anger and dissatisfaction, which can cause friction with both their
loved one and the staff. Meanwhile all involved ask themselves, "Why is this
happening?" "What does this mean?" and "Will this happen to me?"
Staff Grief
Our institution, St. Joseph's Manor, is a 297-bed LTC facility in Trumbull,
CT. I direct the Pastoral Care Department, which is composed of four certified
chaplains, one appointed priest chaplain, and one pastoral assistant.
When I first began working in long-term care, I was struck by the complete
dominance of the medical model. It seemed to me that the "nursing" part of the
phrase nursing home had completely overshadowed the comfort implied by
"home." I later came to realize that the medical model reigns in long-term care
because people with medical backgrounds dominate the LTC regulatory process.
Current regulations, rooted as they are in the concept of self-determination,
are meant to help caregivers formulate care plans according to resident values
and goals. Of course self-determination involves risk; self-determining elderly
people sometimes fall and hurt themselves. Yet those who do the regulating question
the resident's every fall, every pound of weight lost, and every decline in
his or her health status.
In such an atmosphere, it is understandable that acute care
methods have gradually become accepted as proper care for the
chronically ill and aged. LTC professionals, who work very hard
to care for their residents, sometimes feel overwhelmed and
discouraged by a system that continually criticizes their efforts.
Because people today live longer than they used to, society
contains more people suffering incurable, progressive, and eventually
fatal illnesses.1 It is thus no wonder that grief
is so common.
Professional Pastoral Care
One way LTC leaders can begin to address this situation is by adding staff
members trained to deal with grief in all its varied forms, namely certified
pastoral chaplains. Health care chaplains are generally certified by one of
several bodies, for example the National Association of Catholic Chaplains (NACC).
NACC certification is based on professionally determined criteria designed to
produce competent, qualified chaplains.
The criteria are:
- Theological training (usually an advanced degree)
- Four units (a unit is 400 hours) of clinical pastoral education (CPE)
- Endorsement by a faith community
- Certification by the commissioning body
CPE combines pastoral theology and psychology. After completing
it, a candidate for certification in NACC submits documentation
of his or her compliance with 30 standards addressing personal,
theological, and professional competencies.2 The
NACC reviews these documents and then schedules an interview
for the candidate with a certification team of three examiners.
Following the interview, the team forwards its recommendation
to a seven-person certification commission. Although the commission
often accepts the team's recommendation, it is not bound to
do so.
Every five years, to maintain their status, certified chaplains submit documentation
of 150 hours of continuing education and are quizzed by a peer reviewer on their
skill in applying what they have learned. These actions, which ensure the chaplain's
competence and ability, are important because the certifying body shares in
the chaplain's liability, according to Michele LeDoux Sakurai, a former NAAC
official. "Many healthcare administrators are unaware that they are liable for
the actions of visiting clergy," Sakurai said in a telephone conversation. "But
a certified director of pastoral care has the training and background to observe
other ministers coming in to provide pastoral support and to assess their competency
to 'do no harm.'"
Most chaplains also receive some training in ethics. Some people view the
ethical issues that arise in long-term care as less dramatic than those in acute
care, but LTC issues are equally challenging to discern. Professional chaplains
have much to offer in helping residents, their families, and other LTC staff.
Pastoral Care and Nursing
The impact of any health care service is usually measured according to the
perceptions of those who are affected by the service. Medical and nursing staff
tend to see the benefits of pastoral care most clearly in end-of-life situations.
In my experience, most health care professionals are instinctive caregivers.
Although the disciplines they train in vary, such people generally want to "do
something" to make things better for others. As a result, they often feel extremely
helpless when they see that a patient is dying.
Death often causes health care professionals to note the importance of the
chaplain staff, whom they see keeping vigil with the resident and his or her
family. "Especially at the time of death, the nurses recognize the support of
pastoral care," Alice Mondi and Cecilia Roberge, our director and assistant
director of nursing, respectively, recently told me. Mondi went on to say:
They often feel that someone needs to be at the bedside, and because they
are so busy doing other things, knowing that you are sitting there helps them
not to feel guilty. If nurses want to be with the resident and can't be, it
seems to them to leave a void; pastoral care fills that void. . . . Because
nurses are very task oriented, they find it difficult to understand the more
"nebulous" nature of pastoral care. However, nurses want to feel that they
did all they could, even when that can't "fix" it. The presence of pastoral
care staff enables nurses to become more comfortable with and adept at the
practice of palliative care and pain management.
Health care professionals' perception of pastoral care staff
as "sitting and praying" is accurate, but it fails to note the
work they do before a death vigil begins. Chaplains are often
the LTC staff members to whom residents convey their hopes and
values. From admission onward, a trained chaplain encourages
residents to express their feelings, both negative and positive.3
This procedure allows the chaplain to measure residents' emotional
and spiritual well-being. Even those residents who have lost
the ability to speak clearly can, through gestures and simple
responses, demonstrate what they consider meaningful.
LTC facilities should consult their residents' wishes when
drawing up care plans. Unfortunately, doing so requires giving
residents the time to express their wishes — time that nurses
often do not have to give. Chaplains, however, do have
time for such conversations. Residents can also call on the
chaplain to help them work through memories, issues, and relationships
that need healing. Residents who spend time with a chaplain
exploring their personal and spiritual histories, religious
backgrounds, and family values will find the results helpful
in expressing their goals. (Family members can provide such
information for residents with cognitive loss.)
Having learned about a resident's history and values, a chaplain can share
this vital information with the medical and nursing staff (always respecting
the resident's right to confidentiality, of course). Thus informed, the care
team will have a more three-dimensional view of the resident and can more easily
take his or her goals into consideration.
"The Horse on the Table"
It is during the time immediately before and after admission that residents
and their family members think most about the approach of death, although few
verbalize it. The situation is reminiscent of an old story in which a man goes
to a guru to ask about the meaning of life and death. In reply, the guru describes
a dinner party. The guests at this party are led into a room containing a long
table. On the table is a horse. The guests, hoping to spare the host from embarrassment,
say nothing about the animal. The host, also shocked at the sight, is silent
as well. The guests, uncomfortable at the sight, hurry through the meal and
leave the party. Later, when they happen to meet, they are unable to recall
the joy they once took in one another's company. All they can remember is the
discomfort they experienced in the presence of the horse.
So it often is with residents and their families at admission. One cause of
the negative thinking surrounding long-term care is our society's denial of
the fact of death. When an aged person is admitted to a nursing home, everyone
involved senses that the new resident's life is becoming more fragile and that
death is approaching. For this reason, a LTC facility should ascertain the resident's
wishes concerning end-of-life care at the time he or she is admitted — because
doing so is a way of acknowledging the "horse on the table."
Increasingly these days, residents arrive with their advance directives already
signed, a phenomenon that indicates a growing public awareness of the need to
be prepared for the end of life. Chaplains can be called upon to assist those
new residents who do not have advance directives, however. Indeed, simply being
introduced to a chaplain often induces a new resident to talk about his or her
values concerning end-of-life care. Sometimes family members are shocked to
hear the issue raised. But the residents themselves usually respond directly
and with grace, which indicates that they have already given the matter a good
deal of thought.
As the horse story suggests, once a forbidden subject has finally been raised,
people feel much more free to talk openly. In LTC facilities, once death has
been mentioned, both residents and their loved ones are freer to share their
hopes, express the love they feel, and admit the pain they anticipate at being
separated.
Pastoral Care and Residents
Speaking of our pastoral care staff, Judith Ryan, the director of admissions,
recently said:
When you conduct a resident admission interview, you speak very clearly
about our mission and philosophy of care. You seem more comfortable getting
into the "sticky stuff" concerning resuscitation, do-not-resuscitate orders,
and our palliative care and comfort care protocols. You answer questions about
our policies and explain what the resident and his or her family can expect
if the physician should order one of these approaches. Your ease in discussing
this enables all of us to feel more comfortable. Both resident and family
members gain a clearer picture of the religious [values] component of care.
And that, I think, is why many of our residents choose to come here.
Ryan went on to say that admissions personnel often find that potential residents
and their families respond positively when they learn that St. Joseph's Manor
has a pastoral care department. "They seem to become much more comfortable.
Learning that we have pastoral care appears to alleviate a lot of the guilt
and gives them a chance to express their spirituality, and that makes a huge
difference."
A resident's spiritual needs and his or her desire to be a part of religious
services are important — but often undervalued — aspects of care in any LTC facility.
Many of our residents decide to come here because it is a Catholic facility,
a place where they can celebrate daily Mass in the presence of the sacraments.
Concerning the facility's pastoral care program, Ellen O'Brien, our former recreation
director, once said:
Each year, I have the opportunity to attend a meeting of the presidents
of Resident Councils from across the state. The [Connecticut] Department on
Aging sponsors this meeting. One of the top three hot topics discussed is
the lack of spiritual and religious support that many facilities report. I
have heard such comments as "Catholic mass is held once a month" and "No one
comes to visit unless you belong to the local church in that community." [In
this state], it is the responsibility of the Recreation Department to provide
religious and spiritual support under the public health code. . . . I cannot
begin to express the value of having a Pastoral Care Department.
Pastoral Care and Administration
"Residents come here for our spiritual care as much as for our nursing care,"
agreed Sr. Michelle Anne Reho, O.Carm., St. Joseph's Manor's administrator.
Some LTC administrators hesitate to spend money on pastoral care because they
see it as a "luxury." In Sr. Reho's opinion, however, spiritual care is an integral
part of health care. She recently described the launching of our pastoral care
program in 1986. "Once we had determined that our residents' spiritual needs
were being met, we looked at the money we had available and then we looked for
someone who would agree to work for that amount," she said. "As the department
grew, we borrowed resources from other departments. Let's face it: Pastoral
care is not our most expensive department. For what we pay one nurse, we could
almost hire two chaplains. Unfortunately, that's how the salaries are."
Sr. Reho explained the salary problem. "In Connecticut," she said, "the only
fully reimbursable positions are nursing positions. Pastoral care — like recreation,
social work, dietary, housekeeping, and laundry services — is described as an
'indirect service.'" The cost of pastoral care, like that of those other services,
must thus be partly borne by the facility itself. "But we would no more try
to do without pastoral services than we would do without dietary or laundry
services."
The facility's Pastoral Care Department provides a variety of services. "For
example, the chaplains bring up the 'comfort cart'* for family members sitting
vigil for a dying loved one," Sr. Reho said. "They make sure the kitchen understands
that it must send up meals for family members. These may seem small things,
but they are greatly appreciated by the families involved. They are also appreciated
by the nursing staff, who are thus spared doing those chores themselves."
Of course, the department's primary duty is providing spiritual care to residents
and their families. "The chaplains help residents, regardless of their denominational
background, to express their values, reconcile their lives, and prepare for
death," Sr. Reho said. "They help families make decisions in the dying resident's
best interests, get ready for separation, and enjoy the precious time left at
the end of life."
Should the leaders of an LTC facility that does not have a
pastoral care program establish one? "I would advise them to
do it," Sr. Reho said. "A facility without a program should
hire a certified chaplain and get started. It will soon see
the benefits."
NOTES
- Joanne Lynn, "Learning to Care for People With Chronic
Illness Facing the End of Life," JAMA, November 2000,
pp. 2,508-2,511.
- Michele Le Doux Sakurai, "Certification: Professionalism
in Chaplaincy," Vision, May 2001, pp. 9-11. The description
of the NACC certification process comes from this article.
- See Karin "Teddi" Tomsic, "Pastoral Care in a Long-Term
Care Setting," Health Progress, May-June 1998, pp.
42-44. The article is one of seven in a special section entitled
"Pastoral Care across the Continuum."
St. Joseph's Manor Is Honored
In July 2001, St. Joseph's Manor was named the winner of the second annual
Circle of Life Award, honoring the facility's innovations in end-of-life care.
The award is cosponsored by the American Medical Association, the American Hospital
Association, the American Association of Homes and Services for the Aging, and
the National Hospice and Palliative Care Organization.
Speaking to the facility's staff, a member of the award committee said, "You
obviously want to help people live as fully as possible, but you've somehow
made peace with the fact that they are eventually going to die." In that remark,
the speaker caught something of St. Joseph's Manor's essential spirit.
— Karin "Teddi" Tomsic
Pastoral Support Survey
Sixty-five St. Joseph's Manor residents, family members of residents, and staff
members responded to a recent survey concerning pastoral care at the facility.
The survey questions were:
- Do residents benefit from the presence of the pastoral care staff?
(Thirty-six respondents said "Most often"; 11 said "Often"; 17 said "Sometimes";
and none said either "Rarely" or "Not at all.")
- Do family members benefit? (Twenty-five said "Most often"; 18 said
"Often"; 16 said "Sometimes"; no one said "Rarely"; and 4 said "Not at all.")
- Does the staff benefit? (Eighteen said "Most often"; 10 said "Often";
22 said "Sometimes"; 5 said "Rarely"; and 7 said "Not at all.")
- Is your job easier because of the presence of pastoral care? (A
dozen said "Most often"; 8 said "Often"; 14 said "Sometimes"; 8 said "Rarely";
and 10 said "Not at all.")
- Do you feel personally supported by pastoral care? (Twenty-nine
said "Most often"; 8 said "often"; 10 said "Sometimes"; 6 said "Rarely"; and
10 said "Not at all.")
Copyright © 2002 by the Catholic Health Association of the United States
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