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Advancing Advanced Care Planning Services

Hopefully by now, all chaplains and others involved in spiritual care are aware that the Centers for Medicare and Medicaid Services (CMS) have proposed new rules which allow for the reimbursement of “Advanced Care Planning Services” provided by physicians and other “qualified health professionals.” This development certainly has to be viewed as a positive one by all those in health care who support whole person care, person centered care or the inclusion of patient beliefs and values in patient care. This proposal is hopefully a sign that we have moved past the day when the idea that this is about “death panels” derailed attempts to let patients have a true voice in planning their care, especially near the end of their lives.

However, there are a couple of issues involved in this discussion to be aware of.  First, it is important to be clear that this is not officially a done deal. The rules have not been finally approved and implemented and the forces which oppose them are still very active- if a little less publicly vocal. Thus, it is incumbent upon us who believe that patients should be provided an opportunity to discuss their wishes with their health care providers to continue to make our voices heard- in our local health care settings, our faith communities, and beyond. Yes, it looks like this change will become official but we are not there yet.

Second, it is important to remember that, like most change, the move toward fully implementing patient and family centered care is going to be incremental. If we get there, it is going to be one step at a time and not by trying to get everything we want at one time. If we do not recognize that one step at a time is the way it has to be, we are in danger of getting nothing.

I make this point because I have heard from some of my chaplain colleagues the “we’ve been left out again” refrain. Yes, it does seem clear that the category “qualified health professionals” who are the people who can also be covered under this new rule does not include chaplains- or likely social workers either. This change is about instituting two new physician billing codes and there is no precedent in US health care reimbursement for including reimbursement for chaplains under this kind of process.

However, I believe it is a mistake to read this as yet another indication that chaplains are not taken seriously or included in the health care team. The reality is that if those advocating for this change insisted on including chaplains- or even social workers- in the category of “qualified health professional”, the adoption of this change would be at least held up and most likely dealt a deathblow. Whether the reasons for that reality are ones we like or not is irrelevant. That is the reality.

It is essential to the progress of patient-centered care and the integration of spiritual care in health care that this change be implemented. All chaplains should support it and do so vocally and without reservation. When that is done, we can move on to the next steps. My discussions with our physician and nurse colleagues in this debate, especially those in palliative care, convinces me that they fully understand that doing advance care planning well with patients and families is a team process to which chaplains and social workers add value and need to be, and already are, centrally involved.

When we get to that step, I am convinced those physicians and advance practice nurses will join us in supporting inclusion and even reimbursement for chaplains and social workers to participate in advance care planning. Right now, we should be supporting the proposed change- not because it is about reimbursing physicians and advance practice nurses, but because it is the right thing to do for patients and their loved ones. 


Same-Sex Marriage- Reminding Us Again About Being Vigilant on Equality

This week the Supreme Court declared same-sex marriage legal in all 50 states of the US. A great victory for equality for sure and one that sets the stage for other legal and regulatory changes that integrate this ruling into all aspect of life including health care. It also reaffirms that in the US faith groups have the right to act on their beliefs within their communities even if they are contrary to the “law of the land”.

However, as great a victory as this is for justice and equality and as necessary as it is to set the stage for other changes, there is still a long way to go before this equality that is now mandated by law becomes practice on the ground.  The literature, both anecdotal and quantitative, well documents how deep bias runs. I recently read a report on some research that suggests that skin color becomes salient for babies within the first few months of life so the oft-used parental strategy of teaching equality by pretending that differences in skin color do not exist simply will not work.  Children will make attributions based on skin color no matter what we do so the way to have those attributions be that people are not better or worse based on skin color is to discuss that belief openly and early.

The examples are everywhere. Just like skin color becomes salient early, the idea that people do not marry others of their own gender is deeply ingrained in most of us. That belief does not even have to be positive or negative. It is just how we learned the world works. How often have we in health care observed a situation or participated in one where a health care provider “naturally” turned to the parents of the adult patient in the bed to ask a question about care not even considering the possibility that the other person in the room could be the patient’s spouse simply because that person was the same sex as the patient?  And do we then consider how the rest of the family feels about that marriage and what that means for the patient’s coping?

As the research on the salience of skin color points out, we humans register all sorts of visual and verbal cues as keys to categorizing people. It seems to be a hard-wired part of being human.  Asking us to override those cues in the name of cultural/religious/ethnic equality is a very tall order indeed. However, it is exactly these types of overrides that we are being asked to make. And we as health care providers would seem to have a special responsible to work at these changes because without them some of our patients and their family members will not receive the best or the most respectful care.

I believe that these changes can be taught. We as chaplains are taught to try to recognize the places and situations that make us uncomfortable and thus separate us from being fully present to the person we are serving. We do not do away with those discomforts- that is too tall an order. But we try to put those feelings aside so that they do not get in the way of our care. None of us are perfect at this of course but our call is to keep trying.

The Supreme Court decision simply reminds us of another place in our lives where those discomforts might appear. Denying them is not a good option. Admitting to them at least to ourselves so we can put them aside and give the best care is a strategy that can work.




Spiritual/Existential Issues in the Consideration of Palliative Sedation- A Case Example

The May 28th issue of the New England Journal of Medicine presents a very interesting case of a 44-year old woman with intractable pain due to metastatic lung cancer (pgs. 2137-2147).  The presentation details the woman’s medical history in great detail including diagnosis, treatment history, and the attempts to control her pain. The latter evolves through a number of well-documented stages until all physiological options short of palliative sedation are exhausted. The team then describes the process of discussing and implementing palliative sedation including consideration of spiritual and existential issues.  In the final meeting with her family, her pastor is included and seems to be supportive of this course of treatment. Finally, the ethical issues involved in implementing palliative sedation are presented in some detail.

While this is, in almost all ways, a thoroughly presented case, and the team is to be commended for presenting it and publishing it in this forum, it is also a good example of how spiritual/religious/existential issues while present and acknowledged in this kind of case are not given the full consideration they are due leading to possible under utilization of spiritual/religious resources.

As already mentioned, the physical issues in this case are presented in great detail.  However, while there is eventually a passing acknowledgement that “existential suffering” and “spiritual distress” can drive physical pain and a statement that the team consensus was that this was not an influence in this case, there is no presentation of a spiritual assessment done by a spiritual care professional as recommended by National Consensus Project Guidelines (Domain 5) nor any discussion of how the team reached consensus on this important question. There is no evidence that a spiritual care professional was involved in this case even though it was apparently known to the team and mentioned in the presentation that the patient was seriously involved in a faith community and had a pastor who was involved to a high enough degree that he/she would attend a family meeting. 

One common assumption is that if the patient has good support for spiritual/existential issues in the community, as apparently was the case here that is sufficient to deal with this domain of care. However, Balboni and colleagues have demonstrated that when spiritual needs are met by community resources and not provided by the medical team, increased use of aggressive treatment at the end of life and decreased use of hospice can result. [i]  While that result did not occur here, it was not possible for the team to anticipate that ahead of time given the apparent absence of a detailed spiritual assessment. Further, and maybe most importantly, while the team clearly considered the possible influence of spiritual distress on the patient’s pain, there is no evidence that there was any consideration or trials of spiritual interventions as a way to moderate the patient’s pain.

To be clear, the team is to be commended for presenting this case and for the acknowledgment of and inclusion of the patient’s faith community in this process. Further, all the evidence does point to physiological causes for the intractable pain.  That said, NCP Domain 5 guidelines were apparently not followed leading to lack of consideration for spiritual interventions as a possible moderator of this pain and the risk that lack of spiritual support from the team could have resulted in a death in the ICU rather than a much more comfortable outcome for all involved.



[i] Balboni, T. A., Balboni, M., Enzinger, A. C., Gallivan, K., Paulk, M. E., Wright, A., ... & Prigerson, H. G. (2013). Provision of spiritual support to patients with advanced cancer by religious communities and associations with medical care at the end of life. JAMA internal medicine, 173(12), 1109-1117.



Getting to One Voice in Professional Health Care Chaplaincy

After my recent talk at HCCN’s Caring for the Human Spirit Conference in Orlando, one of the questioners raised the issue of the long-time and oft-acrimonious splits within professional chaplaincy membership organizations.  The issue focused especially on the rift between the College of Pastoral Supervision and Psychotherapy (CPSP) on one side and the Association of Professional Chaplains (APC) and the Association for Clinical Pastoral Education(ACPE) on the other.  For those who may not be professional chaplains or who may be new to the profession, one of the great embarrassments in the profession (to me and many others) is our inability and/or unwillingness to have one organization that would speak for the profession- or even sometimes to get along among ourselves.

This questioner focused on the lack of reciprocal certification between CPSP and the other groups and within that, the lack of recognition by groups like APC of training by CPSP that would fulfill a requirement for certification. Currently those with only CPSP training cannot apply for certification in the APC. This issue is likely the one that is most apparent and troubling to the respective memberships and those preparing to be certified as chaplains. 

While I had not thought a lot about this particular issue, it occurred to me that, rather than tinker with and try to reconcile the current systems of training and certification - which likely would just devolve into discussion about whose system is better - we should start over with the whole enterprise. Many of us have come to the conclusion in any case that the whole system of training and certification for health care chaplaincy is not reliably or demonstrably producing competent chaplains and needs a ground-up overhaul. And I say this as one of the people who led the effort that established Common Standards for Certification and as a former APC Certification Chair.  

Further, I would suggest an approach that (1) seems more appropriate to the current way professionals do things in health care and (2) would help us operate with a clear slate because none of us have done it this way before. I would suggest proceeding as follows:


  • The first premise is that everyone who wants to be at the table is welcome as long as they covenant to treat everyone else at the table with respect publicly and privately and agree that all past hurts and disagreements are past and not part of this process.
  • The second premise is that (1) the relevance of any and every part of a new system will be evaluated only on the extent to which it brings benefit to patients, their caregivers and the health care system and (2) the patients, their caregivers and the system would have a voice in defining what constitutes “benefit” for them. The corollary of this premise is that no consideration would be given to any proposal whose primary purpose is to serve or preserve particular groups of chaplains, particular faith communities, or particular membership associations.


The process would seem to need to proceed in the following steps:


  1. Building consensus around outcomes, with the process requiring the inclusion of patients, caregivers, members of other health disciplines, health care leaders, payers, and policy makers. What are the benefits that chaplains do or could provide? What beneficial outcomes can be anticipated in the near and long term future?
  2. What does our best evidence suggest are interventions that promote these desired outcomes?
  3. What competencies do chaplains need to deliver these interventions with maximum effectiveness?
  4. What are the components of a system that would most reliably, efficiently, and fairly evaluate whether a given chaplain has these competencies? The evaluation system is going to be critical because this proposal does not require any particular prior training or assume that any kind or amount of prior training produces competence. 


We have little or no evidence that the current system of training or certification of any of our associations produces chaplains who actually help people or support the deliver of good health care. We owe our patients and caregivers a better effort. 


The Problems and Opportunities of Change

I should state right up front that I’m not a person who does change all that well. My default position on almost anything is to stick with what I have, what I’m doing, or what I believe. Staying with the familiar is comfortable. Changing is stressful. Sometimes this characteristic works for me in that I always try to work out issues with where I am rather than change but often it keeps me from realizing and taking advantage of new opportunities and experiences that would enrich my life.

So it is I think with many businesses, organizations and professions. Despite all we know about how our world and society is changing at an increasing pace and that to prosper and even survive in the new world emerging around us calls for at least re-examining if not changing some basic assumptions about how we function professionally, we resist-often to our detriment and to the detriment of the people who benefit from what we do.

I have had only one career in my life- clergyman. And for almost all of that career I have done my work focused on one setting- the acute care hospital and how to minister to people who are sick and suffering. Health care chaplaincy and ministry in general is based on some assumptions that are so fundamental that they are often not even acknowledged or discussed- let alone disputed. Maybe the most basic is that, to be “successful” -which I will translate as being able to help people relieve pain and suffering- one must be in “relationship” with them.  Further, this “relationship” is assumed to be most effective or even only effective if it is face-to-face. It is assumed that to be “helpful’ we as chaplains need to be physically with the person to whom we are ministering. Anyone who wants to be certified as a chaplain must take clinical pastoral education (CPE) that focuses on teaching us how to satisfy this standard. To foster this goal, CPE has required that students be able to meet with a peer group face-to-face and meet in person with a supervisor.

To be clear, I do not want to argue that this model or the assumptions that drive it need to be abandoned. I know that the training I received and my ability to relate deeply to people has helped a lot of patients, caregivers and health care providers. However, it is increasingly clear that this model of training and assumptions about how chaplaincy care needs to be delivered are barriers to both raising the level of training for health care chaplains generally and to the deliver of spiritual care to many, many people in need. There are many people doing spiritual care who want to be trained but cannot do it because they live at a prohibitive distance from a training center, cannot take the time, or cannot afford the tuition.  There are many people who want the services of a chaplain who cannot access one because they are home bound, live in rural areas, or otherwise have no way to go to a chaplain.

But maybe most importantly, these assumptions about how chaplaincy training and how chaplaincy itself “must” be done have never been tested. Do we have any evidence that CPE done remotely with virtual groups would produce less effective chaplains than the current model? No. Do we have any evidence that patients and their caregivers would feel less supported and have their suffering less well addressed by a chaplain who communicated with them over the telephone or even by email or Skype than one who communicated with them in person? No. What we do know is that our long-held and sacred assumptions are keeping many people from receiving care for their spiritual and religious suffering.

All health care disciplines are currently struggling with the pros and cons of delivering care remotely. Chaplaincy is not special in that regard. Many of us went into health care because we want to be with people and relate to people. Delivering care or even being trained over the phone or by Skype simply may not be as fulfilling. However, it seems very evident to me that given the realities of health care in the US and, more importantly, given the fact that our assumptions are barriers to delivering spiritual care to many people, new models have to be tried. The time for remote or virtual CPE has come. The given reasons for not doing this have no evidence to support them. Likewise, the time has come for leveraging emerging technology to deliver spiritual care to many who need it and want it but who won’t receive it any other way. There is no evidence that these delivery systems will produce results inferior to the current model.

Finally, this is all not about us- the chaplains. It is about what best serves those in need. What will be effective in the end? I have no idea. I do know we owe it to those in need of spiritual care to try new methods and models.