Chaplain Care in the MICU at the End of Life: A Qualitative Analysis
Ian McCurry, Medical Student/Adjunct Clinical Chaplain, University of Pennsylvania Health System
Background: The intensive care unit (ICU) presents a unique challenge to family caregivers facing difficult choices about goals of care and intensity of treatments for their loved one. Trained chaplains often serve to guide and contextualize these medical choices. One of these roles includes exploring how a patient’s wishes prior to their hospitalization can help to prioritize treatment focused on comfort. Cancer patients who received adequate spiritual care from a chaplain were less likely to die in the ICU(p=.03)1 and patients whose spiritual leads were met had lower end of life expenditures (p=0.03)1 . Another study found patients who were admitted to hospitals with chaplain services had lower rates of hospital death (p<0.05) and higher hospice enrollment (p<0.001)2. Previous research has focused largely on the quantitative analysis of chaplains’ impact on patient outcomes. This study qualitatively described the care provided by trained chaplains in the medical intensive care unit (MICU) at the end of life to better understand the care provided and how this care may impact outcomes.
Methods: A retrospective chart review was performed to identify all patients who met inclusion criteria at a large academic medical center. Inclusion criteria were met if the patient received care in the MICU, had visits with a chaplain documented in the electronic health record, and the stay progressed to an “end-of-life” outcome. These outcomes included: death in the ICU, discharge to a palliative care facility or discharge to hospice. Data was identified between February and April of 2017. Patient charts were reviewed (n=123), and demographics and clinical diagnoses were documented. Directed content analysis was performed on the notes written by chaplains, primary codes were established by the lead author and secondary coding was performed with all members of the research team to ensure accuracy. These codes were then compiled into themes of care rendered.
Results: Analysis yielded four themes for the types of care provided by chaplains at end of life. The first theme was comfort. Chaplains provided comfort to individuals facing complex decisions surrounding end-of-life care. This care was provided to patients when they were able to participate and family members when patients were non-responsive. Prayer was the second theme identified. Sub-themes for prayer included spiritual reflection of concerns and priorities, requests for strength and healing, family unity and expressions of grief, and disappointment. The third theme was decision making support. This type of care included chaplains providing humanistic consultation about the continuation of invasive therapies, transitions to comfort care and creation of meaning in the illness narrative. The final theme was provision of logistical support. This care occurred through referrals to social services, connection with religious officials and coordination of end of life sacred rituals.
Discussion: This analysis demonstrated the variety of spiritual supports provided by chaplains at the end of life in the MICU. Considered in context with the body of literature, these findings begin to clarify the roles chaplains fill to improve end of life outcomes. Further research is warranted to better elucidate the mechanism of these impacts.
Methods: A retrospective chart review was performed to identify all patients who met inclusion criteria at a large academic medical center. Inclusion criteria were met if the patient received care in the MICU, had visits with a chaplain documented in the electronic health record, and the stay progressed to an “end-of-life” outcome. These outcomes included: death in the ICU, discharge to a palliative care facility or discharge to hospice. Data was identified between February and April of 2017. Patient charts were reviewed (n=123), and demographics and clinical diagnoses were documented. Directed content analysis was performed on the notes written by chaplains, primary codes were established by the lead author and secondary coding was performed with all members of the research team to ensure accuracy. These codes were then compiled into themes of care rendered.
Results: Analysis yielded four themes for the types of care provided by chaplains at end of life. The first theme was comfort. Chaplains provided comfort to individuals facing complex decisions surrounding end-of-life care. This care was provided to patients when they were able to participate and family members when patients were non-responsive. Prayer was the second theme identified. Sub-themes for prayer included spiritual reflection of concerns and priorities, requests for strength and healing, family unity and expressions of grief, and disappointment. The third theme was decision making support. This type of care included chaplains providing humanistic consultation about the continuation of invasive therapies, transitions to comfort care and creation of meaning in the illness narrative. The final theme was provision of logistical support. This care occurred through referrals to social services, connection with religious officials and coordination of end of life sacred rituals.
Discussion: This analysis demonstrated the variety of spiritual supports provided by chaplains at the end of life in the MICU. Considered in context with the body of literature, these findings begin to clarify the roles chaplains fill to improve end of life outcomes. Further research is warranted to better elucidate the mechanism of these impacts.