Chaplains Play Important Part in Integrated Palliative Care

Abstract

WASHINGTON — Hospital chaplains are key partners in meeting the needs of palliative care patients, according to an expert at the annual meeting of the American Association for Geriatric Psychiatry. Laura B. Dunn, MD, professor of psychiatry and behavioral sciences at Stanford University in California said in an interview that the relegation of chaplaincy and spiritual care in medicine has been unfortunate. After all, the level of a patient’s spiritual health is an inherent aspect of quality of life in palliative care, particularly for those older than 60 who often want help reconciling with loved ones, data collected by Dr. Dunn show. How is spiritual health measured? There are few models and even fewer empirical studies, but Dr. Dunn said in addition to learning how to deliver pastoral care, professional chaplains are trained to assess, intervene, and observe outcomes in spiritual health. To begin with, spirituality is defined not in terms of religiosity but more as following an ethical path, similar to the idea of the golden rule or the ethic of reciprocity. The spiritual maturity to follow such a path requires the ability to love oneself, balanced with a connection to others and to God “if your belief includes God,” said Dr. Dunn. She pointed out that chaplaincy programs for atheists also exist. By observing a person’s behavior and conversing with him or her, paying close attention to the person’s attributions of blame, if any, and expressions of chief concerns, a chaplain will assess where on the continuum that person is in three key components of spiritual health: the need for meaning and direction, a sense of self-worth and belonging, and an ability to love and be loved. This last component often is facilitated through seeking reconciliation when relationships are broken. In the face of crisis, such as with terminal illness, one of those needs typically supersedes the others. This is what is known as the person’s “core spiritual need,” said Dr. Dunn, who also serves as director of Stanford’s Geriatric Psychiatry Fellowship Training Program and has extensive research and clinical experience evaluating and managing older adults with mood, anxiety, and cognitive disorders. As part of her research, she and her colleagues have developed a schematic called the Spiritual AIM (Spiritual Assessment and Intervention Model), which depicts those three concerns in relation to one another (Palliat Support Care 2015;13:75–89). Chaplains also are trained to rely on their own feelings about people. “It is not intrapersonal; it is interpersonal,” Dr. Dunn said. Chaplains undergo standardized clinical pastoral training programs predicated on a combination of theological reflection and psychological theory, plus critique from professional peers and students. Depending on which aspect of spiritual health is most lacking, the chaplain will choose the role of either a “guide” to help with balancing the need for meaning and direction, a “valuer” to help restore feelings of worth and belonging, or a “truth-teller” who will explore with the patient ways he or she might have contributed to broken relationships, and actions the patient might take in order to heal them. This is all done within the context of an interdisciplinary team, Dr. Dunn said. Dr. Dunn and a team of researchers, including a chaplain, conducted a study of 31 advanced-stage adult cancer patients in an outpatient palliative care service that measured self-reported changes in their spiritual, psychological, and physical symptoms both before and after Spiritual AIM sessions with a chaplain. The need for balancing one of the three key components of spiritual health was determined by the chaplain to be fairly equal across the cohort, although just more than half of patients younger than 60 years of age struggled more with self-worth and belonging. Those older than 60 were equally concerned with either reconciliation or meaning and direction. Two-thirds identified as Christian, just over one-third identified as Jewish, and the rest identified as either Buddhist or nondenominational. Using a variety of validated palliative care scales, Dr. Dunn and her associates found that the change in baseline of overall spiritual health after intervention from the chaplain improved slightly in most measures. For example, Edmonton Symptom Assessment System mean baseline scores went from 25 to 24.4 post-intervention. The difference between baseline depression scores fell from 4.2 to 4.1. Mini-Mental Adjustment to Cancer Scale scores improved, particularly in “fighting spirit” and levels of fatalism. In addition, maladaptive coping skills also improved. “I think of patients in terms of their core needs and what I can do right now to help patients meet those needs,” Dr. Dunn said. She cited patients who feel as if they don’t belong and are lonely. “If they’re in an assisted living home, can I get them to enter [the communal space]? That’s very different than thinking of them in terms only of depression.” Whitney McKnight is a reporter with Frontline Medical News. Most PA/LTC facilities do not have a budget for a chaplain or a full-time spiritual counselor, acknowledged Maryann C. Galietta, MD, who practices family and geriatric medicine in Doylestown, PA. A spiritual presence is “certainly needed, not just for palliative care and hospice care, but in the long-term care setting. It’s a drastic vacuum there without any services like that, but the main reason it’s not there is cost. There’s nothing in the budget for chaplaincy.” Spiritual needs are often not considered critical in the PA/LTC setting, she said. “If a nursing home were to try to get a chaplaincy program going, they’d have to designate one of their already overworked social workers to get additional schooling in chaplaincy, and then function part time as a chaplain. And to get a volunteer chaplain — there’s just not a vehicle for that.” She said a culture change is needed to raise awareness of residents’ spiritual needs, and to differentiate spiritual needs from religious needs. “The only way you get culture change in the nursing home setting is to start identifying the problems. It can take years to bring real change,” Dr. Galietta said. For example, there is “no clear appreciation” of the difference between chaplaincy, which meets spiritual needs, and religious practice. If it is determined that an individual, in meeting with a chaplain regularly — and exploring their spiritual need is part of that — has specific religious needs, “the chaplain doesn’t take care of that. That gets designated to the clergyperson or someone in their specific religion.” She said there should be more focus on spirituality in long-term care, but the industry hasn’t really jumped on board, again, because of cost. However, some individual facilities are beginning to address these needs in their programs, through activities, recreation, and volunteering. Results from the study by Laura B. Dunn, MD, and colleagues (Palliat Support Care 2015;13:75–89), which assessed the relationship between spiritual needs and patient outcomes, point to the health benefits of addressing patient spirituality. There’s “no question” that physical and spiritual improvements lead to better health, Dr. Galietta said. Evidence of improved quality of life outcomes is important, as are “outcomes that utilize money less, like less hospitalization and less aggressive care.” An academic study and assessment of spiritual needs in the nursing home would take time and presents hurdles regarding resident privacy, but “it could be done. It would be tied to satisfaction and [quality of life], and day-to-day comfort,” she said. Further study exploring the spiritual needs of residents with dementia might yield positive behavioral outcomes as well, she said. “What are their needs? How can we identify them? Are they different from the general nursing home population? Are they any calmer, better or less difficult to manage if their spiritual needs are met?” One possibility to bring chaplaincy, even in a limited way, into the nursing home is through community involvement. “If there were an academic institution that had a chaplaincy diploma program, and as an offshoot of that, they wanted to sponsor some type of community outreach to gain volunteers, it could work that way,” Dr. Galietta said. Formal chaplaincy programs offer master’s or bachelor’s degrees, but other less stringent diploma programs could provide training to people in different fields, who could work on a part-time basis. “Smaller institutions or hospice programs that may have difficulty attracting a full-time chaplain might work with a part-time chaplain,” she said. Although the idea of employing a full-time chaplain in the nursing home might be cost-prohibitive at this time, helping residents explore their spiritual needs can promote healing and acknowledges their dignity, Dr. Galietta said. “I can’t tell you how many residents, and how many times — they’ll come right out and tell you, ‘Oh, I never went to church much, I wasn’t a religious person,’ but then their spirituality hits you as they talk about their lives or their values,” she said. “You can talk all you want about a resident’s dignity, but if you don’t acknowledge their total needs and their spiritual needs, you’re not satisfying that criteria about their dignity.” Carey Cowles is the managing editor of Caring for the Ages.