Developing a Spiritual Plan of Care

Session 01: Assessment and Documentation

Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Introductions I

D.W. “Donovan” Director of Mission Leadership in

Mission Hills (Los Angeles), CA Providence Holy Cross Medical Center Board Certified Chaplain Author of “Assessments” in Professional

Spiritual and Pastoral Care: A Practical Clergy and Chaplain’s Handbook, Rabbi Stephen Roberts, Editor.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Introductions II

Jane Mather Director, Spiritual Care Providence Sacred Heart Medical Center

Mark Thomas Director, Mission Integrity and Ethics Providence Hood River Memorial

Tim Serban Vice President, Mission and Spiritual Care Providence Health and Services, Northwest Region

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Special Thanks

Special thanks to Alan Sanders and Catholic Health East for their commitment to contribute to the development of professional chaplaincy.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Outline I: Preliminaries

I. Preliminaries / PremisesA. Do we have something to offer?B. If so, WHAT?C. How can we be more effective

in integrating our work into the care of each patient/family?

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Outline II:The Assessment

II. The AssessmentA. Covey: Begin with the End in MindB. What Elements Do We / Should We

Consider in our Assessment?1. Current practices2. A proposed model

C. Tips: Developing an Assessment Model

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Outline III:Documentation &

Discussion

III. DocumentationA. Tips for Developing a

Documentation ToolB. Tips for Documenting in the

Medical Record

IV. DiscussionV. Closing Comments

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Do we have something to

offer? Does anyone

read our notes? If not, why not?

Have we allowed our work to be put in a silo?

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

What Is It That Chaplains Do?

The Equilibrium Model

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

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The Equilibrium Model

The role of the clinically-trained chaplain is to assess the degree to which the patient's

emotional and spiritual equilibrium has been disturbed by the healthcare event and to determine what interventions would be

appropriate to help the patient restore their equilibrium and when such interventions

should be employed. (Donovan / Dowdy)

Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

What Is It That Chaplains Do?

The Equilibrium ModelMoving from A to W, then X, Y, and ZHelping the Patient / Family Apply

Existing Values and Beliefs to the Current Clinical Situation

Key Points / Executive Elevator Speech

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

What Is It That Chaplains Do?

Key Points / Elevator Speech:The chaplain is an integrated member of the interdisciplinary team,

contributing to the overall plan of care for the whole person from a spiritual perspective. Our particular expertise lies in our ability to help create a sacred space where the relevant values and beliefs can be explored and applied to the current situation / decisions.

Requires that “emotional and spiritual needs are considered inextricable from physical and psychological needs.” (Clark)

Visualizes spirituality as the leaven that permeates the bread, rather than the icing that covers the cake. (Dowdy)

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

What Is It That Chaplains Do?

Key Points:Our ministry is grounded in extensive training

to help us recognize emotional and spiritual distress and to help people process through emotionally-charged experiences. Our assessments reflect a “whole person” approach, and require us to be familiar with interpersonal dynamics, theology and theodicy, and the medical milieu in which these dynamics are now operative.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Integrated Chaplaincy

Holistic Health Care …Requires that “emotional and spiritual

needs are considered inextricable from physical and psychological needs.” (Clark)

Visualizes spirituality as the leaven that permeates the bread, rather than the icing that covers the cake. (Dowdy)

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

A Question …

How effective have we as a profession been in integrating attention

to the spiritual perspectives, values

and beliefs of our patients and families

into each plan of care?

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

… and a Challenge

How can we be more effective in integrating our

work into the care of each

patient/family?

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Integration-Focused

DocumentationMany answers

Focus today on how we do that through documentation that includes a professional assessment.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Outline II:The Assessment

II. The AssessmentA. Covey: Begin with the End in MindB. What Elements Do We / Should We

Consider in our Assessment?1. Current practices2. A proposed model

C. Tips: Developing an Assessment Model

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Covey: Begin with the End in Mind

Preliminary Note: Assessment Vs. Screening

Important at the Personal Level: Know Me … Care for Me … Ease My Way

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Covey: Begin with the End in Mind

Important at the Plan of Care Level for your Colleagues: “How does your

expertise make my job easier?”

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Is it accessible by our colleagues and useful to

our colleagues?

Accessibility: Speaking the

Language Providing

Takeaways Accessibility:

Nuts and Bolts

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Is it accessible by our colleagues and useful to

our patients?

Useful : The “Quality Question” How do we “assess” the quality of

our documentation? Advance the plan of care Advance the professionalism of the

chaplain

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Covey: Begin with the End in Mind

Important at the Organizational Level:Reduced LOSReduced

Turnover

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Wait A Second!!!!

“Many pastoral care professionals believe that presence and relationship are the alpha and omega of their work. …”

“They hold that pastoral care cannot be measured; that to attempt it would be almost an affront to God.”

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Wait A Second!!!!

“We say beware. Those who shun accountability should not be surprised if they are first in line for budget cuts.”

--Brian Yanofchick Health Progress, May 2009,

p. 21

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Current Practices

Christina Puchalski, G-Wish: FICA (Spiritual History Tool) Faith and Belief Importance Community Address in Care(See

http://www.hpsm.org/documents/End_of_Life_

Summit_FICA_References.pdf)26

Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Current Practices

The Joint Commission Q&A: “Does the Joint Commission specify what needs to be included in a spiritual assessment?”

“No. Your organization would define the content and scope of spiritual and other assessments …. Examples of elements that could be … but are not required include the following questions:”

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Current Practices

Who or what provides the patient with strength and hope?

How does the patient express their spirituality?

How would the patient describe their philosophy of life?

What is the name of the patient’s clergy, ministers, chaplains, pastor, rabbi?

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

OtherCurrent Practices

Are there values and beliefs that would affect your treatment decisions?

Would you like to see a chaplain / pray with a chaplain?

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

A Proposed Model

Assessments: A Medical Model Listen Observe Evaluate Determine

Paradigm Shift from Faith-Based Coping Mechanisms to Values and Beliefs

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

A Proposed Model

Three Elements Element I: Relationships and

Connectivity Element II: Meaning and Purpose Element III: Degree of Understanding

and Congruence of Response

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Element I: Relationships and

ConnectivityObservations from Unit 01: Counting

People and CardsSpectrum from Fully Connected to Sense

of Isolation / AbandonmentTo / from friends and familyTo / from a sense of the sacred / divine

Theological Principle: RelationshipsPossible Interventions

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Element II: Meaning and

PurposeObservations

Often a Need to “Make Sense” of the Illness / Injury / Event

Coping Mechanisms / Complex Beliefs May Be Compromised

Values and Beliefs Applied to Current Situation

Possible InterventionsTheological Principle

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Element III: Degree of Understanding and

Congruence of Response

Assessment A: Does the patient / family / surrogate have an accurate understanding of what the physician has indicated to them? (LaRocca, Assessing)

Assessment B: Is the response internally congruent with previously expressed values and beliefs? (NCCN)

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Element III: Degree of Understanding and

Congruence of Response

Look for statements such asWhat does the doctor know anyway!?! She’s

not God!God’s in charge and my baby won’t go

anywhere until God decides it’s time. (But don’t you dare touch the ventilator!)

Possible Interventions -- with a goal in mind!

Theological Principle

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Tips for Developing an

Assessment ModelBuild on what comes naturally:

relationships, meaning, medical.Build upon the uniqueness of the

chaplain: “connecting the dots” between the individual and the institutional milieu.

Thus, work to be “out of the box” of any particular faith tradition.

Don’t confuse “tools” with an assessment.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Outline III:Documentation &

Discussion

III. DocumentationA. Tips for Developing a

Documentation ToolB. Tips for Documenting in the

Medical Record

IV. DiscussionV. Closing Comments

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Tips for Developing a

Documentation Tool

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics39

Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Tips for Documenting in

the Medical RecordAvoid Statements that are Not

Observable.Patient understood the clinical situation.Patient stated, “I understand what the doctor

is saying.”Avoid Statements that are Outside your

Scope of Practice.The patient is close to death.The nurse indicated “death is imminent.”

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Tips for Documenting in

the Medical RecordReinforce your Professionalism.

Visited with nurse before seeing patient.Consulted with RN to review recent events /

social hx. (Note: families visit; professionals see patients or consult.)

Do Not Imply that Showing Up Is EnoughPlan: Follow-up DailyYour suggestions?

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Tips for Documenting in

the Medical RecordUse Legal Language Carefully and

CorrectlyAMD Consult: Patient did not seem

competent.Patient was alert and oriented to year,

but not to place, president, or situation. I was not comfortable proceeding at this time.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Tips for Documenting in

the Medical RecordDo Not Put Another Team Member in

a CornerThe family is upset because their

questions have not been answered.Family indicated that they have

additional questions to ask and would appreciate additional time with Dr. X. Called Dr. X’s office and left a message for her with Nurse Susan.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Discussion

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

References

Clark, Paul A. Drain, Maxwell, and Malone, Mary P. Patient Centeredness: Addressing Patients’ Emotional and Spiritual Needs. Joint Commission Journal on Quality and Safety. Dec 2003 (29:12).

Dowdy, Melvin, and Donovan, D.W. The Pastoral Assessment Tool: Developing the Centerpiece of the Pastoral Care Strategic Plan (unpublished presentation).

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

References

Joint Commission, The. Standard FAQs: Spiritual Care. Downloaded from:

http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId=290&StandardsFAQChapterId=29

.

LaRocca, Mark. Assessing the 4-F’s of Spiritual Assessment. Downloaded from: http://www.plainviews.org/AR/c/v2n23/pp.html.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

References

Puchalski, C. Spiritual Assessment Tool: FICA. Downloaded on July 14th, 2012 from http://www.hpsm.org/documents/End_of_Life_

Summit_FICA_References.pdf.

Roberts, Stephen, ed. Professional Spiritual and Pastoral Care. Skylight Paths Publishing. 2011.

Yanofchick, Brian. Do We Care Enough about Pastoral Care? Health Progress. May 2009.

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Chaplain D.W. Donovan, BCC M.A. Theology M.S. Patient Counseling M.A. Medical

Ethics

Thank you!!!

Looking Ahead! August 15th, 2012

Communicating the Spiritual Care Plan: Chaplain as Educator

Jane Mather: September 12th, 2012

Integrating into a Holistic Plan of Care Mark Thomas

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