Chaplaincy: A Continuum of Caring

ABSTRACT: A diagnosis of cancer evokes a patient's ultimate existentialand spiritual concerns. These concerns can be quite pronouncedin the patient with pancreatic cancer due to the generally advancedstage of the disease at diagnosis and the short life expectancy.The role of the chaplain is to maximize the patient's abilityto use religious resources as a source of coping with pain andsuffering throughout the course of the disease and its treatment.When a patient enters the health-care setting, the chaplain canperform a spiritual assessment and identify patients at "highrisk" as a result of a disturbance in the functioning oftheir belief system. The chaplain can assist these patients byoffering alternatives to beliefs that cause suffering and strengtheningbeliefs that ward off distress. Chaplains also minister to theneeds of the patient's family and members of the medical center.Ritual and discussions about hope or suffering apply equally tostaff, patients, and patients' families. [ONCOLOGY 10(Suppl):45-47,1996]

Introduction

The central task of the chaplain is to care for the human spirit.The Merriam-Webster dictionary [1] defines spirit as "ananimating or vital principle held to give life to physical organisms."It is that part of us through which we relate to God.[2] Chaplainsdiffer from other health-care professionals in that they are publiclypeople of religious faith who believe in a god and hold that beliefas central to their lives.[3] Chaplains offer people alternativesto beliefs that cause suffering and help people strengthen beliefsthat ward off distress.

A diagnosis of cancer invariably elicits a patient's ultimateexistential and spiritual concerns. [4] For pancreatic cancerpatients, these existential questions can be quite pronouncedbecause of the extent of disease at diagnosis and the short lifeexpectancy. This leads to a profound awareness of death as potentiallyimminent. Regardless of the patient's ethnic, religious, or culturalbackground, the chaplain can address these issues, both in termsof the common human experience and with an informed perspectiveon and reverence for the specifics of the patient's background.

Spiritual care essentially is touching the spirit of another personin an intense and purposeful way. With a diagnosis of pancreaticcancer, life itself is threatened. The chaplain acknowledges the"everlasting" aspect of the patient and guides the patientthrough the exploration of meaning and hope that arises as a resultof such an extreme diagnosis. Commonly, a patient may define hisor her spirit as "the inner person," "the realme," or "the part of me that nobody can see." [5]It is to this part of each person that the chaplain devotes hisor her attention.

Spiritual care essentially is a supportive process. Efforts aredirected toward maximizing the ability of the patient and familyto use religious faith as a source of coping. When patients feelin touch with a god who is loving and comforting, they gain thehope that they will be able to deal with the pain and sufferingof their disease. [3]

Hope and Suffering

The word "suffer" literally means "to endure more."The answer to the implied question, More than what? can only besupplied by the sufferer. Whether an experience qualifies as sufferingdepends essentially on the meaning that a person gives to it.

Pancreatic cancer patients experience many physical symptoms--epigastricpain and profound weight loss, among others. It is critical toteach patients that symptoms can be aggressively managed so asto decrease pain. This knowledge, in and of itself, can be veryhealing. Physical discomfort obstructs the patient's ability todevote energy to fundamental existential or spiritual questions.

Pastoral counselors view spiritual or existential suffering asthe core of the experience of suffering. The focus from a chaplain'svantage point is spiritual distress, a deeper disease than anxietyor 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 riseto 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 strengthenedby learning that the physical pain can be controlled; it may bereflected in patients' knowledge that their particular ritualsare valued and understood within the American hospital system;or it may come from patients' discovery of new ways of thinkingabout God.

Historically, hope has been largely misunderstood with regardto its relationship to terminal illness, and it has become intertwinedwith the concept of denial [2]. One's ability to transcend thefacts of the seriousness of one's illness is not denial. As Callan[6] noted, "Denial is a defense mechanism that consists ofavoiding the facts, whereas hope accepts painful facts but placesthem in a wider perspective . . . ."

It is important to know both the content of a patient's beliefsand the meaning that the patient ascribes to these beliefs. Somepatients may believe that having an illness may actually meanthat they are being blessed by God; they may further believe thatthe illness is essentially good, although they may not be ableto see the goodness at the moment. If, on the other hand, thepatient's beliefs dictate that God can remove all cancers fromone's body and it doesn't happen, that person may feel abandonedand reject God as unloving [2]. Many people use God as a meaningfulresource when they view God as Comforter rather than focusingon God as Doer [3]. The popular Twenty-third Psalm does not saythat God will keep us away from the valley of the shadow of death,only that God will walk with us through the valley. The chaplainseeks the patient's permission to actively revisit theologicalbeliefs.

Spiritual Assessment of the Patient

At first glance, the notion of a spiritual assessment may seemto violate the noninvasive, patient-directed approach of chaplaincy[3]. However, religious and spiritual activities are used by avast majority of patients to cope with illness and suffering.It is therefore fitting that spiritual assessment be done on everypatient as soon as he or she enters the health-care setting.

Spiritual assessment encompasses three important areas: religiouspractices, religious community, and spiritual issues. Religiouspractices include rituals, such as going to services, contemplatinga line of scripture, chanting, fasting, lighting candles, performingsacred dances, engaging in reverent bowing, praying, reading fromthe

Koran, wearing special clothing or jewelry, studying the Torah,and practicing meditation. Even an apparently small ritual mayhave great meaning for a patient; it makes him or her feel secureand anchored.

Religious community is a central factor in helping people cope.Access to one's religious group or leader is very helpful. Supportgroups are also useful in helping people cope with cancer. Properlystructured worship in the hospital helps create a support group[3]. Hospital chaplaincy departments, knowing the value of contactwith one's community in worship, hold regular services.

The concept of "spiritual distress" is of great valueto members of the helping professions as they seek to minimizepatient suffering. The Pocket Guide to Nursing Diagnosis [7] defines"spiritual distress" as follows: "Disruption inthe life principle which pervades a person's entire being andwhich integrates and transcends one's biological and psychosocialnature." 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-careconditions allow time for obtaining only very specific assessmentdata. Chaplains can teach nurses and other professional staffmembers to perform quick assessments, to refer patients at highrisk to chaplains, and to recognize the spiritual components ofcoping. The emphasis in assessment is placed on the function ofthe patient's belief system.

Spiritual Care of the Patient

The newly diagnosed cancer patient frequently grapples with feelingsof anger and betrayal. This is frequently the case with pancreaticcancer, since its early symptoms often are attributed by the patientto other, less serious conditions. The body did not forewarn thepatient and yet the patient has advanced, even life-threateningdisease. Susan Sontag wrote about this aspect of cancer--its surpriseemergence--as an important part of the essential cancer experience[4]. Patients frequently need help dealing with intense feelingsof betrayal and anger at the time of diagnosis.

A survey was conducted at the Memorial Sloan-Kettering CancerCenter to ask patients about their perception of the most importantservices that chaplaincy could offer. Preoperative prayer wasthe item selected by most respondents (75%), along with visitsduring a crisis and sacraments for Christians. When people arehighly anxious, they often need someone to pray with them. AtMemorial Sloan-Kettering Cancer Center, a chaplain visits allpreoperative patients to join them in prayer, if so desired.

Many chaplains have served in local congregations prior to theirservice in a medical center. Counseling family members of dyingpatients, planning funerals, arranging for cremation, and providingfor the cultural and ethnic customs related to death and dyingare some of the skills that chaplains have acquired from theirformer service that are invaluable in the medical setting.

Staff Ministry

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 concernedabout the spiritual well-being of every member of the town, eventhough not everyone in town is a member of that leader's congregation.In a medical center, ritual and discussions about hope or sufferingapply equally to staff and patients. The chaplain, in caring forthe human spirit, ministers to the health-care team members, everreminding us of God's presence.

References:

1. Webster's Tenth New Collegiate Dictionary, p 1134. Springfield,Massachusetts, Merriam-Webster, 1993.

2. Handzo G: Where are the children: Ministry in pediatrics. TheCaregiver 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 andGiroux, 1978.

5. Stoll RI: The essence of spirituality, in Carson VB (ed): SpiritualDimensions of Nursing Practice, p 4. Philadelphia, WB Saunders,1989.

6. Callan DB: Hope as a clinical issue in oncology social work.J Psychosoc Oncol 7(3):31-46, 1989.

7. Kim MJ, McFarland GK, McLane AM: Pocket Guide to Nursing Diagnoses,2nd ed, p 55. St Louis, CV Mosby, 1987.