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Chaplaincy in the Modern Healthcare System

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Current research, published by experts such as Dr. Harold Koenig, Duke University’s School of Medicine and Dr. George Fitchett, chaplain and CPE Supervisor at Rush University Hospital in Chicago, continues to highlight the vital and life-giving connections between spirituality and patients’ health outcomes. In turn, more and more hospitals appear receptive to the critical role that chaplains play as part of the healthcare team.

A survey in the Wall Street Journal, “Bigger Roles for Chaplains on Patient Medical Teams,” (December 6, 2011) suggests that as many as two-thirds of US hospitals include professional chaplains as a part of their services to patients.

At Hospice of the Bluegrass (HOB) in Lexington, the connection between spirituality and health is a serious issue. Reverend Bonnie Meyer, Director of Spiritual Care and Bereavement Services, said that HOB currently has 30 professional chaplains on staff who are assigned to various teams throughout the state, routinely working with patients and members of the clinical team.

“The spiritual concerns of patients are instrumental in the overall health of a patient,” says Todd R. Cote, MD, chief medical officer of HOB. “It’s essential for physicians to identify these concerns as they often can contribute to suffering and to healing. A chaplain, working with a physician, can be an essential healthcare provider and team member to help our patients.”

Psychiatrist Courtney Markham-Abedi, MD, of the Lexington VA Medical Center, shares similar sentiments. “Chaplains help us understand the patients more fully by attending to their spiritual needs. Having a chaplain at the bedside, especially during end-of-life situations, is very helpful for both the family and staff,” she asserts. Markham-Abedi has chaired the professional advisory group for the Clinical Pastoral Education (CPE) at the Lexington VA Medical Center for the past two years.

Explaining the work of the professional chaplain, however, is a bit more nebulous. As chaplain and pastoral educator Reverend Dr. Martha Jacobs writes in the Hastings Center Report [Nov–Dec 2008], “It can be really hard – or really easy – to explain what I do for a living. Chaplains share academic training with clergy, but we complete clinical residencies and work in health care organizations. Our affinities are with the patient and families, but we may also chair the ethics committee or serve on the institutional review board, and we spend a lot of time with staff. We must demonstrate a relationship with an established religious tradition, but we serve patients of all faiths, and of no faith, and seek to protect patients against proselytizing. We provide something that may be called ‘pastoral’ care, ‘spiritual’ care, or just ‘chaplaincy’ – but even among ourselves, we do not always agree about what that thing is.”

Chaplains have long been a source of comfort to patients but recently the Association of Professional Chaplains (APC) upped the ante in 2009 with the release of its standards for professional practice. The APC, the professional organization for board certification, mandated that chaplains document their work in patient records, stay apprised of current research in the field, and concern themselves with evidence-based outcomes of treatment modalities and spiritual interventions.

Roles of the Chaplain in Hospital Care

How can chaplains assist hospitals in embracing their mission and contribute to a doctor’s desire to provide holistic and patient-centered treatment? While certainly not an exhaustive job description, I suggest four basic ways the chaplain contributes on healthcare teams. These four include the chaplain as clinician, educator, advocate, and pastor. The roles are certainly not distinct of one another with considerable overlapping between the four.

As a clinician, the professional chaplain is trained to integrate one’s theology with the behavioral sciences. The chaplain is trained in such diverse areas as grief and grief theory, healthcare ethics, family systems, personality theory, life cycle concerns, multiculturalism, diversity, boundaries, conducting spiritual interviews and assessments, and conflict management among others. At the Lexington VA Medical Center chaplains routinely complete spiritual assessments on patients in the hospice and palliative medicine wards as well as mental health units. This meets The Joint Commission requirements and is used for the ongoing delivery of spiritual care during the patient’s hospitalization. As members of the interdisciplinary and discharge planning teams, the chaplain contributes pertinent information with the healthcare teams for the benefit of the patient. Confidential information that does not have a direct impact on the patients’ health outcome, such as confession of a personal indiscretion, remains confidential and has no place in the patient’s medical record.

A clinically-trained chaplain practices from their spiritual and theological heritage. In recognizing professional boundaries (we are not the doctor, nurse, psychologist, social worker, etc.) the chaplain’s heritage will often guide his or her spiritual intervention.

“We recently had a very challenging patient,” recalls Reverend Dr. James Rayburn, Chief of Chaplain Services at the Lexington VA Medical Center. “He was an AIDS patient. All of his potential caregivers were out-of-state. Earlier in his life he had been a seminary student. The medical staff was frustrated and finding it very difficult to communicate with him. So I asked our priest to visit him and attempt to ‘draw him out.’ Not only was the priest able to draw him out, but the next day he celebrated communion with the patient. This communion service also involved confession. Our staff reported a change in the patient’s more open communication and participation in his treatment plan. This is an important role a chaplain is trained to do – to draw out the deepest, darkest hurts and heartaches of the human soul and then to explore the meaning of these with the patient.”

Advocacy is an important chaplain function because chaplains are advocates for the patient first and secondarily for the patient’s family. A colleague shared the story of a late-stage cancer patient who was frustrating the interdisciplinary team because she refused to leave her home and enter a hospice care facility. The team described the patient as being in denial and non-compliant. At the next visit, the chaplain learned that the patient was more than ready to go, but had promised her deceased husband years ago that she would take care of a family matter before her death. After discussing this with the chaplain, arrangements were made to fulfill her promise, and she peacefully made the transition to the care facility.

The role of the advocate can be difficult. Sometimes it means promoting spiritual practices and resources for faith groups of the nondominant culture, navigating an oppressive or exploitive environment, and making sure that the patient and/or family voice is heard within a system with inherent power differentials.

As a former parish pastor, I intentionally use the word “pastor” to describe a very important function of the chaplain. The image that many have of a pastor is one concerned with building and maintaining relationships, stewards of the institution’s best interests, and the one trusted with our emotions, hurts and joys, as well as disappointments and failures. The pastor is the one that hears our confessions, stories and jokes. While I like the word pastor to describe this chaplain function, I am aware that it emanates from my tradition as a Christian minister. Perhaps other concepts – facilitator, organizer, or coordinator – might more aptly describe this role of the chaplain.

Whatever one decides to call this function, it plays an important role in the life of the hospital. “Chaplains are trained in ethics, systems, and relationships. We’re able to bring clarification and new lenses to the table in order to help the healthcare team do the right things for the benefit of our patients,” says Chaplain Rayburn.

Chaplains have an ethical responsibility to care for doctors who want to practice the very best medicine, Rayburn says. “We have a unique role to be a ‘pastor’ to the caregivers who have moments of heartache when they are expected to make life-giving decisions and then live with them. But where do caregivers find their support, someone to come alongside of them? Chaplains can be a listening ear, support them, debrief with them. I remember one young doctor who had lost a child and then six months later had to run the code on a child and then here comes the grief returning from the loss of his own child. The chaplain was able to sit down, hold, and support the doctor. This allowed some powerful healing to happen.”

As educators, chaplains are involved in facilitating support and spirituality groups, participating in psycho-educational programs, responsible for educating the hospital staff as to the role and scope of chaplaincy, and interfacing and teaching community clergy – when used as PRN chaplains – spiritual care skills and methods.

Does chaplain presence enhance the medical treatment offered by physicians? “Yes, obviously,” asserts Cecil “Pep” Peppiatt, MD, hospice and palliative medicine doctor at the Veterans Affairs hospital in Lexington. “In my field, especially with end-of-life practice, there are many issues that come up that are not exclusively of a physical nature. Our veterans have spiritual concerns and issues that need to be address before death. The chaplain is there to address them.”

“It gives me personal support knowing that the chaplain is working with me and a greater sense of confidence to address spiritual areas with patients and their families,” says Pepiatt.

Reverend Donald Chase, M.Div., M.A., is a clinical chaplain and coordinator for the Clinical Pastoral Education (CPE) program at the Lexington VA Medical Center. He is an Associate Supervisor with the Association for Clinical Pastoral Education. Previous to chaplaincy and involvement in clinical work, Chase served as a parish pastor for 22 years. He has also been a chaplain at the University of Kentucky hospital and Methodist Hospital in Ft. Worth, TX.