1. Spirituality, Religion, and Health Interest Group, October 4, 2006 Should the Roles of Physician and Chaplain be Fused? A Personal Reflection Robert M. Nelson, M.D., Ph.D. Assoc Prof of Anesthesiology, Critical Care and Pediatrics The Children’s Hospital of Philadelphia University of Pennsylvania School of Medicine

2. Caitlin and Todres JAMA 2002 2 Fusing the Roles “We agree… that the roles of physician and pastoral counselor should be separate in the early stages of the relationship because patients and their families may not be prepared initially to trust or understand the role of such a fused figure. However, as the patient-physician relationship develops, …it may be of value to both the patient and the caregivers for the physician to explore the patient's existential and spiritual concerns.… Our experience in a clinical pastoral education program modified for clinicians provided us with the skills, language, and experience….”

3. 3 Context: The Experience of Illness Religiosity and Spirituality –Set of beliefs and practices; finding meaning in relationship to transcendent (other than oneself) Vulnerability - “the body betrays the spirit” –Depersonalization and technology Spiritual Crisis of Meaning (“distress”) –Ethics: “How should I respond?” (interpretation) The Goal of Medicine? –Technical Good, Personal Good and Ultimate Good

4. Todres et al CCM 2005 Spiritual Care Training Program Modified CPE Program (5 months) –Weekly class work, 400 hours of supervision Didactic Sessions (e.g., faith traditions) Professional Training –Pastoral call reports (“verbatims”) Personal Reflection –Weekly process notes, experience of faith Goals –“allow them to accompany their patients along these pathways with similar spiritual integrity” –Incorporate “spiritual care… into clinical practice”

5. An Important Distinction Diagnostic Interventions (assessment) –Knowledge of the impact of religion and spirituality on medical care –Sensitive to spiritual distress Therapeutic Interventions –Appropriate referral (non-controversial) –Able to intervene personally? Too intrusive? Coercive? Crossing a “fine line”? Abuse of power?

6. Sulmasy JAMA 2006 Spiritual Assessment: Explore questions of meaning, value and relationship

7. Sulmasy JAMA 2006 Assessing Spiritual/Religious Needs

8. Sulmasy JAMA 2006 Whose Job Is It, Anyway? “Physicians should not ignore the spiritual needs of their… patients, but neither should they over- estimate their skills in addressing these needs.” Physicians “should be able to…take a spiritual history, elicit a patient's spiritual and religious beliefs and concerns, try to understand them, relate the patient's beliefs to decisions that need to be made regarding care, try to reach some preliminary conclusions about whether the patient's religious coping is positive or negative, and refer to pastoral care or the patient's own clergy as seems appropriate.”

9. Attending to Spiritual Needs? Language: presence, accompany, partner –Spiritual care is fundamentally relational. The Compassionate Clinician –How can we nurture the ability to “suffer with” our patients? –Presence requires being attentive to (mindful of) our own spiritual needs/distress. –Making sense of the suffering we witness. –Risk of burnout (”jading”) and loss of moral responsiveness (“confronting the dark side”)

10. Some Reflections on Suffering The limits of technology –Technical good fails to achieve personal good –Technology obscures our vision of the good Common Assumption –Technology is “value neutral” (apply/remove) Recapturing vision of “good of the patient” –Set aside our “attachment” to technology –Confront our own values, beliefs, meaning

11. Physician and Chaplain? Technical Good –Does it make a difference whether a physician who is technically competent also cares about the patient’s spiritual well-being? Good of the Patient –Can a physician (or chaplain) who is not self-aware of their own questions of meaning assess a patient’s spiritual or religious needs? Ultimate Good –Can a “generic” clinician meet the spiritual or religious needs of patients from various religious communities?