INTRODUCTION
Addressing spiritual issues, particularly among patients with terminal illness and near the end of life, can improve quality of life (Balboni et al., Reference Balboni, Vanderwerker and Block2007; Puchalski, Reference Puchalski2007). In 2004, the National Consensus Project identified spiritual, religious, and existential aspects of care as one of eight domains in the framework for clinical practice guidelines for quality palliative care (Puchalski, Reference Puchalski2007). Recently published guidelines for spiritual care in palliative care programs build upon this framework (Puchalski et al., Reference Puchalski, Ferrell and Virani2009). The Department of Veterans Affairs (VA) also recognizes the importance of spiritual care at the end of life. VA hospice and palliative care is a covered service with priority equal to that of any other medical care service. Veterans' Health Administration (VHA) Directive 2008-066 established palliative care consult teams (PCCT) to provide comprehensive management of veterans' needs, including spiritual needs, at the end of life. These multi-disciplinary teams are mandated to include chaplains.
Despite the mandate to provide spiritual care, the nature of this care and the process by which it is provided is unknown. This information would allow identification of strengths of current spiritual care practices and areas for care improvement.
Chaplains are the primary spiritual care providers in VA PCCT. As a result, they can provide first-hand information about end-of-life spiritual care in the VA, including areas for potential improvement. To date, only one study has reported on spiritual care in the VA. This study conducted interviews with VA healthcare providers in focus groups. Participants responded to questions about their views of spirituality, its role in patients' health, and barriers to discussing spiritual issues with patients (Fletcher, Reference Fletcher2004). Two chaplains participated, but most participants were nurses (n = 27 out of 55) and social workers (n = 10). These healthcare providers came from various practice areas (Fletcher, Reference Fletcher2004), including 12 from extended care/hospice. However, the study did not separate end-of-life spiritual care from spiritual care in other contexts. Notably, this study found breakdowns or deficiencies in communication between healthcare providers and chaplains.
Information regarding chaplains' perspectives on care for non-VA patients at the end of life is also scarce. A Swedish study surveyed hospital chaplains regarding questions most frequently posed by patients at the end of life (Strang & Strang, Reference Strang and Strang2002). The most frequent questions concerned existential issues such as the meaning of life and death and dying. Questions about medical issues and anxiety over separation from family were also frequently asked. The study reported that only 8% of issues raised by patients related directly to religion, including the existence of God, why God does not heal, the impact of prayer, and wishes for forgiveness and peace in one's soul. Patients rarely requested religious rituals such as Holy Communion or devotions. The authors commented that a low rate of church attendance (6% of Swedes reported attending at least once a month) might explain why religious issues were less important to patients at the end of life. The findings were similar to those of a study in England, which found that patients required a range of non-religious spiritual care such as discussing the meaning of suffering and their love for and care of their family (Wright, Reference Wright2001).
Our study addresses the gap in the literature regarding the current state of spiritual care provided in the VA. The purpose of this study is to understand the process and content of end-of-life spiritual care provided in a VA Medical Center (VAMC) from chaplains' perspectives.
METHOD
Five chaplains in a VAMC in the northeastern United States participated in face-to-face individual interviews. These chaplains were the primary members of the chaplain service and all had provided care to patients at or near end of life and to their family members. Two were members of the PCCT. All five chaplains (four men and one woman) were Christians, two Catholic and three Protestant with lengths of VA service ranging from 1 to 19 years.
The chaplains signed institutional review board (IRB) approved informed consent before they were interviewed by the study psychologist. They were asked eight open-ended questions (see Appendix). Based on the answers, the interviewer often asked follow-up questions. The average interview lasted approximately an hour (range: 45–80 minutes).
The interviews were recorded and transcribed. Analyses were based on a grounded theory method that involved reading the transcriptions line by line, initial coding of each interview, reducing initial codes into categories, and deriving themes from the categories (Strauss & Corbin, Reference Strauss and Corbin1990). Two authors (B.C. and N.S.) independently coded the interviews. They then discussed and resolved discrepancies to agree on final themes for each question.
RESULTS
Although all of the questions refer to both patients and their families, chaplains tended to respond concerning care provided to patients. We summarized chaplains' responses into five areas: communication among care providers, types of spiritual care services provided, veterans' unique spiritual needs, ideas for care improvement, and influence of chaplain's own spirituality on care.
Communication among Interdisciplinary Care Providers
Chaplains reported receiving referrals for spiritual consultations through a range of mechanisms including the computer alert system, admission lists, communications with nurses, direct contacts with patients, and calls or pages from staff for emergency cases. All five chaplains indicated that every patient referred to PCCT is visited by a chaplain. In weekly rounds of the PCCT, every patient is discussed. One chaplain attended this meeting to learn about each patient. A Catholic chaplain reported checking with nurses for patients who are deteriorating quickly. He also carried a pager for alerts to the emergency needs of patients, especially those who are dying. These measures were taken because the presence of a priest at their dying moments is important for many Catholics.
Chaplains reported communicating with other team members about the care they provided through written notes in medical records, discussions at meetings, and personal communications. Notes recording chaplains' visits to patients are required at this medical center. Chaplains can also request that other team members (e.g., psychologists) co-sign their notes when patients have issues that require interdisciplinary care (e.g., psychological or emotional issues). Sometimes chaplains attend family meetings with the PCCT to provide their perspectives.
This systematic way to refer patients to chaplains applies only to patients. A similar mechanism does not exist for referral of family members. Most chaplains did not mention how they were contacted for care to family members. One chaplain reported meeting family members when they came to visit patients.
Spiritual Care Services Provided
The following quotation captures the many aspects of spiritual care and the team work required.
Spiritual care is kind of the whole gamut of life that they are reviewing … they are trying to … become at peace with themselves and others and I think it's a listening process or a questioning … The social worker and … the rest of the staff are helpful too, and … we approach them as a team…
Another chaplain described the meaning of spiritual care.
I don't approach it as … spiritual care. I approach this as a relationship. I'm not interested in their spiritual care necessarily. I'm interested in their journey, their process … what they think I need to give them and … what they really need, may be two different things.
A chaplain described the difference between working in a hospital and in a parish, indicating that hospital care is more intense. Patients ask for spiritual care such as prayers and Bibles during their hospital stay. Providing these services in a hospital can be more intense because chaplains do not have long-term relationships with the patients, the way they do with parish members. In addition, a hospital chaplain can have more roles than a pastor.
… They come in and they want to make contact and then you've got a base line with them and that is different from … a parish. And then palliative care, you really are becoming more than a pastor, because you are an individual counselor … an individual chaplain for them.
The types of spiritual care services reported by the chaplains included performing religious rituals and ceremonies, offering religious materials and prayers, being present, being an empathetic listener, helping patients heal and reconnect with God, assisting in creating a legacy, facilitating communication among patients and family members, assisting in resolving relationship issues, helping patients accept illness and death, providing counseling, and making funeral arrangements.
Catholic chaplains reported receiving requests for religious rituals or ceremonies. These provided an opportunity for patients who lost connection with the Catholic Church to be reconnected. A chaplain reported helping patients to heal their traumas, for example, helping a patient forgive his father, who had abused him verbally and emotionally. According to the chaplain, the patient then became a different man, which was noticeable to his wife and nurses. Chaplains also reported providing care outside the context of religion. For example, they reported helping patients cope with emotional distress, accept the illness, and resolve family issues.
Another thing as a chaplain, we try to … bring out the story … Just help them to get out what's underneath the surface. We're a little bit like psychologists.
Although chaplains worked with PCCT members when psychological or medical issues arose during patient interactions, they would have liked to have had more psychologists available when issues arose that were not covered by a chaplain's professional training. Chaplains also commented that they assisted patients in creating their legacy.
I try to raise [the issue] of their own legacy — who they are and how they want to be remembered.
Finally, they reported that being present with the patients and being an empathetic listener can bring comfort to patients.
Unique Spiritual Needs of Veterans
Chaplains underscored that veterans have unique spiritual care needs because of their experiences in combat, social isolation (divorced, homeless), mental health problems (high prevalence of post-traumatic stress disorder and substance use disorders), and lack of connection to a religious parish.
There's a unique…set of problems … that we're still learning how to deal with … a lot of persistence is necessary to deal with unique problems of Veterans.
Spiritual care unique to veterans includes forgiveness for war crime or sin, working through guilt related to killing in war, reconnection to God, honor for what they have done for their country, and connection to religion through hospital chaplains because of the lack of their own churches or pastors. The chaplains claimed that many veterans have guilt, but sometimes they are not aware of it until the end of life. As a result, the veterans might not know that they need forgiveness.
They may not even know … they need it. But, sometimes … if you touch them in a certain place … it shows that…they want the forgiveness … They want cleansing, closure
Typically, World War II Veterans who would not talk about the war … at end of life, things come to the surface, combat scenes … and traumatic experiences.
One chaplain described the impact of war on veterans' spiritual growth, especially those who joined the military at an early age. This chaplain commented that losing a connection with God at a young age makes it hard for veterans to deal with the question of why God would allow war and tragedies to happen. The chaplain believes that these veterans also have a harder time making spiritual connection and relying on God while dealing with life's difficulties.
I talked with plenty of guys who said [they] left God in Vietnam. So, at 18, 19, 20 years old, they cancelled their spiritual growth and shut God out.
Chaplains reported that some veterans believe that they committed sins in war and have a hard time forgiving themselves. The patients want to work this out before they die. They may have confessed what they did to someone, but they never forgave themselves for it.
Chaplains also recognized that veterans need to be honored for who they are and what they did.
When I pray for them, I always say thank you. Thank you God for who this man is and for the service he's given his country.
Ideas for Care Improvement
Aspects of spiritual care that chaplains wish they could have provided to patients or family members include more time to work with them, ways to honor veterans, more veteran volunteers, bereavement care and support to families, and connection to patients' own chaplains of different religious background. Chaplains experienced helplessness when patients are dying because they cannot change the reality.
There's a lot of powerlessness when you enter a room and somebody's dying, and the family's there … I don't see myself there to [say] “okay, come on … I want to lift your spirits … I just have to be there with them in the powerlessness.
One chaplain suggested a project for honoring veterans.
There is a project, which I would really love to see happen, called the Voice of Veterans Project from the Library of Congress, and they go and they take a … report and they interview Veterans about their war experiences, about their life … and about their legacy.
A chaplain, who is a veteran, indicated that veterans like to be visited by veterans, especially from the same era. This chaplain suggested forming a committee to address the need for more veteran volunteers to visit veteran patients.
Another service that chaplains would like to provide is a support group for family members to talk to one another prior to the death of the patient, receive bereavement care, share their grief with other families, and honor the passing of the veterans. Currently, family members are referred to outside agencies for bereavement services for logistical reasons. Chaplains also feel that a little gathering, such as a memorial service with the staff after the patient dies, can help grief.
Influence of Chaplain's Personal Spirituality
Chaplains reported that various aspects of their personal spirituality influence the nature of their care. For example, broad religious background, faith in God, belief in the power of hope, respect and acceptance of patients' beliefs, being a veteran, and life experience. One chaplain thought that exposure to different religions had made him a better person.
I'm involved as much as possible in inter-denominational dialogues … I think I'm better than I was ten years ago [in] being able to see the dignity and worth of every religion … of every human being.
The chaplains expressed the importance of respecting patients' own religious beliefs and traditions and admitting their own limitations in providing care to patients with different faiths.
So I respect their [religion] … I bring who I am to it, but … in a format that is going to be meaningful for them, and not offensive to them.'
… I deal with not only Catholics … but Jewish patients, and … Buddhist, and … the whole gamut … And it's frightening a bit to deal with some of them …
because I am not … learned in that tradition and … I have to let them tell me … some spirituality … I am not comfortable with at all … I basically say this is my spirituality and I can't help you with … yours … maybe I can get someone to talk to you.
Recognizing that working with end-of-life patients is rewarding and yet stressful and emotional, chaplains reported that they rely on God to help provide spiritual care to patients.
Oftentimes when I go to visit somebody, I don't feel like I'm emotionally strong … So, I feel in my own faith, I have to say you know God … I need you to give me the strength (laughing) to do this today.
One chaplain, however, admitted faith issues and struggling at times.
Some days I don't want to talk to God if it's been a particularly difficult day.
DISCUSSION
Our study of chaplains providing spiritual care to patients at the end of life in a VAMC shows that the team seems to have a reliable referral and communication system. Chaplains reported that they visit every patient referred to palliative care. An alert system in the electronic medical record and weekly PCCT team meetings contribute to good communication. This feature of the electronic medical system could be used to resolve the deficiencies in communication between healthcare providers and chaplains that were reported in a previous study (Fletcher, Reference Fletcher2004).
Chaplains reported providing a range of spiritual care services, which address religious, spiritual, emotional, family, and illness concerns. These findings are consistent with European studies, which found that religious issues account for only a small portion of questions that patients with terminal illnesses posed to hospital chaplains (Wright, Reference Wright2001; Strang & Strang, Reference Strang and Strang2002). Chaplains in our study reported referring patients to psychologists or physicians for issues that were beyond their professional capacity. These findings emphasize the importance of a multidisciplinary team in palliative care and the communication among the team members.
This study highlights the unique spiritual needs of veterans, especially the need to work through guilt for killing in war (Grassman, Reference Grassman2007; Litz et al., Reference Litz, Stein and Delaney2009). At the end of life, guilt can resurface and cause significant distress and internal conflict, particularly for those with strong religious backgrounds. Studies have found that negative religious coping and religious struggles, such as feeling punished by God, anger at God, and spiritual discontent, are associated with poor health and increased mortality among medically ill elderly (Koenig et al., Reference Koenig, Pargament and Nielsen1998; Fitchett et al., Reference Fitchett, Rybarczyk and DeMarco1999; Pargament et al., Reference Pargament, Koenig and Tarakeshwar2001). Spiritual counseling to address the guilt of war sins is therefore an essential skill for VA hospital chaplains. Veterans might also benefit from having more chaplains who are veterans, because their military experience could facilitate rapport with the patients.
Finally, this study provides insight into the impact of chaplains' spirituality on their spiritual care. Diversifying their religious background, maintaining their own faith and managing stress from caregiving are ways that chaplains in this study reported using to strengthen their capacity to provide spiritual care. These findings reveal the importance of paying attention to the well-being of care providers, which can have impacts on the care they provide to patients.
CONCLUSIONS
In conclusion, the chaplains in our study provided rich information that can be used to improve the quality of palliative care in the VA. Although this study, which was conducted in one site and only included Christian chaplains, may have limited generalizability, it provides valuable information for future studies at other VAMCs across the country. For example, the information provided by chaplains could inform development of a scale for assessing spiritual needs and care provided to patients and families. This scale could then be used to study the impact of spiritual care on patient satisfaction and quality of life. Future studies can also collect spiritual care information from other care providers' perspectives to compare with that of chaplains.
ACKNOWLEDGMENTS
This study was funded by the VA Health Services Research and Development Services: PPO-10107 and reviewed by the Institutional Review Board. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. We appreciate the time the chaplains spent in the interview in providing the information for the study.
APPENDIX Interview Questions
1. Please tell me how you generally get contacted to consult with a patient or family member?
2. What kinds of spiritual care do you provide to the patients, and their family members?
3. How do you communicate a “plan” for the patient's or family's spiritual care to the other members of the healthcare team? For example, do you participate/how often do you participate in daily rounds, write notes in the record, talk informally with nurses or physicians, or do anything else to tell other members of the care team about the patient or family spiritual history?
4. How do you provide spiritual care to patients and their family? For example, when you talk with family or friends, how often do you need to use another room or private space? Do you provide the care individually or in a group?
5. What spiritual care do veterans or their family/friends generally ask for?
6. What do you think the patients' spiritual needs are? In your experience, how do these needs differ from the wishes of non-veterans/people outside the VA system?
7. What types of care do patients or family ask for that you wish you could provide or provide more often?
8. How do your own spiritual or faith traditions affect your caregiving?
