By Rich Woodley, MAPM
As I write this article, it is the middle of the Advent season. A question I often ponder during this season is why? Why did Jesus come at the time he did in the course of history? Why am I living in this time in human history? Obviously there is not an answer to either question. But what I have come to understand is that events happen, people come into our lives not by accident but for a reason, and often that reason will not become known until later.
The palliative care effort at CHRISTUS Santa Rosa began about seven years ago. We had a team composed of the usual suspects, a physician, nurse practitioner, chaplain, and social worker. It was an in-patient consultation service and we did a few palliative consults, mostly patients who met criteria for hospice. But the program never developed into anything more than an occasional consult for end-of-life care transition. Eventually even these consults faded away as the team lost focus and were pulled in other directions.
In 2011, through an initiative by the ethics committee, an ICU support team was formed. The focus of the team, which included a chaplain, social worker and ethics director, was to identify patients in the intensive care unit where the goals of care were not clear or there was a disconnect between the expectations of the patient and family and the treatment team. Over the next year, this concept of the ICU support team was utilized in all three of our adult facilities and was successful in decreasing length of stays in the ICU and dramatically reducing the need for conflict resolution ethics committee meetings. However, the team became aware that while patients were being moved out of the ICU much more quickly, the overall hospital length of stay did not improve. The patient just spent more time in the medical-surgical unit since the ICU team did not have the resources to follow the patient’s progress after leaving the ICU. Thus the need to revive the palliative care program became apparent.
In 2012, I became the interim vice president for mission at CHRISTUS Santa Rosa and I made the palliative care initiative a priority. In a casual conversation during the ICU rounds, a staff member mentioned that there was a new hospitalist who had just joined the service and he had some background in palliative care. I would later discover that this physician was board certified in palliative care but was also determined to make his career solely focused on palliative care. The moment in time had come for the program. With the assistance of a multi-disciplinary advisory committee and the support of my colleagues on the executive team, a plan was formulated. In August 2013, the first of the three adult facilities began providing palliative care consultations. The first team consisted of a chaplain, social worker and a palliative care physician. This was a second palliative care physician that had been in the system for several years who also had a desire to develop a more robust palliative care program. While I would like to report that the program is going strong and having a major impact, that is not the case. Rather it has been a slow process. There was a missing part to the team which I would discover after we began to provide services in the second adult facility.
In the second facility the team again was formed with a chaplain, a social worker and the new palliative care physician. The next moment in time came with the hiring of a dedicated palliative care RN, who brought both expertise and passion to the service. I am happy to report that the service is now well-established at this facility and a dedicated RN will be added to the first team shortly.
In early 2014, the palliative care initiative will begin at our third adult facility. The team will look similar to the other two but the difference is that this team has been together the longest as they were the original ICU support team. The hospital system’s foundation office is currently securing a grant for educational development for the palliative care teams; this will likely allow several team members to attend the CAPC conference in Orlando, FL, in November 2014.
You may be asking yourself what is significant for chaplaincy in this story. There are two parts to the answer. The first is somewhat obvious. In all of our formulations of the palliative care teams, the chaplain is a vital team member. The chaplain brings not only the skills of working with patients and families in exploring their spiritual resources and spiritual dynamics, but also brings spirituality to the palliative care team. At our facilities, the chaplain staff is highly regarded by nursing and physician staff. We are blessed to have chaplains who are passionate about palliative care. They have taken on the task of pursuing certification in palliative care chaplaincy.
There is a saying that if you have seen one palliative care program, you have seen one palliative care program! This is the second part of the answer. While there are common characteristics of palliative care programs, the teams are made of different personalities and the institutions in which they work have different cultures. Our first facility is in an area of a major concentration of retired persons and so the patient population is the oldest in our system. It is also the smallest census-wise and was recently acquired by the system. The general population of the city is Caucasian in ethnicity. The second facility is in an area of significant medical competition, with four major hospital organizations in a two square mile block. The patient population is younger than at the first hospital, but is shifting to a more geriatric focus and the population has a greater Hispanic component. The third hospital is the newest and largest with a much more diverse ethnic mix than the other two. These cultural and population differences influence the scope of the palliative care service. We are still learning the nuances of this as we develop the program.
There is a third element that is significant to the future of chaplaincy. The challenge of in-patient consultation model palliative care programs is the follow-up process post hospitalization. Out-patient clinics are very expensive to maintain and require a significant service population to sustain them financially. An approach we are taking is to develop relationships with the long-term facilities (rehab, nursing homes, among others) in our service areas. This would offer a great opportunity in the future for chaplaincy to develop ongoing follow-up with patients/clients/residents in the palliative care service. The future of healthcare is in the development of integrated networks to improve health outcomes.
Rich Woodley is director of ethics for the CHRISTUS Santa Rosa Health System in San Antonio, Texas.
