Abstract
Within hospital settings, chaplains offer emotional support, spiritual counseling, and healing services to patients and simultaneously address ethical considerations by upholding confidentiality and impartiality. This study examines the impact of chaplains in hospital settings on patients, families, and healthcare teams by analyzing diverse case studies and personal anecdotes. Further, it highlights the significant spiritual and pastoral roles of chaplains, which potentially contribute to ethical decision-making in end-of-life situations. Results reveal that chaplains play a crucial and dynamic role in providing ethical support to patients, families, and healthcare personnel. Additionally, the traits possessed by chaplains can help ensure the continuous provision of care and adherence to best practices. This study further examines the various ethical conflicts of interest that may occur when chaplains participate in and discuss effective conflict management strategies. Finally, it contributes to the ongoing academic discussion on chaplains’ role in and impact on patient-centered care and ethical decision-making within healthcare organizations.
Introduction
Chaplains within hospital settings offer emotional support, spiritual counseling, and healing services to patients and simultaneously address ethical considerations by upholding confidentiality and impartiality. 1 The provision of spiritual care is widely considered a key component of high-quality patient-centered care. 2 Hospital chaplains are individuals who provide spiritual guidance and care to patients and their families. They have wide-ranging spiritual backgrounds and draw on insights from various domains, such as psychology and theology, while providing care. Many healthcare chaplains are certified by the Association of Professional Chaplains, which requires them to have a master's degree in divinity and be ordained, endorsed by a religious organization, and in good standing. 3
For centuries, chaplains have been educated, commissioned, and professionally engaged to provide religious and pastoral care to military survivors of the traumatic effects of war. 4 Further, chaplains play a key role in healing by facilitating spiritual or pastoral care interventions and formally notating the spiritual screening and treatment activities that improve the health and well-being of their patients. 4 The foundational principle of spiritual care lies in the needs of the patient always taking precedence over the needs of others. This means the professional, who seeks to care for the soul—to facilitate joy and meaning—of the patient, respects said patient's paradigm, their needs, and desires. Chaplains tend to the emotions a patient may experience, including sadness, confusion, and/or distress, as well as their psychological state. The chaplain's work also entails being present with the patient. Chaplains perform religious rituals that comfort the patient and explore with the latter's family what gives meaning to the patient (e.g., rosary beads, the Bible, comfort blanket, pictures, music); eventually, these rituals become especially important. 5 Certain research findings indicate that chaplains help screen veterans who may be suffering a moral injury. This is particularly relevant in cases where veterans are exposed to traumatic events or become involved in morally ambiguous situations during their time in the military. Due to their deep understanding of religious and ethical values, chaplains can provide a nonjudgmental and supportive environment for veterans to express their feelings of guilt, shame, and moral conflict. By encouraging open conversations and offering guidance, chaplains can help veterans navigate their moral injuries and find a path toward healing and reconciliation. According to a case study by Waterman et al., 6 many patients with long hospital stay durations lose touch with their metanarratives and sense of identity. Chaplains play a key role in setting care goals for such patients. Moreover, Fitchett 7 opines that case study research is an excellent method using which healthcare chaplains can contribute to the body of knowledge pertaining to the evidence-based practice of pastoral and spiritual care in hospitals and healthcare institutions. This type of research strengthens chaplains’ practice, connects it to theory and theology, and clarifies that chaplains’ actions are effective and impactful. The current case study examines: (1) a board-certified chaplain's role in supporting a patient overcome spiritual distress and embark on a journey toward self-discovery; and (2) the board-certified chaplain's responsibilities. 8 In the context of this study, board-certified chaplains refer to the chaplains certified by the Association of Professional Chaplains.
Role of chaplains in end-of-life care
Daaleman et al. 9 conducted an exploratory study on 12 participants who considered themselves spiritual caregivers and provided spiritual support and guidance to dying patients and their families. The participants were 27–60 years of age, and half of them were women. Many find the provision of spiritual care challenging due to several factors, such as time constraints; the absence of social, religious, and cultural discernment; privacy issues; and limitations in continuity arising from the brevity of caregiver–patient relationships. Smith 10 asserts that the chaplain offering their presence in the event of death is an act no other staff member in the hospital can equal. The chaplains’ interventions and presence often mean the difference between a disruptive, unmanageable family response and healthy, supported bereavement. Nolan 11 reminds us that the chaplain's role includes making assessments of, building rapport with, and actively listening to patients; chaplains demonstrate core attitudes such as empathetic and reflective listening to engage with and understand the patient's experience.
The facilitation of spiritual care becomes a positive experience when patients understand the caregiver's and family's experiences, caregivers spend ample time with patients and family members, and patients communicate effectively and positively with their caregivers and/or families. Daaleman et al. 9 noted that the spiritual caregiver's presence itself indicated their purposeful action of providing care and paying attention to the emotional, social, and spiritual needs of patients and their families. Spiritual care ensures the emotional and psychological well-being of patients in their end-of-life journey and comprises a set of holistic care practices for not only the body but also the mind and spirit. 12 Although spiritualism and religion share overlapping aspects, they comprise independent concepts, both playing important roles in the lives of many people of the USA Religious practice includes beliefs, behaviors, rituals, and ceremonies that may be held or practiced in public and/or private settings; however, spirituality comprises an aspect of humanity that refers to the way individuals seek and express meaning and purpose, and how they experience their connectedness to the moment, to self, to others, to nature, and to the significant and/or sacred. 13 Professional chaplains are employed by medical institutions to address the needs of patients from all backgrounds. Professional chaplains are unique in affirming the divine or supporting transcendence, working with belief, and performing rituals that may or may not be religious. Chaplains address death and dying goals, as well as existential and spiritual distress. Through this work, chaplains act as a bridge between the patient and the medical team to facilitate the needs of the patient and their family, as well as provide emotional and spiritual support to patients and their loved ones in times of need. 12
While providing spiritual care, chaplains are required to respond to sudden, good, and expected deaths. Board-certified chaplains have experience and engage in many interventions, irrespective of whether the patient is receiving palliative care, comfort care, hospice, critical care, or emergency care. The chaplain provides spiritual care to patients, their families, and staff. Chaplains are spiritual care specialists in the healthcare department trained to address the spiritual needs of patients and their families from diverse backgrounds and/or without religious affiliations. 14 They may perform rituals, such as Code Lavender, to provide emotional support to staff members or conduct a memorial service for a patient or staff member who may have died suddenly. Code Lavender is designed to increase acts of kindness after stressful situations. Code Lavender can be used for an individual or an entire team. The Code Lavender Kit includes words of comfort, emotional support, chocolate, lavender essential oils, stress relief coloring books, and employee health referral information to reduce the stress of the concerned individual or team. 15 In other words, chaplains provide emotional and spiritual support, particularly when a patient dies at a particular time, to mark a sudden pivotal point of transition for families, staff, and their institutions. Chaplains create a space for all patients, irrespective of their type of death, sometimes together, to guide and structure otherwise disturbing experiences. 3
In the space created by chaplains with the patients and their families, anthropologists have long described the key roles of rituals in preserving social order and group stability and offering methods to understand the emotionally difficult aspects of human life, such as death and dying. Moreover, all cultures have rituals associated with bereavement that can validate relationships with the deceased and help families bid farewell to the dead. 3 Research suggests that the chaplain's role in end-of-life care rituals and the enhancement of awareness of the potential benefits of such rituals among doctors, nurses, hospital administrators, and other chaplains will be beneficial to everyone, ensure the development of these practices, and eliminate the barriers to practicing these rituals. 3 Important dimensions of spiritual care include the timing and context in which the care is requested, provided, and offered. Studies reveal that when chaplains are called to tend to patients—who expressed a desire to be visited by a chaplain—at the end of life, the former bridge the gap between patients and medical providers. 16
Understanding the barriers that prevent some institutions from practicing these rituals is beneficial, as well. 3 Some rituals practiced by chaplains involve placing comfort quilts or shawls on a dying patient or lighting a candle to represent hope and provide light. Further, some faith affiliations, such as Catholicism, may require a priest to perform the final rites or anoint the sick. Similarly, in diverse cultures, patients may hold different mementos during their final moments. The family members decide what mementos they want present (a rosary, cross, or picture) at the time of death. Symbolic objects, such as clay hands or footprints, hair lobes, and cremation memorabilia urns, can represent cherished memories of a good death. Although a sudden and tragic death may not allow for the performance of these rituals, chaplains can play a crucial role in helping patients and their families navigate the emotional and spiritual aspects of the end-of-life process in cases of anticipated death. 17 By enhancing the awareness and understanding of the importance of these rituals, more compassionate and holistic care can be provided to those facing the end-of-life situation. Chaplains can facilitate conversations about end-of-life wishes and help individuals plan for their preferred rituals. 18 By acknowledging the significance of these practices, healthcare providers can better support patients and their families by honoring their cultural and spiritual beliefs during such difficult situations. The conduction of these rituals can bring comfort and peace to those facing the end of life and enable all involved individuals to have a dignified and meaningful experience. Several recent studies, including those conducted by Jeuland et al., 19 and Handzo et al., 20 have examined how often chaplains engage with patients in various broad categories of activities with patients and families, building relationships at the time of death (69%) and providing ritual support (64%). Performing a rite/ritual is the top activity, along with grief counseling, bereavement, and empathetic listening.3,19
Healing and conflicts of interest in chaplaincy
Chaplains facilitate interventions for healing by profoundly listening to patients to understand their pain and suffering; in general, a chaplain is aware of a patient's emotions and memories associated with a story. Further, chaplains exercise their ability to set aside personal emotions and judgmental thoughts to develop intrapersonal mindfulness. 21 Their insights on and ability to remain mindfully aware of patients’ emotions and thoughts facilitate the latter's return and re-return to understand their internal emotions and thoughts; this helps the patients develop their own intrapersonal mindfulness, which leads to self-healing. 21 This form of care involving a chaplain's mindfulness regarding the emotions and thoughts of another individual, that is, a patient, may be conceptualized as a transpersonal model of mindfulness. In this model, a chaplain attempts to connect with the patient on a deeper level beyond the physical and, thereby, help the patient focus on the present moment, which establishes a deep connection between the self and transcendence. Healing takes place within this model of care, which includes a chaplain who (1) actively listens to the emotional pain and struggles of a patient; (2) is aware of how the patient's story is triggering emotional memories within that person; (3) remains mindfully aware of what they are experiencing but does not “suffer” with them; (4) avoids cognitive calculations or judgments about a patient's behavior or life choices; (5) refocuses to empathize with a patient's pain or struggles, using verbal and nonverbal communication; (6) facilitates patients’ willingness to share painful emotions or stories, which increases their intrapersonal awareness; and (7) resists their own urge to rush the patients out of their pain and suffering, that is, avoids making treatment plans for patients. 21 This model's physiological mechanisms build our theoretical framework for the chaplaincy process.
Ethical questions surrounding end-of-life decision-making arise most often when chaplains are providing spiritual support to patients in their end-of-life stage. In a study by Farr et al., 22 the results of an exploratory, qualitative approach to specific fields of ethical conflict—the provision of end-of-life care among Protestant chaplains from Australia, Germany, and Sweden—showed a 17% response rate of identified ethical conflicts that chaplains had encountered while working. The Association of Professional Chaplains drafted the Guidelines for the Chaplain's Role in Bioethics. 23 Ethical conflicts can arise in a clinical setting and at the organizational level. The obligations of healthcare organizations include the provision of a forum for ethical reflection, a deliberate process for ethics consultation, and personnel trained in ethics consultation. 23
The chaplains encounter a wide range of moral conflicts involving patients, family, or medical staff during personal patient contact, and these conflicts can be structural (i.e., those involving clinical ethics committees) or nonstructural. 22 The areas of conflict are dependent on the chaplains’ involvement in ethical decision-making in the context of end-of-life care. 24 Despite operating in a multidisciplinary team and functioning as pastoral caregivers for both patients and staff, everyone approaches chaplains to address ethical questions. 22 Regarding the concept of healing in end-of-life care, existing publications and research findings highlight the crucial role played by spiritual care in enhancing a patient's ability to heal oneself and maintain mental health. 25 In addition to healing, spiritual care is recognized as a key component of high-quality patient-centered care. Chaplains provide comfort to families at the end of patients’ lives by offering spiritual guidance. End-of-life care is defined as supportive medical care patients receive during the time approaching death. Support provided during end-of-life care involves the addressal of not only physical symptoms, but also psychosocial concerns; thus, spiritual care is the fundamental component of quality palliative care. Accordingly, chaplains’ step in to respond to the emotional and spiritual needs of patients, which is crucial during the provision of end-of-life care. 26 Stilos et al., 26 Idler et al., 27 and Puchalski et al. 13 have made some remarkable strides in defining the role of the chaplain that extends beyond just reading sacred text. This serves various purposes, including the promotion of healing, provision of strength, enhancement of hope, act of serving as a reflective listening tool, and summarization of family priorities and discussions in the form of prayer. 2 The provision of spiritual care by chaplains is linked to improved satisfaction and decreased expenditure in end-of-life situations. Furthermore, there is evidence that patients who receive care in hospitals with integrated spiritual care services record significantly low rates of in-hospital deaths and high rates of hospice enrollment. 28
Case analysis A: Ethical issues involving critically burned children
My personal experience involving a house fire is the topic of my first case study: This is my story of what happened to me following a house fire in 1968, which I consider an unforgettable, profoundly life-altering experience. The fire inflicted burns on more than 90% of my body surface, leaving scars that I would bear for the rest of my life. In the aftermath, I found myself in the hospital grappling with physical and emotional pain and struggling to rebuild my life from the ashes. Although recovery was a long and arduous process, it taught me resilience, gratitude, and the importance of cherishing every precious moment that I was afforded to live.
My parents were away, and my older siblings remained home to care for me. We lived in a small house in the Midwest that had a coal stove sitting in the front of the living room, and I would always see people coming through the front door of the house and leaning over to light their cigarettes. I was 9 years of age and, one particularly cold morning, while getting warm near the coal stove, my nylon gown caught fire; I could not stop the fire from burning my skin. My father came running into the house and shouted, “Stop, drop, and roll!” Then he took a blanket and covered me up to put the fire out.
I was rushed to Cardinal Glennon Hospital in St Louis, Missouri, in critical condition. I was bandaged and had intravenous lines in my arms, which were wrapped in more bandages. I was in a bed that looked like a cage with silver bars. I did not see my parents for a long time. I remember, when I became conscious, nurses and chaplains came to my bedside and fed me and cared for me deeply.
When my parents came to visit me, I was so happy to see them. My father told my mother I was a miracle baby because the doctors had opined that, since I had burns on over 90% of my body, I would have to undergo skin grafting every year. I was a fighter and a believer in God, and I was going to make it. Soon, I began to sit up in a chair and attempt to walk, and I will never forget the chaplain who came to my room and read the Bible to me and the effect of that reading on my healing process.
However, in many cases, the chaplain's role extends beyond reading sacred texts and praying. The chaplain may be required to advocate for a patient and perform a spiritual care assessment that respects diversity with respect to culture, gender, sexual orientation, spiritual and religious affiliations, and so on. The chaplain model of spiritual care includes active listening to the emotional pain and struggles highlighted in the patient's story; becoming aware of how the patient's story is triggering the individual's emotional memories; remaining mindfully aware; and encouraging the patients to share their emotions and stories and, thereby, enhancing their intrapersonal awareness. Further, chaplains provide religious and spiritual resources appropriate to diverse settings and needs and assess whether the patients have had any religious affiliation before extending any service. In this case study, I requested the chaplain to read from the Bible. In general, chaplains are unbiased and form an integral part of the healthcare team. They are valuable to the team because they provide a safe harbor and bridge the gap in difficult conversations, as indicated by the case study. I appreciated the moral, emotional, and psychological support and religious guidance the chaplain provided. Moreover, I knew that when I grew up, I wanted to be a chaplain so that I could care for people in the same manner.
Further, a chaplain assesses the aspects that are meaningful to the patient and the patient's values in life. This is like the concept of “faith” in James Fowler's faith development model; faith is a “search for meaning” that revolves around centers of value, which may or may not be religious or spiritual in nature., 29 p. 3] Fowler's model incorporates a multidimensional faith development approach that enhances the significance of life and values. 29 Accordingly, patients’ age influences their values and priorities throughout their lifecycle. In the case study, the chaplain's approach was appropriate for a 9-year-old who was at the mythic literal stage, believed in justice and fairness as stated in the Bible, and had an anthropomorphic image of God.
I understood my family was under a lot of pressure, and I asked them why. My mom cried and told me that the doctors had told her that I would never make it out of the hospital because my burns were so severe. However, she kept the faith that I would wake up and tell them that I wanted to survive, and that is what I said. I wanted to live and not die. To this day, I am grateful to the hospital chaplain who never stopped visiting me, even when I could not speak. What a difference those visits made in my life! In addition, many discussions on whether I would be able to have a productive life took place around my bed among my parents, the chaplain, doctors, and the rest of my medical team.
Case summary: Patient A incurred 90% burns on her body following a house fire when she was 9 years old; she had to be intubated. She received nutrition through a tube in her nose. Her parents lived in Illinois and, hence, could not visit her every day. The team was concerned about Patient A's ability to survive and whether their care would prove futile.
Perspectives of Patient A's doctors, nurses, and parents: The patient's doctors met the family to discuss care goals and opined that their daughter would need a miracle to survive. After much discussion, the parents notified the medical team that they would do whatever they could in the best interests of their child. However, the parents did not accept the doctors’ proposal regarding receiving end-of-life care; instead, they consented to let their child undergo further medical treatment, including skin grafting. Moreover, an ethics consultation was arranged to facilitate a conversation with the parents about the possibility of Patient A not surviving or to acquiesce to the patient's wishes.
Ethical consultation: Burn specialists discussed Patient A's likelihood of survival with her parents, explaining that it would not be more than 4–6 years. The parents disagreed and said they were expecting a miracle. They maintained that it would be in their daughter's best interests to continue with the treatment plan and discussed it with their child. Accordingly, the treatment continued; soon, Patient A was able to articulate her feelings. She chose life and decided to persevere with the treatment plan. Today, Patient A is healthy and six decades have passed since the occurrence of the horrible house fire that could have taken her life. God let her live in the care of her praying parents, the hospital chaplain, and the nurses and doctors on her medical team.
Case analysis B: Ethical issues involving unrepresented patients at end-of-life care
In everyday clinical practice, difficult situations occur when patients are admitted to hospitals without representation. In such cases, if physicians decline to provide further treatment, irrespective of whether it is dialysis, medical care, or nursing care, the patients have no family or support structure to clarify various aspects of the care to be provided once they are no longer able to care for themselves or make rational, well-considered decisions.
Patient B was admitted to a hospital after she moved back to Washington state from Louisiana. Her family did not want anything to do with her and refused to consent to any treatment or answer the case manager's calls to ascertain if the patient should be admitted to a skilled nursing facility. The family was afraid they would have to pay Patient B's medical expenses. Meanwhile, the patient's prognosis was poor, and the chaplain and palliative care staff continued visiting the patient since she was still lucid; however, her body was going into multiorgan failure, signifying imminent death. Social workers attempted to contact her last known relatives; however, they did not return the care team's phone calls. Being the chaplain in this case, I was asked to assist in the efforts to contact Patient B's family. Soon, I succeeded in talking with the patient's sister, who later gave me the phone number of Patient B's daughter. I assisted Patient B's family members in complex decision-making regarding her medical condition. I managed to make the daughter understand the medical prognosis that death was imminent and clarified that, at that point, transferring the patient to a skilled nursing home would not be necessary because the patient had already commenced agonal breathing and had been placed on comfort care by two physicians to keep her comfortable and ensure that she was not in pain. I was able to provide comfort to the patient and her family in that end-of-life situation. I was asked to pray with the patient's daughter, and I did so over the phone. Moreover, I provided grief counseling and empathy and sympathy to Patient B's daughter for her loss and emotional support to the medical staff who had been working on this case.
Ethical consultation
I reviewed all available notes and interviewed all stakeholders, including Patient B's sister and daughter, to determine whether any of the family members had been aware of the patient's condition, secure consent for her transfer to the nursing home, and inform them that the patient was on comfort care and facing the end of her life. It is always a difficult ethical decision to determine how long a patient should continue receiving therapeutic or life-sustaining treatment once doctors consider it fruitless or when the patient's condition is nonreversible. The ethical assessment of this case is as follows: Once the patient's two physicians decided that further medical intervention was futile, she was placed in comfort care without her sister's consent. By the time the family returned the care team's call, the patient had only hours to live. I talked with the family members and referred them to a funeral home director in Washington State, who assisted them in making appropriate funeral arrangements.
Conclusions
In hospital settings, chaplains offer emotional support, spiritual counseling, and healing services to patients and simultaneously address ethical considerations by upholding confidentiality and impartiality. This study examined the chaplains’ impact on patients, families, and healthcare teams in hospital settings by analyzing two case studies, one of which included personal anecdotes. Further, it addressed aspects of chaplaincy services, such as healing and conflicts of interest, and ethical questions on end-of-life decision-making.
However, the study has some limitations. One limitation is the absence of any scientific corroboration for the well-characterized and well-accepted role and position of chaplains in end-of-life services. Another limitation is that this study considered only two case studies. A new role for chaplains in healthcare ethics will be to support end-of-life decisions and, when appropriate, family-witnessed resuscitation. Finally, medical staff should understand chaplains’ functions clearly and acknowledge the increasing importance of their contributions to healthcare systems.
Footnotes
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
Data availability statement
Example text of a Data statement, as provided by the author.