Status and limitations

Have a look at this article by two medical ethicists clearly declaring that hospital chaplains should not have automatic access to every patient or ever to patient notes. I acknowledged the part of my psyche that objected: “Bah! This is just another way of keeping religion in its lowly place.” But it isn’t. We know that there are individual chaplains who feel the need to impose their religion – they’re likely to perceive it as offering a very important service to vulnerable people. Indeed, we probably know of Pagan friends who found a Christian chaplain at the end of their bed offering their services, and how inappropriate that was. That’s an abuse of power.

I remember being fairly pushy myself when it came to having Paganism recognized in hospitals and I’m grateful for the other Pagan individuals and groups who’ve also made it their responsibility. Wherever there are institutions who have a chaplaincy service and who’re likely to have Pagans amongst them then Paganism should be officially represented on the chaplaincy panel, that’s pretty straightforward. That whole debate is about status, primarily the status of Paganism, but also about the status of chaplaincy.

If this is the case then we need to think hard about what chaplaincy is about and what our role is. Chaplaincy seems to me to be about perceiving a person as unique and as part of their own ‘ecosystem’ – relationships, history, hopes and dreams, fears, desires, abilities, the whole kit and caboodle - rather than simply as their diagnosis, and serving individuals and groups so that they can find meaning and purpose for themselves. I really like this quote

Helping, fixing, and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service the work of the soul.

Chaplains are not part of the medical team. Although spirituality has a role in wellbeing and health this doesn’t mean that chaplains have the same role as doctors, nurses and radiotherapists. This is no threat to our status: we wouldn’t expect doctors, nurses and radiotherapists to be experts in spiritual care. I know that if I read a patients notes I will form a certain set of beliefs and expectations around those written words, it’s why notes are so confidential and the writing of them always under review. ‘Witty’ shorthand such as ‘FLK’ (Funny Looking Kid) is now recognized as reducing the humanity of the individual and being unethical and unacceptable. So it is that the chaplain – and every other person who isn’t directly concerned with the symptoms and cure of the patient – has no need to know anything about them other than what they see in front of them.

I’d say that the strict adherence to limiting who has access to patient notes is a measure of the quality of care patients receive. I know a very ethical, professional complimentary therapist working in a local mental health hospital who is given access to patient notes. She doesn’t take it but it’s not too surprising that the hospital is well known for the number of patients who abscond.

Certainly, doctors have a godlike status. Nurses are, of course, angels. I’m not sure where in the heavenly hierarchy radiographers might fall but as far as pay and conditions are concerned it’s somewhere above ward cleaners and canteen workers. That’s just the way it is, that’s a matter of society deciding that junior doctors and professional football players should be paid more than experienced nurses and firefighters. Chaplains, well we’re strange altogether, with Deity as our employer and the general public feeling both that they respect us and feel weird around us. For me, that’s just a symptom of our liminality and whilst that’s not always the most comfortable place to be it’s also entirely appropriate. This is not to say that chaplains should be content to creep around being thankful to be allowed into a hospital: that’s to get status and role confused.

Paganism should be given the same status as any other religion. Pagan chaplains should be treated with the same respect that other chaplains are offered, and all chaplains should be treated with the same respect as any other member of the healthcare team. But our role is not to tell people what’s best for them. Neither is it to do things at or to a patient. Although chaplains of all faiths have a responsibility to our gods and the culture of our religions we have a greater responsibility to offer something that other people who work in healthcare cannot: we offer love. We are with patients in a unique manner; we bring the empathy of the professional psychotherapist, the communication skills of mediators, and leadership functions of senior staff. We add a thorough, boundaried and flexible knowledge and understanding of our religion and, on top of it all, the wisdom that whatever a persons religion, spirituality or atheism they are equally worthy of our attention.

High status is lovely but the role of the chaplain is not to compete, it is to Be With people who have requested spiritual input. As long as that is facilitated in a quality manner and chaplains of all faiths are treated respectfully what more do we need, and why?

Note Keeping

Because of audits and keeping track of who is where with whom chaplains have to keep some notes. It’s worth remembering the intent of these notes, what they’re not intended for and how they may be used.

The written word has such enormous authority and at the same time can be so ambiguous as to be used and misused by people with very varying purposes.
There’s an art to note keeping, you need to record the fact that you and a particular patient met at a certain date and time and that’s it. There’s a temptation to go into detail and things can begin to unravel quickly, sometimes years after the event.

“X seemed excited today” can be read as “X was sexually aroused.” “X was agitated:” was that generally or specifically around you? Did that agitation have any connection to his behaviour later in the evening, and who did you inform about his agitation? If X goes on to offend or if a clinician or a barrister wants to make a point about X or about your relationship with X or with your way of practicing you can see how your own words can be used to prove something that you did not intend. If we use words that we don’t really know the full meaning of – like ‘manic’ or ‘depressed’ or ‘labile’ – then those words can come back to bite us, used both to prove something about a patient or to demonstrate our own lack of knowledge. You can imagine in a court being asked: “Can you describe what you understand the meaning of ‘manic’ to be? And can you tell the court what your professional qualifications are?”

I get a bit weary when overly anxious people start making noises about the desperate threat of litigation and how we must protect ourselves by messing everyone else about. Personally, as long as the patient, the ward staff and I are happy for something to happen, like taking a patient off the ward, then off we go. It would be so much more safe if we remained in a glass box with audio and videotaping but there are implications for the quality of our relationship. But. The written word supersedes memory in importance. Notes are, not unreasonably, assumed to be an accurate, contemporaneous record of events.

I write notes as if the patient is going to read them which helps me stay focused on what I’m communicating and how it may be read. It’s easy to forget that whilst we are afforded the same respect as other professionals in a clinical setting we are not serving the hospital but the patient. It’s tempting to try and match specialist language or to demonstrate to a putative professional reader that we function at the same level as they do; a paradoxical temptation since the less confident and settled we feel in the role of chaplain the more likely we may be to fall into this style of writing. In the very unlikely event that you’re asked to write anything more than the fact you met then you really should ask for written guidelines about how to write notes for that hospital, then discuss them in depth with the lead chaplain and write those notes under their guidance at the same time as keeping your highest ideal very clear in your own mind.

Perhaps the most fragile and important aspect of the relationship between chaplain and patient is trust and every attempt must be made not to break it. Patient confidentiality should be the basis from which anything is written. If you have a doubt about their safety or the safety of people around them, your notes are not the place to record this in the first instance, you should seek immediate and appropriate support, almost certainly from the lead chaplain. Before you discuss a patient with anyone else it’s an article of faith that you discuss it first with the patient themselves. Saying “I’d like to talk to my boss about this,” creates a space for meaningful communication, you’re demonstrating that you know your limitations, that you’re confident in discussing your limitations with the patient – because it’s not a matter of weakness to know when things are going beyond your remit, quite the opposite. And it models the normality and safety of knowing that we can’t deal with everything on our own, that discussing a difficult matter with someone trustworthy is worthwhile.

When you’ve talked with the lead chaplain and come to a decision, put that in the notes. A patient told me he was going to try to abscond. We talked about why and what this might achieve and so on and still, he declared he was going to try to escape. I didn’t actually believe that this was the case at all, but an expression of despair, a desire for boundaries and attention which would be achieved when I told the staff, which I was obliged to do. But first I told the patient that this was the case (as he knew it was) and that I would have to talk to my boss. I made a verbal contract with the patient that they would not abscond and not make a final decision about absconding until I’d spoken with my boss. Then I asked for an urgent meeting with my boss which primarily served to help me feel better about talking to the ward staff, 15 minutes later. My notes remained very short, about 2 sentences more than normal and limited to absolute fact. Life in hospitals is dramatic and gossipy enough: there’s no need to add to it or get caught up in it.

Confidentiality is entirely breached if you are summonsed by a court, which may happen if your patient does something unlawful or accuses the hospital of something unlawful. In my private psychotherapy practice I simply don’t keep client notes any more which simplifies matters no end and I shred my personal reflections, which are about me rather than clients, around a year after we finish meeting. But hospitals keep notes for a minimum of 5 years and particularly in psychiatric care they can be kept a lot longer and have the potential to be incendiary.

Some of the patients I see are likely to reoffend when they leave hospital and it’s possible that some years into the future I may be asked to give evidence in court. What are my responsibilities? Who am I serving? My answer is that I am serving the cause of truth, that I am not a judge or a jury and that justice will be served by them, not me. The relationships that are co-created with the people I see are delicate, part of the healing process is served by offering and being able to sustain deep trust. If they are then accused of something grave I have to just answer questions as faithfully as I can and put a great deal of trust in the Goddess. I fervently hope it never happens.

Note keeping is a vague subject at the best of times and there are differences between US and UK practice. In the US the Health Insurance and Portability Act appears to cover this minefield. (In an avalanche of impenitrable information, Wikipedia seems to have the best coverage. But my keyboard doesn't have a hash key and the link requires it.)

http://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act#Privacy_Rule

Here is something less fuzzy for US chaplains that is also of interest to UK chaplains.

Frankly, I have little idea what the Data Protection Act has to say on the matter but believe in keeping it really simple: I keep no chaplaincy notes on my own computer. I used to send my notes by email, but now write them at home, print them out, hand them over to the Chaplaincy Office at my next visit, and keep one copy in a file in a locked filing cabinet. If I know my next visit is going to be longer than a week I’ll write the notes at the end of the day in the hospital itself and take them to the office.

Wherever you practice your chaplaincy notes should be kept separate from the clinical notes. Although spirituality has a proven positive contribution to wellbeing and health, chaplains are not part of the clinical team for excellent reasons. We are not primarily concerned about cure or illness or insurance, it’s not our role to be involved in diagnosis or medication or anything other than the wellbeing of that persons essential being that exists beyond their body or their mind. It’s impossible to capture that relationship on paper and so lets not attempt to. Keep it simple: 'Met with X. Spirituality discussed'