Developing a Spiritual Plan of Care Session 01: Assessment and Documentation

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Developing a Spiritual Plan of CareSession 01
Assessment and Documentation
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Introductions I

• D.W. Donovan
• Director of Mission Leadership in Mission Hills
  (Los Angeles), CA
• Providence Holy Cross Medical Center
• Board Certified Chaplain
• Author of Assessments in Professional Spiritual
  and Pastoral Care A Practical Clergy and
  Chaplains Handbook, Rabbi Stephen Roberts,
  Editor.

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Introductions II

• Jane Mather
• Director, Spiritual Care
• Providence Sacred Heart Medical Center
• Mark Thomas
• Director, Mission Integrity and Ethics
• Providence Hood River Memorial
• Tim Serban
• Vice President, Mission and Spiritual Care
• Providence Health and Services, Northwest Region

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Special Thanks

• Special thanks to Alan Sanders and Catholic
  Health East for their commitment to contribute to
  the development of professional chaplaincy.

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Outline I Preliminaries

• Preliminaries / Premises
• Do we have something to offer?
• If so, WHAT?
• How can we be more effective in integrating our
  work into the care of each patient/family?

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Outline IIThe Assessment

• The Assessment
• Covey Begin with the End in Mind
• What Elements Do We / Should We Consider in our
  Assessment?
• Current practices
• A proposed model
• Tips Developing an Assessment Model

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Outline IIIDocumentation Discussion

• Documentation
• Tips for Developing a Documentation Tool
• Tips for Documenting in the Medical Record
• Discussion
• Closing Comments

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Do we have something to offer?

• Does anyone read our notes? If not, why not?
• Have we allowed our work to be put in a silo?

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What Is It That Chaplains Do?

• The Equilibrium Model

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The Equilibrium Model

• The role of the clinically-trained chaplain is to
  assess the degree to which the patient's
  emotional and spiritual equilibrium has been
  disturbed by the healthcare event and to
  determine what interventions would be appropriate
  to help the patient restore their equilibrium and
  when such interventions should be employed.
• (Donovan / Dowdy)

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What Is It That Chaplains Do?

• The Equilibrium Model
• Moving from A to W, then X, Y, and Z
• Helping the Patient / Family Apply Existing
  Values and Beliefs to the Current Clinical
  Situation
• Key Points / Executive Elevator Speech

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What Is It That Chaplains Do?

• Key Points / Elevator Speech
• The chaplain is an integrated member of the
  interdisciplinary team, contributing to the
  overall plan of care for the whole person from a
  spiritual perspective. Our particular expertise
  lies in our ability to help create a sacred space
  where the relevant values and beliefs can be
  explored and applied to the current situation /
  decisions.
• Requires that emotional and spiritual needs are
  considered inextricable from physical and
  psychological needs. (Clark)
• Visualizes spirituality as the leaven that
  permeates the bread, rather than the icing that
  covers the cake. (Dowdy)

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What Is It That Chaplains Do?

• Key Points
• Our ministry is grounded in extensive training to
  help us recognize emotional and spiritual
  distress and to help people process through
  emotionally-charged experiences. Our
  assessments reflect a whole person approach,
  and require us to be familiar with interpersonal
  dynamics, theology and theodicy, and the medical
  milieu in which these dynamics are now operative.
  

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Integrated Chaplaincy

• Holistic Health Care
• Requires that emotional and spiritual needs are
  considered inextricable from physical and
  psychological needs. (Clark)
• Visualizes spirituality as the leaven that
  permeates the bread, rather than the icing that
  covers the cake. (Dowdy)

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A Question

• How effective have we as a profession been in
  integrating attention to the spiritual
  perspectives, values and beliefs of our patients
  and families into each plan of care?

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and a Challenge

• How can we be more effective in integrating our
  work into the care of each patient/family?

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Integration-Focused Documentation

• Many answers
• Focus today on how we do that through
  documentation that includes a professional
  assessment.

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Outline IIThe Assessment

• The Assessment
• Covey Begin with the End in Mind
• What Elements Do We / Should We Consider in our
  Assessment?
• Current practices
• A proposed model
• Tips Developing an Assessment Model

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Covey Begin with the End in Mind

• Preliminary Note Assessment Vs. Screening
• Important at the Personal Level Know Me Care
  for Me Ease My Way

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Covey Begin with the End in Mind

• Important at the Plan of Care Level for your
  Colleagues
• How does your expertise make my job easier?

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Is it accessible by our colleagues and useful to
our colleagues?

• Accessibility
• Speaking the Language
• Providing Takeaways
• Accessibility Nuts and Bolts

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Is it accessible by our colleagues and useful to
our patients?

• Useful The Quality Question
• How do we assess the quality of our
  documentation?
• Advance the plan of care
• Advance the professionalism of the chaplain

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Covey Begin with the End in Mind

• Important at the Organizational Level
• Reduced LOS
• Reduced Turnover

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Wait A Second!!!!

• Many pastoral care professionals believe that
  presence and relationship are the alpha and omega
  of their work.

• They hold that pastoral care cannot be measured
  that to attempt it would be almost an affront to
  God.

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Wait A Second!!!!

• We say beware. Those who shun accountability
  should not be surprised if they are first in line
  for budget cuts.

• --Brian Yanofchick
• Health Progress, May 2009, p. 21

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Current Practices

• Christina Puchalski, G-Wish FICA (Spiritual
  History Tool)
• Faith and Belief
• Importance
• Community
• Address in Care
• (See http//www.hpsm.org/documents/End_of_Life_
• Summit_FICA_References.pdf)

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Current Practices

• The Joint Commission QA Does the Joint
  Commission specify what needs to be included in a
  spiritual assessment?
• No. Your organization would define the content
  and scope of spiritual and other assessments .
  Examples of elements that could be but are not
  required include the following questions

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Current Practices

• Who or what provides the patient with strength
  and hope?
• How does the patient express their spirituality?
• How would the patient describe their philosophy
  of life?
• What is the name of the patients clergy,
  ministers, chaplains, pastor, rabbi?

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OtherCurrent Practices

• Are there values and beliefs that would affect
  your treatment decisions?
• Would you like to see a chaplain / pray with a
  chaplain?

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A Proposed Model

• Assessments A Medical Model
• Listen
• Observe
• Evaluate
• Determine
• Paradigm Shift from Faith-Based Coping Mechanisms
  to Values and Beliefs

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A Proposed Model

• Three Elements
• Element I Relationships and Connectivity
• Element II Meaning and Purpose
• Element III Degree of Understanding and
  Congruence of Response

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Element I Relationships and Connectivity

• Observations from Unit 01 Counting People and
  Cards
• Spectrum from Fully Connected to Sense of
  Isolation / Abandonment
• To / from friends and family
• To / from a sense of the sacred / divine
• Theological Principle Relationships
• Possible Interventions

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Element II Meaning and Purpose

• Observations
• Often a Need to Make Sense of the Illness /
  Injury / Event
• Coping Mechanisms / Complex Beliefs May Be
  Compromised
• Values and Beliefs Applied to Current Situation
• Possible Interventions
• Theological Principle

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Element III Degree of Understanding and
Congruence of Response

• Assessment A Does the patient / family /
  surrogate have an accurate understanding of what
  the physician has indicated to them? (LaRocca,
  Assessing)
• Assessment B Is the response internally
  congruent with previously expressed values and
  beliefs? (NCCN)

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Element III Degree of Understanding and
Congruence of Response

• Look for statements such as
• What does the doctor know anyway!?! Shes not
  God!
• Gods in charge and my baby wont go anywhere
  until God decides its time. (But dont you dare
  touch the ventilator!)
• Possible Interventions -- with a goal in mind!
• Theological Principle

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Tips for Developing an Assessment Model

• Build on what comes naturally relationships,
  meaning, medical.
• Build upon the uniqueness of the chaplain
  connecting the dots between the individual and
  the institutional milieu.
• Thus, work to be out of the box of any
  particular faith tradition.
• Dont confuse tools with an assessment.

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Outline IIIDocumentation Discussion

• Documentation
• Tips for Developing a Documentation Tool
• Tips for Documenting in the Medical Record
• Discussion
• Closing Comments

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Tips for Developing a Documentation Tool
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Tips for Documenting in the Medical Record

• Avoid Statements that are Not Observable.
• Patient understood the clinical situation.
• Patient stated, I understand what the doctor is
  saying.
• Avoid Statements that are Outside your Scope of
  Practice.
• The patient is close to death.
• The nurse indicated death is imminent.

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Tips for Documenting in the Medical Record

• Reinforce your Professionalism.
• Visited with nurse before seeing patient.
• Consulted with RN to review recent events /
  social hx. (Note families visit professionals
  see patients or consult.)
• Do Not Imply that Showing Up Is Enough
• Plan Follow-up Daily
• Your suggestions?

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Tips for Documenting in the Medical Record

• Use Legal Language Carefully and Correctly
• AMD Consult Patient did not seem competent.
• Patient was alert and oriented to year, but not
  to place, president, or situation. I was not
  comfortable proceeding at this time.

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Tips for Documenting in the Medical Record

• Do Not Put Another Team Member in a Corner
• The family is upset because their questions have
  not been answered.
• Family indicated that they have additional
  questions to ask and would appreciate additional
  time with Dr. X. Called Dr. Xs office and left
  a message for her with Nurse Susan.

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Discussion
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References

• Clark, Paul A. Drain, Maxwell, and Malone, Mary
  P. Patient Centeredness Addressing Patients
  Emotional and Spiritual Needs. Joint Commission
  Journal on Quality and Safety. Dec 2003 (2912).
  
• Dowdy, Melvin, and Donovan, D.W. The Pastoral
  Assessment Tool Developing the Centerpiece of
  the Pastoral Care Strategic Plan (unpublished
  presentation).

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References

• Joint Commission, The. Standard FAQs Spiritual
  Care. Downloaded from
• http//www.jointcommission.org/mobile/standards_in
  formation/jcfaqdetails.aspx?StandardsFAQId290Sta
  ndardsFAQChapterId29.
• LaRocca, Mark. Assessing the 4-Fs of Spiritual
  Assessment. Downloaded from http//www.plainview
  s.org/AR/c/v2n23/pp.html.

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References

• Puchalski, C. Spiritual Assessment Tool FICA.
  Downloaded on July 14th, 2012 from
  http//www.hpsm.org/documents/End_of_Life_
• Summit_FICA_References.pdf.
• Roberts, Stephen, ed. Professional Spiritual and
  Pastoral Care. Skylight Paths Publishing. 2011.
  
• Yanofchick, Brian. Do We Care Enough about
  Pastoral Care? Health Progress. May 2009.

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Thank you!!!

• Looking Ahead!
• August 15th, 2012
• Communicating the Spiritual Care Plan Chaplain
  as Educator
• Jane Mather
• September 12th, 2012
• Integrating into a Holistic Plan of Care
• Mark Thomas