Some New Video Resources

Recently I had the opportunity to particiapte in a webcast presentation from the recent National Funeral Director’s Association (NFDA) Annual Conference. The title was "End-of-Life Care: From One Set of Caring Arms to Another," and the presenting panel included Robert Friedman MD, FAAHPM, the Chief Medical Officer at Hospice Austin in Austin, TX; Dr. Thomas G. Long, the Bandy Professor of Preaching at Candler School of Theology at Emory University in Atlanta, GA; Thomas Lynch, a writer and funeral director from Milford, MI; and Dr. Alan Wolfelt, an author, educator and grief counselor. This was an interesting conversation among the presenters. While initially intended to discuss the interactions when a person in hospice or palliative care dies between the care provider and the funeral home, it became a wider discussion on current styles in our culture of expressing, and perhaps repressing, grief. 

At the time the NFDA web site stated that the presentation would eventually be available for viewing on line. I shared that at the time, and now have the link. This and other presentations from the NFDA Annual Conference are now available on YouTube. If you link to this page you will find links to this and other presentations. Note, too, that NFDA has a YouTube channel, and there may be other videos of interest there. A note for Board Certified Chaplains: if you haven’t fulfilled the 50 contact hours required for continuing education, I think at least some of these presentations would apply. 

 I hope readers find these links and these presentations helpful.

For the Saints of God

This past Sunday's sermon at St. Mary Magdalene Episcopal Church is now posted. You can listen here. I preached a bit longer than normal. It's just that there was a story. There's always a story....

Episcopal Health Ministries

I think most of my readers are aware that I am a member of the Standing Commission on Health of the Episcopal Church. One of the tasks I undertook for the Commission was trying to get some idea how many “health ministries” could be identified within the Episcopal Church. To get some idea (and it’s only an idea), I went through those pages of the Episcopal Church Annual that listed “Special Agencies and Institutions/General Service Organizations,” and specifically those pages of “Health and Welfare Agencies Related to Diocese or Parishes of the Episcopal Church.”  These are listed by Diocese, and are generally sorted in to the categories of Children, Youth, and Families; Chaplaincy Services and Counseling; Facilities and Services for Older Persons; Hospitals, Convalescent Homes, and Clinics; Neighborhood and Community Services; Residences, Rest Homes, and Retreat Centers; and Specialized Ministries.

So, I simply went through and counted. As I did so, I set up a spreadsheet that listed the number of such organizations with specifically identifiable health ministries. I also added a few organizations and institutions I knew of that were not associated with diocese or parishes, but instead with other Episcopal bodies. At the end I had the numbers of such ministries where I could determine that they existed. In the process, I developed some comments and assumptions:

1. One can ask "what is an Episcopal health care ministry?" All the institutions and ministries counted for this report were identified as associated with a specific diocese or Episcopal organization in The Episcopal Church Annual.

2. Within that list, the relationships between individual dioceses and individual institutions may take several different forms.

3. Note that most of the institutions listed serve primarily seniors. Not all provided information about levels of health care offered. Where I could find the information, whether in the Annual or on line, that an institution provided skilled care, long term care, etc., I included it in my count. Where information seemed to indicate a residence facility for seniors who were fully independent, I did not include it.

4. My best guess is that this number is low: that there are programs associated with congregations that are not associated with dioceses in the Annual, or ministries listed once that have multiple locations.

5. As we know, this is always a changing list. For example, this includes ministries in the Diocese of Texas where institutions are in transition.

That list has been posted and is now available on the Documents page of the Standing Commission on Health in the General Convention web site. The numbers are on the first sheet and the comments and assumptions on the second. Note that where I couldn’t identify such a ministry in a particular diocese, I did not include that diocese in the list. That said, note my comment (4) above. I’m certain there are ministries that this didn’t capture. I thought folks might find it of interest, and so you can now find it here. If there are questions, they can be posted here or emailed to me through this site.

Conformed Consent

Yesterday in a conversation about ethics a turn of phrase occurred to me, and the more I've thought about it the more sense it's made. Let me make it in context.


The specifics of the conversation had to do with informed consent and the decisions of patients and/or families - perhaps especially families when the patient can't participate - regarding goals of care and possible treatments. Now, there have been many discussions on what "informed" consent might mean, and whether we can really and accurately inform patients and families. Those discussions are important, but I was struck in the conversation by another point. Even when we try hard and do our best to provide information that is accurate, and try to provide it in a form comprehensible by the person in front of us (usually someone who would not comprehend the word "comprehensible"), people make decisions or ask further questions that seem to us as professionals as if the person didn't understand. With some further conversation the person might completely and accurately recount back to us the information provided, and then still ask for information or, more importantly, for an intervention that seems to us unhelpful. Once again, we wonder whether the information has really been comprehended (understood more deeply than simply the level of definitions and concepts).

Most of the time over the years I have noted and pointed out to colleagues that this is one consequence of the principle of autonomy, and especially of how in our American context (by which I mean specifically the United States, and not including Canada or Mexico) autonomy has become the overwhelming principle applied in making health care decisions. If we allow folks to make the decisions, we need to be prepared for them to make decisions we find foolish. As I have often said after a difficult family conference, "It's not that they don't "get it." The problem is that they don't want it."

It occurred to me, though, that this reaction doesn't do justice to the families of patients, because it doesn't claim our part in our own frustration. It occurred to me that we expect that informed consent will in fact be conformed consent - that is, that the information that we find compelling will also be found compelling by the other party.We have been persuaded by our own information and logical reflection, and we expect it to be persuasive to any other rational person. Ergo, if it isn't persuasive the other person must not be rational.

And that is our sin. That dishonors the other persons' values and frames of reference. It is also as much a cause of our frustration as the other persons' responses. It's the unclaimed, usually unrecognized prejudice - literally, our pre-judging of what constitutes reasonableness, if not of the person specifically - through which we set ourselves up to be disappointed.

In that light I'm humbled by how often we aren't disappointed or frustrated - that it doesn't happen more often than it does. That is, in fact there is enough of a shared social frame of reference that much of the time the "best medical advice" that we offer is persuasive for those who listen. Let me be clear: it is also part of that, and a part that we need to be self-aware about, that some of that social frame of reference has to do with the status of the expert and of the physician (in these instances combined in one), so that it is not the information or the logic that is persuasive but instead the perceived authority of the physician. Still, even recognizing that caveat, it is a fact (one that we don't appreciate often enough) that there is enough shared sense in our culture of what constitutes "reasonable" that we don't have more moments than we do when we project that the patient and/or family are "unreasonable."

Nonetheless, these encounters happen more than we like, and perhaps should happen more often than they do. That is, we are too hasty to present our information and our reason from our context without taking the time to step into the other person's. We think what we find compelling must surely be compelling for others. We expect an informed consent process to result in conformed consent, and get frustrated when it doesn't work out that way. Unfortunately (and this is not really news), our expectations are as much an issue as another's lack of understanding or unreasonableness; and our frustration with the situation and with them is in no small part our own fault.

Sermon for Saint Luke's Day, 2013

I have the privilege of preaching this sermon for the Celebration of the Feast of Saint Luke at Saint Luke's Hospital, October 18, 2013. I note above that these are my words and my reflections, and not a reflection of or from the hospital where I work. I especially want to reiterate that here, since for once in this blog I make specific reference to it. 

It is the feast of Saint Luke; but let me begin with Ecclesiasticus. This is perhaps the only Scriptural book for which we know the author’s name: Jesus ben Sirach. Ben Sirach wrote: 

Honor physicians for their services,
  for the Lord created them;
for their gift of healing comes from the Most High,
  and they are rewarded by the king.
The skill of physicians makes them distinguished,
  and in the presence of the great they are admired.
The Lord created medicines out of the earth,
  and the sensible will not despise them.
And he gave skill to human beings
  that he might be glorified in his marvelous works.
By them the physician heals and takes away pain;
  the pharmacist makes a mixture from them.
Then give the physician his place, for the Lord created him;
  do not let him leave you, for you need him.
There may come a time when recovery lies in the hands of physicians,
  for they too pray to the Lord
that he grant them success in diagnosis
  and in healing, for the sake of preserving life.

The scholars that put together today’s readings began with this one because it is one of our few references specifically to physicians, and the only one I recall in which the physicians are actually the subject. Those scholars noted this because, of course, Luke was, as Paul called him, “the beloved physician.”

Now, physicians can get a bad rap. You know the reputation: arrogant and self-important. My broader experience is that physicians know quite well that they are part of a network of care, working with and dependent on the skills of others. That’s how the world is, really: none of us in our work is self-sufficient. All of us have to rely on others to some extent for our own work to be effective.

Ben Sirach was quite aware of this. Let me read something else that he wrote.

The wisdom of the scribe depends on the opportunity of leisure;  

   only the one who has little business can become wise. 

How can one become wise who handles the plow, 

   and who glories in the shaft of a goad, 

who drives oxen and is occupied with their work, 

   and whose talk is about bulls? 

He sets his heart on plowing furrows, 

   and he is careful about fodder for the heifers. 

So it is with every artisan and master artisan 

   who labors by night as well as by day, 

those who cut the signets of seals, 

   each is diligent in making a great variety; 

they set their heart on painting a lifelike image, 

   and they are careful to finish their work. 

So it is with the smith, sitting by the anvil, 

   intent on his ironwork; 

the breath of the fire melts his flesh, 

   and he struggles with the heat of the furnace; 

the sound of the hammer deafens his ears, 

   and his eyes are on the pattern of the object. 

He sets his heart on finishing his handiwork, 

   and he is careful to complete its decoration. 

So it is with is the potter sitting at his work 

    and turning the wheel with his feet; 

he is always deeply concerned over his products, 

   and he produces them in quantity. 

He moulds the clay with his arm 

   and makes it pliable with his feet; 

he sets his heart on finishing the glazing, 

   and he takes care in firing the kiln. 

All these rely on their hands, 

   and all are skilful in their own work. 

Without them no city can be inhabited, 

   and wherever they live, they will not go hungry. 

Yet they are not sought out for the council of the people,* 

   nor do they attain eminence in the public assembly. 

They do not sit in the judge’s seat, 

   nor do they understand the decisions of the courts; 

they cannot expound discipline or judgment, 

   and they are not found among the rulers. 

But they maintain the fabric of the world, 

   and their concern is for the exercise of their trade. 

(Ecclesiasticus 38:24-34a)

I love the phrase in that last verse: “they maintain the fabric of the world.” Without all those other trades – without all those other professionals, really – the city falls apart. They may not get the attention that city leaders get, but they are critical to the city’s survival.

That’s also true of a hospital. We all know that if we give it only a moment’s thought. Small steps have big value. There are things that are required of physicians, and also required of all of us, that don’t make headlines and yet are very important to our care of patients and their families. So, good hand sanitation is a standard precaution, required of all of us; and not just part of the scrub-in for surgery. Good communication is a standard of care for all of us, and not just for the physician or the nurse. Some of us will remember when Saint Luke’s South [Hospital] opened, with a hide-a-bed couch in every room. One of the things the Kansas inspectors were most concerned about was how well our environmental services staff could sanitize the inner workings of those couches. That was because they knew, and we know, that excellent housekeeping is important for the safety of our patients; and how a lapse in how we clean our beds or our tools or our hands can undo all the good accomplished by physicians and nurses and others. So in modern health care we do honor the services of physicians - and also the pharmacists mentioned with them – and we also honor the care taken by all of us who serve, professionals and staff and volunteers alike.

Which is really appropriate when we think of Luke. Luke was a physician, but like so many physicians he had real concern for the poorest and most vulnerable around him. Think about how Luke understood Jesus’ mission, given to us in today’s Gospel lesson:

"The Spirit of the Lord is upon me,
because he has anointed me
  to bring good news to the poor.
He has sent me to proclaim release to the captives
  and recovery of sight to the blind,
  to let the oppressed go free,
to proclaim the year of the Lord's favor."

The poor, the imprisoned, the blind, the oppressed – that’s not an exhaustive list, but it does lay out a theme. Luke understood that good news for those who were vulnerable and suffering was central to what God was accomplishing in Jesus. This was, really, what the year of the Lord’s favor was about. Luke was probably modeling this on the year of the Jubilee, when every 50 years debts would be cancelled, land would be returned to its original owners, and slaves, or at least Israelite slaves, would be freed. The good news, according to Luke, was about setting the world right so that the vulnerable were restored.

That’s really something of a theme for Luke. Think of how he differed from other Gospel writers. Matthew wrote, “Blessed are the poor in spirit.” Luke wrote, “Blessed are you poor.” Matthew wrote, “Blessed are those who hunger for righteousness.” Luke wrote, “Blessed are you hungry.” Luke’s sense of God’s care for the suffering was quite concrete. It was Luke who described how a Samaritan cared for the wounds of a beaten man with oil and wine. It was Luke, too, who wrote in Acts of the first Christians who were communal, where “all gave according to their means and all received according to their need.” Like so many physicians today, Luke was concerned about the real needs of individuals and the communities in which they lived.

And for Luke this was not simply professionalism. It was holy work. This is clear again from his record of Jesus’ vocation. His concern for the vulnerable comes because “the Spirit of the Lord is upon me;” and his understanding of God’s goal is “the year of the Lord’s favor.”

All of this is what we claim when we associate ourselves and our institutions with Saint Luke. More than 100 years ago a group of Episcopalians picked up the pieces of an earlier unsuccessful effort and started a hospital in Kansas City. They named it for Saint Luke, the physician who proclaimed God’s care for the sick and the vulnerable. Naming it for Saint Luke they claimed for it the conviction that God’s work is seen when the sick and suffering are made whole. They claimed for it the heritage that care for the poor, the blind, the trapped, and the oppressed is holy work.

And we continue to claim that heritage. That’s why we honor Saint Luke and with him all physicians. And with the physicians we also honor all the other members of the team, professionals and staff and volunteers, whose contributions great and small make this hospital and this health system resources for healing and wholeness, for relief and rescue and restoration.

Now, I know we do not all understand God the same way. It is one of the privileges of my job that I work where we appreciate, and even celebrate our diversity. I’m happy to be able to say to one and all, “Your spirituality is welcome here.” So, I know that Saint Luke as a model will be compelling for some and not for others. At the same time, in almost twenty years in this System I have seen again how many of us, coming from many different perspectives, still reflect the convictions of those who founded Saint Luke’s Hospital: that whatever “holy” might mean, care for the sick and the suffering is holy work; that however Spirit might be experienced, it was Spirit that calls us to care for the poor and the vulnerable. From every bedside to every office to every closet we continue to see how we all work together to see for our patients recovery and restoration. And as long as we continue in that work together, we share in the heritage of Saint Luke – of Saint Luke the Physician, and of Saint Luke’s the hospital.

Another Voice, and Early in the Process

From one blog to another. Regular readers may know that each year I go looking in May and June for folks blogging about the CPE experience. I realized a bit too late that I hadn’t done that search this year. However, honored colleague George Handzo has pointed me to a new one. Christine Davies is a CPE Supervisory Education Student in New York, and she’s blogging about her experiences at Journeying Alongside ~ Chaplaincy & CPE in NYC.


I think it’s good every now and again to read, and to offer some support, for folks in the process. Readers of the blog abbaye have had the opportunity to get his perspective on that practice. Now we have the chance to follow with Christine. (And be sure to look at abbaye and at George’s blog, both linked in the sidebar under “Blogs Discussing Chaplaincy.”)

A Friendly Voice From a Different Location

My regular readers are aware, I hope, of my sidebar list of Blogs Discussing Chaplaincy. One of long standing is "The Hoosier Daddy - In Oz!" from Clair Hochstetler. Some years ago he moved from a chaplaincy position in Indiana to take a chaplaincy position in Australia (hence the name). Well, Clair has moved to a new blog. It's called Bringing Clair-ity To Life Down Under. I suppose that doesn't seem a new location: he's still in Australia. However, he's on a new server with a new address; and in the blogosphere that's as much a move as a geographic change. I encourage you to go over and take a look.

I haven't deleted the earlier site yet, because his earlier observations about chaplaincy are still relevant. So, you can have the benefit of both.

On Pride of Place; Well, On Pride and Place

I've been preaching a bit more at St. Mary Magdalene Episcopal Church lately because they're in transition. Here's my comment on knowing one's place, and the fundamental sin.

Getting the Fire Lit: A Sermon on Proper 15 C

I am a bit late posting, but I had the opportunity again to preach at St. Mary Magdalene Episcopal Church on August 18th. I began by wondering what happened to "Fairest Lord Jesus." If you wonder where I ended up, you can listen here.

Confession Is Good for the Soul - Not to Mention Credibility

Over the years I’ve been blogging, I’ve cited a number of stories from National Public Radio (NPR). I have said here and elsewhere that if I say I’ve heard something on the news, it’s most likely that I’ve heard it on NPR. Now, I’ve been listening to NPR since folks in the Reagan Administration called it “Radio Managua,” because it questioned (among other things) the value of U.S. support for anti-Sandinista paramilitary forces - the support that ended up in the embarrassing Iran-Contraaffair. And I know there are those who question the quality and/or the editorial perspective of NPR.

I still find NPR credible, and one of the reasons is visible in this report that I heard today. It is a report on a report. More specifically, it reports about a series of investigative reports, and how the NPR Ombudsman came to question the quality of the investigation and of the reporting. In the end, the report today noted that the Ombudsman raised his questions in an extensive report, and the NPR leadership agreed on the one hand that the investigation could have been done better and reported better, while also feeling that the conclusions of the investigation were still valid.

Now, I’m sure there will be those who cry, “See how perfidious!” and proclaim that NPR is corrupt. I, on the other hand, am reassured. I respect an organization that not only reviews its own work but publically exposes the results. This shows a commitment to integrity and honesty, and a willingness to accept public embarrassment to demonstrate good faith. This is not just a correction, buried on the radio equivalent of page 3. It is self-examination, carried out for all the world to see.

Any news organization will have mistakes happen. They are, after all, human institutions. I look forward to seeing just how committed other news organizations are to acknowledging not only that “mistakes were made,” but also letting the rest of us really see just how.

On All Kinds of Greed

I preached again this past Sunday at St. Mary Magdalene Episcopal Church in the Village of Loch Lloyd in Missouri. The lessons for Proper 13 led me to a reflection on "stuff," and on all kinds of greed (it's in the Gospel lesson). You can listen here. I hope you enjoy it.

The Best Connection for Endorsement

I have been making some changes to the web site of the Assembly of Episcopal Healthcare Chaplains. One of the changes I’ve requested there I’m also going to make here. The Application form for Endorsement for Healthcare Ministries has a new web site. The best place to connect now is here. In addition to this post, I’ve updated the link in my sidebar.

　

The process hasn’t changed. Complete the form and submit it electronically. It will be received at the Episcopal Church Center. The person who receives it will contact the diocesan bishop for consent, and with the bishop’s consent will forward the application to our Endorsing Officer. That person will then send the letter of endorsement, with copies to the appropriate professional organization and the appropriate bishop. And, of course, you should have picked up from this that the first step is really to meet your bishop so that she or he knows of your ministry.

　

I’ve written before of the importance of Endorsement. It is still important, not only for those seeking certification, but also to raise the visibility of professional healthcare ministries in the Episcopal Church. So, make that appointment if you haven’t; and then get the application in. It serves you, and your colleagues, and the whole Episcopal Church.

The Anglican Health Network Carries On

I learned yesterday that a new edition of the Newsletter of the Anglican Health Network is available. Paul Holley, Coordinator of the Network, has shared that news. It isn't actually up at the AHN web site yet, but you can read it here.

The Network has had some changes lately, including some loss of donors. However, it continues to share information and resources about health care activities across the Anglican Communion. So, take a look at this edition of the newsletter; and then from the web site look at earlier editions. There are many health care ministries across the Communion, and the Newsletter of the Network is helping to spread the word.

Context Is Everything - or At Least an Awful Lot!

An ongoing problem in health care is the use of Emergency Rooms as primary care providers. With that in mind, I was interested to see the story, How Oregon Is Getting 'Frequent Fliers' Out Of The ER by Kristian Foden-Vencil on the NPR web site.

The article describes efforts to address the social needs and issues that keep patients out of primary care, and so in the Emergency Room. It looks at one patient as an example, and speaks to the needs he has for housing, clothing, dependable food - all those things that make for stability. With stability, he has been able to avoid expensive ER care and instead see a primary care physician, get necessary medications, and stay on them. Without stability, he has hardly any choice.

This is a well known problem; and, really, this is not a new solution. However, it's not always the first to come to mind. There is some expense in meeting his social needs and in following through with him so that he uses resources effectively. However, as the article notes, those are only a fraction of the expenses generated with avoidable visits to the ER and avoidable admissions to hospitals.

On the other hand, this is very different from our more common use of resources in health care. It involves spending money on folks who aren't at the time in crisis (leaving aside for the moment that social crises that is defined by the social needs). Our current insurance structure (including Medicare and Medicaid), built as it is on paying for procedures and interventions, isn't oriented this way. Some efforts have been made in the past toward that - think HMO's and "capitated care" (providing so much reimbursement per person) - but they were still oriented toward the traditional categories and the traditional venues of health care: medical and nursing and pharmacy care provided in medical and nursing and pharmacy settings. 

This answer is different, if not original. It is investment, really, in the life and situation of a person to provide the resources that prevent crises and so prevent crisis-level health care expenses. 

There are aspects of how health care is changing under our feet that might better coordinate the traditional aspects of health care. The important buzz words are medical home and accountable care organization. These are new to most of us, but there are good ideas behind these words. That said, they are still focused on how we provide and pay for the traditional categories of health care. It remains the case that for so many without the resources that provide social stability those good ideas won't accomplish all we hope.

A New Look from an Old Friend

I've spoken before about the good work and the good folks at the Center for Practical Bioethics in Kansas City. That's why they are always in my sidebar. Well, if you haven't visited the web site in a while, it's time you looked again. 

The new web site for the Center has more than a new look. There are more resources than ever, from articles and forms to podcasts, blogs, and videos. Of special note are more case studies than ever, there to be shared and discussed. What's more, the entire site is searchable, so you can find what you want. The Center's special programs are easy to see, as are sponsored events.

So, go take a look. The Center for Practical Bioethics is one of the nation's premier organizations for the study of ethics, health, and medicine. The new web site will only make it that much easier for all of us to benefit who work with those issues.

Price and Value in Health Care

Oscar Wilde wrote in The Picture of Dorian Gray, “Nowadays people know the price of everything and the value of nothing.” (Yes, I know he also used that as the definition of a cynic in Lady Windermere’s Fan, but Dorian Gray was earlier. Isn’t Google wonderful?) That was the thought that occurred to me as I read in my local paper, “Consumers may not be using health savings accounts as expected.” The reporter wrote, “A new research report suggests that consumer-directed health plans — which give employees more control over how they spend their employer-subsidized health care dollars — are getting the opposite of the results intended.”

The article points to a study published in Health Affairs titled “Consumer-Directed Health Plans Reduce The Long-Term Use Of Outpatient Physician Visits And Prescription Drugs.” (Paul Fronstin, Martín J. Sepúlveda and M. Christopher Roebuck: Health Affairs, 32, no.6 (2013):1126-1134) The study compared employees of two large companies over a period of five years. One company offered consumer-driven health plans (CDHP) that included a health savings account (HSA) to which the company contributed. One plan was high deductible and another low deductible, with related differences in premium costs but no differences in the company’s contributions to the HSA. The other company offered a Preferred Provider Organization (PPO) fee-for-service insurance plan. Employees were matched between the two companies based in their demographics, etc.

The results were not what the investigators expected.

Although no significant effects were detected for inpatient hospitalizations and days, the CDHP was associated with an increase in ED visits… after three and four years, respectively. For outpatient visits and prescription drug fills, CDHP had a significant negative impact that persisted over the four years after the CDHP’s adoption. Specifically, numbers of physician office and clinic visits were lower…after one year (in 2007) and… after four years (in 2010). Moreover, enrollees filled… fewer prescriptions after one and four years, respectively, under the CDHP..

That is to say, employees with CDHP’s didn’t spend fewer nights in the hospital than PPO employees. On the other hand, they made fewer outpatient visits and had fewer prescriptions filled. The study also showed that employees with CDHP’s had fewer screenings for certain cancers in the first year, but that effect equaled out or reversed over the five years of the study.

These results were not expected because CDHP’s were supposed to result in fewer nights inpatient and fewer emergency visits, and increased outpatient visits. The expectation has been that with more control and also more personal money on the line employees would make wiser and less wasteful decisions. That is, they would choose more carefully and focus on “essential” care, without spending money carelessly. With that in mind, the thought was also that they would choose preventive care so as to avoid the hospital or the Emergency Room.

My regular readers will be well aware of my own concerns of making too much of one study. This is a very preliminary study, albeit with a large study pool. The authors are conscious of important limitations of the study. Among those is the fact that this only involves two companies, and only one offering CDHP’s. Within that one company, too, there were differences between those in the high deductible and low deductible plans. The results may not generalizable.

At the same time, in their discussion they offer some interesting reflections for public policy and employer decisions. Among other issues they raise are whether specific preventive measures are or are not subject to the deductible. If annual physicals and preventive screenings are subject to the deductible, even with the resource of a health savings account, patients may avoid the out of pocket expense – only to find that a medical need catches up with them when it’s more developed and more serious. That, then, could result in more ER visits and more, or at least as many, inpatient stays.


Which gets at a concern I have about how we talk about health care spending in this country. “Nowadays people know the price of everything and the value of nothing.” In the public square there’s an assumption that spending wisely would mean spending less. The point is for the patient to focus on health care that is essential, and not be wasteful. But for the longest time we’ve focused our health care on paying and reimbursing for interventions. That begs the question of what we mean by “essential.” Many of us would think “essential” could include preventive care; but preventive care might actually mean spending more now with an expectation of spending less later – like, in fewer ED and inpatient visits. If, on the other hand, there’s a focus on the price and expense rather than the goal of care, “essential” can mean “when you can no longer put it off” – which all too often means once you’re already seriously ill or injured.
This individual study won’t resolve the question of whether CDHP’s are ultimately better or worse for the health of employees, or whether they really reduce costs. At the same time, the authors are alert to just these issues. They write,

If CDHPs are to succeed in getting people to make more cost-sensitive decisions about the use of health care services and to engage in health-promoting activities such as using recommended preventive services, plan sponsors will have to design plans to provide incentives for primary care and prevention, intensely educate members about plan coverage, and provide needed information to assess options. Employers and insurers will need help from public policy makers to allow employers more discretion over health savings account–eligible plan designs. For example, primary care coverage could be exempted from the deductible, so that high-value preventive services not subject to the deductible would not be affected by changes to coverage of other health care services.

In other words, it’s not enough to think about the price of health care, especially when that’s simply an excuse to shift the burden of the price from the employer to the employee. It’s not enough to think about the price if we don’t also think about the value.

On the Human and the Sciences: Newest at Episcopal Cafe

My newest piece for the Episcopal Cafe has now been posted. It was stimulated by a recent column in which David Brooks commented on "heroes of uncertainty." I did largely agree with him - and then went further.

So, go over and take a look. If you're inclined, leave a comment, either there or here. After all, this is all about reflecting in community. 

From the Other Side of the Rail

For years I have written about what it means to be the Episcopal Chaplain at the Bedside. Today I am at the bedside, but, as I have often said to hospital staff in my care, I’m “on the other side of the rail.”

Specifically, today I am the husband of a patient. My Best Beloved is the patient, and as we have long been explicit about, I am her husband, and neither her priest nor her chaplain.

This is not the first time I have been “on the other side of the [bed] rail;” but it is one of the most acute we have known. Let me share some of those feelings.

First, I have great hope. I know who is caring for her. I know everyone’s credentials, and something of their skills. Indeed, we are in the hospital I serve, and by her choice. She wanted to be here, trusting in the people and in the care. I know what to expect, and what to expect is very good.

Second, I am afraid. I have been a chaplain more than 30 years. I know what can happen. My Best Beloved has been a nurse more than 20 years, and she knows, too. This is not a matter of distrust. It’s an awareness that stuff happens, even in the best of circumstances; and suddenly those circumstances aren’t “best” any more. As I often comment, I know too much. I’ve seen too much. With the best people, and all the hope in the world – which is pretty much where I’ve started – I’m all too conscious of the randomness in life. So, I can’t get away from the fear.

Third, I have good support. The Rector spent hours with us this morning – well, with me, because we didn’t have that much time before she was taken to the OR. I am in my own house, as it were, with people who know me and are concerned for me. My colleagues have already been with me – in one moment literally surrounding me – assuring me of their concern and of their prayers. I do not have the stress some have of going through such an experience alone; and I can’t say just how much that helps me.

Fourth, I trust that God is with me. Granted, there’s that part of me that can say, “I wish God had prevented the need for this altogether.” However, since I’ve long believed that God doesn’t micromanage, I know that’s an emotional reaction, an awareness of my own powerlessness. So, it’s a bit of a stretch to say that I’m aware that God is with me. But in the moments come those things that sustain me: support from others; the snippets of music, and especially the Taize chants, that reassure me; the narrow but important Pentecostal streak that runs through me. I’m no better than anyone else at touching God and knowing; but I trust.

And that is today. That is my morning as the patient’s husband. It helps for me to share this. With time and reflection, too, this will help me be a better chaplain and a better priest (and I will never be done learning to be a better chaplain and a better priest). But that’s down the road. These feelings, these concerns, these hopes: this is my morning on the other side of the rail.

Coming Soon: Fewer Episcopal Hospitals

In case you haven’t heard, the Diocese of Texas has decided to sell the St. Luke’s Episcopal Health System, including the flagship Saint Luke’s Episcopal Hospital of Houston, to Catholic Health Initiatives (CHI). You can find the story in the Episcopal New Service at ; and it was picked up at Episcopal Cafe. According to reports, “CHI has committed to maintain all current physician models and all employees will continue to be employed by St. Luke’s.” You can learn about more CHI here. Their network is literally coast to coast.

Not quite six years ago I wrote at Episcopal Cafe about Episcopal health ministries. In that article I noted at that time 17 hospitals, identified by digging through the Episcopal Church Annual (better known as The Red Book). Since that post the systems in the Diocese of Texas and in the Diocese of West Missouri (in which I serve) have both added services and hospitals. I don't know these days how many Episcopal hospitals or health systems remain. I appreciate the continuing commitment of the Diocese of Texas to supporting primary care in underserved communities. At the same time, I'm sad that there will now be that many fewer Episcopal hospitals.

On Practice and Discipleship: Sermon for Third Easter, Year C

I preached this Sunday at St. Mary Magdalene Episcopal Church in Kansas City. The lessons brought me to the practice of discipleship - or, rather, practice and discipleship; and a favorite hymn. Take a few minutes and listen. You can link to it here.

A Conversation on Conversations

This past week the Center for Practical Bioethics hosted the 2013 Joan Berkley Bioethics Symposium - Conversations at the Crossroads. At the web site you can see the list of speakers who participated in the Symposium. In due time as well the individual presentations will be available at the Center's web site. However, one part of the Symposium is already available. In the midst of the day, keynoter Ellen Goodman was interviewed live on "Up to Date," a daily program of KCUR, the Kansas City NPR station. Goodman, well known as a Pulitzer Prize-winning columnist, spoke about The Conversation Project, an organization she started to support and encourage families in talking about values and goals for care at the end of life. That show has been archived, and can be heard here. 

I have long said that these are conversations that need to happen at home and well before there is a need. That is also the purpose of The Conversation Project. Goodman speaks about how this program grew out of her own experience. It's well worth an hour of your time to hear what she has to say.

Good Friday 2013

I did not go tonight

To my accustomed place.

I chose instead something familiar

Yet different.

Some place known and convenient,

Yet different.

And it was not right.

I do not say that anything was wrong –

Wrong in the doing,

Wrong in the intention.

I do not say that anything was done wrong –

Wrong in the preparation,

Wrong in the execution.

But, it was not right.

It was not as I expected;

But that was what I expected.

It was not as I would have done it;

But, I was not doing it.

I did not expect it to be right.

But, it was not right.

It was beautiful,

But just enough wrong

To cause discomfort.

It was fitting,

But just enough off of fit

To leave me frustrated.

It was familiar,

But just enough unfamiliar

To set me on edge.

It was comfortable,

But just enough uncomfortable

To cause distress.

And I was stressed;

And my feet didn’t fit,

And my knees were out of place,

And my hamstrings ached,

And my back was tight,

And my shoulders were strained.

I did not go tonight

To my accustomed place;

And where I went

What I heard unsettled me;

What I saw distressed me;

What I felt discomfited me.

And on reflection,

It was absolutely right.

Back at Episcopal Cafe

After a long break, I'm back again at the Episcopal Cafe. You can find here my reflection on Lent and outcomes.

And once again, if you haven't before take some time to peruse the Cafe. I think it offers some of the best information  and best writing associated with the Episcopal Church. Read, reflect, leave a comment. All of us associated with the Episcopal Cafe will be glad to hear from you.

Standards of Practice: Standard 2, Part B

This is a continuation of my reflections on the Standards of Practice for Professional Chaplains in Acute Care. If you are interested, you can access Standards and related information from this page. You can find my earlier posts on this subject by clicking on the link for Standards of Practice under the Label menu in the sidebar.

So, in “Section 1: Chaplaincy Care With Patients And Families” we continue to reflect on “Standard 2: Delivery Of Care: The chaplain develops and implements a plan of care to promote patient well-being and continuity of care.” I’ve been thinking about that especially in light of the added interpretation:

The chaplain develops and implements a plan of care, in collaboration with the patient, the patient’s family, and with other members of the health care team. It includes interventions provided to achieve desired outcomes identified during assessment. Chaplains are able to adapt practice techniques to best meet patient needs within their health care setting. Care will be based on a comprehensive assessment.

When I ended the previous post, I noted that the topic of “outcomes” was more important and more difficult than that of “interventions.” However, it is important to think about outcomes, and about how we as chaplains choose and measure them.

I have written before about measuring outcomes for chaplains (and readers might want to review that post).  As I have noted before, the difficulty we wrestle with is that the outcomes most important for us are not readily amenable to measure; while the outcomes amenable to measure aren’t necessarily most important. In my earlier post I noted some difficulties related to outcomes

• Correlation is not causation. Just because we can show something happened during the time we were engaged with the patient doesn’t mean we can demonstrate that it was the chaplain’s intervention that made the difference.
• Some high correlations might still not be specific to chaplains or to spiritual care. For example, there is plenty of evidence that social support benefits emotional health and a sense of wellbeing. However, good social support might not require the skills of a chaplain, or any professional. For many folks (perhaps for most), a good friend or supportive family member is just as effective. Much of the studies with high correlations demonstrate the value of support in religious communities. However, we can’t somehow show that “religious” communities are inherently more effective than other communities that support the individual in a disciplined, healthy lifestyle.
• Some of the outcomes we might want to track can be hard to talk about. What does “a sense of peace” look like; and what impact does it have on this patient’s health? We believe profoundly that peace, hope, and reconciliation are good not only for the soul, but also for the body and the mind. How do we make that argument to our colleagues on the healthcare team?
• Some of the outcomes we might want to track aren’t ours to measure. For example, we might want to show that a chaplain’s visit can lower a patient’s blood pressure. However, that measurement isn’t ours to make. For such measures we’re dependent on the support of other members of the team.

 

 

 

With all that, I still agree that we need to be tracking outcomes. As I said in the earlier post,

Working as chaplains do in a environment of evidence based practice, measuring outcomes could be of great importance, especially in seeing pastoral care departments as necessary rather than as luxuries – useful and desirable, but still luxuries that can be dispensed with in hard times. At the same time, measuring outcomes can be difficult, especially because correlation is not necessarily causation, and because much of the information can be subjective. However, to the extent that we can measure outcomes and can relate those outcomes to patient wellness, it is worth our effort. It contributes to our claim that we are members of the team and important parts of the hospital’s purposes; and it adds to our abilities to communicate with professional colleagues in our institutions.

 

I wanted to wrestle with this especially in light of one of the Examples offered in the interpretive material in the Standards of Practice: [the chaplain] “Uses an outcome-oriented plan of care as found, for example, in The Discipline for Pastoral Care Giving: Foundations for Outcome Oriented Chaplaincy.” (Let me note that I don’t think the committee working on the Standards of Practice wanted to automatically prefer one such work over another. The fact is that there just aren’t that many examples of a systematic approach to the subject.) In the opening paper in The Discipline, Arthur Lucas addressed outcomes, and specifically “desired contributing outcomes,” as he and colleagues had come to understand them.

 

Lucas began by distinguishing between outcomes and activities – or as others would say, between outcomes and processes. He established three parameters in establishing the goals: that they be sensory-based, or essentially observable and demonstrable; that they be communicable to other members of the healthcare team; and that they be shared, agreed and recognized by the chaplain and the patient. In addition, and relevant to them being communicable, they should be outcomes that contribute to the goals of the healthcare team for the patient; and they should be straightforward enough that the chaplain can describe to the team in three sentences or less that the outcome either did or didn’t happen.

 

I think there is much to be said for the standards and parameters that Lucas and his colleagues set for outcomes. It will not surprise anyone that I also have some reflections. First, I think Lucas and his colleagues underestimated the importance of good processes. Many of the measures used in evaluating our colleagues in healthcare are in fact process measures. For example, among the measures reported to the Center for Medicare and Medicaid Services (CMS), and publically reported about our institutions, are process measures. When a patient comes to an ER with chest pain, does that patient receive an aspirin? When that patient is sent home, did he or she get a prescription for a beta blocker? Is every patient above a certain age offered a vaccination for pneumonia? Notwithstanding that whether a process is or is not performed is in and of itself a measurable outcome, most of the time these processes are offered when the outcomes of the specific processes with the specific patients may never be known. Rather, they are based on population studies that show that these steps have benefited most recipients. While I can see the attraction of outcomes, I think we should not underestimate the value of our own processes. Indeed, we might want to evaluate our interventions not only for their value in pursuing specific outcomes, but also as valuable processes.

 

Second, I am thoughtful about how we consider outcomes that contribute to the work of the healthcare team. It is indeed worthwhile to choose outcomes that contribute to the healthcare teams goals for the individual patient. How, then, would we identify what contributes? Certainly, we want to determine those for ourselves, based on our spiritual competence. As Lucas wrote,

 

What are our contributing outcomes? How are they uniquely spiritual? How do we define and contextualize them? How can that be done in the case-by-case care of patients and in the larger context of health care? Defining our contributions out of a ministry of presence, relationship, process, dialogue, knowledge, and faith continues to be hard work.

No one appreciates the difficulty more than I. At the same time, I think we can meaningfully use choose processes and interventions that we share with other colleagues. For example, we might consider Kenneth Pargament’s work on religious coping, or the research on the health impacts of spiritual practice coming out of centers at Duke or George Washington Universities. We might meaningfully apply Benson’s work on the Relaxation Response, or the various studies on the benefits of meditation. The fact that these researchers are not themselves spiritual professionals does not change how well established both these processes and their positive outcomes in many spiritual traditions. And as much as I regret having to say so, there is value to the rest of the healthcare team that so many of those researchers have M.D. after their names. On the other hand, we are called (well, at least many of us are) to be wise as serpents, as well as innocent as doves.

 

We can also think about the goals of the healthcare team, and of the institutions of which we all are a part. While goals for individual patients are essential, so are goals for the healthcare team and for the institution as a whole. These are in fact addressed later in the Standards.

 

However, there are points where the institution’s goals and the patients experience are directly related. The most important, and another against which our institutions are measured, is patient satisfaction. While the questions on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys do not include questions about chaplains (or almost any other ancillary service), they include a number of questions about how well the patient was listened to by physicians and nurses. We can make a significant contribution to the patient’s experience of being listened to over all. While this will certainly contribute to pursuit of specific outcomes, it is in itself an intervention, a process. It is a process that will, I believe, contribute significantly to the patient’s experience of support during hospitalization.

 

Moreover, I would want to consider recent research. We would want to consider the work done at Mayo Clinic, and published as Predicting Patients’ Expectations of Hospital Chaplains: A Multisite Survey (Mayo Clinic Proceedings, November 2010; 85 (11): 1002-1010). To quote from that article,

 

The results of the current study provide insights that may be helpful to health care administrators, hospital chaplains, physicians, nurses, and others involved in the clinical aspects of health care as they consider allocation of staff and other resources. First, the results showed that most hospitalized patients in the 3 diverse geographic regions studied wanted to be visited by a chaplain. Second, an affiliation with a Catholic or Protestant denomination was the strongest predictor of wanting a chaplain to visit. Third, participants who wanted to be visited were most likely to value a chaplain as a reminder of God's caring presence and as one who prays or reads scripture with them. (Op cit, p. 1008)

At the same time, it should be noted that many patients in the study did not request or did not know how to request a chaplain.

 

As chaplains we have moved away from a “denominational model” for deploying chaplains, in favor of a clinical model that may be structured by territory (unit assignment) or acuity (crisis and/or referral response). If we take seriously that we want to meet patient needs and expectations, and that our involvement leads to “contributing outcomes,” we need to consider this information with as much respect as we consider the psychosocial contributions we might want to make related to specific medical and nursing diagnoses.

 

So, I am convinced indeed that identifying “contributing outcomes” is important, and that selecting relevant interventions to pursue those outcomes is important. I also think that our comprehensive assessment and the outcomes we identify from them will certainly need to bring to bear information from other disciplines; research from within our own disciplines; a sense of participating in institutional goals in addition to patient-specific goals; and an appreciation that in our communities there continues to be appreciation for the more traditional roles of clergy that chaplains can reflect within the institution. I am convinced that these are all part of what it means for chaplains to meet the second Standard of Practice.