THE CHAPLAINS' NOTES IN PATIENT CHARTS -- BY RAYMOND J. LAWRENCE
A very useful study was
reported in the journal Palliative and Supportive Carein May, 2016, entitled
"Documenting presence: A descriptive study of chaplain notes in the
intensive care unit." The research was completed in September, 2015. The
authors of the report were Brittany M. Lee, B.S.; Farr A. Curlin, M.D.; and
Philip J. Choi, M.D. The setting of the research was Duke University Hospital,
Division of Pulmonary and Critical Care Medicine, in Durham, North Carolina.
The study was done with input from the Director of Pastoral Services, Jim
Rawlings.
The researchers proposed
that the recent emphasis on evidence-based practice may be leading chaplains to
the use of a reduced, mechanical language insufficient for illuminating
patients' individual stories.
Whatever the cause may be,
it is clear that the chaplains in this study are at sea on the matter of what
should be appropriately reported in patients' charts.
The researchers in this
study reported that the patients' charts in this particular hospital unit
contained both an 18-point checklist section and a free-text section. The
checklist section consisted of the following:
Compassionate presence
Meaning-oriented presence
Life review
Continued presence and
follow-up
Supported patient's sources
of spiritual strength
Inquiry about spiritual
beliefs, values, and practices
Open-ended questions to
elicit feelings
Advocated with staff for
patient/family needs
Used story telling
Reflective listening, query
about important life events
Facilitated communication
with interdisciplinary team
Facilitated expressions of
lament
Referral to spiritual care
provider as indicated
Celebrated/offered
thanksgiving with patient/family
Advance directive
information given
Spiritual support groups
Spiritual practice
interventions
Reconciliation with
self/others
This research project did
not focus on the checklist above, but on the section of the patient chart where
the chaplain was asked to make free-text comments. There were such chaplain
comments made on 109 patients in the survey. The free-text opportunity would in
fact seem to be the only useful kind of clinical chaplain reporting.
The summary conclusions of
these researchers were not flattering. The chaplains' free-text comments
consisted mostly of information already available in the charts. The notes
seldom included what would be considered an assessment of needs and resources.
The notes rarely referred to any plans or expected outcomes. And the notes did
not convey a deeper connection that clinical chaplains, in fact, often have
with patients. Chaplain interactions with patients appeared to the researchers
more as "products for delivery." The researchers viewed the checklist
as actually conveying to chaplains that their work consisted of delivering so
many product units of "compassionate presence" and other such
ambiguous objectives.
The research team concluded
that chaplains frequently resorted to code language that signified nothing more
than the chaplain was present. Many of the free-text notes repeated vague terms
already in the checklist itself. Chaplains typically described what they
observed rather than interpreting its clinical significance. Chaplains
generally indicated passive follow-up plans, waiting for patients or family to
initiate further interaction.
The chaplains often
described in the free-text section simply what they observed, such as
"family is quite large," or "patient's mother standing and
holding patient's hand," observations bereft of any useful interpretation.
The researchers also found
that chaplains' free-text notes often recapitulated what was documented
elsewhere in the chart, or readily available elsewhere, such as "patient
has lung cancer and has been in hospice." Chaplains rarely made what would
be considered a pastoral assessment. And the researchers concluded that the
chaplains seldom incorporated in their notes what might be interpreted as
"spiritual assessments." The chaplains' notes did not convey the
deeper spiritual––or pastoral––connection that chaplains often have with
patients and families.
The free-text notes often
described patient's spiritual and religious characteristics without any
interpretation of significance, such as stating that "patient is a Presbyterian."
On the other hand, the
researchers found that chaplains did in fact provide what they considered a
pastoral or spiritual assessment in three of the 109 cases. In one the chaplain
wrote: "I believe the family is aware of the seriousness of their mother's
situation." In another the chaplain described an upset wife determined to
focus on assisting her ill husband. In the third the chaplain wrote a long note
about each of three children of a dying mother and their differing postures
toward the dying process. The researchers found such clinical observations
promising, though few and far between.
The researchers also found
that follow-up plans for patients were mostly passive, indicating that the
chaplains would be available if needed. Of the 109 free-text chaplain notes,
only two referred to any prior chaplain visit, suggesting that there was a
paucity of follow-up work with patients.
The researchers argued for
chaplains providing clinically relevant communication.
This study should be
examined by all serious pastoral clinicians. I believe that the results of this
study are not idiosyncratic to Duke University Hospital. In my travels I have
found that clinical chaplains are generally at a loss as to what appropriately
belongs in a patient's chart. It should be a fairly easy task to decipher what
is important and to orient chaplains to just that.
We should be clear however,
that there are systemic problems in chaplain reporting stemming from the very
recent shift in language use, a shift that has resulted in obfuscation of the
chaplain's role. I refer to the substitution of "spiritual" for
"pastoral" that has been in process on a wide scale for two decades
now. (It is heartening to see that Duke still retains a "Department of
Pastoral Services.") If chaplains simply can remember that they are
pastors or in the pastoral arena and not spiritual gurus, they will be able
better to describe what they do. The pastor, like the shepherd of a flock,
actually needs to do neither more nor less than to see that the animals and
crops are safe, healthy, and in all respects progressing. It is a
broad-spectrum task. Much of the time that means doing nothing more than paying
close attention. Thus the chaplain can write in the chart, "made myself
known to the patient and will follow up as needed." No need to add any
fancy new-age language. No need to parse the new fad of "spiritual but not
religious." Just present oneself in a pastoral––like a shepherd––posture,
establish a potential new relationship, and return later if possible.
In any case, it is
advisable for chaplains to present themselves as pastoral professionals if they want to be
understood.
Thus, in the typical
hospital a high percentage of chaplain visits would likely be appropriately
charted as "pastoral visit." That is to say, nothing much of
significance occurs beyond the simple dramatization of the chaplain's
availability. This is, of course, no small matter. Informing the patient by way
of a brief visit, rather than by a written announcement, that there is a
chaplain available for consultation or counseling, is an important contribution
to a typical patient's sense of institutional well-being.
Paradoxically, the clinical
chaplain in making routine visits to patients will find that some of the most
receptive and needy patients, in terms of pastoral counseling, are not those
with acute medical emergencies in play, but rather those with routine, everyday
medical problems. And generally such patients have the luxury of time for
talking, unlike those facing critical emergencies. In my own experience through
the years, I have found that the most significant pastoral counseling I was
able to do was with patients (and staff) who had time on their hands and were
happy to encounter a trained person willing to listen to them.
[Having said that, we
should note in seeming contradiction, that it is not unusual for a routine
patient courtesy visit to morph quickly into what should be properly labeled
pastoral psychotherapy. A competent clinical chaplain is always nimble and
ready for surprises.]
For a minority of patients,
where something of note emerges in the chaplain's visit, or a crisis is
underway, charting is especially important as a way to notify the staff of what
specific action the chaplain is taking. The staff needs to know.
Clinical chaplains
everywhere should take note of this credible and well-done piece of research.
It should be considered a warning shot announcing the danger of the trend
toward the irrelevancy of institutional chaplaincy. To counter this impending
danger I recommend the following:
1. Clinical
chaplains move away from "spiritual" as the supposed arena of the
chaplains work, seeing it as a recently invented poorly defined category, and
move back to the more concrete "clinical pastoral."
2. Clinical
chaplains recognize that one-time pastoral visits are less likely to accomplish
much more than introduction and minimal trust building. Effective pastoral work
generally––but not always––comes from repeat visits, after which the patient
has learned that the chaplain at least is able to get in and get out of a room
and listen, without doing something foolish.
3. Clinical
chaplains, more than any other professionals, take interest, theoretically, in
the whole person, medical, social, mental, physical, et alia.
4. Clinical
chaplains avoid all flowery language in defining their role, such as
"compassionate presence," especially any that is similarly
self-aggrandizing.
5. Clinical
chaplains avoid any prefabricated "outcomes." Any chaplain-patient
outcome should be rooted in the idiosyncratic needs and values of the
particular patient. Not every patient seeks the same outcome. And most patients
seek only an intelligent caring listener to hear his or her story. Most
patients want to live, and to live fulfilling lives, but only they know what
such a life might look like.
On a given day most patient
visits would likely qualify for a simple documentation of "pastoral
visit." Beyond making him- or herself known and available, there typically
is not much else to offer on a first visit. In a few cases, especially repeat
visits, the chaplain may move into the role of counselor, therapist, confessor,
or guide––cases in which persons expose their lives to an intelligent other,
with the unspoken hope for both care and wisdom. A competent chaplain has the
time, and hopefully the expertise, to fulfill that role where most other
medical staff must keep moving. Such in-depth pastoral visits need to be
documented for the benefit of the other staff members.
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