EXECUTIVE SUMMARY
Chaplains can play an important role if family is requesting aggressive interventions and clinicians believe such care to be inappropriate. Chaplains can do the following:
- Explain that dying surrounded by loved ones is a blessing.
- Be realistic with the family during conversations and prayer.
- Make sure clinicians give the family the space and time they need.
Editor’s note: This is the first in a two-part series on the role of chaplains in the hospital setting. In this story, we explore how chaplains can help to resolve conflicts over whether to withdraw life-sustaining interventions. Next month, we’ll report on how chaplains and ethicists can work together to ensure ethical care.
“We’re waiting on a miracle.” “We’re not giving up on him.” “If we pray hard enough, she will be healed.”
When family members make these, or similar, statements, clinicians often find it difficult to respond. A chaplain can be of great help, says F. Keith Stirewalt, PA, MBA, MDiv, chaplain for clinical engagement at Wake Forest Baptist Medical Center in Winston-Salem, NC.
“While we might think that each of these arguments around arguably futile end-of-life treatments can be refuted with science, the faith components of these statements need to be addressed,” says Stirewalt.
Stirewalt says the following are important considerations:
- What does the patient/family mean by these phrases?
- How can theological hope be transitioned into end-of-life in a way that maintains meaning for the patient and his or her support system?
- What does a miracle look like?
“I like to explain that dying while being surrounded by people you love and by people who love you is the greatest of gifts and miracles,” says Stirewalt.
“BRAINSTORMING” OTHER MIRACLES
When Vance Goodman, MDiv, a chaplain in the cardiac ICU at Children’s Health in Dallas, encounters a patient or family who talks about “miracles,” she asks how they’d define the term.
“Often, a miracle is defined as an event that is unexpected and inexplicable by natural laws or science,” says Goodman. Many families talk about their faith and how their faith in God allows them to believe in miracles. “God will be the agent of healing,” they may explain. “We are depending on God for a miracle.”
Goodman then asks about the exact miracle that the patient or family is expecting. “We brainstorm other miracles, still consistent with their beliefs, that may manifest during the course of treatment, that may not include full physical healing,” she says. Emotional and spiritual healing is something that people hold onto even after the death of their loved one, for instance. “The small relational moments, hand holding, whispers and brief conversations are miracles that are granted to the patient, the family, and the staff observing the interactions,” says Goodman.
If at the end of life, medical staff have no options to offer the family, and the family continues to insist that a miracle will happen, Goodman usually inquires about the machines, medicines, and decisions that may be getting in the way of a possible miracle.
“I attempt to do this gracefully, without judgment, so that the family might consider the miracle of death, freedom from suffering — the patient’s and theirs — as a viable option,” says Goodman.
Dying patients deserve the opportunity to explore theological meaning, says Stirewalt. “This exploration requires adequate time for a trusting relationship to develop, and for the patient and their support system to reconcile their life’s meaning in the last days of earthly life,” he says.
Direct challenges as to the existence of miracles can have the opposite of the desired effect, resulting in entrenchment and institutional distrust of the medical team. “This is another opportunity for chaplain involvement,” says Stirewalt. “In negative terms, the chaplain team should not be called upon to ‘bust up’ theology that the medical team feels is disserving.”
While an attack on someone’s faith is not appropriate, gentle probing is beneficial, says Stirewalt. “We seek to understand the grounding of stated faith. When appropriate, some risk can be taken,” says Stirewalt.
In conversation with Christian families awaiting a miracle, Stirewalt has occasionally observed that none of the miracles of the Hebrew or New Testament scriptures mentions modern medical technology. “If miracles are caused by things unexplained in our realm of influence, does God need a ventilator to enact a miracle?” he asks.
Often, families are slower to understand what clinicians see as inevitable. “Guiding them through the process, we allow that understanding to influence a trajectory that families may have initially resisted,” says Stirewalt.
REALISTIC AND SUPPORTIVE
At Mercy Hospital Fort Smith (AR), chaplains recently played a key role in the care of an elderly gentleman who had been hospitalized for two months. “He had made it to inpatient rehab, but suffered a code blue early one morning,” says Fr. Paul Fetsko, MDiv, BCC, director of ethics.
The patient was placed on a ventilator in ICU, but coded two more times. The patient’s wife and daughter were present at the hospital, but the son, who was power of attorney, was not in the state.
Just a few days earlier, the patient had executed a living will in which he stated he wanted “everything done” to save his life, unless he became permanently unconscious. The son communicated to Fetsko that it was important for him to honor his father’s wishes as stated in the living will.
“After a few days, the son was able to arrive at the hospital and awaited further test results. He did consent to a DNR order,” says Fetsko.
The medical team felt that continued support was futile, even though it could not be stated with certainty the patient was permanently unconscious. “Visits by our hospice team did not change the son’s mind,” says Fetsko.
Several chaplains provided the family with daily support. “They described their role as a mediator between the care team and family, helping both to understand the perspective of the other,” says Fetsko.
The chaplains were realistic with the family during conversations and prayer, but made sure clinicians gave the family the space and time they needed. “The chaplains did a good job not taking hope away from the family, but also reminded them of the patient’s Christian faith in eternity,” says Fetsko.
After the neurologist had concluded the patient would not wake up, and the intensivist had done everything medically suitable, the son was satisfied that the wishes of his father had been met. The family arranged a time when they could all be present at bedside. The son agreed to remove life support, and the patient died peacefully in the hospice unit. “Our chaplains were critical in this case by providing continued and consistent care,” says Fetsko. “Thankfully, their support to the family helped avoid a more protracted ethics consultation.”
When a family has not come around to the recommendation of the medical team, Fetsko sometimes asks, “If God is calling the person home, why are we holding them down by the feet? The family needs assurance that they are not causing the person’s death; rather, it is the underlying disease process,” says Fetsko.
SOURCES
- Fr. Paul Fetsko, MDiv, BCC, Director of Ethics, Mercy Hospital Fort Smith, AR. Phone: (479) 314-8119. Email: [email protected].
- Vance Goodman, MDiv, Chaplain, The Heart Center, Children’s Health, Dallas, TX. Phone: (214) 456-2822. Fax: (214) 456-8310. Email: [email protected].
- F. Keith Stirewalt, PA, MBA, MDiv, Chaplaincy & Pastoral Education, Division of Faith & Health Ministries, Wake Forest Baptist Medical Center, Winston-Salem, NC. Phone: (336) 716-5811. Fax: (336) 716-5075. Email: [email protected].
