Editor's Note: The month of November is dedicated to Palliative Care. Chaplain Poorbaugh's article is not only informative but timely. CPSP offers a specialty certification in Hospice and Palliative Care.
Meriwether Lewis stood by the headwaters of the Missouri, a trickling stream that would become the mighty river. His first goal was thus done. His second goal - to find a good passage to the Pacific Ocean – might be done soon. Thomas Jefferson had told him to expect the West to be like the East: some big mountains like the Appalachians lowering slowly to the ocean. He decided to mount the ridge ahead, hoping he might look down on the Pacific Ocean.
Instead, he looked up at the Grand Tetons.
(Paraphrased from Undaunted Courage, by David McCullough.)
When I began Palliative Chaplaincy years ago, I felt like Lewis by the stream. Having been a pastor most of my life, with many hospital visits and beloved flock dying, I knew I could navigate the Appalachians. When I got a little farther in the field I felt like Lewis on the ridge, seeing Palliative Chaplaincy as the Grand Tetons.
For chaplains new to Palliative Chaplaincy, this article has three goals: to have fun, to see in the Q’s (questions) how big it is, and to gain from the A’s (answers) some nuggets of fundamental knowledge.
Q
Names:
1. What historical figure gives us both “Palliative” and “Chaplain?” ____________________Credentials:
1. Name all the specialties in which a BCCC or BCC can earn Board Certification. _______________
2. Who leads in certifying Specialty Chaplains? ____________________
3. What fact led to creating this Specialty? ____________________
Basic:
Contrast Palliative Care and Hospice Care three ways.
1. ________________________________
2. ________________________________
3. ________________________________
Suffering:
1. Compare Pain and Suffering by circling all that are true:a. Pain is physical; Suffering is spiritual.
b. Both are physical
c. Both are spiritual
d. Neither can be measured.
2. Match each medical writer with their theory of Suffering:
| Cicely Saunders | Broken Personhood |
| Ira Byock | Loss of Capacity |
| Jane Brody | Total Pain |
| Eric Cassell | Loss of Meaning |
| Thomas Gleich | Broken Story |
Spiritual Distress:
1. Your Patient may have any of these spiritual conditions. Circle the three that count as Spiritual Distress.a. Fear of being in the hospital
b. Isolation
c. Repentance
d. Ritual Need
e. Remorse/Regret
f. Hopelessness
g. Denial
Preferred Practices:
The National Consensus Committee for Quality Palliative Care has set preferred practices. For this question, try marking each option:
1. Everyone on the Palliative Care IDT must learn to spell “palliative.” ____+ we do that already
0 we don’t do that yet
R right answer
! Fat Chance!
2. The IDT must provide access to spiritual care for all patients. ____
3. The IDT must have a standard for spiritual assessment, use it for each patient, and include it in the care plan. ____
4. The IDT must meet every morning to coordinate care. ____
5. The IDT Chaplain must be Board Certified in Palliative Care. ____
6. The IDT must work in the community for education and End of Life care. ____
7. The IDT must order in pizza at least once a month. ____
A
Names:
1. St. Martin of Tours
A young Roman cavalryman, seeing a poor man freezing at the city gate, cut his heavy woolen cloak and gave away half. That night, he dreamed he saw Jesus wearing the half-cloak he had given. Later in the IVth Century, Martin became bishop of Tours. His cloak became a relic. The Latin verb for cloak –palliare – gives us palliative. The Latin noun for cloak –capella – gives us chaplain.
Credentials:
1. Hospice and Palliative Chaplaincy2. CPSP
In 2013, CPSP certified its first Clinical Fellows in Hospice and Palliative Care. In 2014, the Association of Professional Chaplains followed with their Hospice and Palliative Chaplains.Entering 2015, CPSP had certified 43 Palliative Chaplains; APC, 4.
3. Death
Because modern medicine is based on the philosophy of materialism (only matter that can be measured is real), death means failure. Hospitals hate to have people die there. Doctors hate to deal with dying people. As Atul Gawande, author of the best-seller Being Mortal, writes: “Our job is to fix someone; when we can’t fix someone, we have failed.” Death is being transformed from the dirty work of medicine into the holy work of palliative chaplaincy.
Basic:
1. When does it start?2. May I receive curative treatment for my main disease while enrolled?Palliative – at diagnosis of a chronic or terminal illnessHospice – at prognosis of six months or less to live
3. When does it end?Palliative – YesHospice – No
Palliative – Hospice (unless declined)Hospice – Death (unless dis-enrolled)
Suffering:
- 1. (c) and (e) -- Because neither can be measured, both are spiritual.
Medicine avoids suffering by reducing it to pain. Ira Byock claims in his book, The Best Care Possible, never to let a patient suffer, but the index for “Suffering,” reads: “see Pain and Suffering.”
Medicine must deal with pain to relieve the symptom, so measures pain with a highly precise scientific instrument – the frowny face cartoon.
2. Author/Title Match:| Cicely Saunders | Total Pain |
| Ira Byock | Loss of Meaning |
| Jane Brody | Broken Story |
| Eric Cassell | Broken Personhood |
| Thomas Gleich (doesn’t exist, but if he did, he might have written Loss of Capacity) |
Spiritual Distress:
Dealing with Suffering matters a great deal in the practice of Palliative Chaplaincy, but is too complex to do more here than point out as a Grand Teton we must surmount.
1. Isolation, Hopelessness, Ritual NeedIsolation. One might think that life-threatening disease would produce above all fear of death. Cicely Saunders stated that what people in the end of life fear most is isolation. Next come pain and death. Anything scarier than pain and death must be distressing.
Hopelessness. The Gate of Hell in Dante’s Inferno commands “Abandon hope, all ye who enter here.” It comes - by its theological synonym despair- when I am so far down I believe not even God can help me. To be hopeless is to be already in Hell.
Ritual Need. A well-known formal example is a Roman Catholic who may believe that receiving the Sacrament of the Sick will ensure dying in a state of grace. A less-recognized informal example is an Evangelical who believes that a dying loved one must say the Sinner’s Prayer - accepting Jesus as personal Lord and Savior – to ensure going to Heaven. The formal and informal needs may be equally intense.
Identified in the National Comprehensive Cancer Network Compendium and Guidelines, updated January 6, 2012. These Guidelines have been vetted and revised for over 10 years, so provide solid evidence-based standards. I find them both theologically and clinically accurate. http://www.nccn.org/about/news/ebulletin/ebulletindetail.aspx?ebulletinid=154
Preferred Practices:
1. (b), (c), (e) and (f) are real. The others are just good ideas. Here are the real spiritual standards to be met for Quality Palliative Care.
SPIRITUAL, RELIGIOUS, AND EXISTENTIAL ASPECTS OF CARE
PREFERRED PRACTICE 20
Develop and document a plan based on assessment of religious, spiritual, and existential concerns using a structured instrument and integrate the information obtained from the assessment into the palliative care plan.
PREFERRED PRACTICE 21
Provide information about the availability of spiritual care services and make spiritual care available either through organizational spiritual counseling or through the patient’s own clergy relationships.
PREFERRED PRACTICE 22
Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained and certified in palliative care.
PREFERRED PRACTICE 23
Specialized palliative and hospice spiritual care professional should build partnerships with community clergy and provide education and counseling related to end-of life care.
National Consensus Project for Quality Palliative Care, “Clinical Practice Guidelines for Quality Palliative Care, 3rd edition, 2013,”cited at http://www.nationalconsensusproject.org/Guidelines
__________________
Frederick Poorbaugh