How Community Clergy Provide Spiritual Care: Toward a Conceptual Framework for Clergy End-of-Life Education

Part of the solution: A survey of community organisation perspectives on barriers and facilitating actions to Advance Care Planning in British Columbia, Canada

Background

Despite the established benefits of Advance Care Planning (ACP), engagement remains low in British Columbia. Since 2016, a growing number of community‐based nonprofits have offered ACP education. To date, no study has focused on the perspectives of nonprofits on ACP in British Columbia.

Objective

This study aimed to identify barriers and facilitating actions to ACP as perceived by British Columbian nonprofits.

Design

A mixed‐methods design was used. Data were collected through online surveys and telephone interviews.

Setting and Participants

Staff and volunteers from British Columbian nonprofits that are providing or interested in providing public education on ACP were recruited for this study.

Results

The lack of public awareness of ACP, the emotional difficulty of the conversation, the complicated ACP process, the belief that ACP is synonymous with completing a medical order form, the challenge of introducing ACP in different cultural contexts and the siloed approach to ACP education were rated as the most important barriers to ACP engagement. The most important facilitating actions were developing clear messages, improving ACP literacy, reframing ACP as part of life planning, simplifying ACP documentation and transfer, integrating ACP conversations into clinical practice and better collaboration between the health system and nonprofits.

Discussion

This study identifies numerous opportunities to improve ACP engagement in British Columbia from a community lens. To maximize ACP engagement, community‐led ACP education should be offered in coordination with the health system.

Conclusion

Community‐led ACP education as well as collaboration and consultation with nonprofits are part of the solution to the low ACP engagement in British Columbia.

Public Contribution

Study participants, including staff and volunteers at nonprofits, are members of the public.

Implementing quality improvement efforts in spiritual care: outcomes from the interprofessional spiritual care education curriculum

The Interprofessional Spiritual Care Curriculum (ISPEC) was created to train interdisciplinary health care teams to recognize and address the spiritual needs of seriously or chronically ill patients. The curriculum, in a train-the-trainer format, employs didactic presentations, discussions, lab sessions, skill demonstrations, and video clips. In course applications, participants were required to submit goals to achieve and demonstrate institutional support. For the first ISPEC course, in July 2018, 48 clinician-chaplain teams attended. Following the 2½ day course, participants had access to online training modules for 1-year, ISPEC faculty mentoring support, and regular conference calls on goal implementation progress. Participants reported recognizing the importance of providing spiritual care and a new understanding of how collaborating as interprofessional teams enabled them to integrate this care into their home institution settings. In a mixed-methods evaluation survey completed 12 months after the ISPEC course, participants reported on the percentage of their goals completed, number and types of professionals they had educated in spiritual care, and personal confidence regarding spiritual care leadership skills. This data can serve as a model to guide other organizations striving to improve spiritual care, practiced collaboratively by clinicians and chaplains, as an essential aspect of overall QI efforts in palliative care.

A Roadmap for conducting psychosocial research in epidemiological studies: perspectives of cohort study principal investigators

BACKGROUND

Psychosocial adversity disproportionately affects racial/ethnic and socioeconomic minorities in the USA, and therefore understanding the mechanisms through which psychosocial stress and resilience influence human health can provide meaningful insights into addressing US health disparities. Despite this promise, psychosocial factors are infrequently and unsystematically collected in the US prospective cohort studies.

METHODS

We sought to understand prospective cohort principal investigators' (PIs') attitudes regarding the importance of psychosocial influences on disease aetiology, in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research. One-hour, semi-structured qualitative interviews were conducted with 20 PIs representing 24 US prospective cohort studies funded by the National Institutes of Health (NIH), collectively capturing health data on 1.25 of every 100 American adults. A hypothesis-free, grounded theory approach was used to analyse and interpret interview data.

RESULTS

Most cohort PIs view psychosocial factors as an important research area to further our understanding of disease aetiology and agree that this research will be crucial for future public health innovations. Virtually all PIs emphasised that future psychosocial research will need to elucidate biological and behavioural mechanisms in order to be taken seriously by the epidemiological community more broadly. A lack of pertinent funding mechanisms and a lack of consensus on optimal scales and measures of psychosocial factors were identified as additional barriers to advancing psychosocial research.

CONCLUSIONS

Our interviews emphasised the need for: (1) high-quality, longitudinal studies that investigate biological mechanisms and pathways through which psychosocial factors influence health, (2) effort among epidemiological cohorts to broaden and harmonise the measures they use across cohorts, to facilitate replication of results and (3) the need for targeted funding opportunities from NIH and other grant-making institutions to study these domains.

Building towards common psychosocial measures in U.S. cohort studies: principal investigators' views regarding the role of religiosity and spirituality in human health

BACKGROUND

The goal of this study was to understand prospective cohort study Principal Investigators' (PIs') attitudes regarding the importance of religion and spirituality (R/S) on disease etiology in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research.

METHODS

One-hour, semi-structured qualitative interviews were conducted with 20 PIs, who represent 24 different National Institutes of Health (NIH)-funded prospective cohort studies in the U.S. Collectively, these PIs collect detailed health data on approximately 1.25 of every 100 adult Americans. Sample size was calculated to achieve thematic saturation.

RESULTS

The majority of PIs we interviewed viewed R/S as potentially important factors influencing disease etiology, particularly among minority communities that report higher levels of religiosity. Yet nearly all PIs interviewed felt there was not yet a compelling body of evidence elucidating R/S influences on health, and the potential mechanisms through which R/S may be operating to affect health outcomes. PIs identified 5 key areas that would need to be addressed before they would be persuaded to collect more R/S measures in their cohorts: (1) high-quality, prospective studies that include all appropriate covariates for the outcome under study; (2) studies that posit a plausible biological mechanism of effect; (3) well-validated R/S measures, collected in common across multiple cohorts; (4) the need to address bias against R/S research among investigators; and (5) NIH funding for R/S research.

CONCLUSIONS

Results of this study provide a roadmap for future R/S research investigating the impact of R/S influences on disease etiology within the context of U.S. prospective cohort studies. Identifying significant R/S influences on health could inform novel interventions to improve population health. Given the higher levels of religiosity/spirituality among minority communities, R/S research may also provide new leverage points for reducing health disparities.

Paediatric oncology providers' perspectives on early integration of paediatric palliative care

BACKGROUND

Healthcare providers' perceptions of palliative care in children with cancer influence care management, specifically that of its early integration. Thus, it is crucial to understand the perspectives of the providers on early integration of palliative care so that measures to create informed care decisions are based on reconciling their views.

AIMS

To explore the perceptions of paediatric oncology providers at the Children's Cancer Institute (CCI) in Lebanon regarding the integration of early paediatric palliative care (PPC) in the management of children with cancer.

METHODS

A qualitative descriptive research design with focus groups was used in a leading paediatric oncology setting.

FINDINGS

The thematic analysis yielded four themes: (1) healthcare providers understood palliative care as pain relief and psychological support mainly at the end of life; (2) the timing of integrating PPC is linked to end of life, advanced disease or treatment failure; (3) interdisciplinary collaboration is important for addressing patients' and families' needs effectively; and (4) communication with the child and family is one of the most difficult aspects of integrating PPC.

CONCLUSION

This study demonstrated the perceptions of healthcare providers about early palliative care in paediatric oncology in Lebanon. It also highlighted the importance of interdisciplinary collaboration and effective communication with the child and family for better management of PPC.

Training Community Clergy in Serious Illness: Balancing Faith and Medicine

Community-based clergy are highly engaged in helping seriously ill patients address spiritual concerns at the end of life (EOL). While they desire EOL training, no data exist in guiding how to conceptualize a clergy-training program. The objective of this study was used to identify best practices in an EOL training program for community clergy. As part of the National Clergy Project on End-of-Life Care, the project conducted key informant interviews and focus groups with active clergy in five US states (California, Illinois, Massachusetts, New York, and Texas). A diverse purposive sample of 35 active clergy representing pre-identified racial, educational, theological, and denominational categories hypothesized to be associated with more intensive utilization of medical care at the EOL. We assessed suggested curriculum structure and content for clergy EOL training through interviews and focus groups for the purpose of qualitative analysis. Thematic analysis identified key themes around curriculum structure, curriculum content, and issues of tension. Curriculum structure included ideas for targeting clergy as well as lay congregational leaders and found that clergy were open to combining resources from both religious and health-based institutions. Curriculum content included clergy desires for educational topics such as increasing their medical literacy and reviewing pastoral counseling approaches. Finally, clergy identified challenging barriers to EOL training needing to be openly discussed, including difficulties in collaborating with medical teams, surrounding issues of trust, the role of miracles, and caution of prognostication. Future EOL training is desired and needed for community-based clergy. In partnering together, religious-medical training programs should consider curricula sensitive toward structure, desired content, and perceived clergy tensions.

Spiritual distress and spiritual care in advanced heart failure

As patients face serious and chronic illness, they are confronted with the realities of dying. Spiritual and existential issues are particularly prominent near the end of life and can result in significant distress. It is critical that healthcare professionals know how to address patients' and families' spiritual concerns, diagnose spiritual distress and attend to the deep suffering of patients in a way that can result in a better quality of life for patients and families. Tools such as the FICA spiritual history tool help clinicians invite patients and families to share their spiritual or existential concerns as well as sources of hope and meaning which can help them cope better with their illness. This article presents ways to help clinicians listen to the whole story of the patient and support patients in their care.

The Views of Clergy Regarding Ethical Controversies in Care at the End of Life

CONTEXT

Although religion often informs ethical judgments, little is known about the views of American clergy regarding controversial end-of-life ethical issues including allowing to die and physician aid in dying or physician-assisted suicide (PAD/PAS).

OBJECTIVE

To describe the views of U.S. clergy concerning allowing to die and PAD/PAS.

METHODS

A survey was mailed to 1665 nationally representative clergy between 8/2014 to 3/2015 (60% response rate). Outcome variables included beliefs about whether the terminally ill should ever be "allowed to die" and moral/legal opinions concerning PAD/PAS.

RESULTS

Most U.S. clergy are Christian (98%). Clergy agreed that there are circumstances in which the terminally ill should be "allowed to die" (80%). A minority agreed that PAD/PAS was morally (28%) or legally (22%) acceptable. Mainline/Liberal Christian clergy were more likely to approve of the morality (56%) and legality (47%) of PAD/PAS, in contrast to all other clergy groups (6%-17%). Greater end-of-life medical knowledge was associated with moral disapproval of PAD/PAS (adjusted odds ratio [AOR], 1.51; 95% CI, 1.04-2.19, P = 0.03). Those reporting distrust in health care were less likely to oppose legalization of PAD/PAS (AOR 0.93; 95% CI, 0.87-0.99, P < 0.02). Religious beliefs associated with disapproval of PAD/PAS included "life's value is not tied to the patient's quality of life" (AOR 2.12; 95% CI, 0.1.49-3.03, P < 0.001) and "only God numbers our days" (AOR 2.60; 95% CI, 1.77-3.82, P < 0.001).

CONCLUSION

Most U.S. clergy approve of "allowing to die" but reject the morality or legalization of PAD/PAS. Respectful discussion in public discourse should consider rather than ignore underlying religious reasons informing end-of-life controversies.

Upstreaming and Normalizing Advance Care Planning Conversations-A Public Health Approach

As a society, we simply don’t talk about this universal experience called dying and death; in fact, we ignore it until we have to face it. Thus, it is often in a crisis experience when we have to make decisions while we are laden with uncertainty and intense emotions. Sixty percent of people say making sure their family is not burdened by tough decisions is extremely important, yet 56% of them have not held a conversation about its context. Instead of waiting to make end-of-life decisions, let us begin to think about what matters most while we are living, what we value most, and how we translate these values into conversations about what is important. As a public health concern, if we can upstream the advance care planning discussion into usual health promotion activities, perhaps, as a society, we can begin to normalize and reshape how we make decisions about the last chapters of our lives.

Seeking and Accepting: U.S. Clergy Theological and Moral Perspectives Informing Decision Making at the End of Life

BACKGROUND

People with serious illness frequently rely on religion/spirituality to cope with their diagnosis, with potentially positive and negative consequences. Clergy are uniquely positioned to help patients consider medical decisions at or near the end of life within a religious/spiritual framework.

OBJECTIVE

We aimed to examine clergy knowledge of end-of-life (EOL) care and beliefs about the role of faith in EOL decision making for patients with serious illness.

DESIGN

Key informant interviews, focus groups, and survey.

SETTING/SUBJECTS

A purposive sample of 35 active clergy in five U.S. states as part of the National Clergy End-of-Life Project.

MEASUREMENT

We assessed participant knowledge of and desire for further education about EOL care. We transcribed interviews and focus groups for the purpose of qualitative analysis.

RESULTS

Clergy had poor knowledge of EOL care; 75% desired more EOL training. Qualitative analysis revealed a theological framework for decision making in serious illness that balances seeking life and accepting death. Clergy viewed comfort-focused treatments as consistent with their faith traditions' views of a good death. They employed a moral framework to determine the appropriateness of EOL decisions, which weighs the impact of multiple factors and upholds the importance of God-given free will. They viewed EOL care choices to be the primary prerogative of patients and families. Clergy described ambivalence about and a passive approach to counseling congregants about decision making despite having defined beliefs regarding EOL care.

CONCLUSIONS

Poor knowledge of EOL care may lead clergy to passively enable congregants with serious illness to pursue potentially nonbeneficial treatments that are associated with increased suffering.