Caring for the Spiritual Needs of Patients

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Welcome to Yale Cancer Answers with doctors Anees Chagpar, Susan Higgins and Steven Gore.  I am Bruce Barber.  Yale Cancer Answers is our way of providing you with the most up-to-date information on cancer care by welcoming oncologists and specialists, who are on the forefront of the battle to fight cancer.  This week Dr. Gore is joined by Dr. Kristin Moyer and Chaplin Randall Spaulding for a conversation about ways to address the religious and spiritual needs of cancer patients.  Dr. Moyer is a clinical instructor in the Department of Medicine at Yale School of Medicine, Chaplin Spaulding is Chaplin of the Oncology and Sickle Cell Units at Yale New Haven Hospital and Dr. Gore is Director of Hematologic Malignancies Smilow Cancer Hospital.

Gore If each of you could maybe take a minute or two and tell us what you do.

Moyer Thanks so much for having us.  I am, as you said, currently a chief resident in internal medicine this year and looking forward to starting a palliative care fellowship at Ohio State University coming up in July.  As a chief resident this year, I had an opportunity to give Medical Grand Rounds and my topic was caring for the spiritual needs of patients and this was really a combination of interests that have spanned the past several years for me, really starting in medical school. I had an opportunity to be a patient and recognized the vulnerability and the fear that comes along with being in that position and at that point, felt very strongly about the spiritual care that I received while I was a patient and also the way that I depended on my spiritual beliefs to help me make decisions in those times was so powerful that it ultimately framed my experience in going back into medicine after that time and constantly would just hear the themes of the patients that I cared for, the existential themes, the fear, the distress and that really led me to take a break from medicine for a couple of years and pursue additional theological training and to do an internship and that experience really was one of the hardest clinical experiences of my entire training, the chaplaincy, and Reverend Spaulding can speak to that, and what that training looks like, but the number of on-call shifts and the responses to all deaths that occur in a given period of time when you are on-call, what a Chaplin goes through in a given period to respond and be present with people during those times of fear and loss is amazing and even for me just having a few months to glimpse that experience propelled my interest more to be a physician and try to integrate those skills that I learned from my Chaplin colleagues but also to find ways in medicine to integrate the care that we give with our Chaplin colleagues and find ways to do interdisciplinary spiritual care better and so that was really an opportunity that presented itself this year to talk about a topic that was interesting and 

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important to me. Palliative care certainly brings that interdisciplinary care and spiritual care to the bedside in a way that is important to me and that is the next step for my career.

Gore Thank you and does that resonant with you, Randall?

Spaulding Of course it does.  Thank you Dr. Gore, it is a pleasure to be here and Dr. Moyer.  As a Chaplin, one of my jobs is to assess the spiritual needs of my patients and not just patients, but also family and we also act as chaplains to the staff as well.  We are in an acute facility and there is a lot of struggle and there is a lot of need and a lot of distress.  My job is to meet with patients, see how they are doing, assess where their support systems are, what, if any, spirituality is supportive to them, is helpful for them in dealing with this kind of lousy situation that they find themselves in and then to offer an additional layer of support to the medical staff in meeting the needs of patients.  I really appreciate the work that Yale New Haven Hospital does in addressing a holistic approach, they really see the needs of patients, not just in medical terms but also mind-body-spirit approach and so we have whole department for spiritual care, we have a department for social work to address both the emotional and spiritual needs and I think that is really important.  Patients come with a lot of pain, a lot of struggle, a lot of questions about what is going on and why is this happening to me and you know, we help them journey through this process that can often be confusing and frustrating and filled with a lot of anxiety.  My job as oncology Chaplin and Chaplin to the sickle cell patients is to help provide that layer of support to them.

Gore Does every patient who is hospitalized in your hospital get a visit from the Chaplin or is it upon request, how does that work?

Spaulding There are a variety of ways that can happen.  Between our campuses, there are 1500 beds, so we have about 25 chaplains and it is impossible to see every patient and to meet everyone's needs.  One of the ways we work is referrals or consults, so if a nurse is assessing a patient or a physician is assessing a patient or a social worker has seen them and they detect some sort of spiritual need or that they could benefit from a Chaplin, they put in a consult and that appears and we see that patient within 24 hours.  We also have a great relationship with the unit staff, with the nurses, with the nurse managers, with the social workers and so we are always talking to them and saying you know, what is happening today, who could use a visit, who is really struggling and our staff is great at saying, or tapping me on the shoulder and saying, "hey I think you need to go see Mrs. So and So or you know, this person just received a really bad diagnosis and they are in tears, can you help them?"  We also have a goal of trying to 

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see patients who have been in the hospital up to 7 days, so if it is getting close to 7 days I make sure that I knock on the door and go in and say, "I'm here, we are here to support you, how are you doing, and what is helping you get through this?"

Gore That is great.  You wear a clerical garb on a daily basis, whenever I see you, and clearly many of the patients and families are going to be coming from non-Christian faith, what is that like if you walk into an orthodox Jewish room or a Muslim room or a Hindu room, what is the response, are people open to that?

Spaulding Let me just say that we do not have a particular dress code, some chaplains wear a collar and other chaplains do not, they wear regular attire. And every once in a while you get someone whose eyes just sort of pop open up and they are like, am I dying? And I work very quickly just to say, no I am here as a part of the team and we are here to support you, we know that sometimes spiritual needs and religious practices are important to patients when they are struggling with illness and trying to cope and so how can I help you.  Our job as chaplains is not to impose our particular spirituality or religious practice but to find out what is your practice and what is your spirituality, what is connecting you to something greater than this present difficult moment, it might be your faith community, it might be your prayer practice, it might be meditation, it could be nature, it might be your pets, or your family is your greatest source of spiritual strength and so we have conversations, we try to support them in any way that we possibly can.

Gore Are we talking sort of small spirituality or a bigger umbrella spirituality as opposed to religion really or even faith necessarily?  I mean I guess we get into semantics here?

Spaulding You can, but we also assess if they do have particular religious practices.  If their religious community is very important to them and I, you know, will say does your faith community know you are here, would you like me to call your priest or your imam or your community and let them know, would you like a visit from them, what practices are helpful to you, can I bring you a religious text that is important to you.  Some people ask for the Quran, other people ask for the bible, some people want a rosary, some people want healing oil and we try to make as much as possible all those things available to our patients to help them to cope and define a way to ease their anxieties and the stress of what they are going through.

Gore Kristin, what was your training like, doing your chaplaincy intern, did you have to take classes, what is involved?

Moyer Clinical pastoral education is really several steps in the process of becoming a board-certified Chaplin and as a theology student, I was able to take 1 unit of CPE and several 

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CPE units are required to become a board-certified Chaplin. I was able to do one semester long process that involved a combination of clinical care, and providing clinical spiritual care to patients.  My particular assignment was in a pediatric hematology-oncology ward and then to take a handful, approximately 30-hour call shifts throughout the semester whereby you are at least at night the only Chaplin in the hospital and so you are responding to all deaths, really any needs of people.

Gore On site in the hospital like a resident?

Moyer Exactly, and so you are it and there could be 10 deaths in a 12-hour period or you know several patients admitted for urgent surgery the next morning that need to talk about their advanced directives and need to fill out those forms and so you are responding to all of those needs overnight and I think the biggest lesson for me in those moments was just the amount of grief they are experiencing over a period of time and how do Chaplains cope with that and kind of self-care in addition to being able to be present for each and every new family they are kind of coming into contact with.  So that was the bulk of the clinical experience and then there is a component called interpersonal relation group or IPR group and that is really where you do a lot of the inner work and the reflective work of processing the clinical encounters that you are having with patients.

Gore That is in parallel.

Moyer That is in parallel exactly and so you have a small group, our group was I think 5 or 6 Chaplin interns at the same time and a leader and they would really push us to reflect we used an assignment called A verbatum where you literally write a script retrospectively of your encounter with the patient and what they said and what you said and really try to hone in on, why did you jump in and change the subjects there or why did not you wait?

Gore How uncomfortable were you feeling, right?

Moyer Exactly, and why did you use that theology speak right there and make things more complicated than the patient really intended?

Gore Well, I have my guesses, but you can tell me if I am wrong after our break, but right now, we have got to interrupt this really fascinating discussion, I am sorry, for a medical minute.  Please stay tuned to learn more information about the spiritual needs of patients with Dr. Kristin Moyer and Chaplin Randall Spaulding.

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Gore Welcome back to Yale Cancer Answers.  This is Dr. Steven Gore and I am joined tonight by my guest, Dr. Kristin Moyer and Chaplin Randall Spaulding and we are discussing ways of caring for the spiritual needs of patients.  Kristin, before the break, you were telling us about some of the training you did in chaplaincy internship and you described the difficulty of having all of this grief on your shoulders or at least in your face if you will and that you actually did your chief residency piece on how the spiritual caregivers care for themselves, did you come up with an answer because apparently you are going into palliative care, so this is not the end for you in this direction.

Moyer It is a great question and I think it is a complicated one.  My supervisor of the chaplaincy r during that time really talked a lot about this process of engaging and disengaging and when you are really present with someone to be fully present and be there in the moment, but I tried to practice, as soon as you step out of the patient's room to be able to let it set and let it be and to be able to move on and practice self-care and find outlets of regeneration for yourself in ways, even if it is a small of a ritual as, we talk about washing hands and how that can be ritualistic and just taking a moment to meditate over something simple in the hospital as you go from patient to patient after a death to take a moment of silence and be present with the caregivers around the bed, ways that you can honor that life and also honor your work and then be able to kind of step away and be ready for the next.  I think those things are important especially in the time that we talk so much about physician and Chaplin burnout and how important those issues are and caring for one another and being part 

17:53 into mp3 file https://ysm-websites-live-prod.azureedge.net/cancer/YCA-0702-Podcast-Moyer-Spaulding_308711_5_v1.mp3of an interdisciplinary team, the way that palliative care does or the way that the sickle cell team at Yale does to really be able to provide staff care for one another and to reflect on the loss and the grief that we deal with on a day-to-day basis.

Spaulding Yeah, I agree.  One of the things that we are starting to do here at Yale is something called ‘the pause’ when there is a death, especially in the Emergency Department, the Chaplin has a process of, once a patient has been declared, they will ask everyone to just pause a moment, instead of just cleaning up and everybody leaving the room, we just take one short moment to remember this person's life that they meant something to someone and that whatever our belief or philosophy or spiritual practices, we just pause for just a moment and reflect on what just happened here and we also you know, just say a note of appreciation and thanks to the staff who worked so hard, you know, to try to save this patient.  This practice, we are beginning also during codes on some of our floors as well.

Gore Following codes, I hope.

Spaulding Following codes, yes, not before and it has become something that the staff has really found to be meaningful and helpful for them in processing, sometimes the grief that they just hold as they go on to the next patient or the next code or the next critical process, it all just sort of builds up and doing something simple, that is not really tied to a religion has been really meaningful and very helpful for staff.

Gore In my previous place of employment, one our chaplains would come around once in a while and do this ritual, I do not remember exactly what it was, but it was pouring of water and blessing and it was nondenominational for the staff and it was really, really wonderful and it was really special just to take that moment and be together and I am not sure what it was touching, but it was very, very centering for everybody and calming.

Spaulding Yeah, exactly.  We often take moments throughout the year to have staff come together on the floor to remember often patients who have died, to also offer care to the staff who worked so hard and again store up a lot of this energy and we do take small moments.  During nurse's week, we do a blessing of the hands, we just thank the nurses for all their care and compassion and for the healing that they provide.  We offer the same thing to physicians, to all of our staff and it is just a way again to connect to remember that we are doing is for the needs of our patients and we care about them and it is an act of kindness and compassion.

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Gore Beautiful.  I am wondering if either or both of you have a brief anecdote of a family or patient encounter where you really feel that you are able to intervene or I am not sure intervention is the right word, but helped in a certain special way that would not have happened without the spiritual peace?

Moyer I think about these moments every day and many of them are what we would consider big moments. But I think it is in the simple things, what you listen for when patients are talking to you, you can often pickup small threads of need or of a sacred moment that you can kind of grab hold of it. Yesterday we had a woman who really wanted to go home and I said, I wish that for you, I really am hoping for that and we are going to work as hard as we can to get you home and to get you back to your previous functioning and she said, from your lips to God's ears and when you hear something like that, I think it can be an invitation to further ask, what does that mean to you? Are you a person of faith? Would you consider yourself a spiritual or religious person and, I hear that language tell me a little bit more and so that opened up the door to a longer conversation about her self-identity as a Jewish woman and what that meant and she was really looking forward to spending some time with her rabbi and nobody had called that person yet and so, just a moment of listening to a type of language that patients will use and probing a little bit more allowed me to connect her with her spiritual advisor which I would not have otherwise really been able to do if I let that pass by and whether that made a huge difference in her hospitalization I am not sure, but whatever we can do to connect people to the resources that they have as internal locuses of support and comfort, I think that is our job and I know that is our job and sometimes we have the tools as physicians and oftentimes, we do not, there are things outside of our realm and our job is to ask the right questions, to listen, and then to refer or put the wheels in place which is often referring to our Chaplains.

Spaulding I can think of one instance recently and this happens a lot when a patient is first diagnosed with having cancer, it is a very very scary moment for them and the word cancer brings up such a monstrous connotation and they wonder about their future and everything is up in the air and it could bring a lot of anxiety and so I was called to sit with a patient who had just been told that she had cancer and one of the first questions she said is, why is god doing this to me? Why me, I am a good person and ran off a list of things of service that she had been involved in and caring for others, but her main situation in the moment was a lot of spiritual distress, why is god doing this to me and just in sitting with her a spending time in sort of what we all a non-anxious presence, I invited her just to hold for a moment and we breathed together a little bit and we took a few deep breaths and then through the course of the conversation, we started talking about, let's unpack that, why is god doing this to me and first of all I wanted to know what her understanding of god was and who is the god that she knows and in the course of that conversation, we found out that really her god is not a god 

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who causes people to have cancer, but in that moment we sort of lose sight of sort of our ground and part of our job as chaplains is to help people remember that they do have a ground and for her it was a strong faith that she had and she was able to remember that her god is a god of healing and that through her prayer practice he can bring a lot of comfort and it brought her anxiety level down to a very manageable place where she could begin the process of sort of looking at you know what is going to happen and talking a little bit more concretely about things and it was just a sort of a beautiful moment for her to go from this high of spinning out of control to remembering who she is and what her faith and her spirituality was and I think it was, you know, really helpful moment for her.

Gore It sounds like it was.  Do you ever have ongoing longitudinal relationships with these patients or is it always sort of in this acute setting?

Spaulding I do and I have been working as a fulltime Chaplin now for about 2 years and I am realizing and I am starting to process my own feelings about when I first started, I am starting to see some of the patients that I first met 2 years ago who began their treatment process coming to the end of their life and my journey with them has been quite long.  I see them when they come in for their treatments, I also am the Chaplin for the outpatient units too, so when they come in for chemo or radiation, I visit them or they call and ask to see, you know the Chaplin and we have journeyed together through this whole process of diagnosis and treatment and the transition often to hospice or something like that.  So, it is not just a onetime experience that chaplains have with patients, but sometimes it is an ongoing process and we walk the journey with them.

Gore One of the things that I remember as a young attending many years ago was a woman from a very strong faith tradition who was diagnosed with a bad leukemia, at the same time her young daughter was hospitalized in the same hospital for recurrence of her leukemia and you know, I tried to be compassionate and let her talk about how stressed that must be and she was very comfortable in her faith that of course she wanted to be there for her 4 kids as much as possible but she knew that she would be seeing them from another place and that she was okay with that, and that was great, you know I admire that well, and some months later, things were not going so well and she was nearing the end of her life and I was not actually her doctor at that time but I came by to say hello and she was distressed because she was having a crisis in faith but not being sure what was going to be next and in her church community she did not feel that it was okay to talk about that, that it was her impression that her feelings would invalidated.  I look back at that and I was able to listen and just say, that sounds so hard and lonely but I realized I probably should get the Chaplin for her.

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Moyer I think the fact that you acknowledged and validated that situation says a lot, again and it is a small way, but it is an interdisciplinary way to say you recognize it and even if you did the call the Chaplin later, I think that was a very appropriate thing to do because we continue the care because it is all about caring for our patients and providing that holistic approach.

Dr. Kristin Moyer is a Clinical Instructor in the Department of Medicine at Yale School of Medicine and Randall Spaulding is Chaplin of the Oncology and Sickle Cell units at Yale New Haven Hospital.  If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org.  I am Bruce Barber reminding you to tune in each week to learn more about the fight against the cancer, here on WNPR, Connecticut's public media source for news and ideas.