Pastoral Care in the LTC Setting

March-April 2002

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

  1. Joanne Lynn, "Learning to Care for People With Chronic Illness Facing the End of Life," JAMA, November 2000, pp. 2,508-2,511.
  2. 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.
  3. 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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