November 2020 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
Galchutt, P. and Connolly, J. "Palliative chaplain spiritual assessment progress notes." In Peng-Keller, P. and Neuhold, D., eds.,
Charting Spiritual Care: The Emerging Role of Chaplaincy Records in Global Health Care (Cham, Switzerland: Springer Nature, 2020): 181-198.
[Editor's Note: This month's selection was recommended by Revd. Dr. Steve Nolan, Chaplain at Princess Alice Hospice, Esher, Surrey, UK; and a leader in spirituality & health research.]
SUMMARY and COMMENT: This month's featured work has been published as a chapter in Peng-Keller & Neuhold's open access collection on chaplains' documentation in medical records. The research was funded by a grant from Transforming Chaplaincy (www.transformchaplaincy.org), for which Paul Galchutt had been a Research Fellow. The work followed from Galchutt's interest in and development of an original palliative care spiritual assessment [--see Related Items of Interest, §I, below]. The focus here is on "spiritual assessment conducted by a palliative care chaplain as it takes the form of a narrative progress note," with one purpose of that note being "to contribute to the palliative care team's shared care plan for the patient" [p. 182].
Motivation behind this project was to ask, essentially, what information can best help chaplains make a relevant and meaningful difference together with palliative care team members to reduce suffering and improve quality of life. We conducted focus groups with non-chaplain palliative care team members to address the research question: What content is most helpful as well as missing from palliative chaplain spiritual assessment progress notes as perceived by non-chaplain palliative care team members? [Seven] 90-minute focus groups were conducted approximately once every 10 days over a span of roughly 3 months from September to November 2018. Participants were from six palliative care teams based out of six acute care hospital locations within a metropolitan area within the upper Midwest region of the United States. Two focus groups were hosted in [a] pediatric setting. The other five focus groups were hosted with...inpatient palliative care teams caring for adult patients. [p. 183]
The authors provide their eight-point discussion guide for the group sessions and a table of demographics for the 42 non-chaplain palliative care interprofessionals who participated [--see pp. 184 and 185]. Among the demographics, 62% identified as Christian and 16% claimed no spiritual affiliation. Physicians comprised 41% of the participants.
Responses to the research question yielded the identification of 12 themes, which the authors address according to "Descriptive content" and "Summary content":
DESCRIPTIVE CONTENT THEMES
- Decision-Making --
- "...the most discussed theme across all groups (extensiveness) and mentioned among all the themes with the most frequency within each group"; "...also prompted the most stories (specificity) and generated the most passion (emotion), especially within the context of palliative care teams facilitating goals of care discussions"; "...[participants] explained a chaplain's detailed reporting about the subtheme of a patient's religion/spirituality and how or why it conflicts with a medically recommend course as being most helpful"; "[p]articipants expressed their expectation that a chaplain would be descriptively attentive to this information in a progress note when a patient shared their sense of hope or future, as a second subtheme, related to decision-making." [pp. 186-187]
- Suffering --
- "In addition to suffering being addressed from a whole person perspective such as paying attention to 'trauma, grief, and loss,' it was also clear that chaplains are expected to be specialists concerning religious and/or spiritual suffering and to have that reflected in the progress note. The wish for chaplaincy notation about a patient's overall sense of suffering emerged, including what this means related to physical symptoms." [p. 187]
- Coping --
- "[P]articipants often reflected on how it is helpful to read in a progress note about some aspect of how a patient is adjusting or what their 'strengths' are, overall, related to their serious illness circumstances and what it means for them in terms of their personal suffering/distress." ..."A descriptive sense of what orients a patient or family member to that which is sacred or significant during a disorienting and uncertain time of serious illness was named as helpful. Also discussed was how this potentially positive source of coping can or has changed during illness." [p. 188]
- Religion/Spirituality --
- "First, palliative team members want information about where a patient is on a 'spiritual spectrum' with religion being included within that construct." Second, they wanted a description of "how religion or [patient's] version of spirituality shapes their 'view of the world...into a way to make sense of it all," as well a description of a "patient's religion/spirituality and practices and how it 'influences their decision-making,' suffering, and coping...." And third, they wanted a sense of the "importance" and "intensity" of a patient's religion or spirituality in serious illness and hoped for a "weighted 'need' in a chaplain's note." [p 188]
- Story --
- "A palliative chaplain is expected to be a 'story-listener' and to integrate an appreciable interpretation and then translation of the meanings and values from these stories into, first, an understanding of illness and, second, when religion/spirituality is identifiably present, the reporting of how his/her 'spiritual story' influences illness apprehension." [p. 189]
- Family --
- "...[P]articipants indicated that it is helpful to know who the patient defines as family, whether they are involved or influential, and how supportive they are..."; also, "who supports the patient" and "who is a source of conflict or produces tension in manifesting family complexity and dynamics." [pp. 189-190]
- Perception of Emotion --
- "...a desire for chaplains to communicate some sense of what was perceived emotionally in the room to make the interprofessional partners aware and provide some context" also, "a chaplain's insights are sought to help describe emotional tensions and create awareness for other team members." [p. 190]
SUMMARY CONTENT THEMES ("...needing information that was immediately accessible at a glance that was 'succinct' or in 'bullet points'" [p. 190])
- Logistics --
- Participants wanted to see "front and center" in the note just why/how the chaplain was involved with a patient; also, how much time was spent with the patient. [--see p. 191]
- Synthesis --
- Participants wanted a "synthesis at the top in the summary section of a palliative chaplain's note" regarding "the most important information about a care encounter" [p. 191]
- Scales --
- "Participants...wanted scales or some kind of a ranking or score concerning both a patient's suffering/coping continuum and decision-making to be immediately accessible in a summary section." It was however, acknowledged that while there may be a desire for a "quick or easy, readable, and interpretable scale," such a scale may presently be elusive. [p. 192]
- Recommendations to Staff --
- "Participants also identified a clear need for help with language ... that may help staff navigate critical moments and conversations, rather than potentially sabotage them" (for example, language regarding miracles). Also, participants wanted recommendations around religious or spiritual practices that staff should keep in mind in their care for patients and families. [pp. 192-193]
- Needs/Goals of Care/Action Plan --
- Participants expressed their "wish to see some listing of how ongoing spiritual needs are being addressed, what goals of care the chaplain has in relation to those needs, and what is the plan of care to address those needs and meet those goals." [p. 193]
The authors highlight key findings in their discussion:
- "The results illustrate that decision-making is the theme where information and insight about a patient's religion/spirituality as well factors concerning a patient's story, family, and perception of emotion are most desired." [p. 193]
- " ...[N]on-chaplain palliative care team members want a chaplain's progress notes to address patient suffering as well as to know how the patient is coping with it. ...[T]here is a desire to know how a patient's suffering and coping is influenced by religion/spirituality, specifically, as well as by a patient's story, family, and perception of emotion." [p. 194]
- One "surprise" was "the extent to which non-chaplain team members wanted a sense of a chaplain's perception of emotion in the narrative progress notes related to a patient and family's response to the serious illness." The authors elaborate: "While related to coping, this theme was distinctive as it was identified more to be helpful for a non-chaplain palliative team member's preparation for and possible approach to care with that patient and family. While feelings were described as a part of this sense of emotion, there was also a sense that it was a perception of what was significant for a patient." [p. 194]
- "[A theme] not previously mentioned in the literature about a palliative chaplain's progress note, is the practical need for an efficient and weighted summary of content at the top. A participant captured this desire with, '...you don't need to scroll down or look for buried treasure.' Meriting a focused discussion about what treasure needs to be at the top of the progress note, as it is not apparent in the literature, is the need for a synthesis, scales, and recommendations." [p. 194]
Suggested future research includes attention to outpatient palliative care settings and hospice and greater focus on pediatric care staff and on nurses as a particular subgroup of palliative care providers (since nurses often are the ones who make referrals, and the present research had only a 17% nursing representation). Additionally, "to build on this research, focus groups of non-chaplain palliative care team members could gather to converse and seek feedback preferences for three or four different palliative chaplain spiritual assessment pre-formatted templates" [p. 196].
Galchutt and Connolly characterize their findings overall as good-news-bad-news:
The good news is that there was a robust valuing of the chaplaincy role for partnership in palliative care. ...[And]...it was also verbally acknowledged that palliative chaplain progress notes are read. The bad news, however, is that, "sometimes spiritual care has a reputation for not having a helpful note" and that what was being sought for by palliative partners in the note was often missing. [p. 195]
The final takeaway for the authors is: "When palliative care chaplains prioritize the stories of how existential, spiritual, and religious factors influence decision-making and suffering/coping, they not only help reduce that suffering; they uncover treasure that enriches the contribution of each person on the palliative care team" [p. 196]. In this way, chaplains' "unique perspective" and the "'insights' that would not have arisen [for other team members] without the chaplaincy/patient conversation" [p. 195] may be "quickly and thoroughly communicate[d]" [p. 196] and have the greatest effect. The article ultimately challenges chaplains to see how documentation can be critical to being "practically relevant to the shared work" [p. 196] of the multidisciplinary team.
Suggestions for Use of the Article for Student Discussion:
While our featured work would certainly "hit home" for chaplains in a palliative care setting, it should be engaging and useful to chaplains in any setting where medical charting is at the center of team communication. Discussion could begin with a check-in about chaplains' individual feelings and approaches to documentation. Do they find documenting difficult? Do they believe that their charting is read? Why? Does the system of charting at their institution allow for the possibility of "an efficient and weighted summary of content at the top" [p. 194]? If not, are there other ways that the "treasure" in their notes could be highlighted? Looking at the particular findings of the research, do any of the twelve themes stand out? What about the interest in the chaplain's perception of emotion [pp. 190 and 194]? What about the desire for "scales," and what might those scales be? If the group had to choose which aspects of documentation raised in the results might be the focus of their energies, which would they select? Could this perhaps lead to a group project around documentation? Might the same questions at the heart of this research be put to groups of non-chaplain caregivers at the chaplains' own institution? Discussion of this research could be an opportunity to invite members of other disciplines to join as guests. Finally, do the chaplains have difficulty reading the notes from other disciplines? If so, how could that inform the way they might think about their own documentation?
Related Items of Interest:
I. Paul Galchutt's own proposal for a palliative care spiritual assessment is outlined in:
Galchutt, P. "A palliative care specific spiritual assessment: how this story evolved." OMEGA - Journal of Death and Dying 67, nos. 1-2 (2013): 79-85. [(Abstract:) This article reflects a project to create, refine, and use a palliative care specific spiritual assessment, with the intent to implement its use for both an inpatient Palliative Consult Service (PCS) and a Spiritual Health Service (SHS) team. Extensive meetings with these services to confirm a shared understanding of the use of this spiritual assessment to facilitate communication with PCS through consistent language about the patient's story, suffering, spirit, and sense-making. Following a pilot phase of using this palliative care spiritual assessment, five presentations were shared with the SHS team to explore using this assessment. Although the SHS team decided not to use its content, these presentations spurred dialogue toward what was to become a SHS standardized documentation process, eventually called data, intervention, outcome, plan (DIOP).]
II. Paul Galchutt was a presenter for Transforming Chaplaincy's January 2020 webinar, Chaplain Documentation: Best Practices and Emerging Research, available for viewing via YouTube at https://youtu.be/QJu7O2ZmMxI.
III. Our September 2019 Article-of-the-Month presented a quantifiable assessment of spiritual concerns: the PC-7, from George Fitchett, et al. (Such an assessment may speak to the finding in our currently featured study that there is a desire for chaplains to incorporate scales into documentation.) In connection with the PC-7 article, Transforming Chaplaincy and the ACPE offered a webinar on "Spiritual Assessment in Palliative Care," hosted by Paul Galchutt, available via YouTube at https://youtu.be/wm3YRQLJVx8.
IV. Regarding documentation, see our October 2016 Article of the Month: "Documenting presence: a descriptive study of chaplain notes in the Intensive Care Unit." This study goes beyond the palliative context but is certainly relevant to it, and it was published in a palliative care journal.
V. For more regarding chaplains' documentation, especially in light of its close ties to the dynamics of assessment, see Gordon J. Hilsman's book, Spiritual Care in Common Terms: How Chaplains Can Effectively Describe the Spiritual Needs of Patients in Medical Records [London and Philadelphia: Jessica Kingsley Publishers, 2016/2017].
Publisher's Description: Encouraging a broad, compassionate, humanistic approach to spirituality, this book shows how patients' spiritual needs can be communicated well within interdisciplinary teams, leading to better patient wellbeing. This book describes the art of charting patients' spiritual perspectives in an open way that will help physicians and nurses to better direct medical care. It includes practical information on how to distil spiritual needs into pragmatic language, helping to demystify spiritual experience. Drawing on his extensive practical experience, the author also suggests key points to emphasise that will enrich chart notes for medical records, including brief, relative narratives, trusting one's own impressions, reflecting holistically on the patient's life, patient attitudes towards treatment and recovery, and describing families' opinions on the health care situation of their loved one. The book shows healthcare professionals of all disciplines how to engage in a shared responsibility for the spiritual care of their patients.
The book was reviewed by Steve Nolan (who recommended the Galchutt & Connolly's work for our feature this month) in Practical Theology [11, no. 1 (2018): 105-106] and in the Journal of Health and Social Care Chaplaincy [5, no. 2 (2017): 329-331]. The latter review is available freely online from the publisher. Another review was published in the Journal of Pastoral Care and Counseling by Yoke Lye Lim Kwong [vol. 72, no. 2 (2018): 147-148] and should be available to ACPE members through the ACPE website (though at present the link from the ACPE site to the JPCC site is not operational).