There are certainly multiple causes for this change. The rise of palliative care probably leads the list because spiritual care is so prominently featured but interest internationally in the integration of spiritual care is also a factor. 

I prefer to leave the “whys” to others and focus on the “whats” and “so whats”.  In most cases while we have to understand the “what”, it is the “so what” that is critical for the practice of spiritual care. In the last few weeks at least three very interesting pieces have appeared or been announced- all of which deserve the attention of the spiritual care community. 

The recent article by Tracy and Michael Balboni and their team in Boston (Provision of Spiritual Support to Patients With Advanced Cancer by Religious Communities and Associations With Medical Care at the End of Life) published in JAMA Internal Medicine has understandably gotten a lot of press for its well-documented finding that the patients they surveyed  who were religious and who were well supported by religious communities used more aggressive care at the end of life and spent less time in hospice.  This result, if not counterintuitive, is certainly not what those of us who believe that religious community is a support to people would have hoped for. It appears that the medical teams have done a better job of meeting patient’s spiritual needs at the end of life than the religious community. 

The authors speculate on what is happening here and probably every spiritual care provider will do the same.  However, I think the “so what” here as Martin Montonye has helpfully pointed out on Linkedin is to see this as a research opportunity to be followed by a training opportunity.  The research doesn’t have to be that involved.  Most chaplains in acute care often see patients who are very religious and members of religious communities and who also are asking for aggressive care at the end of life.  Starting to document these cases, especially the reasons behind the requests wouldn’t be that difficult.  Then we need to find a way to aggregate our findings and start to discover some trends. In the mean time, it is important for chaplains to access and read the actual study- not the news reports of the study- so we can discuss it with our teams with full knowledge of what it actually says and does not say. 

The other two pieces to pay attention to are the revised Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life which is available for pre-order and the new English translation of the Spiritual Care Guidelines from the Netherlands available free online at http://www.oncoline.nl/spiritual-care. The stellar reputation of the Hastings Center in this area of expertise is well known and well earned. The table of contents of the new guidelines alone is enough to convince me that this will be a must read for anyone in spiritual care especially at the end of life.  These guidelines will be much discussed in palliative care and hospice teams and chaplains need to have firsthand comprehension of what they say in order to contribute knowledgably.  The quality and relevance of the Dutch work might be a surprise to many in North America. Yes, there are some differences in context and language usage.  However, in general, I think many of us in North America are missing out on a lot of excellent work being done in spiritual care and palliative care internationally.  The work of the European Association for Palliative Care is a prime example. These guidelines are aimed at physicians and nurses and will be especially useful in contexts where members of the health care team are willing to deal with the spiritual and existential domains but don’t think they should have anything to do with religion. 

So I haven’t answered George Fitchett’s implied question on how to keep up. Nor do I really have a good answer. I do know that finding ways to pay attention to the writing in spiritual care in health care is more and more critical to the practice of spiritual care and the ability to access and evaluate that literature is more and more critical to those of us who are spiritual care professionals as we seek to be increasingly integrated into the care our patients receive. 

Nowhere is health care changing more fundamentally than in how it regards the role of the patient in the process of care. Patient satisfaction has long been a standard metric for many health care institutions, but for many never rose above a “nice to have” next to the “must haves” of clinical effectiveness and financial viability. In fact, many thought patient satisfaction often got in the way of the other two goals because giving patients what will satisfy them was thought to cost money and slow down or even subvert the clinical process.

Then HCAHPS drove a change to “patient experience” – related to patient satisfaction but not the same. Experience is about how reliably a given process like pain control happens and satisfaction is about how happy the patient is with that process.  And finally we have arrived at “patient engagement”- a subset of “patient experience” perhaps but maybe the biggest change of all. Fundamentally, patient engagement requires that we who provide care involve the patient as a full partner in the planning and carrying out of that care. This change would seem to mark the official death of medical paternalism. But, it certainly feels like “selling the farm” to many.  How can good care result when we let those without training in the field have at least a vote in the treatment decisions and maybe even a veto? Certainly lots of people will make “bad” decisions.  

To those of us who are familiar with the history of how authority has operated in western religion, this debate has to sound familiar.  Arguably, the most far reaching change Martin Luther and other reformers brought about in western Christianity in the 16^th century is the idea that every Christian can have their personal relationship with God and can independently decide what they believe. This change was implemented in part by translating the sacred text of Christianity into a language that each believer could read or at least understand. For the most part, the authority of the ordained religious leader remained as the expert on belief and practice but that role became much more advisory than prescriptive.  The religious leader now had to convince the faithful that a certain belief or behavior was “right” rather than having the belief or practice followed just because the leader said so.

Modern professional health care chaplains have long been trained to operate in this advisory model. It has been for years against the codes of ethics and best practice in professional chaplaincy to tell someone what to believe or practice unless specifically asked for that advice. Patient engagement has been the standard of care. Those of us who have worked in this way for a long time are very comfortable letting the patient lead the conversation and reach their own conclusions about what their own religious or spiritual belief and practice should be even when they differ from our own and how that belief and practice can help them cope with their illness. In fact, this model of care seems to work better than dictating to the patient beliefs and behaviors which they then mostly don’t follow.

That experience of chaplaincy practice leads me to feel confident that true patient engagement of the kind professional chaplains have long practiced will in fact improve, not only the process, but the outcomes of health care.  Many will resist as many have and still do resist this model of chaplaincy.  However, I am convinced that professional chaplaincy can be a major facilitator of this necessary change and can help our patients and our health care colleagues embrace this new and strange but ultimately very beneficial model. 

In observing this day, Dr. Eric Widera offers a very provocative post on GeriPal (www.geripal.org). He cites a recent editorial by Theresa Allison and Rebecca Sudore in JAMA Internal Medicine and a related study by Heyland and colleagues investigating documentation of treatment preferences by a sample of elderly patients in Canada.  One of the most dramatic and disturbing findings of the study was that, for those who had stated preferences, over two-thirds of those preferences were either not documented at all or documented incorrectly in the medical record. This finding calls into serious question the basic premise of advance directives.  If one’s stated preferences are likely not to be observed, why even bother?

But Allison and Sudore up the ante even further when they state:

“Discussions about goals of care and code status constitute a medical procedure every bit as important to patient safety as a central line placement or a surgical procedure. Much as we have developed systems to improve patient safety in surgical procedures, we need to develop systematic approaches to discussing patient values and goals of care."

Dr. Widera then raises the obvious question, “Should failure to follow preferences be a medical error?”

For those of us who are not physicians, this could be an invitation for doctor bashing.  However, we need to all take seriously that patient safety is everyone’s responsibility.  So if this is about patient safety, we are all culpable.  But, even if this is not a patient safety issue, I would expect that all of us believe that patient’s wishes should be respected and every effort should be made to make that happen. 

The newly released 3^rd edition of the NCP Clinical Practice Guidelines contains the following criterion under Guideline 8.1. This criterion applies equally to all members of the treatment team.

“All expressed wishes, preferences, values, goals, plan of care, surrogate decision makers and advance care plans are routinely documented, including the completion of clinical orders such as inpatient resuscitation status, out of hospital do not resuscitate orders, and health care surrogate declaration documents for adult patients.”

So it seems to me the bottom line here is that all members of the treatment team are obliged, individually and as a group, to make sure that all stated treatment preferences and advance directives are well documented, well understood by the team, and observed. If the finding of this study turns out to be true more widely, all of us bear responsibility. Dr. Widera along with the authors of the editorial raise an interesting and provocative question.  However, no matter whether consensus ever develops around the answer to that question or not, the findings of this study should galvanize us all to action.  The findings point out that while getting patients to fill out their advance directives is a necessary first step, there is another necessary part to the process which may be seriously broken.  Each of us needs to be committed to point out that brokenness each and every time we see it.    

Likewise, Toby Cosgrove, CEO of Cleveland Clinic, shared a video on empathy with his staff during his annual report  http://www.youtube.com/watch?v=cDDWvj_q-o8. This wonderful video encourages his staff to see patients, family members, and even colleagues in the light of what may be happening in their lives- positive and negative- rather than through the negative lens which so often assumes that the other person is being intentionally obnoxious or just acting badly for no good reason. To stand in the other’s shoes.

All too often we attribute negative motivations or at least thoughtlessness to our colleagues. It is often tempting to tell “war stories” about how badly our health care system is functioning and attribute much or all of that dysfunction to those in the system who don’t treat patients or each other well when we presume they clearly know better.  We fall into the classic mistake of blaming individuals for the problems in the system rather than the system itself. 

To them I want to say, yes, we all know the system is broken. We all know that very often communication between health care providers and patients and between providers and other providers is not handled well.  However, telling these stories that often draw sighs and knowing nods from our listeners does not contribute to fixing the problem.  In fact, I suspect it just makes the problem worse because blaming people or even disciplining them by itself does not help people change.

I think that, at least in part, the message that Wendy Leebov and Toby Cosgrove are trying to send is that we should presume no one wants to act insensitively or communicate badly.  We should presume that everyone who goes into health care as a career wants to be compassionate and communicate caring for their patients and their colleagues. We should presume that what is broken in the system is not the people but the system itself. One of the mantras of quality improvement that is well documented in the research is that the primary cause of most error is not the employee’s lack of desire to do something right, but a lack of training. Often we think or presume adequate training has been provided when, in fact, the training was ineffective or absent all together.  A good example from my own discipline is that most people presume that all clergy must get training in counseling and providing spiritual care including some training in how to visit in hospitals.  This presumption is absolutely false.  And yet, at least in part because of that presumption, we expect a level of performance by these clergy in stressful health care crises which is totally unwarranted and unfair because they simply do not have the training and then we blame them personally when clinically sensitive behavior is not forthcoming.

With that presumption of good intention, we should be looking for ways to help our colleagues be the compassionate and communicative health care providers we presume they want to be. Thus Wendy Leebov’s new book and Toby Cosgrove’s video.

Telling and retelling stories that cast blame on individuals does not help.  Finding ways to make the system better is the way to go.  For us as chaplains, these interventions often can occur on a very personal level.  Witnessing or hearing about an incident of less than excellent communication or caring often incents us to seek out the person on the receiving end of that communication, especially if it was the patient, or even to report the “offender” to their superiors.  But how often to we seek out the provider who gave the communication, not to blame, but to offer our help and understanding?  For us as chaplains, this can often be listening to them vent about the stresses of their job or even an issue in their personal lives which is influencing their job performance. In the process, we might discover that the provider simply doesn’t know the best way to communicate and is open to learning.  That discovery can then lead us to training needs or process improvements we might propose to institutional administration. All of this can be done not in the spirit of “I know how to do this right and you don’t” but in the spirit of “we are all in this together and I want to be helpful”.

At the end of the day, the goal is to cease the negativity which only tears people down and helps no one, and focus on how we can ourselves act in a caring and compassionate manner which will, I believe, bring caring and compassion in response. 

And this example is seen lots of other places in our lives.  For those of us who work in health care, we almost daily see patients and their loved ones who are confronted with tremendous suffering. Some become bitter and angry, but others genuinely acquire a greater appreciation for parts of life they had previously taken for granted.  What is still unknown is what causes individuals to turn one way or the other.  For those of us who are chaplains, we look for what parts of spirituality or religious belief support this kind of resilience and what parts impede it.

In this search, case studies are important. They are each unique of course but they each give us powerful insights into the ways some people live life to the fullest in the face of suffering and death and others give up on life almost completely. 

Those of us who attended the recent AAHPM annual assembly were treated to a plenary by David and Deborah Oliver which I, and I know many others, felt was not only highly educational, but awe-inspiring.  David has been living with stage 4 cancer. He and Deborah have “gone public” with virtually all aspects of their journey- both the struggles and the triumphs. But what impressed me more than anything else is their determination to live their lives in all the fullness they can muster including family, friends, travel, and each other.  They are determined to find joy and fulfillment in their lives and, because they keep looking, they find it in abundance. There have certainly been trials along the way mostly with the medical system which are also instructive and well documented.  David is determined to keep control of both his life and his death.  His “HOPE” for dying is:

(H) to die in my own home

(O) surrounded by others

(P) pain free

(E) and excited about living

 Many of you may already be familiar with David Oliver from his series of YouTube videos (http://bit.ly/10szL2g). He also has an ebook out called, Exit  Strategy: Depriving Death of its Strangeness that is available on Smashwords. Whether you are a veteran in the field who can always learn more, someone just entering health care, or a patient or caregiver yourself, both David’s videos and book are must sees. 

While there are several options for how to do this, one that has been highly worthwhile for me over the past four years is the American Academy of Hospice and Palliative Medicine (AAHPM) which just concluded its yearly conference.  I would immediately acknowledge that there are several barriers to chaplains being involved here- mostly involving money and time.  Dues and attendance at the conference are expensive by chaplaincy standards although I do run into chaplains attending AAHPM whose way is being paid by their teams. And the time to go, especially if one is also attending one’s professional chaplaincy association meeting, often winds up cutting into vacation time. Thus, I’m not claiming that this integration will be easy to accomplish.  I am claiming that unless we find ways over these barriers, the continuing integration of spiritual care and chaplaincy care into palliative care will be seriously impeded.

Some of what chaplains might imagine as barriers are not.  Two “barriers” I know some chaplains presume are “This is an organization mainly for doctors so I won’t be welcome there” and “There will be no content at the meeting relevant to my work”.  Both of those assumptions are decidedly false.  Remember- these are palliative care and hospice people.  By and large, they appreciate and welcome the inclusion of the spiritual dimension of care. And this is a very large organization so the range of offerings in any one time slot at the conference is very wide and deep.  My problem in most time slots is picking between the several offerings I want to go to.

The number presentations involving chaplains is still small but increasing. I’ve been part of a team that has presented a very popular pre-conference seminar for the past four years.  Tim Ford (VCU), Edie Meyerson (Mt. Sinai-NYC), and this year Terry Irish (City of Hope) and Denise Hess (Providence Health, Torrance, CA) have all made excellent contributions. One of the interesting parts of AAHPM culture is that it is almost impossible to get a workshop accepted unless there are presenters from more than one discipline. This supports the value placed on team work in palliative care. For chaplains, this means that the place to start if you want to present is to talk to your team and be part of a team presentation or a presentation with at least one other member of your team.  This year Terry presented with a social worker and Denise with a physician from their respective teams.  Note- the deadline for workshop submissions for next year’s conference in San Diego is April 19th.  Now is the time! You don’t have to be a member to submit.

Another feature of AAHPM is that it heavily promotes social media. Even if you are not an AAHPM or NHPCO member you can follow various palliative care and hospice blogs and tweets.  Pallimed and GeriPal are two of my favorites along with following AAHPM itself and palliative care luminaries like Diane Meier on Twitter. These will give you a good sense of the conversation and hopefully incent you to respond or comment occasionally. This is a major way the voice of chaplaincy and spiritual care is more often heard in the conversation. And it only costs a little time!  I recently signed up to contribute to the AAHPM blog itself again to get the chaplaincy voice into the conversation.

For me the highlight of this AAHPM conference was the official release of the 3^rd edition of the Clinical Practice Guidelines for Quality Palliative Care from the National Consensus Project which is a consortium of the major palliative care and hospice groups in the US.  The guidelines can be downloaded free at www.nationalconsensusproject.org.  Notably, Domain 5 (Spiritual, Religious, and Existential Aspects of Care) is tremendously expanded with significant chaplaincy input. The guidelines present powerful evidence for the necessity of professional chaplaincy on these teams. This set of guidelines is now the standard for palliative care and hospice teams and will hopefully become incorporated into the advanced certification standards for the Joint Commission as the 2^nd edition was.  

 So, talking to each other as chaplains is essential.  But if those are the only conversations we have, we are in danger of remaining pretty insular as a profession and worse, spiritual care will not be fully present in palliative care. We have to find a way!

Their thesis is that we need both educated palliative care generalists and palliative care specialists. Thus, they are proposing that palliative care become like every other medical specialty.  That is, every physician is taught something about cardiology, certainly including how to assess and at least preliminarily diagnose cardiac issues. The general internist will also be able to treat some number of these issues, especially in their less severe forms, without referring to a cardiologist. However, at some point for some patients, a referral will be necessary.  Part of the debate in US health care is exactly when a referral is actually necessary.

This thesis exactly parallels the provision of spiritual care on at least at two levels. Over the past several years, many of us have been promoting the exact same generalist-specialist model with regard to spiritual care.  Dr. Harold Koenig and I published an article on this topic some years ago (Handzo, G. F. & Koenig, H. G. (2004). Spiritual Care: Whose Job is it Anyway? Southern Medical Journal, 97(12), 1242-1244).  That is, we need generalists (physicians, nurses, social workers, etc) and specialists (Board Certified Chaplains).  The generalists are responsible for screening for spiritual need and making referrals when appropriate. Dr. Christina Puchalski, among others, has posited the concept of “simple” vs. “complex” spiritual interventions. Simple interventions are those that every health care practitioner should be able to do such as reflective listening and compassionate presence. 

As chaplains who are the spiritual care specialists on the team, we need to be about educating the generalists and helping them learn about and be comfortable with their role in spiritual care.  We have to be sure that we as professional chaplains are trained and committed to fulfill our role as spiritual care specialists on the team. The competencies recently released by the Association of Professional Chaplains for specialty certification in palliative care chaplaincy are a helpful addition in this regard.

The second level has to do with the place for palliative care generalists and palliative specialists within the ranks of professional chaplains.  Just like Quill and Abernathy describe in medicine, relying on the palliative specialist is not always possible or best practice.  Yes, the large academic medical centers of the world which should have robust palliative care teams should have a chaplain who has advanced certification in palliative care  and is attached to that team. However, most hospitals in this country are too small to ever be able to provide that level of palliative care. Further, much (or maybe even all) of what chaplains do routinely could be seen as falling under the rubric of palliative care.  Thus every chaplain in health care should be at least a palliative care generalist.

This model for the delivery of spiritual care needs to drive chaplaincy training much more than it currently does. There should be a palliative care component even in basic levels of the training of clinical chaplains just as there is some basic level of training in cardiology in the education of every physician. The learning goals for programs like Clinical Pastoral Education (CPE) need to reflect this growing reality of US health care.  We also need more opportunities for specialist spiritual care training.  The recently announced collaboration between HealthCare Chaplaincy and the Palliative Care Institute at the California State University-San Marcos (http://www.healthcarechaplaincy.org/palliative-care-chaplaincy.html) and the Summer Institute at the George Washington Institute for Spirituality and Health (www.gwish.org) are great offerings but we need many more opportunities.

We have to give up one of chaplaincy’s articles of faith- that what we do cannot and maybe even should not be measured. We have to banish from our collective professional vocabulary the premise that “chaplains don’t have an agenda”.  If we don’t have any agenda, then we are saying that we have no intention of helping patients in any way. In that case, why should we be included on the care team?

However, even if one buys all of the above, where do we start?  It is very easy to look around and get paralyzed by the options.  Many want to start with the question “What is best practice?”. Christina Puchalski and Betty Ferrell lay out a whole system for integrating spiritual care in Making Health Care Whole. Since the answer to the question is a moving target, it is easy to do nothing while we wait for “best” to emerge.

I would propose that we need to pick a measurable outcome that is easy to integrate into the health care process as it is now structured. In other words, we want to avoid any proposition that requires significant change in how the systems now operate.

I would propose starting with the premise that professional health care chaplaincy needs to focus on those with a need for spiritual care as opposed to a desire for a chaplaincy visit.  This premise would immediately eliminate, “Do you want to see a chaplain?” as a screening question because, as George Fitchett pointed out years ago, those with spiritual need are least likely to ask for a chaplain. The next premise is that this need for spiritual care is best (at the moment) captured by the concept of spiritual struggle or spiritual distress. I would leave aside for the moment whether “struggle” and “distress” are the same or different and assume that for clinical purposes, any distinction if it exists, is not important. And the third premise is that at least some significant portion of spiritual struggle in any given patient population can be discovered with a couple simple screening questions administered as part of standard screening protocols by those in the system who do the overall screening- usually nursing. Thus, chaplains do not need to visit every patient.

As to which screening questions to use, what is now being called the Rush Religious Struggle Screening Protocol designed by George Fitchett is the best known and has several studies to back it up[i]. However, it still needs to be tested in different populations and alternatives may emerge.  If someone in a given institution has energy behind other questions, I would try them rather than hold up the whole enterprise over insisting on the Rush questions.

Accepting these conditions sets us up to:

1.   Engage the health care team- especially those doing the screening- in the spiritual care process.

2.   Begin identifying the number of patients in our institution who exhibit spiritual struggle which demonstrates from a quality perspective that there is need for chaplaincy.

3.    Begin to measure, even in very simple ways, how chaplains help patients. The measure could be as simple as how often does the patient report reduced spiritual struggle after a chaplain’s visit?

4.    Begin discovering some of the correlates of patients with spiritual struggle. Do they have lower patient satisfaction scores? Do they have longer stays? Do they as Tracy Balboni and her colleagues have suggested use more aggressive care and less hospice care at the end of life?

I would try to avoid becoming hung up in issues that, while maybe not unimportant, are not important enough to derail this whole process. Those would include the issue of struggle vs. distress and exactly what questions to use in the screen. 

The most common obstacle I encounter in this process is the legitimate concern from those doing the screening (normally nursing) that every clinical department in the institution wants to add questions to the screening process and to accept all of them will make the screening too time consuming and unwieldy.  The counter to this is (1) to compile and present the growing evidence for the undesirable consequences of spiritual struggle and (2) to point out that if the institution and the team want to live out what most claim to be their goal of caring for the whole person, they must attend to the person’s spiritual domain. The next obstacle is that often those doing the screening will need training to become comfortable asking questions in this domain.

I understand that I have made this way forward sound simple. I understand that is true in concept but often far from true in execution.  This change requires commitment, focus, and building alliances over time.  And it is not the way forward that will be the most appropriate for all institutions. I offer this plan simply as a way forward that seems to appeal in a lot of settings, will help spiritual care become more integrated into whole person care, and doesn’t require significant change to the prevailing culture of most health care institutions.

[i] King S., Fitchett G, Berry D. (2012) Screening for religious/spiritual struggle in blood and marrow transplant patients. Support Care Cancer. Published online 11 October 2012.

GWISH Catalyzes a Global Movement to Improve Spiritual Dimension of Whole-Person Care

Washington (Feb. 7, 2013) - International leaders from a variety of disciplines, faiths, and cultures held a landmark gathering in Geneva last week to develop recommendations on integrating spirituality into health care systems worldwide.  Convened by the George Washington University Institute of Spirituality and Health (GWISH) and Caritas Internationalis, the conference challenged this diverse group of researchers, educators, and policymakers, physicians and nurses, and chaplains and clergy from more than 20 countries to look critically at the current state of health care and creatively assess how to better serve patients by integrating spirituality into compassionate and person-centered health care.

For centuries, medicine and spirituality worked hand-in-hand to address suffering and healing. However, early in the 20^th century, technological advances in diagnosis and treatment—though dramatic and resulting in the saving of countless lives—shifted the culture of medicine away from a holistic, service-oriented model. However, over the last 25 years, visionaries such as Christina Puchalski, M.D., founder and director of GWISH, have led a groundbreaking effort to look at the role spirituality—defined broadly as the very essence of compassionate care—plays in health care. The 2013 conference was a follow up to a 2009 consensus meeting in the U.S. at which the process of developing guidelines for integrating spirituality into health care began to take shape. This earlier event catalyzed significant interest in the topic—now considered a major field in health care—and sparked discussion of creating global guidelines.

“Reasons for the distress that a patient experiences is complex and far beyond the physical symptoms, size of a tumor or biochemical abnormalities that the present day health care care system tries to address,” said Suresh Kumar, M.D., director of the Institute of Palliative Medicine, Calicut, Kerala, India, and conference attendee. “Spiritual care as part of whole person care is particularly important today.”

In Geneva, the group achieved a consensus on an appropriate multi-cultural definition of spirituality as related to health; proposing consensus-driven standards of care that focus on the whole person; developing a broad framework for a proposed global strategic plan to improve the quality of spiritual care in health; and building a coalition for evaluating spirituality as a vital sign. Complete findings will be published in an academic journal.

”The fact that we achieved consensus on the full integration of spirituality into mainstream health care, with so many different cultures and countries represented in the room is inspirational” said Puchalski. “There is recognition globally of the importance of honoring the dignity of each human being, responding to all patients’ suffering with compassion as a fundamental professional obligation and recognizing that health is more than merely the absence of disease”.

“Caritas Internationalis believes strongly in the dignity of each and every person. We believe that all health care and human development must be holistic and encompass the entire person – body, mind, and spirit,” said Msgr. Robert Vitillo, M.S.W., head of the Caritas delegation to the United Nations in Geneva. “We saw many of our own values reflected in the work of GWISH and were pleased that this consensus conference is inspiring action and initiatives to elevate the quality of health care to benefit all patients, regardless of their faiths, values, cultures, and beliefs.”

Buoyed by the energy that was generated, conference participants are returning home with ideas that were developed in consensus to create demonstration projects all over the world, such as education programs and training centers for health care providers.  They have committed to work together as a coalition for change, advancing their vision of a world in which every patient is treated with dignity and respect, whose values are respected and integrated into care, and who can lead meaningful and authentic lives, even in the midst of suffering and illness.

“Beyond the definitions and standards of spiritual care which the conference produced, it brought together people who practice, teach, research and promote spirituality in health care,” said Manuel Dayrit, M.D., Former Secretary of Health in the Philippines, who attended the conference. “These are the kind of people who will fervently support the global momentum towards enkindling the spiritual dimension in health care worldwide, a momentum which has already begun in many countries.”

Shane Sinclair, Ph.D., spiritual care coordinator, Tom Baker Cancer Centre, Calgary Alberta Canada and adjunct assistant professor, faculty of medicine, University of Calgary, has three new research projects he is working on as a result of the conference.

“This is the first conference that I am aware of, where international experts met for the sole purpose of enhancing the spiritual aspect of health. The conference represented an important first-step in meeting this goal but it was clearly that—a first step,” said Sinclair. “The recommendations that came out of these meetings are not going to be buried in a 12-point font of a health care journal; the recommendations are part of a living document that will be put forward within health care settings globally.”

The Fetzer Institute supported the conference to help move the needle forward in this burgeoning field.

“Fetzer has long been interested in how intangible aspects of everyday life—like stress, social support, and one’s spirituality—affect our overall wellbeing. Having leaders of this caliber gather on this topic promises to add to our understanding of the many markers that define our health and—for Fetzer—where and how compassion, love and forgiveness appropriately exist in the course of care. We are proud to have been a part of this event,” said Angela Graham, program officer at the Fetzer Institute, a partner in the conference.

GWISH and Caritas are committed to further advance advance the framework developed by this consensus conference and to foster a movement that includes spirituality as an essential component of person-centered health.

To interview Dr. Puchalski, please contact Lisa Anderson at lisama2@gwu.edu or (202) 994-3121.

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About the George Washington University Institute of Spirituality and Health (GWish)

GWish was established in May 2001 as a leading organization on education and clinical issues related to spirituality and health. Under the direction of Founder and Director Christina M. Puchalski, M.D., professor of medicine at the George Washington University School of Medicine and Health Sciences, GWish is changing the face of health care through innovative programs for physicians and other members of the multidisciplinary health care team, including clergy and chaplains. www.gwish.org.

About Caritas Internationalis

Caritas Internationalis is a global confederation of 164 national Catholic Church-inspired organizations working in humanitarian emergencies, international development, social and health services. www.caritas.org. 

Value = Quality/Cost

I am one of those who believe that this conversion is a good thing for patients and for those providing care.  None of us who have been patients appreciate being processed through a system that feels like an assembly line which is focused on churning out the maximum amount of product. I think all of us, patients and providers, would prefer a system that is focused on and rewards providers for providing the best care, not the most care.

However, this is a huge adjustment for the system.  One of the initial barriers is that we have trouble populating the equation because we can’t clearly nail down either Quality or Cost. That said, those involved in physical care at least would seem to have some way forward in making this conversion. Hospitals will have to do some work to specify cost vs. price but the elements of cost are mostly available (e.g. how much does a CT scan really cost?). On the quality side, there are also some obvious options for metrics such as readmissions, number of contacts with the system and at what level of care, and safety issues such as medical errors and hospital acquired infections. To be clear, this conversion will not be easy even here.

But what about those of us who work in the psychosocial-spiritual domains of care? How do we compute the value we provide? Speaking from my chaplain experience, we have certainly resisted any form of accountability be it in volume or value terms so this whole emphasis requires a completely new mind set for us. When forced to show it, we do look pretty good in a volume-based economy.  We spend most of our time providing direct care to patients and families and our costs are outrageously low.  We don’t require any kind of equipment or even an office since we most often go to patients where they are and our salaries are pretty low compared to other health care professionals. We have also often sold our chaplain training program (Clinical Pastoral Education) to institutions as an even lower cost way to boost the volume of chaplaincy care.

But what value do we provide? What difference does it make that a chaplain visits? What are the outcomes associated with high quality chaplaincy care? Certainly we have some guesses and anecdotal evidence that points to several valuable outcomes including raising patient satisfaction, increasing treatment compliance, reducing the use of costly aggressive care at the end of life, and even reducing law suits but the data is weak to non-existent. While we in chaplaincy tend to think of ourselves as the most evidence-challenged of any discipline, my impression is that many of our psychosocial colleagues, especially in social work, think of themselves as pretty much in the same place.  

The temptation in this situation is for each discipline to stake out and protect its own turf. My experience is that this can quickly become a zero sum game is which, for instance, chaplaincy is pitted against social work for preeminence in the provision of both emotional and spiritual care. I would argue that scenario will inevitably reduce the overall quality of psychosocial-spiritual care and that models including palliative care and pediatric oncology where I spent most of my career have demonstrated that the value of coordinated, transdisciplinary team care is greater than the sum of the value of care provided by individual disciplines operating in silos. All of our disciplines can contribute to the outcomes named above, and, I would argue, the effects will likely be greater in quality and lower in cost if they are done in a coordinated, team-based fashion. Yes, we have to demonstrate the value of psychosocial-spiritual care and, yes, we need to do it in a way that doesn’t tempt systems to conclude that they can provide that value without a full team. That said, I am most interested in and I see the most potential in demonstration projects that posit psychosocial-spiritual care as essentially a single domain of care whose value to the system will be highest when care is provided by a transdisciplinary team staffed by psychosocial and spiritual care specialists.