ct vol 24 no 2 - professional chaplains• core beliefs level, shaped by a balance between ex-isting...

1Chaplaincy Today • Volume 24 Number 2 • Autumn/Winter 2008

Chaplaincy TodayJOURNAL OF THE ASSOCIATION OF PROFESSIONAL CHAPLAINS

Volume 24 Number 2 • Autumn/Winter 2008

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LOUIS NIEUWENHUIZEN

KATRINA SCOTT

MARY MARTHA THIEL

CONSTANCE M. DAHLIN

BARBARA BRUNK GASCHO

PAUL DERRICKSON

DICK MILLSPAUGH

KEITH W. GOHEEN

CHRISTOPHER M. HOLMS

JOHN KEVIN ALLEN

WADE MEYER

MARCI POUNDERS

CHARLES CHRISTIE

ROBERT W. DUVALL

SUSAN CAROLE ROY

W. NOEL BROWN

BEVERLY C. JESSUP

ROZANN ALLYN SHACKLETON

MARK A. BONNEMA

DAVID J. ZUCKER

MICHAEL G. DAVIS

GUS MARTSCHINK

ROY OLSON

AL VOORHIS

CHRISTIAN DEMLOW

ANNIE CLAY

GEORGE A. BURN

PSYCHOSPIRITUAL SYMPTOMS IN TIMES OF CRISIS: STUDYING THE LIVED EXPERIENCE OF HOSPITAL PATIENTS AND ITS INTEGRATION INTO THEORY

THE NATIONAL AGENDA FOR QUALITY PALLIATIVE CARE: THE ESSENTIAL ELEMENTS OF SPIRITUALITY IN END-OF-LIFE CARE

CARE TEAMS AND ALS PATIENTS:BRIDGING A GAP

DIALOGUE: STANDARDS OF PRACTICE FOR

PROFESSIONAL CHAPLAINS

A POLICE CHAPLAIN’S REFLECTION

HER DAWN

POETRY

IN THE LITERATURE

MEDIA REVIEWS

EXPRESSION OF FAITH

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The Journal of the Association of Professional Chaplains2

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New e-mail address for Chaplaincy Today: [email protected]

C HAPLAINCY TODAY REPRESENTS OUR PROFESSION AS A PEER-REVIEWED JOURNAL in which we report our research and share its practical application for our collective ministry. You’ll find excellent examples of this within these pages: Louis Nieu-

wenhuizen’s study of psychospiritual symptoms exhibited by hospital patients in crisis; a description of essential elements of spirituality in end-of-life care, authored by Katrina Scott, Mary Martha Thiel and Constance M. Dahlin; a model developed by Barbara Brunk Gascho and Paul Derrickson for establishing congregational care teams to assist ALS patients and their families. In addition, the dialogue on standards of practice for professional chaplains continues.

CT also provides a venue for us to reflect on our call to serve and on how this impacts us professionally—and personally. This issue is particularly rich in this respect with prose and poetry written from the vantage points of CPE student/seminarian, chaplain resi-dent/police officer and board certified chaplain out of their experiences from the ED to the ICU to the NICU to the world beyond.

Often when I contemplate the work we do as chaplains, I am struck anew by the power of story. Our stories define us. Telling them validates our past, anchors us in our present and helps us to set our sights on our future—who we have been, who we are and who we hope to become.

As chaplains, our role is that of listener, the foil for another’s story, and we are skilled at this endeavor. We also have stories of our own. Some of these are rooted in the joys or sorrows that we have witnessed or shared with patients and their families. All reflect aspects of our individual journeys of faith.

Editing CT continually affords me a twofold joy: “listening” via e-mail to your stories and then sharing them through the pages of this journal with colleagues the world over. I hope that you—as readers of this journal—not only will find meaning in listening to your peers, but that you will consider sharing your words as well.

CT’s editorial board and I welcome your submissions of articles, which add to the knowledge base and contribute to our professionalism as chaplains, and reflections, which provide the opportunity for you to be the storyteller. Please note the new e-mail address for CT printed below. I look forward to listening to you.


Psychospiritual Symptoms in Times of Crisis: Studying the Lived Experience of Hospital Patients and Its Integration into Theory

Louis Nieuwenhuizen

THIS STUDY IS A FIRST ATTEMPT TO ASSOCIATE RESEARCH DATA with a model developed by the author, which illustrates the individual’s experience of the transformational process

due to crisis experience.1 It investigates the possibility of using psychospiritual symptoms expressed by hospital patients as an as-sessment aid in determining the individual’s progress along the healing journey curve.

This qualitative study consists of eighteen transcribed patient interviews, which produced five unique symptom clusters that have significant implications for chaplain’s assessment practices. It originated from a need to make sense out of the plethora of psychospiritual symptoms caused by spiritual distress and fre-quently observed by hospital chaplains during visitation.2 In the medical tradition, signs and symptoms tell a story. They provide clues about the function or malfunctioning of vital life sustain-ing systems. The physician is trained to associate unique com-binations of symptoms with specific illnesses and to use this as a diagnostic aid.

Utilizing psychospiritual symptoms in a similar way uncovers exciting possibilities. It urges us, as chaplains, to address a very important question: how is the spiritual constellation of a patient impacted by spiritual distress?3 Answering this question requires comprehension of the composition of a complex responsive sys-tem called the “spiritual self.”4

Symptoms need to be understood both within the context of this system and as manifestations of a compromised spiritual self. Making sense of symptoms outside of this context is futile and leaves the chaplain/spiritual caregiver operating in a contextual

Louis Nieuwenhuizen MDiv MTh MS BCC serves as chaplain at Rogue Valley Medical Center, Medford, OR.

[email protected]

This article details application of a model developed by the author—the healing journey curve—which uses psychospiritual symptoms as a spiritual assessment aid. In this initial qualitative study, a questionnaire designed to identify symptoms present in each stage of the healing process was administered to eighteen patients. Five unique symptom clusters emerged, reflecting stages of the healing journey from the point of crisis to the establishment of a “new normal.” The results support the author’s hypothesis that disequilibrium in the spiritual self seems to cause stage specific spiritual distress symptoms.


vacuum.5 Spiritual care is poorly practiced when it reverts to such a band-aid approach to issues that de-fine the very core of the individual.

The author’s initial approach to this challenge was to create a mul-tilevel model of the spiritual self, superimposed with a schematic il-lustration of the transformational process involved in the healing journey. The resulting diagram sug-gested the occurrence of clusters of unique spiritual distress symptoms at distinctive phases of the healing process.

The author tested his initial the-ory against the lived experience of patients who were in the midst of transformative situations. Follow-ing is a brief review of the spiritual self and the healing journey curve, which were detailed in an earlier article published in the Journal of Pastoral Care & Counseling.6

The spiritual selfThe spiritual self is not separate

from the physical, psychological or social self; it is simply a natural, in-terconnecting dimension.7 An ever-growing body of scientific research supports the idea of multiple com-plex connections between the psy-chological, physical and spiritual components of individuals.8

In a rich academic history of more than 150 years, psychologists have argued that the deepest and most fundamental component of the self is to be found in everything from primal drives to societal influences to subjective experience to the in-dividual’s ability to learn to stable enduring characteristics. Support-ed by the work of Bowlby, Epstein, Kauffman and Janoff-Bulman, the author argues that the deepest and most fundamental component of the self is spiritual in nature and

that it is centered in the individual’s core beliefs.9

Core beliefs typically relate to the individual’s beliefs regarding fairness and justness of the world; meaningfulness of the world; trust-worthiness of others; safety of self and others; and self-efficacy, self-worth and expected future. They form the hard frame of the individual’s identity and shape the templates that represent the indi-vidual’s roles, habits and typical behavior.10

As explained in the JPCC article, the author posits that the spiritual self consists of three distinguish-able levels each containing a vital balance that helps to maintain equilibrium throughout the whole system:

• Core beliefs level, shaped by a balance between ex-isting core beliefs and ev-ery new experience.

• Personal and spiritual practice level, shaped by the balance between the “walk” and the “talk.”

• Skills level, which stays in-tact through the successful application of coping be-haviors to past or present situations.

The spiritual self finds its greatest equilibrium in the absence of spiri-tual distress symptoms. Conversely crisis or illness causes disequilib-rium, resulting in the appearance of spiritual distress symptoms. The author defines spiritual distress as a break or a disconnect due to over-stretched resilience, which renders one or more levels of functioning unable to maintain an acceptable level of equilibrium. The presence

of spiritual distress symptoms of-ten leads to a permanent and pain-ful restructuring of the whole self system.11

The healing journey curveThe healing journey curve works

in close conjunction with the multi-tiered spiritual self but repre-sents a different dimension. While the spiritual self system may be labeled as a complex self-organiz-ing system primarily focused on discrepancy production and reduc-tion, the Healing Journey Curve acts as a process model, focused on tracking the individual’s progres-sion through the healing process. Self-organization is a term used in systems theory relating to the evo-lution of order from random parts based on the constellation of the environment. Albert Bandura’s so-cial cognitive motivational theory and Klein’s control theory explains how individuals can produce per-sonal goal-behavior discrepancies. The existence of such a discrepancy, whether self enforced or enforced by an external entity, creates a self-correcting tendency to reduce it.12

Prior to a crisis, life generally un-folds according to the individual’s expectations. The author refers to this state as the old normal. Then disaster strikes, overwhelming the individual’s coping mechanisms. Four stages of crisis may be identi-fied. (See Figure 1, p. 5.)

1. Period of mounting ten-sion and disorganization.

2. Gathering and mobiliza-tion of resources.

3. Application of these re-sources and adaptation to new circumstances.


4. Stabilization and settling into a new normal, frequent-ly experienced as a changed and often more refined level of functioning.13

Erikson discusses the impor-tance of the successful nego-tiation of certain developmental tasks in order for an individual to progress through lifetime de-velopment. Once the individual solves these stage specific devel-opmental tasks s/he progresses to the next and more advanced de-velopmental stage.14

Superimposing this curve on the multi-tiered spiritual self gener-ates a multidimensional model that specifically explains the spiri-tual dynamics experienced by an individual during times of crisis. The healing journey diagram is specifically tailored as a micro slice of a patient’s spiritual movement

through a trauma induced healing process.

Where authors like Erikson and Fowler did valuable work on life-time developmental processes, this model is focused on explaining and assessing only a single crisis induced transformational process, making it ideal for use in the hospital en-vironment. The six stages coincide with the different levels of the spir-itual self. It presents the assessor with a schematic of the individual’s sequential progression through the healing process and begs the ques-tion about the association between psychospiritual symptoms and specific stages of the journey. The answer to this question has sig-nificant implications for chaplain’s assessment practices. The healing journey diagram maps the healing path indicating the spiritual work done by those in crisis in each of

the levels of the three-tiered spiri-tual self.15 (See Figure 2, p. 6.)

Background and literature review

As the practice of spiritual care is a developing discipline, there are many voices asking for more re-search based assessment tools and intervention strategies.16 A litera-ture search reveals a host of spiritu-al care assessment tools and models of intervention. Few, however, are backed by published research re-sults or present explicit anthropo-logical or personality theories that underly their assumptions.17 Even fewer present process models fo-cused on the spiritual/emotional healing process.18

Although healing process models related to grief, crisis management and myth do exist, they rarely in-corporate the role of deep-seated

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spiritual beliefs and the process of utilizing and or adjusting these beliefs. The author could not find any research-based models that both integrate spiritual beliefs into the healing process and explain the impact thereof on the individual’s personality structure.

Extensive work has been done within the disciplines of trauma-tology and grief to group and label physical and psychological reaction or symptoms related to adverse events. However, while they rec-ognize the existence of a spiritual dimension, these disciplines seem to be content with using psycho-logical verbiage in their reference to distress.19 Within healthcare, nurs-ing and psychiatry have created aca-demic definitions and lists of symp-toms related to spiritual distress, viewing it as a part of total pain.20

Over the past two decades, pastoral care’s need for a better understanding of spiritual pain has produced a flurry of published work, most of which fo-cuses on a core cluster of spiritual dis-tress symptoms arising out of loss of relationship, of meaning, of purpose and/or of hope.21 These usually are accompanied by feelings of anxiety, anger, confusion, loneliness, ques-tioning, guilt, shame, bitterness and/or despair.22 Though these symptoms ring true as authentic spiritual distress symptoms, they rarely are presented in a systematic way.

Alleviating spiritual distress The challenge surrounding the ques-

tion of spiritual distress symptoms is twofold: identification of symptoms and their informative value. Pastoral care literature and research seem to provide a means for the first; how-ever, exactly how these symptoms in-form and guide pastoral care practice continues to evolve.

A reforming healthcare system in the United States is moving away from a reactive paradigm focused on the relief of symptoms and toward a more proactive empha-sis on etiology and prevention.23 These two paradigms essentially differentiate themselves by the way they observe and utilize symp-toms. The former is based on two assumptions:

1. Symptoms experienced by a patient inform the practitioner that the individual is ill.

2. Once these symptoms are successfully treated, the patient is no longer ill.

Alternatively, a healthcare approach focused on etiology and prevention has three very different assumptions:

1. Symptoms inform the practitioner that something is wrong.

2. The practitioner uses these symptoms to arrive at a causal understanding of why an individual’s system produces this particular combination.

3. The practitioner treats the cause, rather than the symptoms, in the assumption that the symptoms will subside once the problem is treated successfully.

In a reforming and evolving spiri-tual care discipline, the challenge becomes one of identifying spiri-tual distress symptoms and under-standing what these symptoms are communicating about the dynam-ics within the spiritual self.

In his quest to listen for and to understand the language of spiri-

tual distress symptoms, the author hypothesized that disequilibrium on the different levels of the spiri-tual self causes stage specific spiri-tual distress symptoms. His pri-mary objective in this study was to identify them.

Study design and methodsThis preliminary study was ex-

plorative and phenomenological in nature. Intentional sampling was used to capture a target popu-lation of patients in Rogue Valley Medical Center of Southern Or-egon. Patients were recruited from cardiac, medical, oncology and postsurgical units as these are the open floor units most frequently served by pastoral care. Patients admitted to these units typically are conscious and do not experi-ence immediate acute life-threat-ening traumatic events.

Recruitment focused on patients requesting chaplain support as the working assumption was that they were most likely to be in crisis and would therefore display spiritual distress symptoms. This population was narrowed by asking recruiters to make interview requests only to those patients who verbalized a cri-sis experience related to their hos-pitalization.

Due to Institutional Review Board (IRB) requirements, interviewers were not permitted to assume both the roles of spiritual care provider and interviewer. Thus, chaplains providing normal spiritual care and therefore involved in recruitment referred patients to one of four board certified chaplains (BCCs), who conducted the interviews.

Ultimately, twenty-eight requests were made to patients within a five-week period. Eighteen agreed to par-ticipate and completed audio-taped


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interviews. Ten were female, and eight were male. They ranged in age from fifty-two to seventy-six.

Patients were asked twelve open-ended questions which probed for psychospiritual symptoms. These questions were designed to identify those symptoms presenting them-selves in each of the stages of the healing process. (See p. 14 for a copy of the questionnaire.)

Stage one questions pertained to the individual’s first reaction to the crisis. This stage of the healing journey overlaps with the first level of the spiritual self and occurs as the individual’s coping mechanisms are overwhelmed by the crisis at hand.

Stage two of the healing journey overlaps with the second level of the spiritual self and relates to the individual’s attempt to maintain balance between current personal or spiritual practice assumptions and the application thereof. Ques-tions focused on the appearance of psychospiritual symptoms result-ing from the impulse to cling to or to question existing spiritual prac-tice assumptions and probed for fears of loss.

Stage three, which overlaps with the third level of the spiritual self, is concerned with the balance be-tween core beliefs and real life ex-perience.24 Core beliefs are formed through the integration and mean-ingful organization of the sum of an individual’s cognitive and expe-riential memories. They continue to be shaped by in-the-moment experiences and hope or dreams for the future.

As a result of this massive in-tegration campaign, core beliefs frequently are hard to call to the conscious mind. They are general, abstract, show perseverance even in the face of contradictory evidence

and seem to be hierarchically orga-nized in terms of value to the indi-vidual. They form the hard frame of the individual’s identity and shape the templates that represent the individual’s roles, habits and typical behavior. Core beliefs typi-cally relate to the individual’s be-liefs with regard to the following:

• Fairness and justness of the world.

• Meaningfulness of the world.

• Trustworthiness of others.

• Safety of self and others.

• Self-efficacy and self-worth.

The question pertained to the contemplation of whether deep personal change was occurring.

Stage four, still located within the third level of the spiritual self, relates to the reconstruction of compro-mised core beliefs. The questions at this stage inquired about core belief adjustments, moving from con-templation of whether change was occurring to the individual’s experi-ence of the change and its effect.

Stage five represents the recon-struction of roles and habits within the personal and spiritual prac-tice level—the second level of the spiritual self. The question for this stage focused on intended changes in roles and habits, i.e., what will be different.

Stage six coincides with the re-structuring of the skills level—first level of spiritual self—and relates to adjusted coping strategies, i.e., the new normal. The question focused on how the individual would han-dle a similar situation in the future.

As a result of their differing stages of progression through the healing journey curve, not all patients were

able to answer all questions. All in-terviews were transcribed to paper and digital format. Additional de-mographic details were logged, and all confidentiality protocols were followed.

Psychospiritual symptoms ex-pressed during the interviews were grouped by stage. The raw data was processed by three of the BCC in-terviewers, who identified the types of pscychospiritual symptoms oc-curring within each stage.

OutcomesAlthough there was some over-

lap between responses to different questions, five unique symptom clusters emerged. (See Figure 3.)

Stage one symptoms were divided into three subgroups: emotional, embodied and intuitive. Emotional symptoms included, anger, stress, crying, fear and anxiety. Embod-ied symptoms included physical pain, anxiety and eczema. Intuitive symptoms included the feeling that the individual knew that some-thing was wrong or was going to happen. Symptoms not expressed by the study population that may fall into this category include the following: numbness, labile emo-tions, diminished mental capacity, eating/sleeping disturbances, head-aches, weight gain/loss.

Stage two symptoms also were divided into three subgroups: emo-tional, embodied and questioning. Emotional symptoms included guilt, shame, fear, depression and feeling trapped. Issues related to guilt and forgiveness are central to the Christian tradition. A recent study indicates that forgiveness training actually lowers a patient’s blood pressure.25 Embodied symp-toms generally were expressed as a feeling of being worn out. The


questioning subgroup was voiced as why me, what did I do to deserve this, could I have done something differently as well as doubt relating to God and feelings of abandon-ment.26 An additional potential sub-group is loss of hope.

Stage three symptoms were divid-ed into two subgroups: emotional and loss of meaning. Emotional symptoms included feeling terri-fied, angry and frustrated. Loss of meaning symptoms related to disil-lusionment, disbelief and seeing no purpose in current reality. Another potential sub-group is loss of self, which relates to the loss of “who or what I once was.” This essentially acknowledges that “I will never be the same.”

All of the above-mentioned symp-toms seem to be characterized by a negative, painful and deconstruct-ing ambiance. Although this was to be expected in an inquiry about spiritual distress symptoms, re-spondents also expressed positive, reconstructing effects based on the situation at hand.

Stage four produced positive symptoms that may be subdivid-ed into two groups: emotional and the construction of mean-ing. Emotional symptoms such as being more emotional and being grateful or thankful were recorded. Responses relating to the construction of meaning in-cluded statements such as the following:

• It was a learning process.

• It was a maturational experience.

Some also spoke of finding a new focus or mission in life.

Stage five questions also produced positive symptoms relating to new intended habits or behavioral pat-

terns. Patient responses included the following:

• I am not going to hold back any more.

• I am going to be more concerned about others.

• I will be obedient to God.

DiscussionThe data collected in this study

provide the opportunity to iden-tify and group patient reported symptom clusters, creating several points of reference along the heal-ing journey curve. In Figure 3, cluster one represents initial shock reactions to traumatic situations frequently observed in emergen-cy departments (EDs) across the country.

Cluster two also manifests sig-nificant emotional and embodied symptoms; however, it is differ-entiated from the initial numb-ing shock reaction by displaying greater cognitive processing. In-dividuals attempt to make sense of their predicaments by evalu-ating existing habits, behavioral patterns or even God’s intentions against the immediate disorient-ing experience. Their inability to provide immediate answers to these questions may result in loss of hope symptoms.

In cluster three, the emotional symptoms show a greater empha-sis on the experience of loss and the acknowledgement that the “old me” may have changed for-ever. This symptom cluster pri-marily relates to the individual’s existential identity, implying that a painful change may be immi-nent in what is normally a safe and stable sanctuary.

Loss of meaning and/or loss of self symptoms alert the chaplain to

a disconnect at the individual’s ex-istential core. This symptom clus-ter should not be confused with cluster two where the individual’s attention is focused on personal and spiritual practice—the “how to” of the spiritual self. This level is concerned with the “being” and identity of the spiritual self and should be treated as such by the chaplain, who must guard against anecdotal “how to” advice.

Cluster four symptoms indicate a significant transformation in the core beliefs or the being of the spir-itual self—essentially a change in identity. The individual’s assump-tive world is rearranged and adjust-ed in order to incorporate the crisis causing situation into the existing view of self, the world and being-in-the-world. Once this work has been completed, the individual may look back on it as a learning experience, which has produced gratefulness for the refinement or recreation of the self. This often takes the form of a new mission or focus in life.

An individual who presents cluster three symptoms, finds him/herself in the dark night of parting with that which previously provided meaning and stability, and ultimate-ly experiences the deconstruction of the spiritual self. It is only through accepting the death of the old self that the reconstruction associated with the birth and excitement of the new spiritual self may begin.

Cluster five is a natural response to the transformation that oc-curs at the core beliefs level. These symptoms represent new behavior-al intentions, the hope of a better future and a greater inner ability to deal with future crises.

The structure and sequence of these five symptom clusters illuminates


three important psychospiritual dy-namics within the spiritual self:

1. Deconstruction and reconstruc-tion of the spiritual self

There is a clear distinction be-tween the deconstruction and the reconstruction of the spiritual self following a traumatic situation reaching its critical mass for an individual.27 Clusters one through three, characterized by discomfort and inner turmoil, represent disori-entation and deconstruction.

Clusters four and five, character-ized by a new creative lease on life and hope for the future, represent reorientation and reconstruction. This natural and ancient death and rebirth rhythm occurs numerous times throughout any person’s life and must be understood and as-sessed accurately by chaplains.

2. Difference between “doing” and “being” functions

This dynamic relates to the dif-ference between level two symp-toms, i.e., the “doing” functions, and level three symptoms, i.e., the “being” functions, of the spiritual self. Being relates to the individu-al’s existential identity. As several studies have found correlations between existential well-being and spiritual or religious well-be-ing, it is clear that the content and structure of identity forming core beliefs is an important con-sideration.28

Thomas Webb affirms this con-clusion by explaining that the re-covery from spiritual symptoms is central in an individual’s identity.29 It is therefore important to under-stand that being is the bedrock of the spiritual self, which shapes and informs doing. Though they can-not be separated, this distinction needs to be clear.

3. Transformation of the individu-al’s core beliefs

The third and most crucial psy-chospiritual dynamic plays out within the core beliefs level, the being domain. It is evidenced by the transition from cluster three to four, which represents a trans-formation of the individual’s core beliefs and indicates an essential change in identity. In nursing and psychological language, this magi-cal transformation has been re-ferred to as self-transcendence or struggle and breakthrough.30

Vladimir Prop refers to it as the struggle and victory found in ancient hero folklore stories.31 Christian Scripture refers to this transitional process through a variety of stories and metaphors, e.g., the prodigal son, the parable of the seed that must die in order to grow, Jacob’s name change fol-lowing his struggle with the angel and, finally, the death and resur-rection of Jesus Christ.

Participants in a phenomeno-logical study conducted by Carol Smucker explained their transfor-mation by describing spiritual dis-tress as a time of increased emo-tional vulnerability and openness to change.32 Indeed, such transfor-mation seems to be characterized both by change and by stability.

Change within the core self im-plies a partial reconstruction of the whole rather than a total re-placement of the old self. There needs to be some stability of being to create an environment within which the altering process may occur. Change and stability therefore should not be seen as contradictory or opposing forces, but rather as intertwined trans-formational agents.33

Conclusion This study was a first attempt to

associate research data with a re-cently developed model. Though the sample size was small, the re-sults were congruent with the au-thor’s model as well as with other literature. Further, the outcomes of this study support the author’s pri-mary hypothesis. Disequilibrium in the spiritual self does seem to cause stage specific spiritual distress symptoms.

The next step is replication of this study with larger populations and more finely tuned research de-signs aimed at further exposing the dynamics involved in the healing journey. Such continuing research may provide deeper insights that not only strengthen the discipline of pastoral care but also answer the call for well grounded, authentic spiritual assessment theories.

The author’s primary goal in the application of this data lies in the area of spiritual assessment. To that end, he invites those engaged in the topic to participate in the debate and development of more uniform and widely used spiritual assess-ment instruments.34

References1 Louis Nieuwenhuizen, “Spiritual care illustrated: Creating a shared language,” Journal of Pastoral Care & Counseling 61, no. 4 (2007): 329-41.

2 Mark Bartel, “What is spiritual? What is spiritual pain?” Journal of Pastoral Care & Counseling 58, no. 3 (2004): 187-200.

3 Siroj Sorajjakool et al., “Chronic pain, meaning and spirituality: A qualitative study of the healing process in relation to the role of meaning and spirituality,” Journal of Pastoral Care & Counseling 60, no.4 (2006): 369-78; Paul L. Kimmel, Seth L. Emont et al.,


“ESRD patient quality of life: Symp-toms, spiritual beliefs psychosocial fac-tors and ethnicity,” American Journal of Kidney Diseases 42, no. 4 (2003): 713-21, found that pain, along with psychosocial and spiritual factors, is an important determinant of quality of life for patients in their study.

4 K. Dooley, Complex Adaptive Sys-tems, Arizona State University, 1996. http://www.eas.asu.edu/~kdooley /casopdef.html

5 Denice Adcock Colson, Stop Treat-ing Symptoms and Start Resolving Trauma (Bloomington, IN: Author-House, 2004).

6 Nieuwenhuizen, “Spiritual care.”

7 Larry VandeCreek and Laural Burton, “Professional chaplaincy: Its role and im-portance in healthcare” The Journal of Pas-toral Care 55, no. 1 (2001). In this white paper, the authors state that the Spirit is a natural dimension of every person.

8 Antonio Damasio, Descartes Error: Emotion Reason and the Human Brain (New York: Putnum Berkley Group, Inc., 1994); Joseph E. LeDoux, The Emotional Brain (New York: Touchstone, 1996); Daniel Goleman, Emotional Intelligence (New York: Bantam Books, 1997); Can-dace Pert, Molecules of Emotion: The Sci-ence Behind Mind-body Medicine (New York: Scribner, 2003).

9 John Bowlby, Attachement and Loss, vol. 1 (London, Pimlico edition: Ran-dom House, 1997); S. Epstein, “The self-concept: A review and the proposal of an integrated theory of personality,” in Personality: Basic Issues and Current Research (Englewood Cliffs, NJ: Pren-tice-Hall, 1980); Jeffrey Kaufman, Loss of the Assumptive World (New York: Brunner-Routledge, 2002); Ronnie Janoff-Bulman, Shattered Assumptions: Towards a New Psychology of Trauma (New York: The Free Press, 1992).

10 George S. Everley, Rob Dewey et al., Pastoral Crisis Intervention Course Work-book (Ellicott City, MD: International Critical Stress Foundation, Inc., 2002);

Janoff-Bulman, Shattered Assumptions.

11 W. S. Overcash, L. G. Calhoun et al., “Coping with crisis: an examina-tion of the impact of traumatic events on religious beliefs,” Journal of Genetic Psychology 157, no. 4 (1996), 455-64; F. F. MacDonald, “Social work notes: Crisis for change,” Annals of the Amer-ican Psychotherapy Association (2002), M. I. Fischer, “From crisis to growth: Race, culture, ethnicity, conflict and change,” Education (Winter 2003); K. Erin, “Embracing crisis and culti-vating change: Engle and Glass facili-tate seminars on life transformation,” Des Moines Business Record December 2003; B. K. Ritchie, “Progress through setback or mired in mediocrity? Crisis and institutional change in Southeast Asia,” Journal of East Asian Studies (May 2005).

12 See Stuart Kauffman’s landmark 700-page book, The Origins of Or-der: Self Organization and Selection in Evolution (New York: Oxford University Press, 1993); also Neil Anderson et al., Handbook of Indus-trial, Work & Organizational Psy-chology, vol. 2 (London: Sage Publi-cations, 2001): 64-68.

13 Alan Rosen, “Crisis management in the community,” Medical Journal of Australia 167 (1997): 633-38; Coenie Burger, Ge-meentes in Transito (Cape Town, South Africa: Lux Verbi, 1995): 28-35.

14 See D. A. Louw, D. M. Van Ede and A. E. Louw, Menslike Ontwik-keling (Pretoria, South Africa: Kagiso Publishers, 1998); Nieuwenhuizen, “Spiritual care”; Daniel J. Louw, Illness as Crisis and Challenge: Guidelines for Pastoral Care (Doornfontein, South Africa: Orion Publishers, 1994).

15 Nieuwenhuizen, “Spiritual care.”

16 Larry VandeCreek, Hilary Bender and Merle Jordan, Research in Pastoral Care and Counseling: Quantitative and Quali-tative Approaches (Journal of Pastoral Care Publications, Inc., 1994): XI.

17 Thomas St. James O’Connor, Kath-

leen O’Neill et al., “Not well known, used little and needed: Canadian chaplains’ experiences of published spiritual assessment tools,” Journal of Pastoral Care & Counseling 59, no. 1-2 (2005): 97-109.

18 Dennis Kenny, Promise of the Soul (New York: John Wiley & Sons, 2002) addresses the process of the restoration of spiritual covenants.

19 Elizabeth Kubler-Ross, On Death and Dying (New York: Macmillan, 1969); Numerous internet sites, e.g., http://emotional.health.ivillage.com/depres-sionbipolar/grief4.cfm, list a plethora of grief related symptoms; Thomas Webb, “Assessing a crisis of faith and making a pastoral crisis intervention,” International Journal of Emergency Mental Health 3, no. 3 (2001): 181-86; Kenneth Doka, “Loss and the spiritual ssumptive world: How could God?” in Loss of the Assumptive World: A Theory of Traumatic Loss (New York: Brunner-Routledge, 2002), 49-55.

20 Gertrude McFarland and Elizabeth McFarland Nursing Diagnoses and In-tervention: Planning for Patient Care (St. Louis: Mosby, 1996), 852; www .learnwell.org health and ethics cours-es; The Emotional and Spiritual Care Committee of the National Volun-tary Organizations Active in Disaster (NVOAD) outlines a list of fourteen spiritual symptoms that may be ob-served during times of crisis; Ameri-can Psychiatric Association, Diagnostic Criteria From DSM IV (Washington DC: American Psychiatric Association, 1994); David Lukoff, “From spiritual emergency to spiritual problem: The transpersonal roots of the new DSM-IV category” Journal of Humanistic Psychology 38, no. 2 (1998): 21-50.

21 J. Georgesen and J. M. Dungan, “Managing spiritual distress in pa-tients with advanced cancer pain,” Cancer Nursing 19, no. 5 (1996), 376-83, shows that grief was a character-istic of spiritual distress experienced by all patients in their study; Georgia Gojmerac-Leiner, “Revisiting Vic-


tor Frankl: His contributions to the contemporary interest in spirituality and health,” Journal of Pastoral Care & Counseling 59, no. 4 (2005); Vic-tor Frankl, Man’s Search for Meaning: An Introduction to Logotherapy (Lon-don: Hodder and Stoughton, (1982); Christine Kennedy, “Spiritual distress at life’s end: Finding meaning in the maelstrom,” Journal of Pastoral Care and Counseling 57, no. 2 (2003), 131-41; L. H. Heyse-Moore, “On spiritual pain in the dying,” Mortality 1, no. 3 (1996), 297-315, which regards mean-inglessness, anguish, duality and dark-ness as the primary spiritual distress symptoms; Bartel, “What is Spiritual?” which provides a meta-analysis of what the author terms the five spiritual needs—love, faith, hope, virtue and beauty; spiritual suffering arises when these needs go unmet.

22 Laura Waters Jackson, “PAUSE for as-sessment: A multi-level long-term care assessment tool,” Journal of Pastoral Care & Counseling 58, no. 1-2 (2004).

23 L. G. Seidl, “The value of spiritual health,” Health Progress 74, no. 7 (Sep 1993): 48-50.

24 Janoff-Bulman, Shattered Assump-tions; Craig A. Anderson, B. Lynn New

and James R. Speer, “Argument avail-ability as a mediator of social theory perseverance,” Social Cognition 3, no. 3 (1985), 235-49; Rachel Naomi Re-men, My Grandfathers Blessings (New York: Riverhead Books, 2000); Everley et al., Pastoral Crisis Intervention.

25 Greg Ellis, Chris Piramelli et al. “Hypertension reduction through forgiveness training,” Journal of Pas-toral Care & Counseling 60, no. 1-2 (2006), 27-35.

26 Carol Smucker, “A phenomeno-logical description of the experience of spiritual distress,” Nursing Diagnoses 7, no. 2 (1996), 81-91 showed that ques-tioning or wondering is an integral part of the deconstruction process.

27 Ibid., also found a significant distinc-tion between what she calls “breaking [and rebuilding] the web of life,” which consists of three phases: falling apart, wondering and something beyond.

28 D. Edmonson, C. L. Park et al., “Deconstructing spiritual well-being: existential well-being and HRQOL in cancer survivors,” Psycho-Oncology (2007), e-published ahead of print.

29 Webb, “Assessing a crisis of faith.

30 Lisa M. Wayman and H. Lea Barba-to Gaydos, “Self-transcending through suffering” Journal of Hospice and Palli-ative Nursing 7, no. 5, (2005), 263-70; Wendy C. Budin, “Birth and death: Opportunities for self-transcendence,” Journal of Perinatal Education 10, no. 2 (2001), 38-42; Harry R. Moody and David Carroll, The Five Stages of the Soul (London: Rider, 1997).

31 Vladimir Propp, Morphology of the Folktale, 2nd ed., trans. Lawrence Scott (Austin, TX: University of Texas Press, 1968).

32 Smucker, Phenomenological.

33 A. K. Siti-Nabiha and Robert W. Scapens, “Stability and change: an in-stitutionalist study of management ac-counting change,” Accounting, Audit-ing and Accountability Journal 18, no. 1 (2005), 44-73.

34George Handzo and Harold G. Koe-nig, “Spiritual care: Whose job is it anyway” Southern Medical Journal 97, no. 12 (December 2004), 1242-44; Paul W. Pruyser, The Minister as Diag-nostician (Philadelphia: The Westmin-ster Press, 1976).


Interviews were begun with introduction of the interviewer and a description of the study. Permis-sion to audio tape the interview was requested. The consent form was discussed and the patient’s signature obtained.

The following questions were asked to trace the patient’s movement through the healing curve to his/her current stage.

Stage one:What is happening with you at the moment?Have you ever had to deal with something like this before?Tell me about your first reactions caused by this situation?

Stage two:How do you cope with this situation?How do you typically cope with stressful situations in your life?What is it that you hold on to in this situation? How does this situation challenge “what you hold on to?”

Stage three:What is it that you are most afraid of losing? Is this experience changing you?

Stage four:How has this experience changed you?What do you experience when change happens to you?

Stage five:What will be different in your life?

Stage six:What would you do differently if you hypothetically had to deal with the same situation again?

Psychospiritual symptoms in times of crisisQuestionnaire


IN DECEMBER 2001, REPRESENTATIVES FOR THE LEADING END-OF-LIFE organizations came together to discuss palliative care guide-lines. From this meeting emerged the National Consensus

Project for Quality Palliative Care (NCP), consisting of members from the Hospice and Palliative Nurses Association (HPNA), the American Academy of Hospice and Palliative Medicine (AAHPM), the National Hospice and Palliative Care Organiza-tion (NHPCO), the Center for the Advancement of Palliative Care (CAPC), and the Partnership in Caring: America’s Voice for the Dying. With the intention of describing optimal pallia-tive care as well as providing a foundation for education and re-search in the United States, the NCP released the Clinical Prac-tice Guidelines for Quality Palliative Care in April of 2004.1 The guidelines delineate eight domains of quality palliative care with criteria for implementation. (See Table 1, p. 16.)

This article demonstrates how the guidelines and preferred prac-tices may be operationalized in practice, focusing specifically on Domain 5 of the guidelines, “Spiritual, Religious and Existential Aspects of Care.” This domain incorporates many pertinent as-pects of hospice and palliative care related to addressing the spiri-tual needs of the dying patient and his/her family. In particular, the article addresses methods for assessing need for spiritual care,

This article demonstrates how guidelines and preferred practices for quality palliative/hospice care, written by the National Consensus Project and the National Quality Forum, may be operationalized. It focuses specifically on Domain 5 of the guidelines, “Spiritual, Religious and Existential Aspects of Care.” Included are methods for assessing need for spiritual care and for communicating with patient/family about such need; role of the spiritual advisor on the interdisciplinary team and the advantages of including certified chaplains; need for sensitivity toward cultural/religious diversity in administering spiritual care; and relationship building with community clergy.

The National Agenda for Quality Palliative Care:

The Essential Elements of Spirituality in End-of-life Care

Katrina Scott • Mary Martha Thiel BCC • Constance M. Dahlin

Katrina Scott MDiv serves as oncology chaplain at Massachusetts Gen-eral Hospital, Boston, MA. An officiant in the Ethical Society of Bos-ton, she is endorsed by the American Ethical Union (Ethical Culture). The Reverend Mary Martha Thiel MDiv BCC is director of clinical pastoral education at Hebrew SeniorLife, Boston, MA. An ACPE su-pervisor, she is endorsed by the United Church of Christ. Constance Dahlin MSN APRN BC ACHPN is clinical director, palliative care ser-vice at Massachusetts General Hospital Boston, MA. She also serves as editor of the National Consensus Project for Quality Palliative Care Do-main Series.

[email protected] [email protected] [email protected]


methods for communicating with the patient and family about spiri-tual care needs; role of the spiritual advisor on the interdisciplinary palliative care team; advantages of including certified chaplains on the palliative team; need for sensitivity toward culture and religious diver-sity in administering spiritual care and need for specialized palliative care spiritual advisors to build rela-tionships with community clergy.

In 2006, the National Quality Fo-rum (NQF) used the NCP guide-lines as a basis for its document, A National Framework and Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report.2 Significantly, NQF accepted and endorsed NCP’s definition of pal-liative care as “family- and patient-centered care that optimizes quality of life by anticipating, preventing and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and facilitating pa-tient autonomy, access to informa-tion and choice.”

This framework/practices docu-ment articulates thirty-eight evi-dence-based preferred practices developed from the eight domains of the guidelines. These preferred practices provide assessment crite-ria that allow for measurement and evaluation of quality of care, while identifying areas for research that apply both to hospice and to pal-liative care across settings of care, as well as to all members of the inter-disciplinary healthcare team.

Domain 5 of the guidelines address-es spiritual, religious and existential aspects of care. Spiritual care provid-ers are identified as integral members within the interdisciplinary palliative care team and therefore need to

Table 2

National Quality ForumPreferred practices associated with spirituality

20 – Develop and document a plan based on assessment of reli-gious, spiritual and existential concerns using a structured instru-ment and integrate the information obtained from the assessment into the palliative care plan.

21 – Provide information about the availability of spiritual care services and make spiritual care available either through organi-zational spiritual counseling or through the patient’s own clergy relationships.

22 – Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained and certified in palliative care.

23 – Specialized palliative and hospice spiritual care professionals should build partnerships with community clergy, and provide education and counseling related to end-of-life care.

24 – Incorporate cultural assessment as a component of compre-hensive palliative and hospice care assessment, including, but not limited to, locus of decision making, preferences regarding dis-closure of information, truth telling and decision making, dietary preferences, language, family communication, desire for support measures such as palliative therapies and complementary and alter-native medicine perspectives on death, suffering and grieving and funeral/burial rituals.

Table 1

National Consensus Project for Quality Palliative Care Clinical practice guidelines for quality palliative care

Domain 1: Structure and Processes of Care

Domain 2: Physical Aspects of Care

Domain 3: Psychological and Psychiatric Aspects of Care

Domain 4: Social Aspects of Care

Domain 5: Spiritual, Religious, and Existential Aspects of Care

Domain 6: Cultural Aspects of Care

Domain 7: Care of the Imminently Dying Patient

Domain 8: Ethical and Legal Aspects of Care


a four-level competency model for spiritual assessment and care based on the individual competence of all healthcare professionals and vol-unteers involved in patient/family care as follows:

• Level 1 – all staff and vol-unteers with casual contact with patients/families.

• Level 2 – all staff and vol-unteers whose duties re-quire contact with patients and families/caregivers.

• Level 3 – staff and volun-teers who are members of the multidisciplinary team.

• Level 4 – staff or volunteers whose primary responsibil-ity is for the spiritual and religious care of patients, visitors and staff.9

This core competency frame-work allows for spiritual/reli-gious/existential concerns to be thoroughly integrated into all aspects of care rather than func-tion as a subset of care. Tools for training and measuring compe-tencies at each level include but are not limited to the following: case reviews, seminars and chart reviews. They are facilitated by the healthcare team’s chaplain/spiritual care specialist.

Availability of servicesPreferred Practice 21: Provide in-formation about the availability of spiritual care services and make spir-itual care available either through organizational spiritual counseling or through the patient’s own clergy relationships.

In order to meet the various spir-itual needs of both patients and

understand both NCP guidelines and the NQF preferred practices. This article discusses five preferred practices associated with Domain 5. (See Table 2, p. 16.)

Overview of chaplaincy or spiritual care assessmentPreferred Practice 20: Develop and document a plan based on assessment of religious, spiritual and existential concerns using a structured instru-ment and integrate the information obtained from the assessment into the palliative care plan.

Spiritual care is considered a basic tenet of palliative care. The provision of continual end-of-life spiritual care is the responsibility of the entire palliative care/hos-pice team. Nonetheless, the clini-cal assessment of a dying person’s spiritual, religious, and existential needs must first be discerned be-fore the appropriate interventions may be made.

The palliative care team should complete an assessment during an initial evaluation. While the Joint Commission mandates spiritual as-sessments of patients and families, there are no specific requirements for a spiritual assessment. Thus, the specifics as to how spiritual as-sessments are performed and the response to spiritual issues are de-termined by the individual health-care organization.

During their initial meeting, a palliative care team member should ascertain the patient’s and his/her family’s spiritual/religious/existen-tial beliefs, practices, preferences and needs. This is often referred to as “taking a spiritual history.” A va-riety of formal assessment tools and guides have been designed to mea-sure and assess existential, religious

and spiritual beliefs and practices along with any associated commu-nity support of such practices.

One of the best known interview-ing tools for taking a spiritual his-tory is the four-point FICA (Faith, Importance/Influence of beliefs, Community involvement, and Ad-dressing issues in providing care).3 Another is the six-point SPIRITual History assessment (identifying Spiritual beliefs, Personal spiritual-ity, Integration in spiritual commu-nity, Ritualized practices, Implica-tions for medical care, and Terminal event planning).4

Standardized structured formats that are self-administered include the FACIT-Sp (the 12-item Func-tional Assessment of Chronic Ill-ness Therapy-Spiritual Well-Being which focuses on meaning/peace and faith) and SBI-15R (Systems of Belief Inventory which focuses on beliefs/practices and religious com-munity/support).5

Each of these spiritual assessment tools adequately identifies and ad-dresses the most frequent and im-portant qualitative questions raised by serious illness: those of meaning/purpose, death/dying, illness/pain, value/dignity, and relationship/for-giveness.6 Information entered into the patient’s medical record should be reviewed by a chaplain/spiritual care specialist. The chaplain then devises and implements a patient-focused spiritual care plan, which may or may not include faith/de-nomination-specific interventions.7

While these assessment tools are useful in providing valuable in-formation to the healthcare team, there remains the underlying co-nundrum of using a clinical model to assess or address the non-clinical realm.8 Gordon and Mitchell offer


families, it is essential to provide in-formation about available services. This should be multidimensional, reflecting the various formats avail-able for adult learning, e.g., written materials, Web sites with healthcare networks, and should incorporate verbal descriptions from health-care professionals. Any brochure or written information about support-ive care programs should include mention of the availability of spiri-tual care services as well as how to access them.

Ideally, the chaplain will meet ev-ery new patient to assess whether spiritual care may be welcome and helpful; however, the reality of staff-ing may preclude this. In the latter case, a palliative care team member should routinely offer these servic-es to the patient/family during the initial visit, just as they offer ser-vices from other disciplines. Docu-mentation of the patient’s and/or family’s responses should be made in the medical record as well as at team meetings.

If the patient or family declines spiritual care services at admission, it may be appropriate to again of-fer such services at a later date, par-ticularly at times when the patient begins working on such themes as love, forgiveness, hope, trust and meaning. This may be ac-complished through open queries such as the following: “Sometimes it really helps to explore those im-portant spiritual questions with a trained chaplain. Would you like me to ask our team’s chaplain to come by and visit?” In situations where the family is looking for re-sources to support them as their loved one grows closer to death, a member of the team may again of-fer spiritual care: “Our chaplain is really good at helping people figure

out what spiritual resources work for them. Would you like me to have her call?”

If at any point the patient or fam-ily requests that spiritual care ser-vices not be offered, this request should be documented in the chart and honored. The clinician might say, “We will be glad to honor your request. At any point you may ask for the service, and we will provide it, but we will not offer it again.”

The second element of this pre-ferred practice pertains to the ac-tual provision of professionals to provide spiritual care. The best method is for the palliative care or hospice program to hire a pro-fessional chaplain or spiritual care specialist. This provides the orga-nization control over the quality of spiritual care, as well as a guarantee of responsiveness and availability. Moreover, staff chaplains may col-laborate with the other disciplines in the care of patients and families and fully document their contribu-tions in the medical record.

Utilizing the patient’s own clergy relationship for primary spiritual care may be helpful to the patient and family if those relationships are positive and strong. Being known by the clergyperson may help the patient feel safe and understood. Prayer and ritual may be offered in the exact vernacular of the pa-tient. Moreover, knowing that the clergyperson will continue to sup-port family members through their bereavement often is comforting to the patient.

A number of risks, however, are inherent in relying solely on com-munity clergy. The patient/family may not have a solid congregational connection. The clergyperson may neither feel comfortable in health-care settings, nor be equipped with

the specialized spiritual care skills needed to support the dying and their families. This may result in their failing to respond to requests or doing so in a manner that is unhelpful to the patient/family. Many clergy have minimal train-ing in supporting people through bereavement. Clergy who lack the skills and/or confidence to min-ister in end-of-life situations, but who have pastoral relationships with patient/family members may be amenable to mentoring by the chaplain. This is an excellent role for a staff chaplain.

Training in palliative spiritual carePreferred Practice 22: Specialized palliative and hospice care teams should include spiritual care profes-sionals appropriately trained and cer-tified in palliative care.

Specialized palliative care and hospice teams should include pro-fessionally certified chaplains. Pro-fessional chaplains are trained to work within the worldview of the patient or family member, be that secular or religious, similar or dis-similar to their own religious be-liefs. They are capable of working across religious lines, with knowl-edge about spiritual care in many forms, rites and rituals. Chaplains are the spiritual care specialists on the team. However, if they are ap-propriately trained and comfort-able with the role, team members from other disciplines may serve as spiritual care generalists.10

In the United States there are currently three major professional organizations that certify chap-lains: the National Association of Jewish Chaplains (NAJC), the National Association of Catholic


local clergy may lead to sustained partnerships within a compassion-ate community that continues to offer supportive spiritual care not only at life’s end but also into the family’s bereavement.

Preferred Practice 24: Incorporate cultural assessment as a component of comprehensive palliative and hospice care assessment, including, but not limited to, locus of decision making, preferences regarding disclosure of information, truth telling and deci-sion making, dietary preferences, lan-guage, family communication, desire for support measures such as pal-liative therapies and complementary and alternative medicine perspectives on death, suffering and grieving, and funeral/burial rituals.

Optimal spiritual care should strive to conform to the personal and communal needs of the indi-vidual, especially at the end of life. Although spiritual/religious/exis-tential concerns vary from person to person and family to family, all necessarily entail a connectedness to something or someone that im-bues life with a sense of purpose or meaning.11

Cultural diversity mandates hon-oring the differences presented in the world community. Rather than an attempt to direct another’s life decisions, it is a convergence of mutual support, which respects the individual’s belief system, a funda-mental principle of empowerment. The hospice/palliative team should use the patient’s personal goals as measurement, accepting that the patient’s goals often are quite dif-ferent than theirs. For example, some culturally specific interven-tions that address and honor belief in the healing power of God’s will,

Chaplains (NACC) and the Asso-ciation of Professional Chaplains (APC). The first two certify chap-lains only within their respective faith traditions. The APC certifies chaplains from all faith traditions listed in the Yearbook of American and Canadian Churches, plus oth-ers by application and approval. Standards for certification in any of these organizations include the following: master’s level theologi-cal education, endorsement from one’s religious group, at least four units of clinical pastoral education (CPE) and a rigorous committee review process. Certification for palliative care specialists does not yet exist for chaplains. Although some CPE students choose to focus their advanced CPE learning on a specialty area, such as end of life, such clinical specialization is not required for certification.

Certified chaplains are required to pursue at least fifty hours of continuing education each year. Those working within palliative care should focus on educational experiences that further their de-velopment of a clinical specialty in end-of-life care. This may include work in hospices, palliative care services, cancer centers or within settings that serve patients with life-threatening illnesses.

Across the healthcare continuum, the cultural and religious diversity of patients/families is significant. It is important that chaplains develop a nuanced knowledge of the beliefs and behaviors of the populations served by their team. This knowl-edge will help chaplains to indi-vidualize care that addresses each person’s uniqueness. This degree of expertise, comfort and creativity is less likely to be found in a noncer-tified chaplain.

Specialized spiritual carePreferred Practice 23: Specialized palliative and hospice spiritual care professionals should build partner-ships with community clergy and provide education and counseling related to end-of-life care.

The strength of the team ap-proach in hospice/palliative care extends to building relationships with various faith/religious groups in the surrounding community. Pa-tients and families often have very specific religious needs. For many, the ability to attend services, re-ceive sacraments and/or participate in meaningful rituals and commu-nity gatherings is greatly curtailed as a disease progresses.

In order to meet both individual and communal needs, the chaplain establishes and facilitates contacts with community faith group lead-ers, e.g., minister, rabbi, imam, elder, monk, and programs, e.g., mediation groups, AA, other twelve-step programs, that con-nect, and in some cases reconnect, patients with their chosen faith/re-ligious traditions. Utilizing the re-sources in their communities, chap-lains direct patients and families to those with special competence and comfort in end-of-life issues.

In order to support community clergy in their provision of spiri-tual/religious care, the chaplain should implement multifaith out-reach programs both to promote open dialogue and to provide edu-cational opportunities focusing on end-of-life care. Some clergy may have completed a unit of CPE as part of their ordination process. Others may have extensive expe-rience providing pastoral care to patients and families within their congregations. Collaboration with


rather than a biomedical approach, may empower and contribute to the self-esteem, sense of control, and well-being of patients, espe-cially religious African Americans and Latinos.12

The chaplain should be well-versed in faith traditions represent-ed in the local patient demograph-ic; nevertheless, variations within an ethnic group may be as wide as those between groups. Asking the patient or family directly, “what is important to you at this moment?” helps to cross ethnic and cultural barriers. Awareness of the impor-tance of cultural expressions and symbols of religious and spiritual devotion, e.g., icons, prayer beads, should be encouraged and wel-comed in the palliative care/hos-pice setting.

The use of integrative therapies in patient care may include dietary restrictions, herbal remedies and other homeopathic treatments. The use of such therapies should be respected unless the healthcare team determines the patient would be harmed or that its use would in-terfere with proven beneficial ther-apies.13 Some patients and families with certain cultural backgrounds may have different views on the appropriateness of medical disclo-sures. They may request that the family become the gatekeepers of information, linking beneficence to family decision making over the value of personal autonomy.14 This is quite often the case with death rituals and funeral customs. For many cultures, death is viewed not as an instantaneous or individual act but as an organic and com-munal one, a natural connection that affects not only the immedi-ate family of the deceased but the entire community.

ConclusionThe goals of palliative care are to

prevent and relieve suffering and support the best possible quality of life for patients and their families. Spiritual care is an essential aspect of the delivery of palliative care. The diagnosis of a life-threatening illness often results in the person reflecting on the meaning of life with concomitant spiritual, reli-gious and existential questions. In fact, spiritual and religious needs and concerns may be equally, and sometimes more, important than those physical in nature. The NCP’s Domain 5, Spiritual, Re-ligious, and Existential Aspects of Care, and the associated NQF’s Preferred Practices underscore the importance of the spiritual domain as an integral and vital component of palliative care clinical practice.

The multidisciplinary team re-quires a specific skill set to support patients and families from various faith traditions and belief systems throughout the course of illness, the process of dying and its immediate aftermath. It is important that the palliative care staff be capable of recognizing a person’s spiritual and existential concerns, and that they be supported and trained by the professional chaplain or spiritual care specialist on the team. Several assessment tools have emerged to help practitioners at many levels.

Following the initial assessment, it is critical that professionally trained chaplains be available to provide continuing support to pa-tients and families, especially those with complex issues. In order to support patients along the con-tinuum of sites of care, chaplains should have a thorough knowl-edge of community resources out-side the healthcare system. All of

these interventions provide a ho-listic approach to help promote a collaborative process in attending to the various physical, psycholog-ical, social, and spiritual needs of patients at the end of their lives.

References1 National Consensus Project for Quality Palliative Care, Clinical Practice Guidelines for Quality Palliative Care (2004). www.nationalconsensusproject.org

2 National Quality Forum, A National Framework and Preferred Practices for Palliative and Hospice Care Quality (Washington, DC: National Quality Forum, 2006).

3 C. M. Puchalski and A. L. Rommer, “Taking a spiritual history allows cli-nicians to understand patients more fully,” Journal of Palliative Medicine 3, no. 1 (2000): 129-37; P. Storey and C. Knight, UNIPAC Two: Al-leviating Psychological and Spiritual Pain in the Terminally Ill (American Academy of Hospice and Palliative Medicine, 2003).

4 T. A. Maugens, “The SPIRITual his-tory,” Archives of Family Medicine 5 (1996): 11-16.

5 A. H. Peterman, G. Fitchett, M. J. Brady, L. Hernandez and D. Cella, “Measuring spiritual well-being in people with cancer: The functional assessment of chronic illness therapy-spiritual well-being scale.” Annals of Behavioral Medicine 24 (2002): 49-58; J. C. Holland, M. Kast, S. Passik et al., “A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness,” Psycho-Oncology 7 (1998): 460-69.

6 S. Strang and P. Strang, “Questions posed to hospital chaplains by palliative care patients,” Journal of Palliative Medi-cine 5, no. 6 (2002): 857-64; D. Sulmasy, “Spiritual issues in the care of dying pa-tients ‘...it’s okay between me and God,’” JAMA 296, no. 11 (2006): 1385-92.


7 L. VanderCreek, “Spiritual assess-ment: Six questions and an annotated bibliography of published interview and questionnaire formats,” Chaplain-cy Today 21, no. 1 (2005): 11-22.

8 J. Cassidy and D. Davies, “Cultural and spiritual aspects of palliative med-icine,” Oxford Textbook of Palliative Medicine (Oxford, England: Oxford University Press, 2004), 951-57.

9 T. Gordon and D. A. Mitchell, “A competency model for the assessment and delivery of spiritual care,” Pallia-tive Medicine 18, no. 7 (2004): 646-51. These competencies are promot-ed by Marie Curie Cancer Center’s “Spiritual & Religious Care Compe-tences for Specialist Palliative Care”

(www.mariecurie.org.uk/healthcare) and supported by the Association of Hospice and Palliative Care Chap-lains (AHPCC).

10 M. R. Robinson, M. M. Thiel, M. M. Backus and E. C. Meyer, “Matters of spirituality at the end of life in the pediatric intensive care unit,” Pediat-rics 118 (2006): 719-29.

11 H. M. Chochinov and B. J. Cann, “Interventions to enhance the spiritual aspects of dying,” Journal of Palliative Medicine 8 (2005):103-15.

12 T. Balboni, L. Vanderwerker, S. Block, M. Paulk, C. Lathan, J. Peteet and H. Prigerson, “Religiousness and spiritual support among advanced

cancer patients and associations with end-of-life treatment preferences and quality of life,” Journal of Clinical Oncology 24, no. 5 (2007): 555-60; J. Swinney, “African Americans with cancer: the relationships among self-esteem, locus of control, and health perception,” Research in Nursing & Health 25 (2002): 371-82.

13 E. D. Pellegrino, “Ethical issues in palliative care,” Handbook of Psychia-try in Palliative Medicine, (Oxford, England: Oxford University Press, 2000), 337-56.

14 A. N. Siriwardena and D. H. Clark, “End of life care for ethnic minority groups,” Clinical Cornerstone, Diver-sity in Medicine 6 (2004): 43-48.


When people are overwhelmed by illness, we must give them physical relief, but it is equally important to encourage the spirit through a constant show of love and compassion. It is shameful how often we fail to see that what people desperately require is hu-man affection. Deprived of human warmth and a sense of value, other forms of treatment prove less effective. Real care of the sick does not begin with costly procedures, but with the simple gifts of affection, love, and concern. His Holiness, The Dalai Lama Time for Listening and Caring

THE PERPETUALLY DEBILITATING EFFECTS of amyotrophic lat-eral sclerosis (ALS), also known as Lou Gehrig’s disease, greatly impacts both patients and their families. This ter-

minal disease produces numerous physical manifestations, e.g., decreasing mobility, difficulty eating, loss of energy and eventual paralysis. Activities of daily living (ADLs) become increasingly difficult for the patient, which has a rippling effect on family members, making everyday existence difficult for the whole fam-ily. A natural source of nonmedical support is the faith commu-nity. Whatever the denomination or tradition, such action fulfills the mission to “carry one another’s burdens” in time of need.

The care team model utilizes a congregational care team (CCT), which is an intentionally formed group of three to five volunteers who are committed to coordinating nonmedical support to a fam-ily living with a challenging illness—whether chronic or terminal.

Care Teams and ALS Patients: Bridging a Gap

Barbara Brunk Gascho • Paul Derrickson BCC

The trend in healthcare toward expecting patients

and their families to assume more responsibility in terminal situations often

quickly overwhelms both patient and caregiver. This

care team model was developed for individuals

suffering from amyotrophic lateral sclerosis (ALS)

by the ALS chaplain at Milton S. Hershey

Medical Center as a viable means of addressing this

concern. The process and procedures for establishing such a care team detailed

in this article were the subject of a presentation

at the International Symposium on ALS/MND

(motor neurone disease) in Toronto, November 2007.

Barbara Brunk Gascho RN CPN (certified parish nurse) serves as ALS clinic chaplain at Penn State’s Milton S. Hershey Medical Center, Her-shey, PA. Paul E. Derrickson MDiv BCC is coordinator of pastoral ser-vices and CPE supervisor at MSHMC. He is endorsed by the Presbyte-rian Church USA.

[email protected]@hmc.psu.edu


This model assures that all volun-teers receive education appropriate to a particular illness and agree to serve under the direction of a co-ordinator and to follow specific guidelines.

In the ALS model, developed at the Milton S. Hershey Medical Center (MSHMC), Hershey, PA, the chaplain works closely with the designated CCT coordinator as the disease progresses and support needs change. Thus a significant bridge is created to fill the gap be-tween the world of medicine and the place of home and community life. The chaplain serves with one foot in each world.

Throughout the process, the chaplain advocates for the patient/family’s nonmedical support needs while respecting the resources and present life of the congregation. This balance helps those providing support as well as those receiving support in order to assure that ex-pectations are realistic.

This article delineates the pro-cess for CCT organization and the implementation of a nonmedical support plan for ALS patients/families. In order to work together effectively with compassion and re-spect, all individuals involved must understand the purpose and role of the nonmedical support system and its ability to accommodate the changes in the life of a patient/fam-ily living with ALS.

Organization of the care team ser-vices with the goal of reducing fam-ily stress while adding support is vital if excellence is to be achieved. Timely implementation of support is critical to the well being of both patient and family. Interacting with the patient in the clinic setting pro-vides the chaplain the opportunity to observe the disease progression

and assess needs for altering the care plan. Following is a descrip-tion of the MSHMC process for creating care teams to serve ALS patients and their families.

Approaching the familyThe initial approach usually occurs

though the chaplain’s contact with patients/families in the ALS clinic. The chaplain’s focus in this setting is to offer the opportunity for devel-oping a congregation care team for a variety of reasons. The “art” of pas-toral care at this juncture rests in the chaplain’s ability to discern if such a network may be useful. Consider-ation is given to the family’s existing resources, the impact of the disease process on the patient/family. Sev-eral other considerations also are critical to the process.

Sometimes patients are referred late in the disease process, which changes the type of support that may be offered. In these situations, although a CCT could add support, it may prove to be too overwhelm-ing for the family to incorporate. Further, asking a congregation to come on board at a chaotic time in the disease process may be over-whelming for them as well. Fami-lies that were dysfunctional prior to the ALS diagnosis are not likely to follow the CCT guidelines and boundaries. If the chaplain deems it appropriate, she invites the paa-tient/family to review the CCT brochure, which clarifies the details of such support.

If they wish to explore the care team option, follow-up conversa-tions take place at the patient’s home. All family members are en-couraged to ask questions and to identify immediate nonmedical support needs as well as those they foresee. Through these discussions,

families become familiar with the use of the CCT model—its func-tions, boundaries and limitations. The family is asked to provide the telephone number of an initial contact person from their congre-gation, e.g., pastor, parish nurse, person in charge of compassionate care ministry/visitation. Families are given a clear timeline and reas-sured that they will be “in the driv-er’s seat” throughout the process.

The most frequently encountered concern is invasion of privacy. The chaplain explains that both job de-scriptions and expectations of the volunteers are designed to prevent this. One quiet, elderly man, who knew that his wife needed someone to stay with him while she did er-rands, said, “I’m afraid that people will expect me to talk or they will think that they need to entertain me while they are here. This makes me stressed.” The chaplain reassured him that anyone coming to offer support would understand and re-spect his wishes at any given time.

Openness is crucial. One patient who was receptive to a care team did not want them to know that he had ALS. The initial exploration of the care team program is a time for trust building as well as an op-portunity for the patient to name losses experienced, which some-times helps to lessen their impact. After one visit, the spouse of the patient said, “I cannot believe the hope you have brought tonight. We trust you, and now we under-stand and will trust a care team.” A dedicated homemaker shared, “I am no longer able to cook for my family, and I need assistance.”

Involving the faith communityWith the family’s wishes to pro-

cede, the chaplain contacts the


faith community. After explain-ing the family’s need, she offers to meet with interested members of the congregation to educate them about ALS and the CCT concept. During her presentation, the chap-lain distributes brochures on ALS and the activities of the ALS clinic and familiarizes her audience with other resources.1 She identifies criti-cal issues, including the importance of confidentiality, respect for the “home” and awareness of the patient/family members’ limited amount of energy. She stresses the importance of promptness in performing tasks such as delivering meals on time as patients and families often arrange their days so that they will have enough energy to eat together.

This is a time not only to educate potential volunteers about ALS but also to clarify what being a part of an organized nonmedical support team entails. Just hearing “non-medical” often opens persons to the concept. They are assured that they will not be responsible in medical emergencies beyond calling 911. At the same time, volunteers are alerted to medical interventions, such as suctioning, which they may witness during care team visits.

The chaplain explains how the care team functions and how to become involved. Guidelines for entering the sacredness of a patient’s home are clearly articulated as is the neces-sity for strict adherence. For exam-ple, fatigue is a huge issue for ALS patients. Care team support is not visitation time. Individuals must arrive when scheduled, perform the given task and leave promptly.

Many patients have expressed their gratitude for this instruction:

• I get exhausted when peo-ple come and stay and stay.

• Thank you, thank you, for telling everyone to treat me like they treated me before. I am still the same inside.

• You understand the medi-cal part and the spiritual and emotional part and it helps to have you educate our congregation. Now I don’t have to say things over and over. Everyone hears it at once. Now may-be I can go back to church and not get too tired.

The chaplain’s interactive format quickly elicits participants’ con-cerns. One person commented, “I was afraid to call and offer any help, because I did not understand what was happening to B.” Anoth-er shared her own experience with multiple sclerosis. “I have come up with the term, ‘compassionate con-descension.’ When I go to a restau-rant, the waitress asks my husband what I want to order! Let’s not do this to E.” The chaplain took ad-vantage of this comment to reiter-ate that persons with ALS retain all senses—touch, taste, smell, sight and hearing—and that it is im-portant to engage these wonderful senses—the parts not being lost.

Though attendance at these pre-sentations has ranged from fifteen to one hundred, the average is sixty-five. Typically the reaction is one of deep gratitude and increased awareness of the needs of fellow congregants. The family is invited, but not required to attend. Often their feeling is that their absence allows the congregation to ask tougher questions about the illness or about their own hesitations and fears, such as that voiced by one at-tendee: “How can you help us deal

with our grief as we witness what is happening to A?”

At the conclusion, sign-up sheets are circulated, each listing one task to meet an identified need of the family. Individuals are asked to indicate their willingness to serve as team leader and to organize vol-unteers offering a specific support, such as meals.

Organizing the care teamA care team coordinator, who

usually is selected prior to the chaplain’s presentation, heads the CCT. Often the family identifies someone they know to fill this role. The coordinator meets with the patient/family to identify their im-mediate needs. (See the organiza-tion chart on p. 25.)

The coordinator’s main respon-sibility is to support both the pa-tient/family and the volunteers. This is accomplished by seeing that needs are met in a timely fashion, that respect among all participants is reciprocal, that boundaries are maintained and that questions/concerns are promptly addressed.

The coordinator oversees the ac-tivities of the team leaders, each of whom is responsible for a group of volunteers assigned to meet a par-ticular patient/family need as men-tioned above, e.g., meals, transpor-tation, shopping, respite care, light housekeeping, making small home handicap modifications, such as a small wheelchair ramp. For example, if the family requests two meals five days each week, the care team leader would organize volunteers to prepare and deliver them. Additional team leaders and volunteers are recruited as necessary to meet the additional or changing needs of the family.

The coordinator is the sole con-tact person for the patient/family.


This protects them from unneces-sary calls or complications with communication. All questions and concerns, whether they come from patient, family members or volun-teers are funneled through the co-ordinator.

The chaplain regularly confers with the coordinator and occasion-ally meets with the team leaders as well. One family chose to coordi-nate these care team meetings with clinic visits in order to update ev-eryone on the latest developments at the same time.

In one instance, the patient agreed to a number of new inven-tive supports during a clinic visit, e.g., wheelchair, med-alert necklace and a ramp for her home. By the time she returned home, she was overcome with grief. The following day, her spouse attended the regu-larly scheduled care team meeting and shared the details as well as his

family unit, elicited the following from one of the volunteers, “You were there to help us to remember our ongoing role and goal. We needed your reassurance that we were doing nothing wrong, nor were we responsible for the ravages caused by ALS.”

One patient, who was debating whether or not to accept mechani-cal ventilation, asked a volunteer if care team members would be taught how to care for his ventila-tor-related needs. The volunteer appropriately referred this ques-tion to CCT coordinator who in turn spoke with the chaplain. She “coached” the coordinator for a subsequent conversation with the patient about CCT guidelines and meaning of nonmedical support. At the same time, the patient was assured that such medical support would be available from medical professionals.

Typically, the CCT contract or covenant is for six months. Most teams hold a formal meeting three to four months into the process, which brings together the family members, coordinator, and volun-teers to reflect and evaluate the program. Though patients may attend, more often than not they do not. The most frequently en-countered issues at this stage are the progression of the disease and the resulting changing needs of the family. Often these are related to the patient/family’s need to further conserve energy or to adapt to the patient’s increasing limitation.

Response to this initiative The Hershey care team model has

been used with twelve patients and their families. Most were created for families within a faith commu-nity. In one instance, the model was

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wife’s need for understanding and time to adjust. As a result, both the coordinator and the patient’s pastor stopped by to offer spiritual sup-port later that day. Through fur-ther conversation with the spouse, the chaplain was able to clarify several misunderstandings that had occurred and to follow up with the ALS clinic coordinator as well.

As the disease progresses, the chaplain watches for compas-sion fatigue within the care team. Sometimes the family becomes ex-hausted and overwhelmed by all of the patient’s needs. One family’s desperation and grief in this situa-tion manifested itself in hostile and disrespectful behavior not only to ALS clinic and palliative care staff but also to the CCT volunteers. In this situation, the chaplain’s guid-ance, which helped them to main-tain support that was both caring and firm in the face of a crumbling

Care team organization chart


stretched to include people from the spouse’s workplace as members of the volunteer team. In another, the care team coordinator was not a member of the congregation.

Ten of the eleven teams ran smoothly. The eleventh faced added challenges when the couple separated due to ongoing marital issues compounded by the ravages of the disease on one partner. This family dysfunction made it inad-visable to continue, and with the support of the chaplain, the family and the care team decided to end their covenant.

Through this program patients retain a measure of control over the nonmedical aspects of their lives. Their privacy is respected. Typically, they also discover that as they receive help, they also give by providing an opportunity for oth-ers to live out their faith through compassionate service. Volunteers often see patients as role models for persevering even when the go-ing gets tough.

Caregivers and spouses acknowl-edge a sense of continuity with their faith communities. Perhaps most importantly, both caregiver and pa-tient are given a sense of hope:

• I know that this [care team] will be a very help-ful thing for us, and it will give some direction for those who want to support us. I’m not always sure how people can help or what to ask people to do.

• This is all so touching to us. We are so overwhelmed, but you have brought us some hope today.

Volunteers appreciate the op-portunity to give. With clear job

A care team in action – the story of J and his family

J and M, both 36-years-old, are the parents of three children, ages ten, eight and two. Six months after he was diagnosed with amyotrophic lateral sclerosis (ALS), J had to leave his job as a university professor due to the rapid progression of the disease. M, a registered nurse, also resigned her part-time job in order to care for J and all of the family’s other needs.

J soon experiences difficulty eating and communicating. His mobility has dwindled to the extent that he needs a power chair, and he feels guilty about the care he requires.

M is on overload as the children are acting out as well. The 10-year-old wants to be on a soccer team. The 8-year-old doesn’t understand why Mommy isn’t always available to take her to piano and dancing lessons. The toddler, who senses that something is wrong, has become fretful and clingy. The family is in chaos.

In conversation with the chaplain at the ALS clinic, M says that individuals from the church they attend have offered help, “but when they call, I’m too busy to talk with them, and I don’t know what we need at that point. I do know that there are times that I need help and that I need to have people around me beyond those who are providing medical care to J.”

When the chaplain describes the CCT program and how it may support them, they ask her to contact their pastor. The pastor is most willing to have a knowledgeable person assist the congregation in forming a care team. Persons in the congrega-tion have expressed a desire to help J and M, but they do not know where to begin.

Several weeks later, fifty persons stay on after Sunday ser-vices, to participate in the ALS education/care team explora-tion. During this time they not only learn about ALS as a disease, they are briefed on how to be most helpful to families who have to live with this terminal illness. They begin to un-derstand that breathing machines, communication devices and other medical equipment are now part of J’s daily life. At the same time, it is emphasized that their roles will be as nonmedi-cal caregivers.

Under the direction of the care team coordinator meals are prepared and delivered, lawn care is handled, transportation for the children’s activities is arranged as well as respite time for M, including child care for her toddler. On Monday nights, several friends join J to watch football.

The chaplain continues as liaison, meeting every three months with the team members to assess present needs and/or issues. It is a time for affirmation and support not only for this family caught in the throes of terminal illness, but also for the care team members themselves.


descriptions and boundaries, they find comfort and reassurance in knowing that what they do is ap-propriate and helpful and that will be well received. Congregations see the program as an act of faith that answers their call to care. It also develops and reaffirms the breadth and depth of their fellowship. In the words of one team member, “The care team has brought the congregation closer together as we supported L.”

The role of the chaplain is criti-cal to the overall functioning of the program. Initially, she serves as the intermediary between the patient/family and the congregation, help-ing to shape their working agree-ment and to insure that the needs of both parties are met. Comments from patients/families include the following:

• I so appreciated the chap-lain’s sensitivity to our feelings.

• It was a great emotional journey that I have never walked before. The chap-lain gave us a sense of di-rection as to what to ex-pect and the affirmation we so desperately needed.

To provide closure for CCT mem-bers following the patient’s death, the chaplain offers a time of debriefing. She also sends a letter of appreciation to the pastor of the supporting con-gregation and offers bereavement fol-low-up for the family.

No charge is levied for the chap-lain’s services as her position is fund-ed by the ALS Association, Greater Philadelphia Chapter. Participating congregations are invited to con-tribute to the ALS Association as it makes this service possible.

ConclusionThrough the implementation of

the CCT program, ALS patients receive nonmedical support with-out having to surrender control and management of their lives. This service also helps to mitigate the stress experienced by family members, who receive support at a critical time.

Results of the Penn State MSH Medical Center ALS Clinic quality of life research by Simmons et al. indicate that quality of life is not correlated with measures of physi-cal function and strength, but rath-er with psychological, existential and social support factors.2

In another study of eighty ALS patients, the single most impor-tant factor related to their quality of life was their social support. Pa-tients who receive emotional sup-port from their families and friends are more compliant with medical regimens, less likely to be depressed and less likely to suffer from other adverse health consequences than those that do not receive effective support.3

Volunteers know that they are helping in important ways, which will be appreciated. They feel sup-ported in their efforts and know where to turn when they have ques-tions. The congregation’s vision of itself as a caring community is rein-forced and members are challenged to envision new ways they may make an impact on others’ lives.

The success of the CCT model with ALS patients/families chal-lenges chaplains to expand their institutional ministry by stretching it to incorporate faith communi-ties into their healing work in new ways. It also encourages them to explore the viability of this model for use with those who suffer from

chronic illnesses, whether or not there is a terminal diagnosis.

References

1 Cappy Capossella and Sheila War-nock, Share the Care (New York: Si-mon & Schuster, 1995).

2 Z. Simmons, B. A. Bremmer, R. A. Robbins, S. M. Walsh and S. Fisher, “Quality of life in ALS depends on fac-tors other than strength and physical function,” Neurology 55 (2000): 388-92.

3 A. Chio, A. Gauthier, A. Montuschi, A. Calvo, N. Di Vita, P. Ghiglione, R. Mutani, “A cross-section study on de-terminants of quality of life in ALS,” Journal of Neurology Neurosurgery and Psychiatry 75 (2004): 1597-1601.


dial

ogue

:

THANKS TO MARK LAROCCA-PITTS et al. for their exposition on better practices. I am impressed by their

effort to deliberate across hospital systems on what better practices could mean for professional chaplaincy.

Thanks to George Handzo for delineat-ing twelve practice areas to be considered in the discussion of best practice, broadly divided into direct patient care and institu-tional concerns.

I appreciate Susan Wintz’s response stat-ing that standards of practice should focus on “what works.” Further, Wintz states that determining standards of practice begins with the “foundational basics” and builds outward. What then are these foundational basics, stated in a language that chaplains and medical staff and administrators can understand?

May I suggest the foundational basic of both the patient and the institution is well-being? The basic question chaplains and institutions must ask is “How does the chaplain’s practice contribute to the well-being of the patient and the well-being of the institution?”

Theologically, chaplains understand that “being” implies the “ground of being.” Thus, well-being is more than patient or institutional survival. For the patient, a be-ginning definition of well-being may focus on the quality of internal states that is life giving and life affirming. For the institu-tion, well-being may have to do with ap-propriate utilization of resources and staff in an ethically sensitive way to accomplish a mission established in both compassion and justice.

So now the problem is engaged. Once one states the foundational basic, in this case well-being of the patient and institution, how does one define that foundation basic in quantifiable terms that allows a common language; respects the disciplines of theol-ogy, medicine and social sciences; and em-powers chaplains to think creatively about how they might create better practices?

I am reminded of when I sat with a group of directors of chaplain services from six hospitals. I suggested that if we were to do spiritual assessments, a foundational issue was how we defined spiritual. Over the course of several months, each chaplain attempted to bring a definition of spiritu-ality that we could affirm as a group. We were unequal to the task.

Some would argue that the nature of spir-ituality is such that it can’t be defined. Is this then the foundational basic—the mys-terium tremendum that lies outside human definition or quantification? Some do not think so. As Mildred Best suggests when it comes to defining these basic issues, “If we don’t, they will.”

Dick Millspaugh BCCChief, Chaplain ServiceVA San Diego Healthcare System

THE RESPONSES WRITTEN by Larry VandeCreek and Susan Wintz in the Spring/Summer 2008 issue

throw light into a corner of the wider myth-ological landscape of modern healthcare that has gone largely unexamined in recent

Editor’s note: The previous issue of Chapalincy Today (24:1) included an article authored by chaplains from eight hospitals in north Georgia, which focused on the development of “better practices” in chaplaincy. It was followed by responses from five board certified chaplains. Additional responses were invited in the hope that the dialogue around the is-sue of standard of practices/best practices would continue. The following responses were received from Chaplains Dick Millspaugh and Keith W. Goheen.

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decades. In this dimly remembered corner lives an unhappy half-truth. Its malicious mutterings spread out-ward, confounding us chaplains as we struggle with standards of prac-tice. The unhappy half-truth tells us that the practice of medicine is a sci-ence. This message is a distortion.

Medicine is an art. True, it is an art that has armored itself with a gargantuan array of scientific ma-terial and processes. Nevertheless, medicine remains an art because all of the scientific might that it holds in its collective hand only can be wielded in the service of the artful judgment of the practitioner. At its heart, medicine is about judgments rising from the disciplined applica-tion of inspiration. Science allows the medical practitioner to exercise a greater degree of precision in as-sessment and treatment, but sci-ence will never be a substitute for sound medical judgment. Science can clarify, but it cannot inspire. I propose that in the quest for a

universal standard of care among chaplains, our efforts take into ac-count this same reality.

Like medicine, chaplaincy is an art. Like the medical practitioner, the chaplain’s efficacy can be re-fined and amplified through the inclusion of the discoveries of sci-ence and the application of its pro-cesses. If chaplaincy, like its sister profession medicine, is to become a modern profession, its practi-tioners must incorporate the rich trove of resources made available by the work of respective compli-mentary sciences.

Concurrently, we chaplains must be tireless in our efforts to define and to implement sound pastoral judgment. Like our medical peers, nothing science can offer us will be an adequate substitute. Good outcomes derive directly from wise choices.

It is not our impact that defines us as professionals, it is our demon-strable ability to make artfully and

scientifically informed choices. I believe that the foundation of the profession of chaplaincy is nothing other than our capacity to choose our actions wisely and that wisdom only can be held collectively. Thus, to be wise, we need to be in com-munity. Our professional commu-nities must serve as conduits to and reservoirs of our shared wisdom. We must be the keepers of aestheti-cally grounded, scientifically vali-dated practices, and most impera-tively, inspired guardians of sound judgment.

It is time to dislodge the unhap-py half-truth and to free ourselves from its warping gibberish. Chap-laincy does not need to surrender its inspiration to become more sci-entific. It needs to become more artful in its application of science.

Keith W. GoheenAPC associate chaplainBeebe Medical CenterLewes, DE


essa

y

I N THE DRIZZLING GREY OF A COLD and early afternoon, my feet soak in the dampness of the mud beneath me. There is a chill

in the air, which seems so familiar here. I look out across a sea of thousands. The black, blue, tan, green and white uniforms crisscross the landscape. Flags of every size, color and de-partment flap in the wind. Rain spits across the American and Connecticut flags held high by an honor guard that looks like statues. The barking of the canines is muffled as hundreds of motorcycles slowly proceed up and around the rank and file until the everlasting proces-sion disappears behind the hills.

I am so proud to be here, so honored to stand among the generations of servicemen and women who are with me now and who came before me. I smile as I hear laughter from the troops, and some off color jokes actually make me laugh as well. It is therapeutic to laugh, and there are hundreds of jokesters all around me. Then the laughing stops.

The procession of the fallen police officer’s department comes marching quietly through the sludge. I want to say something, but this is a time for silence. They take their places by the family who have been waiting pa-tiently, their black coats, black dresses, black umbrellas emphasizing the gloom. There is a quiet rumbling of the motorcade that follows: the patrol cars, all decked out to impress the masses, and then the hearse. As always, I feel a tightness in my chest, a burning in my throat.

I watch as the casket is taken out, and this is still okay, tolerable. Then the music begins.

No words speak to the soul as music does. When there is nothing left to say, music fills the void. The off pitch ringing of the bagpipes finds its mark and continues beautifully with the beating of drums. The colors of Ireland and Scotland become visible as the fife and drum marches forward, dressed in kilts, even in the cold. They play the “Ave Maria,” and my heart sinks.

Throughout the service, we stand as statues, moving only to salute and return arms. As the flag is folded and given to the widow, I see in the distance the lone State Trooper and hear the sound of “Taps.” This is when my heart breaks. I cannot even begin to describe the feeling I have when the patrol car calls out the badge number of the fallen officer, and no response is given.

As I reflected on loss and grief for an as-signment in clinical pastoral education (CPE), I discovered that the death of the man I will call Officer Frank sparked a lot of emotions within me. Most of these I would not have acknowledged, let alone processed, if it were not for CPE. I realized that the Kubler-Ross stages of death and dying were present with this officer’s death, even more than with the two suicides that had occurred in my own department over the years. I paused to wonder why?

A Police Chaplain’s Reflection

Christopher M. Holms

The Reverend Christopher M. Holms serves as a chaplain for the Norwalk (CT) Police Depart-ment. An APC student affiliate member, he is an ordained deacon in the Episcopal Church USA and certified by the International Conference of Police Chaplains (ICPC).

[email protected]


I remember quite vividly sitting in my living room when I heard on the news that Frank had died. I could not believe it. It had been only a few years since my wife and I met Frank at his benefit dinner. He was wearing his “halo,” to prevent his neck from moving and dislodg-ing the bullet stuck in his neck. I remember that it looked so pain-ful—the screws of the halo looked like they were screwed into his skull. Although Frank was not able to function in the full capacity of his duties and could not ride a mo-torcycle anymore, he continued to coach ice hockey as his children grew up. Now all of a sudden, he was dead.

It was believed that his death stemmed from complications of the shooting, but whether or not that was the cause wasn’t impor-tant to me. I had been convinced that this was one tragic shooting that did not end with someone in the graveyard, and now, I was proven wrong. It just had taken longer. I did not want to believe this. This went against hope, and as I am a Christian, hope is very important to me.

The night of the funeral I was very angry, and my anger carried over into the next day. Why did this have to happen to this officer and to his family? They had struggled for so long. Where was the justice?

I felt that Frank and his family had been gypped. It was not the same as my aunts and uncles who had died in old age. I felt that they had lived their lives. They had seen their children grow up and move on.

It was this denial of Frank’s po-tential that angered me the most: the potential to be a good father, a loving husband, to repent and to

change, to become a better person, to make the world a little better than he had found it. That’s what tore me up inside, and I focused my anger on the selfish, murderous bastard that pulled the trigger.

Give him the death penalty, I prayed. He should die. I knew that this was not right, but I felt that since this liberal state does not care for the officers who protect it, then neither should it care for the filth that kills them. In my heart I knew I was wrong to think these thoughts, but I felt that I had to think them for some reason even if down deep I didn’t agree with them.

Someone told me that Frank went to the prison to forgive the guy that shot him. For me, this is totally un-acceptable. The snuffing out of hu-man potential seems beyond for-giveness. Who’s the Christian now? Was it easier for him because the ball was in his court to act while all I can do is speculate? Perhaps.

As I stood in the cemetery that day and saw my sons standing everywhere, I realized why I was so angry. On any given day, this could be me. I wondered how old my sons might be before seeing something like this. I wondered what would happen to my wife if this were me.

I realized that I wanted to punish the shooter, not for killing Officer Frank, but for killing me, not for making his wife and children cry, but for doing that to mine. Now that I had given my anger a name, I found myself praying to God. I thought of Psalm 55 and prayed that God would watch over me. Looking across the sea of officers, I prayed that I would make it through the next fifteen or twen-ty years. I knew that many others

prayed to this same God, and ap-parently it made no difference. How depressing.

How depressing indeed. As I went home that day, I thought long and hard about my family. I felt sad for what they must go through, not only in an officer’s family, but now also a clergyman’s family—a double whammy. Perhaps two negatives will make a positive, and everyone will be okay. Yes, there is humor in sadness. It becomes the great shield.

In the following days, the idea of my family being left alone haunted me. I felt scared for the first time in my career. I stopped pulling over cars as this is the second most dangerous act for an officer. Still I denied these feelings, telling my-self that I was just tired from the process of becoming an Episcopal deacon and that CPE was taking too much out of me. All the while, I knew that I was hiding from the truth—and from my fear.

As I read through this paper, an-ger over Officer Frank’s death re-turned. I realized that the loss of Frank’s potential was what both-ered me so much, and now I was not fulfilling my own potential. I remember saying that I felt no joy in my calling anymore. I had be-come powerless against fear. That powerlessness was going to con-sume who I was as a chaplain and officer unless I could embrace the fear and rise above it.

My prayers changed as I began to think of Paul’s letters to the Ephe-sians. I realized that I was not giving myself to God but to fear. I began to have a new respect for life and for my role in it. I began to hear things in sermons that pertained to my challenges, and I began again to pray prayers and Psalms that


gave me strength. It still is on my mind and in my heart, but I am not overcome by it anymore.

In retrospect, I feel that God gave me time to ponder, to question and even to hide for a while. I no-ticed that other officers were step-ping up to take my calls during this time even though we hadn’t spoken about my feelings or con-cerns. Eventually I was “back in the saddle” again and working as I always had.

I wonder if this is why I become so angry at the mindless taking of life when there is so much poten-tial left in that life? I remember a woman in her late eighties—though she looked older—crying and beg-ging her twin sister not to leave her. The twin was in so much pain and so gaunt. There was a relief in me that she was leaving this existence and going to the next realm, an ex-istence of which I believe there to be no more pain or suffering. As she was passing, I felt happy for her as though her soul longed for this. Her face was so peaceful in her last breaths and she looked happy.

The sister was asking, “How can you do this to me? You promised you wouldn’t leave me. We were supposed to go together.” I felt so disheartened for the woman amidst her sister’s pleas. Did her sister not know the pain she was in? Did she not realize that her twin did not even know who she was? The pleading went on and on, and I must admit that I was becoming upset.

How could she be so selfish? Then as I reached out to touch her shoulders, I felt ashamed. She was being honest, and I was holding back. I don’t believe that the sister was as upset about her twin dying as much as about being left alone.

Her sadness and anger were direct-ed toward her twin because, in this time of helplessness, she needed someone to blame for her being left alone, old and without her lifelong companion. Since there was no one else to blame, she focused on the person she loved. As I put my hand on the sister, I told her that her twin loved her very much. At this point she was able to take her twin’s hand.

As I write this paper, I see a glar-ing similarity that I did not want to notice, or maybe didn’t realize, between me and the pleading sis-ter. We both needed someone to blame. For the sister, it was possi-bly to shame her twin into living so that she would not be alone. She was angry at the situation for taking over this part of her life. This is not the way she wanted to live her life. For me, it was anger at the thought of my family being separated from me in death. I was mad that some-one could make my wife and sons cry and that I could not comfort them. Who would comfort my family? Where is God there?

But as I held that sister and prayed with her family and as the tears still streamed, faint smiles were upon their lips. They thanked me that I was there for them. They thanked me for being compassionate and sharing in their grief. So the twin was not there to comfort her griev-ing sister, but, a stranger in a white coat was—and did. Will there be someone there for my family?

Therein dwells God in all his wonder. The Holy Spirit that re-sides in all of us moves us, if we are willing, to bring God to each other in time of need. A weight is partially lifted from my heart in this realization. The world is no longer suspended on my shoulders,

for the moment. In the instance of this death in front of me, lives con-tinued to glow, even if faintly, for a time. A love brought us together in the presence of God and in the presence of those leaving us.

As I have dealt with families in the hospital I have been a part of death on several occasions. Sometimes it is part of my police job that crosses over to the hospital and I deal with the situation in that aspect. There have been just as many elderly and expected deaths, as well as young and unexpected deaths. Just as with my own family members that have gone before me, I am much more at ease with the death of the people who are closer to death than the unexpected.

Both as a chaplain intern and as a police officer, the vast majority of people in grief that I encounter are feeling the initial shock, anger and sadness. Rarely, do I have the op-portunity to go beyond that as our paths diverge and the families leave the hospital, or I leave the scene.

There is a feeling of perpetual loss and grief in my memories of these encounters as the families have, more than likely, moved on, but I have not. I have now brought them into my prayer life. I pray that light perpetual may shine upon the souls of the deceased. I pray that in their grief the family members may re-ceive strength and whatever else they may need.

It is difficult for me when I feel that there has been no closure. I wonder if this will retard my own processing of grief in the days and years to come. Will I be able to comprehend and deal with the emotions in a mature manner or will I be more childlike in my new experience? I am very used to be-ing part of the grief but then mov-


ing on to another call or another experience right away. How will I deal with my own grief?

As a Christian, I believe in after-life. I believe in heaven and hell. What they are, I am not certain, but I know their existence is as real as this world, if not more so. I believe that God loves us and that the shedding of this mortal coil is

only part of the journey. I believe and “know” a lot of things about death and resurrection, but when it is my turn to stare it in the face, to be on the receiving end of family loss, I wonder how that belief and knowledge will be tested? As I read through the Psalms, I find comfort that generations before me have asked the same questions of God.

Did they receive answers? Per-haps they did, perhaps they didn’t, but the Psalmist is persistent in of-fering both cries and joys to God. We laugh, we lament, we laugh, we move on. God is always there, but it is in going through the trials and coming out on the other side that I think God becomes most visible to our human eyes.


on h

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ndEditor’s Note: In 2000, when Bill DeLong and I succeeded George Fitchett as editors of Chap-laincy Today, we envisioned expanding this peer-reviewed journal to make room for the work chaplains do “in the trenches” as Bill put it. The title “on holy ground” echoes the biblical pas-sage in which God calls to Moses from the burning bush: “Remove the sandals from your feet, for the place on which you are standing is holy ground.” (Ex 3:5 NRSV).

Over the years, I have been awed by the varied experiences of my colleagues that reflect these words. Sometimes my e-mailbox overflows with possibility; occasionally, I wonder how I will fill the space. This was one of the latter times. I already had begun blocking out this issue of CT when the note reproduced below appeared in my inbox—a snapshot from the life of John Allen, a clinical pastoral education intern at the end of an long overnight on-call shift.

On the surface, it’s just part of the “job” of being a chaplain. At the same time, it’s the essence of why we respond when we are called to what Michele Lowery described as “this strange ministry called chaplaincy.” (Chaplaincy Today 2008, 1:34)

Reading John’s e-mail on that August morning reinforced my firm belief that the sacred truly does lie in the ordinary—we have but to bear witness to the moment.

John Kevin Allen BA served as a summer CPE intern at Barnes Jewish Hospital, St. Louis, MO. An APC student affiliate member, he currently is pursuing an MDiv at Eden Theological Semi-nary. He is endorsed by the United Church of Christ.

[email protected]

I AM A CPE STUDENT interning for the summer at Barnes Jewish Hospital in St. Louis, MO. Overall, it has been

an extremely gratifying and eye-opening experience. As part of my training, I am required to work a few overnight on-call shifts. My most recent experi-ence prompted the haiku below. Please use it if you would like.

Let me offer some back-ground. During my shift, I had attended a number of deaths throughout the night. Near 5:00 AM, I was called to a code on one of the floors. I rushed to the scene and watched as the med-ical staff flooded the room and worked furi-ously to save the patient’s life. After twenty minutes of hard work, they withdrew their efforts; the patient could not be revived.

I usually stand outside the room dur-ing these codes and pray silently for the patient and the medical staff. I was told

after it was all over that no family would be coming and that the body would be removed soon.

I felt called to spend a few minutes with the patient before she was wheeled down to

the morgue and asked the staff about it. They cleaned her up and cleared the room.

I sat quietly in that room with her—a woman whose face and body revealed a hard and difficult life

of abuse and drug addiction. I felt that I needed to be a witness to her life. As I sat with her and gazed outside, dawn began to creep across the horizon. It was a pen-etrating moment.

Called to a code – too late.Time of death: 05:21.Outside, rosy dawn beckons.

Her Dawn

John Kevin Allen


poet

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Somewhere There is War (November 2007) Two kids trot dutifully, dragging a teddy bear,try to look strong, behindtheir mother pushing their father in a wheelchair.

He was once their father, if they remember him,touching their noses in wonder,letting them wrap their tiny handsaround his thick fingers — before he went.

Now, in a wheelchair, he smells funny,takes up Mommy’s time, makes her cry.

He was once her husband, touching her here,and there, wrapping his thick armsaround her waist — before he went over.

Now he wants their attention,somewhere in his brain he knows this.He wants their love, their touch;he wants to tell them he loves them;he wants to tell them that somewherehe knows — he is her husband, their father,a man, a soldier, proud.If he makes this sound, this unearthly sound, It curdles; it condenses dread and fear in the air into sandThat sifts down softly into the pits of stomachs. Ifhe makes this sound, they’ll pay attention to him,maybe they’ll look in his eyes and maybe they’ll seethat — somewhere in his brain he knows, somewhere inthat egg yolk rattled too much in its shell by the blast wave,somewhere in the leaking yellow fluid, he knowswho he used to be,who he is,who he wants to be.

Wade Meyer

Wade Meyer wrote this poem out of his experience with a patient on the traumatic brain injury unit during his chaplain residency at VA Palo Alto Health Care System, Palo Alto, CA. An APC student affiliate member, he currently is pursuing an MDiv at Pacific School of Religion, Berkeley, CA.

[email protected]


Cadillac

One chromosome and a womanRemained a girlFor a lifetime.

Thirty years stolen by hard loveEnd, turning softAnd mom gentlyMoves her daughter

Onto the funeral gurney.As the hearse glidesAway mom smiles,“Her first ride inA Cadillac.”

Charles Christie BCC

Mona Lisa, ICU-2008

A photo by the bed reveals the vibrant life, Bleeding into a colorless palette beyond the unknown.“She never used to go out without her makeup,” Remark her friends.She concurs, and sighs.Sepia and yellow tones meld togetherIn her face,Cheekbones curving gently into her black hairResting on the pillow, hands folded, gently crossed.Too weak now to sweep ocean blue into her eyesOr seal a kiss with ruby wine.This lovely one needs anointing,A bit unorthodox perhaps,A palliative ritual for her eyes only.Lips still capable of love,Her brows, arching into the golden meadows of her foreheadLike darkened sheaves of wheat.Her lashes, inky, fluttering like midnight butterflies,Resting delicately on an eye-liner branch All their own.With blush and prayer and every sacred touch,The human canvas blooms again, shadows, nuance.I hold up a mirror to her face,The veil applied now masking nothing,Revealing the slightest glimmer of a self-satisfied smile.And I stand back with powder brush in hand and know DaVinci’s satisfaction was no less than my own.

Marci Pounders


The Beauty of Daughters

The beauty of daughters carries mefar past the strength of my legs.At times the profile is more than enough.The line of a classic jaw,nape of her neck is all that is needed.

Their mother sat up with dis-ease and tremorsmasked with a smileand back lit by the soft glow of her young women.

Mother is center stage butthe audience is carried by daughters.All eyes hold mother dearly yet all eyes follow daughters from scene to scene.All eyes follow them.All queries are answered.

The flow and motion rides their back.Yet mother remains centerand in the best light.The blocking and the dialoguecarried with gentle gracelike silk streams of color winding around the mother maypole.

Robert W. Duvall BCC

NICU

The baby, born in the toiletOf a Good WillStore, left and foundSwimming for life

Suckles an intravenous breast.Born too soon sheSlowly dies longBefore she lived.

“Bad Religion,” reads Mom’s tee shirtAs we baptizeThe child this timeWith clean water.

Charles Christie BCC

The Reverend Marci Pounders MDiv serves as palliative care chaplain at Baylor University Medical Center, Dallas, TX. An APC student affiliate member, she is a transitional deacon endorsed by the Episcopal Church USA (chaplainmarci@yahoo .com). Charles Christie MDiv BCC serves as staff chaplain at Gwinnett Medical Center, Lawrenceville, GA (cchristie @gwinnetmedicalcenter.org). Robert W. Duvall MDiv BCC is director of chaplaincy at Gwinnett Hospital System, Law-renceville, GA. He is endorsed by the Cooperative Baptist Followship ([email protected]).


God’s Sitting This One OutWritten on the occasion of suspectedgang retaliation during a funeral

Screams...follow the screamingand you will learnawful truthsyou do not want to know.

Grief explodesricocheting againstan illusionary,protective shield,of prescriptivehospital productivity.

Do not make us witnessesto your grief,to our violence,to another son or daughtergunned downbefore they’ve beenraised up.

The hospitala second assaultof power and violenceborne of our own disgust and spread by our own dis-ease.

Gang will rise up against gang,fear will rise up against love,demands for increased security will distract from greater self awareness,judgment will conspire against more expansive souls.

Grief implodes retaliating againstdreams unborn,crack ceilings,anger turned inward,Evil incarnate.

One brother’s blood barely replaced with embalming fluidBefore the next one’s blood runs down a shiny gurneyas grief runs down sterile corridorsand drowns the hearts of motherswith a murdering madness.Rachel weeping for her childrenand she will not be consoled.

God’s sitting this one out, chaplain says his father.He was my baby, says his mother.They are like animals hunting each other down, says the nurse.No, they cannot see the body, says homicide.They are not like you and me, says the tech.Develop a policy to control their behavior, says administration.Do not grieve my heart, says the Holy Spirit.

I do not sit this one out.I am the face of betrayal.I am the story of Redemption’s triumph over retaliation Evil’s failed attempts to execute love.

I do not sit this one out.I have hung in thisfor this onefor everyonefor all eternity.

Susan Carole Roy

The Reverend Susan Carole Roy DMin BCC is director of pastoral care services at the University of Maryland Medical Center, Baltimore, MD. She is endorsed by the Evangelical Lutheran Church in America (ELCA).

[email protected]


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The following summaries of articles have been selected from the database of The Orere Source, a bimonthly publication of summaries of pastoral and other literature of potential value to chap-lains. The summaries are created by W. Noel Brown STM BCC.

[email protected]

Paul S. Bay, Daniel Beckman, James Trippi, Richard Gunderman, Colin Ter-ry. “The effect of pastoral care services on anxiety, depression, hope, religious cop-ing and religious problem solving styles: A randomized controlled study,” Journal of Religion and Health 47, no. 1 (Mar 2008): 57-69. • Can it be demonstrated by means of scientific study that pastoral care by chaplains effects changes in hospitalized persons, changes that move them towards greater health and wholeness? Most chap-lains, indeed most health care professionals, will agree that what chaplains do in their ministry does have value for patients, but this question is more specific. Can the effect of pastoral care be identified and measured in a tangible way? Bay and his colleagues have made an impressive attempt to do just that. They report a study designed to mea-sure the effect of one chaplain’s ministry on coronary artery bypass graft (CABG) patients over a period of time, with test-ing done presurgery, at one month post-surgery and at six months postsurgery. In establishing the project, they followed the necessary steps for gathering reliable data, creating a pool of patients of sufficient size to produce relatively reliable results. The patients were randomly assigned to either a group which received pastoral care from the chaplain or a group which received no pastoral care other than visits from their in-dividual clergy. A staff member other than the chaplain did the initial qualifying and subsequent testing of the patients so that the chaplain’s interactions with the patient and family were limited to the planned pastoral care. The authors review the lit-erature concerning some of the links be-tween religion and health. They also care-fully describe the method of their research, including the four questionnaires they

used: Hospital Anxiety and Depression Scale (HADS); Herth Hope Index; Brief R-COPE, which identifies coping styles; and the Religious Problem Solving Scale, which Pargament first described in 1988 and which is now a well-tested instrument. The article very carefully describes exactly what the chaplain did during the presur-gery visit, the visit to the family during the actual surgery and three postsurgical visits. The mean time of the five visits was forty-four minutes per patient and family. Data gathering and results, which are described in this article, include comparison scores and analysis for anxiety, depression, hope and positive/negative religious coping styles for both groups. There was a signifi-cant difference between the two groups in positive religious coping and a marginally significant difference in negative religious coping. No significant differences were found between the groups in the categories of anxiety, depression and hope or in the self-directing, deferring or collaborative subscales of the Religious Problem Solv-ing Scale. In the extended discussion sec-tion, the authors seek to understand why some of their anticipated findings did not emerge. This paper is important for two major reasons. First, it is an example of a very useful piece of research that is sophis-ticated in its design and execution. The writing itself provides a model for other chaplains to emulate. Second, as with all good research papers, it gives information we chaplains need as we discuss and think about ways to advance and strengthen the field of pastoral care.

Erika Blacksher. “Carrots and sticks to promote healthy behavior: A policy up-date,” The Hastings Center Report 38, no. 3 (May/Jun 2008): 13-16. • Over ten years


ago, I was employed by a health-care system in greater Chicago that instituted a new healthcare pro-gram for employees. We were in-vited to sign up for a program that paid each employee $125 a year in return for taking certain steps to-ward maintaining health, e.g., not smoking, keeping weight below a certain figure, wearing a seatbelt. Blacksher describes how this “car-rot” approach to promoting health has spread throughout the United States over the past decade. She also describes the “stick” approach, referring to the 2005 Deficit Re-duction Act, which allows states the option of reducing Medicaid benefits for persons who are medi-cally noncompliant, e.g., don’t undergo certain screening exams, don’t take prescribed medications, don’t show up for medical appoint-ments. Blacksher argues that such policies are unlikely to achieve their intended public health goals. She points out that penalty-driven policies are at odds with a number of values which are central to the traditions of U. S. public health and medicine. In fact, she thinks they may even cause harm. She maintains that reward-based poli-cies may not work either. Her cen-tral argument is that in order to get people to change their health behaviors, we must begin by asking where a person is located in their “social hierarchy.” She says that a person’s social/economic status can be viewed as a “fundamental cause” of disease: “Diseases and their risk factors may change over time, but the ability to protect oneself from health risks—and, failing that, to get treatment—remains tethered to one’s location in the social hier-archy.” (p. 15) Carrots and sticks don’t address this reality.

Paolo Bruzzone. “Religious as-pects of organ transplantation,” Transplantation Proceedings 40 no. 4 (May 2008): 1064-1067. • This paper, presented at an international conference, presents information about organ transplantation and its acceptability within a wide range of religious traditions the world over. Among his findings are the follow-ing: No religion formally forbids donation or receipt of organs or is against transplantation either from living or deceased donors. However, some orthodox Jews may have religious objections to “opt-ing in,” and transplantation from deceased donors may be discour-aged by Native Americans, Roma Gypsies, Confucians, Shintoists as well as some orthodox rabbis. Some Southeast Asia Muslim ule-mas (scholars) and muftis (jurists) oppose donation because the hu-man body is an “amanat” (trustee-ship) from God and must not be desecrated. However, they encour-age xenotransplantation research. Other areas that Bruzzone explores include payment for organs, ac-ceptability of xenotransplantation, directed organ donation, obliga-tion to be a donor. This fact-filled paper is recommended for your de-partmental resource file.

Rachel E. Dew, Stephanie S. Dan-iel, David B. Goldston, Harold G. Koenig. “Religion, spirituality and depression in adolescent psy-chiatric patients,” Journal of Ner-vous and Mental Disease 196, no. 3 (Mar 2008): 247-51. • This paper presents early research designed to better understand the relationship between different aspects of reli-gion/spirituality and depression in adolescents who have sought help for their depression. One hundred

and seventeen teenagers aged twelve to eighteen completed the Beck Depression Inventory, 21-item self-report questionnaire in use for twenty years and well-validated; a substance abuse inventory, two questions created especially for this study; and the BMMRS, a 40-item questionnaire created by a work-ing group of the Fetzer Institute in 2003, which asks about vari-ous aspects of religion and spiri-tuality. The authors found that in this group, depression was related to feeling abandoned or punished by God, to feeling unsupported by one’s religious community and to a lack of forgiveness. Those adoles-cents who said they exercised for-giveness less frequently and felt un-forgiven by God were significantly more depressed. A higher depres-sion score also was related to nega-tive religious support, meaning the degree to which they perceived oth-ers in their religious communities as critical or demanding. Further, depressive symptoms were found to relate to negative religious cop-ing or religious struggle. The au-thors note that these findings have been reported by others. Further, because of the way their study was conducted, evidence of forgiveness issues, lack of religious support or religious struggle does not necessar-ily indicate depression. However, the authors do maintain that until more research is completed, any-one working with depressed teen-agers should be sensitive to their religious and/or spiritual lives.

Kevin J. Flannelly, Christopher G. Ellison, Kathleen Galek, Har-old G. Koenig. “Beliefs about life after death, psychiatric symp-tomology, and cognitive theories of psychopathology,” Journal of


Psychology and Theology 36, no. 2 (Summer 2008): 94-103. • This study reports an examination of the association between beliefs about life-after-death, and men-tal health. The authors used data from a national Web-based survey of approximately 1,900 adults in the United States. Beliefs about life-after-death were divided into five pleasant beliefs, which includ-ed three widely accepted in this country: union with God, peace/tranquility and reunion with loved ones. The remaining two were that life after death is a paradise of plea-sures and delights or a world of eternal reward/punishment. The two unpleasant beliefs were that life after death is a pale shadowy form of life—hardly life at all—or that persons are reincarnated into another form. Analyses of each were checked for association with six classes of psychiatric symptoms. As the authors had postulated, after controlling for age, gender, educa-tion, income, race, marital support, prayer and church attendance, pleasant afterlife beliefs were asso-ciated with better mental health, and unpleasant beliefs were associ-ated with poorer. This is a unique study as it examines specific iden-tified beliefs about life-after-death and psychopathology. However, as the authors point out, it does not clarify whether unpleasant beliefs lead to pathology, or vice-versa—the chicken/egg question.

Christine J. Guth. “Legion no more: Confessions of a Gerasen (Mark 5:1-20),” Journal of Reli-gion, Disability and Health 11, no. 4 (2007): 71-77. • In this first-per-son narrative, Guth tells the story of Mark 5:1-20 from the imagined perspective of the man from whom

Jesus cast out demons. The manner of the retelling reflects Guth’s wish to allow this biblical story to speak to contemporary experiences of mental illness and trauma. She at-tempts to incorporate understand-ings of demon possession and faith that ancient readers may have held, while at the same time respecting the struggles that modern persons of faith experience as they cope with mental illness. Guth herself suffers from mental illness, as have four generations of her family, and so she writes as an “accidental expert.”

Sarah E. Harrington, Thomas J. Smith. “The role of chemo-therapy at the end of life: ‘When is enough, enough?’” JAMA 299, no. 22 (11 Jun 2008): 2667-78. • Please don’t let the title of this pa-per suggest that it has nothing to say to you if you are a chaplain. It does. As most chaplains are pain-fully aware, terminally ill patients may become caught up in treat-ment interventions that have little or no value. Palliative care special-ists Harrington and Smith point out that patients sometimes are offered treatments that may pro-long life but have the potential for serious adverse effects. These in-clude preventing the patient from engaging in meaningful life review and preparing for death as well as precluding entry into hospice. The authors present a vivid description of what can go wrong between pa-tient, family and oncologist, using the story of a Mr. L., a previously healthy 56-year-old man, who wanted to survive his lung can-cer at all costs. They highlight the problems facing doctors and others in the healthcare team who treat and care for such patients. In this study, only 37 percent of doctors

discussed life expectancy with pa-tients, even when asked directly for such information. Many doctors assume talking about death will de-press their patient. A paper recently presented in Chicago—and as yet unpublished—indicates that this is not true; however, less than a third of the patients in that study actu-ally had such conversations with their doctors. If you consider that part of your role as chaplain is to improve doctor/patient communi-cation, the suggestions on p. 2672 of this article may prove helpful.

Julie K. Kuzin, Jennifer G. Ybor-ra, Michael D. Taylor, Anthony C. Chang, Carolyn A. Altman, Gina M. Whitney, Antonio R. Mott. “Family-member presence during interventions in the inten-sive care unit: Perceptions of pe-diatric cardiac intensive care pro-viders,” Pediatrics 120, no. 4 (Oct 2007): 895-901. • Historically, it was unthinkable for family mem-bers to be present in certain situa-tions where medical care was being planned or provided, e.g., medical team rounds, invasive interventions (tube placement, intubation), ex-tremely invasive interventions (car-diopulmonary resuscitation [CPR]). Times are changing however, and there is a greater degree of openness to the presence of families at such events. This paper reports the results of a study of attendees—mainly doctors and nurses—at a pediatric cardiac intensive care symposium. One year after the event 145 doc-tors and 66 nondoctors completed questionnaires. An examination of the answers found that 75 percent thought that families should be al-lowed to be present during CPR, 77 percent at team rounds and 57 percent during invasive procedures.


The paper includes additional infor-mation about these and related issues, especially the beliefs of doctors versus nondoctors, primarily nurses.

Dorothy A. Lander, John R. Graham-Pole. “Love medicine for the dying and their caregivers: The body of evidence,” Journal of Health Psychology 13, no. 2 (Mar 2008): 201-12. • Love medicine appears to be a relatively new concept in both the pastoral care and nursing litera-ture. The authors deliberately draw back from giving a precise defini-tion of the concept, saying simply that it “originates in the sacred, shamanic healing art characterizing physical/spiritual touch as an im-perative force to bind people and cultures together.” (p. 202) “We re-frain from defining love medicine further, except to say that, like an intimate relationship, you know it when you experience it; like all art, it is better shown than told, so the data for this qualitative study take the form of exemplars.” (p. 202) Not the same as examples, exem-plars represent the essence of what one wants to convey. The intention of this research is to show that love medicine should be the central real-ity for the best possible end-of-life palliative care. The authors believe that the “European biomedical model of evidence-based medi-cine” cannot identify the essence of the best care for persons who are dying. They gathered their exem-plars using a methodology known as “appreciative inquiry (AI),” a research approach that attempts to blend knowledge and empathy. AI “steers attention … toward storying the best of what is, [in order to] to envision what might be.” (Watkins and Mohr, in Appreciative Inquiry: Change At the Speed of Imagination,

Jossey-Bass, 2001.) Lander and Graham-Pole’s agenda is a radical one. Their paper not only presents a new concept, it utilizes a com-paratively recent research method-ology for illuminating the nature of the concept. In some ways, it makes for frustrating reading be-cause it lacks the familiar evidence of most contemporary research. Nevertheless, their exemplars leave the reader with glimpses of the es-sences about which they seek to in-form. It is worth the effort.

Arthur J. Matas, Jeremy Chap-man. “Should we pay donors to increase the supply of organs for transplantation?,” British Medical Journal 336, no. 7657 (14 June 2008): 1342-43. • Although there continues to be a major shortage of human organs for transplantation, payment to living donors is illegal in most countries. Matas, who is a transplant surgeon, believes that legalization of such payments is needed in order to shorten wait-ing times, which currently may be five to ten years. In a supplemen-tary piece, Chapman, who directs a transplant center, argues that paying donors actually will reduce the supply of organs. What at first glance may seem like a helpful sug-gestion by Matas is strongly chal-lenged by Chapman, making this a useful point-counterpoint paper.

Susan H. McFadden. “Mindful-ness, vulnerability and love: Spiri-tual lessons from frail elders, earnest young pilgrims and middle-aged rockers,” Journal of Aging Studies 22, no. 2 (Apr 2008): 132-139. • There is now a long list of studies from the past quarter century de-scribing religion and spirituality in relation to aging. Many of these

struggle with the issue of how el-ders’ religious beliefs and practices affect their well-being. In this ar-ticle, McFadden critiques many of the assumptions on which this research was built and is especially critical of its “individualistic” ori-entation. She maintains that it is more revealing to think in terms of community. Her experiences in religious/spiritual communities have shown that such communi-ties help everyone to be mindfully present to others, to recognize that we are all vulnerable to the afflic-tions of aging and the certainty of death, and to love and care for others. McFadden describes how her marriage to a parish minister, who is now a chaplain, enabled her to develop relationships with frail elders and young adults. In this well-written piece, she describes how these relationships have influ-enced her thinking and her work as well as how they have shaped her view of her own aging.

Jay M. Milstein. “Introducing spir-ituality in medical care - transition from hopelessness to wholeness,” JAMA 299, no. 20 (28 May 2008): 2440-41. • This article was not written for chaplains, but it may be one that you can pass on to a medi-cal colleague or medical student. Milstein, a neonatologist, values the importance of spiritual inter-ventions and suggests that healing and curing can “coexist” within the clinical setting. He writes that by creating and using healing space, a spiritual intervention may serve as an “experiential basis to restore a sense of order and meaning for pa-tients and their families, improving their ability to cope and to attain a sense of wholeness.” (p. 2440) He describes, in secular language, what


may happen as a result of such spiritual interventions. He briefly introduces a theoretical and empir-ical framework that would support his ideas and suggests to his medi-cal colleagues that such interven-tion may be assessed scientifically. In effect he is saying, let us, as a profession, embrace spiritual inter-ventions as a part of “conventional medical culture.”

Nancy P. Morgan, Kristi D. Graves, Elizabeth A. Poggi, Bruce D. Cheson. “Implementing an ex-pressive writing study in a cancer clinic,” The Oncologist 13 (2008): 196-204. • A writing program has been in place in the Chemotherapy Infusion Clinic of the Cancer Cen-ter at Georgetown University Hos-pital for seven years. Its goal is to enable patients and their caregivers to experience the therapeutic ben-efits of writing without increasing stress. People are not asked to write about cancer or any illness. The themes are more universal, e.g., nature, relationships, identity. This paper describes how the program migrated out of a quieter clinic set-ting into a busy oncology clinic. Subsequently, a research protocol was established to examine its ef-fect in the new setting. There are several important points in this pa-per: discussion of the considerable value of writing for these patients, description of the process of add-ing a new component to an already busy hospital unit, enumeration of the ways in which the authors discovered that writing does have measurable therapeutic benefits.

Susan E. Morgan, Michael T. Stephenson, Tyler R. Harrison, Walid A. Afifi, Shawn D. Long. “Facts versus ‘feelings’: How ratio-

nal is the decision to become an organ donor?,” Journal of Health Psychology 13, no. 5 (Jul 2008): 644-58. • The lack of organ donors is a major problem in the western world, and various organizations have been trying to figure out ways to encourage donations. Educa-tion, changing the laws, allowing the sale of organs have been con-sidered. The authors of this paper take the problem back to square one, asking what drives the deci-sion making process in a potential organ donor. There already have been hints in the research that the process is not always driven by rational or cognitive-based deci-sion making. The authors gath-ered data from 4,426 participants in six different locations across the United States. They found that cognitive-based factors, such as knowledge about donation, are less influential than noncognitive fac-tors, such as the desire to maintain bodily integrity, worries that sign-ing a donor card may be a “jinx” and/or medical mistrust. These are unstated and powerful factors lying behind the inaction of a majority of the population. These findings give chaplains a window into the inner world of potential donors, one that is not always shared, even with a trusted caregiver.

Katherine M. Piderman, Dean V. Marek, Sarah M Jenkins, Mary E. Johnson, James F. Buryska, Paul S. Mueller. “Patients’ expectations of hospital chaplains,” Mayo Clinic Proceedings 83, no. 1 (Jan 2008): 58-65. • This study was conduct-ed in the hospitals associated with the Mayo Clinic. Four of the au-thors are chaplains, who report the results of research to discover what patients expect of hospital

chaplains and their actual experi-ences of this ministry. Question-naires were sent to 1,500 persons within three weeks of discharge. Just over one third were returned, and no follow-ups were attempted. The questionnaire was constructed by the research committee of the Mayo Clinic Department of Chap-laincy Services in consultation with staff chaplains and the authors. Questions focused on four areas: demographics; length and loca-tion of hospitalization; awareness of the availability of chaplains; and expectations regarding visit ini-tiation, follow-up and frequency of visits. The findings revealed that just over half of the respondents re-ported they had been visited, and 86.4 percent of those said the visit was important to them. The main reason for wanting to see a chap-lain was “to be reminded for God’s care and presence.” Other reasons included ritual, prayer and pastoral support. Further analysis showed that responses were related to gen-der, age, religious affiliation and length of hospitalization.

Justin F. Rigali, William E. Lori. “On basic care for patients in the ‘vegetative’ state: A response to Hardt and O’Rourke,” Health Progress 89, no. 3 (May/Jun 2008): 70-72. • The Nov/Dec 2007 issue of this journal published an inter-pretive article by John Hardt and Kevin O’Rourke about the Roman Catholic Church’s teaching on ar-tificial nutrition and hydration. While avoiding saying so directly, Rigali and Lori write to challenge and correct the interpretation that Hardt and O’Rourke provided concerning the care of patients, especially where the provision of food and water is involved. In


order to understand the issues in-volved and the arguments being made, one should read the 2007 article along with this response. For Roman Catholic chaplains, there are important issues in-volved. Lori is chair of the Com-mittee on Doctrine, USCCB. Ri-gali is archbishop of Philadelphia and chair of the Committee on Pro-life Activities.

Kevin S. Seybold. “Physiological mechanisms involved in religion/spirituality and health,” Journal of Behavioral Medicine 30, no. 4 (Aug 2007): 303-9. • Within the past quarter century, psychology rediscovered spirituality/religios-ity (S/R) as a legitimate focus for inquiry. In large part, this interest resulted from a growing under-standing in the literature that there is a positive association between S/R and health. Seybold develops a rationale for why such an associa-tion may be expected and describes various mechanisms that could me-diate the effect of S/R on health. He draws on research from neuro-science, psychology and cognitive science. It should be noted that his possible pathways, while plausible, have yet to be demonstrated. “It is increasingly being recognized that religiosity and spirituality are em-bodied, that is to say, a person re-lates to God, or a ‘higher being,’ or the transcendent, using one’s body. (Coakley 1997). As such, one should not be surprised that any effect of ritual, meditation, prayer or potentially any other religious or spiritual practice would express it-self through physical mechanisms.” (p. 304) This is one of five papers in a special section on Religion/Spiri-tuality and Behavioral Medicine in this issue of the journal.

Allen C. Sherman, Stephanie Simonton, Umaira Latif, Rebecca Spohn, Guido Tricot. “Religious struggle and religious comfort in response to illness: Health out-comes among stem cell transplant patients,” Journal of Behavioral Medicine 28, no. 4 (Aug 2005): 359-67. • There is growing inter-est in the relationships between health and religious coping among cancer patients, but the focus has been mostly on the positive aspects of the relationship. This is one of the few studies to explore negative or conflicted religious responses. This paper focuses on 213 patients with multiple myeloma, who were evaluated at the same point during their initial work-ups for a stem cell transplant. They were asked about their general religiousness and two kinds of cancer-specific religious coping methods: drawing closer to faith (positive) and struggling with faith (negative). During their treat-ment, the patients were assessed for depression, general distress, physi-cal functioning, mental health functioning, fatigue and pain. The results were clear: negative religious coping was found to be “modestly” associated with significantly poorer functioning on all outcomes except for physical functioning. That is, negative religious coping was as-sociated with depression, distress, poor mental health, fatigue and pain. These findings confirm and expand on earlier work. The fol-lowing from the discussion sec-tion is worth noting: “In recent years, medical practitioners have begun to pay greater attention to religious or spiritual dimensions of quality of life. In addition to ask-ing whether faith or spirituality is an important coping resource for the patient, it may be helpful to

inquire about negative or disrup-tive spiritual changes, so that these experiences can be normalized and appropriate referrals can be offered as warranted. Importantly, efforts to support patients in their reli-gious struggle or to help them ex-plore and contextualize their sense of alienation are not necessarily the same as attempting to impose a more beneficent religious view, or to ‘correct distorted’ perceptions. As Pargament et al. (in 1998) sug-gest, the goal is not to ‘judge an individual on the basis of what he or she holds to be religious truth, but rather to assess how that person is able to integrate his or her reli-gion with the demands of life.’ The challenge for chaplains, it seems to us, is how to educate doctors about the findings of this research, and to ensure that we can make effective responses when doctors refer such struggling patients.”

Joan M. Teno. “The wrongful re-suscitation,” Medscape.com (9 Jun 2008): 5 pp. • This is an ethics case, intended for those who care for terminally ill persons who are nearing the end of their lives. An 80-year-old man with diabetes, peripheral vascular disease, be-low-the-knee amputations and poor quality of life has a do not resusci-tate (DNR) form. Subsequently, he is brought to the emergency room in extreme pain and diagnosed with a ruptured aortic aneurysm. He has his DNR form with him, but no one looks at it, and he is rushed into surgery where the aneurysm is repaired. Afterward, an internist finds the DNR form and discusses resuscitation preferences with both the patient and his family. The man reiterates his desire to be DNR, ex-pressing anger at the surgery. His


family supports him. The internist writes a DNR in the chart, but the surgeon who had just successfully completed the aneurysm repair is “furious” and changes the patient’s status back to “full code.” This article asks the following ethical questions: What is your assessment of this situation? If you found this change in the patient’s record, what would you do and why? Teno also provides an ethical commentary. (http://www.medscape.com/view-program/14699_pnt)

U. S. Department of Health & Hu-man Services. “HIPAA and fami-lies,” http://www.hhs.gov/hipaafaq .html (20 Mar 2008) • You may find it useful to bookmark the link to this site in your computer. The Health Insurance Portability and Account-ability Act (HIPAA) is the subject of

numerous discussions and arguments in healthcare settings, and this is the official government site for general information and answers to ques-tions. One question often asked by a hospital’s policy-makers is whether a hospital may display patients’ names next to the doors of the hospital rooms that they occupy. The answer is “yes” with a proviso that is includ-ed. The site is user friendly. (accessed March 20, 2008).

Jeffrey Zaslow. “A final farewell,” The Wall Street Journal (3 May 2008): R1. There are thousands of articles summarized in The Orere Source computer database, but this is the first one concerning an article in The Wall Street Journal. You also may think it strange that a business newspaper has an extended article about dying and death. In aca-

demia, there is a long tradition that when professors retire, they are in-vited to give a last lecture in which they may impart wisdom that they have gained during their lives. This article describes “last lecture” of Randy Pausch PhD, a 47-year-old Carnegie Mellon University pro-fessor who had just been diagnosed with incurable pancreatic cancer. It was delivered at Carnegie Mel-lon on September 18, 2007. The article provides additional back-ground about Dr. Pausch, his fam-ily and his dying. His lecture is available via YouTube.com (type in his name: Randy Pausch). These resources may provide further in-spiration for the ways to interact with people who are terminally ill. Dr. Pausch died July 25, 2008.


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Attentive to God: Thinking Theologically in MinistryCharles M. Wood and Ellen BlueNashville, TN: Abingdon Press, 2008 softcover

Charles M. Wood and Ellen Blue bring solid academic credentials to their works. Wood is professor of Christian doctrine at Perkins School of Theology, Southern Methodist University, Dallas, TX, and Blue is assistant professor of Christian his-tory and United Methodist studies at Phil-lips Theological Seminary, Tulsa, OK. In this collaboration, they suggest that the development of pastoral identity and pas-toral practice are mutually formative. They believe that the capacity to reflect theologi-cally on a pastoral encounter increases ef-fective leadership in ministry.

The book is divided into four parts: an introduction, which serves as the corner-stone; a brief orientation to Christian the-ology, which draws on historical and sac-ramental theological concepts that may be restrictive and noninclusive of other theo-logical perspectives; nineteen fictitious case studies for consideration in ministry, each with a universal flavor that should resonate with most clergy professionals re-gardless of faith orientation; and notes on selected cases.

Among the case studies are the following: dealing with a homeless person who takes up residence under the church’s steps, at-tempting a reconciliation following sexual misconduct, using inclusive theological language for a child’s baptism, addressing a newly appointed pastor’s need to challenge another minister’s differing theological perspective, responding to a parishioner’s request to spend time at the parsonage while the pastor is away on vacation, un-derstanding a child’s bereavement process and attempting multiethnic ministries

in the face of opposition from one of the powerful members of the congregation.

The notes on selected cases represents the authors’ collaborative effort to present brief background interpretations and sug-gestions with the intention of highlighting resources and considerations that may be more broadly applicable to the theological reading of human interactions. They assert that separating these case study reviews from the rest of the text is a strength. Read-ers have the opportunity to digest the facts of a pastoral encounter or ministerial pre-dicament and to form their own theological assessments and responses prior to reading what an “expert” would have done.

Appropriately, various professional chap-lains and clinical pastoral education (CPE) supervisors may find this volume helpful in their specific settings. The CPE supervi-sor may use it for curriculum development or suggested reading for enhancing theo-logical reflection. A supervisor-in-training with limited congregational or pastoral experience may find the case studies uni-versal in nature and thus informative and instructive. The professional chaplain may find this approach strengthens or renews his/her skills in theological reflection.

The essential approach for reflection may be distilled into six formative reflec-tion questions. What is going on in the case study? How is God involved in what is going on? What is the fitting response to what is going on? What is going on with you as you consider this case? How is God involved in what is going on with you in this process? How might you re-spond to what is going on with you? The interpersonal reflective process of the first three questions may be defined as story, reflection or pastoral response-action. Questions four, five and six balance the scales, by encouraging the reader toward

If you wish to suggest books for review or if you are interested in serving as a reviewer for CT, please contact Paul Buche MA MS, CT book review editor.

[email protected]


intrapersonal theological reflec-tion. As the writers explained their reflections on the specific ministe-rial predicaments included in the “notes” section, I would have pre-ferred more of their intrapersonal theological reflection.

The professional chaplain—whether in a healthcare institution, prison, long-term care or industry setting—may find this volume valuable for use in volunteer train-ing programs as well as chaplain associates’ continuing education events and/or training programs.

Beverly C. Jessup DMin BCCCPSP Diplomate, Pastoral SupervisionClinical Director, Pastoral CareFirstHealth Moore Regional HospitalPinehurst, NC

Good Mourning: Getting Through Your GriefAllan Hugh Cole Jr.Louisville, KY: Westminster John Knox Press, 200896 pages, softcover

Despite its “punny” title, which reminds me of Granger Westburg’s Good Grief, this is a serious book. In a sense, it parallels the concept of a good death for the patient, offering the survivor(s) a “good” mourning.

Central to the author’s thesis is the concept of bereavement, grief and mourning as distinct, though relat-ed, entities. Bereavement is defined as the occurrence of loss, and grief as the immediate response. “Mourn-ing proceeds from an experience of grief. … [It] describes the manner of getting through loss over time. … [and] also involves learning how to live with a lasting void created by what we have lost.” (p. xvii)

The first half of the book focuses on loss: what makes it difficult, its effect on the individual’s thoughts and feelings and what helps an indi-vidual to cope. Cole maintains that in order to mourn well, one must prepare. Much of this preparation centers on initial coping, which is essentially coming to terms with loss in the immediate aftermath. He writes that as the farmer culti-vates the ground for planting, one must cultivate the “ground of be-ing” for mourning.

The strategies put forth by Cole focus on acknowledgment of the loss sustained. They include facing reminders, both verbal and visual, through the process of a funeral/memorial service as well as talking with family, friends, clergy and/or counselor. Feelings are to be ac-cepted and articulated rather than denied or minimized. Tears should be welcomed. At the same time, one also should seek enjoyment and comfort in people and activi-ties enjoyed prior to the loss. Other coping tools in the grief stage in-clude physical activity and forgive-ness/reconciliation.

The second half of the book is devoted to the mourning process, beginning with what Cole terms the “requirements.” All of these are related to the loss which has been experienced: receiving, enduring, adapting, relocating and returning to sojourn with as necessary.

His strategies for achieving “good” mourning overlap those for coping with grief, and most will be familiar to chaplains: acknowledge the loss and go forward toward living with this void in life; make use of ritual that encourages con-frontation with loss; seek support from others, and yet dare to be alone; identify feelings, thoughts

and behaviors, assigning each an intensity level; identify and priori-tize changes that need to be made. Finally, cultivate a “place” for that which has been lost—this is the relocating/sojourning piece—and consider the new opportunities/goals as they present themselves. Cole reminds the reader that each person mourns uniquely. In the words of my first clinical pastoral education (CPE) supervisor, “It’s not one size fits all.”

On the whole, Cole writes from a universal viewpoint; however, the last two chapters, which explore the role of faith and prayer, have a pre-dominantly Christian focus. The appendix provides a concise list of the strategies for coping with grief and for good mourning, which are detailed in the text.

Though the professional chap-lain may find nothing new in this book, its clear delineation of strategies makes it an excellent resource for CPE or congrega-tion-based educational programs. While it certainly would be appro-priate to give this book to a griev-ing individual as noted in one of the back cover comments, I see it as having more value as a means for dialogue either in one-on-one pastoral counseling sessions or be-reavement support groups.

Coles both honors and validates all of the griever’s thoughts and feel-ings. At the same time, he provides a process for working through these to achieve a “good” mourning.

Rozann Allyn Shackleton MDiv MA BCCEditorChaplaincy TodayBarrington, IL


The End-of-Life Handbook: A Compassionate Guide to Connecting with and Caring for a Dying Loved OneDavid B. Feldman and S. Andrew Lasher Jr.Oakland, CA: New Harbinger Publications, 2007186 pages/softcover

Society’s approach to aging and death is generally one of avoid-ance. In fact, the authors compare receiving a terminal diagnosis to stepping into a raft on a river with class four rapids. “Things abruptly begin moving too fast; people de-scribe feeling unsteady, never fully in control. They are aware that un-seen dangers may await them at ev-ery turn. People who are seriously ill—and those caring for someone who is ill—urgently need a guide who has run rivers like this before.” (p. vii) The physician and the psy-chology professor who authored this book certainly fill this role.

In the first half of the book, the authors help the reader to navigate the bewildering array of medical personnel and information. They point out the differences between attending physicians, residents and specialists. Further, they provide helpful suggestions regarding plan-ning for meetings with physicians as well as for other family members. One chapter provides a summary of the most common terminal ill-nesses. Another addresses the pain and suffering that may accompany them. A look at the where, how and when of death rounds out this section.

The second half of the book looks at the nonmedical issues of death and dying, which may be equally perplexing. “Most people have no idea what emotions are normal to

experience when a loved one is dy-ing. How could they? Most of us grew up in families where death was not talked about. Most parents explain ‘the birds and the bees’ to their children but wouldn’t touch ‘the cycle of life’ with a ten-foot pole.” (p. 93) The authors discuss common feelings, and they make the important point that distort-ed—and often overly self-criti-cal—thinking also is common and may be voiced as the following: I’m being a wimp; I should be stronger; I’m being selfish.

One helpful chapter is titled, “What Should I Be Saying? Learn-ing to Talk with Someone Who Is Dying.” The authors point out that talking openly helps to “de-toxify” death. They provide help-ful exercises and good questions. There also are examples of rituals for saying goodbye and rituals for grieving.

This book is intended for people who have little or no experience in the healthcare maze. Though chap-lains and others in healthcare won’t find much that’s new, this book may be a helpful resource for pa-tients and/or families who need a navigator to accompany them on the journey toward the end of life.

Mark A. Bonnema MDiv BCCStaff ChaplainSwedish Medical CenterSeattle, WA

Encountering Other FaithsMaria HornungMahwah, NJ: Paulist, 2007 112 pages/softcover

The basic premise of this book is that in some ways all religions are true; they are different because they arose in different geographi-

cal areas, with different languages and meet the needs of different people by providing diverse ritu-als. Alongside this are the beliefs that all religions may lead to spiri-tual enlightenment; that particu-larism/exclusivity—the notion that there is one right way, and that all others are in some way de-ficient, and wrong—is destructive and dangerous; and that through mutual respectful encounters, people may move closer to world peace. Within these parameters, the author offers suggestions as to how women and men of goodwill may engage each other in order to learn and to appreciate their re-spective faith traditions.

Hornung begins with a short overview of interreligious dialogue in both global and American soci-ety. The second chapter explores the meaning of that term and then considers ground rules and modali-ties of such a dialogue. In a major chapter devoted to the “theoretical underpinnings” of interreligious dialogue, Hornung highlights in particular the thinking of Milton Bennett and James Fowler.

The book concludes with a practi-cal nine-step program for encoun-tering other faiths. Hornung readily notes that this is not one-size-fits-all. She is clear that this model “lends itself to adjustments in accord with an assessment of each group’s skills and needs” (p. 78).

As professional chaplains, many of us encounter people of other faith traditions on a dally basis. By increasing our knowledge about, and experience of, these traditions, we may become more effective in our caring. In my mind, a limitation of this book is that it appears to repeat some of the basic theses, but it may be


that the author simply reframes those ideas in different ways.

Readers who find this work of in-terest and relevance will be pleased with the bibliography at the book’s conclusion. Hornung studied in-terreligious dialogue with Professor Leonard Swidler at Temple Uni-versity in Philadelphia. Swidler, along with Paul Mojzes of Rose-mont College, edits the Journal of Ecumenical Studies. Articles in that journal likewise would be of inter-est to someone who wants to en-gage in this kind of interreligious dialogue. David J. Zucker PhD BCCRabbi/ChaplainDirector of Behavioral ServicesShalom ParkAurora, CO

Reflections on Psalm 23 for People with CancerKen CurtisWorcester, PA: VisioVideo, 2007 DVD

No one could accuse the pro-ducer of this DVD of speaking from an ivory tower. Dr. Ken Cur-tis, president of Vision Video, has been diagnosed with stage 3-B lung cancer. He opted for a combina-tion of traditional and alternative treatment, and he has done much better than originally expected. The Twenty-third Psalm was a key part of the spiritual component of his treatment plan, and in these thirteen meditations he does a nice job of applying the message of this psalm to living with cancer. He ably demonstrates that Psalm 23 is more than “just a spiritual sedative to give at funerals!”

In the opening segment, “The Lord is my Shepherd,” Cur-

tis points out that “we are not in charge.” He talks about the sense of powerlessness that accompa-nies being diagnosed with cancer. “Cancer is a defining experience,” he says, “but it can be a good defin-ing experience.”

As the film shows a shepherd and flock in Israel, Curtis talks about the phrase, “Your rod and your staff comfort me.” He does quote from Hebrews 12 about God’s dis-cipline, but he is quick to add that he is not saying that God sends cancer. Curtis’s approach is one that I frequently hear from cancer patients. While they would not have chosen a cancer diagnosis, they are astounded at the good that has come to their lives.

“Reflections” is composed of thir-teen 8-minute segments. Some lis-teners may find Curtis’s voice annoy-ing, but the scenery on the DVD is beautiful, and the background music is both pleasant and peaceful.

While the focus of this DVD is people with cancer, people with other serious illnesses also may find it meaningful. With its biblical and religious connections, it probably would be more appropriate for use in a church-based cancer support program than in one that is hospi-tal or community based.

Mark A. Bonnema MDiv BCCStaff ChaplainSwedish Medical CenterSeattle, WA

Teilhard de Chardin – The Divine Milieu Explained: A Spirituality for the 21st CenturyLouis M. SavaryMahwah, NJ: Paulist Press, 2007

Having read The Phenomenon of Man and The Divine Milieu, I

was excited to learn that Louis M. Savary had written a book that fo-cused on how Teilhard’s spirituality may be relevant to the practice of ministry. One of the challenges in chaplaincy is to offer ministry from a well thought-out theology. As a Jesuit priest and scientist, Teilhard took seriously the need to integrate religion and science into a practical Christian spirituality. I’ve long felt that Teilhard’s work provides such a theology and welcomed the assis-tance that Savary seeks to provide.

There are many who may identify with Savary’s reason for writing: “I have always felt attuned to Teilhard’s mind. So at the urging of friends ea-ger to explore—and even practice—Teilhard’s spirituality, I have tried in these pages to simplify without dis-torting The Divine Milieu for the Teilhardian beginner and to turn it into a spirituality that any person can actually practice.” (p. xvi)

The French word milieu “encom-passes our English words ‘atmo-sphere’ and ‘environment,’ yet for Teilhard it connotes still something more that he tries to capture in the image of light, inner luminosity, or fire” (p18) According to Teilhard, the divine milieu is always in a state of evolving, developing and pro-gressing towards the Omega point, the Cosmic Christ.

The choices we make daily may promote activities for growth and diminishments that shape our lives and the Body of Christ. There are activities that come from an outside source and activities we choose. For example, you may choose to go for a drive in the country, but you have no control over the drunk driver who slams into your car and leaves you paralyzed. Both are part of one’s personal development and that of the Body of Christ.


The strength of this book is the exercises it provides to guide read-ers into experiencing their part in developing the Body of Christ. The following exercise is a good exam-ple: “Just as you might come home after work and tell your spouse or your family what you accom-plished at work today, in a similar manner you may begin to tell God in prayer what you accomplished today that furthered the work of the Christ Body.” ( p. 79)

The exercise concerning our di-minishments provides an especially helpful perspective: “Not only are you struggling for life against the diminishments that befall you, but so is the Christ Body struggling with you and through you against the diminishments that befall it. Thank God for the strength that comes to you through the divine milieu” (p.108)

Chaplains may see as helpful Savary’s explanations for Teilhard’s three ways that the divine milieu may transfer evil—which he sees as a diminishment—into good. For example, “While I was in the hospital with my broken leg, I met the person I was going to marry.” (p. 112) “First, the diminishment diverts our attention and activity toward a framework that will turn out to be more beneficial than what we were doing before the diminish-ment.” (p. 112)

“Second, and perhaps more often, our loss or affliction will force us to turn for satisfaction to less material purposes. Lives of many saints expe-rienced this form of transformation. ‘My child was killed by a drunk driver; now I dedicate my energies to finding ways to prevent inebri-ated people from driving.’’’ (p. 112)

“Third, the more we deepen our attachment to the fulfillment

of the Christ Body, the less we need to set limits to the ‘tearing up of our roots.’ This describes a shift of primary attachment from self to the Christ Body, where to serve God is all we wish to do.” (p. 113) This may help persons to deal with suffering due to ac-cidents, unexplained premature deaths or permanent damage to the physical body.

This work could be used to en-gage Christian chaplains to think through their ministry praxis, es-pecially as it relates to the Body of Christ. Is ministry offered from a sense of being a part of the Body of Christ? In what way does Teil-hard expand the Pauline view of the Body of Christ? How does Teilhard’s idea of evolution apply to the changes patients experience when they enter the hospital? Sea-soned chaplains may want to evalu-ate some of their ministry practices through the lens of Teilhard’s di-vine milieu. It should be noted that Savary’s responses to Teilhard’s crit-ics are insightful. However, it is the practical value of Teilhard’s work that is the intent of Savary’s book as well as this review.

Michael G. Davis DMin BCCRetiredHernando, MS

Let Them Go Free: A Guide to Withdrawing Life SupportThomas A. Shannon and Charles N. Faso, OFMWashington, DC: Georgetown University Press, 200761 pages/softcover

Let Them Go Free: A Guide to With-drawing Life Support sends a gentle message to those family members

and close friends who find them-selves in the middle of the chaotic environment of the emergency room or intensive care unit with-out warning and with little time to prepare for major decision making. The book begins with a dialogue that describes the process of dy-ing, the burdens as well as benefits inherent in modern technology. It recognizes limiting treatment as a sign of wisdom, even though the consequences may be difficult to accept. This thoughtful introduc-tion comfortably moves the reader into the purpose of this well-writ-ten and informative book, which asks the question voiced by many family members: “what should I do?” The authors discuss openly, honestly and without judgment both sides of questions that often go unspoken and/or unanswered during this stressful time, many of which may manifest later as state-ments of anger or resentment.

Is it possible for family members to read thirty-four pages of text in a stressful atmosphere and re-ceive insight to the point of being comfortable with their next deci-sion? This reviewer answers with a resounding yes! The authors lay the groundwork for open consid-eration and discussion of family members’ individual viewpoints and permitting others to do the same without confrontation. Fur-ther, they present thoughtful ques-tions for this personal and private family decision. Let Them Go Free creates the opportunity for open honest family dialogue in which appropriate decisions may be made for the patient, leaving the family with a path toward closure.

“The Family Prayer Service” found in the back of the book affirms belief in the living God and is based in the


Judeo-Christian tradition. Readings from Jewish and Christian Scrip-tures as well as a prayer of commen-dation are included in this section. Family members may be invited to choose those familiar passages that bring them peace and comfort. It is suggest this service be spoken just before artificial life support is with-drawn. This service provides a sup-port tool for the family’s personal reflection and a comforting walk through familiar rituals and prayers that may help individuals truly to let their loved ones go free.

Though the worship section is faith specific, Let Them Go Free: A Guide to Withdrawing Life Support is a valuable resource for chaplains ministering in end-of-life situations and a worthwhile addition to clini-cal pastoral education libraries.

Gus MartschinkAdjunct ChaplainMoses Cone Health SystemsGreensboro, NC

Pastoral Care of Depression: Helping Clients Heal Their Relationship with GodGlendon MoriartyNew York: The Haworth Pastoral Press, 2006239 pages/softcover

My hope that this text would pro-vide increased understanding of the impact depression has upon a per-son’s religious/spiritual experience and how to respond or intervene as a chaplain was partially met. The author’s goals are to “provide the reader with a strong understanding of depression and the God image … [and] to furnish the reader with the therapeutic ability to change the God image.” His decade-plus study of the God image led to founding

an institute (www.godimage.com) dedicated “to helping people change their God image.”

Moriarty is a psychologist who supervises doctoral level trainees and teaches psychodynamic thera-py and psychology of religion. He lacks pastoral counseling creden-tials or formal theological train-ing. To his credit, he addresses the ethics of therapists entering into a client’s spiritual life. Grounded unambiguously in the Christian tradition, he writes primarily for therapy students and the counsel-ing office setting.

Chapter 1 describes exogenous depression and its etiology—that which results “from personality development and situational cir-cumstances.” He does not explore the possibility that the biological imbalances of endogenous depres-sion also may lead to unhealthy God images. After an explication of the distinction between head and heart expressions of religion, two case studies are introduced and intertwined throughout the remaining text.

Chapter 2 invites the reader into self-assessment—to identify one’s own operational God image by completing several exercises. Inter-pretation of the assessment results is presented in the context of an extended discussion about how a God image develops. The author sees operational images of God as the result of childhood experiences with parents.

Chapter 3 leaves the reader with a tantalizing hypothesis not yet suf-ficiently tested. It has been dem-onstrated that the therapy jour-ney may result in a revised image of God. Could a revision of one’s image of God lead to healthier psy-chological functioning? How the

person suffering from exogenous depression exhibits a damaged im-age of God is described in greater detail—what chaplains would term “unhealthy spirituality.”

In Chapter 5, the author pres-ents a number of assessment tools. Some are his, others he reprints with permission. His own “God image assessment protocol” de-scribes the use of traditional psy-chological assessment processes to develop a biopsychosocialspiritual assessment (Level 1).

Level 2 uses additional tools to focus on the client’s God image, including the author’s God Image Drawing and God Image Sentence Blank Completion Test, God Im-age/Parent Grid (Robert McGee), God Image Questionnaire (Wil-liam Gaultiere), God Image Inven-tory (Richard Lawrence) and Spiri-tual Assessment Inventory (Todd Hall and Keith Edwards). Some of these tools could be used in clinical pastoral education (CPE). Chap-lains likely will find Gaultiere’s description of fourteen “Unloving God Images” and the correspond-ing “Unlovable Self-Images” the most interesing of these.

Additional chapters outline psy-chodynamic and cognitive therapy approaches to assist clients in revis-ing their God images. A final chap-ter arranges all this into a treatment plan and discusses how to secure the client’s consent and investment in the journey. Overall the text is well writ-ten and has relevant charts and dia-grams throughout. It also includes a good bibliography and index.

Roy Olson DMin BCCCoordinator ChaplainAlexian Brothers Behavioral Health HospitalHoffman Estates, IL


Coming of Age: Exploing the Identity and Spirituality of Young MenD. Martinson, David W. Anderson and Paul HillAugsburg/Fortress Press, 2006 214 pages

Coming of Age is the outgrowth of research—the Young Male Spiritu-ality Project—which was a joint ef-fort of Lutheran Men in Missions, the Evangelical Lutheran Church of America and the Luther Seminary Faith Factor Research Teams. The impetus for this project was the re-alization that “‘twenty-something’ guys are scarce in worship services and acts of ministry” as well as the concern that the “young adult postmodern generation seemed to possess a skepticism” for the insti-tutional church, apparently side stepping it for a “more personal connection with God.”

The study included eighty-eight young men, aged 18 to 35 with differing faith experiences and en-compassing four ethnic groups. The study protocol included one-hour interviews, which focused on “spirituality or faith with its par-ticular practices.”

The chapters are organized to include observations of where the church is in relation to this cohort, trends and dynamics, observations from interviews and theological responses. The most helpful chap-ters provide anecdotal information from individual men, theological discussion and implications/guide-lines for the church/ministry. The final chapter offers guidelines for transforming ministry to better reach this age group of men.

Coming of Age could be a valu-able resource to anyone seeking to understand the spiritual expres-

sion of young men and ways to connect with them through their current lifestyles and identities. I heartily recommend this book for anyone who works regularly with young men.

Al Voorhis MDivPark Ridge, NJ

Sacred Living, Sacred Dying: A Guide to Embracing Life and Death.Sharon Lund Lincoln, NE: iUniverse, 2006127 pages/softcover

Sacred Living, Sacred Dying: A Guide to Embracing Life and Death is a wonderful treasure, truly some-thing to savor. In this multipurpose and multiuse book, Sharon Lund acknowledges that “death is a chap-ter in life few people are comfort-able talking about.” (p. 98)

In the introduction, the reader is greeted with the rollercoaster ride that is Lund’s life: her child-hood experience of violent sexual abuse from a close relative; the loss of most of the people she has loved; giving birth to the joy of her life; being diagnosed with AIDS; her spiritual awakening in the midst of marriage, divorce and domestic abuse.

She concludes, “I have danced with life and death throughout my life, and each challenge seeded the gifts and wisdom I share with you. By facing all of my challenges and releasing them, they have become sacred—sacred because they have healed me, brought me to self-dis-covery, to wholeness and to living my life purpose.” (p. xxi) With this profound statement, she sets the tone for the rest of the book.

In chapter 1, titled “Legacy of Love,” Lund provides a series of topics and questions. This is more than a workbook for recording one’s life; it is a self-help book fo-cused on learning to accept and celebrate one’s life experiences. She includes suggestions on how to begin a dialogue journal. Rather than merely being an end product, this journaling becomes a holy and spiritual journey. Lund encourages the reader to find a safe, quiet en-vironment and to set aside a cer-tain amount of time to write. She includes detailed instructions for “oral journaling” via audio or video recording, a means of life review that will provide a lasting legacy.

Chapter 2 is filled with informa-tion and resources for celebrating life through a memorial or funeral service. Readers are encouraged to “step out of the box” and to fash-ion an event truly reflective of their individual life journeys.

Chapters 3 and 4 review in great detail the decisions one must make in preparation for death. Having this information neatly complied serves to relieve the anxiety of fam-ily and friends in making deci-sions during a final illness and after death has occurred. Lund cautions that each state has its own regula-tions and laws and that one should investigate their particular state’s regulations prior to making plans.

Finally in chapter 5, Lund re-turns to her own life as she invites the reader to travel with her as she recreates her near-death expe-rience, a very powerful and emo-tional journey through life and death and finally life again. What might have been the end was really the beginning. As she embraced the negative events, the hurts and frustrations, the losses—all were


transformed into a passion for life. It is from this passion the Sacred Living, Sacred Dying springs. As Lund observes, “Sacred Living, Sa-cred Dying is a gift of tools which will allow you to ‘practice dying.’” (p. 107) As one practices dying, one is able to live more fully in the present moment.

Lund’s Web site describes Sacred Living, Sacred Dying as a book that “embraces all people, regardless of race, religion, or spiritual beliefs. It is truly a universal document with enormous potential.” Does it live up to that statement? Cer-tainly some aspects, such as the suggestion in the section on crema-tion that the remains be scattered or mixed with pottery clay and made into items for distribution (p. 78), are not acceptable within some faith traditions. That being said, this book provides a plethora of ideas and information that does make it universal in many respects.

One further observation is that in developing what she terms a legacy of love, Lund focuses on the posi-tive. As one intention in creating this document is that it become public—at least within one’s fami-ly—this is understandable. Howev-er, for those who wish to go deeper, as Lund did in her autobiographi-cal introduction, questions such as the following that evoke negative experiences may prove helpful. What was the most terrifying event you’ve experienced? How did you feel? Wat did you do? How do you regard that experience now?

In reviewing Lund’s life journey, it becomes evident that she has found positive aspects in many of her neg-ative experiences. Inclusion of the negative in preparing one’s legacy of love may result in a transformative experience for others as well.

For those who find Lund’s autobi-ography in this book much too short, she currently is working on Sacred Ashes, a fuller account of her journey toward self-discovery and wholeness. Additional information on her books and lectures is available on her Web site (www.sharonlund.com).

I consider Sacred Living, Sacred Dying to be a valuable resource for anyone who is involved with caring for others. First of all, one may use it to write one’s own story and to encourage others to tell their sto-ries. It provides a manual to assist elderly patients in completing a life review. It also includes ample resources to assist patients, families and staff in creating a meaningful memorial service and dealing with the details that are the responsibil-ity of those who survive.

Finally, this exceptional book demonstrates the personal impact each of us has on the lives of those we touch whether they are personal friends, patients or casual acquain-tances. The many creative sugges-tions are a valuable resource and as-sist us in thinking outside the box of our day-to-day chaplaincy.

Christian Demlow DMin BCC Chaplain Coordinator Spiritual Care Services Scripps Mercy Hospital Chula Vista, CA

Healing the Hidden SelfBarbara Sheldon RyanNotre Dame, IN: Ave Maria Press, 1982 (reissued 2005)126 pages/softcover

Is a book published in 1982 rel-evant for today? Clearly, some books are timeless classics, but much has oc-curred since 1982. Ryan, a Catholic laywoman, nurse, therapist, retreat

director and conference speaker has written a book that continues to speak to the twenty-first century reader.

The opening precept of this well-crafted work is that traumatic epi-sodes are “often pushed deep into hidden recesses” and are stored in the unconscious, which “like an el-ephant, never forgets.” These deeply stored traumatic/unhealed hurts color one’s life and may lead to de-structive behavior and constant ten-sion. Ryan’s response to these deeply stored and life-shading memories is “inner healing,” which may oc-cur as part of one’s faith journey as one gradually becomes infused with the light of God’s love. Ryan recommends that one seek the com-panionship of clergy, therapist or a Christian friend during this time.

The journey of life and potential trauma moves from the prenatal state through to that of “seasoned citizen.” Each chapter of Healing the Hidden Self considers a particu-lar season of life along with Ryan’s observations from her experiences of supporting others through inner healing, observations from sound researchers and clinicians, scripture for reflection. Each ends with guid-ed prayer.

Is this book for you? I must admit that my initial response was mixed. I came to realize that my time with it was not going to be merely one of reading and reviewing, but rather a journey through my own landscape of buried trauma. The journey was worth the time spent. Although brief, Healing the Hidden Self is not a quick read. Rather, it is an invita-tion to journey through one’s own soul and to find healing.

Al VoorhisPark Ridge, NJ


Medicine and Compassion: A Tibetan Lama’s Guidance for CaregiversChokyi Nyima Rinpoche with David R. ShlimSomerville, MA: Wisdom Publications, Inc., 2004174 pages/softcover

“We shouldn’t lose sight of the main point, that it is not a matter of creating compassion, but a pro-cess of just allowing it to occur. Just like water is wet, or a flame is hot, our basic nature is inherently com-passionate.”

In this book, Tibetan lama Chokyi Nyima Rinpoche explores and helps the reader to set an in-tention for the cultivation and use of compassion in a medical set-ting. Rinpoche and his coauthor, Dr. David Shlim, take the reader through basic Buddhist teachings about the nature of suffering and then into aspects of training to en-hance the calm and compassionate mind. They also include practical advice on subjects such as dealing with difficult patients and being with people who are dying.

Medicine and Compassion is di-rected specifically to physicians, who are encouraged to develop their skills of compassion along with their medical training. This reviewer thinks that the ideas and tools for growing the compas-sionate nature will be helpful for anyone in the caring professions, especially chaplains. Though the writers address the issues from a Buddhist perspective, there also is a universal spiritual tone and use-fulness. Chaplains likely will feel validated for their present compas-sionate work and will be inspired to continue the development, per-haps in new ways.

As healthcare institutions strug-gle with the “bottom line,” and the focus seems to be shifting to numbers of visits, census counts and outcomes, this book reminds chaplains of the importance of di-rect attention to patients and their families. While chaplains may be coaches and mentors to other pro-fessionals, they first must be com-mitted to an ongoing expansion of their own compassion. Rinpoche talks about the barriers profession-als may create for protection and how these interfere with good self-care or open service to patients. He writes about meditation, honest inquiry into the mind and train-ing to broaden one’s capacity to act from an open, compassionate heart. Compassion comes out of the feeling of connection with oth-er humans. By strengthening the connection or feeling of sameness, one reduces the perception of “me and other” which in turn strength-ens one’s wisdom and compassion.

Rinpoche encourages the cultiva-tion of positive traits, e.g., kind-ness, generosity, perseverance, empathy, compassion, until com-passion becomes a driving force rather than just a concept. A tra-ditional Buddhist metaphor sees compassion as that which a parent feels for a child—free of judgment or comparison. Part of the training is to become aware of one’s feelings of judgment and to examine them so that healing may occur and posi-tive traits may be enhanced. “The spiritual practitioner is striving to see things as they really are, not as they seem.”

I recently loaned this book to our hospice medical director, who reported the book gave him much encouragement to balance medi-cine and compassion in a way he

hadn’t understood before. I recom-mend this book as a further sup-port to the work chaplains already do and as a resource to share with medical colleagues.

Chokyi Nyima Rinpoche ends the book with this final blessing: “I wish that you may be happy and healthy, and that your wisdom and loving-kindness may increase like the waxing moon. This is my wish and my prayer.”

Annie ClayChaplainProvidence Sound Home Care and HospiceOlympia, WA

Guide to Ministering to Alzheimer’s Patients and Their FamiliesPat OtwellNew York: Routledge, 2007195 pages, softcover

Early on, the author presents the statistic that “4.5 million people in the United States had Alzheimer’s disease in 2000. By 2050, the pro-jected number … is expected to in-crease threefold.” (p. 22) Certainly this is reason enough for chaplains to become educated about the dis-ease and, most importantly, how to minister to patients and families caught in what frequently is de-scribed as “the long goodbye.”

Otwell does a credible job of de-scribing the disease itself and its process as well as dispelling myths that surround it. Speaking out of her twenty years of Alzheimer’s work, she maintains that ministry to these patients is not difficult, just different, and that much can be done for them spiritually. She has little patience with the excuse that the patient will not remem-


ber a visit: “You will know—fam-ily and friends might know. Far more important, God knows.” (p. 30) As for being at a loss for words, she reminds the chaplain/spiritual caregiver that it is the ministry of presence that matters most.

She emphasizes the value of nonverbal communication with Alzeheimer’s patients and the ne-cessity of validating their reality rather than imposing one’s own. As they suffer short-term memory loss, she stresses the importance of using the familiar and original, whether it is the person’s birth—rather than married—name or the faith tradition of childhood. “Tra-ditional religious symbols that can be touched, seen, heard or smelled might trigger spiritual memo-ries or associations. … Patients still may be able to recite familiar prayers and to sing well-known hymns. Ministry is in the ‘here and now’ because visits will likely not be remembered.” (p. 71)

Above all, she encourages fre-quent visitation to support both patient and family, especially as the disease progresses. A chapter devot-ed to spiritual care for families pro-vides insight into the issues faced by those related to the patient, who also may be the primary caregivers, during the different stages of the disease.

Otwell advocates for clergy atten-dance and participation in support groups and seminars as a way of increasing their awareness and edu-cation about Alzheimer’s. Much of this book is directed at commu-nity clergy, and she recommends that faith communities sponsor workshops, displays and informal discussion groups to educate con-gregations as well. Such activities may help to lessen the isolation of-

ten experienced by family members as the patient’s behavior becomes more erratic.

Beyond education and commu-nication, I found the sections on grief, guilt and ethical issues to be the most pertinent for chaplains. The progression of Alzheimer’s dis-ease frequently spans years, result-ing in anticipatory grief. As with other progressive diseases, e.g., ALS, there are the periodic losses, which also need to be grieved. Overlapping this is the guilt fam-ily members often experience when the patient can no longer be cared for safely at home. Ethical issues, such as defining when the patient’s getting behind the wheel of a car endangers others, have overtones of grief and guilt as well.

Clearly, Otwell writes with a Christian audience in mind. Two-thirds of the 15-page appendix titled “Strength from the Scrip-tures” is devoted to quotes from the New Testament; the remainder are primarily from Psalms. All of the worship services contained in the appendix “Sample Programs, Services and Forms” have a Chris-tian focus.

Overall, I found the content un-even, ranging from the strengths mentioned above to portions that seem quite simplistic. Further, Ot-well punctuates her prose with an overabundance of subheadings, which I found intrusive and un-necessary, especially as her chap-ters are short. She also frequently resorts to bullet-point lists, giving the impression that she assumes her readers have little or no train-ing in pastoral care.

Despite these criticisms, I think this book does qualify as a basic guide to the multiple dimensions of Alzheimer’s disease. The 28-page

resource section, which includes an extensive listing of organizations plus an annotated bibliography, makes it a worthwhile addition to the department library.

Rozann Allyn Shackleton MDiv MA BCCEditorChaplaincy TodayBarrington, IL


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ithI HAVE ALWAYS BEEN FILLED WITH WONDER AT THE NIGHT SKY. I grew up near New York

City where reflected ground light kept me from seeing the heavens in all their glory. But for three summers when I was a teenager, I worked at the Baptist Conference

Center, which at that time was located in the middle of rural New Jersey farmland. On clear nights, I took my blanket out into the field and looked at the sky.

The wonder of this universe we live in captures me. It draws my imagination away from the mundane tasks of daily life. I am awed by the following description from StarDate, a presentation of the Texas McDonald University that aired on NPR:

The earth is zipping straight toward the moon today. We’ll cover the quarter-million-mile gap in about three and one-half hours. But it’s nothing to panic about. By the time we cover that distance, the moon will have moved that much farther away, and that’s just one of their many motions through space.

Earth, moon, sun and everything else in our solar system orbit the center of the Milky Way Galaxy, a 200-million-year journey, even at an average speed of 500,000 miles per hour. The Milky Way is moving too! It’s being pulled toward the Andromeda Gal-axy, and both are being pulled toward the Great Attractor, a dense cluster of hundreds of galaxies. (StarDate, May 2007).

Wow! All of this motion going on without any awareness on my part is astounding. I am traveling through space at mind-boggling speeds without ever knowing it.

In Psalm 8 it is written, “When I look at your heavens, the work of your fingers, the moon and the stars that you have established; what are human beings that you are mindful of them, mortals that you care for them?” (Psalm 8:3-4 NRSV) I feel so tiny, miniscule and insignificant compared to the grandeur of what is out there. Maybe it is better that I am unable to see it all, for it might fill me with fear. In the deep vastness of space, it appears that there are only mind-blowing stretches of emptiness in which stars are being born even as others are dying. One writer described our being here in the midst of that mass of noth-ingness as “cosmic loneliness.”

Is it any wonder that those who first looked out into space, with the consciousness to understand asked the primeval questions. How did we get here? Why are we here? What comes after this? These are difficult questions, and without faith, I would perhaps be with-out any answers. This reality also causes me to ask other questions, questions related to my faith, and to my understanding of how I fit into the laws that operate in the universe.

Many of us tend to think of God as providing stability, the constant in the midst of change: a rock, a fortress, an anchor in the storm. There are many metaphors which portray God in this way. But what if God is also in the change—the movement and process not only of planets, but also of our daily activities and of the development of humankind upon the earth? What if God is the cause that moves not only planets in their orbits but moves us as well toward morality and purpose? What if the struggles that humankind endures—politi-cal, moral, and cultural—also are a process through which God works out God’s purpose on earth? To use a phrase from the United Church of Christ, “God is still speaking.” My faith calls me to attempt to discover what is being said.

George A. Burn BCC

The Reverend George A. Burn MDiv BCC is the director of pastoral care at Mount Nittany Medical Center, State College, PA. He is endorsed by the American Baptist Churches USA.

[email protected]

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