Palliative medicine's growth may mean an opportunity for spiritual care to reach new areas — if chaplains are able to seize it.
The team approach of palliative care focuses on quality of life for patients with serious or chronic illness, and their families. A palliative team ideally includes a physician, nurse, social worker, chaplain and other specialists to assess and address body, mind and spirit. In addition to controlling pain, treatment goals may cover depression, physical strength for improved daily life, and faith and spirituality. Palliative care also can complement curative care from the patient's other clinicians.
As medical practice slowly becomes more receptive to treating the mind and spirit along with the body, the team model of palliative care is rippling into other disciplines. Qualified chaplains and receptive physicians already are taking the "whole person" approach, and greater acceptance may lead to happier patients.
Awareness in the United States is growing that spiritual care is an essential part of medicine, said Tina Picchi, executive director of the Supportive Care Coalition, a group of 19 Catholic health organizations that advocates for palliative care.
"The whole domain of spirituality is something every palliative care professional should see as part of their role," Picchi said. The Joint Commission made it clear several years ago that chaplains are expected to be core members of the palliative care team, she said, but although that carries weight with executives, she has not seen hospitals adding chaplaincy positions as a result. As of 2012, about 30 percent of U.S. hospitals had a palliative care program.
Many chaplains serve as mentors to palliative care teams, but that role is not yet seen as a universal part of the chaplain's job. Staffing shortages also are a problem. A recent study of 413 hospitals, Picchi said, found that palliative programs employed an average of only 0.3 chaplain FTEs — and "it was no better for Catholic hospitals than for others, which really surprised us."
Palliative medicine is beginning to reach outpatient clinics, but "how you get chaplaincy out to those programs is a big concern," Picchi said. Few chaplains are currently assigned to those settings, and there is little money to fund them. Spiritual care is mandated for hospice care, that is, palliative or "comfort care" treatment at the end of life, but not for the broader field of palliative medicine.
Interest groups in Washington are lobbying for more reimbursement for palliative medicine in general as a cost-effective way to provide care. Chaplains can help prove their value and play a crucial role in those savings by helping families understand that forgoing heroic but futile measures to prolong life when a cure isn't possible, and concentrating instead on the patient's quality of life for his or her remaining time.
What's more, primary care providers need education in how to recognize and refer for spiritual care. "Chaplains have an important role in that," Picchi said. "They have a unique skill set. They know what it is to nurture and build community," and how to start conversations with patients and families.
But some chaplains are better prepared and more confident than others. Those others, she said, may be uncomfortable with "people observing, judging, evaluating them. … They have to get past that and see themselves as really team players."
The team approach of palliative care makes it "the poster child for all of medical care," said Jane Mather, director of spiritual care services for two Providence hospitals in Spokane, Washington. "It's almost trans-
disciplinary, where everyone is so aware of everyone else's job that they could step in for a moment." Speaking of palliative doctors, she said, "Ten years ago, they had to work pretty hard to get regular physicians to refer to them. Now, there's more referrals than there are hours in the day to cover them."
"The whole goal is to transform the culture of caring," Picchi said. "There's never going to be enough palliative care professionals" to take care of every patient who needs their services. But palliative workers "can become role models and mentors for the rest of the hospital."
Along with the team model, the move toward reimbursement based on measurable outcomes may be an opportunity for chaplaincy. Mather said of fee-for-service, "That model is going away. All doctors have to look at outcomes." And when patient satisfaction is considered as an outcome, chaplaincy comes into play. "Patient loyalty comes in how they are treated. The psycho-social-spiritual aspect isn't embedded in technology; it's in us." And chaplains can teach clinicians listening skills to enhance their relations with patients. "We're probably as well-educated in relationship work as anyone," Mather said, "and we're a whole lot cheaper than hiring a psychologist to educate the team."
Even with the spread of interest, integrating spiritual care into the model "comes down to the credibility of the chaplain," said Karen Pugliese, an advanced practice chaplain at Central DuPage Hospital in Winfield, Illinois. "If you're credible and the doctors see your work, they'll ask for you." Also, she said, "It's not just competence, it's leadership. You have to jump on an opportunity."
One place where opportunities occur regularly is in chaplains' routine conversations with patients and families. "Both palliative medicine and hospice need to step up and engage people earlier, and help people make the decisions that are uncomfortable," she said.
Linda Piotrowski, a chaplain who became the first nonmedical professional on the palliative care team at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, said that the entire discipline was "viewed with suspicion" when she arrived in 2006. But nationally known palliative care advocate Ira Byock, MD, who led Dartmouth's program for many years, was very charismatic and kept plugging away, and other doctors realized, "hey, this does help my patients," she recalled.
Often, Piotrowski said, Byock would say their job was to put themselves out of a job, because palliative care is just good medicine. It's interdisciplinary care. But, she conceded, that is hard to achieve. Everyone in a hospital already is overscheduled, and interdisciplinary care values daily gatherings of representatives of each discipline. Instead of rounding in patients' rooms, the team meets to report to one another on their interactions with the patient the day before, and "everyone listens attentively."
In other settings, she said, "people stay in their own silo." But now, "people recognize the value of palliative care. It doesn't bring money into the hospital, but it saves money. People make decisions sooner." Palliative care workers on the Dartmouth-Hitchcock team spread awareness in the larger community by speaking at churches on topics such as advance care directives, to help future patients "die where they want to," Piotrowski said.
Piotrowski's situation was unusual in at least one way: Relatively few hospitals have dedicated palliative chaplains. However, as of last year, chaplains now can be certified in palliative care by the National Association of Catholic Chaplains or by the Association of Professional Chaplains, which serves most other faith groups. "It says a lot about the future of medicine that this is the first [specialty] area where we're offering certification," Pugliese said.
As for spiritual care, palliative doctors "get it," Pugliese said. "They understand that the issues patients are facing can't be separated into just body and mind." She said they will tell a patient, "I can't manage your existential pain, so I'm sending Karen in."
Attitudes have changed hugely, Pugliese said, as concern for quality of life in medical care has increased, along with the realization that patients who are not terminal or who are still in treatment can benefit from palliative medicine. The team in general, and chaplains in particular, can listen to nonmedical problems and make referrals. "What are your financial issues that cause anxiety? What's your nutrition?" Pugliese asked. "It looks at the whole person, and that has evolved over the years."
Palliative care chaplains also pay attention to the spiritual needs of their co-workers. "A lot of work I do is with staff feeling compassion fatigue or moral distress," Pugliese said. "A doctor will often say to me, ‘You need to talk to this nurse; it's getting to her." At Central DuPage, Pugliese facilitates monthly meetings where staffers talk about their psychological and emotional work-related issues.
"The staff need support, as much as patients and families," Mather said. "We do this together. There aren't nice, neat chunks of care; we overlap."
One creative area of overlap is teaching other team members to screen for spiritual needs for referral to the chaplain — which may be a starting point for the long process of integrating spiritual care into the outpatient setting. In recent years, Providence has bought many clinics, Mather said, and, at monthly meetings, chaplains now get the first 15 minutes to talk about spiritual skills, both in screening patients and to help doctors and nurses be aware of their own needs and issues. "That's a lot of time for a busy medical practice," she said. "It's been very well-received."
Even with new initiatives, "as chaplains, we haven't done enough to show our value" across the entire industry, Mather said. "It's a challenged measure. How many chaplains does it take to do the job, what good does it do, how do we know? That's always been a problem. … We're really good at cost avoidance, but we're not reimbursed. Could we be someday? I think we could."
DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.
SPIRITUAL FORMATION PRACTICE
Apart from new opportunities in palliative care, chaplains have found other creative ways and places to minister. In the Detroit area, Bridget Deegan-Krause has formed a private practice to offer spiritual formation, mostly to large health systems that want to develop their midlevel managers' sense of mission.
She also teaches "the capacity for listening" to organizations and is working to develop affordable online learning programs — particularly in health care settings, which she said have been willing to invest resources in formation.
Sometimes ministry in nonreligious settings brings unexpected spiritual rewards. Deegan-Krause fondly remembers speaking to an association of county treasurers and tax collectors who "followed a call to be a public servant." Even though many were Southern religious fundamentalists, Deegan-Krause had to avoid specifically religious language due to their government function. "You avoid the word ‘holy,' but you can use the word ‘sacred,'" she said. "They had a sense of service and personal mission, and a reverence for their work."
In Lebanon, New Hampshire, Dartmouth-Hitchcock Medical Center operates the Aging Resource Center, which, along with information, support groups and referrals, also offers spiritual care from Jeanne Childs, a certified Catholic chaplain. "It's not a treatment site," Childs said, "but people come in in tears. … In my definition, it all has a spiritual side. Not necessarily at the belief level, but at the meaning, purpose, connection level." People who "just need someone to talk to" are referred to Childs.
The original plans for the center did not call for a chaplain, but Childs interned there during her clinical pastoral education and was able to persuade the center to hire her and find funding after she was certified. "I got a job because I went out and made it happen," she said.
In addition to one-on-one meetings, she runs support groups for caregivers, bereavement and dealing with change and loss. She also speaks to medical professionals about spirituality research — "the medical research that says to forgive people or else you'll have a heart attack," she said, only half joking.
"How do we contribute to the spiritual health of the whole population?" asked Frank Mächt, director of chaplaincy at Dartmouth-Hitchcock. "This was not on our radar screen even two or three years ago [but] you look at the levels of despair in the population, I would say it's a crisis." Mächt's program is exploring setting up support groups, facilitated by clinical pastoral education students, in churches, nursing homes and other settings.
"It's all in how we explain what we do," Childs said. Seated recently on an airplane next to the director of a mental health crisis center, she struck up a conversation, and "if I was looking for a job, I could have had one by the end of that plane ride," she said. "I'm a midwife to the soul. I help you with whatever's eating you."
Copyright © 2015 by the Catholic Health Association of the United States
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