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]

• "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.