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March 2019 Article of the Month
 
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA

 

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.

[Editor's Note: The first author's name is currently listed in the Medline/Pub Med/National Library of Medicine database as Jeanne Wirspa, M.]

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]:

  1. Helping patients and families clarify factors that impact treatment options and direction of care;
  2. Mediating conflict between patient and family members and/or between different family members regarding goals of care;
  3. Communicating patient values and beliefs relating to medical decision making to the health care team;
  4. Supporting patients and families in the emotional processing of medical decision making;
  5. Facilitating advance care planning and documentation in the form of advance directives; and
  6. Educating patients and families regarding the specific details of medical procedures and interventions such as CPR, intubation, among others.

Among the quantitative results:

  • "...[O]nly years of experience and being a designated palliative care chaplain were significantly related to the outcome variable of Integration into the health care team SDM" [p. 28].

  • "All of [the] six activities were significantly associated with high self-reported integration into SDM." [p. 28]

  • Regarding the six discrete activities [listed above], "while chaplains reported involvement in supporting patients and families in the emotional processing of medical decision making with the highest frequency (71% half the time to frequently or always), only 43% of those reported high levels of integration with the health care team's process of SDM." [p. 28]

  • "...[M]ost chaplains (92%) perceived that they were well prepared to assist patients and families with medical decision making. Over half of the respondents (58%) indicated they had enough time for this aspect of their care." [p. 30]

  • "...[C]haplains with 21 years or more experience and those who frequently support patients and families in decision making were almost four times more likely to be included in self-reported integration into team discussions regarding medical decision making." [p. 30]

  • "Designated oncology chaplains, however, were 55% less likely to be integrated into team decision making." [p. 30]
Qualitative analysis led the authors to make a number of observations that they link to dominant themes in the SDM literature. Among these:
  • "Chaplains identify their theological education and identity as spiritual leaders as central to their ability to integrate religious teachings and beliefs, spirituality, and ethical frameworks into medical decisions and to respect diverse cultural values and practices that impact how patients and families approach the decision making process. ...Understanding differing views of afterlife and religiously proscribed ways of dying, the grief process, and the transformative role of ritual is identified by chaplains as critical in supporting the decision making process, especially at the end of life." [p. 32]

  • "...Chaplains describe their role as normalizing, validating, and 'blessing' patient/family decisions." [pp. 32-33]. A theme of pastoral authority was connected here.

  • "A prominent theme throughout chaplain comments is their role in promoting patient-centered care by paying attention to the whole person." [p. 33] And, "Chaplains report that their training in family systems provide them tools to negotiate challenging family dynamics that arise during difficult medical decision making processes." [p. 33]

  • "[Chaplains] claim skill in providing a nonanxious and unbiased presence that creates a safe container for conflictual or unacceptable feelings around complex value-charged situations and end of life situations." [p. 33]

  • "Respondents identified an important contribution of the chaplain's role as slowing down the rapid pace of decision making prevalent in most health care settings but especially in the ICU." [p. 34]

  • "Chaplains claim a unique location on the health care team with 'a foot in both worlds.' They bridge the gap between patients/families and health care providers by speaking the language of the lay person and the language of medicine. Chaplains repeatedly use the metaphor of 'interpreter'...." [p. 34]

  • "Informing other members of the medical team about cultural differences in approaches to decision making is another way that chaplains see themselves as a bridge in communication between the team and the patient/family." [p. 34]

  • "In team meetings and family conferences, chaplains empathize with multiple viewpoints and serve to mediate conflicts, clear up confusion, clarify miscommunications, and resolve misunderstandings. Some chaplains serve as 'coaches' providing formal and informal information, education, and support for both patients/families and physicians and team members." [p. 34]

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):

Our set of case studies focuses on one specific, and often underrepresented, area of chaplaincy care -- support of the medical decision making process and key factors in communication with the medical team about how and when decisions are made. The set of case studies depict and analyze three interventions that support the larger outcome of facilitating medical decision making and identifies potential questions for future research. Does the involvement of the chaplain in the medical decision making process lead to value-concordant care and decisions? Does early involvement of the chaplain where there are high stakes decisions to be made lead to less aggressive care at the end of life or impact length of stay? What kind of interdisciplinary education of the healthcare team leads to increased integration of the chaplain into shared decision making? To what degree do other members of the medical team welcome chaplains' involvement in medical decision making? Should chaplaincy case studies follow a proscribed format, or would varying formats allow for unique insights into chaplaincy care? Does isolating a specific dimension of care promote or make more difficult the task of drawing out unified themes for hypotheses or conceptual framework development? Finally, is it possible to maintain the integrity of the thick narrative of story while "abstracting from the particular"?

 

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 john.ehman@uphs.upenn.edu
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