Saturday, December 29, 2012

Chaplains in the News on the Left Coast

Perhaps it was because it was the Feast of Stephen: check out this article at SFGate, the on line presence of the San Francisco Chronicle. It shares with the public a story of those who are "going out," not only on the 26th, but day by day (and, yes, one of them is an Episcopal priest). It's a good piece, highlighting the work that chaplains do for all patients, and how important that work is to those served. So, head over and take a look. (Hat tip to Episcopal Cafe, who saw it first.)

Monday, December 17, 2012

Standards of Practice for Chaplains: Standard 1, Part B

I left off my last reflection on Standard 1 of the Standards of Practice for Acute Care with this paragraph:

Which confronts us with the qualifying term: what makes the data relevant? Actually, the Standard is to evaluate the data for relevance. Our models for evaluation are the frameworks within which we determine whether the data is relevant. So, let me think a bit and then come back in the next reflection.
So, how shall we evaluate the data as relevant and/or pertinent (in this case, that may be a distinction without a difference)? Well, we do have some help in clarifying that. In fact the Committee that drafted the Standards of Practice went farther, and did offer some further reflection. (Again, you can link to the Standards from this page, and then scroll down to the more detailed reflections.) The interpretation of the Standard includes,

A chaplaincy assessment in health care settings involves relevant biomedical, psycho-social, and spiritual/religious factors, including the needs, hopes, and resources of the individual patient and/or family.

A comprehensive chaplaincy assessment process includes:

  • Gathering and evaluating information about the spiritual/religious, emotional and social needs, hopes, and resources of the patient or the situation
  • Prioritizing care for those whose needs appear to outweigh their resources

My first reaction is that the first sentence doesn’t help us a lot. “Relevant biomedical, psycho-social, and spiritual/religious factors” would, in a hospital, seem to cover just about all the information gathered. However, I think the further categories are helpful. “[T]he spiritual/religious, emotional and social needs, hopes, and resources” do give us something to work with. Note, too, that both the persons (“the individual patient and/or family”) and circumstances (“of the patient or the situation”) are important.

So, if we return to the language of the Standard itself, “relevant” and “pertinent” are related to the needs, hopes, resources, and capacities (whether needs outweigh hopes and resources) of particular persons in specific situations. This, then, gives us categories that allow us to structure our assessments and organize our responses. It also allows us to set some boundaries and make appropriate referrals. For example, while the patient’s biomedical needs might well outweigh resources (after all, how else would someone end up in our institution?), our response is going to be limited primarily to advocacy. We can let the nurse know when the patient reports pain, but we won’t be providing medication ourselves. The same applies to psycho-social needs. Depending on how professionals relate in a specific institution, the chaplain can advocate about social needs, and may have some resources to bring to bear. On the other hand, except in particular circumstances, a chaplain will not be providing psychotherapy for a patient. (Let me say explicitly that I do think we all share in the same first intervention: therapeutic listening. And while therapeutic listening is therapeutic, it only extends into therapy per se if we’re trained for it.) And in most of our institutions even social needs will be referred. While we may have some resources, most chaplains depend heavily on the social workers, case managers, and discharge planners they work with to meet social and/or financial needs.

Which leads us to focus especially on “spiritual/religious factors,” which will certainly include “the needs, hopes, and resources” available. The fact is that this is something of a soapbox of mine. Institutions have or make available professionals trained in psychology and social work. Most of them are quite conscious that they aren’t trained to address spiritual/religious needs. We are. The reasons institutions have us is to address those spiritual/religious needs. So, while we want to be alert to the impact that biomedical and psycho-social needs have on spiritual/religious needs, it is the latter that are our domain and should be our focus.

So, what is relevant and pertinent is data that assesses spiritual/religious needs, hopes, and resources of this person (which may not be expressed in religious language at all), as these are expressed in this situation and affected by biomedical and psycho-social factors. We would hope that, as we would refer appropriate when biomedical and psycho-social needs are affecting the spiritual/religious needs, our colleagues in other professions would refer when spiritual/religious needs seem to be affecting biomedical and/or psycho-social needs. (Well, one can hope….)

Let me make one further reflection on the further explication of the Standard from the Committee. The examples they offer of how one might demonstrate compliance with the Standard is focused not on the data but on qualifications of the tools. Specifically, the Examples refer to “an accepted model” or to “published models for spiritual/religious assessment.” The problem is that these are really more aspirational than real. There are certainly published models for spiritual/religious assessment. However, none of them has been “accepted” across the profession. Each has its strengths. The good folks at Healthcare Chaplaincy Inc. have compiled a list of articles and book chapters that highlight a number of them. But, beyond publication per se none of them has been accepted broadly, or in any official sense.

Moreover, most of them were developed prior to the development of electronic documentation. While one would expect that the categories of any model could be adapted to an electronic platform, each platform has its own limitations – How many fields for data? How many characters per field? As we merge those two tools, we then have to make our own interpretive decisions. What is amenable to a list of bullets or boxes to check? What requires narrative? Knowledge of a variety of models is interesting, but we can only apply one or two in shaping our documentation – and that will inherently shape our assessment. (Remember the proverb that begins, “If your only tool is a hammer,….”)

So, it seems to me that the specifics of the tool – Which model? Which platform? How configured – are secondary to the intent. The measure has to be whether the assessment tool gathers information about spiritual/religious needs, hopes, and resources, with room to note how biomedical and psycho-social needs have impact on them. If the tool does that, it would seem adequate and appropriate to the task. If the tool does that, and the chaplain uses the tool faithfully, I think the chaplain would be meeting the Standard.

Wednesday, December 12, 2012

What Was the Cause of the Stomach Upset?

Last week my Best Beloved pointed me to this article in the New York Times on line. The topic is a new research study that takes a close look at one of the most common medicine regimens in use: taking low dose aspirin to prevent clots that might lead to heart attack or stroke.

The article highlights several questions about aspirin therapy that have come up over the years. There’s general agreement that a lot of folks benefit from taking low dose aspirin. On the other hand, aspirin, even at low doses, has some risk of irritating the stomach lining and causing some bleeding. So, does an enteric coating – a coating that delays the digestion and absorption of the aspirin – spare the stomach and prevent the bleeding? On the other hand, does it interfere with absorption so that the benefit isn’t as great? There has been a theory, too, that some people don’t benefit at all from the aspirin because of “aspirin resistance.” So, is that a real problem? Or does perhaps the enteric coating prevent the absorption, creating the symptoms of “aspirin resistance?”

This is a news article. While it provides a good general description of the clinical questions, it doesn’t go into detail. I’m sure that articles written for more clinical audiences will address the scientific questions in more detail.

However, what I really do like about this article is how well it highlights the various conflicting interests. Read it at all carefully, and you’ll see the questions the reporter raises about the relationships between research funding and research results. There are legitimate questions, really. I believe that the researchers want to benefit patients. I believe they look at their research results and interpretations, and are honest. At the same time, it’s also clear that there are commercial supporters for each position, prepared to fund further research that will help seem to argue for their products. And while correlation is not causation, those connections between research funding and research results are as worthy of study as the medications themselves.

So take a few minutes with this article. It’s hardly definitive. There will need to be more research to justify any of these clinical positions. But it shines a light on the interconnections between research, researchers, and funders – connections that are arguably troubling.