Developing a Spiritual Plan of Care Session 01: Assessment and Documentation

1. Developing a Spiritual Plan of CareSession 01: Assessment and Documentation

2. Introductions I • D.W. “Donovan” • Director of Mission Leadership in Mission Hills (Los Angeles), CA • Providence Holy Cross Medical Center • Board Certified Chaplain • Author of “Assessments” in Professional Spiritual and Pastoral Care: A Practical Clergy and Chaplain’s Handbook, Rabbi Stephen Roberts, Editor.

3. Introductions II • Jane Mather • Director, Spiritual Care • Providence Sacred Heart Medical Center • Mark Thomas • Director, Mission Integrity and Ethics • Providence Hood River Memorial • Tim Serban • Vice President, Mission and Spiritual Care • Providence Health and Services, Northwest Region

4. Special Thanks Special thanks to Alan Sanders and Catholic Health East for their commitment to contribute to the development of professional chaplaincy.

5. Outline I: Preliminaries • Preliminaries / Premises • Do we have something to offer? • If so, WHAT? • How can we be more effective in integrating our work into the care of each patient/family?

6. Outline II:The Assessment • The Assessment • Covey: Begin with the End in Mind • What Elements Do We / Should We Consider in our Assessment? • Current practices • A proposed model • Tips: Developing an Assessment Model

7. Outline III:Documentation & Discussion • Documentation • Tips for Developing a Documentation Tool • Tips for Documenting in the Medical Record • Discussion • Closing Comments

8. Do we have something to offer? • Does anyone read our notes? If not, why not? • Have we allowed our work to be put in a silo?

9. What Is It That Chaplains Do? • The Equilibrium Model

10. The Equilibrium Model The role of the clinically-trained chaplain is to assess the degree to which the patient's emotional and spiritual equilibrium has been disturbed by the healthcare event and to determine what interventions would be appropriate to help the patient restore their equilibrium and when such interventions should be employed. (Donovan / Dowdy)

11. What Is It That Chaplains Do? • The Equilibrium Model • Moving from A to W, then X, Y, and Z • Helping the Patient / Family Apply Existing Values and Beliefs to the Current Clinical Situation • Key Points / Executive Elevator Speech

12. What Is It That Chaplains Do? • Key Points / Elevator Speech: • The chaplain is an integrated member of the interdisciplinary team, contributing to the overall plan of care for the whole person from a spiritual perspective. Our particular expertise lies in our ability to help create a sacred space where the relevant values and beliefs can be explored and applied to the current situation / decisions. • Requires that “emotional and spiritual needs are considered inextricable from physical and psychological needs.” (Clark) • Visualizes spirituality as the leaven that permeates the bread, rather than the icing that covers the cake. (Dowdy)

13. What Is It That Chaplains Do? • Key Points: • Our ministry is grounded in extensive training to help us recognize emotional and spiritual distress and to help people process through emotionally-charged experiences. Our assessments reflect a “whole person” approach, and require us to be familiar with interpersonal dynamics, theology and theodicy, and the medical milieu in which these dynamics are now operative.

14. Integrated Chaplaincy • Holistic Health Care … • Requires that “emotional and spiritual needs are considered inextricable from physical and psychological needs.” (Clark) • Visualizes spirituality as the leaven that permeates the bread, rather than the icing that covers the cake. (Dowdy)

15. A Question … How effective have we as a profession been in integrating attention to the spiritual perspectives, values and beliefs of our patients and families into each plan of care?

16. … and a Challenge How can we be more effective in integrating our work into the care of each patient/family?

17. Integration-Focused Documentation • Many answers • Focus today on how we do that through documentation that includes a professional assessment.

18. Outline II:The Assessment • The Assessment • Covey: Begin with the End in Mind • What Elements Do We / Should We Consider in our Assessment? • Current practices • A proposed model • Tips: Developing an Assessment Model

19. Covey: Begin with the End in Mind • Preliminary Note: Assessment Vs. Screening • Important at the Personal Level: Know Me … Care for Me … Ease My Way

20. Covey: Begin with the End in Mind • Important at the Plan of Care Level for your Colleagues: • “How does your expertise make my job easier?”

21. Is it accessible by our colleagues and useful to our colleagues? • Accessibility: • Speaking the Language • Providing Takeaways • Accessibility: Nuts and Bolts

22. Is it accessible by our colleagues and useful to our patients? • Useful : The “Quality Question” • How do we “assess” the quality of our documentation? • Advance the plan of care • Advance the professionalism of the chaplain

23. Covey: Begin with the End in Mind • Important at the Organizational Level: • Reduced LOS • Reduced Turnover

24. Wait A Second!!!! “Many pastoral care professionals believe that presence and relationship are the alpha and omega of their work. …” “They hold that pastoral care cannot be measured; that to attempt it would be almost an affront to God.”

25. Wait A Second!!!! “We say beware. Those who shun accountability should not be surprised if they are first in line for budget cuts.” --Brian Yanofchick Health Progress, May 2009, p. 21

26. Current Practices • Christina Puchalski, G-Wish: FICA (Spiritual History Tool) • Faith and Belief • Importance • Community • Address in Care (See http://www.hpsm.org/documents/End_of_Life_ Summit_FICA_References.pdf)

27. Current Practices • The Joint Commission Q&A: “Does the Joint Commission specify what needs to be included in a spiritual assessment?” • “No. Your organization would define the content and scope of spiritual and other assessments …. Examples of elements that could be … but are not required include the following questions:”

28. Current Practices • Who or what provides the patient with strength and hope? • How does the patient express their spirituality? • How would the patient describe their philosophy of life? • What is the name of the patient’s clergy, ministers, chaplains, pastor, rabbi?

29. OtherCurrent Practices • Are there values and beliefs that would affect your treatment decisions? • Would you like to see a chaplain / pray with a chaplain?

30. A Proposed Model • Assessments: A Medical Model • Listen • Observe • Evaluate • Determine • Paradigm Shift from Faith-Based Coping Mechanisms to Values and Beliefs

31. A Proposed Model • Three Elements • Element I: Relationships and Connectivity • Element II: Meaning and Purpose • Element III: Degree of Understanding and Congruence of Response

32. Element I: Relationships and Connectivity • Observations from Unit 01: Counting People and Cards • Spectrum from Fully Connected to Sense of Isolation / Abandonment • To / from friends and family • To / from a sense of the sacred / divine • Theological Principle: Relationships • Possible Interventions

33. Element II: Meaning and Purpose • Observations • Often a Need to “Make Sense” of the Illness / Injury / Event • Coping Mechanisms / Complex Beliefs May Be Compromised • Values and Beliefs Applied to Current Situation • Possible Interventions • Theological Principle

34. Element III: Degree of Understanding and Congruence of Response • Assessment A: Does the patient / family / surrogate have an accurate understanding of what the physician has indicated to them? (LaRocca, Assessing) • Assessment B: Is the response internally congruent with previously expressed values and beliefs? (NCCN)

35. Element III: Degree of Understanding and Congruence of Response • Look for statements such as • What does the doctor know anyway!?! She’s not God! • God’s in charge and my baby won’t go anywhere until God decides it’s time. (But don’t you dare touch the ventilator!) • Possible Interventions -- with a goal in mind! • Theological Principle

36. Tips for Developing an Assessment Model • Build on what comes naturally: relationships, meaning, medical. • Build upon the uniqueness of the chaplain: “connecting the dots” between the individual and the institutional milieu. • Thus, work to be “out of the box” of any particular faith tradition. • Don’t confuse “tools” with an assessment.

37. Outline III:Documentation & Discussion • Documentation • Tips for Developing a Documentation Tool • Tips for Documenting in the Medical Record • Discussion • Closing Comments

38. Tips for Developing a Documentation Tool

40. Tips for Documenting in the Medical Record • Avoid Statements that are Not Observable. • Patient understood the clinical situation. • Patient stated, “I understand what the doctor is saying.” • Avoid Statements that are Outside your Scope of Practice. • The patient is close to death. • The nurse indicated “death is imminent.”

41. Tips for Documenting in the Medical Record • Reinforce your Professionalism. • Visited with nurse before seeing patient. • Consulted with RN to review recent events / social hx. (Note: families visit; professionals see patients or consult.) • Do Not Imply that Showing Up Is Enough • Plan: Follow-up Daily • Your suggestions?

42. Tips for Documenting in the Medical Record • Use Legal Language Carefully and Correctly • AMD Consult: Patient did not seem competent. • Patient was alert and oriented to year, but not to place, president, or situation. I was not comfortable proceeding at this time.

43. Tips for Documenting in the Medical Record • Do Not Put Another Team Member in a Corner • The family is upset because their questions have not been answered. • Family indicated that they have additional questions to ask and would appreciate additional time with Dr. X. Called Dr. X’s office and left a message for her with Nurse Susan.

44. Discussion

45. References Clark, Paul A. Drain, Maxwell, and Malone, Mary P. Patient Centeredness: Addressing Patients’ Emotional and Spiritual Needs. Joint Commission Journal on Quality and Safety. Dec 2003 (29:12). Dowdy, Melvin, and Donovan, D.W. The Pastoral Assessment Tool: Developing the Centerpiece of the Pastoral Care Strategic Plan (unpublished presentation).

46. References Joint Commission, The. Standard FAQs: Spiritual Care. Downloaded from: http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId=290&StandardsFAQChapterId=29. LaRocca, Mark. Assessing the 4-F’s of Spiritual Assessment. Downloaded from: http://www.plainviews.org/AR/c/v2n23/pp.html.

47. References Puchalski, C. Spiritual Assessment Tool: FICA. Downloaded on July 14th, 2012 from http://www.hpsm.org/documents/End_of_Life_ Summit_FICA_References.pdf. Roberts, Stephen, ed. Professional Spiritual and Pastoral Care. Skylight Paths Publishing. 2011. Yanofchick, Brian. Do We Care Enough about Pastoral Care? Health Progress. May 2009.

48. Thank you!!! • Looking Ahead! • August 15th, 2012 • Communicating the Spiritual Care Plan: Chaplain as Educator • Jane Mather: • September 12th, 2012 • Integrating into a Holistic Plan of Care • Mark Thomas