Joan E. Carlson
Patients have the fundamental right to considerate care, which safeguards their personal dignity and respects their cultural, psychosocial, and spiritual values. These values often influence a patient’s perception of care and illness. Understanding and respecting these values guide the health care provider in meeting the patient’s needs and preferences. – The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Patient’s Rights and Organizational Ethics Overview, R1-1.
A pastoral assessment of a patient’s spiritual/emotional status and need for spiritual care is the task of a professional chaplain as part of the hospital’s clinical health care team. The chaplain provides the complementary spiritual component of whole person care—body, mind, and spirit. Spiritual care as a clinical service fulfills a patient’s right to availability of spiritual care and emotional support.
If a hospital asks a patient upon admission, “Do you want to see the chaplain?”, I believe this question is a breach of the patient’s fundamental right to pastoral care. Many people do not understand what the role of a chaplain is and when admitted to the hospital may decline the service without really understanding the benefits to themselves and their families. Let me give you several examples.
On my daily rounds as hospital chaplain, I introduce myself to newly admitted patients to assess their needs and offer pastoral care. On one occasion, a new patient acknowledged my knock at the doorway of his hospital room. I inquired, “Hello, am I speaking to John Smith?” The patient validated my question. I continued, “May I come in?” The patient nodded yes. “I’m Joan Carlson, the hospital health care chaplain. I’m here to lend support, if need be.” “Well, I’m an Atheist,” the patient responded. I validated his response with an affirmative nod, respecting his preference. The patient continued, “But I can sure use some support and someone to talk to.” “OK,” I replied, “Would you like me to sit down?” “Yes, please,” patient exclaimed.
John slowly unraveled his story of struggle and distress. He shared the excruciating losses that have occurred in his family life this last year. A trusting and safe environment developed for him in my presence in the role of a chaplain. He expressed his deep grief. John requested that I return in the afternoon to meet his wife. He was grateful someone stopped by to “lend support.”
I returned in the afternoon to meet John’s wife, who was also receptive to a chaplain’s listening presence and pastoral support. As I was leaving the hospital room, I asked John, “If some one had asked you, upon admission to the hospital, ‘Do you want to see a chaplain?’ might I ask how you would have responded?” He said, “I would have said a definite no since I’m an Atheist and this a Christian hospital. You did not ask me why I do not believe in God. You came to support and listen. We sorely needed that. I’m glad they didn’t ask me that question. You helped us work through a hard time.”
After leaving this family’s room, I reflected. There are patients admitted to the hospital who have no faith/religious preference. These patients may appreciate the listening presence and support that a chaplain offers.
Another patient I visited stated that she was encouraged and feeling more hopeful after our conversation. Receiving pastoral support and counsel for losses she was struggling with was helpful. This patient’s spiritual and emotional stress encompassed a painful loss of independence. In a follow-up visit I asked her how she would have responded to the question about seeing a chaplain when admitted to the hospital. “I would have said no,” she responded. “Many people do not know what a chaplain does. I’m glad I was not asked that question. I would not have received support and a new way of looking at life. Do they ask that question here?”
Often family members experience similar or more intense distress than their hospitalized loved ones. In some studies, patients have indicated that one of the most important chaplaincy functions is helping their family members with feelings associated with illness and hospitalization. – Professional Chaplaincy, Its Role and Importance in Healthcare (The White Paper), Larry VandeCreek and Laurel Burton, Editors, 2001, p. 13.
Another patient thought that a chaplain was just present if someone was dying or critically ill. This patient had a surgical procedure. She was estranged from her daughter and had recently lost her spouse. I was able to offer some support and comforting prayer enabling her to look inside herself to uncover coping skills and begin reconciliation with her daughter. I asked her what her response would have been to the chaplain question. She emphatically responded, “I would have said no. I would not want to bother a chaplain because I was not at death’s door. What a shame, I would not have had the support I needed.”
In another instance, a patient came into the hospital with a seemingly minor illness and was diagnosed with a very serious illness. The patient’s family was experiencing deep feelings of helplessness and anger. They appreciated the chaplain’s validation of their feelings and supportive presence in working through their feelings to some semblance of strength and hope. The patient’s daughter would have said no to the question about the chaplain when her father was admitted. They thought his illness was minor and that he would only be there for a short stay. She was grateful they were not asked that question.
Studies demonstrate that religious faith and practice impact emotional and physical well-being. Professional chaplains play an integral role in supporting and strengthening these religious and spiritual resources. –– Professional Chaplaincy, Its Role and Importance in Healthcare (The White Paper), p.11.
While chaplains provide supportive services regardless of a preference of faith, it is worth noting that some folks do not state their faith community affiliation upon admission to the hospital for one reason or another. When a chaplain introduces supportive services and does an assessment of spiritual/religious need and issues, a patient may then decide to contact his or her faith community. Because of an emergency admission, a patient may be unresponsive or unconscious and therefore unable to respond to a faith/religious preference question. A reconnection with their faith community can be forthcoming in which case a chaplain can provide the patient and family with meaningful religious support.
It is inappropriate to ask patients upon admission: “Do you want to see a chaplain?” because simply asking the question does not provide patients with enough information to make an informed decision. There is a wide scope of spiritual services. Questions that are not carefully crafted can convey the wrong meaning.
In his article “Never Not the Professional” in the October 2000 issue of Vision, Father Joseph J. Driscoll wrote:
“Do you want to see a chaplain during your stay?” is not a good question. A person could respond, “No,” meaning “I don’t want to bother anyone—there are people much sicker than I am,” or out of anxiety or fear, the “no” could mean, “I am not that sick!” Perhaps a more appropriate statement/questions could be: “At our institution we are committed to holistic care of our patients, part of which is spiritual care. Do you have a religious congregation or Church that you would like us to contact?” . . . I don’t believe that any question should restrict the professional staff chaplain any more than one would exclude the respiratory therapist in the care plan for the COPD patient, for example.
Upon entering a patient’s room, the professional health care chaplain assesses patient’s religious and spiritual needs. The chaplain provides a spiritual/emotional need assessment and intervention treatment for the patient, offering compassionate care and support. The patient is given the option of saying yes or no and to be informed as to what the chaplain is offering. A patient’s right to spiritual services can be protected upon admission to the hospital by the way information is obtained.
Some hospitals view a chaplain’s role as a perk or extra benefit instead of an integral part of the healing and treatment team even though JCAHO requests that the chaplain be treated as part of the clinical health care team. Chaplains are professional clinical health care providers involved in the treatment of patients.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has been misunderstood by some hospitals to mean that chaplains are not exempt from the patient confidentiality regulations in HIPAA. In effect, it has been interpreted that chaplains need permission before entering a patient’s room. A hospital’s interpretation of HIPAA needs to take into account that the chaplain is an employed professional clinical member of the health care team involved in the treatment of the patient and not a faith community visitor. Therefore, the professional clinical health care chaplain has access to patient information, medical records, and to patients’ rooms to offer spiritual care and provide spiritual/emotional assessment.
JCAHO requests that spiritual services be treated with the same respect as any other clinical health care service professional walking into the room:
RI.1.3 - The hospital demonstrates respect for the following patient needs: RI.1.3.5 pastoral care and other spiritual services. Recognition of the spiritual needs and rights of the person is reflected in policies, procedures, and the administration’s ability to articulate these needs and rights.
Michele Le Doux Sakurai, JCAPS Chair Emeritus (Joint Commission for the Accreditation of Pastoral Services) and NACC representative to JCAHO’s Liaison Network, conveyed to me that, “Spiritual services are patient directed just as much as any other clinical health care service. With spiritual services, the patient dictates the spiritual care treatment agenda and is fully empowered without expectation.”
The provision of spiritual care services is about empowering patients to make meaning out of the greater or lesser crisis of hospitalization. It’s about building healing bridges within the family and out in the faith community. It’s about offering hope in the midst of change. There are a myriad of stressful changes that can occur in hospitalization or that can be brought to the surface during hospitalization. The chaplain can be a relevant catalyst in bringing these stressful changes to the surface by assisting the patient to look within themselves and find inner strengths and coping mechanisms.
In addition, chaplains have the ability to bring patient issues to the table early in the course of treatment. The denial of chaplain support at the front desk can impact a patient’s ability to respond to ADLs (activities of daily living) and pain management/palliative care. For instance, palliative care is a complex issue that involves physical, psychogenic, social, and spiritual aspects. Pain is modulated by the variables of life experiences. When a patient is experiencing anxiety, fear, anger, loneliness, grief, and so forth, the physical pain threshold is lowered. Therefore, the patient has a right to the best quality of life without debilitating pain and undue suffering. The question, “Do you want to see the chaplain?” at the front door can prevent the availability of the chaplain to meet this patient right.
With a family at odds, a chaplain can be effective, always listening to inferred ethical legal action helping to reduce possible litigations. The chaplain in many instances is a significant mediator between the community at large and the hospital. “A patient’s right to support can benefit a hospital because patient issues of concern and spiritual distress are addressed early in the course of treatment, thereby paving the way for other members of the clinical staff to focus on their plan of care” (Michele Le Doux Sakurai).
In conclusion, a hospital’s mission is to be in the business of offering and providing wholeness and healing in body, mind, and spirit to the patients it serves. This is the patient’s basic right upon admission to the hospital, throughout the continuum of care of which the chaplain is an integral part.
Attending to new life in body, mind and spirit is a sacred business. Moved with compassion, Jesus sought an abundant and dignified life for all people. “ I came so that all may have life, and have it more abundantly” (John 10:10). We are called to do likewise throughout the continuum of care.
This article first appeared in Vision, May 2002.