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An elderly woman, hospitalized with a chronic medical condition, refuses to consent to a surgical procedure her physician believes is necessary to treat her illness and doesn’t offer a reason. After speaking with the patient, the physician calls the hospital chaplain, also the co-chair of the ethics committee, and asks her to speak to the woman.
"I will go up and spend some time talking to her, eventually getting around to saying, I understand you don’t want this surgery, could we talk about that a little bit?’" explains the Rev. Martha Jacobs, director of pastoral care at New York (NY) United Hospital, about her role as a member of the health care team. "It turns out she may be afraid of many things, fears about dying, about her children, lots of things they may not talk to their doctor about because they do not think the doctor will understand."
Jacobs is usually able to initiate a dialogue with such patients, eliciting their concerns and working with the patient to address them.
"I ask them, What do you think happens when you die? What are your concerns about your children? Let’s talk about them. Let’s get your children in here and talk about the fears that you have," she says. "I have the time to do that, which a lot of health care professionals don’t have."
Jacobs and other hospital chaplains also have specialized education and training that uniquely prepares them to help providers and patients address the complex emotional, spiritual, and psychological aspects that go hand in hand with the provision of clinical care in the hospital setting.
"When someone trains to be a chaplain, they go through a program called clinical pastoral education (CPE). Part of what you do during that time is, not only do you see patients, but you sit with your peers and talk about different issues in your life and how they are affecting your ability to minister or not to minister," Jacobs says. "You have to look at what your own issues are: whether it is an issue about abortion, about a respirator being turned off, about euthanasia, you look at all of those things about yourself."
Extensive examination of situations that challenge their beliefs and standards ensures that chaplains are aware of their own biases and perspectives when such situations arise with individual patients and even caregivers, says the Rev. Curtis Hart, director of pastoral care and education at New York-Presbyterian Hospital and Weill Cornell Center in New York City.
"We had an experience at this institution with some staff who found it very hard to accept the reality of late-term abortions," Hart says, providing an example. "I was not involved in the counseling of the individuals. I was involved in the counseling of the staff involved — all of whom were, interestingly, lapsed’ Catholics. They had been instilled with the values that all life is sacred and you do not do this. Yet, they are bound by their roles as professionals to uphold a person’s autonomy."
His task was to help the clinicians resolve their own feelings and beliefs about the care that should be provided and to help them decide how they could balance those beliefs and respect the autonomy and differing beliefs of the patients, he adds. "Part of balancing the competing interests and goods and conflicting alternatives really has to do with our understanding of what our values are and what we are honestly uncomfortable advocating."
Chaplains, by virtue of their recognized religious status, are invested with a high level of trust by the public and by health care providers at their hospitals.
Maintaining this level of trust is a vital but difficult line to walk for most pastoral care providers, says Hart.
"In the pastoral relationship, if people don’t have trust and people do not feel safe, they are never going to tell you what is really on their mind," he explains.
For many of the people she encounters — patients, families, and providers — she represents "God’s presence," whether she wants that role or not, Jacobs notes.
"One of the things I think chaplains face all the time is people saying to them, You have a closer connection to God,’" she continues. "I have to say back to them, No, I don’t. I am no more perfect than you are.’"
At the same time, she senses that providers and patients feel that pastoral care providers’ main function on ethics committees and in patient encounters is to "make sure things are done the right way," she says.
They are then much more willing to share their thoughts, beliefs, and fears about a particular situation.
"And, people know that as an ordained minister, what they tell me stays with me," she says. "And, many chaplains are willing to talk about difficult issues with patients — like death and dying — that many doctors are not willing to talk to patients about."
Many patients and providers have beliefs about a higher power, or about right and wrong that they want to see addressed by someone they feel knows what they are talking about, adds Hart, an Episcopal priest and certified professional chaplain.
This person does not necessarily have to share their specific faith, he says. "Many times, providers want to know whether we will try to convert the person. No, but we can help each patient get their religious needs met, whether we are of that faith or not."
Pastoral caregivers provide a link between patients and members of the clergy of that person’s faith, and can help the patient talk about their beliefs and feelings in order to help them determine what course of care would be consistent with their values, he says.
"These kinds of things happen when people are needing a great deal of emotional support, particularly in end-of-life issues," he continues. "We often provide what I would call some helpful re-education about religious ethics and values."
For example, a member of the pastoral staff at his hospital was recently asked to counsel a family of an elderly patient in the intensive care unit. The family was aware there was no apparent hope for significant improvement in the patient’s condition, let alone a cure, but they were conflicted about ceasing medical intervention, he says.
There had been no precise advance directive written, but the family members felt they knew the patient well, Hart says.
The pastoral care provider, in this case, a Roman Catholic nun, was able to help the family in a number of ways:
"While listening carefully and responding with respect to the family members expressing this belief, the pastoral care staff person shared that life is sacred in the eyes of God and the church, and that it is possible to provide support and comfort without extending life, and that this approach would seem appropriate and, in fact, a benefit," Hart explains.
The relieved family eventually was able to accept comfort care measures as not only a medically reasonable choice, but a morally acceptable one as well, he says.
The role of the hospital chaplain is not just to counsel patients and families and work with providers on individual patient issues, say both Hart and Jacobs. They also serve as a resource for providers and administrative staff as well.
"If I have a definite role here, it is to be a kind of sounding board for the staff. To have an atmosphere where people feel free to ask questions about different issues, and then to incorporate those values," says Hart.
Jacobs is frequently called by physicians and administrators to help them "talk through" difficult situations, she says.
"I have had several doctors say, Can you come talk to me about this patient?’" she explains. "Sometimes, it is just having someone else who knows what questions to ask. What do you think? Do you think she will be safe if discharged home? Can we ensure her safety? If there’s a way, let’s try that. If there isn’t a way, maybe the family needs to talk about admitting the person to a nursing home.’"
Many times it is simply a matter of helping the caregiver understand that they have done all that they can do for a patient, she adds.
"Particularly in cases at the end of life, physicians often feel as though there should be something more to do, that there might be something they are just not thinking of," she says. "Some-times, my function is just sitting with that doctor and saying, It really sounds like you’ve tried everything. I think you’ve done everything you can do.’"
Pastoral staff not only play a role in clinical ethical decision making, but also are starting to play a part in shaping a hospital’s organizational ethos as well, says Hart.
However, chaplains serving on organizational ethics committees and advising administrators on organizational issues is a role that requires careful examination, he believes.
"It can become a very sensitive issue because, as a religious figure, you run the risk of blessing’ certain courses of action by your presence," he says. "You don’t want to end up being the mouthpiece of the organization. I don’t personally believe that ministers are more sacrosanct than anyone else, but people tend to project certain values and beliefs on to them."
There is a perception among nonpastoral providers and administrative staff that clergy often have an "anti-business" bias, and that feeling is not always unfounded, he adds.
The atmosphere at most seminaries, academic institutions, and religious institutions tends to discount concerns about financial viability and may lead people to, indeed, have an anti-business bias, he says. "It can be a problem for people who have not been exposed to nor associated with people who have a different set of cultural norms and values."
Pastoral staff must determine whether or not they can overcome these obstacles to provide a valuable perspective to those shaping the hospital’s future, he says.
"They must decide whether they have a well-developed, articulate outlook and philosophy suited for involvement in major institutional decision making and can avoid simply vacillating between passivity and outrage in the face of perceived organizational and system dysfunction," he says.
If they can, pastoral providers can provide a vital perspective and resource for shaping organizational ethical decision making as well as clinical situations, he says.
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