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Case Study of a Chaplain's Spiritual Carefor a Patient with Advanced MetastaticBreast CancerRhonda S. Cooper aa The Sidney Kimmel Comprehensive Cancer Center at JohnsHopkins , Baltimore, Maryland, USAPublished online: 29 Apr 2011.

To cite this article: Rhonda S. Cooper (2011) Case Study of a Chaplain's Spiritual Care for a Patientwith Advanced Metastatic Breast Cancer, Journal of Health Care Chaplaincy, 17:1-2, 19-37, DOI:10.1080/08854726.2011.559832

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Case Study of a Chaplain’s Spiritual Carefor a Patient with Advanced Metastatic

Breast Cancer

RHONDA S. COOPERThe Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins,

Baltimore, Maryland, USA

The case study seeks to describe an oncology chaplain’s pastoralrelationship with a 64-year-old woman with advanced metastaticbreast cancer. The patient’s distress was complicated by a history ofanxiety and other chronic medical conditions. Approximately 16pastoral encounters occurred during the last year of the patient’s life.The patient, chaplain, and the pastoral conversations are presentedas well as a retrospective assessment of them. The chaplain’s interven-tions were appropriate for the patient’s spiritual needs, particularlyin regard to her fear of death, loneliness, grief that her life was ‘‘tooshort’’ and estrangement from her inherited faith tradition, withobservable benefits for the patient. The oncology chaplain has a dis-tinctive role in the healthcare teamas onewho canmeet the patient atthe point of their spiritual need, provide appropriate interventionsand, thereby, ameliorate the distress, particularly in regard to deathanxiety, peace of mind, and issues of meaning.

KEYWORDS cancer, case study, chaplaincy, outcomes, pastoralcare interventions

INTRODUCTION

The primary spiritual and religious needs of patients with advancedmetastatic cancer include: Meaning, connection with God=Higher Power,forgiveness, death and the afterlife, peace of mind, and religious=spiritual

I am grateful for the feedback from other members of the oncology case study project(George Fitchett, Dick Maddox, and Stephen King) on earlier versions of this manuscript.

Address correspondence to Rhonda S. Cooper, MDiv, BCC, Chaplain, The Sidney KimmelComprehensive Cancer Center at Johns Hopkins, 401 N. Broadway, Suite 1210, Baltimore, MD21231-2410, USA. E-mail: rcoope23@jhmi.edu

Journal of Health Care Chaplaincy, 17:19–37, 2011Copyright # Taylor & Francis Group, LLCISSN: 0885-4726 print=1528-6916 onlineDOI: 10.1080/08854726.2011.559832

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practices (Alcorn et al., 2010). In a qualitative study of patients with a ter-minal cancer diagnosis who participated in life review therapy, Ando, Morita,and O’Connor (2007) found that the main concerns for the patients in their60’s included death-related anxiety. Interventions on the part of healthcareproviders that lessen death anxiety may enhance the patient’s quality oflife (Sherman, Norman, & McSherry, 2010); affirmative relationships withprofessional caregivers may reduce the use of health resources (Grant et al.,2004) as well as improve the patient’s overall sense of well being.

Oncology chaplains have a unique role in the healthcare team as thosewhose primary role is to provide care for the patient in spiritual distressand mediate a meaningful connection with a transcendent presence, parti-cularly for those who may be out of touch with the practices of their inher-ited faith tradition or religious community. A patient’s more fully realizedconnection with God=Higher Power may in turn mitigate their fear of deathand bring about greater peace of mind. Borrowing imagery from the prac-tice of spiritual direction, the chaplain has the unique opportunity tobecome a spiritual companion and, thereby, journey alongside the patientin their distress and provide encouragement, support, reflective listening,and direction.

Literature is extant which clarifies the relationship between cancerpatients and their needs around issues of spirituality (Fitchett & Canada,2010; Visser, Garssen, & Vingerhoets, 2010) and the chaplain’s role in theprovision of care (Burton & Handzo, 1992; Fitchett, 2002). Apart from anotable case (Berger, 2001) and an interesting volume of brief cases usedfor the education of pastors (Mahan, Troxell, & Allen, 1993), publishedpastoral care case studies are few and far between.

This case study describes the pastoral encounters of a ComprehensiveCancer Center chaplain with a middle-aged woman who had advancedmetastatic disease, throughout the last year of the patient’s life. The woman’sexpressed spiritual needs, chief among them fear of death and fear of God,are considered as well as the interventions provided by the chaplain and theresultant benefits for the patient. The case study also supports the aim ofdeveloping a body of pastoral care case study material (see Fitchett, thisissue), particularly with regard to chaplains’ work with patients who havebeen diagnosed with advanced metastatic cancer.

METHODS

Doris is a 64-year-old woman who had been diagnosed with incurable meta-static breast cancer five years before meeting the chaplain. She was initiallydiagnosed with breast cancer 15 years earlier and treated with surgery(radical mastectomy) and radiation therapy. She was considered cured untilthe disease recurred a decade later. She had struggled with a host of chronic

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medical conditions and issues of anxiety for many years and had beentreated through psychotherapy and pharmacological management. Dorislived alone and relied upon her only sibling, a brother, and his wife for sup-port. Despite her medical, social, and emotional challenges, she had enjoyeda meaningful career as a clinical social worker until shortly before I met her.Doris was raised in the Roman Catholic faith, although she had not beenconnected to a church or spiritual leader since childhood.

The chaplain is a middle-aged Caucasian female, ordained United Metho-dist clergy for 30 years, serving the inpatients and outpatients, family membersand staff of a Comprehensive Cancer Center in a large research-oriented,academicmedical center in Baltimore, Maryland.Many of the patients who seekcare in the Cancer Center receive treatment as part of research protocols. Often-times, standard treatment for their cancer has failed to effect a cure; the patientswho choose to seek treatment at the Cancer Center are usually very forthrightthat they want to exhaust all avenues of treatment before ‘‘giving up.’’

This case study is based upon 16 encounters with Doris over a one-yearperiod in both the inpatient and outpatient settings and through her tran-sition to hospice care. Doris considered the chaplain to be her ‘‘spiritualcounselor’’ with whom she made requests for sessions in the chaplain’soffice, and on occasion by telephone. At one time Doris had an acute medicalneed due to side effects from chemotherapy, and the chaplain initiated visitsduring her brief hospital admission. On several occasions, after she hadbecome a hospice patient, the chaplain visited Doris in her home.

History of the Pastoral Relationship

The caller introduced herself to me by tentatively stating, ‘‘My therapist toldme to call you. She thinks I need a chaplain, although, frankly, I am not tooreligious.’’ During the 10-minute telephone conversation, Doris gave me abrief overview of her medical condition and religious background. Shereported that despite her participation in a number of rigorous clinical trials,she knew that the cancer was advancing. She also shared that she wasparalyzed by the thought of dying before she was ready. During the briefconversation with Doris, I provided reflective listening and the assurancethat ‘‘religiosity’’ was not a condition of talking with the chaplain.

The Cancer Center counselor, Joan, had told me a few days earlier aboutDoris, a longtime client with advanced metastatic breast cancer who was‘‘very scared about dying,’’ and who had other religious concerns as well.I had served for five years as the Comprehensive Cancer Center Chaplainand valued the referrals from my social work colleagues, including Joan,the counselor, who had been on staff for many years in the Center. I waspleased that Doris (all names have been changed to protect the confidential-ity of the persons in the case) had called so quickly. This patient wasnot afraid to access Cancer Center resources for support, but she was

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unaccustomed to reaching out to a ‘‘religious person’’ and initially spoke tome with wariness in her voice.

Doris’s initial tentativeness soon gave way to a purposeful sharing ofthe salient points of her story. I was aware that she was doing her ownassessment of the chaplain during the brief telephone conversation. As amental health professional herself, Doris was interested in our ability to relateor connect around issues that were deeply and definitively spiritual. She didnot inquire about my religious or professional credentials and requested tomeet with me in person only after she determined that I could engage withher in a sincere and empathic manner.

Doris was prompt for our first meeting in my office. She was soft spokenand somewhat shy, a thin woman of slight stature. She told me more abouther initial diagnosis, treatment, and recurrence of metastatic disease withoutpossibility of a medical cure. She spoke about her increasing frailty and her dis-pleasure about taking early retirement from her social work practice. Shelamented the loss of her expectation of living a long life like other familymembers. I listened intently as she expressed her grief at these losses—ofthe hope of a medical cure, of the practice of a meaningful occupation, and ofthe expectation of living to ‘‘a ripe old age’’ like her parents and grandparents.

Doris talked about her family, with a focus on her mother whom shehad experienced as overbearing and critical. She attributed her mother’s pro-tectiveness, which she reported as ‘‘stifling,’’ to the death of an infant girlprior to her birth. Doris did not leave home until her late 20’s, and then onlywith the help of her older brother who encouraged her to attend college. Sheworked and eventually supported herself entirely while earning a graduatedegree in social work. She stated with pride that she had achieved goalsshe never expected to realize, educationally or professionally, with minimalsupport from family and friends.

Doris said she feared that God would not receive her into heaven (‘‘ifthere is a heaven,’’ she quipped) because of her negligence of religiousattendance and practice. ‘‘I haven’t done much for God or the church,’’she said, ‘‘so why should God do anything for me?!’’ She shared that shehad experienced the teachers in parochial school as rigid and harsh. Whenshe became increasingly frightened and ‘‘nervous’’ as a first grader, the familydoctor advised a transfer to a public school. From childhood on, she said, ‘‘Idid not have much to do with God or religious people.’’

Doris became more animated as she spoke about her belief in angels,who were present with her for comfort, strength, and warmth. When I askedDoris to say more about these angels, her countenance brightened. Sherecounted times in which the angels had helped her when she was fright-ened or uncomfortable. She told me that she had difficulty with closedspaces, like the MRI scanner. She then talked about her strategy of connect-ing with her angel when she was anxious during the procedure, therebyfocusing on a benevolent presence surrounding her.

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At the close of the session, she laughed and said, ‘‘My, I’ve just talked somuch you haven’t had a chance to say hardly anything!’’ I replied, ‘‘That’salright; I’m here to listen and learn about your story, which is very interesting.After listening, however, I would like to reflect back one thing before youleave.’’ She said, ‘‘Yes, please!’’ I said, ‘‘As you describe your angels, this isreminiscent of my ideas about God!’’ She said, ‘‘Oh!’’ and laughingly said,‘‘It sounds like my idea of God is really like my mother—punitive and with-holding!’’ With that, we parted, and she asked if she could call and makeanother appointment.

The Third Encounter

Two weeks later, Doris was again in my office immediately following hersession with Joan. As we sat with one another, the conversation beganwithout hesitation.

Doris: I am terribly upset that my doctor may not have any more treat-ments to offer me. (Her brow was creased when she said this,her facial demeanor congruent with her words.)

Chap: This has come as difficult news from your doctor, I hear yousaying.

Doris: Yes, and even if there are the treatments available, the side effectswill be terrrrrrrrible (drawing out the word ‘‘terrible’’ foremphasis)!

Chap: The intensity of the side effects will be part of your decision-making about accepting new treatments then?

Doris: Well, yes. And, no. I just hope that I will be able to live longer. Ido not want to die yet, and nothing about dying brings me anypeace.

Chap: You seem ambivalent about treatment, yet very firm that youwant to live longer.

Doris: Yes, even though my mother had cancer she lived to be in her70’s. By the way, did I tell you about my sister-in-law’s beliefsabout religion?(Doris had a difficult time focusing on one subject for very longduring the hour, and jumped from subject to subject. When shequickly changed the subject, I followed her lead in conversation,despite my perplexity at this pattern.)

Chap: This is your brother’s wife, the one who has helped you duringprevious treatments?

Doris: Yes, the same. She was raised a Catholic, like me and my brother.And she always went to mass. A lot. Then when she learned thather only son was gay, she went to the priest with her worries.

Chap: Ah, this was a difficult time for her.Doris: Oh yes, and this priest was so judgmental and harsh. He said that

the son had made a sinful choice and that he had to change or hewould be outside the good graces of the church forever!

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Chap: Wow, that was pretty cut and dried opinion, wasn’t it?Doris: My sister-in-law was crushed, and had no more to do with reli-

gion since that time. She said that no priest and no church wouldmake her choose between them and her son. And since then shehasn’t attended church or claimed any religion at all.

Chap: Wow, that was a big deal. She clearly loves her son a lot.Doris: Yeah, but here’s the hard part for me. I understand her decision,

but I don’t feel like I can discuss anything that has to do withreligion AT ALL – all because of this priest.

Chap: So you don’t havemany opportunities to explore your faith these days.Doris: Oh, did I tell you about those guided imagery classes I took at the

Wellness Center a few years ago?Chap: (I was surprised again at her abrupt change of subject, but I did

not try to re-direct conversation. Previously, I had experiencedDoris as very focused in her conversation.)I know of the Wellness Center and understand they have goodprograms. Was the class helpful?

Doris: Yes, we used tapes with music and affirmations; it was awhile agoand helped me with my anxiety. You know I have had longstand-ing issues with anxiety; did I tell you that?

Chap: Yes, you did share that you had struggled with anxiety issues,even before your cancer diagnosis 15 years ago.

Doris: Yes, those tapes helped me quite a bit.Chap: Have you used the meditation tapes recently?Doris: No, I’ve nearly forgotten about them until now. Maybe I’ll try to

find them and try again.Chap: Let me know if you do; I’m interested in the results of your experi-

ment to try again.Doris: OK! Well, my time is up. I feel so much better now. May I call you

again when I am back in the Cancer Center for an appointment?Chap: Yes, of course. It is always good to be with you. (Doris left with-

out lingering.)

Doris jumped from subject to subject during the hour and seemed tohave a difficult time focusing on one topic, although she was consistentlycalm and soft spoken as before. I consulted with her counselor=therapist,Joan, who reported that a lack of focus in conversation was one of theprimary ways Doris’s anxiety presented.

The Fourth Encounter

Doris appeared to arrive early for her appointment two weeks later.

Chap: (I approached Doris who was sitting in the waiting area outsidemy office.) Hello, Doris! I see you are here; would you like tocome into my office a little early, or would you like to wait afew minutes more?

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Doris: I’ll come in; that would be great. My therapist is out sick today,and she told me I should keep the appointment with you anyway!So, you get to be my therapist as well today! (She laughed in aplayful way.)

Chap: I am glad you were able to come, even though Joan is not heretoday.

Doris: I was glad to come because I really feel like talking to someone.I am feeling so much more tired lately. And, I learned that thecancer has metasticized to my lungs now.

Chap: (I nodded, leaned forward and furrowed my brow a bit, tocommunicate without words my concern and interest.)

Doris: When it’s in the organs, you know that’s a bad sign. (Said deject-edly and wistfully).

Chap: (I nodded slightly in agreement, not enthusiastically, and kept theslight leaning-in posture, which encouraged her to continue.)

Doris: You know what? I watched that Farrah show the other nightwhere she talks about having cancer. Do you know of it?

Chap: No, I did not see the show but I’ve heard a few people mention it.You are speaking of the actress who has advanced cancer?

Doris: Yes, it was all about her treatment, and the great lengths she hasgone for a cure—even going to Europe for special treatments.

Chap: What did you think about it all?Doris: I found it very depressing . . .but couldn’t turn off the t.v.Chap: How was it depressing?Doris: Ms. Fawcett prays a lot and says the rosary. She’s a devout Cath-

olic. She really believes she will be healed by a miracle, but herprayers don’t seem to be answered. That is depressing to me.

Chap: Yes, I can see that. You have said you would like a miracle too.Doris: Yes, and get this: All the treatments, including European treat-

ments not offered in the USA, gave her only temporary relieffor a little while, and then she is in pain again. (Doris’s voice rosea little at this point.) And Farrah referred to her cancer as ‘‘themonster.’’

Chap: That’s a pretty strong sentiment!Doris: And that’s exactly how I feel too, like cancer is a monster. These

metastases are appearing in my bones, legs (gesturing to herright thigh), back, skull—and now my lung! And nothing will stopit!

Chap: What does it mean that this monster has intruded upon your life?Doris: Both my parents lived until nearly 80, and my mother had surgery

and radiation treatments for lung cancer! (Emphatically, notdejectedly) I feel cheated at not having as many years to live!

Chap: One time you told me you did not want to die because you feltyou still had things to do, that you wanted to return to work,for example.

Doris: O yes, I still have the potential to help people, to make their livesa little better. I feel like I haven’t accomplished enough.

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Chap: Yes, I hear that. However, as you have talked with me about yourlife story, I am so amazed at the choices you have made in life—choices which have not been the easiest ways but the ones thathave yielded so much good for you and others.

Doris: (With a surprised and curious facial expression and sitting a littlestraighter and forward in her seat.) Give me an example of whatyou are saying.

Chap: I remember your story about being very sheltered, and then tak-ing the opportunity to move into your brother’s home, then yourown apartment, working, going to college and graduate school,and being an independent woman.

Doris: Yes! When I left my mother’s home, I found an escape andfreedom, and I loved the changes in my life.

I then engaged Doris in a 20 minute dialogue about her accomplish-ments during her life, a conversation which essentially comprised a lifereview of her professional life and was punctuated by stories of personalevents which she considered turning points in her life. Doris spoke of collegeprofessors who made an impact on her life. She spoke of friends, mentors,colleagues, and patients she had counseled. Her mood lightened; shelaughed at times when recounting some of the anecdotes.

Doris: I haven’t thought about these things in a long time; I’ve been soanxious about my illness, about treatment, about insurancerunning out.

Chap: Let me suggest something. I believe that we all have an importanttask, regardless of our age or state of wellness=illness: that is, toembrace the meaning we have made with our lives and findpeace with ourselves as we get older. This is the spiritual task,regardless of our religiosity or lack of religiosity.

Doris: I have not thought about it in this way. (Surprise showed on herface, and then she looked pensive. We closed the session as thehour was up. Doris was considerably brighter on her exit thanwhen she had entered the session.)

The Fifth Encounter

Ten days later, Doris and I had a brief telephone conversation because wecould not meet due to scheduling conflicts. The next day Joan told me thatDoris seemed ‘‘lighter’’ in their sessions around issues of spirituality, religion,and death. Joan believed that Doris had isolated herself from support inmany regards, and considered it a ‘‘good sign’’ that she desired to meet withme as her ‘‘spiritual counselor.’’ Joan also reported to me a therapeuticbreakthrough when Doris ‘‘stood up to’’ her longtime oncologist anddeclined the offer of a clinical trial protocol with very debilitating side effects.

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The therapist remarked that it was one of the first times she experiencedDoris acting out of choice rather than her fear of death. In a recent sessionwith Joan, Doris also had raised the subject of her personal and professionalaccomplishments throughout her life. Joan said that Doris was delighted totalk to her about her life and its value.

The Sixth Encounter

A fewweeks later, Doris met with me and began, ‘‘I want to tell you, my 97 yearold aunt died last month, who was my mother’s last surviving sister.’’ She saidthat this elderly aunt called a number of family members from the rehabilitationfacility where shewas receiving care—even the oneswhowere long distance—‘‘to tell us she loved us.’’ She continued, ‘‘She also recounted events in the past,like family reunions and holidays, during which she had enjoyed being witheach of us.’’ Doris also told me the story of her ownmother calling family mem-bers to her bedside before she died, at which time she told each one that sheloved him=her. I asked Doris if she thought that the two women were takingcare of the business of closure in similar ways. Doris quietly replied, ‘‘Maybeso, maybe so.’’ She thanked me for my time and left at the 30-minute mark.

The Seventh Encounter

One afternoon, Doris unexpectedly stopped by my office for a brief visit toask for ‘‘silent’’ prayer for the pain in her legs due to the metastases to herbones. She would soon learn about treatment options from her oncologist,and she reported that she was nervous about her options or lack thereof. Ilistened and assured her that she would be in my prayers, and I said that Iwas glad she had stopped by my office.

The Eighth Encounter

Several weeks later, Doris left a lengthy voice mail for me, during which shetold me that she had been offered the option of radiation treatment for thepain in her legs. She was very pleased, and continued: ‘‘Thanks for theprayers. I found two pennies the other day. I was told once that ‘found pen-nies’ were angels, so I took those pennies and put them right in my pocket!(She giggled a bit mischievously at this point.) I’m not sure if that’s why thedoctor’s appointment went so well or not, but anyway, that’s what I did. AndI do appreciate your prayers.’’

The Ninth Encounter

Several weeks later I called Doris at home. She was pleased to hear fromme and updated me about the radiation treatment that would begin soon.

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She said that she experienced a lot of pain in her legs, especially at night, andshe added that her little elderly dog was also having trouble getting up anddown the stairs!

Doris asked if I remembered the story about the pennies from her voice-mail; I said yes, and we both laughed at the same time. She said, ‘‘Yes, Ibelieve those angels in my pocket helped with the doctor’s appointment!’’Also, she said that she felt her Aunt Florence, the one who had recently died,was watching over her. She asked for my prayers, and I assured her she wasin my thoughts and prayers.

The Tenth Encounter

Several weeks later I sought out Doris in the radiation therapy waiting area.Her appointment time was delayed so that we had 20 minutes to converse.Near the end of the encounter her sister-in-law, Louise, joined us; this wasthe first time I had actually met her. Doris was in a wheelchair and we spokeof her hopes for the radiation giving relief for her pain and also to prepareher for additional chemotherapy treatments. I was warmly received andwas glad to provide encouragement and a spiritual presence for Doris. I alsolearned that her little dog had died at the age of 16.

The 11th Encounter

Several weeks later, I received news from Joan that Doris was in theEmergency Department. The side effects from the chemotherapy, includingextreme cramping and intractable diarrhea, were acute, and her conditionwarranted admission to the inpatient unit. I found Doris and Louise, hersister-in-law, in the emergency transitional unit and spent a half-hour withthem. Before I left, Doris asked for prayer in the name of the Blessed Virgin,and the three of us joined hands during the prayer.

The 12th Encounter

The next morning Doris left a voicemail with the message that the visit theevening before had helped so much. She had been admitted to an oncologyunit in the middle of the night and was exhausted and requested that I comethe next day. She said she had some things to discuss after she was morerested. I learned from the medical record that her physician had introducedthe idea of hospice and discontinuation of all but palliative treatments. Hestated in the documentation, ‘‘Although Ms. M wants to live as long as shecan, she is nearing the end of her life.’’

The next day, Doris told me that she had decisions to make aboutadditional treatment, and that the side effects from the chemotherapy mostassuredly would affect her quality of life. She also mentioned that she had

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contacted a Catholic priest in her neighborhood not long before becomingvery ill, although he had not been able to visit her at home. I asked Dorisif I could invite a Roman Catholic Chaplain to visit her, and she agreed. Imade the referral, and Fr. John, a gentle, kind man, provided counsel, Gen-eral Absolution, and Holy Communion. The next day, Fr. Zach visited andprovided the ritual of the Anointing of the Sick. Doris reported that theserituals helped her feel connected to God, and that she felt supported andcomforted by both priests’ visits. She also laughed and said that she was so‘‘out of touch’’ that she did not know that ‘‘last rites’’ were a thing of the past!

The 13th Encounter

A telephone call from Doris after her discharge let me know that she hadaccepted home hospice. However, she said she was told by the hospicenurse that she would have six or less months to live. ‘‘I don’t think I’m goingto die that quickly!’’ she exclaimed. ‘‘What do you think, Rhonda?’’ I assuredher that she could ‘‘graduate’’ from hospice if she didn’t die ‘‘on schedule,’’and because she could hear the mild teasing in my voice, she laughed andsaid, ‘‘SURE, I can live with that!’’

The 14th Encounter

After she became a home hospice patient, Joan and I both kept in touch withDoris by telephone. Once she told me about a visit from the hospice chap-lain. ‘‘He’s nice, but he reads the Bible to me, and I can’t say it is particularlyhelpful.’’ I encouraged Doris to share with the hospice chaplain what she feltwould be helpful. I then asked her what she experienced as helpful interven-tions in our relationship. She quickly replied: Letting her set the agenda forthe conversation, not acting too religious, being on the same level as her, lis-tening, praying when she requested prayer in the hospital, and introducingher to the hospital priest at the ‘‘right time,’’ (i.e., when she was receptive).

The 15th Encounter

I visited Doris at home when she reported that the hospice chaplain was ‘‘outfor surgery.’’ I learned from the hospice office that Doris had refused aninterim chaplain because she did not want to meet anyone new. I consultedwith Joan, her counselor, and then set an appointment with Doris as she hadrequested. During the 40-minute visit she proudly showed me photographsof her family members, including her niece and nephew and their children,as well as photos of her deceased parents and grandparents.

Doris told me about the hospice services that were allowing her to livesafely in her own home. She talked about the aide who helped with laundryand bathing, and her nurse who was competent and kind. Her sister-in-law,

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Louise, helped with shopping and rides to appointments and, in tandem withhospice caregivers, supported Doris in a marvelous way.

Doris spoke also about how much more connected to God she felt aftermeeting with the Catholic chaplains in the hospital and noted that theirwarmth and compassion were affirming. The General Absolution, along withAnointing and Holy Communion, helped her feel less guilty about prayingand asking God for help and comfort. She said that she considered this a sig-nificant turning point in her spiritual journey. I was surprised when Dorisnext brought up the subject of her funeral preferences. She said she wasthinking about writing down her ideas, including an invitation list of friendsand family for a simple memorial service. She asked if I would consider hav-ing simple prayers and a eulogy at a service she would plan as an alternativeto a funeral Mass.

During this visit, I realized how much Doris had touched my life, evenas I had touched her life. Not often do chaplains have the opportunity tobecome so well acquainted with a patient—much less receive reflective feed-back on their interventions. At this point, I asked Doris if she would give mewritten authorization to prepare this case study so that I might share some ofthe wisdom I had gained from her. She enthusiastically said, ‘‘Yes, of course,I am so honored to have you ask me this.’’

Before I left my home that morning, I put two small terra cotta angels inmy purse to give to Doris if it seemed appropriate, in part because it was theholiday season. Before I left her home I gave her the angels in remembranceof earlier conversations. She was pleased and said that one of the angelsappeared to be telling the other one ‘‘a happy secret,’’ and we laughed aboutthis as she set them on the shelf among other mementoes.

A week later, Doris left me a voicemail. ‘‘Thank you somuch for coming tosee me and bringing the little angels. I set them side by side, and pretend thatone is telling the other, ‘Watch over Rhonda and Doris. Keep them safe andhealthy.’ ’’ She continued, ‘‘So you see, we are both watched over by the angels.I am so honored you want to write my story; let me know if you need any extrainformation about my sins.’’ Then, a mischievous giggle, and she said goodbye.

The 16th Encounter

On a snowy day in January, I again visited Doris in her home, in part toobtain her signature on the hospital’s authorization form so that I might shareher story in a case study. She was noticeably lighter in mood and explainedthat she had been prescribed an ‘‘old fashioned’’ antidepressant for neuro-pathy in her feet. The unintended consequence, she added with a laugh,was that she felt a lot better emotionally. She reported that she was readingmore, eating more, and even planning a luncheon date with Louise after hernext doctor’s appointment. She welcomed me warmly, and the 45-minutevisit went quickly as we sat together in her cozy kitchen.

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Doris said that her family had encouraged her to write an invitation listfor her memorial service, but that she had ‘‘not gotten around to it.’’ Shespoke of ‘‘letting her social work license go’’ because she did not thinkshe could complete the CEU requirement by the deadline. I realized thatshe was still ambivalent about her eventual ‘‘premature’’ death, and I foundmyself both amused at and in admiration of her resistance to dying. As I leftshe said, ‘‘Look at the little angels (on the ledge of a bookcase, positionedright next to one another). One is still saying, ‘Take care of Rhonda andDoris!’ Can’t you just see it in their eyes that they are listening to each other?’’At the door I took her hands and said, ‘‘Let me bless you.’’ She said, ‘‘Yes ofcourse,’’ and we prayed together.

By early April, Doris suffered more pain from the neuropathy andadvancing metastatic disease. She fell on Easter Sunday and could not getup without assistance from the EMS, so she moved to her brother andsister-in-law’s home an hour away. We spoke several times more by tele-phone, and she reported that during their first meeting she told the new hos-pice chaplain that Bible reading was not her cup of tea and that talking andshort prayers would suit her just fine! Doris died three months later in thecare of family and hospice. Her sister-in-law, Louise, described her deathas ‘‘peaceful,’’ and commented to me in a telephone conversation that shebelieved that Doris had finally made peace with God ‘‘in her own way’’ withthe help of her chaplains.

Assessment

Doris believed that providing care for others was a human obligation, andhad strived to hear and understand as she had hoped to be heard and under-stood—first by her parents and later by colleagues, mentors, and teachers.She did not frame this as a religious or spiritual task, and stated early inour relationship that she ‘‘had not done anything for God lately,’’ (e.g.,attending services, tithing, praying the rosary). Therefore, Doris feared thatGod had no obligation to do anything for her.

Doris claimed not to be religious. However, she spoke about the impor-tance of the angels, who clearly represented a spiritual presence in her life.She reached out to spiritual caregivers for support; and she unambiguouslyarticulated her fear of God and of what might happen to her after death. Earlyin our relationship I was touched and captivated by her openhearted sharingof herself as well as her hopes and fears. I also experienced Doris as akindred soul in her struggles with religious authority=authorities in the past.

I consulted with several trusted colleagues, including Joan, my col-league in the Cancer Center, about my interactions with Doris. Through thisprocess, I came to recognize that Doris’s most important spiritual task wasthe unreserved claiming of her spiritual authority and the importance of herown voice in terms of connection with the Holy Dimension of life—and

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death. I did not try to help her re-invent her religious practice but rather torecognize and claim the meaning she had made in her life, including her pro-fessional life, and possibly find a measure of peace with the religious experi-ences of her earlier life.

As our pastoral relationship grew, Doris began to affirm both the comfortof religious conversation and the intercessory prayers of another person—not the prayers of a saint but a companion on the journey. She began toopen herself to the possibility of a caring Divine Presence which transcendedreligious practice or dogma. She began to feel more connected to Godwithout becoming ‘‘more religious.’’ She also began to discover that herprofessional choices were part and parcel of the spiritual and vocationalquest of her life, that is, ‘‘to make a difference in the lives of others.’’

Doris’s rapprochement with her inherited religious tradition came, inlarge part, as a result of the kindness and gracious sacramental ministry ofthe Roman Catholic chaplains in the hospital. She yearned to feel acceptedby and reconciled with the God of her guardian angels, and she needed tobe in touch with a Holy and Abiding Presence that would not desert her inher frailty or at the time of her death. Her positive experience with the priestsintersected with her desire to make peace and find solace in the rituals andprayers of the church of her childhood (see Gall, Kristjansson, Charbonneau,& Florack, 2009).

Doris struggled throughout her life with issues common to women: Thestruggle for autonomy, the expression of obedience versus disobedience, thecare-taking of others versus being taken care of, and being visible or invisible(Freud, 1999). I could relate to these and other ‘‘feminine’’ challenges, and Irespected her independence as well as her ability to establish autonomywithin an overprotective family system. Doris struggled to find the balancebetween visibility and invisibility within her profession and family. Shewas a professional woman with keen intelligence, despite her issues withanxiety and a constellation of chronic medical challenges.

Doris had exhibited tremendous growth and courage in her life, parti-cularly in the risks she took in leaving home in her late 20’s, attendingcollege, working fulltime while earning her graduate degree, even choosinga workplace in a large, complex medical institution. Since the recurrence ofthe breast cancer, she had endured many difficult treatments, including anumber of clinical trials, without a cure in sight. She remained as inde-pendent as possible even in her weakened condition. Doris continued toresist death, even as she made peace with the reality and inevitability ofher demise.

Joan and I both knew that Doris would not survive the advancingcancer, and we worked together to help Doris find the peace and comfortshe deserved as a child of God. We experienced her as winsome, endearing,resourceful, resilient, and engaged fully in conversation at every point. Iwas grateful that my collegial and pastoral relationship with Joan yielded

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not only the referral for spiritual care but also opportunities to reflect uponthis case in our separate (but related) encounters with Doris. Joan’s insightsand reflections helped me gauge the planning and effectiveness of mypastoral interventions.

DISCUSSION

A number of effective interventions in this case of a woman with advancedcancer resulted in positive outcomes. Doris found a greater measure of peaceabout the purpose and meaning of her life in the face of dying. She foundrapprochement with her inherited religious tradition while claiming herown spiritual authority to meet the challenge of living and dying. She relin-quished her fear of God and replaced it with the faith that she was acceptableto the Holy One.

Table 1 represents a retrospective schematic presentation of the needsidentified as a part of my assessment and year-long interaction with Doris.I was challenged by the team members in this case study project to state con-cisely the interventions I employed and the outcomes I observed. I also drewupon the observations of Joan, Doris’s therapist, who validated my assess-ments and on several notable occasions added to my knowledge of Doris’sprogress. Ultimately, through consultation and mutual support, Joan and Ihelped each other meet the needs of Doris, who clearly came to considerus a team in her care.

I was aware from the beginning of our pastoral relationship that Dorishad an anxiety disorder which exacerbated her recurring thoughts aboutdeath and God’s absence or presence (Roth & Massie, 2007). Her therapistand psychiatrist were instrumental in the management of her anxiety, whilemy role was to help her reframe her ideas about God and explore her innerbeliefs and experience, primarily through reflective listening, reframing, andfaithful companioning. I encouraged Doris to claim that resilience and cour-age that had helped her overcome many obstacles in her life and utilize theseto address her fears.

When Doris’s generalized anxiety was most acute and she movedquickly from subject to subject in conversation during the third encounter,I chose to follow her train of thought rather than refocus so as not to heightenher anxiety. I respected Doris and wished to nurture the pastoral relationshipas sensitively as possible. Always of paramount importance was mycommitment to being a colleague or companion of Doris in her desire forconversation and reflection around spiritual issues.

Doris was an articulate woman who processed many of her feelingsand ideas through conversation (this evidenced by her many years of fruitfulpsychotherapy). Only through conversation would I have the opportunity tolead her in a life review (fourth encounter) which allowed her to claim her

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TABLE 1 Needs, Interventions, Outcomes

Patient’s need Chaplain’s intervention Outcome=benefit for patient

1. Spiritual struggle; i.e.,fear of God=fear ofdeath

Normalized her fears She discussed freely her fearswithout fear of punitive or‘‘religious’’ response on partof chaplain(s)

Helped her reframe her ideasabout God and DivinePresence (e.g., angels) andencouraged her to exploreher inner beliefs andexperience

She claimed her own spiritualauthority as she navigatedthe path between strictadherence to inherited faithand her own experience

Encouraged her to reclaim herresilience and courage thathad helped her overcomesignificant obstacles in herlife

She drew upon these and usedthem to address her fear ofGod

Supported her as she exploredher fears, especially of deathand ‘‘dying before she wasready’’

At one point she chose toforego treatment withserious, undesirable sideeffects, rather than accept thetreatment out of fearfulnessof death

Prayed with her and providedblessing during later pastoralencounters

She felt more connected toGod, and came to have more‘‘peace’’ with her eventualdeath

2. Loneliness in herspiritual struggle

Allowed pt to ‘‘tell her story’’with intentional, reflectivelistening, positive regard,and mirrored feedback

She felt valued, heard, andaffirmed as a whole person,despite her physical frailty

Faithfully followed-up bytelephone, hospital visits,and at home with hospice asappropriate

She felt less isolated in that shehad found a viable outlet forreligious conversation andjoined in the common task ofmeaning-making and findingthe Holy

Affirmed the role of thehospice chaplain

She accepted the hospicechaplain’s role as anotherbearer of God’s grace andlove and companion in thespiritual journey

3. Grief that her life wastoo short (i.e., ‘‘dyingbefore she wasready’’)

Led her in a verbal life review She claimed the ways she hadimpacted the lives of othersand then shared this with hertherapist

Encouraged her to reframe herlife’s work as vocation

She embraced the meaning herlife had, despite her(possible=probable) death‘‘before she was ready’’

Allowed her to talk aboutfuneral preferences;encouraged her to make

Discussion about deathseemed more normal: Shewas less anxious when

(Continued )

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life’s work as vocation and embrace the meaning her life had, despite its‘‘premature’’ ending. Only through conversation could she speak and beheard, and then claim the ways she had impacted the lives of others, specifi-cally the clinic clients she served as social worker.

Although Doris did not express the need to ‘‘become more religious,’’she did benefit greatly from the kindness and validation of the Roman Cath-olic priests. She mentioned this to me and others on several occasions after-wards, saying that she felt closer to God and more at peace because of theseinteractions. My care for Doris included the provision of resources that wouldvalidate and support her spiritual well being, including the ministry of thepriests ‘‘at the right time’’ with their assurance of God’s forgiveness and God’sacceptance of her.

McClain-Jacobson et al. (2004) has suggested that ‘‘spirituality has amuch more powerful effect on psychological functioning than [specific]beliefs held about an afterlife,’’ and that interventions ‘‘aimed at increasinga person’s spiritual well-being and developing a sense of meaning and peacewithin oneself may have substantial benefits for improving mental health atthe end of life’’ (p. 486). As Doris neared the end of her life, her embrace ofher ‘‘own way’’ of being connected to God decreased her anxiety aboutdeath and brought her more peace than specific conversations about theafterlife (Lin & Bauer-Wu, 2003).

The aim of spiritual care is not to stand apart from the other, but to jointhe person in the struggle just as the Holy One joins us all in our daily living

TABLE 1 Continued

Patient’s need Chaplain’s intervention Outcome=benefit for patient

notes for her family abouther funeral preferences

discussing the subject thanwhen we first met andeventually initiatedconversation about herpreferences

Explored her resistance tohospice care

She accepted, albeit tentativelyat first, home hospiceassistance

4. Estrangement from theGod of her inheritedfaith tradition

Allowed her to express andclaim her feelings of beingdisconnected with God

She felt empowered to reclaimconnection

Introduced her to Catholicchaplain-priest at the timeshe was most receptive

She felt reconciled with Godthrough sacramental ministryand reported that she beganto pray ‘‘without guilt’’ forstrength from God

Encouraged her tocommunicate her particularneeds for spiritual supportand=or religious resources tohospice chaplain

She stated her needs to hospicechaplain (who was alsoCatholic) without fearfulnessor guilt and felt heard andrespected

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and dying. My primary pastoral care method in my encounters with Doriswas to become a companionable spiritual guide as she struggled withprofoundly spiritual issues. I blessed her through my presence as surely asthrough spoken prayers, as we explored her feelings of dying before shehad accomplished enough. I sought to empower her to claim her own spirit-ual authority through my encouragement, respect, and positive regard. Thesmall terra cotta angel pair with which I gifted Doris became emblematicof our relationship, in that the conversations we shared over the months trulyhad contained the ‘‘happy secrets’’ of grace, acceptance, and sorority.

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