March 2019 Article of the Month
Wirpsa, J. M., Johnson R. E., Bieler, J., Boyken, L., Pugliese, K., Rosencrans, E. and Murphy, P. "Interprofessional models for shared decision making: the role of the health care chaplain." Journal of Health Care Chaplaincy 25, no. 1 (January-March 2019): 20-44.
SUMMARY and COMMENT: The authors of this month's study hold that "[c]entral to the role of professional health care chaplains is support for the complex, emotionally laden process of medical decision making" [p. 39]. And so, here they look at chaplains' involvement in decision-making processes, analyzing results from a national online survey of chaplains working with adults with serious or life-limiting illness. This is a report of the first part of a three-phase project, with the later phases involving phone interviews with chaplains and an invitation to contribute detailed case studies. The authors focus on the idea of Shared Decision Making (SDM) in health care and apply their results to propose a revised model formally integrating chaplains.
Members of major US chaplaincy organizations (i.e., APC, NACC, NAJC, and NAVAC) were emailed invitations to participate, yielding 722 respondents, of which 463 had full-time positions and met inclusion criteria. The participants' views of their integration into health care team decision making processes was assessed by three questions: "I find it easy to communicate (in person, by phone, or electronically) with members of the health care team in order to support patient and family medical decision making"; "I am always included in health care team discussions about patient and family medical decision making"; and "The health care teams in which I work welcome my contributions to patient and family medical decision making" [p. 25] --each with responses to be given on a five-point Likert scale. To these were added a pair of open-ended questions: "As a chaplain, what do you feel you uniquely contribute to the medical decision making process for patients and their families with a serious or life-limiting illness?" and "What, if anything prevents you from being involved in the medical decision making process for patients and their families with a serious or life-limiting illness?" [p. 26]. Other data elicited by the survey addressed demographic information, chaplains' sense of their adequate preparation and time to engage patients and families in decision-making (referred to in the article as "assets"), and estimation of total time supporting patients and families in this way, along with time spent in "six discrete aspects or activities that constitute their role in supporting medical decision making" [p. 25]:
Among the quantitative results:
Regarding barriers to chaplain integration into SDM, the authors highlight three areas. First, "...high case loads, being assigned to too many areas of coverage rather than being a dedicated team member, and carrying a system wide on-call pager precluded them from supporting patients and families in medical decision making" [p. 35]. Second, the "persistence of the biomedical model" [p. 36], which emphasizes medical evidence and so may discount "emotional and spiritual components" [p. 36] in patient/family decision making was "highlighted by chaplains in our study as a central reason for the lack of chaplain inclusion in SDM" [p. 36]. Contributing to this was believed to be misunderstandings of the chaplain's role, including views of chaplains -- especially by physicians -- "as just 'pastors'" [p. 36]. And third, respondents noted that "many physicians claim primary responsibility for guiding patients and families in treatment decisions to the exclusion of other team members" [p. 36].
In light of these barriers, the authors put forward a revised model of SDM [diagrammed on p. 32], "moving beyond the physician-patient dyad to include contributions by other members of the health care team and...re-envisioning the stages of the decision making process" [p. 37]. Here, the chaplain would perform a key role in the stages of Information Sharing, Processing, Clarifying, Decision Making, and a final Supportive stage. The authors state:
Our results suggest that integration of the chaplain at every stage of SDM could impact the timing of decision making: the chaplain may alert the team to the readiness of patients and families to hear specific information or negotiate for a postponement of a decision so patient/family may attend to unresolved business. Integration also has the potential to directly address many of the "dialogue barriers" to SDM cited in surveys.... ...Most significant among the dialogue barriers that chaplains could help address is a physician's lack of time to engage with patients and families to clarify options, explain procedures, process emotions, and elicit values and concerns. [p. 38]
A principal limitation of the study is that data represent only chaplains' own perceptions of their work with SDM, bringing into play the "potential bias in self-report and the impact of social desirability" [pp. 38-39] in responses. Also, the study "fails to measure the actual difference chaplain integration into the team has on patient care outcomes" [p. 39]. With these limits in mind, the authors suggest possibilities for future research [--see p. 39].
This study fills an important gap in the literature on SDM and points up how chaplains both experience and envision their role as part of the multidisciplinary health care team. It also suggests a revised model for SDM that could at least be a touchtone for discussion about processes for health care decision-making inclusive of chaplains. There is much here to empower chaplains to take more of a place at the table of the multidisciplinary team. However, while chaplains would certainly bring a great array of expertise and skills to SDM, this reader was surprised by the stridency of some of the quotes used to illustrate the findings. For example, regarding the "exercise of pastoral authority" with religious patients and families: "I am able to speak to how God will honor their decisions" [p. 33]. To this reader, such a statement is not just an example of how a chaplain "moves the decision-making process along and provides a greater sense of satisfaction and peace with the decision" [p. 33], but of how a chaplain's use of authority may be worth some debate. Similarly, the activity item of "Educating patients and families regarding the specific details of medical procedures and interventions..." [p. 25 and 34] seems open to questions about the chaplain's role itself, even though reported as common by 27% of the sample [--see p. 30]. Now it was not a goal of the authors to deliberate the respondents perspectives but rather to elucidate them and explore possibilities, yet the overall effect for this reader was to experience the article as extremely thought-provoking on multiple levels. The next phase of the project, the book, Chaplains as Partners in Medical Decision Making: Case Studies in Healthcare Chaplaincy, due out later this year, should be equally fascinating [--see Items of Related Interest, §I, below].
The bibliography is quite good, with 58 references.
Suggestions for Use of the Article for Student Discussion:
This month's article could be a convenient way to place the subject of decision making on the agenda for students, though it might be best used with students who have had significant clinical time and can put the content of the article in a practical context. What is the group's experience with involvement in health care decision-making? Has it revolved around individual encounters with patients? Just how do they think they've been helpful to patients in this regard? Do they find that the activity of helping patients or families with decision-making is distinctive for end-of-life circumstances? To what extent has there been input or discussion at the care team level? What do they personally believe to be potential barriers to this? Which findings of the study resonate most with the group, and do any seem out of sync with their own experience or perspective? The group could look particularly at the listing of the six activities [p. 25] and consider how much those would seem to apply to them. Also, what quotes from participants in the study stand out? And, the revised model for Shared Decision Making [p. 32] could be walked through. Does it seem feasible? Finally, students might discuss whether chaplains need to deviate from the norm of pastoral interaction when involved with decision making.
Related Items of Interest:
I. The book, Chaplains as Partners in Medical Decision Making: Case Studies in Healthcare Chaplaincy, is not yet listed on the Kingsley Press site, but a description by Jeanne Wirpsa and Karen Pugliese has appeared in the program of the International Conference on Case Study Research in Chaplaincy Care, "Do We Have a Case?" (Amsterdam, The Netherlands, February 25-26, 2019):
II. For more on this particular article and project, see a December 13, 2018 interview of M. Jeanne Wirpsa on the Transforming Chaplaincy website. Also, Transforming Chaplaincy has posted a video (December 15, 2018) of Chaplain Wirpsa's presentation of "A Place at the Table: The Role of the Chaplain in Shared Decision Making."
III The subject of decision making was twice last year considered in our Article-of-the-Month features: May 2018 and December 2018. In addition, see our older features from June 2010 and December 2008.
IV. Rabbi David A. Teutsch, Professor Emeritus and Senior Consultant at the Center for Jewish Ethics of the Reconstructionist Rabbinical College (Wyncote, PA) published online a "A Chaplain's Guide to Values-Based Decision Making." It is available from the RRC archive and from the Penn Medicine Pastoral Care site.
If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman, Article-of-the-Month Editor, at firstname.lastname@example.org