EXECUTIVE SUMMARY

Of 463 chaplains surveyed, about one-third reported being often or frequently included in clinical team discussions on medical decisions. Chaplains also reported:

  • educating patients and families on specific medical concepts such as CPR or brain death;
  • acting as a liaison between the patient, family, and medical team;
  • slowing down the fast pace of medical decision-making.

As an oncology chaplain in an acute care hospital, M. Jeanne Wirpsa, MA, BCC, became the “go-to” person if there was a conflict between the medical team and family. “I frequently asked the hard questions about the goals of treatment that few others were prepared to ask,” Wirpsa says.

After a long course of treatment, some patients stated very clearly that they wanted comfort care only. “But then the next day their voice would get lost, as if the treatment plan had taken on a life of its own,” says Wirpsa, a clinical ethicist and chaplain researcher at Northwestern Memorial Hospital in Chicago.

Attending family meetings and care conferences helped Wirpsa to integrate the patient’s voice into the treatment plan. “My colleagues on the research team confirmed the same in other settings, such as advanced cardiac disease and intensive care,” Wirpsa reports. The chaplain researchers wanted to see if this experience was shared by other healthcare chaplains across the United States. It already was well-established that when chaplains are involved with decision-making for serious or life-limiting illness, patients and families are more at peace with their decisions. “But the connection to medical decision-making had never been explored,” Wirpsa notes.

In a survey of 463 full-time chaplains, 38% reported being included in healthcare team discussions regarding medical decisions “often” or “frequently.”1 “What was more unexpected was the degree to which chaplains were involved in specific activities associated with decision-making,” says Wirpsa, the study’s lead author. Chaplains reported educating patients and families on specific medical concepts such as CPR or brain death.

“Chaplains provided rich examples of helping the medical team gauge when a family was ready to even engage in discussion about a difficult decision,” Wirpsa explains.

The key role chaplains perceived themselves to play was as liaisons between the patient, family, and medical team. Survey respondents often used terms such as “mediator,” “interpreter,” “coach,” and “bridge” to describe this. Chaplains reported coaching patients to share their fears and concerns. They also believed it was important to deliberately slow down the fast pace of medical decision-making. “They discussed interrupting the clinical momentum that fails to ask: ‘Who is this patient?’ and ‘What really matters to them moving forward?’” Wirpsa says.

The barriers to involvement in medical decision-making voiced by the respondents sounded very familiar to the researchers. The least-experienced chaplains found it difficult to claim a place at the table or approach an attending physician with their insights into patient and family values. Even more experienced chaplains, well-versed in medical culture and trusted by their care teams, reported some difficulty with this. “They complained that they were stretched too thin to be able to participate fully in situations where their skills would be useful to the process of medical decision-making,” Wirpsa says.

Many chaplains indicated they were underused in their healthcare settings. They believed this was because their role was narrowly viewed or misunderstood altogether. “Core competencies of healthcare chaplains were not recognized by other members of the healthcare team,” Wirpsa says.

This expertise includes knowledge of religiously derived health directives, the ability to identify values that affect healthcare decisions by listening to a patient’s story, and negotiation skills. “If experienced, proactive, and embedded in the care team, chaplains help ensure the care we offer is truly patient-centered,” Wirpsa offers.

Instead, chaplains said they were called only to provide religious counsel, rituals, and emotional support to help patients cope with illness and hospitalizations. “One aim of the study was to educate other members of the healthcare team about how the chaplain could be a valued partner in medical decision-making,” Wirpsa says.

Many chaplains are tapped to serve as ethics consultants because of their training in narrative methods, values, cultural diversity, and excellent communication skills. However, many have obtained little formal training in clinical ethics. Wirpsa developed a course for chaplains to address these knowledge gaps.

“Our research suggests that ethicists might benefit from the insights of a chaplain who has been involved with a patient or family,” Wirpsa says. Chaplains can offer insights on readiness for conversations, family dynamics, and the family’s religious beliefs. “An ethics consult is often called late in the game,” Wirpsa notes. By that time, there are near-intractable value conflicts, both sides are firmly entrenched in their positions, and distrust has been building for a quite a while. Similarly, palliative care often is involved too late. Early involvement of chaplains can help both situations. Everyone involved “might more easily welcome the neutral, unbiased, nonthreatening presence of the chaplain,” Wirpsa says.

Wirpsa says models for shared decision-making need to be revised. These approaches must take into account the unique role each member plays in promoting a care plan that aligns with patient values, beliefs, and preferences. “Interestingly, we see considerable overlap in roles between that of the professionally trained healthcare chaplain, palliative care, and ethics consultant,” Wirpsa notes.

Consulting a chaplain early could prevent the need for a consult altogether. “Conflicts between worldviews of medicine and those of faith could be avoided, or at least minimized, if a skilled healthcare chaplain were fully integrated into the care team,” Wirpsa adds.

REFERENCE

  1. Jeanne Wirpsa M, Emily Johnson R, Bieler J, et al. Interprofessional models for shared decision making: The role of the health care chaplain. J Health Care Chaplain 2019;25:20-44.