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May 2019 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


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.

[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 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].

  • To explain and educate the patients and their caregivers that the hospice philosophy is to take care of suffering in all its forms -- physical, emotional, spiritual, and psychosocial -- and that spiritual care is born of respect for every person and for diversity of culture, belief, and religious practice
  • To explain and inform that persons who receive spiritual support from chaplains experience better coping with life threatening illness and report greater quality of life
  • To explain and educate that such support helps to protect patients and their families from despair and contributes to greater well-being, happiness, hope, optimism, and gratefulness
  • To explain and inform that hospice chaplains, who are part of the hospice caregiving team, focus on each person's unique spirituality and are available to help patients and their caregivers find meaning in the presence of human suffering and death
  • To explain that the importance of spiritual care may differ from person to person
  • To clarify that hospice care involved in the study has no affiliation with a particular religious group and respects the wide range of cultural and religious traditions and beliefs of its patients and their caregivers
  • To explain and inform that hospice chaplains are professional spiritual care counselors with comprehensive training in many areas and do not evangelize, attempt to change patient or caregiver beliefs, impose uncomfortable practices, or replace someone's pastor or spiritual leader
  • To offer examples of services provided by hospice chaplains

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]:

  • Facilitates search for meaning in dying process
  • Assists in coping with fears regarding decline and dying
  • Assists with issues of divine/human forgiveness
  • Helps with closure in important relationships
  • Assists with coordination of services with Patient/Caregiver's faith community
  • Offers support and counseling when someone feels worried, lonely or anxious
  • Provides prayer, sacraments and religious rituals
  • Offers help to those experiencing distress and provide empathic listening
  • Assists with planning and celebration of funerals

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:

Gomez-Castillo, B. J., Hirsch, R., Groninger, H., Baker, K., Cheng, M. J., Phillips, J., Pollack, J. and Berger, A. M. "Increasing the number of outpatients receiving spiritual assessment: a Pain and Palliative Care Service quality improvement project." Journal of Pain and Symptom Management 50, no. 5 (November 2015): 724-729. [(Abstract:) BACKGROUND. Spirituality is a patient need that requires special attention from the Pain and Palliative Care Service team. This quality improvement project aimed to provide spiritual assessment for all new outpatients with serious life-altering illnesses. MEASURES. Percentage of new outpatients receiving spiritual assessment (Faith, Importance/Influence, Community, Address/Action in care, psychosocial evaluation, chaplain consults) at baseline and postinterventions. INTERVENTION. Interventions included encouraging clinicians to incorporate adequate spiritual assessment into patient care and implementing chaplain covisits for all initial outpatient visits. OUTCOMES. The quality improvement interventions increased spiritual assessment (baseline vs. postinterventions): chaplain covisits (25.5% vs. 50%), Faith, Importance/Influence, Community, Address/Action in care completion (49% vs. 72%), and psychosocial evaluation (89% vs. 94%). CONCLUSIONS/LESSONS LEARNED. Improved spiritual assessment in an outpatient palliative care clinic setting can occur with a multidisciplinary approach. This project also identifies data collection and documentation processes that can be targeted for improvement.]

And along similar lines of having a provider introduce a chaplain:

Glombicki, J. S. and Jeuland, J. "Exploring the importance of chaplain visits in a palliative care clinic for patients and companions." Journal of Palliative Medicine 17, no. 2 (February 2014): 131-132. [(Abstract:) Data were obtained from 21 outpatients and 12 of their companions during clinic visits. Among the findings: patients and their companions valued a chaplain's visit as part of their "overall visit" (average of 3.93 on a 5-point scale). If a medical provider introduced the patient or companion to the chaplain, the chaplain's visit was rated at an average of 4.38 vs. 3.43 for when there was no such introduction. Also, "Data suggested that 12.82 minutes was considered 'enough' time for an outpatient visit, challenging previous studies' hypotheses that SRE [i.e., spiritual, religious, existential] support in outpatient settings may be difficult due to complexity of providing SRE with limited time" [p. 131]. Analysis of comments by the patients and companions also suggested a handful of themes regarding how chaplains were positively valued: chaplain visits are different from other fields, the visits were helpful in the expression of thoughts and feelings, the visits were generally valuable in the outpatient setting, the visits give an additional layer of support, and the visits communicate encouragement. Illustrative quotes are given in a table [--see p. 131]. ]


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:

Lindholm, K. "Handling stereotypes of religious professionals: strategies hospice chaplains use when interacting with patients and families." Journal of Pastoral Care and Counseling 71, no. 4 (December 2017): 284-290. [Open-ended questions were conducted with 44 current or former hospice chaplains. Four main stereotypes emerged chaplains' experience: 1) chaplains as religious professionals whom others try to impress, 2) chaplains as people who only talk about spiritual and religious topics, 3) Chaplains as male, and 4) Chaplains as those who try to convert others. The article also covers ways that chaplains may try to overcome these stereotypes.]


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.

Prasad, K., Jaeschke, R., Wyer, P., Keitz, S. and Guyatt, G. for the Evidence-Based Medicine Teaching Tips Working Group. "Tips for teachers of evidence-based medicine: understanding odds ratios and their relationship to risk ratios." Journal of General Internal Medicine 23, no. 5 (May 2008): 635-640 [--available online].

And see additionally a brief commentary on the use of odds ratios:

Norton, E. C., Bryan E. Dowd, B. E. and Maciejewski, M. L. "Odds ratios -- current best practice and use." JAMA 320, no. 1 (July 3, 2018): 84-85 [--available online].


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:

Canada, A. L., Murphy, P. E., Stein, K. D., Alcaraz, K. I. and Fitchett, G. "Trajectories of spiritual well-being in long-term survivors of cancer: a report from the American Cancer Society's Studies of Cancer Survivors-I." Cancer 125, no. 10 (May 15, 2019): 1726-1736. [(Abstract:) BACKGROUND: Existing research indicates that religion, spirituality, or both are important to the quality of life of patients with cancer. The current study is the first to characterize trajectories of spiritual well-being (SWB) over time and to identify their predictors in a large, diverse sample of long-term cancer survivors. METHODS: The participants were 2365 cancer survivors representing 10 cancer diagnoses from the American Cancer Society's Studies of Cancer Survivors-I, and they were assessed at 3 time points: 1, 2, and 9 years after their diagnosis. SWB was assessed with the 3 subscales of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp; ie, Meaning, Peace, and Faith). Predictors included demographic, medical, and psychosocial variables. Latent growth mixture modeling was used to identify trajectories and test their predictors. RESULTS: Four distinct trajectories of SWB were identified for each of the FACIT-Sp subscales: stable-high (45%-61% of the sample, depending on the subscale), stable-moderate (23%-33%), stable-low (7%-16%), and declining (6%-10%). Significant predictors of these trajectories included age, sex, race, education, comorbidities, symptom burden, social support, and optimism, but not always in the hypothesized direction. For some of the subscale trajectories, a recurrence of cancer, multiple cancers, or metastatic cancer was associated with lower SWB. CONCLUSIONS: This is the first study to establish the existence and predictors of heterogeneous trajectories of SWB in long-term survivors of cancer. Because SWB is an important component of quality of life, the current results indicate characteristics of persons who could be at greater risk for a decline or consistently low scores in SWB and may warrant clinical attention.]



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