The Chaplains' Notes in Patient Charts -- by Raymond J. Lawrence

27 Jan 2017 12:12 PM | Krista Argiropolis (Administrator)

Raymond J. LawrenceA very useful study was reported in the journal Palliative and Supportive Care in May, 2016, entitled "Documenting presence: A descriptive study of chaplain notes in the intensive care unit." The research was completed in September, 2015. The authors of the report were Brittany M. Lee, B.S.; Farr A. Curlin, M.D.; and Philip J. Choi, M.D. The setting of the research was Duke University Hospital, Division of Pulmonary and Critical Care Medicine, in Durham, North Carolina. The study was done with input from the Director of Pastoral Services, Jim Rawlings.

The researchers proposed that the recent emphasis on evidence-based practice may be leading chaplains to the use of a reduced, mechanical language insufficient for illuminating patients' individual stories.

Whatever the cause may be, it is clear that the chaplains in this study are at sea on the matter of what should be appropriately reported in patients' charts.

The researchers in this study reported that the patients' charts in this particular hospital unit contained both an 18-point checklist section and a free-text section. The checklist section consisted of the following:

Compassionate presence

Meaning-oriented presence

Life review

Continued presence and follow-up

Supported patient's sources of spiritual strength

Inquiry about spiritual beliefs, values, and practices

Open-ended questions to elicit feelings

Advocated with staff for patient/family needs

Used story telling

Reflective listening, query about important life events

Facilitated communication with interdisciplinary team

Facilitated expressions of lament

Referral to spiritual care provider as indicated

Celebrated/offered thanksgiving with patient/family

Advance directive information given

Spiritual support groups

Spiritual practice interventions

Reconciliation with self/others

This research project did not focus on the checklist above, but on the section of the patient chart where the chaplain was asked to make free-text comments. There were such chaplain comments made on 109 patients in the survey. The free-text opportunity would in fact seem to be the only useful kind of clinical chaplain reporting.

The summary conclusions of these researchers were not flattering. The chaplains' free-text comments consisted mostly of information already available in the charts. The notes seldom included what would be considered an assessment of needs and resources. The notes rarely referred to any plans or expected outcomes. And the notes did not convey a deeper connection that clinical chaplains, in fact, often have with patients. Chaplain interactions with patients appeared to the researchers more as "products for delivery." The researchers viewed the checklist as actually conveying to chaplains that their work consisted of delivering so many product units of "compassionate presence" and other such ambiguous objectives.

The research team concluded that chaplains frequently resorted to code language that signified nothing more than the chaplain was present. Many of the free-text notes repeated vague terms already in the checklist itself. Chaplains typically described what they observed rather than interpreting its clinical significance. Chaplains generally indicated passive follow-up plans, waiting for patients or family to initiate further interaction.

The chaplains often described in the free-text section simply what they observed, such as "family is quite large," or "patient's mother standing and holding patient's hand," observations bereft of any useful interpretation.

The researchers also found that chaplains' free-text notes often recapitulated what was documented elsewhere in the chart, or readily available elsewhere, such as "patient has lung cancer and has been in hospice." Chaplains rarely made what would be considered a pastoral assessment. And the researchers concluded that the chaplains seldom incorporated in their notes what might be interpreted as "spiritual assessments." The chaplains' notes did not convey the deeper spiritual––or pastoral––connection that chaplains often have with patients and families.

The free-text notes often described patient's spiritual and religious characteristics without any interpretation of significance, such as stating that "patient is a Presbyterian."

On the other hand, the researchers found that chaplains did in fact provide what they considered a pastoral or spiritual assessment in three of the 109 cases. In one the chaplain wrote: "I believe the family is aware of the seriousness of their mother's situation." In another the chaplain described an upset wife determined to focus on assisting her ill husband. In the third the chaplain wrote a long note about each of three children of a dying mother and their differing postures toward the dying process. The researchers found such clinical observations promising, though few and far between.

The researchers also found that follow-up plans for patients were mostly passive, indicating that the chaplains would be available if needed. Of the 109 free-text chaplain notes, only two referred to any prior chaplain visit, suggesting that there was a paucity of follow-up work with patients.

The researchers argued for chaplains providing clinically relevant communication.

This study should be examined by all serious pastoral clinicians. I believe that the results of this study are not idiosyncratic to Duke University Hospital. In my travels I have found that clinical chaplains are generally at a loss as to what appropriately belongs in a patient's chart. It should be a fairly easy task to decipher what is important and to orient chaplains to just that.

We should be clear however, that there are systemic problems in chaplain reporting stemming from the very recent shift in language use, a shift that has resulted in obfuscation of the chaplain's role. I refer to the substitution of "spiritual" for "pastoral" that has been in process on a wide scale for two decades now. (It is heartening to see that Duke still retains a "Department of Pastoral Services.") If chaplains simply can remember that they are pastors or in the pastoral arena and not spiritual gurus, they will be able better to describe what they do. The pastor, like the shepherd of a flock, actually needs to do neither more nor less than to see that the animals and crops are safe, healthy, and in all respects progressing. It is a broad-spectrum task. Much of the time that means doing nothing more than paying close attention. Thus the chaplain can write in the chart, "made myself known to the patient and will follow up as needed." No need to add any fancy new-age language. No need to parse the new fad of "spiritual but not religious." Just present oneself in a pastoral––like a shepherd––posture, establish a potential new relationship, and return later if possible.

In any case, it is advisable for chaplains to present themselves as pastoral professionals if they want to be understood.

Thus, in the typical hospital a high percentage of chaplain visits would likely be appropriately charted as "pastoral visit." That is to say, nothing much of significance occurs beyond the simple dramatization of the chaplain's availability. This is, of course, no small matter. Informing the patient by way of a brief visit, rather than by a written announcement, that there is a chaplain available for consultation or counseling, is an important contribution to a typical patient's sense of institutional well-being.

Paradoxically, the clinical chaplain in making routine visits to patients will find that some of the most receptive and needy patients, in terms of pastoral counseling, are not those with acute medical emergencies in play, but rather those with routine, everyday medical problems. And generally such patients have the luxury of time for talking, unlike those facing critical emergencies. In my own experience through the years, I have found that the most significant pastoral counseling I was able to do was with patients (and staff) who had time on their hands and were happy to encounter a trained person willing to listen to them.

[Having said that, we should note in seeming contradiction, that it is not unusual for a routine patient courtesy visit to morph quickly into what should be properly labeled pastoral psychotherapy. A competent clinical chaplain is always nimble and ready for surprises.]

For a minority of patients, where something of note emerges in the chaplain's visit, or a crisis is underway, charting is especially important as a way to notify the staff of what specific action the chaplain is taking. The staff needs to know.  

Clinical chaplains everywhere should take note of this credible and well-done piece of research. It should be considered a warning shot announcing the danger of the trend toward the irrelevancy of institutional chaplaincy. To counter this impending danger I recommend the following:

1.     Clinical chaplains move away from "spiritual" as the supposed arena of the chaplains work, seeing it as a recently invented poorly defined category, and move back to the more concrete "clinical pastoral."

2.     Clinical chaplains recognize that one-time pastoral visits are less likely to accomplish much more than introduction and minimal trust building. Effective pastoral work generally––but not always––comes from repeat visits, after which the patient has learned that the chaplain at least is able to get in and get out of a room and listen, without doing something foolish.

3.     Clinical chaplains, more than any other professionals, take interest, theoretically, in the whole person, medical, social, mental, physical, et alia.

4.     Clinical chaplains avoid all flowery language in defining their role, such as "compassionate presence," especially any that is similarly self-aggrandizing.

5.     Clinical chaplains avoid any prefabricated "outcomes." Any chaplain-patient outcome should be rooted in the idiosyncratic needs and values of the particular patient. Not every patient seeks the same outcome. And most patients seek only an intelligent caring listener to hear his or her story. Most patients want to live, and to live fulfilling lives, but only they know what such a life might look like.

On a given day most patient visits would likely qualify for a simple documentation of "pastoral visit." Beyond making him- or herself known and available, there typically is not much else to offer on a first visit. In a few cases, especially repeat visits, the chaplain may move into the role of counselor, therapist, confessor, or guide––cases in which persons expose their lives to an intelligent other, with the unspoken hope for both care and wisdom. A competent chaplain has the time, and hopefully the expertise, to fulfill that role where most other medical staff must keep moving. Such in-depth pastoral visits need to be documented for the benefit of the other staff members.

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Raymond J. Lawrence, General Secretary
lawrence@cpsp.org