February 2021 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
Kwak, J., Cho, S., Handzo, G., Hughes, B. P., Hasan, S. S. and Luu, A. "The role and activities of board-certified chaplains in advance care planning." American Journal of Hospice and Palliative Medicine (2021): published online ahead of print, 1/28/21.
[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]
SUMMARY and COMMENT: This month's study works from a convenience sample of US chaplains, but while the findings may have limited generalizability the research should help professional chaplains overall think about the role and importance of their with Advance Care Planning (ACP). The data is notably very recent, having been collected in 2020 from members of the Association of Professional Chaplains, the National Association of Catholic Chaplains, and the Spiritual Care Association, though the influence of the COVID-19 pandemic on responses is unclear. The article may also be useful to raise awareness of chaplains' capabilities for supporting ACP within institutions and alongside of other disciplines.
The three target organizations reached out to their members (potentially 5,562 chaplains) and invited them to participate in an online survey, March 16th to July 31, 2020. "Board certification" was identified by self-report. The final participation rate was 11% (n=585), which the authors acknowledge as "lower than the typical response rate for surveys of organizations, 35.7%" [MS p. 6]. Nevertheless, the reported demographics and work settings were similar to those of other chaplaincy surveys.
Among the findings:
- 90.3% "viewed ACP as an important part of their work, with 70% helping patients complete advance directives and 90% discussing preferences about end-of-life treatment." [MS p. 3]
- "Almost all respondents reported having detailed (48%) or basic (50%) knowledge of important features of state and national legal frameworks regarding advance directives." [MS pp. 3-4]
- "Few respondents reported barriers to chaplains' facilitating ACP. Most reported that they could always find a way to communicate with members of the healthcare team (90%) and felt that their contributions to patients' and families' medical decision making were welcomed by health care teams (86%)." [MS p. 4]
- "45.3% indicated that they were not always included in medical decision-making discussions with healthcare teams," though those "working in hospice settings (inpatient or home) were more likely to agree that they were always included in decision making than were those in other work settings." [MS p. 4]
- "...[M]ost respondents (between 74% and 86%) reported being confident or very confident in carrying out various ACP tasks" [MS p. 4]. The strongest score was for the task of "Support[ing] the patient in the emotional process of medical decision making," with 85.8% saying they felt "confident" or "very confident"; and the weakest scores were for "Determin[ing] the patient's specific wishes for types of medical treatment," "Ensure[ing] the patient's treatment preferences will be honored at your facility," and "Determin[ing] how much the patient wants to know about the prognosis," with 69.7%, 69.9%, and 70.3%, respectively, saying they felt "confident" or "very confident" --still all being relatively strong scores. [See Table 3, MS p. 6.]
The authors contend that since "ACP comprises a complex series of steps that require overcoming discomfort, anxiety, and fear about considering one's current or future illnesses and mortality, evaluating values, and eliciting support and agreements among patients, surrogates, and healthcare providers," and because there is "a lack of training in communication and a lack of time and resources to engage in ACP among advance practice clinicians" [MS p. 1], chaplains' "unique skill set and professional scope of practice" [MS p. 2] qualifies them to make a significant contribution to ACP. Moreover, chaplains have "a unique strength...[in] that they are simultaneously both 'insiders' as members of the medical team and 'outsiders' who are not responsible for clinical decisions" and are in a position to "build rapport and trust with patients and families" [MS p. 2, and see also MS p. 6]. "Given their purpose and the required training and skills of the profession, chaplains can facilitate meaningful ACP with patients by exploring uncertainty and meaning, building awareness of the patient's self-identified sources of inner strength, community, and belief, and engaging in communication and shared decision making with interdisciplinary healthcare teams" [MS p. 2]. One particular finding of this research was that 87.6% of participants reported that it is patients who "bring up the subject" of ACP [MS p. 5 --see Table 2 and text].
The study "did not directly assess the specific ways by which chaplains function to facilitate ACP with patients and other members of the health care teams" [MS p. 5] -- and the authors look forward to in-depth research precisely along such lines -- but they say in sum:
Still, the findings from this study strongly suggest that professional board-certified chaplains regularly facilitate ACP discussions with patients and families with knowledge and confidence in carrying out patient-centered communication that promotes shared decision making. There is a need to recognize and support the role of chaplains in proactively and consistently assessing and clearly documenting information about ACP conversations, and, moreover, to integrate chaplains into interdisciplinary team meetings and family meetings on a regular basis. [MS p. 6]
One of the ways that this article may be helpful to chaplains is in its measure of ACP tasks relevant to chaplaincy. The authors work out of a previously published "Advance Care Planning Self-Efficacy (ACP-SE) Scale" that was created for physicians [--see Related Items of Interest, §I (below)]. They report "keeping 8 of the scale's original 14 items" [MS p. 3; though the source scale appears to have 17 items] and adding 3 new ones [--see Table 3, MS p. 6]:
Advance Care Planning Tasks (--with new items marked here with *)
This 11-item measure could itself become the subject of further research (e.g., validity and reliability) and through its refinement might be useful to guide chaplaincy education in this area.
- Openly discuss uncertainty with the patient when it exists
- Discuss how a patient's religious/spiritual beliefs impact their end of life choices *
- Discuss existential values and fears and how they interact with an end-of-life prognosis *
- Provide the desired level of information and guidance needed to help the patient in decision making
- Determine how much the patient wants to know about the prognosis
- Determine the level of involvement the patient wants in decision making
- Determine the patient's specific wishes for types of medical treatment
- Support the patient in the emotional process of medical decision making *
- Reassess the patient's wishes when a shift in care goals is needed
- Ensure the patient's treatment preferences will be honored at your facility
- Help the patient complete an advance directive
The bibliography is current and contains 35 references.
Suggestions for Use of the Article for Student Discussion:
This is an easily readable article suitable for any CPE group, though some prior experience with Advance Care Planning would seem optimal for discussion. The findings are pretty straightforward and could be compared or contrasted with students' own encounters with patients, families, and staff on the subject. Do they see ACP as an important aspect of their work, and do they believe they are prepared for it? Do they feel they are involved in medical decision-making discussions with healthcare teams and/or are able to communicate their input to other disciplines? If not, then why? The group might brainstorm about how progress in this area might be pursued, institutionally and personally. Which of the 11 Advance Care Planning Tasks items stand out to them, either as areas of strong confidence or areas in need of some attention? This article could be a general entree to the subject of ACP, and an opportunity to invite in palliative care team members, including social workers, or individuals who can offer information about state laws governing Advance Directives. Finally, have the students themselves ever filled out an Advance Directive? If not, then perhaps the discussion could lead into an exercise to that end. What is the personal experience of filling out an Advance Directive vs. just the thought of doing so? Further exercises could deepen students' engagement with the topic: for example, the end-of-life conversation game that was the focus of our November 2017 Article-of-the-Month.
Related Items of Interest:
I. The following is the source for the measure adapted by the authors of our featured article regarding Advance Care Planning Tasks.
Baughman, K. R., Ludwick, R., Fischbein, R., McCormick, K., Meeker, J., Hewit, M., Drost, J. and Kropp, D. "Development of a scale to assess physician advance care planning self-efficacy." American Journal of Hospice and Palliative Medicine 34, no. 5 (June 2017): 435-441. [(Abstract:) BACKGROUND: Although patients prefer that physicians initiate advance care planning (ACP) conversations, few physicians regularly do so. Physicians may be reluctant to initiate ACP conversations because they lack self-efficacy in their skills. Yet, no validated scale on self-efficacy for ACP exists. Our objective was to develop a scale that measures physicians' ACP self-efficacy (ACP-SE) and to investigate the validity of the tool. METHODS: Electronic questionnaires were administered to a random sample of family medicine physicians (n = 188). Exploratory factor analysis was performed to determine whether the scale was multidimensional. An initial assessment of the scale's validity was also conducted. RESULTS: The exploratory factor analysis indicated that a single factor was appropriate using all 17 items. A single, unidimensional scale was created by averaging the 17 items, yielding good internal consistency (Cronbach alpha = 0.95). The average scale score was 3.94 (standard deviation = 0.71) on a scale from 1 to 5. The scale was moderately correlated with a global single-item measure of self-efficacy for ACP ( r = .79, P < .001), and the scale differentiated between physician groups based on how much ACP they were doing, how recently they had an ACP conversation, formal training on ACP, and knowledge of ACP. In a multivariate analysis, the ACP-SE scale was a strong predictor of the percentage of patients with chronic life-limiting diseases with whom the physician discussed ACP. CONCLUSION: The final ACP-SE scale included 17 items and demonstrated high internal consistency.]
II. Our authors cite the following brief research letter in terms of the feasibility of chaplains conducting ACP conversations in a medical office, however, note that a physician's introduction of the chaplain was vital to the project. This suggests a further line of potential collaboration between chaplains and clinicians that goes beyond merely communicating information to the care team.
Lee, A. C., McGinness, C. E., Levine, S., O'Mahony, S. and Fitchett, G. "Using chaplains to facilitate advance care planning in medical practice." JAMA Internal Medicine 178, no. 5 (May 2018): 708-710. [Between April-October 2016, a board-certified chaplain scheduled time for Advance Directive consultations in the office of one primary care physician at a primary care group practice affiliated with a community hospital in suburban Chicago. The physician introduced the patient to the project and the chaplain and invited patients' participation, and the consultation with the chaplain took place in the examination room once the physician's visit was completed. The mean time of the chaplain's consultations was 23 minutes. Of 60 patients were invited to participate, all agreed to do so, and completed an Advance Directive or provided documentation of an existing one for their medical record. The project demonstrated that it is feasible and acceptable for a qualified chaplain to conduct Advance Care Planning conversations in a medical office and that most of these conversations (80%) led to completion or documentation of Advance Directives. The physician's introduction of the chaplain was vital.]
III. Chaplains involvement in Advance Care Planning has come up in a number of our Article-of-the-Month features in recent years. See particularly:
Idler, E. L., Grant, G. H., Quest, T., Binney, Z. and Perkins, M. M. "Practical matters and ultimate concerns, 'doing,' and 'being': a diary study of the chaplain's role in the care of the seriously ill in an urban acute care hospital ." Journal for the Scientific Study of Religion 54, no. 4 (December 2015): 722-738. [Among the findings of this study out of Emory University and Healthcare was: "Chaplains reported...providing some form of assistance with advance directives in 10.1 percent of visits" (p. 730).] [This article was featured as our June 2016 Article-of-the-Month.]
Jeuland, J., Fitchett, G., Schulman-Green, D. and Kapo, J. "Chaplains working in palliative care: who they are and what they do." Journal of Palliative Medicine 20, no. 5 (May 2017): 502-508. [Among the findings of this national online survey conducted February-April 2015: Goals of Care Conversations was identified as a major type of activity for palliative care chaplains, and over half (55%) of participants reported addressing goals of care 60% of the time or more.] [This article was featured as our March 2017 Article-of-the-Month.]
Teague, P., Kraeuter, S., York, S., Scott, W., Furqan, M. M. and Zakaria, S. "The role of the chaplain as a patient navigator and advocate for patients in the intensive care unit: one academic medical center's experience." Journal of Religion and Health 58, no. 5 (October 2019): 1833-1846. [This study out of Johns Hopkins covers a variety of ways that chaplains may serve in a navigator role, including setting up goals-of-care meetings and helping with clarification of goals of care.] [This article was featured as our October 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. [This survey of members of major US chaplaincy organizations (i.e., APC, NACC, NAJC, and NAVAC), with 722 respondents, broadly addresses chaplains' involvement in decision-making, but one specific area of activity identified was that of facilitating Advance Care Planning and documentation in the form of Advance Directives.] [This article was featured as our March 2019 Article-of-the-Month.]
IV. A February 15, 2018 webinar sponsored by Transforming Chaplaincy with the ACPE addressed "Advanced Care Planning" as part of a program on Advancing Chaplaincy: Learning to Think and Act Strategically. The session covers research by Chaplain Aoife Lee and colleagues that resulted in article noted (above) in our Related Items of Interest §I, but it also presents a pilot study by Chaplain Amy Greene on Advanced Care Planning in a pre-anesthesia clinic. The webinar and the slide deck are available online.
V. The following slightly older article should be thought-provoking on connections between religion and Advance Care Planning.
Garrido, M. M., Idler, E. L., Leventhal, H. and Carr, D. "Pathways from religion to advance care planning: beliefs about control over length of life and end-of-life values." Gerontologist 53, no. 5 (October 2013): 801-816. [(Abstract:) PURPOSE OF THE STUDY: To evaluate the extent to which religious affiliation and self-identified religious importance affect advance care planning (ACP) via beliefs about control over life length and end-of-life values. DESIGN AND METHODS: Three hundred and five adults aged 55 and older from diverse racial and socioeconomic groups seeking outpatient care in New Jersey were surveyed. Measures included discussion of end-of-life preferences; living will (LW) completion; durable power of attorney for healthcare (DPAHC) appointment; religious affiliation; importance of religion; and beliefs about who/what controls life length, end-of-life values, health status, and sociodemographics. RESULTS: Of the sample, 68.9% had an informal discussion and 46.2% both discussed their preferences and did formal ACP (LW and/or DPAHC). Conservative Protestants and those placing great importance on religion/spirituality had a lower likelihood of ACP. These associations were largely accounted for by beliefs about God's controlling life length and values for using all available treatments. IMPLICATIONS: Beliefs and values about control account for relationships between religiosity and ACP. Beliefs and some values differ by religious affiliation. As such, congregations may be one nonclinical setting in which ACP discussions could be held, as individuals with similar attitudes toward the end of life could discuss their treatment preferences with those who share their views.] [This article was featured as our November 2013 Article-of-the-Month.]
VI. In 2018, the National Association of Catholic Chaplains, which participated in our featured study, devoted virtually a whole issue of its Vision publication to commentary pieces regarding chaplains and Advance Care Planning. The issue is available online
Lichter, D. "Chaplains' skills are suited to the advance directive conversation." Vision 28, no. 2 (March/April 2018): 2.
N.A. [Gundersen Health System]. "Advance care planning takes hold across a system and a region." Vision 28, no. 2 (March/April 2018): 3-4.
Robinson, J. L. "Chaplain in outpatient office gets reimbursement for 'the conversation'." Vision 28, no. 2 (March/April 2018): 5-6.
McCarthy, M. " Ethical and Religious Directives can help form care plan." Vision 28, no. 2 (March/April 2018): 7-8.
Waters, D. " POLST might help more patients get the care they want." Vision 28, no. 2 (March/April 2018): 9-10.
Sapega, D. "Chaplains should know advance directive laws in their state." Vision 28, no. 2 (March/April 2018): 11-12.
Crowley, T. "How one advance care meeting led to three directives." Vision 28, no. 2 (March/April 2018): 13-14.
Waters, D. "Psychiatric advance directive might help patients with mental illness." Vision 28, no. 2 (March/April 2018): 15.
Finley, M. " The Five Wishes serve as helpful planning tool." Vision 28, no. 2 (March/April 2018): 16-17.