NACC: Vision Online

Minister with sensitivity to

bariatric patients, their families

By Carey Landry, BCC

In 1998, during my third year of chaplaincy, our hospital, St. Vincent-Carmel, in Carmel, IN, began performing bariatric surgeries. Bariatric patients are people who suffer from morbid obesity. This kind of surgery was still relatively new at the time, but the surgeons who became part of our staff already had several years experience in doing this type of surgery. As the years have gone by our staff has adapted well in serving the needs of the bariatric patient, so much so that in 2006 our center was given the distinction of being named a “bariatric center of excellence.” I was here when the first patient came for surgery, and I have had the privilege of being part of an interdisciplinary team that has helped more than 11,000 people who struggle with morbid obesity. To date, more bariatric surgeries have been performed at St. Vincent-Carmel Hospital than at any other hospital in the United States.

Bariatric refers to a branch of medicine dealing with the causes, prevention and treatment of obesity. Morbid obesity is a life-long, progressive, life-threatening, genetically related, costly, multi-factorial disease of excess fat storage with multiple co-morbidities (obesity related health conditions). Morbid obesity is defined as being 100 pounds over ideal body weight, with a “body mass index” of over 40. Morbid obesity is the second leading cause of preventable deaths in the United States. It is estimated that more than 300,000 people die unnecessarily each year as a direct result of this illness.

Obesity related co-morbidities include: Diabetes, hypertension, cardiac disease, respiratory diseases (including sleep apnea), arthritis, depression, and several different cancers: esophageal, breast, uterine, ovarian, prostate, colon, and cervical. Morbid obesity radically affects one’s quality of life. Morbidly obese people suffer from “crippling isolation.” They have difficulty doing simple tasks, including walking, playing with their children, or doing ordinary housework.

There are numerous societal views and biases against obese people:

Society is not very tolerant of obese people, especially females. Many experience abuse and discrimination throughout their lives. They are often seen as “second class citizens” and described as lazy, dirty, and ugly.
They are blamed for their own condition and are not afforded the same consideration as others who suffer from a disability. “Fat jokes” by comedians and derogatory portraits of obese people in popular media are common.
Obese individuals experience problems in public accommodations and public settings, such as restaurants, theaters, airplanes, buses, and trains because of inadequate seat size and inadequate features such as seat belts. (When our hospital began doing bariatric surgeries we purchased new furniture that could accommodate the obese patient. When we renovated our chapel we made sure that several of the 25 or so chairs in our small chapel could accommodate obese patients and their family members.)

Obese patients also suffer from the biases of healthcare professionals.

Studies have shown that many physicians view persons who are obese as unintelligent, non-compliant, hostile, dishonest, unsuccessful, inactive, and weak-willed. Noncompliance was rated the most likely reason for obese patients’ inability to lose weight. (I had to overcome my own biases when I began ministering to patients with this illness. It was when I admitted to myself the struggles I have had with my own weight that I was able to overcome my biases. Without their knowing it, the patients themselves helped me to overcome those biases, and now they are the patients to whom I minister the most in our hospital.)
Because of these biases, obese patients often shy away from doctors and
Even “good intentioned” professional staff members can make statements that are hurtful and derogatory, such as: “You don’t look like you need this surgery!” “You carry your weight well.” Staff members will sometimes assume that visitors know what type of surgery the patient has had, and thus may present real risks to breaches of confidentiality.

How have we been able to grow in our own sensitivity to individuals with this disease?

In our hospital we try to avoid identifications that indicate obesity to others in signs, return addresses on mailings, messages on phones, marketing campaigns, and identification labels on equipment.
All of our associates are trained to 1) recognize obesity as a disease; 2) use sensitivity in their choice of words; 3) refrain from announcing in a loud or public manner that they need help with a patient; and to 4) recognize that obese patients are looking for any sign that indicates that they disgust you.
From a positive standpoint, our associates are trained: 1) to be willing to help with obese patients’ activities; 2) to include patients in decisions about their care and to ask them what works best for them; 3) to be overly sensitive when weighing patients, to weigh them in a private area, and to never announce their weight loudly.
Obesity is a chronic illness. No one laughs at other chronic illnesses, such as diabetes or coronary artery disease. Obesity can be just as deadly. We train our staff to be sensitive by being good role models. We encourage them not to tolerate behind-the-back whispers and jokes about obesity, even in private. Our mission statement states: “All caregivers and support personnel must demonstrate sensitivity to and respect for the obese patient.”
As with any illness, there are legal implications to good care giving: Bariatric patients who are being treated with dignity and respect and have close relationships with the hospital staff are less likely to bring suit against the program, even when a complication or fatality occurs.
There are also marketing implications: Most patients seeking to undergo bariatric surgery have done about a year-and-a-half research on the matter. Even though surgeon skills and multidisciplinary program offerings are important, patients will not refer other patients to a program in which the patient felt he or she was not treated with dignity and respect.

I invite you to describe honestly to yourself the feelings you have toward obese people, especially those who are severely obese. Have you used any labels to describe them? Is the obese person worth your best effort?

Various types of bariatric surgeries are done in the United States today, the most requested being the Lap-Band or Laparoscopic Adjustable Gastric Band, which is a restrictive procedure; the “Roux-en Y” Gastric Bypass, which is both restrictive and malabsorptive; and the “BDP with Duodenal Switch,” which is a malabsorptive procedure.

Patients sometimes make tremendous sacrifices to be able to have the surgery. Some insurance companies will not cover this surgery or will only cover partial costs. Some patients to whom I have ministered have had to take out a second mortgage on their home to pay for the surgery.

Bariatric surgery yields many positive physical and psychological aspects. Many patients testify to no longer having diabetes, for example, after having had the surgery and losing a significant amount of weight, and many show marked improvement in hypertension and cardiac related illness. Numerous areas of one’s emotional life improve following bariatric surgery, particularly a marked decrease in forms of depression, greater self-esteem, a more hopeful outlook on life, and overall better mental health. Social functioning, in addition to physical functioning, improves dramatically.

This is not to say that all is “rosy” after bariatric surgery and significant weight loss. Some weight loss patients have unrealistic expectations for the amount of weight they will lose and overestimate the degree of weight loss. “Healthy marriages tend to improve following surgical weight loss; unhealthy marriages tend to deteriorate.” I have personally experienced that last phenomenon with some of our patients. Some patients struggle with compliance to the regimen required to maintain their weight loss. Some patients have significant medical problems following their bariatric surgery.

My own ministry to bariatric patients and their families takes place in different ways at five different times:

Prior to their coming to the hospital for surgery.
With the patient at the hospital just before surgery.
With patients who have no significant medical problems after surgery and who are discharged within a few days.
When a bariatric patient has significant medical issues after surgery, has to return to the hospital because of medical difficulties, or who has frequent re-admissions because of ongoing medical issues.
With those patients and their families who never recover from the surgery.

1. Ministry prior to the patient’s coming to the hospital for surgery.

Some might ask, “How is this possible?” In the case of the bariatric patient, there is a series of meetings and required classes before their surgery. Because we believe the spiritual component of care is just as vital as the physical component of care, the bariatric surgeons requested that the “spiritual component” be addressed in one of the pre-surgical classes. Our Bariatric Center of Excellence is located in a professional office building connected to our hospital, and I go to the class every Tuesday and Thursday to provide a short musical meditation based on the passage in Psalm 46:10, “Be still and know that I am God.” This allows me to provide a meaningful prayer experience for the patients, and it also “introduces” me to the patients in such a way that there is often an immediate connection with them when they come for their actual surgery. During the meditation I always acknowledge that there may still be anxiety or fear about having the surgery and that God is with them in the midst of those fears. Many patients have told me how much that has helped them to have a greater sense of peace about having the surgery. The feedback about the musical meditation has been very positive, so much so that I made a CD of the meditation so that our staff can use it when I am unable to be there. Because of the calming effect of the musical meditation, I have had several patients call me a week or so before their surgery to request that I be there to have prayer with them when they come for their surgery.

2. Ministry with patients at the hospital just before surgery.

In many ways this is no different than ministering to those who are coming for other forms of surgery. I am able to make an initial spiritual assessment that helps me to determine if they belong to a particular church or other form of spiritual community and if that community is supportive; if they have any spiritual needs that need to be addressed in an ongoing way, and if their spiritual or religious beliefs provide comfort and support. With the bariatric patient there is often anxiety and more of a need to provide a supportive presence. Most of our patients request prayer before surgery. In my prayer I emphasize the new “journey” they are beginning, asking God to be with them not only during the surgery but in the days and months following their surgery. Many times the patient will be in tears after my prayer. I provide comfort and support, but I also try to get them to articulate what they are feeling. For many it is anxiety, but for some, it is an overwhelming feeling that they have finally come to the day when real change can come to their lives. They have been struggling for so long, and there is hope now that good things will come. The majority of our patients come with supportive family members and some have clergy support both before and after surgery, but others come without family members because they don’t want family members to know they are having the surgery. They rely on the staff to be their “family” while they are here.

3. Ministry with patients who have no significant medical problems after their surgery and are discharged within a few days.

The days following surgery are very crucial for the bariatric patient. Most of our patients have no difficulty with the surgery and are discharged within two to three days. With those patients my ministry usually takes the form of encouragement and tends to take on characteristics of “outcome oriented chaplaincy” as described in the excellent book, “The Discipline for Pastoral Care Giving.” I participate with other members of the healthcare team in contributing to the desired outcome of helping the patient to heal, with the motivation they need to begin the new weight-loss journey on their own.

4. Ministry when a bariatric patient has significant medical issues after surgery, has to return to the hospital because of medical difficulties, or keeps returning to the hospital multiple times because of ongoing medical issues.

The percentage of our bariatric patients who have continuing medical issues is small in comparison to the large number of surgeries we perform at our hospital, but when those patients have difficulties they tend to be complex issues that are not easily resolved. This often leads to several readmissions over a period of weeks or months. With these patients and families I seek to form a pastoral relationship of trust. In that relationship of trust I am able to offer a listening presence that is consistent and supportive. I make every effort to provide emotional and spiritual support daily.

Questions often arise for patients who have complications and continuing medical issues after their initial bariatric surgery:

Did I make the wrong decision? Or, if it is the spouse of a patient who is in serious or critical condition: should I have let him/her have this surgery? Should I have protested his/her decision more?

My intervention here begins with providing compassionate care and comfort, validating their present feelings, then taking them back to the time of their decision making and how they felt at the time / what they knew at the time. Most often, when I have explored this with individuals, they have responded that their desire for better health was so great that they saw this surgery as their only hope.

Is God still with me? I don’t feel that God is with me as much any more. Am I losing my faith?

I seek to validate their feelings of discouragement, and reassure them that there is no dichotomy between being a person of faith and having those feelings. My intervention here includes inviting the patients to examine other difficult moments in their lives and whether they felt the presence of God helping them. Are there some previously helpful beliefs or experiences of the Holy (even early in life) that can serve the patient now, during this period that feels like a significant step backward physically as well as spiritually?

Many of these patients exhibit the characteristics of a spiritually distressed patient. Because they are in the hospital for an extended period, intense loneliness or separation from their family is often experienced. Sometimes I have felt that patients were “testing” me to see if I would tolerate complaints about their family or faith community. (“My church (and/or) my family has let me down … those whom I thought would help have not come to see me.”)

My response is one of “hearing” their disappointment and their feelings of loneliness, but also eventually moving to a place where they can be invited to identify what has become their most helpful community -- in some cases, it is the hospital staff itself.

Because I have provided pastoral care to so many patients over a period of several months and have seen them eventually come to healing, I am able to offer other patients authentic hope and encouragement. Prayer plays a significant role in bringing comfort, hope and peace. Quiet music and relaxation techniques are of help to many, particularly in being able to sleep at night. There are times when I need to make a referral for a psychological consult or other form of intervention for the patient. The interdisciplinary team approach (as described in the book, “The Discipline for Pastoral Care Giving,”) to the patient is crucial for the long-term patient and our staff is well trained to provide emotional (and spiritual) support. Our once-a-week interdisciplinary patient care conferences help us work together as a team in providing care to the patients and their families.

5. Ministry to the bariatric patient and family when the patient does not recover from the surgery.

It cannot be denied that the weight loss surgical patient has a risk of not recovering from the surgery. Each of these patients has a higher risk secondary to the health conditions with which they present. Fortunately, the advances in evaluation and surgical techniques continue to improve patient outcomes. There are some patients who have serious respiratory problems and need to be placed in our ICU on a ventilator when they come out of surgery. My ministry then becomes one of support to the patient, the family and/or friends of the patient, acting as a liaison between the family and other members of the staff, and providing the kind of spiritual care needed for an ICU patient. .

Four years ago, we had one patient who was in our hospital for 13 months because her insurance would not allow her to be transferred to a Long Term Acute Care Hospital. Her surgical wound never healed because of continuing problems with fistulas and abscesses. I became very close to the patient and her family. Both patient and family went through a variety of emotions from intense anger to a deep sense of peace in their long ordeal. The patient’s illness actually drew the family closer together in ways that several members never would have thought possible. This ordeal profoundly affected our staff members, and my ministry was as much to our staff as it was to patient and family throughout. Many of us were at her bedside when she passed away peacefully not long after her second Christmas in our hospital. I remain close to the family to this day, and her mother sews “prayer blankets” for me to give to other patients, similar to the one I had given her daughter.

For several years now our Bariatric Center of Excellence has hosted a Christmas Party for patients who have had the surgery. It is an evening that allows us to see the “after” effects of their weight loss, and many of the women wear cocktail dresses that they have never felt comfortable wearing before. Party food consists of fruit, cheese and vegetables, testimonies are given by former patients, and a DJ provides music for dancing after the short program. Former patients cannot wait to reintroduce themselves to staff members as their “new” selves and have their photos taken with the surgeon who performed their surgery. I am always eager to provide the opening prayer and reflection at this wonderfully positive evening for patients, families, and especially for our staff.

Carey Landry is a chaplain at St. Vincent-Carmel Hospital in Carmel, IN. He and his wife, Carol Klinghorn-Landry, are composers of Catholic liturgical music.

References

Bocchieri, L.E. (2002). Pastoral care ministry to the bariatric patient and family. Journal of Psychosomatic Research 52, 155-165.

Vandecreek, L. & Lucas, A. (2001). The discipline for pastoral care. Binghampton, NY: The Haworth Pastoral Press.

A sample prayer before a patient’s bariatric surgery

O Lord, I place _________ and all of his/her needs into your loving hands today. I pray that you will lead and guide those who will be working with him/her during the surgery. I pray that there will be no complications whatsoever and that he/she will have a completely successful surgery. Be with _________ and help him/her know that you are there. Be with his/her family members (if present). Grant them peace and comfort as they wait, and then help them to be of support to ________ on this new journey he/she is beginning in his/her life.

Lord, I pray that you will be with _________ not only today during the surgery, but that you will walk with him/her as he/she walks each day after the surgery. Throughout this new journey, be for _________ a source of strength and courage, peace and patience, and ultimately healing and new life. We ask this in your most Holy Name. Amen

ARTICLES

Chaplains in Outpatient Ministry

More articles

NACC Board Chair

REGULAR FEATURES

References