ICU Management & Practice, Volume 18 - Issue 1, 2018

Establishing a relationship of trust and care

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The chaplain is a resource of ethically competent support and a compassionate caring presence for patients, families and ICU staff.

An admission to the intensive care unit (ICU) is often a traumatic experience for both patients and families. Although members of the critical care team are specially trained to provide care and treatment requiring close, constant observation, the environment can be overwhelming with machines, tubes, and equipment used in the care of the patient. With what feels like a barrage of requests for information about the patient’s medical history, advance care directives and goals of care, families are often challenged to focus on the goal of the healthcare team to help their seriously ill loved one heal and recover. Within the environment of sophisticated diagnostic and therapeutic care in almost every specialty and subspecialty of medicine and surgery, the salient role of the chaplain in the ICU is to be a resource of ethically competent support and a compassionate caring presence for patients, families and the ICU staff. The quality of chaplaincy care is determined by the ethically-competent and compassionate caring connections that are made with patients, families and staff throughout the hospitalisation.

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For many patients and families, the ICU admission may elicit fear, frustration, anxiety, and sometimes anger, which are common signs of emotional and spiritual distress.

Addressing spirituality is invaluable to patients and families with severe illness. The spiritual beliefs of patients and their family members are known to influence ethical decision-making about goals of care and end-of-life choices.

Cheryl Palmer, manager of spiritual care services at Barnes Jewish Hospital in St. Louis, Missouri, expresses how important it is to provide spiritual services to the ICU staff:

Working in a hospital is difficult because it means watching people suffer and sometimes die, and then observing the emotional family dynamics that result. It all takes a toll on the staff. Medicine is very demanding, and it does not matter what your job is, everyone feels the intensity in a hospital.

Compassionate care for all

Challenges to providing optimal spiritual care in the ICU centre around education and communication. According to William Nelson, PhD, Director of the Rural Ethics Initiatives at the Dartmouth Initiative for Health Policy and Clinical Practice at Lebanon, New Hampshire:

Clinicians sometimes misunderstand the chaplain’s role. Some healthcare workers think the chaplain is trying to impose or only attend to religious beliefs.

The reality is that the chaplain is a trained professional with specialised education and training in mobilising spiritual resources so that patients are enabled to cope more effectively with their illness. Chaplains maintain confidentiality, are held accountable to a certifying chaplaincy organisation as well as the employing institution, and offer compassionate care and concern to all who are in need, regardless of a person’s beliefs, religion, or cultural values. For many people, spirituality includes religious practice, but for others applying a contemporary understanding of spirituality may include nature, art, music, family or community. Their spiritual beliefs may allow for an appreciation of the beauty of nature and the world around them, which draws them inward to their deepest core where they discover the resources they need to cope with their illness. Furthermore, chaplains provide one of the greatest gifts one person can give another who is experiencing a severe crisis in their life, and that is a listening presence.

According to chaplaincy staff at Lancaster General Health in Lancaster, Pennsylvania: “Everyone’s life is a unique and precious story.” Having a calm, compassionate and attentive listening presence to hear a person’s story is crucial when one is hospitalised with a serious illness. The experience of sharing one’s story and having it truly heard helps to relieve stress and tension, with the possibility of bringing about renewed hope and healing. As the designated chaplain assigned to the palliative care interdisciplinary team, I often describe the chaplain’s role as the member of the healthcare team who pulls up a chair at the bedside to listen to a patient’s story, providing ethical discernment, requested prayers and/or rituals without an agenda, and usually without time constraints.

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Chaplaincy care at NYU Winthrop Hospital


Addressing a need or desire for spiritual support is a part of routine care in the ICUs at NYU Winthrop Hospital, a 591-bed university-affiliated medical centre and New York State-designated Regional Trauma Centre. There are five ICUs: Medical (20 beds), Surgical (23 beds), Neuroscience (14 beds), Paediatric (8 beds) and Neonatal (27 beds). One chaplain is assigned to cover an adult ICU unit and is required to round on that unit daily. The Paediatric and Neonatal units are covered by the chaplain managing the daily code pager, who works closely with the social workers assigned to those units. Contact information for the chaplains assigned to the ICUs is posted on the unit’s white board for easy access during daytime hours. After hours, referrals are made for the on-call chaplain through the hospital operator. At the end of each day, the ICU chaplains provide updates to the on-call chaplain for continuity of care and coverage during the night. Over a six-month period, there were 207 referrals for chaplaincy care in the ICUs (from nurses, patients, family members, other members of the healthcare team, including palliative care). These numbers reflect the commitment, connections and rapport the staff had already established with the chaplains, and the ongoing connections made between the chaplains, patients, and families.

Supporting patients and their families


In addition to making referrals to a patient’s spiritual leader, rounding with the ICU healthcare team, and providing a mediating presence for patients—is  paramount. As spiritual and religious concerns and perspectives are often tied to how patients experience illness and their end-of-life decision-making, chaplains support patients (and their families) to clearly articulate what they want—or don’t want—to members of the healthcare team. Conflict and tension generally arise when the diagnosis, prognosis, and goals of care are not explained in terms that patients can understand. In addition, patients report they are not given time to process the information they have received from members of the healthcare team. The chaplain is often used as a sounding board for staff who may be guided by time constraints, healthcare and government regulations related to the provision of quality care for their patients. As patients struggle to make meaning and purpose of their illness, and attempt to make informed decisions, chaplains can greatly enhance the communication process between patients and staff.

Chaplaincy support offered to families allows the healthcare team to focus on providing treatment and care for the patient without unnecessary and sometimes harmful obstruction from family members. Sensitivity and advocacy on behalf of families is a must. Many patients admitted to the ICU are unconscious, unresponsive, and some will die. The family is often terrified and uncertain about the future of their family without their loved one, who now is unable to communicate, and uncertain of their own future without their loved one. Concerns about financial wellness [and the growing medical costs of ICU care], regrets and confessions are known topics that family members bring to the chaplain. The role of the chaplain becomes one of facilitating a growing list of concerns: mounting tensions among family members, supporting and encouraging end-of-life care decision-making, collaborating with members of the medical team in family meetings and consults, advocating parking passes for extended visitations, or with the dietary department to bring an extra food tray for a long-time spouse who will not leave the bedside of her intubated patient-spouse because she/he, “does not know how else to be, except be by his/her side.” The chaplain is also expected to be a “traffic controller” when there are limitations to patient visitations. The communication between the chaplain and members of the healthcare team is invaluable.

Supporting staff


Just as the ICU healthcare team provides patients and family members with education and strategies for improving health and wellbeing on discharge, the chaplain is often requested to help facilitate patient compliance. When a relationship of integrity and trust has been established between the chaplain and patient, outreach to the patient’s faith community/spiritual leader with the patient’s permission can result in a successful compliance strategy and a lower rate of readmission. Moreover, multidisciplinary teamwork extends to documentation of the chaplain’s visit in the patient’s medical chart. The chaplain’s documentation allows multidisciplinary review of the spiritual assessment, goals of care and changes in the patient’s psychosocial-spiritual outlook. Chaplains facilitate an understanding of the role of spiritual, religious and cultural beliefs, values, norms and practices in patient care while at the bedside on the unit. The chaplaincy department can develop and design ICU-specific in-service, didactics and grand rounds as multidisciplinary education opportunities.

The chaplain as a resource of support for staff who need to express existential questions about human suffering, or a safe space to articulate their own vulnerabilities and human frailties after a challenging trauma, or series of traumas on the unit, is in great demand. There are growing data and studies (e.g.“What do I do?” (2017) that suggest the chaplain’s time is spent almost equally providing emotional and spiritual support to patients and families, as with members of the healthcare team, especially nursing staff. It is important for members of the healthcare team to care for themselves in order to better care for their patients. In hospitals around the country, administrators are becoming advocates of stress-reduction interventions which help staff regain equilibrium and balance after particularly overwhelmingly traumatic experiences during their patient care.

At Boston Medical Center, for example, staff members gather for a weekly hour of renewal, facilitated by the chaplain, with soft music, light refreshments and massage equipment stations. “We’ve found that this time helps increase employee morale,” notes Chaplain Jennie Gould, PhD. At NYU Winthrop Hospital, staff members on the Oncology unit requested monthly spiritual support at their weekly huddles. Staff chaplains Jackie Lynch, Carol Schneider and Jayan Daniel lead a group activity called, “What’s popping?” using popcorn as an edible prop to invite staff to share “what’s going on” in their lives. Helping staff to debrief, pause, and take time-outs for just a few minutes of the day, after a “bad”, not necessarily, a “sad” incident may lessen an inclination toward burnout, increase the capacity for better self-care, and in the long run improve work productivity.”

Chaplains are essential members of the multidisciplinary teams working in the ICU. Their education, training, certification, and skills contribute to the goal of providing whole-person care to seriously ill patients and their families. In addition, they bring much-needed and appreciated expertise to support the various team members who work in constantly stress-filled situations.

References:

Choi PJ, Curlin FA, Cox CE (2015) "The patient is dying, please call the chaplain'': the activities of chaplains in one medical center's intensive care units. J Pain Symptom Manage, 50(4): 501-6.

Higgins M, Wilsey JE (2012) Spiritual care in the ICU - a chaplain’s perspective. Critical Connections, Aug 4. [Accessed: 18 January 2018] Available from
sccm.org/Communications/Critical-Connections/Archives/Pages/Spiritual-Care-in-the-ICU---A-Chaplain%E2%80%99s-Perspective.aspx

Lancaster General Health (2018) The role of the chaplain. Lancaster, PA: Lancaster General Health. [Accessed: 18 January 2018] Available from
lancastergeneralhealth.org/LGH/Our-Services/Pastoral-Services/What-is-a-Chaplain-/Role-of-a-Chaplain.aspx

Lee B, Choi P (2015) Chaplain documentation in the ICU. Conference on Medicine and Religion, 6-8 March, Cambridge, MA, USA. [Accessed: 18 January 2018] Available from medicineandreligion.com/2015-conference-on-medicine-and-religion.html

Relias (2016) Chaplain visits in ICU uncommon, study finds. Medical Ethics Advisor, May 1. [Accessed: 18 January 2018] Available from ahcmedia.com/articles/137777-chaplain-visits-in-icu-uncommon-study-finds

What do I do? Developing a taxonomy of chaplaincy activities and interventions for spiritual care in ICU patients. HealthCare Chaplaincy Network 4th Annual Caring for the Human Spirit Conference, 13-15 March 2017, Chicago, USA.




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