The Role of Chaplains in

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• The Role of Chaplains in
• Applying Ethics in Spiritual Care
• Philip Boyle, Ph.D.
• Vice President, Mission Ethics
• www.CHE.ORG/ETHICS

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Goals for todays conversation

• Is the role of the chaplain any different than
  ethics facilitation?
• Boundaries
• The nature of ethics facilitation
• Responsibilities of those engaging in ethics
  facilitation
• Common risks

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Cases

• The curbside consult
• Religious ethical differences
• Interpreting the ERDs
• Looking for moral approval

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Case

• Fr. Dave is a respected member of the hospital
  staff and member of the facilitation team, often
  providing curbside consults. The difference
  between pastoral counseling and an ethical issues
  with the patient is a blurred line. When a nurse
  pulls Fr. Dave aside for an ethics consult about
  nutrition and hydration, what should he say?
  Patient with end-stage Alzheimers is refusing to
  eat. Family wants everything stopped. RNs
  alleging starvation and against religious
  teaching.

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NACC Standards

• 302.4 Incorporate a working knowledge of ethics
  appropriate to the pastoral context
• 302.41 Demonstrate an understanding of the ERDs

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Who is providing consultations?

• ASBH study
• 15,000 consults annually
• 36 MDs
• 30 RN
• 11 LSW
• 10 Chaplains
• 10 Administration

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• The nature of ethics
• The nature of ethics mechanisms
• Promoting appropriate moral agency
• Distinctions
• Consultation
• Mediation
• Facilitation

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What is ethics facilitation?

• A service provided by individual or groups to
  help patients, families, surrogates, healthcare
  providers to address uncertainty or conflict
  regarding value-laden issues.

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Whats the goal of facilitation?

• The proper role of ethics facilitation is to
  advocate for an unbiased robust process and not
  to privilege the needs and agenda of any one
  part. ASBH, 2007

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Commonly performed tasks

• Navigating clinical setting
• Gathering information
• Evaluating, interpreting, and analyzing info
• Facilitating meetings, understanding each
  perspective, assessing options for moral
  acceptability
• Promoting ethically acceptable plan of action
• Implementing quality assurance measures

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Qualified facilitation model

• Identify and analyze nature of value uncertainty
• Gather relevant data
• Clarify relevant conceptual issues
• Clarify related normative issues
• Help identify range of morally acceptable options
• Resolve value uncertainty by building consensus
• Ensure concerned parties have voices heard
• Assist in clarifying values
• Help build morally acceptable share commitment

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Core competencies

• Skills of ethical assessment
• Identify the nature of the value uncertainty
• Analyze the value uncertainty
• Process and interpersonal skills

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The facilitation

• Ability to facilitate meetings
• Introducing oneself properly, explaining what an
  ethics facilitation is and what a person taking
  the lead does, the purpose and limitation of the
  facilitation and his or her recommendations, and
  the relationship between the ethics facilitation
  mechanism and institution.
• Ensure that all relevant parties have been
  invited and encouraged to participate.
• Ensure that all parties are introduced and
  explain their perspective roles
• Explain the goals and process of meeting and what
  can be expected.
• Elicit medical facts
• Elicit views and values of principles regarding
  issue
• Facilitate reflective listening, clarifications,
  summarizing interests.

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The facilitation

• Ability to build moral consensus
• Help individuals to critically analyze their
  underlying assumptions
• Negotiate between competing moral views
• Recognize possible areas of conflicts between
  personal moral views and one role in facilitation

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Practical considerations

• Focus on interests not arguments
• Ethics facilitator is not a judge!
• No constraints on evidence
• But some statements are more useful in resolution

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Practical considerations

• Summarizingmost critical aspect
• Lets the parties know facilitator is listening
• Lets the facilitator test her understanding
• Helps parties organize thoughts
• Helps parties to hear what others are saying
• Shows areas of common interest
• Provides order to discussion
• Lets facilitator remind parties of progress
• Repeat in nondestructive language
• End with question Have I missed anything?

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Practical considerations

• Questioning
• To obtain a broader view
• To obtain information
• To clarify abstract ideas/generalizations
• To focus discussion
• To introduce hypothetical
• To generate new options
• To encourage participation

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Practical considerations

• Generating movement
• Asking problem solving questions
• Reframing
• Raising issues
• Hearing proposals
• Stroking
• Allowing silence
• Holding caucuses
• Reality testing
• Reversing roles
• Normalizing

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Place of personal views

• Cannot remain value neutral
• Do you offer your personal views?
• How to attend to sociological power and authority?

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Case

• Fr. Dave is a respected member of the hospital
  staff and member of the facilitation team, often
  providing curbside consults. The difference
  between pastoral counseling and an ethical issues
  with the patient is a blurred line. When a nurse
  pulls Fr. Dave aside for an ethics consult about
  nutrition and hydration, what should he say?
  Patient with end-stage Alzheimers is refusing to
  eat. Family wants everything stopped. RNs
  alleging starvation and against religious
  teaching.

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Potential risks

• Scope limitation of role
• Conflicting interests
• Challenges of the role
• Responding to unethical practice
• Evaluation accountability

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Role Limitations

• Institutional role v. ethics facilitation
• Misperception misuse of role
• Explaining the role
• Appearance, comportment, interpersonal skills
• Power ethics consultations

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Role Limitations

• Role confusion
• Primary institutional role
• Administrator
• Chaplain
• Lawyer
• Nurse
• Physician
• Social worker
• How could there be role confusion?
• How do you avoid role confusion?

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Role Limitations

• Misperception misuse of role
• Should ethics facilitators be held to a higher
  standard of comportment?
• Common presumptions
• Moral police
• Exemplar
• Fixing the institution
• Common requests that are inappropriate?
• How do you or institution describe ethics
  facilitations?

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Role Limitations

• Appearance, comportment, interpersonal skills
• Implications of wearing white coat, scrubs,
  stethoscope, clericals
• How does appearance of gender, ethnicity
  influence facilitation?
• Can you name a time that appearance, gender or
  ethnicity influenced a facilitation?

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Role Limitations

• Power ethics consultations
• Expertise as power
• Negotiator as power
• Insider as power
• What are the reasons why judgments actions of
  ethic facilitator be misinterpreted and
  misunderstand and lead to abuse of power?
• How do you limit the abuse?

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Conflicting interests

• What situations would be considered conflicts of
  interest?
• Under what set of circumstances would you recuse
  yourself?
• Competing obligations
• Name primary obligations
• What ways to avoid
• Individually
• By all members of team
• During the actual consultation

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Challenges to the role

• Boundaries moral weight of consultations
• Distinctions among
• Moral uncertainty is there a dilemma, which
  values apply
• Dilemmas good reasons for opposing actions
• Distress discomfort unable to act
• Experience of marginalization
• Silencing
• Obviously unethical

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What does it mean to incorporate ethics?

• Case of Fr. Dave
• Place ERD 58
• 302.4 Incorporate a working knowledge of ethics
  into pastoral context
• Help parties apply theory to case
• Help RN with moral distress and issues of
  conscientious objection

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Directive 58

• As a general rule, there is an obligation to
  provide patients with food and water, including
  medically assisted nutrition and hydration for
  those who cannot take food orally. This
  obligation extends to patients in chronic
  conditions (e.g., the persistent vegetative
  state) who can reasonably be expected to live
  indefinitely if given such care.
  Medically-assisted nutrition and hydration become
  morally optional when they cannot reasonably be
  expected to prolong life or when they would be
  excessively burdensome for the patient or
  would cause significant physical discomfort,
  for example resulting from complications in the
  use of the means employed.

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Directive 58

• For instance, as the patient draws close to
  inevitable death from an underlying progressive
  and fatal condition, certain measures to provide
  nutrition and hydration may become excessively
  burdensome and therefore, not obligatory in light
  of their very limited ability to prolong life or
  provide comfort.

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Conclusion

• Dual agency
• Ethics facilitator pastoral counselor
• At minimum qualified facilitation
• Religious interpretation
• Helping patients in religious coping over values
  disputes
• Feeling at odds with religious norms
• Clarity about what you are being asked and
  transparency in what you can cannot do

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Evaluation

• http//www.meddean.luc.edu/depts/bioethics/online_
  masters/ethics20consult/ethics_consult_eval.html
• Q1 Does the ethics facilitator do an adequate
  job of gathering the facts of he case from the
  physicians? What kinds of things must the ethics
  consultant gather in advance of facilitating a
  conference?
•  
• Q2 Does the ethics facilitator give the
  physicians an adequate idea what they might
  expect from an ethics case consultation, in
  general, and in this case, in particular?
•  
• II. The Case Conference  
• Q3 Does the ethics facilitator do an adequate
  job of introducing himself and explaining what he
  does or what the goal of the conference is?
  Should he have said anything else?
•  
• Q4 Does the case conference result in the
  patients surrogate decision maker, understanding
  the medical facts of the case adequately?   

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•  
• Q5 Does the case conference result in the
  patients attending physician understanding the
  patients values and wishes adequately? Does he
  adequately understand the surrogate decision
  makers understanding of the situation?
•  
• Q6 Does the ethics facilitator do a reasonable
  job of supporting the surrogate decision maker
  through the conference? That is, does the
  consultant reinforce the notions that the
  surrogates understanding of the case is welcome
  in the discussion and that the patients
  legitimate rights will be respected?
•  
• Q7 Does the conference flow well or should the
  facilitator have redirected it at points? If so,
  please be specific regarding when.
•  
• Q8 Does the facilitator help to summarize and
  delineate the acceptable options? Is it clear
  what will happen next and how matters will
  proceed?
•  
• Q9 Are the options highlighted within ethically
  acceptable norms?

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Resources

• Bioethics Mediation A Guide to Shaping Shared
  Solutions, Nancy Dubler and Carol Liebman, United
  Hosptial Fund, 2004.
• Mediation Information Resource Websites
• Http//www.mediate.com
• http//www.crinfor.org/narrative_new
  _developments.cfm