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Chaplains' mission is to address the individual needs of specific patients
The goal is to 'meet the patient where he is'
One of the most significant events in a person's life — one often intertwined with his or her philosophies, values, and spiritual beliefs — is the process of dying and death.
To make the transition as peaceful and comfortable as possible, chaplains play what they consider to be an essential role for the patients they counsel. Now, chaplains and hospitals are being challenged to meet the diverse needs of an increasingly multicultural patient population.
There is a growing awareness in all of health care that due to an increasingly multicultural society — and therefore, multicultural patient population — health care providers, institutions — and above all, chaplains, should practice a high level of cultural sensitivity.
According to J. Vincent Guss, DMin and MDiv, and chaplain of Falcons Landing Air Force Retired Officers Community in Potomac Falls, VA, there is a historical link between providing health care and addressing patients' spiritual needs.
"Medicine has always been related to spirituality and religion up until the 18 th century," Guss tells Medical Ethics Advisor. Prior to that time, he notes, "most physicians were priests." "And in certainly the Third World and [certain] other cultures, that's still the case."
"With the rise of modern science, the scientific method, and empirical studies for medicine — and the increasing fundamentalism movement in religion [in the late 20th century], the two became suspicious of each other."
The line between spirituality and the healer is strictly separate in most cases today.
"I believe it's more respectful to the patient when physicians, nurses, and other health care practitioners are interested in spiritual dynamics from a holistic healing perspective — I think then there's a much greater openness," Guss says.
And it is not necessarily the responsibility of the chaplain to deal with patients on a spiritual level; the goal is to meet the needs of the patient, whatever the patient may need. And the responsibilities of the chaplain are fairly universal, according to those who fulfill this role.
"I think as a profession, the responsibilities of a chaplain are pretty global," says David Johnson, DMin, BCC, president-elect of the Association of Professional Chaplains in Schaumburg, IL. "They supposedly meet patients where they are, regardless of their own spiritual beliefs or value systems. So, it's not that the individual is valueless [himself or herself], but the chaplain is trained to be able to engage the patient or the individual at their need, as opposed to what the chaplain believes is a point of need."
Johnson says that chaplains are also trained to "listen intently" not only to what they hear, but also what they observe in the patient.
"We're trained to listen, and not only to the words, but also to the emotional and unconscious messages that might help patients and families be able to verbalize what they may be feeling or thinking, but are afraid to express," Johnson says.
Guss concurs. He says his responsibilities are slightly different as a chaplain at a retirement facility from those of his previous hospital setting.
"Since I'm in a continuing care retirement community, some of the primary things we get involved in are ethical issues regarding residents who don't feel they are ready to be transitioned to a higher level of care, or, — as I did in the hospital very often — of how aggressive one should be in order to treat the patient, whether that's a do not hospital order, if that's appropriate, or if we can treat things at our health care facility, or is it appropriate to go to the hospital."
Chaplains also often play key roles in ethical decision-making regarding care. They often serve on hospital ethics committees; furthermore, they often play a key role in ethics consults.
Regarding his facility, Guss says, "These are ethical issues and clinical issues that have a spiritual dimension, and it's my duty to identify the spiritual dimension, to identify clergy, or religious scripture, or sacramental resources that might be appropriate for those who are religious — or to find other people in the community who can be supportive to address [the patient's] value systems, what is important to them and to identify how they see themselves in relation to these problems."
Chaplains typically minister not just to patients, but also to the health care team.
Public ministers vs. the chaplaincy
There is a difference between a minister or other religious leader and a trained chaplain, according to those in the profession.
"We talk about public ministry a lot — the difference between chaplains and public ministry, [or] individuals in private ministry with churches, because they are basically tending to their flock, based on certain theological understandings," Johnson says.
One of the challenges faced by the profession, he says, is that many health care administrators don't understand the differences and believe that any minister is qualified to serve as a chaplain, Johnson says.
When the line between the chaplain's own religious or spiritual beliefs and the patient's specific needs are blurred, that is not a good thing to have happen from the standpoint of those in the profession, as the chaplain is there to serve the patient and alleviate his or her discomfort or anxiety.
Sometimes, the patient adamantly refuses to discuss religion.
"I had a student one time who had an atheist as a patient, and the person said I'd love to talk to you, but not if you're going to talk about religion, and so they had a great conversation about some philosophical issues," Johnson says. "So, people, whether they're religious or philosophical or emotional, we have to be prepared to meet people at different levels of how they're experiencing their anxiety, because they may come out of their anxiety in different ways."
Board certification requirements for chaplains
Guss and Johnson say that board-certification is the ideal for chaplains, not only due to educational requirements, but other training and standards requirements, as well as a code of ethics all board-certified chaplains must follow. There also are continuing education requirements for board-certified chaplains.
One more requirement is ecclesiastical endorsement by whatever body of religion the chaplain follows.
"For example, I'm a Lutheran pastor, so the Lutheran Church has to endorse me — or Catholic or Episcopal. There are some religions that don't have those endorsement bodies, so then we provide some sort of ad hoc arrangement that can [endorse those chaplains], so there's accountability," Guss says.
Multicultural patients present challenges
The Joint Commission is proposing revised and additional standards, expected to be part of their typical quality surveys at hospitals, on matters which include the following: staff training on cultural sensitivity; inclusion of health literacy needs in learning needs assessment; non-discrimination in care; and informing patients of their right to receive language access services
"I think the challenges today are the issues of diversity," Johnson tells MEA. "As we are becoming more multicultural, less singular in focus, for that reason we have to have a broader understanding of religion . . . and theologies and requirements, so we have to train in [such things as] food requirements and interpret that to the institution."
Guss tells MEA that when he was a hospital chaplain, "probably the most challenging thing was defending, supporting, and advocating for people whose religious convictions were not my own — and that it looked like they may have been going against their medical best interests."
Cases in point include those who are Jehovah's Witnesses, who do not believe in the transfusion of blood, or certain Middle Eastern and other cultures where those religions do not allow women to have "the same participation in their health care," he says.
Despite that, Guss says, he would find a way to advocate for that patient, "although it would go against my values, and the values we have here in Western medicine, as well as Western religion, and yet finding a way to create dialogue and respect with those folks."
To address diverse spiritual and non-spiritual needs, the ACP membership now includes chaplains who are Sikhs, Buddhists, Hindu and Muslims and Jews. ACP has its roots in the College of Chaplains, which was originally part of the American Protestant Health Care Association.
"Very soon we saw, as we were becoming the premier group, that we were shortchanging ourselves and our own understanding of what chaplaincy was by limiting ourselves to Protestants and Christians," Guss recalls.
Guss says that while the National Association of Catholic Chaplains and the National Jewish Chaplains still exist, they exist mainly for specifically religious issues and concerns.
Beth Israel Medical Center in New York City has partnered with the New York Zen Center for Contemplative Care to bring Zen Buddhist chaplains into the hospital as a way of offering bedside meditation, interdenominational prayer, and other spiritual support to patients and staff members.
The Zen Buddhist chaplains operate the New York Zen Center for Contemplative Care to train health care professionals in contemplative approaches, which can help both patients and caregivers deal with illness, disease, dying, and living.
The hospital said in a press release that while the "training is delivered from a Buddhist perspective, the care is accessible and tailored to people of all faiths and traditions."
The Rev. Koshin Paley Ellison, co-founder of the New York Zen Center for Contemplative Care, says in a Beth Israel press release that "there are many patients who may benefit from a different type of spiritual counseling. Our guiding values are compassion, equanimity, courage, inquiry, and learning." (Editor's note: Look for a story in the September issue of Medical Ethics Advisor for a conversation with the Rev. Koshin Paley Ellison, co-founder of the New York Zen Center for Contemplative Care and a chaplain at Beth Israel.)
Separation of church and state
Earlier this year, the National Secular Society in the UK called for an end to chaplains in the National Health Service, according to a report by the BBC, due to its belief that there should be separation between church and state, as explained by Derek Brown, DMin, lead chaplain, NHS Highland, Raigmore Hospital, Inverness, in Scotland.
Brown says he thinks the chaplains in the UK face similar challenges to those in the United States, particularly in convincing some of the value of chaplains.
"I think there are similar challenges in the sense of trying to find a place in the health care system, if you like," Brown tells MEA. "And to some extent, we have a place in that, and it's a valued place.
He said this was demonstrated when a "fury" from various elements arose when the National Secular Society suggested ending public funding of chaplains.
"What I don't think they understand…is the breadth and the scope of the chaplaincy in the UK," Brown says. "It is not just about religious people visiting other religious people and getting paid by taxpayers."
Although British chaplains represent diverse religions, they tend to be Anglican in England and those in Scotland tend to be Church of Scotland Presbyterian. However, there also is a Muslim chaplain who heads a very large health trust in London.
"That's one example of the multifaith [approach] that works very well, but it's not just about caring for that particular faith group, although he would be doing that anyway, but it's not his whole job, if you like," Brown says.
In the United States, Guss says there is discussion ongoing within the chaplaincy community here regarding whether chaplains should be licensed by the individual states, much like physicians and nurses.
"We have that [religious] sensitivity, but even then, when you bring that church and state thing up, it's still an issue of, 'Do we want the secular world to be in any control of the spiritual world?'"