Patient-Centered Pastoral Assessment Framework

1. The Role of Assessment in Patient-Centered Pastoral Care Chaplain John Ehman 11/13/17

2. The purpose of this presentation is not to prescribe a particular assessment but to explore a framework appropriate to patient-centered pastoral care -- into which you may place the particulars of your own assessment practice that you will develop over time.

3. Assessment here refers to all the ways that we, as pastoral professionals, try intentionally to understand a present situation in order to get our bearings on how to work with that situation moving forward, for the patient’s benefit. Assessment is part of a chaplain’s professional discipline.

4. There is increasing attention in health care on chaplains’ assessments, and that usually means issues-oriented assessments of a patient’s “spiritual problems” or evaluations of a patient’s “spiritual health,” along with some description of a patient’s values/beliefs. Such assessments tend to focus on gathering a set of information that interests healthcare institutions. However, an issues-oriented focus can displace our attention to the process of the chaplain-patient interaction --the very personal experience of pastoral care that can itself foster healing. What is the place of process-oriented assessments?

5. Attention to process is important in patient-centered pastoral care… …because patients are invited to take the lead, tell their story, and find help and healing through aninteractive experience with a chaplain.

6. When a chaplain interacts with a patient, the chaplain isn’t the only person in the room making assessments. See handout:

7. What Is the Frame for Patient-Centered Pastoral Assessment Practice? Not simply… Issues Assessment (“Spiritual Assessment”)

8. What Is the Frame for Patient-Centered Pastoral Assessment Practice? ◄ ► Process Assessment Issues Assessment (“Spiritual Assessment”)

9. Pastoral Process Assessment: Some Basic Elements Is the patient able & willing to indicate informed consent? Is the patient empowered to take the lead? Are there special, practical circumstances complicating clear communication (including cultural diversity)? How is the patient engaging cognitively and emotionally? What is the patient’s style of communicating and “testing” whether or not he/she is being heard? Are other people in or near the room? How may role expectations be structuring the interaction? Is the chaplain feeling uneasy or distracted? How much leading is the chaplain doing, and why?

10. The degree of leading that a chaplain does during a visit may be a critical indicator of how much the interaction is really following a patient-centered pastoral care approach. See “Types of Leading” handout:

11. An example of how process assessments may figure into pastoral visits: I am called by a nurse who reports that a patient "wants to see a chaplain." When I ask the nurse if she's aware of any particular circumstances surrounding the request, she says, "She's going to have to have both legs amputated, and she's been crying." I approach the room and notice a contact isolation placard. A curtain is drawn across the doorway. I gown and glove, then knock on the open door. "Ms. B., I'm the chaplain, may I come in?" "Yes, please do," a woman's voice replies. I see a middle-aged woman in the bed with her head raised. She is adjusting her gown up around her shoulders. There is no immediate sign from her face that she'd been crying. She looks eagerly at me and smiles. On each side of the room are two men. They are silent and make no obvious action to engage me (e.g., no eye contact, no move to shake my hand). Both seem to be sitting at a maximum distance from the patient.

12. I walk to the patient, and she shakes my hand. "My name is John Ehman. I'm the chaplain for the hospital. Your nurse just told me that you wanted to see a chaplain, and so I wanted to see how I might be of help to you. Let me also just say hello to… [and I go over to each of the men and shake their hands --they appear to engage me at the most minimal level]. I say to the patient: "I don’t mean to interrupt your visit, so I'd be happy to come back in a few minutes if that works better for you." "Oh, no," she says. "I want to see you"; and she holds out her hand. I go to her and take her hand. She pulls me close to the bedside. I now have my back to one of the men, and the other I notice (out the corner of my eye) is looking at the floor. The patient looks me directly in the eyes and says, "I need you to talk to me about God." She closes her eyes tightly, takes a deep breath, and suddenly appears to be holding back emotion. I smile slightly and say, "We can surely talk about God. Tell me what's on your heart and mind." Emotion wells in her face. She says rather rapidly, "They want to cut off my left leg and my right foot, and I just don't believe that God wants me to lose my legs. I know that God can heal anything, and God doesn't want them to do this. I'm not ready to lose my legs. I know God has something more for me." She pauses, looking intently at me. I allow a few seconds of silence as we look at one another and then say, "Yes. I hear you. Can you tell me more?"

13. She begins a long monologue looking constantly at me (never at the others in the room), except for moments when she shuts her eyes in emotion. She periodically cries as she speaks. The two men appear extraordinarily still and silent. She talks about how she is a very faithful person, how God means everything to her, how she loves to pray all the time, and then how she doesn’t want to lose her legs, how she's done everything she could for the past two years to get her legs to heal and how that effort has meant staying inside all the time with her feet up and keeping them wrapped; how she's done nothing for the past two years but concentrate on her legs. She tells of going to another hospital last week and being told that her legs would have to be amputated, how she insisted on coming to Penn for a second opinion, and how she had just been told again that amputation was necessary. Her story takes on more particular detail as we approach the present moment, and she tells of a doctor saying to her, "The surgeon will be in on Friday, so let's just do it then." She expresses outrage at the perceived casualness of that doctor, saying, "These are my legs, and he's just saying let's do it because it's convenient for the surgeon! God doesn't want me lose my legs!" She becomes quiet, looking intently at me, appearing to expect my response.

14. In light of what you have heard and assessed so far, what might you do next?

15. So, how did this play out? CHAPLAIN: You've said a great deal with deep meaning --about your faith and how hard you've worked for years to get your legs to heal, how for over two years you haven’t been able to do anything else in your life because of your legs, how constantly you've carried that burden and prayed for guidance. And, how much it hurt to have a doctor seem to treat all of this so casually. PATIENT: He never should have said that. Walk in here and just schedule to cut my legs off for people's convenience. After all I've done. [Pause.] I've suffered for these legs. It's my decision. CHAPLAIN: I want to honor your faithfulness through years of suffering. I can’t begin to guess your experience through it all, but I sense the magnitude of it. I also want to honor what it means to be faced now with a decision about whether the way ahead for healing might be a way through loss, a loss you've tried so hard to prevent. PATIENT: I did everything I could. [Looks back and forth to each of the two men – for the first time – and then closes her eyes, with tears.]

16. CHAPLAIN: You've been guided by your love of God through it all. That is a powerful witness. Whatever you decide will also be a witness to your faith. PATIENT: [Looks up at me.] Two years I suffered. I haven't been able to do anything else. [Pause. Deep breath.] I know God wants me to do more with my life. [Pause.] I know what I have to do. I know God doesn’t want me to sit home like this forever. I don’t want to lose my legs, but He didn’t bring me this far for this to be "it." [Pause.] Thank you. I'm ready. Process assessments help chaplains offer a pastoral interaction that is in tune with patients' felt needs and is empowering for patients' self-help. This may bring benefits even before the chaplain is able to gain a good sense of specific issues.

17. The process assessment often slightly precedes -- and then runs along side of -- an issues assessment, and can support communication about issues. Process Assessment Issues Assessment (“Spiritual Assessment”) What should be the elements of an issues assessment, a “spiritual assessment,” in your own practice of pastoral care?

18. Strategy for Building Your Own Practice of “Spiritual Assessment” 1) Start from what you naturally pay attention to in visits. 2) Consider how these indicators may limit your sense of a patient, or be misleading under some circumstances. 3) What values and assumptions are implicit in your assessment items? What theory and theology is behind them? 4) Periodically list your most salient assessment items and think of how they can be refined or rounded out.

19. A personal list of the most salient assessment items during pastoral visitation: For an example, see handout:

20. Strategy for Building Your Own Practice of “Spiritual Assessment” 1) Start from what you naturally pay attention to in visits. 2) Consider how these indicators may limit your sense of a patient, or be misleading under some circumstances. 3) What values and assumptions are implicit in your assessment items? What theory and theology is behind them? 4) Periodically list your most salient assessment items and think of how they can be refined or rounded out. 5) Write verbatims of difficult visits to spur your thinking. 6) Consult the research and professional literature on “spiritual assessment” for new ideas to incorporate.

21. Examples of Popular “Spiritual Assessments” in the research and pastoral literature: FACIT-Sp FICA 7x7 Model (facit.org) (Puchalski) (Fitchett) Brief RCOPE Spirituality Scale Spiritual Needs (Pargament) (Delaney) (Galek) See handouts:

22. A recent study seeking the best brief assessment for spiritual distress in cancer patients tested these: 1) "Do you struggle with the loss of meaning and joy to your life?“ 2) "Do you currently have what you would describe as religious or spiritual struggles?“ 3) "Are you at peace?" 4) "Does your religion/spirituality provide you all the strength and comfort you need from it right now? “ 5) "Do you have any spiritual/religious concerns?" 6) Two-path Revised Rush Religious Struggle Protocol, asking first about the importance of R/S in the patient's life and then, depending on the response, asking either how much their R/S is helping them now or whether R/S has been important previously. --King, S. W. D., Fitchett, G., et al., "Determining best methods to screen for religious/spiritual distress,“ Supportive Care in Cancer (2016): in process

24. A recent study seeking the best brief assessment for spiritual distress in cancer patients tested these: 1) "Do you struggle with the loss of meaning and joy to your life?“ 2) "Do you currently have what you would describe as religious or spiritual struggles?“ 3) "Are you at peace?" 4) "Does your religion/spirituality provide you all the strength and comfort you need from it right now? “ 5) "Do you have any spiritual/religious concerns?" 6) Two-path Revised Rush Religious Struggle Protocol, asking first about the importance of R/S in the patient's life and then, depending on the response, asking either how much their R/S is helping them now or whether R/S has been important previously. --King, S. W. D., Fitchett, G., et al., "Determining best methods to screen for religious/spiritual distress,“ Supportive Care in Cancer (2016): in process

25. What sets up, and what follows from, the Process and Issues Assessments? ► Pre-Visit Information Gathering ◄ Process Assessment Issues Assessment (“Spiritual Assessment”)

26. Pre-Visit Information Gathering SOURCES: the medical record, care team members (especially the primary nurse), family members ADVANTAGE: this “background” information can help identify special issues and can give context for understanding/assessing the patient’s situation DISADVANTAGE: it can suggest an agenda for the visit and can skew the chaplain’s perception and assessment of the patient

27. What sets up, and what follows from, the Process and Issues Assessments? Pre-Visit Information Gathering Process Assessment Issues Assessment (“Spiritual Assessment”) ► End-of-Visit Assessment ◄

28. End-of-Visit Assessment Are there any loose ends to be addressed? (--especially practical matters that might have pulled the visit off course if pursued earlier in the conversation) What is the patient’s expectation for follow-up? A before-leaving-the-room check: Is there anything else that you can do or get for the patient? Is all that the patient might reach for (e.g., call button) within reach? Is the overhead light, window shade, and curtain OK? Are there safety issues apparent (e.g., falls hazards or patient expressions of pain or breathing difficulty)?

29. Note about SPECIAL ASSESSMENTS that extend beyond spiritual issues: When encountering issues like abuse or intent to harm, follow institutional policies and make referrals to institution-identified specialists where necessary. Assess how the disclosure of sensitive information and the involvement of third parties affects the patient-chaplain relationship as you continue to offer pastoral care.

30. What sets up, and what follows from, the Process and Issues Assessments? Pre-Visit Information Gathering Process Assessment Issues Assessment (“Spiritual Assessment”) End-of-Visit Assessment Communication of Assessment and Pastoral Planning ► ◄

31. Communication of Assessment and Pastoral Planning The challenge of documentation: Documentation often requires you to translate a subtle understanding of a patient into a clinical language that “pigeonholes” information. Thinking about the task of documentation can cause you to impose the requirements of that task onto the course of the patient visit.

32. PennChart (Epic) Categories for Documenting Pastoral Care Interventions ●Coping support ●Pastoral de-escalation of crisis/conflict ●Coordination of pastoral/cultural needs ●Prayer / ritual ●Contact made with patient's faith organization ●Decision-making facilitation ●Grief / loss support ●Palliative Care ●End-of-life care

33. Communication of Assessment and Pastoral Planning The challenge of pastoral planning: Your total assessment of a visit helps you plan for follow-up, but it also may lead you to take an agenda into the next visit. Planning for follow-up visits requires balancing knowledge from the previous encounter with openness for the new encounter.

34. Frame for Patient-Centered Pastoral Assessment Practice …takes into account how a “spiritual assessment” does not occur in isolation Issues Assessment (“Spiritual Assessment”)

35. Frame for Patient-Centered Pastoral Assessment Practice Pre-Visit Information Gathering Process Assessment Issues Assessment (“Spiritual Assessment”) End-of-Visit Assessment Communication of Assessment and Pastoral Planning

36. john.ehman@uphs.upenn.edu