Chaplaincy: A Continuum of Caring
Chaplaincy: A Continuum of Caring
The central task of the chaplain is to care for the human spirit. The Merriam-Webster dictionary  defines spirit as "an animating or vital principle held to give life to physical organisms." It is that part of us through which we relate to God. Chaplains differ from other health-care professionals in that they are publicly people of religious faith who believe in a god and hold that belief as central to their lives. Chaplains offer people alternatives to beliefs that cause suffering and help people strengthen beliefs that ward off distress.
A diagnosis of cancer invariably elicits a patient's ultimate existential and spiritual concerns.  For pancreatic cancer patients, these existential questions can be quite pronounced because of the extent of disease at diagnosis and the short life expectancy. This leads to a profound awareness of death as potentially imminent. Regardless of the patient's ethnic, religious, or cultural background, the chaplain can address these issues, both in terms of the common human experience and with an informed perspective on and reverence for the specifics of the patient's background.
Spiritual care essentially is touching the spirit of another person in an intense and purposeful way. With a diagnosis of pancreatic cancer, life itself is threatened. The chaplain acknowledges the "everlasting" aspect of the patient and guides the patient through the exploration of meaning and hope that arises as a result of such an extreme diagnosis. Commonly, a patient may define his or her spirit as "the inner person," "the real me," or "the part of me that nobody can see."  It is to this part of each person that the chaplain devotes his or her attention.
Spiritual care essentially is a supportive process. Efforts are directed toward maximizing the ability of the patient and family to use religious faith as a source of coping. When patients feel in touch with a god who is loving and comforting, they gain the hope that they will be able to deal with the pain and suffering of their disease. 
The word "suffer" literally means "to endure more." The answer to the implied question, More than what? can only be supplied by the sufferer. Whether an experience qualifies as suffering depends essentially on the meaning that a person gives to it.
Pancreatic cancer patients experience many physical symptoms--epigastric pain and profound weight loss, among others. It is critical to teach patients that symptoms can be aggressively managed so as to decrease pain. This knowledge, in and of itself, can be very healing. Physical discomfort obstructs the patient's ability to devote energy to fundamental existential or spiritual questions.
Pastoral counselors view spiritual or existential suffering as the core of the experience of suffering. The focus from a chaplain's vantage point is spiritual distress, a deeper disease than anxiety or depression, which has roots in the soul of the individual. For cancer patients, spirituality takes on a pronounced meaning. Depression, anguish, despair, anger, and/or deep sorrow may rise to consciousness at a never-before-permitted level, but so, too, may gratitude, awe, peace, and a sense of mystery.
A major goal of chaplaincy is to engender hope. Hope may be strengthened by learning that the physical pain can be controlled; it may be reflected in patients' knowledge that their particular rituals are valued and understood within the American hospital system; or it may come from patients' discovery of new ways of thinking about God.
Historically, hope has been largely misunderstood with regard to its relationship to terminal illness, and it has become intertwined with the concept of denial . One's ability to transcend the facts of the seriousness of one's illness is not denial. As Callan  noted, "Denial is a defense mechanism that consists of avoiding the facts, whereas hope accepts painful facts but places them in a wider perspective . . . ."
It is important to know both the content of a patient's beliefs and the meaning that the patient ascribes to these beliefs. Some patients may believe that having an illness may actually mean that they are being blessed by God; they may further believe that the illness is essentially good, although they may not be able to see the goodness at the moment. If, on the other hand, the patient's beliefs dictate that God can remove all cancers from one's body and it doesn't happen, that person may feel abandoned and reject God as unloving . Many people use God as a meaningful resource when they view God as Comforter rather than focusing on God as Doer . The popular Twenty-third Psalm does not say that God will keep us away from the valley of the shadow of death, only that God will walk with us through the valley. The chaplain seeks the patient's permission to actively revisit theological beliefs.
At first glance, the notion of a spiritual assessment may seem to violate the noninvasive, patient-directed approach of chaplaincy . However, religious and spiritual activities are used by a vast majority of patients to cope with illness and suffering. It is therefore fitting that spiritual assessment be done on every patient as soon as he or she enters the health-care setting.
Spiritual assessment encompasses three important areas: religious practices, religious community, and spiritual issues. Religious practices include rituals, such as going to services, contemplating a line of scripture, chanting, fasting, lighting candles, performing sacred dances, engaging in reverent bowing, praying, reading from the
Koran, wearing special clothing or jewelry, studying the Torah, and practicing meditation. Even an apparently small ritual may have great meaning for a patient; it makes him or her feel secure and anchored.
Religious community is a central factor in helping people cope. Access to one's religious group or leader is very helpful. Support groups are also useful in helping people cope with cancer. Properly structured worship in the hospital helps create a support group . Hospital chaplaincy departments, knowing the value of contact with one's community in worship, hold regular services.
The concept of "spiritual distress" is of great value to members of the helping professions as they seek to minimize patient suffering. The Pocket Guide to Nursing Diagnosis  defines "spiritual distress" as follows: "Disruption in the life principle which pervades a person's entire being and which integrates and transcends one's biological and psychosocial nature." It is considered a state in which the patient is "at risk" due to a disturbance in the source of strength. Although comprehensive assessments may be optimal, current health-care conditions allow time for obtaining only very specific assessment data. Chaplains can teach nurses and other professional staff members to perform quick assessments, to refer patients at high risk to chaplains, and to recognize the spiritual components of coping. The emphasis in assessment is placed on the function of the patient's belief system.
The newly diagnosed cancer patient frequently grapples with feelings of anger and betrayal. This is frequently the case with pancreatic cancer, since its early symptoms often are attributed by the patient to other, less serious conditions. The body did not forewarn the patient and yet the patient has advanced, even life-threatening disease. Susan Sontag wrote about this aspect of cancer--its surprise emergence--as an important part of the essential cancer experience . Patients frequently need help dealing with intense feelings of betrayal and anger at the time of diagnosis.
A survey was conducted at the Memorial Sloan-Kettering Cancer Center to ask patients about their perception of the most important services that chaplaincy could offer. Preoperative prayer was the item selected by most respondents (75%), along with visits during a crisis and sacraments for Christians. When people are highly anxious, they often need someone to pray with them. At Memorial Sloan-Kettering Cancer Center, a chaplain visits all preoperative patients to join them in prayer, if so desired.
Many chaplains have served in local congregations prior to their service in a medical center. Counseling family members of dying patients, planning funerals, arranging for cremation, and providing for the cultural and ethnic customs related to death and dying are some of the skills that chaplains have acquired from their former service that are invaluable in the medical setting.
Chaplains consider themselves to be ministers to patients, family, and staff. The analogy of the small town clergy-person is appropriate: Everyone in town knows who the rabbi, priest, or minister is, and the clergy is always on call. The religious leader is concerned about the spiritual well-being of every member of the town, even though not everyone in town is a member of that leader's congregation. In a medical center, ritual and discussions about hope or suffering apply equally to staff and patients. The chaplain, in caring for the human spirit, ministers to the health-care team members, ever reminding us of God's presence.
1. Webster's Tenth New Collegiate Dictionary, p 1134. Springfield, Massachusetts, Merriam-Webster, 1993.
2. Handzo G: Where are the children: Ministry in pediatrics. The Caregiver Journal 10:23, 1993.
3. Handzo G: Where do chaplains fit in the world of cancer care?, in Burton LA, Handzo G (eds): Health Care Chaplaincy in Oncology, p 29. Binghamton, New York, Haworth Press, 1992.
4. Sontag S: Illness as Metaphor. New York, Farrar, Straus and Giroux, 1978.
5. Stoll RI: The essence of spirituality, in Carson VB (ed): Spiritual Dimensions of Nursing Practice, p 4. Philadelphia, WB Saunders, 1989.
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7. Kim MJ, McFarland GK, McLane AM: Pocket Guide to Nursing Diagnoses, 2nd ed, p 55. St Louis, CV Mosby, 1987.