[Editor’s Note: This is the second of a two-part series on the role of chaplains in the hospital setting. In this story, we report on how chaplains and ethicists can work together to ensure ethical care. Last month, we explored how chaplains can help to resolve conflicts over whether to withdraw life-sustaining interventions.]
Chaplain visits in the ICU are uncommon at Duke University Medical Center, usually occur just before the patient dies, and communication between the chaplain and the physician about the visit is rare, a recent study found.1
Researchers in the Division of Pulmonary and Critical Care Medicine at Duke University Medical Center conducted a retrospective chart review of 4,169 adult admissions during a six-month period to five ICUs. Key findings include the following:
- Two hundred forty-eight patients were visited by a chaplain (5.9%).
- Chaplain visits were most frequently requested in the medical ICU (13%) and least frequently requested in the cardiothoracic ICU (2%).
- Of the 246 patients who died in the ICU, 81% were seen by a chaplain. These visits occurred a median of one day prior to death.
- Families were most likely to request a chaplain visit (19%), followed by chaplain-initiated visits (17%), visits requested by nurses (15%), and visits requested by physicians (4%).
- In only 6% of visits did the chaplain speak with the physician about the encounter. More often, the discussion was with the nurse (57%).
Chaplains are often underutilized in the hospital setting because they are not seen as a part of the heathcare team, says Robyn M. Axel-Adams, MDiv, BCC, program manager and senior affiliate faculty at the Charles Warren Fairbanks Center for Medical Ethics in Indianapolis.
“People too often think that you call the chaplain when someone is about to die or needs prayers,” says Axel-Adams. “We are skillfully trained to be with people of all religions or no religion.”
Board-certified chaplains have master’s degrees, are endorsed by their own faith community, receive at least a year of additional training in the clinical setting, and are certified by the Associate of Professional Chaplains after meeting 29 competencies.
William Nelson, PhD, director of the Rural Ethics Initiatives at the Dartmouth Institute for Health Policy and Clinical Practice at Lebanon, NH, notes that the forerunner of the American Society for Bioethics and Humanities was a group called Ministers in Education. The earliest ethics committees at faith-based institutions were called Medical and Morality committees.
“The earliest ethicists really were clergy and chaplains,” he says. “I find it interesting that, for some people, chaplains have sort of lost their place as very vital colleagues in addressing ethical issues.”
The clinical team sometimes feels that involving the chaplain will result in “too many hands in the pot.” “Having multiple people communicating with the patient or family can result in confusion or even mixed messages,” says Jennifer Cobb, M.Div., BCC, director of Mission and Spiritual Care at Mercy St. Louis Missouri, Chesterfield.
Clinicians sometimes misunderstand the chaplain’s role. “Some people might think they are just trying to impose religious beliefs,” says Nelson.
Vance Goodman, MDiv, a chaplain in the cardiac ICU at Dallas-based Children’s Health, sometimes contends with an outdated belief that chaplains only function as religious or faith-based guides. “This antiquated idea posits that chaplains are relegated to the world of religious rituals, prayers, or sacred readings,” says Goodman.
If chaplains round with the clinical team, and attend patient care meetings, they’re more likely to be viewed as part of the healthcare team, says Nelson.
“Chaplains can help the healthcare team understand the role of beliefs, religion, and cultural values in patient care,” he explains.
Some physicians shy away from asking patients if they’d like to see a chaplain. “I’ve had some physicians say, ‘That’s getting too personal.’ Some think of it as a taboo subject,” Nelson says. “It’s an area they just don’t feel comfortable with.”
Spiritual and religious concerns and perspectives are often tied to how patients experience illness, notes Nelson. “Certainly the patient’s concepts of spirituality influence end-of-life decision-making,” he says. “Chaplains can help patients sort through their own story, if you will, of what they want or don’t want.”
Chaplains listen to patients and families’ stories, and translate medical terminology into “regular people talk,” says Axel-Adams. “So many ethics consultations happen due to communication breakdown. Chaplains are able to help bridge between the two worlds.”
Many medical and nursing students have little exposure to chaplains, however. “We have medical students shadow chaplains to better understand what they are all about,” says Nelson. This promotes the view of chaplains as part of the interdisciplinary team that provides ethically grounded care.
The patient’s spiritual, emotional, and moral point of view becomes important as ethical dilemmas arise, says Goodman.
“Chaplains can be helpful where a person’s belief system or religious tradition offers differing views about treatment than what is suggested by the medical team,” Goodman says. One example of such a conflict is when a person needs a blood transfusion, and the Jehovah’s Witness tradition condemns the exchange of blood.
“A chaplain can assist the person, their family, and the staff to navigate conversations around the theological tenets espoused and the reasonable treatment options available,” says Goodman.
Ideally, chaplains are represented on every hospital’s ethics committee to serve as a resource for committee members and during ethics consults. “But like other members of the ethics committee, the chaplain needs to be ethically competent,” Nelson says. “Just because you are an ordained clergy person doesn’t mean inherently you have had lots of bioethics training.”
Nelson says chaplains need to go beyond just using their pastoral care skills and develop a level of expertise in applied healthcare ethics.
“The chaplain may have only had one course in ethics in theology school, and it may have been a course from a religious perspective. They need to go beyond that,” says Nelson.
A basic understanding of how healthcare systems work is also helpful to chaplains. If the root of an ethical dilemma is allocation of resources, for instance, the ethicist needs some understanding of how healthcare is paid for. “Like other committee members, chaplains need to have at least a basic understanding of the types of problems they’re encountering,” says Nelson.
Mercy St. Louis Missouri’s chaplains and ethicists have embarked on a unique education collaborative. “We are building a stronger sense of team between the disciplines and educating both disciplines on the roles, gifts, and challenges of each other,” says Cobb.
Training provided to chaplains includes knowledge of their own role in ethics, and the ethicist’s role. “This careful preparation results in a strong collaborative spirit between the disciplines,” says Cobb. “It helps the chaplain understand what the ethicist is working toward.”
Chaplains at Mercy are involved in complex care, palliative care, and cancer care teams. “Our patients are more than physical beings; they are also emotional and spiritual beings who need care for the whole person,” says Cobb. “As such, we continue to integrate chaplains into the care of patients who are most in need.”
Mercy’s chaplains serve patients beyond the traditional hospital setting. This includes telephone chaplaincy for patients referred from physician clinics, and for patients at high risk for readmission. “We also have virtual chaplaincy for patients who are being treated by our outpatient virtual team,” says Cobb.
Chaplains are encouraged to attend and participate in Ethics Grand Rounds as often as possible. Occasionally, chaplains in a specialty area, such as palliative care, have co-facilitated Ethics Grand Rounds. “Through this process, our chaplains and ethicists continue to become more appreciative and supportive of the different roles,” says Cobb.
Chaplains often educate front-line clinicians about the many positive ways ethicists can help with difficult situations. “Likewise, our ethicists are embracing the role of the chaplain, and encourage clinicians to involve pastoral care as part of the interdisciplinary team,” says Cobb.
- Choi PJ, Curlin FA, Cox CE. “The patient is dying, please call the chaplain”: The activities of chaplains in one medical center’s intensive care units. Journal of Pain and Symptom Management 2015; 50(4):501-506.
- Robyn M. Axel-Adams, M.Div, BCC, Program Manager/Senior Affiliate Faculty, Charles Warren Fairbanks Center for Medical Ethics, Indianapolis. Phone: (317) 962-9260. Fax: (317) 962-9262. Email: email@example.com.
- Jennifer Cobb, M.Div, BCC, Director, Mission and Spiritual Care, Mercy St. Louis Missouri, Chesterfield. Phone: (314) 628-3893. Fax: (314) 628-3606. Email: Jennifer.Cobb@Mercy.Net.
- Vance Goodman, MDiv, Chaplain, The Heart Center, Children’s Health, Dallas. Phone: (214) 456-2822. Fax: (214) 456-8310. Email: firstname.lastname@example.org.
- William Nelson, PhD, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH. Phone: (603) 653-3248. Email: email@example.com.