End of Life Management- a Chaplain’s Role within an Holistic Approach

Rev Lindsay Johnstone, Chaplain at Royal Prince Alfred Hospital Sydney

 

Recently I took part in a seminar at Balmain Hospital, on end of life management, organised by Tracy Greer, Sydney Local Health District End of Life Project Officer. Two scenarios were presented and input was provided by a geriatrics medical officer, a nursing unit manager, a palliative care clinical nurse consultant, a social worker and a chaplain (myself).

 

This reflection focuses only on the chaplaincy response. A chaplain might not be aware of the interactions between a patient and the others in the medical team, and in my case this is mostly as it is.

 

The first scenario was to do with a 76 year old male, Bill, who has been offered pastoral care. He says he “never goes to church”, but it wouldn’t hurt to see someone now. His only daughter Barbara also says she “isn’t religious, but it would be good to talk”. I am asked, “Chaplain, what can you do for this family?”

 

1              First, I would enquire if they would like my support as a chaplain. If they would, then how may I help?

I would then listen and run with what they say.

In my innermost being I am at the same time listening spiritually to God, silently praying that he will help me respond appropriately to what they are saying.

 

2              While either or both are talking I shall be making some spiritual assessment as to what they are saying discerning any pastoral or spiritual concerns that they may have. Through brief discussion they may affirm or correct any impression I may share.  Here this (imaginary) circle (which I draw in the air) represents what Bill or Barbara is saying. A second circle represents what I perceive God is saying. It is wherever those circles intersect that I can operate with them.

 

3              I am there to facilitate emotional and spiritual wellness. In that process I shall not try to argue or persuade, but to be guided by how they supervise in the dialogue.

 

4              From what we know, it is possible that Bill may be thinking about eternity and accountability. He may be concerned about how God might view the key performance indicators in his life. In this case he might be in need of reconciliation or peace with God. If this is how Bill sees it all, I shall aim to help him receive spiritually, drawing on my faith understanding which focuses on what Christ has achieved for Bill by dying on the cross.

 

On the other hand, his presenting concern might be about receiving pastoral care to cope with the process of dying, or concern about how his daughter will cope with his passing.

 

Barbara may have spiritual concerns that are different to those of Bill, and I shall aim to listen for these and to respond to them. She may be seeking reassurance.

 

5              Either or both Bill and Barbara might just want me to listen and respond. Either or both may want me to pray aloud, in which case I shall check if there is some specific way in which they want me to pray. Prayer is not something I shall do to manipulate or control.

 

6              In summary – I want to listen, stay with where they want me to go, and have the freedom to take some initiative in making suggestions, whilst staying within the boundaries that they allow.

The second scenario was to do with a 70 year old female, Glenda, who is likely to die in the next week. In this case the need for a chaplain is raised after she dies, with regard to her nurse. When Glenda passes away peacefully, the nurse looking after Glenda is having emotional difficulties looking after other patients who are dying. She tells a colleague that her faith is something that usually helps. I am asked, “What can you do for the nurse and who else can the nurse speak to about bereavement issues?”

                                 

I mention that the local health district has a Bereavement Counselling Centre, and produce a brochure.

When it comes to talking with the nurse:

1              First I would enquire how the nurse would like me to help. The fact that someone else said she might like spiritual help does not necessarily mean that she wants it. She can decide if she want to give me a “contract”. If so, I want to help her to express what is on their mind.

 

2              Meanwhile, I am silently and inwardly asking the Lord to guide our discussion.

 

3              Inwardly make a spiritual assessment. Discussion may lead me to adjust this.

 

It may be that the nurse has new questions about her faith, or perhaps she is traumatised about the processes of the palliative care. She may be wrestling with exhaustion, or inappropriate guilt feelings. “Did I do enough?” “Did I do too much?”  “Did I make the right decisions?” “Am I just worn out by it all?”

 

It seems that faith may, possibly, be her issue and she may feel her faith has let her down. Does the evidence in what happened support her faith? Is faith evidence-based in Christian understanding? Does she now have a crisis over the righteousness of God, or even his existence?

 

4              In summary, listening and sensitive responses will be the key. The use of prayer cannot be presumed in advance, just because she told someone her faith usually helps. It will again depend on how the conversation goes and what she wishes.

Pastoral Care is Fellowship with Christ

David Pettett
July, 2015

In her book on revitalising pastoral care, Deborah van Deusen Hunsinger says that Christ’s presence determines the pastoral conversation.[1] If this is true, Christian pastoral care is never carer focused. Yet the surprising conclusion is that it is also never client focussed. In Christian pastoral care it is not the chaplain who brings an agenda of their own. And yet it is also not the client who sets the direction which the chaplain responds to. It is Christ who sets the agenda and to whom both the chaplain and the client respond.

Consider three scenarios:

1.       The chaplain who brings their own agenda.

Most pastoral care practitioners agree that this is the worst form of pastoral care. This chaplain will approach the unsuspecting client with a clear purpose such as evangelism at one extreme. This chaplain does not feel they have done a good days ‘chaplaining’ unless they have told someone about the wonderful saving work of Christ. At another extreme, and equally inappropriate, is the desire within the chaplain to ‘make the patient feel calm’. This assumes the patient wants to be calm. What if she wants to ball her eyes out in grief or scream at God in anger?

Bringing your own agenda as a chaplain or pastoral carer says more about your own needs than it does about the work of pastoral care. It is something to be avoided but too often observed even in people who have been acting as chaplains for a number of years.

2.       The chaplain who is determined to respond to the patient’s agenda.

Too often in pastoral care this approach is promoted as the proper way for a chaplain to act. This approach encourages the chaplain to listen and reflect. Not a bad idea, and often very helpful for the patient especially when this chaplain is the first person who has bothered to hear and to be a fellow human being who is present. But this style of pastoral care most often stops at this point when it should go further. Click through to this YouTube video to see how frustrating for the patient this approach can be.

3.       The chaplain who follows Christ’s agenda.

This does not mean simply being biblically correct. Yet, again, being biblically correct is not a bad idea. Neither does it mean waiting for a personal, audible voice from Jesus to know what to do next. As Hunsinger styles it, Christ’s mediation reconfigures every human encounter, desire and aspiration. His mediation is effective because Christ himself is present in the pastoral encounter. His presence will be apparent primarily to the chaplain because he or she has entered the pastoral space in prayer, asking that Christ himself be present, asking that Christ will mediate between the chaplain and the patient. Asking that Christ’s wisdom will be to the fore when human wisdom fails. Believing that Christ’s strength will be present when human strength is inadequate. Knowing that Christ’s suffering stands between suffering and the sufferer themselves. In prayer the chaplain entrusts the pastoral encounter to Christ. In this style of pastoral encounter the client will also ultimately become aware of the presence of Christ.

The ministry of Christian pastoral care is a difficult privilege. It goes beyond compassion and empathy. It does more than listen and reflect. It is more than drawing alongside a fellow human being with empathy. It is more than two people in conversation. In Christian pastoral care three people are always present. Three human beings. One of them is truly human in a way the other two have never been and can only ever aspire to be.

If the chaplain tries to be the well trained expert who moves to their own agenda, they will fail. If the chaplain tries to be the empathic listener, responding to the patient’s agenda they, and sometimes the patient, will feel good. But neither of these approaches has deliberately invited Christ into the encounter. In both, there is human interaction and there may be some level of pastoral care, one for the other. It is hard, however, to see how these methodologies can be truly called Christian pastoral care because Christ is not acknowledged.

Hunsinger believes that because psychotherapy has so dominated pastoral care many practitioners see themselves as agents of change. The pastoral care encounter is thought to be part of the treatment plan. Contra this Hunsinger makes the bold statement that ‘Koinonia is the central purpose of Christian pastoral care.’ She believes that being present, listening with care and praying are ends in themselves. They are not a means to see the patient made well.

Christian pastoral care will see the chaplain enter into koinonia firstly with Christ and then with the patient. Christian pastoral care will take place when all three acknowledge each other’s presence. Christian pastoral care will take place when two of the three recognise that the one true human ‘stands between’ themselves and their human experience. This is why the major activity of the chaplain in pastoral care is prayer; to invite, to experience, to respond to and to encounter the fellowship of Christ in the fellowship of human life.

---

[1] Deborah van Deusen Hunsinger. Pray without ceasing: Revitalising Pastoral Care. Grand Rapids. Eerdmans. 2006