By Linda F. Piotrowski, MTS, BCC
It is Tuesday noon, time for the weekly palliative care interdisciplinary team educational conference. After a brief service honoring those who died under our care the case presentation begins. The palliative care fellow (this year it is a female physician) shares her PowerPoint slide describing a recent patient. The patient, a 72-year-old male, had multiple co-morbidities. Among them were pulmonary hypertension, history of a leg amputation due to complication of diabetes, chronic obstructive pulmonary disease, and worsening kidney function. The fellow directs us to write down questions we would want answered before we decided to go down the road of offering the patient the choice of kidney dialysis.
Knowing that each of the patient’s symptoms was life-threatening, I did not have a deep enough medical knowledge to know what questions to ask related to the details of the medical conditions limiting his life. I did not know the statistics predicting the outcomes for a 70-year-old man undergoing dialysis. I did, however, know what to ask to ascertain what might motivate him to pursue treatment.
My initial observation was: “This is bad, bad, bad!” Everyone laughed. Then I asked my questions: “What gives meaning to his life. Does he have relationships that enable him to face grueling ongoing treatments? Does he have a relationship with a Higher Power or the Sacred? Is he part of a faith community? Does he have relationships to repair or tasks to complete that would make him feel his life had been well lived? What would his quality of life be if he chose treatment? Does he have supports at home to help him during dialysis? Does he have rides back and forth for treatment? Was someone at home to help when the fatigue that dialysis causes sets in? What about payment for the treatments? How will all of this factor into decision-making when the doctors speak to him about treatment choices?”
A visiting nephrologist from the VA (Veterans’ Administration) Hospital across the river from us commented, “This is why I wanted to visit your team. You have members who ask questions that I would never think about asking. I am so focused on the patient’s renal needs and physical conditions.”
The above is an example of a benefit of being a chaplain embedded with a palliative care team. I am able to raise issues that my medically focused colleagues may not ask. Other benefits include being present and participating in daily one-hour interdisciplinary team rounds where the team discusses and develops the plan of care for hospital in-patients as well as for the patients who come to the out-patient palliative care clinic. I have the opportunity to interact with and teach fellows, residents, and interns from specializations, including oncology, anesthesiology, pain clinics, psychiatry, intensivists, clinical pastoral education, social work and nurse practitioner students as well as visitors from numerous medical institutions. Chaplaincy is present at the table and has a voice setting an example and expectation for all of these participants.
It means teaching palliative care fellows for two weeks during the fellowships. Helping them to experience the various skills, techniques, and personalities of not only the palliative care chaplain but also the other chaplains in our institution. It means involving the fellows in planning and participating in our quarterly services of remembrance where the families of patients who died having had a palliative care consult are invited and many attend.
Being embedded with the palliative care team is not without its challenges. An ongoing challenge is attempting to remain an active fully functioning member of two teams: chaplaincy and palliative care. This means multiple meetings and varied assignments. As a member of the chaplaincy staff it means being committed to providing services to one in-patient unit as well as the out-patient oncology services, sharing in on-call, attending chaplaincy department meetings as well as helping to plan and participate in various chaplaincy sponsored events. As a consult service, palliative care in our setting is not confined to a particular nursing unit. Patients are scattered throughout the hospital. With patient-centered care as our focus, we need to constantly communicate about which chaplain will best serve the patients.
Because ours is a teaching institution the make-up of the interdisciplinary team is constantly changing. Core staff remains the same but each week brings an influx of learners and visitors. Physician members of the team cycle in and out due to days off and other assignments. We constantly form and re-form as a team. This stretches us in terms of hospitality and accommodating different personalities and ways of functioning.
A chaplain member on the palliative care interdisciplinary team must have a strong sense of self and call as well as a commitment to the necessity of spirituality as integral to care planning. Along with my social work, healing arts, and artist and writer members of the team, I at times struggle to have my voice heard in the face of necessary medical clinical discussions seeking to alleviate pain, and assist patients and families in making decisions about goals of care, and other life and death decisions.
These challenges of being a member of the interdisciplinary palliative care team are minor when compared with the opportunities afforded to fill the chaplain’s many roles. Primary to these roles is assessment of the patient’s spiritual needs and resources. This is essential to the chaplain’s ability to fulfill his or her other duties to advocate, educate and coordinate.
(This article is not a comprehensive examination of the benefits and opportunities afforded to a chaplain member of an interdisciplinary palliative care team. Rather, it is a glimpse into some of the ways one board certified chaplain attempts to live out her role on an interdisciplinary palliative care team.)
Linda F. Piotrowski, MTS, BCC, holds a master’s of theology from Saint Francis Seminary in Milwaukee, WI. In addition, she was educated in the Center to Advance Palliative Care programs and completed the Metta Institute’s Compassionate Care for the Dying Training. A chaplain for 24 years, Ms. Piotrowski has ministered in acute and long-term care, home hospice, and parish and congregational settings. A member of the Dartmouth-Hitchcock Medical Center’s chaplaincy department, she currently ministers as the pastoral care coordinator and chaplain for palliative care and oncology services at Dartmouth Hitchcock Medical Center and the Norris Cotton Cancer Center in Lebanon, NH.