After the Duke Outpatient Clinic in Durham, NC, added a chaplain intern in 2019, clinicians wanted to effectively integrate this role in the outpatient setting. “In the outpatient setting, patients regularly face challenging decisions in their healthcare and spiritual distress related to grief and trauma,” says Alissa Stavig, MD, a resident physician in internal medicine/psychiatry at Duke University Health System.

Some organizations, like the Veterans Health Administration, incorporate chaplains into outpatient care.1 However, chaplains typically work in the inpatient setting. Stavig and colleagues were curious what patients and staff in the outpatient setting actually knew about the role of hospital chaplains.2 To find out, they surveyed 78 patients, 10 caregivers (who were accompanying the patients), and 74 providers and staff at an outpatient clinic.

They found a few knowledge gaps. Most respondents wrongly believed church approval is all chaplains need to begin their work. Both staff and patients were mostly unaware of the standardized training requirements for chaplains. Few respondents realized chaplains can respond to patient’s needs from any religious background. Finally, most patients incorrectly thought part of chaplains’ role is to teach religious practices and principles.

Many respondents correctly reported that chaplains’ general role was to support patients at the end of life and that chaplains were there to help patients who are struggling for any reason. “Notably, a better understanding of the role and training of chaplains correlated to an increased desire for chaplain services,” Stavig reports.

Those who understood the role of chaplains were more likely to want their help. “It stands to reason that education could result in increased utilization of chaplains,” Stavig offers.

One way to help, according to Stavig, is providing patients and providers with background information on chaplains, with an emphasis on the fact chaplains are certified professionals who are specifically trained to provide patient-focused spiritual care to all people, regardless of belief system. “Efforts designed to clarify and validate the chaplain’s role and expertise can contribute to ethical patient care in both the outpatient and inpatient setting,” Stavig says.

At Ascension St. Vincent Hospital — Indianapolis, the hospital board asked the spiritual care department for data on what Indiana recipients of care wanted from chaplains. The board asked for data specific to the population St. Vincent serves all over Indiana, as opposed to relying on research literature or information from other markets. 

“[Patients] think we are an angel of death or a prayer dispenser. Our research reinforced that chaplains are more than that,” says Beth L. Muehlhausen, PhD, MDiv, BCC, LCSW, researcher for spiritual care and mission integration for St. Louis-based Ascension. 

Muehlhausen and colleagues interviewed 452 hospitalized patients and their loved ones at 16 Ascension hospitals in Indiana.3 Of this group, 93% said they wanted at least one chaplain visit. The number was so high that the peer reviewers for the journal that eventually published this work questioned the findings. Two-thirds of participants expected a chaplain visit without having to request one. Participants thought chaplains would just show up, much like a nurse or respiratory therapist who they do not specifically ask to see. In reality, someone has to put in a request for a chaplain. “The days of having enough human resources to meet and greet every single patient are gone,” Muehlhausen laments.

Participants were asked what religion they identified with, including “none.” Interestingly, many non-religious patients also wanted a chaplain visit. “Despite stereotypes, I think people know a chaplain is someone they can confide in, share their concerns with, and will receive care and emotional support,” Muehlhausen says.

Chaplains can meet the needs of patients from all religious faiths (including none). Chaplains can offer non-religious patients all kinds of help. It might be advocacy, someone to listen, or simply a reminder that they are not alone in what they are going through. Recently, a chaplain had to advocate not to allow a dying patient’s family to baptize a patient once the patient slipped into a coma. The chaplain supported the patient’s desires; in this case, the fact the patient did not share their family’s deep beliefs. “The chaplain protected the patient’s right to self-determination,” Muehlhausen reports.

Another interesting finding: “Participants’ top reasons for wanting a chaplain visit centered around emotional issues,” Muehlhausen says. Patients wanted “someone to listen to me” and “be there for my loved ones.”

“In an increasingly secular society, it was interesting to find that patients and loved ones value emotional support followed by more traditional spiritual or religious support,” Muehlhausen observes.

For clinicians and ethicists, the findings emphasize the importance of screening patients for spiritual distress (with referral to a chaplain if a patient feels hopeless, despondent, lonely, scared, or struggling to make meaning out of their medical diagnosis.

Involve a chaplain in the interdisciplinary team to mitigate clinicians’ anxiety and emotional stress. As a chaplain, Muehlhausen spoke with family members about hospice care, knowing the medical team had ordered palliative care. “I spoke quite highly of hospice, and the family seemed relieved. Afterward, the medical residents thanked me profusely, as they were anxious about bringing up the topic of hospice with the family,” Muehlhausen shares.

Include a chaplain in plan of care conversations, ethical dilemmas, or conversations about palliative care. The Ascension St. Vincent ICU rotates physician teams every Monday. Muehlhausen was called to provide prayer for a patient where mechanical ventilation was going to be withdrawn, as the patient was not expected to be able to survive without it. “As I was speaking with the patient’s sister, the new doctor entered the room, mentioning new drugs that the team could try,” Muehlhausen says.

The sister was confused. Muehlhausen explained the plan to withdraw life support to the physician and asked if his suggestions were simply going to prolong the inevitable. At that point, the physician understood the situation and reassured the sister that withdrawing life support was the appropriate step.

Medical teams often use terminology that is unfamiliar to families. Chaplains consider what the medical team is saying, while also remaining highly sensitive to patients’ and family members’ ability to comprehend it. “This can help bridge the divide that is often felt between patients and loved ones and the medical team,” Muehlhausen says.

REFERENCES

  1. Earl BSW, Klee A, Cooke JD, Edens EL. Beyond the 12 steps: Integrating chaplaincy services into Veteran Affairs substance use specialty care. Subst Abus 2019;40:444-452.
  2. Stavig A, Bowlby LA, Oliver JP, et al. Patients’, staff, and providers’ factual knowledge about hospital chaplains and association with desire for chaplain services. J Gen Intern Med 2021; Jan 22. doi: 10.1007/s11606-020-06388-8. [Online ahead of print].
  3. Muehlhausen BL, Foster T, Smith AH, Fitchett G. Patients’ and loved ones’ expectations of chaplain services. J Health Care Chaplain 2021;April 21:1-15.