 Hi everybody, you see the registration name there which reminded me of the man running from South Bend, the presidency, but welcome this afternoon, the McLean Center and Dr. Meltzer Center for Health and Social Sciences and the Buxbaum Institute, welcome you to this lecture in the series on the present and future of the doctor-patient relationship. Jeannie Werpza is a board certified professional healthcare chaplain. She's a clinical ethicist and an educator with more than 25 years of experience providing spiritual care in the areas of pediatrics, end of life care and oncology. Currently, Jeannie has a dual role at Northwest Memorial Hospital where she serves as the research chaplain for the Department of Spiritual Care and Education and as the program manager and clinical ethicist for the Department of Medical Ethics. Additionally, she's a core faculty member for the Bioethics Clinical Scholars program at Northwestern and teaches a course on the interface between religion and medicine in healthcare practice which is a required course for all students in the Feinberg School of Medicine. Previously, Chaplain Werpza had held faculty positions at Carlton College in Minnesota and at Benedictine University in the areas of religion, ethics and women's study. I'm also proud to say that Jeannie completed the McLean Fellowship here in 2016-17 at the McLean Center. Currently, Jeannie and Asim Bidella who's sitting in the back there raise your hand, Asim, yeah, co-teach the religion, bioethics and medicine course here at the McLean Center in the spring quarter. Jeannie's research interests include moral distress, end of life care, advanced care planning, shared decision making which you'll hear about today and the role of the chaplain on the healthcare team. Jeannie has published her research in the Journal of Healthcare Chaplaincy, Journal of Nursing Administration. Currently, Jeannie is co-editing a book entitled Chaplains as Partners in Medical Decision Making, Case Studies in Healthcare Chaplaincy. The book is due to be released in October of this year. Today, Jeannie's talk is entitled, as you see behind me, Interprofessional Models for Shared Decision Making, The Role of the Healthcare Chaplain. Please join me in giving a warm welcome to Jeannie Werpza. Get our technology going. Welcome, everyone. Thanks for having me here. Thank you, Dr. Siegler and the McLean Center for this invitation to contribute to this 38th annual lecture series. If I counted correctly, I'm only one of four non-physicians in the lineup offering my research and reflections on this important topic. And while I have no conflict of interest to disclose, my location as a member of a professional discipline that stands outside of the doctor-patient relationship inevitably counts as an interest and an interpretive lens worth disclosing. So this is not the first time Dr. Siegler has taken a risk on this chaplain ethicist and reached across professional borders. As you heard in 2016, Dr. Siegler accepted my application to be one of a handful of non-physician fellows in this program. I'm forever indebted to Mark, the McLean family, all the faculty and the fellows for broadening and deepening my clinical ethics knowledge, and actually for making me a more effective chaplain as well. So today, I feel like this is just reverberating really loud. Does it sound okay? You're good? Okay. Who's that talking? So today, I'm gonna present on our research the role of the professional healthcare chaplain in medical decision-making, but in the context of related research to try to make a case for implementing an interprofessional shared decision-making model as one way of addressing at least some of the challenges currently present in or facing the doctor-patient relationship. So let me speak some about interprofessional shared decision-making. This model should be and this definition should be very familiar to most of you, perhaps not the chaplains in the group, but it's worth noting as we look at Kathy Charles's definition, seminal definition, that she says this is a collaborative process between patients, their surrogates, and clinicians, not just physicians, right? But what we know is that, again, historically, this has been researched and kind of played out as a dyad, as a physician and patient or physician and patient family relationship. The goals of shared decision-making are well known, increasing knowledge among patient surrogates and care providers, certainly decreasing decisional conflict, facilitating preference or value aligned, some call it goal concordant decisions, and I think also promoting some realistic expectations and clinically appropriate decisions. I'd add two other goals. One is lifting the emotional burden on surrogates and families, and then secondly, supporting the moral agency of clinicians. And let me tell you why I add that in here. While the model has the medical expertise of physicians plus the values of patients and families coming together in the shared decision-making process, the truth is, of course, that physicians bring themselves. They bring their values and their ethical obligations as well as that clinical or medical knowledge into the process. And so, again, the shared decision-making process as it evolves over time, I think more and more has to take into account that moral agency of our clinicians. So the traditional model, here it is, right? Patient values and preferences plus the physician medical expertise. Along the way over the many years this has been expanded, different people have provided different models. The share approach is one. Notably, this approach wants to integrate an additional step into the process so that when physicians actually make their clinical recommendations, they already choose among options and present a strong recommendation that aligns with patient values. Don't just present all of the options equally, right? With equal weight. Even with or in spite of much attention to this process of shared decision-making, the research literature continues to identify many, many barriers to its success. And I'm sure many of you will recognize these. Depending upon who you survey, primary responsibility for the failure of this model lies with the patient and family. They're unrealistic, they're in denial, and this is especially around serious illness and life-threatening illness. Or their health literacy is in the way. System level challenges, especially time constraints is the big one that physicians list all the time. And I hear from my own primary physician, this is getting worse and worse. And you guys I'm sure have explored this in your series, in this series. And the physician communication style and the different kind of disciplinary lens that a physician brings to speaking with patients and families. I think it's no surprise I sit in on family meetings all the time. Physicians think they're talking in English and lay language. But I'm telling you, I don't understand half the time what they're saying. So again, medical lingo, again just trying to, the way they even frame, way physicians frame patients is as cases. That's how you have to, in order to manage all of the extraneous information and be able to treat a patient. But that is not effective often in taking into account, again, patients' values, stories, and certainly not religious and spiritual beliefs. And then the literature has more recently documented the increasingly fragmented and specialized healthcare system. Somebody might be able to tell me how many touches do they say you have if you come into the hospital, like with different clinicians, different services. I can't remember, but it's a lot, right? Even I don't have lots of health problems, but I have an orthopedic surgeon I'm seeing having surgery next week. I have a cardiologist. I have various folks and my primary care physician tries to organize all of those, but can barely keep up. And then of course, the failure in this traditional model to really consider what I would say is an increasingly interprofessional nature of healthcare service delivery. And I would argue that although this is prevalent most in critical care and inpatient, more and more we're seeing this in primary care places, clinics, specialized care, such as diabetes, and certainly for patient populations deemed to be high utilizers, right, where we're again trying to come around them with a whole team to ensure that they're admitted less frequently, their care is more value effective or value, I don't know what the word is. So just one quick study to point out, again, continued evidence, recent evidence, the failure in this traditional model to consider patient values. Multi-center study, 249 ICU patients, and the coders analyze the audio scripts, audio recorded conversations of clinicians with either patients or patients and their families, especially around, again, in the ICU and around goals of care conversations. The results I think are rather startling. Among the 244 that had actual goals of care conversations, 20, almost 26% contained absolutely no information exchange, the first in the traditional model, right, or deliberation about patients' values and preferences. Physical, cognitive, social functioning or spirituality were each discussed in 35.7 or less of the conferences. Surrogates provided a substituted judgment in only 13.5% of the cases, right. What's the role of substituted judgment? You're supposed to be looking at the patient's values, preferences, beliefs, and then making decision based upon those. And then clinicians only made recommendations based on patients' values and preferences 8.2% of the time. In reference to religion and spirituality, this study included a specific section for that, although the surrogate decision makers in this study endorsed religion or spirituality as important, 77.6% of the time. In these goals of care conversations, it only was brought up 16% of the time. And when it was brought up, healthcare professionals, and these are mostly physicians, there were rarely nurses or chaplains in these conversations. They deflected it and talked about medical things or just, again, in different ways, failed to pay attention to it. And they certainly did not explore further what the impact of these beliefs was on decisions in the treatment plan at hand. So why is this happening, right? Certainly, there's a robust literature, and I'm not going to cite it here, that physicians are not comfortable nor trained to attend to religious and spiritual frameworks beliefs. And that even those who have more of a religious perspective themselves, count themselves as more religious, many of those don't have the training to be able to filter how their own framework actually impacts the treatment recommendations they make. And we see this especially at the beginning of life and at the end of life around more controversial decisions, as you can imagine. And again, there's a lot of research literature on this I don't have time to refer to today. So the point is, we have an opportunity for interprofessional shared decision making. We need it, right? Somehow the things that are supposed to be the core piece of shared decision making is not happening. Is Dr. Peake here? No. So our colleague, our faculty here at the McLean Center has been doing a lot of work looking at how different patient populations actually make decisions, phenomenological research, description of them. And I point this article out because it challenges kind of the reigning model. For this patient population at least, the first step in decision making is not an information exchange or an information delivery from the physician saying, here's equipoise, here are your options. They actually prefer and would find it that it would build trust and facilitate a more honest process if the physician at the outset heard their story, their experience, located them as a person. The second study here from JAMA is again one among many that has begun to advocate for trained non-physician facilitators for shared decision making. Decision coaches or navigators, you'll hear it referred to in the literature, especially to support complex medical decision making in settings like the ICU. So what is interprofessional shared decision making? Nothing more than, well, nothing more. Again, making it happen is challenging as we'll see in a minute, but it really is two or more healthcare professionals who come together to collaborate with patient and families in identifying best options, clarifying patient preferences, and enabling patients to take more control over the treatment plan. And this can happen with all of these professionals together at the same time or obviously with visits in a serial, sequential sort of way, but then some mechanism for actual conversations among the team to guide decision making. Key concepts for interprofessional collaboration in the literature. Some of these you'll recognize and just think to see what I want to just highlight three of them. The first is and have us think about whether, again, these foundational elements are present in our respective healthcare settings to actually facilitate interprofessional shared decision making and collaboration. Symmetry of power. Show of hands, how many of you think that there's a symmetry of power in the healthcare setting among professional disciplines? Yeah, I don't think so either. And not just that chaplains are the lowest on the totem pole, which we often feel like, it's probably environmental services are even lower. But again, the attending, the residents, how training is structured and whose voice can come in and trump at any moment. The second one I would highlight is a mutual understanding of roles really needed to facilitate interprofessional collaboration. So for example, do I as a chaplain really get the weight of responsibility of being a physician or of a surgeon, right? How can I begin to grasp that? Because that's important, right? Where are they coming from? Do we all know or any of us know what it's like to walk in the shoes of a bedside nurse who's caring for a patient 10 to 12 hours a day rather than one hour visit, which is what a chaplain might have or a 15 minute interaction that maybe a physician might have? So this concept includes both what they call a value map, which is do we actually value, respect, appreciate the contributions of this discipline and a cognitive map? Do we get it? Do we understand that those would be needed to facilitate interprofessional? And then finally there's the one I think we have lots of opportunity to advance supportive environment and communication or common work tools. So this would include things like the culture, staffing ratios, how leadership views, decision making and various teams, reimbursement and other regulatory influences, the electronic medical record. We're trying at our institution to design a shared template for goals of care conversations that every person who touches the patient and has something to say about it could make an entry rather than it just being the physician who has that, right? Those just don't exist. But again, ways to facilitate that through the electronic medical record and other environmental communication tools. Our Canadian colleagues in the north are the leaders in the area of developing models for interprofessional shared decision making. Here is, I'll just lift this up and kind of point out what they're trying to propose. One is that the initiator of the shared decision making process could be any member of the team. It doesn't have to be the physician or even the specialist who is, again, trying to help guide the treatment plan for the next decision. Any person could be trained nurse, chaplain, social worker, physician as a decision coach, kind of a neutral party to come up alongside patients and families to help this process, set up family meetings, be sure that everyone's coming together to communicate correctly, hearing patients' values and preferences, and then obviously evaluating the decision that's made and helping to implement it. And notice all the lines back and forth and everything, right? It's a very fluid process. But it requires a shared vision of interprofessional shared decision making because everybody has to agree that this is how we're going to do it. One of those key elements of the interprofessional shared decision making model. They add this pyramid and I put it up here because what we've mostly been talking about to this point are the upper layers, right? The process, the team, relationships. But again, the environment influences. How are our schedules even organized so that we can talk to one another, right? Do we have consistency over time with our colleagues to build the trust that's required for this kind of model? And again, what kind of underlying structures and systems actually support this? Just give you one quick example and that is in the state of Illinois, I'll ask a question. Who is legally entrusted with assessing for decisional capacity? Which member of the health care team? Only the physician, right? And yet, we have psychiatry, we've got social workers, we've got ethicists, nurses who are at the bedside who have lots of information that could weigh in on that. So we're really going to promote an interprofessional collaboration. We might even have to look at some of those regulatory things to see whether something needs to shift. Recent trials trying to make this interprofessional shared decision making better. Doug White was here, right? It was part of the series. Did he talk about the partner trial? Okay. So this was an intervention where they trained nurse educators to be the decision coaches. And they used an emotional cognitive model of decision making so that the training aligned with that. So nurses would be paying attention to the emotional barriers to decision making, values, again, setting up family meetings, et cetera. And the outcomes that they were looking for was, again, did this make for more patient-centered care? Was there the quality of communication was better? What they'd really hoped as the primary outcome was that it would actually help this surrogate anxiety and fear and kind of the depression related to decision making. And it made absolutely no difference on that. Chaplain as patient navigator, recent trial at Johns Hopkins also didn't work very well. And the chaplain was trained in a similar way, but they used residents who you'll see when I refer to our study are the most inexperienced chaplains around, do not understand the medical system. And those were the critiques of this model, that she'd set up family meetings when it wasn't convenient, didn't understand where our perspective was. So, and then finally, we have just finished a study at Northwestern with ethics as the kind of integrating ethics into the shared decision making process for all ECMO patients. We're about ready to publish this. And the outcomes are really stunning in terms of primarily the impact on bringing people together in the process of shared decision making, all the different teams, consistent messaging, and integrating and aligning the decision about whether to continue or stop ECMO with patient values. So, again, opportunities. So let me now get to the heart of what I want to talk about here today. Actually, before I do that, I want to say I'm going to focus on the health care chaplain and integrating the health care chaplain into the interprofessional shared decision making model. There are any social workers here, nurses, APNs, PTOT, right? So this is a challenge for other members of the health care team as well. I was recently part of a focus group for a new study that Jackie Cruiser is doing down at our institution on looking at the whole, like over a five-year study, looking at the whole ICU environment and decision making. And this focus group was specifically on what is the process like when patients need to be emergently intubated, what happens, right? Whose present, whose input is there, and these are critically ill patients, sometimes coming from the oncology floors around the hospital. And I was struck by the fact that the rehab folks there, PTOT, just had incredible insight into who this patient was and what their goals would be that probably should have influenced that decision about whether to intubate or not. And yet, they were lamenting that there was absolutely no system set up for their input to be included. So our research drew upon background literatures I've talked about already and shared decision making, the status of religion and spirituality and medical decision making, and what we know about what chaplains do. We've already talked, as I said, about shared decision making. Let's just briefly look at what we know about the status of religion and spirituality and medical decision making. We could spend about 10 hours on this. There's a volume this thick. Since my colleague, Dr. Padela, is here, I will just lift up that there are colleagues around the nation, like him, specifically looking at the kinds of beliefs and processes that this specific religious tradition and people who adhere to that tradition, how those impact their decision making. He presented at the McLean conference on surrogate decision making, surrogacy, gestational surrogacy, and the use of artificial reproductive technology by Muslim women or by Muslim families. And that's not unique, of course. Within every one of these traditions, Catholic health directives abound that help guide specific decisions to make certain things permissible. And even provide a framework or an approach to how decisions are made, certainly not the principled bioethics approach that we employ here in the hospital setting. Many of you may be aware of the coping with cancer study that drew a direct correlation between levels of religiosity of patients and families and their decisions about the level of aggressive life sustaining treatment they would opt for. That study continued and went on to look at who provides spiritual care and the difference it makes, identifying that if people's oncology were providing the spiritual care and advising about this versus the medical team or chaplains, the prevalence or the trend toward opting for more aggressive care was higher with their oncology. Several articles on ethics consults and religiously based conflicts. Again, miracles, God's sovereignty directly influences how people make decisions, what those decisions are. Our colleague, former fellow Alexia Torque is doing a study, just completed a study on surrogate decision maker religious beliefs, identifying miracles as certainly what leads to opting for more aggressive care and puts an impasse in some of the decision making. And then there's been several studies recently in pediatrics, one in particular by Alexander Superdach and her colleagues looking at, what I titled it, the, let me see if I can find this here. Exploring the vagueness of religion and spirituality in complex pediatric decision making as published in BMC Palliative Care in 2018. It was a longitudinal qualitative descriptive design that looked at, spoke with parents from 13 cases who reported religion and spirituality directly influenced their decision making and that most health care providers were not aware of this, right. How it influenced it was very tricky, it was kind of, that's the vagueness, but that it influenced was established and that the health care providers were unaware. Again is the point I'm trying to make. So the other body of literature that I think is relevant to looking at the role of health care chaplains is, what do we know about what we do and what the expectations from others are about our role. And mostly the literature talks about chaplains role and providing what would you think, emotional and spiritual support, religious support. There's some research coming out now about chaplains work in supporting staff, especially around grief and bereavement and the stress of the job, tea for the soul, does University of Chicago have a tea cart? Tea for the soul, yeah. So again, chaplains bringing, trying to attend to the needs of the staff. But what there is very little on is chaplains role in medical decision making. It's really under-recognized. The only thing we knew up until recently was chaplains self-identify that this is a piece of their job, right, aligning the care plan with patient values. Administrators expect chaplains to be involved in addressing ethical dilemmas and patients and families expect to quote one study that they will help me with moral dilemmas related to care. Some other studies, again, kind of looking at the impact of this, the inner logistics of how chaplains are involved and integration into the team. But not much on what does this really look like? How do chaplains support medical decision making? And so that's what we decided to take a closer look at in our study. So the study is a mixed method study three phases. The first phase was an online survey to board certified healthcare chaplains using all of the major religious, major associations that support those chaplains throughout the U.S. And those that survey had both close-ended questions as well as open-ended free text response sections. Interviews, purpose of interviews with select chaplains. And I'll talk about that later. And then the case studies research that Dr. Siegler mentioned. So in the survey we asked, as I said, both some close-ended questions and more open-ended questions. And we wanted to get a sense of frequency. So obviously this is a self-selecting group. Only people participated in the study or chaplains who identified that they were involved with adult patients who had serious or life-limiting illness. And we picked that definition just because there's so many confounding factors if it were broader. But we also didn't want to narrow it to just palliative care. We know chaplains support this in palliative care and hospice. Right? So we wanted to make it broader to include ICUs, oncology, LVET, patients who have cardiac, advanced cardiac disease. So in a typical week, what percentage of their clinical time? And again, frequently, often, or about half the time, 45% said that they spend this amount of time. It's a lot more than I thought. I'm someone who worked in oncology as a chaplain for years. I always had these discussions. I was the go-to person when there was conflicts, when patients were saying, I'm done, I'm done. And it seemed like the team was just offering one more chemotherapy. But I was interested to see that this is more embedded within our practice throughout the nation than originally thought. We also identified via focus groups and the literature activities or ways that chaplains might support decision-making. And the highest frequency, the area where chaplains identify that they spent the most time in the activity was supporting patients and families in the emotional processing of medical decision-making, hence the support, right? Makes sense. The second way, and I lift this up because I think it's really important, communicating patient values and beliefs related to medical decision-making to the healthcare team so that they would be aware of those. Next, helping patients and families themselves clarify factors that impact treatment options, followed by being involved in advanced care planning and advanced directives. Specific education with patients and families about the details of medical procedures, again CPR, DNR, what's brain death, all of those chaplains did to some degree. And then finally, mediating conflict between patient and family or among family members as it impacts medical decision-making. We looked to see if there was any association among all of these various activities. And of course, they were all strongly correlated with each other. You can just imagine if you're providing emotional support for medical decision-making, you have an opening then to do some of these other activities. Many chaplains throughout the country are tasked with the thankless job, I'll call it sometimes, of being the responders for doing advanced directives for patients when they ask for them, sometimes feel like glorified secretaries running around getting the paperwork done. But interestingly enough, that activity itself was highly correlated with all of these other things that make a difference. Specifically in the highest correlation was with the specific education about CPR, DNR, brain death, and other specific medical interventions. So it's a way in, so to speak, and uses more of the chaplain than one might think. We wanted to find out whether the level of integration or inclusion that chaplains perceived they had in the medical team impacted their involvement in medical decision-making. And what's interesting, although we lumped all of these together under one variable called inclusion, chaplains, in spite of feeling welcome, feeling like they could communicate, did not feel like they were often included. They also thought they were very prepared but didn't have enough time. So we also looked, we asked about many locations where chaplains work, so religiously affiliated hospitals, non-religiously affiliated hospitals, academic medical centers, hospice, nursing homes, community hospitals, and religiously affiliated versus non-religiously affiliated had a little bit of significance. Those who worked in religiously affiliated hospitals more often endorsed frequently or very frequently helping with clarifying factors impacting treatment options. So I think of that as what do the Catholic health directings really say. And again, we can talk later about why that might be that that was higher in religious hospitals than non-religiously affiliated. And then there was a trend for those of us who work in secular institutions to actually function in more of this liaison role, this communicating with the medical team about the religious beliefs of the patients and families. Again, why that is, we can talk later. I have no idea. We ran many regressions looking at correlations and what really in the end became or maintained statistically significance was chaplains with more experience were more likely to be included in team discussions. So again, five years or less versus five or more. When we put 21 years or more, it was like 400% more likely to be involved in these discussions. And again, think about why that might be. You know the lingo, you know the people, you've been around, you can communicate, you can again to support this interprofessional team. And this finding was surprising, which we asked about are you a dedicated or designated chaplain for a certain area? So palliative care owns you, oncology owns you, right? The ICU pays your salary, the advanced cardiac technology area owns you. And palliative care versus other non-dedicated folks, there's no difference at all whatsoever and how integrated they were into the team and how they participate in decision making. But oncology was 55% less likely to be included in these discussions. Again, we don't really know why. So we had a qualitative section to this study as well. As I said, open-ended text questions, we asked two questions. As a chaplain, what do you feel you uniquely contribute to the medical decision making process for this patient population? And then what if anything prevents you from being involved in this area? So if you want to know more about our coding process and the reliability and rigor of that, I certainly can share that. But I really want to share the findings with you. The domains that came to the surface were the following to the answer of what do we uniquely contribute. This one's not surprising, right? We bring religious, ethical, cultural understanding of these frameworks and teachings. I was able to provide the official teaching of the church and they were able to peacefully and good conscience allow nature to take its course. The second one was, again, I think in some ways not surprising given that chaplains are narrative people and proclaim a narrative competence, that chaplains listen to patient stories and are able to identify the values embedded in those stories and that they take into account the whole person, not just the disease. But again, they connect these threads with the decisions at hand. Attention to emotions and the emotional burden of decision making not surprising, again, when our families prepared and ready emotionally even to enter into this process. And I'm reminded here of the work of Doug White, right? I don't know if you've heard him speak about how our brain makes decisions if we're emotionally stressed, right? Then the part of our brain that actually can make good decisions turns off, right? The hot part. I mean, if you're hot, like all worked up agitated, you can imagine, I mean, the burden again of making decisions. So what you want to do is get to the cold, right? You want to move from hot to cold. And chaplains are the people who often sit with families and siphon off, process all of those emotions, grief, fear, loss, resentment, guilt, all of those things that impact family and patients ability to move forward in the decision making process and provide support for this emotional burden of, I have to decide from my loved one. And sometimes in this process, obviously, they integrate a spiritual religious framework if that's what the family has, but not always. And then again, mediating family conflicts, although this, the frequency of times in which these comments appeared in the text notes was also low as it was in the quantitative data. But when chaplains intervene in this way to help refocus the family on this patient and help with some of these dynamics, it certainly presents as a benefit to the decision making process. We're not kind of looking at, what's interesting in the study of the qualitative data is that we move beyond just activities that chaplains do to support decision making to more who the person of the chaplain is that facilitates this process. And there is, again, something about this spiritual authority, this location that chaplains at least said empowered them or provided them with this unique position or opportunity to support decision making. I'm able to speak to how God will honor their decision making, right, for people who are religious that matters or integrating prayer into it. Chaplains also identified that they are the members of the team because they have more time, even though they say not enough, where they can be present, deeply listen. You have this quick meeting with the teams and there's the chaplain able to sit and process. They're not afraid to ask the hard questions to, again, slow down this frenetic pace, I call it the speeding train metaphor in the medical setting, especially in a acute care setting. And then finally, what we found interesting under this domain were the metaphors that chaplains use to refer to this role that they claim for themselves as liaisons or communicators in the process. Being a bridge, a mediator, being a neutral party, non-medical, impartial, a translator, interpreter, both ways. So for the family, what's the docs really meaning when they say that? And for the physicians or for the medical clinicians, right, who speak this different language, what are families saying when they say God will provide this decision, I can't make one. What does that mean? And then coaching both sides again and advocating for the wishes of patients and families. We also looked at barriers to participation, as I said, in this section. And I'll just note quickly that barriers, chaplains did not perceive that there were major barriers from families to their being involved in this process or within themselves. It was much more related to systems and to other members of the team and to communication and timing of referrals. So again, chaplains reported with a very high frequency that they just weren't included. They have all this to offer, but they weren't aware meetings were taking place, decisions were made before they were invited to the conversation, etc. They also identified system and administration issues. And this has to do with, again, one or two chaplains covering a whole hospital of 400 people. So you might know a family very well and be involved in these decisions, but then you have to run and see somebody else or you're also carrying the on-call pager. So you can't stay and participate. And cost cutting again within our systems has really impacted chaplains ability to contribute meaningfully to this area. And then finally, the, not finally, but the one I want to talk about is the understanding that non-chaplains have of what chaplains do. Chaplain, the healthcare team just does not recognize chaplain skill in this area. And physicians and social workers were highly likely to, or at least chaplains, perceive that those were the disciplines that didn't get it. Nurses, they always said, seemed to get it better. And the narrowing of the chaplain role, again, to prayer, ritual, and religion, my favorite quote is, the belief that all I do is pray once the person is dead. Right? Says it all. So, phase two of our study, we did chaplain interviews, purpose of sampling. We talked to chaplains who said, oh, I'm highly integrated in this area and I do this a lot, versus those who identified that they were hardly involved at all, not integrated into the team, were not assisting as much with decision making. And what, again, in this linguistic analysis and content analysis, what came out was that those chaplains who are integrated had a sense of authority or initiative. They also were bilingual. Again, they understood the medical world, the worldview. They could speak that language and they valued other roles. Those who were not involved in this are not integrated, actually kind of self-excluded them, were self-excluding. They didn't think they had medical knowledge, that they were supporting medical decision making. They worked in a silo. So, again, for those of you who are administrators for chaplaincy departments or work as a chaplain, these are important things to consider. And phase three of our studies is case study book, be out actually not in October, but April. And we decided to do case studies as research because one of the, it's kind of the lowest level of qualitative research, right? You can't generalize from it. You certainly can compare case studies and do some analysis to come up with some findings and some insights. But case studies, at least as we received them from chaplains around the country, should represent best practice, right? And so we wanted to see, what is it really when this works that chaplains are doing? Case studies also have the significant benefit of examining processes as they kind of unfold over time, kind of step by step, so you can see what's going on. Whereas, again, surveys and even interviews don't always allow for that. And one of the things we wanted to see, again, was do chaplains or how do they, what happens, how are they positioned that they can interrupt what we call the clinical momentum that often happens in especially the acute care setting? Where just one decision drives the next decision, just drives the next decision, and suddenly we're not thinking about who this patient is or what all the real options are. So you can't really probably don't have time and aren't going to be able to read all of these cases, but a diverse set of cases that we placed under three categories, chaplains paying attention to the patient as person and the patient's story as a way of facilitating shared decision-making, again addressing family dynamics and paying attention to the emotions around decision-making and then serving as a broker for religious and cultural differences. Each of the cases, just FYI, is followed by two responses, one from a chaplain and one from a non-chaplain. So we have a family medicine doc, palliative care doc, psychologist, ethicist, responding to these cases as well, looking specifically as what is it about chaplain's training, what's going on here that makes this possible. And the chaplains themselves identified their interventions that they thought helped, as well as the theoretical framework that undergirds their work. So we step back now and we looked at the cases together and started to do some analysis of the cases, really looking for two relevant findings. And one is what's the chaplain's role on the medical team and the other is how do chaplains support value-concordant decision-making. So specifically just quickly and looking at those, again, the length of service of chaplain just confirmed what we'd already kind of seen in some of the other parts of our research. So the triangulation supports this. They had knowledge and appreciation of other roles and they also had this legitimacy that people granted them from spending extended time with this family and patient, really getting to know them. They were present at care conferences and family meetings. When the doctors visited, clinicians would reach out directly and ask them for help because they had a relationship insights into how do I communicate with this family. And they would even have one-on-one meetings with team members as well. And again, chaplains, many chaplains go into the profession. They're great listeners. They're kind of more passive personalities. That's not me. You probably seem slightly more charismatic, sometimes bossy. But the chaplains who were most successful in this claimed their authority. They took the initiative. They spoke up. They asked questions. They believed they had something to contribute. They would lead family meetings. They would educate about traditions and why this was important. And what was absent were the barriers we mentioned before. And none of these chaplains felt like they were trespassing on the boundaries or the professional role of other members of the team. So when we look at how in this literature in these case studies, chaplains promote value-concordant decision making. Again, the first section of the book looks specifically at the goals, beliefs, who the person is and what really matters. And chaplains assist through this, again, creative and sensitive attention to the patient's story. But I want to point out that this process, especially as you see it in the case studies, is neither static nor unidimensional. None of these patients in these case studies entered into the decision-making process with a clearly delineated health care preference documented, as some might wish in an advanced directive. Chaplain Hogg's patient, Glenn, was arguably the clearest about his goal. And that was to complete his mission, which was a religious mission. And the chaplain ensured that the timing of moving toward comfort care and palliative care coincided with this goal. In terms of the refocusing the family on the patient and addressing emotions, there was one case where Mark, the patient's voice, he was tricked, he was in an ICU, his voice kept being really overridden by his incredibly distressed daughter. Ring a bell, see this all the time, right? And he kept trying to write and tell the clinicians that he wanted to be done, and nobody listened. And the chaplain, again, not just met with, didn't just meet with Mark, but met with the daughter and helped her process those emotions, her fear of being alone, and then brought the two of them together to communicate with one another. Again, identifying approaches to decision making. We see this particularly in the section on culture and religious differences, validating frameworks for decision making that are very different from the Western medical model. What are the sources of authority and truth and accountability, a duty approach versus a principal approach. And I just want to point out the one that stands out for me in this section is the chaplain who did the work of a cultural broker. So it's this elderly African American woman, Alma, whose family later described her as dying from a broken heart. Her grandson had been murdered, and they attributed her illness to this event, to this emotional experiential event. And the medical team kept coming and talking to the family in this language that was completely literal about what was going on with her heart inside. And they just could not talk to one another and move forward. But because the chaplain, again, was trained to pay attention to a whole different level of discourse, was able to bring those two folks together and help the medical team understand that continuing to talk in that way was just going to keep you stuck. Whereas if you can acknowledge this, the reason and explanation that they give for her illness and for her dying, that we'll be able to move forward. And that's in fact what happened. Again, one of the things we saw this was value concordance was not static, that one of the roles that chaplains did was hold intention competing values to quote one of them until the family or the patient could find a version they could live with. And then to reiterate, again, it's the person of the chaplain who facilitates this, their ability to have this therapeutic presence, to see the patient as a person. So we have a lot of debate for the chaplains there between outcome oriented approaches to care versus just this therapeutic presence you're going to show up with no agenda. This really kind of throws into question that dichotomy, the two come together. So conclusion from our work and from the literature. Chaplains have significant contributions to make to the interprofessional shared decision making process by paying attention to values, patient story, and religion spirituality, which is again supported by all the research not happening by other members of the team. By addressing family conflict and emotions that impact decision making, and then mitigating this impact of medical culture's fast pace fragmented doctor-patient relationship and obfuscating use of medical jargon. So we came up with a conceptual model for interprofessional shared decision making, which I've listed here. And again, the ways in which chaplains along at each stage contribute. I think these slides are actually the presentation will be available if you want to see this model and it should be in our article that we published as well. But notice there's even a supportive stage here, right? The work doesn't end when somebody makes a decision like in the regular shared decision making model. Something else needs to happen, right? So in order to integrate the chaplain into this process, I have a few recommendations I'll leave you with. We need to address three major barriers within professional chaplaincy, staffing ratios, time coverage assignments. We need chaplains to be trained to be competent, not just in being a great listener and a pastoral presence and knowledge of their religious traditions of various religious traditions, but actually in medical lingual processes, medical culture, research, outcome-oriented practice, all those things, the setting in which we work. And then we need to figure out how to empower chaplains to have greater authority and claim a place at the table instead of whining, which I hear often, oh, nobody invites me to the meetings, right? How do you again be more proactive in that? We need to teach other disciplines about the impact of religion and spirituality on decision making and about the competence and skills and lens of chaplains. And then finally, promote interprofessional collaboration on the levels that we saw were lifted up by Ligera and colleagues from Canada as essential to this. So I'm going to end by talking a little bit, kind of stepping out on a limb here to talk a little bit about the impact that this all might have on the doctor-patient relationship, since that is the theme for this series this year, right? The two questions of the series is, will the DPR survive and can doctors practice caring personal medicine, right? Yes, I think the DPR can survive, but I just want to say not alone. I think what it's going to look like in the future will be very different. So the traditional DPR might become CPR, clinician-patient relationships, or team-patient relationships, right? I think again, re-envisioning how those relationships work. Will doctors be able to practice personal and caring medicine, not precision medicine, not genetic-based medicine? But I think part of how doctors can do that better is using their resources. So members of the team whose job it is to pay attention to this human side of the equation, right? And having relationships with them. Some would say that we're letting physicians off the hook by kind of letting chaplains do that piece or other members of the team do that piece and doctors don't have to do that, or maybe even robbing them of the opportunity to develop narrative skills, comfort with religion and spirituality. But frankly, over the past decade as we've been trying to work on narrative medicine and teaching doctors about integrating religion and spirituality into medical schools, not much has changed in the failure of the traditional shared decision-making model to work. Oh, let me just, let me go back here for a second. I just want to say that either in my role as an ethicist, which I work mostly as now, 80% of my time is doing ethics, or as a chaplain, I actually love being able to partner with and actually sometimes guide physicians. So we had a recent ethics case where I was the consultant and the sister was the surrogate decision-maker coming up alongside her brother who was on ECMO. His EKG was almost flat. But she kept saying, I can't make a decision. That it's God's will, right? All the powers in God's hands. We've heard this before, right? So I met with the team and then with her and the team to teams. So you have the neurologist, the critical care folks, the ECMO specialists, the who else is there, thoracic surgery, they're all there. And I said to the team before we went in, this family member will never be able to make a decision. You have to say, man has failed, and now it's in God's hands. And say, because human machines have failed to do their job, we're going to stop them. And it worked. And not only did it work, but at the end of this session, she said to the members of the team there, please, they were all in these, it's mostly young people, right? Young doctors. They were all in tears. And it was just this really kind of powerful moment. And she absolved them all. She said, none of you have anything to be sad about or feel bad about. You've done what you can do. And then I turned to the team and I said, and what I need you to hear from her is that when we turn these machines off, God could still pull this one out, right? It didn't happen. But again, so they really appreciated where she was coming from. The question about doctors practicing personal and caring medicine to me goes more to this heart of the challenges of burnout right now and doctors being almost restricted to becoming technicians, right? Rather than full human beings who bring themselves into the picture who have meaningful relationships with patients, focusing on technology and numbers and algorithms and the time constraints that again, kind of narrows that role. I would argue that having an easy access via some of your team members to the human side of the equation actually might also help address this depersonalization or dehumanization that is happening in medicine for physicians themselves and help sustain physicians in this role as they move into the future. And this is a study that's ongoing right now. It's documentation, a documentation study and we, the authors solicited feedback from other members of the health care team on what they wanted to see in documentation. And I just find it really telling that this physician says, I'll read chaplaincy documentation and if I'm in a particularly jaded place about a family, they don't get it crazy, whatever it is, there's something in the chaplain's notes that refocuses me on compassion. It allows me to see it differently, bring a different perspective and you see it differently and can act compassionately within yourself. I think that's what we want to re-infuse medicine with and especially physicians' role. So I don't want to position chaplains as the saviors of the doctor-patient relationship, right? I think I'd be claiming a little bit too much. But then the divine works in mysterious ways, so who knows, right? That's all I have for you. Thank you. So by the word chaplain, do you refer to any specific religions or just any religion in general? So professional health care chaplains are trained to provide spiritual and religious care and fulfill these other functions to patients of all backgrounds, including non-religious patients, right? Spiritual, non-religious is a growing population, right? So there are chaplains. So we have, for example, on our staff, a rabbi who serves in the Neuro Intensive Care Unit. That's his main area. He will assess to see whether somebody in the Neuro Intensive Care Unit might need a Catholic priest, right? That's what we're also trained to do. But he would see non-Jewish patients in the Neuro Intensive Care as well. And there's a bunch of work going on right now about whether matters if there's concordance between the denomination and religious kind of identity of the chaplain and the patients. The one case study with the Muslim family, that was a Presbyterian chaplain who was able to broker that, the difference between what the family was claiming around not giving pain medication, suffering being meaningful in their tradition and therefore, and the physicians again saying, no, we have to treat the pain of this patient. And she was, again, not of that background. But I'm curious, do chaplains here in the United States or in your hospital dress up as in like, you know, do they dress up like the diocesans in churches with those, you know, specially made costumes? I don't know what those are professionally called. But do they dress up in the chaplain costumes or do they have some sort of special gown or even a white coat? So in many settings chaplains wear lab coats just like other members of the health care team, right? It identifies them as part of the health care team. We document in the medical record. We are considered part of the community of confidentiality. We're part of that. We're a profession. We're not just clergy. There are some hospitals who still use community clergy who come in and provide care mostly to members of their own community and their faith community. So it's a very developed role here. Thank you very much for your eloquent and very illuminating talk, especially regarding your thematic analysis. I wonder if you could also speak to patient refusal of chaplain services. So I'm a psycho oncologist and we've done significant amount of research looking at patients refusal of any kind of spiritual support, maybe actually relying more on their ministers if in fact they are religious. And what recommendations could you provide to that clinician if a patient indeed does not want to see chaplaincy? Because of course they are the first people. Does everybody hear the question? So the question is what about patient refusals of chaplain services? So there are, I just step back and say the role of the chaplain as I think evidenced by your question, right? And we see this all the time with patients and families is very misunderstood, right? There are myths around us. Social workers take away your kids and put your elderly in nursing homes, right? Those are their burden that they carry. Chaplains also have the myths around us. And one is that if you have your own clergy, you don't need us. But I think the study that Balboni and folks did really is telling, we used to, I used to prioritize seeing patients who did not have their own clergy until I saw that study. And then I'm like, crap, excuse me. These are the patients I really need to be seeing because their clergy are off there. They have no clue often of what's really happening in this setting. So that's the first myth. And then I'll talk about how to address it. The second myth is we only come when you're dying. The third is that we are going to convert you to Christianity. And then the fourth one is that we're, if you're not religious, we don't have anything to offer to you. So we really need to do education among other team members to help, again, introduce us in ways, break down some of those barriers. I mean, I suggest things like, well, you know, she's such a great member of the team, anybody can talk to her. She just, you know, again, using language that doesn't even use the title sometimes. Patients and families have the right to refuse whatever they want, right? Mostly they can't ask always for a different attending physician or, but they don't have to accept our care. I always say, if I can get into the room, they're not going to refuse me for the most part. Again, once you're there and you start talking to folks, most of us are able to forge a pretty quick relationship. So setting up systems so that the doors aren't closed by other team members. So for example, don't just say, would you like to see a chaplain? People don't know what that is. It's like asking someone if they have an advance directive. No clue, right? So setting it up differently. So these are, here's your team. It includes these people who can provide these services. And having, again, chaplains have in this hospital inpatient setting, it's a little easier because we, you know, can just go into a room. But in clinic setting, oncology, part of the barrier might be, in fact, right, that you kind of need to get permission to go in and see someone. Does that answer your question? I also say, so for social workers, if I had to do a Venn diagram, there's like psychiatrists, psychologists, social workers, chaplains, maybe ethicists, palliative care, there's like this middle area where our skill set and approach overlaps, right? And so, I often say like to social workers, when you get to that point and you're providing or psychotherapists counseling and questions of meaning or religion start to come up, just say something like, you know, these are just such important questions, but I'm not the best person on our team to address them. I do know somebody who is, however, who this is her area of specialty and invite them in that way, especially around spiritual distress because patients who are in spiritual distress will often not want to see a clergy person or a chaplain because they think our role is going to be to defend the faith. You can't tell your priest you're doubting, right? That just is wrong. So some of those strategies. So two questions. First, I was just interested in, you mentioned at one point, I think in regards to one of the studies, like nurses working a little more with chaplains than potentially physicians. And I was just curious if there were other roles on the healthcare team, whether it's like social workers or psychologists that you've also seen effective working relationships with chaplains. And then the second was, I was just curious of other examples of chaplains supporting medical staff that had been effective that you'd encountered in your work. So in answer to the first question, occupational therapists, I think have a lens that's quite similar to chaplains. Many psychologists who do logotherapy and focus on questions of meaning or dignity therapy. Also there's a much better kind of overlap with the perspective and the framework that chaplains bring. Sometimes historically there's been tension between those that kind of the turf war is a territory who's involved, which I don't quite understand. I count social workers as my strongest colleagues, both as an ethicist and a chaplain, because I think we bring both similar frameworks, but also unique strengths that can complement care. Nurses are interesting because I think nurses want to be able to give holistic care and they often are more spiritual or religious themselves. They are at the bedside for longer periods of time. They hear things, but they're often not equipped. They're more task focused, right? Then chaplains are, so they're not often equipped. They don't know the language to respond to things. And so often how I've partnered with nurses is to also give them language to know how to respond when a patient in the middle of the night says, I'm done. I'm dying, but my family won't let me go. What do you say, right? In the middle of the night to that as a nurse? Why hasn't God taken me yet? I'm ready. Just quick administrative question here. If you're looking down the long pipeline, what are the chances that your incredible experience as an important member of the medical team will actually be reimbursed at some point? Zero? No. That's what I was afraid you were going to say. So healthcare chaplaincy located in New York has been doing all this lobbying for a while to get some reimbursement for chaplains. I don't think it's ever going to happen. Kind of like ethic, ethicists to be honest. I don't know. I think there's pros and cons to be in reimbursed. And I think the downside or the fear or the risk is then we're accountable to productivity requirements and RUVs and all these things that other healthcare professionals are potentially. I don't think it's going to happen. Maybe for advanced care planning, right? CMS now reimburses for advanced care planning for physicians. The original list for that included other members of the healthcare team, but it's never been implemented. So perhaps that would be the area to start. You spoke about improving the staffing ratios for chaplains. Could you just say a word on what the typical ratio is between chaplains and patients? Does it compare, for example, to interns and residents and attendings on the inpatient service? It strikes me as it probably doesn't. No, it doesn't. So there are, there have been some studies done talking about what would be ideal ratios. And I think it's like supposed to be one chaplain for 40 or 50 acute critically ill patients, right? If the level of acuity is lower. And again, who decides that, right? And what does acute mean? Is it spiritual acuity? Is it physical acuity? Medical acuity? How would we think about that? It's supposed to be close to one to a hundred. That's nowhere near what, like we have a social worker on every unit in our hospital now, right? So that's about what, one to 30, one to 36. Chaplains normally cover several areas. And because of that, because of the bad ratios or the really kind of pathetic staffing, we wind up using students and residents. And, you know, resident training is great. And some are better than others. But honestly, it's very different than a medical resident who has that already that level of training. It's kind of more like an intern. Would you entrust interns with your most complex patients without a lot of direct supervision? No, but we do that all the time as a way to staff our, our units with spiritual care. So our overnight people are all interns, the lowest level, the least equipped. And I think if our study says anything, it's that if you're going to be integrated and really contribute in the ways that we think at least should make it, would make a big difference in the center of patient-centered care, which is shared decision making, right? What's critical to it. That you need to figure out a way to staff us better so we can do, do what we think we can contribute. Yeah. Please join me. Thank you.