Chaplains are integrally involved in advance care planning, according to the authors of a study.1
“We recognized a gap in the literature in this space and recognized the importance of shining a light on the often behind-the-scenes role chaplains play,” says the Rev. Brian Hughes, MDiv, MS, BCC, study author and director of programs and services for the New York City-based HealthCare Chaplaincy Network.
Hughes and colleagues surveyed 585 board-certified healthcare chaplains on their role in advance care planning. Ninety percent said advance care planning is important to their work, 70% regularly help patients complete paperwork after discussions, 90% facilitate discussions with patients about their preferences, and 45% reported they were not consistently included in team discussions on decision-making.
Some clinicians do not realize advance care planning is part of the chaplain’s role. Even if they do, logistics can block the way if conversations are not scheduled early. “It then falls to whomever is within arms’ reach at the moment,” Hughes notes. If chaplains are not involved, advance care planning documents can be completed — but there might not be anyone who really understands the patient’s values.
“Many ethical dilemmas arise when the paperwork is clear, but it is untethered from the clear articulation of the patient’s values,” Hughes explains.
An advance directive is clear: The patient does not want to be put on a ventilator. The problem is no one on the clinical team knows how to interpret this preference. The patient probably never considered an acute clinical crisis the medical team believes could be remedied with a ventilator, with strong confidence in eventual and successful extubation.
“If the ventilator is the means to the end of healing, then a values discussion becomes paramount,” Hughes says.
Hopefully, it is clear enough to inform the plan of care in real time as new options arise. “Ideally, the chaplain would continue to be involved, to unpack the real-world implications of the patient’s stated values on the potential plans of care,” Hughes notes.
Clinicians should be able to answer the question: Is the care consistent not just with prescribed clinical boundaries but also with the patient’s expressed values? “This values discussion underlying the advance care planning process is one where chaplains excel, and can be of unique benefit,” Hughes offers.
Chaplains connect with patients and families by acknowledging the stress and fear associated with serious illness. “In doing so, they are often able to facilitate conversations that explore a patient’s values,” says Ann L. Jennerich, MD, MS, assistant professor of medicine in the division of pulmonary, critical care, and sleep medicine at University of Washington. Chaplains cannot be involved in every advance care planning discussion; there just are not enough of them. “We just don’t have the number of chaplains necessary to meet the needs of our patients, family members, and healthcare providers,” Jennerich laments.
Chaplains’ documentation can help clinicians, but a direct conversation is ideal. “Patients might describe concerns to the chaplain that they don’t share with the remainder of the medical team,” Jennerich observes. “Sometimes, it is hard to convey that information in writing.”
- Kwak J, Cho S, Handzo G, et al. The role and activities of board-certified chaplains in advance care planning. Am J Hosp Palliat Care 2021 Jan 28;1049909121989996. doi: 10.1177/1049909121989996. [Online ahead of print].