By Cheryl Barnes-Neff, PhD, MDiv, RN

Twenty years ago, I was hired as the Quality Manager for a local hospice. I believed in the concept after years of working as a nurse in hospitals, but I was new to hospice so I was eager to learn all I could about  the regulations, and how an ideal hospice should run. I spent time reading charts, going on site visits with each discipline, and attending team meetings. It was wonderful to see the good work being done by each member of the hospice team: the hospice aides, the nurses, social workers, doctors, and especially the chaplains.

I was distressed, though, when I overheard some chaplains in the break room complaining that they felt the rest of the team didn’t appreciate or value their work. I talked with some of them about their feelings, and asked other staff members about their impressions of the chaplain role. Some of the nurses said that while they felt the chaplains did help in certain situations, they didn’t really know why there needed to be a chaplain on each team – what did they do, exactly? In reading the charts more closely and attending team meetings with a focus on paying attention to the chaplain’s participation, I began to see what they meant!

The chaplains did a great job reporting and discussing the bereavement needs of family members after the patient’s death, but rarely contributed to the plan of care review portion of team meeting, and there was little of substance in their progress notes. In fact, the most common note was something along the lines of “said a prayer; patient grateful for my visit.” Not a very helpful contribution to the interdisciplinary approach to care.

I decided to give a documentation class for the chaplains to help them add detail to their notes, and to stress their participation in the Interdisciplinary Team (IDT). I used examples, and had a list of good vs bad charting entries. They listened to my class politely, but when I asked if there were questions or concerns, they let me know that they couldn’t write any of the things I suggested. I was shocked! Why not? They explained that it was because of patient confidentiality. They thought of themselves as pastors and their patients as their parishioners; they felt duty bound to keep the confidences of their patients. There was little they could share with the rest of the team.

Going back to the drawing board was needed. As I researched this issue, I began to see what the confusion was. They weren’t thinking of themselves as part of a team, but as a kind of independent contractor. It is true that when a minister/ pastor/ priest is functioning in that role, there is a degree of “clergy-communicant” confidentiality. This confidentiality can be different in scope and degree depending on the specific religion or denomination, but it is something that chaplains who have had formal training in their faith tradition take very seriously.

However, when a religious leader becomes a professional chaplain, it is important to understand that the context of their conversations with their patients, family members, fellow staff, and even staff in the facilities where the patient resides are different from within their church, temple, or synagogue. When they are employed by their faith tradition, they are bound to the rules set forth by that tradition’s leadership as well as their conscience. When they are employed as a member of a hospice interdisciplinary team, the scope of their responsibilities changes.

Each member of the team is bound by the confidentiality rules of their organization, and as codified in the Health Insurance Portability and Accountability Act (HIPAA). In fact, I would venture to say that all hospices require all of their employees to sign a confidentiality agreement. All members of the team must communicate the patient’s assessment, goals of care, and the plan for achieving those goals. If the chaplain does not contribute to this process, the patient will miss out on valuable support that the whole team can provide.

One of my favorite questions to ask a class of new chaplains when I cover documentation and care planning, is to ask them what interventions they would add to the plan of care of a patient who is newly incontinent. Sometimes, the first answer is laughingly saying “I only deal with the neck up!” So, I give them a case study about a patient who is newly incontinent. It goes on to explain how independent the patient has been all her life, having taken care of siblings, her own children, and many grandchildren. How she’s always been the one who kept the house clean, everyone neat and tidy, well fed, and tended to them in illness. And now, someone has to change her wet clothes, clean her private areas; sometimes without much reassurance or support. The patient is devastated by what has happened to her.

It never fails that a light bulb turns on – of course, the patient is devastated: her dignity has been assaulted, and she might feel abandoned by not only family and friends, but by God, too. She might begin to withdraw and isolate herself, or become depressed. They suddenly have many things that they want to assess with the patient, and many ideas for interventions that can help.

Likewise, when the chaplain finds that the patient has a risk factor for spiritual distress, it is important to share that with the Interdisciplinary Team. The Association of Professional Chaplains (APC) is very clear about the scope of the chaplain’s responsibilities. In the document “Standards of Practice for Professional Chaplains in Hospice and Palliative Care,” the APC has developed standards for Chaplaincy Care with Patients and Families. Among these standards, paraphrased here, are:

• Assessment – the chaplain gathers and evaluates information about the spiritual/religious, emotional and social needs, and hopes and resources of the patient. A critical component of any assessment is the identification of risk factors.
• Delivery of care – involves not only the patient, but also their family, the staff at the facility where they reside, and also the hospice team members. The chaplain develops a plan of care, implements the plan, and evaluates the plan’s effectiveness, modifying the plan as needed. Each of these aspects must be documented in the patient’s chart.
• Teamwork and collaboration – the chaplain is to be a fully integrated member of the IDT. This can only happen when the chaplain fully participates in the patient’s overall plan of care. There are frequently spiritual, emotional, social, cultural, and religious aspects to a medical diagnosis, the chaplain can assess these needs and help the other staff members understand, and learn ways to interact with the patient appropriately. The chaplain can also alert the members of the team to high risk areas, such as spiritual distress, anger with God, fear of the afterlife, or conflict with the patient’s faith tradition in the disease itself, or treatments chosen. The other staff members can then alert the chaplain if these symptoms worsen, or become acute necessitating urgent intervention by the chaplain. The staff will then understand how to approach the patient with sensitivity.
• Confidentiality – the chaplain must understand the rules and regulations regarding confidentiality on the federal level and their state. They must also understand and follow their agency’s policies and standards, as well as professional standards. Communication about the patient’s assessment, plan of care, interventions, and documentation must be known and available to the members of the team to assure interdisciplinary care.

While there is a lot of detail in the APC standards, the HIPAA laws, and the agencies policies and standards, specific questions can remain. Communication between the chaplain and the patient covers many aspects of the patient’s inner life, and it can be difficult to know what topics discussed are part of the patient’s hospice and palliative care, and which might be personal in nature and not part of their terminal diagnosis. For instance, a patient may state that she has a debilitating fear of going to hell because she had an abortion when she was young, or a former soldier believes that there is no salvation for him because of what he did during the war, or a patient wants to confess to a crime committed that was never discovered, believing that he is being punished for his actions by developing cancer. In these examples, the chaplain must use discernment to decide what aspects of the patient’s distress should be shared with the team. The full team should be aware of the patient’s distress, what signs and symptoms to watch for, and how they can support the patient. The important point is the patient’s spiritual and emotional distress, especially when it is interfering with the effectiveness of treatment.

An effective way of charting in the above examples might include: “During the visit, the patient reflected on life events, and he feels a sense of shame and guilt over unresolved actions. The patient currently feels insecure about his faith. Provided active listening and reassurance.” In other words, the important thing for the team isn’t the abortion, the actions during the war, or the crime, it’s about how the patient’s feelings are impacting their life and the effectiveness of care.

By bring fully part of the team, the chaplain can coordinate additional resources to help the patient. These resources can include the team Social Worker or other counselor, a consult with another mental health professional, and/or a member of the patient’s faith based community who can take the role of clergy as distinct from chaplain care. When in doubt, it is always wise for the chaplain to talk with their Team Manager, a senior chaplain peer, chaplain or social work supervisor, or other member of the management team. In some cases, asking for an Ethics Committee meeting can be helpful to work through problem areas.

We should all take patient confidentiality seriously, and most important is realizing that we are all on the same team and want what is best for the patient. By participating fully in the Interdisciplinary Team, participating the patient’s plan of care and communicating how the patient’s goals are being met, the team will understand the importance of the role of the chaplain, and be able to assist in giving the best possible care to the patient and their family.

Cheryl Barnes-Neff, PhD, MDiv, RN has been a nurse for over forty years, quality and regulatory compliance professional for thirty years, and in the hospice and palliative care field for twenty years. She is a frequent guest lecturer and speaker at professional conferences, and university schools of social work and nursing. She also works as a Buddhist chaplain, and frequently lectures about end of life issues for Buddhist patients, and cultural competency. Please visit http://www.barnesneff.com for more information.