Florida offers a model for improving clergy training in end-of-life care
Clergy get practical help in dealing with EOL issues
A cornerstone of quality end-of-life care is its attention to matters of the spirit. In recognition of this, hospices have offered spiritual care as one of their core services. Still, clergy in the community who support members of their congregations in times of need are often armed only with good intentions when it comes to care for the dying.
There is an almost unquestioned assumption that clergy are equipped to deal with matters of death and dying. That assumption is a dangerous one, says clergyman Kenneth Doka, PhD, professor at the College of New Rochelle (NY) and a senior consultant to the Hospice Foundation of America. "Often, [clergy] are clearly uncomfortable with handling death and dying issues, but in crisis ministry, that’s where you establish your credibility," says Doka.
Although hospices recognize clergy as partners in caring for patients and their families, they also know that some clergy are more informed than others when it comes to end-of-life care. Traditionally, clergy members of all faiths and denominations receive little or no formal training in advising, assisting, and supporting people through end-of-life crises, according to the Clergy End-of-Life Education Project, a state-funded initiative in Florida that is seeking to educate clergy in end-of-life care. Members of the clergy often are called on to minister to the dying and their families, offering counsel and support at moments of trauma and loss. Even today, many theological schools provide little or no instruction in grief and bereavement. "Outside of family and friends, in a health crisis, who are people going to call upon?" Doka says. "Their physician and clergy."
As it turns out, clergy are no different from most people when it comes to end-of-life issues. For clergy to become partners in the movement to improve end-of-life care, hospices must help clergy become more familiar with the principles of end-of-life care. The Clergy End-of-Life Project in Florida serves as an example of how to involve all stakeholders in improving end-of-life care.
The program’s goal was to help clergy members better address end-of-life issues by educating them about bereavement and options for care at the end of life. Empowered with that information, clergy can minister more effectively to the dying and their families.
The statewide project was implemented in 13 counties throughout the state and included an extensive curriculum that addressed key issues in end-of-life care, a tool kit of consumer information, and statewide educational workshops for clergy members. Leaders of the project included representatives from hospice, university ethics and gerontology programs, clergy members, and medical care providers.
The Clergy End-of-Life Education Project was funded by the Florida Legislature and administered through the Department of Elder Affairs for the contract period July 1, 2002 through June 30, 2003. The Hospice Foundation of America (HFA) was designated as the lead agency. Its total funding for the year was $262,500.
According to Doka, who served on the Project’s advisory committee, the project is a good example of how the hospice industry can educate one of its most important partners. One of the strengths of the program, he says, is the ease with which it can be replicated in other parts of the country.
Developing a program
The goal of the program was to develop a curriculum that provided practical knowledge. Project developers adopted three forms of education material:
- resource material;
- consumer material;
- training modules.
The HFA provided the lion’s share of resource material. The clergy resource materials consisted of complimentary copies of HFA’s audio tape set Clergy to Clergy: Helping Clergy Minister to Families Confronting Illness, Death and Grief, and the books Caregiving and Loss and an additional book selection from the HFA Living with Grief series. The Clergy to Clergy series includes lectures and discussions on the following topics:
- "Counseling Those with Life-Threatening Illness"
- "The Funeral Ritual, Empowering Healing"
- "When a Child Dies"
- "Facing Illness as a Family"
- "What is Grief?"
- "Complicated Mourning."
A packet including the six tapes and the accompanying resource guide was given to each clergy member who attended the sessions. The packet also included books in an HFA-published series called Living with Grief. The series included:
- Living with Grief: Loss in Later Life (2002);
- Living with Grief: After Sudden Loss (1996);
- Living with Grief: When Illness is Prolonged (1997);
- Living with Grief: Who We Are, How We Grieve (1998);
- Living with Grief: At Work, At School, At Worship (1999).
Another aspect of the program was the creation of consumer-oriented educational materials that clergy could give to the families to whom they minister. The materials were produced by culling available information that could be adapted into easily readable material.
The consumer materials consisted of information on advance care planning, dealing with end-of-life care options, and undergoing grief and bereavement after the loss of a loved one. Workshop participants were told that these materials could be reproduced and disseminated to members of their respective faith communities. The consumer packet included the following:
- "The Medical Futility Guidelines of South Florida — A Guide for Patients and Their Families, Health Care Surrogates, or Proxies"
- Florida "do not resuscitate" order;
- "What You Should Know About Advance Directives"
- Florida living will;
- Florida designation of a health care surrogate;
- "When Someone You Love Dies"
- "How to Talk About End-of-Life Concerns"
- "Helping a Child Deal with Loss"
- Web-based resources;
- End-of-Life care resources (by county);
- glossary of end-of-life terms.
At the regional education sessions, each clergy participant received three folders containing the consumer materials. In all, 3,000 packages of the consumer materials were distributed at the sessions. A total of 70,000 pieces of material for distribution to families were duplicated, the final report on the project indicated.
Training curriculum materials
Perhaps the centerpiece of the project was its seven-module Trainer’s Manual and accompanying Participant’s Manual. The development of the manual and training objectives were determined by an advisory committee, which determined the training sessions would be done in a one-day workshop format (approximately six instructional hours) with the option to do half-day sessions to meet local preferences.
The overall learning objectives were defined as follows:
- to provide an understanding of the physical and psychological changes brought about by the dying process;
- to enhance clergy members’ ability to provide assistance to families facing the dying process;
- to provide an understanding of the advance care planning process and the care options available to people with terminal illnesses;
- to enhance the understanding of clergy regarding the grieving process;
- to support clergy in fulfilling their role in providing spiritual care at the end of life;
- to increase the clergy’s sensitivity to the need for self-care.
The seven modules included the following:
Module 1. Cultural Considerations at the End of Life
Module 2. The Dying Process
- Medical Issues
- Psychological Issues
Module 3. End-of-Life Options
- Advance Care Planning
- Service Options
Module 4. The Grief Process
- Typical Grief Reactions
- Complicated Grief
- Anticipatory Grief
Module 5. Assisting Families
Module 6. The Role of Spiritual Care
Module 7. Self-Care for Clergy
To provide flexibility at the local level, the Trainer’s Manual included additional text material for review and use by the regional trainers. The content of the material in each module included more than could be presented in the time allotted to the subject matter so trainers could select those key points they wanted to emphasize.
Lessons learned
In the end, program developers seemed pleased with their results. In their final report, project officials said, "The curriculum received high scores for comprehensiveness by participants. When asked what else they would like to have included, they responded more of the same,’" the report said. "There are parts that would benefit from further development . . . but the concepts of the program have proven their worth and relevance to the target audience."
Specifically, the project officials said the following issues could expanded:
- Self-care: Participants wanted to see more training on dealing with their own stress.
- Cultural issues: Attending clergy noted that more attention could have been paid to cultural issues, such as how these issues can affect the quality of their counseling. The final report noted that future programs should include other ethnic groups.
- Spiritual issues: Participants wanted the program to provide time and space for exploration of their own spiritual beliefs regarding death and dying.
The final report noted that the advisory committee wanted to convey the importance of cultural and ethical considerations in end-of-life decisions. "When we approached the subject, it became clear that we could not address all the many cultures that comprise Florida’s population," the report said. "The determination was made to provide material that addressed cultural sensitivity in a general sense, and not specific cultural practices."
A cornerstone of quality end-of-life care is its attention to matters of the spirit. In recognition of this, hospices have offered spiritual care as one of their core services. Still, clergy in the community who support members of their congregations in times of need are often armed only with good intentions when it comes to care for the dying.
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