May 2019 Article of the Month
Soroka, J. T., Collins, L. A., Creech, G., Kutcher, G. R., Menne, K. R. and Petzel, B. L. "Spiritual care at the end of life: Does educational intervention focused on a broad definition of spirituality increase utilization of chaplain spiritual support in hospice?" Journal of Palliative Medicine (2019): online ahead of print, 4/12/19.
SUMMARY and COMMENT: This is a short article that touches on a very practical issue for chaplains: how to introduce to patients what help we may offer, with the hope of maximizing uptake of our care. The study focuses on a printed card for hospice patients and families, but it should be thought-provoking for chaplains in other contexts as well. The principal author, Chaplain Jacek T. Soroka at the Mayo Clinic Health System Hospice (Mankato, MN), has provided to ACPE Research additional information about the card content (below).
Recognizing that "[d]espite the important benefits spiritual support offers to hospice care recipients, the number of hospice patients and caregivers (P/C) who agree to receive spiritual support from the hospice team continues to be low" [MS p. 2], and that "[h]ospice care continues to lack empirical guidance on how to best integrate spiritual support into the care of persons facing terminal illness" [MS p. 2], the authors sought to test an educational intervention to increase acceptance of spiritual care services. Their two-arm quantitative study was carried out between July 1, 2017 and March 1, 2018, involving 200 patients.
Participants in the control arm received standard information about the availability of chaplain support; participants in the intervention arm received additional explanation of chaplain services and the benefits of spiritual support offered by spiritual care providers.... In addition, the intervention participants received a card explaining the nature of spiritual support in hospice. The card's explanation offered concrete examples of services provided by a hospice chaplain, such as facilitation of a search for meaning in the dying process, assistance in coping with fears about decline and dying, and assistance with issues of divine and human forgiveness. The admitting staff, either a master level social worker (SW) or hospice case manager (CM), discussed with the participant the information on the card, which was placed in the admission folder.
The full content of the card is not publically available, but its substance is described in some detail in a table [MS p. 2].
Regarding the last point, the examples of services listed on the card are as follows. [--Note: this list is not in the article but has been communicated to ACPE Research for the present write-up]:
The most central finding: "Of participants in the intervention arm, 64 (64%) accepted spiritual support versus 52 (52%) in the control arm" in univariate analysis. ..."After adjustment [for variables], the intervention arm had a significantly higher acceptance rate than controls...." This was the case even though the data indicated that "[t]hose in a hospice facility had a higher acceptance rate than those living in their home...," and the intervention arm participants were "more likely to be living in the home (41% vs. 22%)." [MS p. 2] --with place of residence being only notable difference in patient characteristics between the control and intervention groups.
Soroka and his colleagues then hold: "When patients understand the role of a spiritual care provider and the nature of spirituality at the end of life compared with other religious practices, hospice chaplains see a greater acceptance rate of the spiritual service"; and, "A greater acceptance rate can be achieved through explanation that hospice chaplains are professional spiritual care counselors with comprehensive training" [MS p. 4].
Increased effort by hospice teams to explain the value and nature of spirituality, to broaden the understanding of spirituality, and to bring to light concrete examples of services provided by hospice chaplains helps widen the acceptance of the benefits that such support provides at end of life. This study confirms this effect. [MS p. 4]
Among other results: "Older patients were less likely to accept chaplain services...per year of older age" [MS pp. 2-3], and "connection to a faith community was not significantly associated with acceptance of chaplain services" [MS p. 3]. Also, the acceptance rate differed among diagnostic groups. For instance, "Those with COPD or heart disease were more likely to accept chaplain services than those with cancer..." [MS p. 4]. Here, the authors speculate that certain disease characteristics may be a key factor, noting that other research has shown COPD patients to request more support than lung cancer patients, despite similarity in well-being. "COPD symptoms might cause patients to fear suffocation, exacerbation, and a range of other symptoms that might prompt a request for additional support from a spiritual caregiver" [MS p. 5]. Moreover, diseases with a less predictable "trajectory of decline" could create greater anxiety "that might cause [patients] to seek comfort in their religious beliefs and spirituality" [MS p. 5]. "The [COPD] trajectory is clearly or markedly different from patients with cancer, whose decline is more predictable and steady" [MS p. 5].
While this study found that "a simple and specific educational intervention at the time of admission to hospice might contribute to greater acceptance rate of spiritual care from hospice chaplains" [MS p. 5], the authors also recognize that this very timing for the educational intervention, when patients and caregivers are often "overwhelmed by the large volume of information at the time of admission to hospice services" [MS p. 5], may be problematic to people understanding the services being offered. This may have been a limitation for the research per se, and it may be an area for further study. Other limits to the study include demographics: all participants were Jewish or Christian and "were white and lived in rural or small urban areas" [MS p. 5].
For this reader, the broad significance of the article is that it focuses attention, from a particular angle, on the issue of how chaplains might be introduced to patients so as to maximize understanding and reception. Consideration of what to print on an information card might help us to think about how we introduce ourselves and our services in person to patients and caregivers, in or beyond the hospice context. What kind of information is optimal to open up potential for a pastoral encounter, and how much information may be too much for patients or caregivers to comprehend at a specific moment or be so much that they experience the introduction as interpersonally off-putting? The authors of this month's article put forward a quite broad explanation of what a chaplain may offer, but might some narrower description be more effective or more constricting? As a chaplain of some years, reading this research made me want to review the different printed descriptions of pastoral services at my hospital, but it also reminded me of the wisdom of my first CPE supervisor (Alan Reed, at St. Luke's Hospital in New York City), who informed his students that at least the first half of the unit -- and maybe even most of the unit -- would emphasize one thing: how we introduce ourselves. This pertained in part to issues of chaplain identity but also practically to the dynamic of patients' understanding for the purpose of their informed consent and hopefully their interest.
The bibliography contains 42 citations, including three publications and an Internet link from 2018.
[Editor's Note: The ahead-of-print version of this article contains several minor typographical errors to be corrected for print publication, but also one significant wording change is in order: in the first full paragraph on MS p. 5, the sentence should read: "Although patients with advanced COPD have well-being similar to patients with lung cancer, they request more support than those with cancer."]
Suggestions for Use of the Article for Student Discussion:
Before discussion, the leader might gather printed information about chaplaincy services at the group's institution(s), to have students review and comment on it in light of the current study. While groups in hospice settings may be able to resonate most directly with this research, any group should be able to relate well to the article. The one caution for students with less familiarity with research might be some clarification about the use of odds ratios in the statistical analysis [--see Items of Related Interest, §V, below]. Discussion could start with a question to the group about the challenge of getting patients to understand what chaplains do. See especially the authors' comments in the third paragraph of the Discussion section [MS p. 4]. Our authors write, "Chaplains are professional spiritual care providers with comprehensive training in counseling, ethics, and religious and cultural diversity, who are able to address P/C and their existential questions, spiritual pain, suffering, concerns with the sacred, and a gamut of other needs" [MS p. 4]. What do the students make of this description, and what more might be implied by the phrase, "a gamut of other needs"? Our authors cite research that suggests that Social Workers and Case Managers might have a "fear of being disrespectful of [patient/caregiver] individual beliefs" [MS p. 5] when introducing spiritual care. Students might think about the various reservations and impediments for non-chaplains in bringing up spiritual care and even in explaining chaplaincy services. How do the students themselves introduce or explain to patients or families what they offer? What language do they tend to use? [This could become a emphasis in verbatim exercises for the group.] The students might also talk about how the idea of spiritual care might play into the circumstances of various patient groups. See the section on MS p. 5 regarding COPD patients vs. heart patients. Finally, there might be some discussion about similarities and differences between the hospice and acute care settings, and CPE groups centered in one might invite a chaplain from the other setting to sit in on the discussion.
Related Items of Interest:
I. For an interesting collection of printed patient materials on chaplaincy services, see the "Chaplaincy Brochures" on the National Association of Catholic Chaplains website.
II. Our November 2015 Article-of-the-Month explored the idea of having the chaplain introduced in person by a medical provider. The purpose here was to increase spiritual assessment, but the method speaks to the broad issue how to introduce patients to chaplaincy in such was as to increase receptivity. See:
III. Helping patients and families (as well as providers) understand chaplaincy services may entail overcoming preconceptions and stereotypes of what chaplains do. On this front, see especially our January 2018 Article-of-the-Month:
IV. The design of printed materials for use with patients requires consideration of the many factors that can make conveyance of the information effective. The US government's Centers for Medicare and Medicaid Services website contains a fairly extensive "Toolkit for Making Written Material Clear and Effective." This is an 11-part resource goes well beyond our immediate topic of explaining chaplaincy services, but it offers a great deal of practical information that may inform the writing of brochures or cards regarding chaplaincy.
V. Our authors speak of the increase of acceptance of chaplaincy services in terms of odds ratios. This is fairly common in case controlled studies in the health care literature, representing how the odds of a thing happening in one arm of a study where an intervening factor has been introduced (e.g., the information card) relate to the odds of a thing not happening in another arm of the study. An odds ratio of 1 means that there seems to be no effect of the intervention: the odds of a thing happening in a group receiving an intervention are the same as the odds of the thing not happening in another group not receiving the intervention. However, an odds ratio of less or more than 1 means that there seems to be some strength of effect from the intervention: either the odds of a thing happening in the group receiving the intervention are less or more than the odds of the thing happening in another group not receiving the intervention. Explanations of odds ratios in the academic literature are often quite statistically sophisticated, but the following article may be one of the more readable, even though it is aimed at physicians and therefore works with medical examples.
VI. Our article brings up the idea of disease trajectories as affecting spiritual needs [--see MS p. 5]. For more on trajectories, see our June 2012 and November 2007 Article-of-the-Month pages. Plus see the recently published:
If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman, Article-of-the-Month Editor, at email@example.com