By Robert Gerard, M.D.
As a palliative care physician, I have learned from thousands of encounters with patients that the work of caring for them is complex and filled with daily challenges. Vulnerable to burnout, I have also learned that the complete psychosocial, spiritual, physical care of a patient demands more than what I can provide. It requires an interdisciplinary health care team.
Robert H Gerard MD
It was perhaps by chance that a health foundation manager approached me 10 years ago to spearhead the initiation of palliative care services for our healthcare members. Notwithstanding the challenge to learn a new paradigm of care, I endeavored to study and practice this newly designated medical specialty in mid-career. I didn’t realize it at the time – just as I hadn’t when I chose the life path of medicine at age 16 – but my family had shaped my devotion to this calling. My father’s joy of reading and reflecting, mother’s ambition to succeed in business, grandmother’s compassion for others, and grandfather’s religious and spiritual devotion all contributed to a lifetime commitment to learning.
Early in my new endeavor, I was fortunate to meet an extraordinary registered nurse and chaplain at Holy Cross Hospital practicing as a new inpatient palliative care team. From the moment I experienced the radiant compassion of the chaplain and helpful mentoring by the nurse specialist, I knew my collegial work would be satisfying.
I began a home-based palliative care program and collaborated with a nurse and social worker. Even though chaplains were not following my palliative care patients, I sometimes shared home visits with the chaplain once a patient transitioned to hospice care. In several encounters in the homes of dying patients, I received solace from the chaplain’s presence. I gathered strength to face the challenges of easing people’s suffering at the end of their lives.
In establishing two hospital-based inpatient palliative care programs, I collaborated with a complete interdisciplinary team including a chaplain (plus physician, nurse, social worker). I was able to work with chaplains training in the residency program of clinical pastoral education at the Washington Hospital Center. Together, we have been able to reflect the latest clinical practice guidelines from the National Consensus Project for Quality Palliative Care. With respect to spiritual care:
“The interdisciplinary team regularly explores spiritual and existential concerns and documents these spiritual themes in order to communicate them to the (health care) team. This exploration includes, but is not limited to: life review, assessment of hopes, values, and fears, meaning, purpose, beliefs about afterlife, spiritual or religious practices, cultural norms, beliefs that influence understanding of illness, coping, guilt, forgiveness, and life completion tasks.”
We have discovered that the team is both interdisciplinary and multidisciplinary. With time, we developed the trust to wear the hat of another team member when necessary. Families and patients are often at their worst when they agree to meet with us, and trusting that your team will carry the conversation during a meeting when one is stuck or in conflict becomes invaluable. Becoming adept at “passing the ball” between team members enables us to move forward and maintain momentum during a goals of care conversation.
It became commonplace to see the chaplain raise issues about physical pain when it was appropriate. The physician thought nothing unusual about discussing the spiritual background of a patient and how it affected the medical decision process. The nurse delved into the social fabric of the home, and the social worker would page the patient’s primary nurse or physician for extra help if a crisis occurred during our meeting.
After our meetings, a debriefing has provided us an opportunity to unpack the facts and emotions of an encounter: What went well and what didn’t? What discomforts were we carrying, and how could we improve our process in future consultations? A seasoned team can offer feedback with carefully worded criticism. The palliative care team’s occasional afternoon teas with the spiritual care department have given us time to socialize, share the news of our departments, and enjoy some lighter moments together.
I reflect often how the presence of the chaplain in palliative care consultations has humanized the team and our work. Even though a handful of folks have refused their presence in our family meetings, their knowledge of palliative care has been integral for the continued holistic care of the sick. It has not been unusual for patients or families to comment how relieved of stress they feel after meeting with us.
According to families and patients, we are often the first healthcare providers that hear what they are saying. The meeting becomes a safe place for them to express anger, frustration, tears, and sometimes rage – but also to be receptive to compassion. When appropriate at the end of a meeting, a hug, an expression of thanks, or a meaningful prayer allows both the patient/family and the interdisciplinary palliative care team to have some closure for the difficult journey ahead.
Robert Gerard, M.D., is a palliative care physician at Mid-Atlantic Permanente Medical Group in Silver Spring, MD.
