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February 2005 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Presbyterian, Philadelphia PA.


Norris, K., Strohmaier, G., Asp, C. and Byock, I. "Spiritual care at the end of life. Some clergy lack training in end-of-life care." Health Progress 85, no. 4 (July-August 2004): 34-9, 58.


NOTICE OF THE ARTICLE'S AVAILABILITY ON LINE: This month's featured article is available on line through, the web site of Ira Byock, MD, one of the article's authors and a leading voice on end-of-life care. Go to for the full text. There is also a link on the page to a PDF version, but this is not a PDF of the actual Health Progress printing and does not have page numbers. (Page numbers noted below are according to the Health Progress printing.)

COMMENT AND SUMMARY: This article was selected in part because it gives an interesting profile of how some community clergy report their training and comfort level in dealing with end-of-life care, and in part because it suggests to this reader how an assessment of training and attitudes about end-of-life care might be useful--and a subject of research--for CPE programs.

First, a brief summary of the research and its findings: At the core of this study is a newly developed instrument, the Faith Community Leader (FCL) survey, that was mailed to clergy in Missoula County in western Montana (population, 88,000). Both this instrument and the overall research project were products of the Life's End Institute [Note (added 9/2/06): As of September 2006, the Life's End Institute has been dissolved, according to an e-mail from Dr. Ira Byock to the Network Convener.] and its initiative to improve end-of-life care in the local area through the Missoula Faith Community Task Force. That task force "determined that before beginning efforts to improve the quality of end-of-life spiritual care, it must first get information from a broader representation of Missoula faith leaders" [p. 35]. The FCL survey was developed as an instrument with which the Life's End Institute "could study the levels of training, perceived assets and liabilities, and experience of local clergy in regard to the provision of spiritual care to dying people and their families" [p. 35]. This is a 50-item instrument, it is said, can be completed in about 30 minutes. It is not given in the article, but copies may obtained from the Life's End Institute (which sells the survey but which may also supply preview copies for interested researchers).

The FCL was mailed to 122 clergy, and 41 copies were returned completed. The relatively low response rate of 34% is noted as a limitation of the study [see pp. 36 and 38]. In general, respondents indicated that they valued end-of-life care and acknowledged the importance of their role in it. Among the findings:

...[Respondents] possessing a higher level of education were likely to provide end-of-life care more frequently than those with a lower level. Respondents who were trained to deal with issues of illness, death and bereavement support reported providing prayer and quiet presence more frequently than those who did not have these types of training. ...Those trained in bereavement support were more likely to report frequently practicing "holding hands or appropriate touch" than those who were not trained in that area. Respondents who were not trained in any of these areas were less likely to engage in holding hands or appropriate touch, prayer, offering quiet presence, or providing sacrament of the sick than those who were trained in at least one of these areas. [pp. 37-38]
A good amount of data are presented in a table on Clergy Comfort Level [p. 37], and CPE supervisors in hospital settings may be especially interested in the findings that a relatively low number of respondents indicated that they were comfortable with medical terminology and that fewer respondents indicated feeling comfortable interacting with physicians than with other professionals. While the authors state that it is "tempting" to draw causal lines between training, comfort level, and frequency and range of services, the small sample size here does not offer statistical support for such conclusions [see p. 39], but this study does hold out promise for future research with these lines of causation in mind.

Second, regarding how this study may have implications for student assessment in CPE: Since pastoral issues around end-of-life circumstances seem to be of practical importance to clergy, and they are often central to the CPE learning experience, a formal pre- and post-CPE assessment on this topic may be a valuable means of tracking the educational impact of a program--especially for programs that enroll experienced community clergy. The FLC survey was clearly designed for a context other that of CPE students, but some of its themes could inform the development of a questionnaire for students: namely, the theme of one's sense of preparation for end-of-life ministry and the theme of one's comfort level both with different types of interventions and in working with other professionals in specific care settings. Such an assessment could potentially measure significant change in students over a single unit of CPE and could be useful in formulating learning contracts with students. The experience of using a formal questionnaire in this way may also come to suggest other specific areas that could be assessed by self-report questionnaires before and after a CPE program. [Any supervisors currently using a similar strategy for formal pre- and post-CPE assessment are invited to share their experience with the Research Network at large.] Analysis of the data from such questionnaires could obviously also be folded into a variety of research projects.

As for the possible use of the FLC survey itself, CPE programs that work with community clergy, and are in dialogue with local extra-CPE training initiatives, may want to follow the very lead of the task force in Missoula. Data from a mailing of the survey to local clergy may provide valuable insights and foster discussion of how a CPE program may work more practically and creatively in and with the community.


Suggestions for the Use of the Article for Discussion in CPE: 

This relatively brief and very readable article may be a good means to begin engaging students on the topic of patients' (or congregants') end-of-life needs (and for other articles that may supplement such discussion, see the suggestions in the October 2002 Articles-of-the-Month page.) The article may be well suited for discussion very early in CPE unit, as students may be drawn to consider how their own sense of preparation and comfort level may inform their CPE learning contracts. However, if a CPE program employs a student questionnaire on the subject (as has been suggested, above), the article may be better suited for discussion late in a unit. Students may also be challenged by the article to think of connections between, on the one hand, their training, experience, and comfort levels; and, on the other hand, the frequency with which they provide certain pastoral interventions--these could be basic and enlightening connections that many students may not think about on their own.


Related Items of Interest: 

I.  This month's featured article focuses on clergy attitudes and experiences, but this is in the service of ultimately benefiting the people who, amid end-of-life circumstances, may utilize clergy support. For insight into laypersons' sense of end-of-life needs, including their sense of how clergy support may figure into their total support network, the authors make reference to two studies [--see pp. 34-35]: one by the AARP and one by the Gallup organization.

In 2002, the AARP (American Association of Retired Persons) surveyed members in North Carolina (n=3,586 for a response rate of 45%) about end-of-life issues. Among the findings, 82% of respondents said that it would be "very important" for them to be spiritually at peace as they dealt with their own dying, and 62% of respondents said that it would be "very important" for them to receive comfort from religious/spiritual services or persons, but only 6% had spoken with clergy about advance directives. An extended section of the survey (i.e., item 17) indicated that in relation to a variety of end-of-life needs, respondents tended to look first to family for help, though support from the "faith community" also figured well in the responses. For more on the AARP North Carolina End of Life Survey, see --there are links to two reports, each including annotated versions of the survey.

In 1997, the Gallup organization issued a report of a telephone survey of 1,200 adult Americans: "Spiritual beliefs and the dying process," which indicated that a relatively low percentage of the population (36% of respondents) thought of clergy as being an effective comfort to them at the end of life. The full report was once available through the web site of the Nathan Cummings Foundation (, but apparantly no longer. For a brief summary of the report, see the Park Ridge Center's coverage in their Bulletin issue #3 (February-March 1998): "The American Way of Death: Gallup Poll Results," by Laurence J. O'Connell, available at [The Park Ridge Center for Health, Faith, and Ethics no longer publishes its Bulletin, but all issues are available on line and are a considerable resource regarding quite a number of topics.]

II.  In addition to other references cited in the notes to this month's featured article, the following may be of interest concerning the role of clergy in end-of-life care:

[ADDED 3/13/06]: Abrams, D., Albury, S., Crandall, L., Doka, K. J. and Harris, R. "The Florida Clergy End-of-Life Education Enhancement Project: a description and evaluation." American Journal of Hospice and Palliative Care 22, no. 3 (May-Jun 2005): 181-187. [The article describes the Florida Clergy End-of-Life Education Enhancement Project and its evaluation data showing the success of this model in educating clergy about loss, grief dying, and death. "The project indicates that clergy both recognize the need for additional training and are anxious to improve their abilities to minister to the dying and bereaved. The model presented here could easily be applied to local organizations such as hospices or denominational training." (--from the article's Abstract)]

Braun, K. L. and Zir, A. "Roles for the church in improving end-of-life care: perceptions of Christian clergy and laity." Death Studies 25, no. 8 (December 2001): 685-704. [This focus group study of 121 Christian clergy and congregants in Honolulu, HI, explored participants' ideas about a "good death" and potential roles for clergy in end-of-life care. Results indicated a number of roles for Christian clergy or "the church": "(a) to help congregants prepare for death, both spiritually and practically; (b) to facilitate resolution of conflict and forgiveness; (c) to clarify if or how church theology should guide attitudes and practices related to death and dying; (d) to administer the appropriate rituals; and (e) to provide outreach to sick, dying, and bereaved members" (--from the article's Abstract).]

[ADDED 1/29/06]: Moran, M., Flannelly, K. J., Weaver, A. J., Overvold, J. A., Hess, W. and Wilson, J. C. "A Study of Pastoral Care, Referral, and Consultation Practices Among Clergy in Four Settings in the New York City Area." Pastoral Psychology 53, no. 3 (January 2005): 255-266. [This study involved 179 clergy from the catchment areas of four hospitals in New York and Connecticut. Among the findings: "Factor analysis revealed two separate sets of problems presented in pastoral counseling, with respect to clergy's ratings of their competence to address them. The first factor included grief, death and dying, anxiety, and marital problems, in descending order of frequency. The second factor consisted of depression, alcohol/drugs, domestic violence, severe mental illness, HIV/AIDS, and suicide. Clergy were significantly less confident of their ability to deal with Factor 2 problems, yet clergy rarely consulted with mental-health professionals about either type of problem. Less than half of the clergy had training in Clinical Pastoral Education, but those who did tended to feel they were more competent to deal with both types of problems. On average, clergy devoted 3.7 hours per week to visiting patients and nearly 55% said they were "definitely more likely" to refer a patient to a hospital with a pastoral care department." (--from the article's Abstract)]

[ADDED 8/8/06]: Williams, M. L., Cobb, M., Shiels, C. and Taylor, F. "How well trained are clergy in care of the dying patient and bereavement support?" Journal of Pain and Symptom Management 32, no. 1 (July 2006): 44-51. [In this study out of the UK, questionnaires were sent to clergy in the diocese of Sheffield and to "clergy training colleges," yielding the following results: "There was a trend across all denominations that those who had trained more recently were more likely to have received relevant training. Most clergy believed that they possessed adequate liturgical skills, but 13% felt they possessed none or little skill in pastoral care of the dying. Seventy-one percent indicated that they would like further training in pastoral care of the dying and 66.3% desired training in care of the bereaved. Of the 50% of training colleges that responded, the number of hours of training on pastoral care of the dying ranged from 6 to 36 hours (median 23 hours and mean 25 hours) and only 26% believed that their training in pastoral support skills was comprehensive." (--from the abstract)]


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