The patient was at the end of her life, recalls Jeremy Lambert, and her physician feared treatment was becoming more harmful than helpful. Yet the patient’s family couldn’t bear to end care, believing that God would save her. Lambert, a chaplain at the Erlanger Health System in Chattanooga, Tenn., managed to bridge the gap.
“Before, it didn’t matter what the physician was saying: the family wasn’t able to hear it,” he notes. Through lengthy discussions about religious beliefs, he helped them accept the idea that God was powerful enough to heal without extensive medical intervention. “Then the family was able to have a conversation with the physician that they hadn’t been able to have before,” Lambert explains. “They could bring themselves to say, ‘Okay, let’s go to comfort measures.’”
Lambert is one of an increasing number of chaplains working in hospitals across the country. In 2015, 70% of 4,862 hospitals surveyed provided pastoral care services, up from 53% in 2002, according to the American Hospital Association. Sometimes, these services are provided by priests, rabbis, and other local clergy, but hospitals more often use chaplains, who are trained to work with people of all faiths—or no faith, explains Deborah B. Marin, MD, director of the Center for Spirituality and Health at the Icahn School of Medicine at Mount Sinai in New York.
A patient’s right to religious and spiritual care is recognized by the Joint Commission, and most U.S. medical schools require some content on spirituality and health. Still, physician-chaplain collaboration varies widely between—and even within—hospitals.
Collaboration is more common in teaching hospitals, for example, because they emphasize exposing students to many disciplines, notes Kimberly Murman, president of the Association of Professional Chaplains. Such teamwork also is prevalent in fields that take a more holistic approach, such as palliative care and biomedical ethics, she says.
Physicians may request chaplains—sometimes called spiritual care professionals—for a patient who wants to fast on a holy day, wear a religious symbol during surgery, or deal with questions of mortality. But chaplains often do more than that, notes Christina Puchalski, MD, a professor at the George Washington (GW) University School of Medicine and Health Sciences and director of the GW Institute for Spirituality and Health.
“These days hospitals can be pretty fast-paced and stressful for patients and families. They feel a lack of connection,” says Puchalski. “Chaplains are able to bring back connection. They’re really good at dealing with even more than strictly spiritual or religious issues. They’re really good at addressing existential issues and at providing support.”
The chaplain as team member
Following a landmark 2013 international conference on spirituality and health, Puchalski coauthored a journal article outlining consensus recommendations for care. She believes firmly in an interdisciplinary team approach. “The ideal is to have board-certified chaplains, [who] are considered members of the health care team,” Puchalski says. “Those of us who have developed models on how this could work consider that patients have spiritual concerns [that] should be addressed by everyone on the health care team—with the chaplain recognized as the expert in spiritual care.”
The Erlanger Health System, in conjunction with the University of Tennessee College of Medicine Chattanooga, took the relatively rare step of fully integrating chaplains into its academic internal medicine team several years ago.
“Personally, it’s amazing to be able to interview a patient together [with a chaplain].... We come out with a richer understanding of the patient.”
Christina Puchalski, MD, George Washington University School of Medicine and Health Sciences
Ramya Embar, MD, a resident when the effort began, was highly skeptical at first.
“I felt it was almost a burden [to have chaplains on daily rounds] because I had to explain things in very layman terms,” she recalls. “I was much more concerned about the medical rather than all the psychological and socioeconomic factors involved.”
But she noticed that chaplains unearthed some essential health information. One patient had experienced sexual abuse, it turned out. Another had been an IV drug user. A third was afraid to go home with an abusive daughter. Such stories may elude doctors, who often don’t have the time, training, or manner to elicit them, Embar believes.
“We stand around the bed in our white coats. We take off patients’ clothes. They are already so vulnerable,” she says. “They are more likely to share their deepest fears and personal issues with someone who is able to sit and talk to them as a confidant.”
And over time, she notes, the Erlanger chaplains discovered how to avoid slowing the team down significantly: they would identify patients they could see on their own and then debrief their colleagues later.
Added value of spiritual care
The Erlanger program reports positive results. A study there, published in August 2017, found that even patients who said they would not have requested a chaplain visit rated the interactions highly.
Other research points to a number of possible benefits of hospitals providing spiritual care. In a study published in 2009, for example, terminal cancer patients who received such assistance had quality-of-life scores that were 28% higher than those who did not. A 2011 paper estimated that routinely providing spiritual care to terminal cancer patients would yield a national savings of $1.4 billion each year. And a study of nearly 9,000 patients at Mount Sinai Hospital found that patients who met with chaplains rated their stay higher and were more likely to recommend the hospital.
Puchalski explains a key value she sees in working together with chaplains: “Personally, it’s amazing to be able to interview a patient together. Each of us has a different perspective we bring from our professions. We come out with a richer understanding of the patient.”
Maggie Keogh, a chaplain at Mount Sinai, shares a story to illustrate how physician-chaplain partnerships can make a difference. “I worked with a doctor in an ICU who’d been there about 10 years. We’d have talks, and he [told me] that he really shut himself off from families,” she recalls. “He’d had some tough experiences with families who misunderstood his intent, who were very angry.”
“He said that from our talking and his watching me work with families, he began to feel his heart opening up to them again. That was a cool way of working with a doctor that indirectly helped patients,” she says. “I suspect chaplains do that in more ways than we even know we do.”