Healthcare Chaplains as Institutional ‘Wildcard’: A Mixed-Methods Study of the Evolving Role of Spiritual Care in Complex Cases
Patrick Tugwell, MDiv, STM, University of California, Santa Barbara, Santa Barbara, CA, Assisted Home Health & Hospice, Santa Barbara, CA
The field of chaplaincy has undergone a transformation. From Christian-centric origins to a diversified education beyond the Abrahamic traditions (Sullivan, 2014; Cadge & Rambo, 2022), chaplains incorporate outcomes-oriented, evidence-based research into practice now more than ever (Cadge et al., 2020). This shift challenges the field’s previous ‘prayer-only’ narrative. Thanks to the modernization of Clinical Pastoral Education (CPE), recent chaplain training prepares practitioners to address not only religious but spiritual, emotional, existential, and cultural needs (Alghanim et al., 2021). With this expanded preparation, chaplains are equipped to engage in a wide range of care situations that go beyond sacred rituals.
Accompanying the recent changes is a general demystification of the nonreligious in the U.S. today. Since the 1980s, the percentage of Americans who identify as “religiously unaffiliated”—atheists, agnostics, ‘nothing in particular’—has increased from single digit percentages to almost 30 percent (Blankholm, 2021). And while most would agree the need for psychosocial and spiritual support is on the rise today, chaplains are poised to meet the potential new demands of a widening spectrum of patient beliefs, practices, and concerns.
Simultaneously, the American healthcare system suffered a substantial financial loss during the years of the COVID-19 pandemic. The actual numbers are frankly astonishing: over USD 200 billion in collective revenue loss, previously recorded at a rate of over USD 50 billion monthly (Kaye et al., 2021; AHA, 2023). Now progressively driven by concerns of profitability, efficiency, and loss of employees, U.S. hospitals are in search of new mechanisms to mitigate risk, enhance discharge efficiency and thus profitability, and manage staff moral (Kaye et al., 2021). So, to whom do hospitals turn
Consider the following examples. Ms. “L” and Mr. “V” were both palliative care patients receiving pain management after terminal diagnoses. Following extended hospitalizations, both were trached and intubated contrary to their prior documented wishes, without the knowledge of their families, who had traveled from Peru and required translation for all discussions. Two years later, with the patients kept alive by life support, hospital management sought a new approach to communicate the terminal nature of their conditions. After multiple unsuccessful family meetings for goals-of-care discussions, which only deepened the families’ distrust of the care team, the hospital’s spiritual care department was instructed to assign a Spanish-speaking chaplain to both cases. The chaplain’s task was to build rapport with each family and facilitate communication about DNR status between the medical team and each patient’s designated power of attorney. Despite these efforts, the chaplain was unable to gain the families’ agreement, leading the care team to obtain two-physician consent to change each patient’s status to DNR, against the families’ wishes. Less than one month later, both patients expired.
In this mixed-methods exploration, I argue that American hospitals will continue to turn to chaplains in complex, long-term cases to assist in discharge facilitation, particularly in cases involving non-English-speaking families. This trend reflects both the expanding role of chaplains and the pressure on departments to demonstrate their tangible value in a time of financial strain for healthcare systems. I call this strategic deployment of chaplains “capitalized hope.”
Language barriers add a layer of complexity to challenging cases. As historian Harriet A. Washington suggests in her seminal book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, one need only study the history of medicine to understand why those in historically marginalized communities maintain a distrust of medical care (Washington, 2008). A 2023 study found that Unilateral Do Not Resuscitate (UDNR) orders were 21% more likely to occur in non-English speaking patients, citing higher risk of hospitalization and communication errors as primary reasons for the discrepancy (Piscitello et al., 2023).
Every day, healthcare practitioners offer hope, even in seemingly hopeless situations. Research suggests, however, that non-English-speaking families receive fewer visits and worse quality care than their English-speaking counterparts (Pandey et al., 2021); and families tend not to see chaplains as directly involved in healthcare decisions (Harris, 2018). Recognizing this, I argue that hospital management views (especially multi-lingual/cultural) chaplains as a unique ‘wildcard’, capable of building relationships outside the immediate circle of primary decision-makers in a patient’s care. Within this context, these chaplains face the challenge of balancing their therapeutic role amid competing institutional interests and pressures. The cases of UDNR in Ms. L and Mr. V reveal an example of the subtle mechanisms by which chaplains might, perhaps unknowingly, become aligned with institutional power, underscoring the potential for unintended complicity.
Accompanying the recent changes is a general demystification of the nonreligious in the U.S. today. Since the 1980s, the percentage of Americans who identify as “religiously unaffiliated”—atheists, agnostics, ‘nothing in particular’—has increased from single digit percentages to almost 30 percent (Blankholm, 2021). And while most would agree the need for psychosocial and spiritual support is on the rise today, chaplains are poised to meet the potential new demands of a widening spectrum of patient beliefs, practices, and concerns.
Simultaneously, the American healthcare system suffered a substantial financial loss during the years of the COVID-19 pandemic. The actual numbers are frankly astonishing: over USD 200 billion in collective revenue loss, previously recorded at a rate of over USD 50 billion monthly (Kaye et al., 2021; AHA, 2023). Now progressively driven by concerns of profitability, efficiency, and loss of employees, U.S. hospitals are in search of new mechanisms to mitigate risk, enhance discharge efficiency and thus profitability, and manage staff moral (Kaye et al., 2021). So, to whom do hospitals turn
Consider the following examples. Ms. “L” and Mr. “V” were both palliative care patients receiving pain management after terminal diagnoses. Following extended hospitalizations, both were trached and intubated contrary to their prior documented wishes, without the knowledge of their families, who had traveled from Peru and required translation for all discussions. Two years later, with the patients kept alive by life support, hospital management sought a new approach to communicate the terminal nature of their conditions. After multiple unsuccessful family meetings for goals-of-care discussions, which only deepened the families’ distrust of the care team, the hospital’s spiritual care department was instructed to assign a Spanish-speaking chaplain to both cases. The chaplain’s task was to build rapport with each family and facilitate communication about DNR status between the medical team and each patient’s designated power of attorney. Despite these efforts, the chaplain was unable to gain the families’ agreement, leading the care team to obtain two-physician consent to change each patient’s status to DNR, against the families’ wishes. Less than one month later, both patients expired.
In this mixed-methods exploration, I argue that American hospitals will continue to turn to chaplains in complex, long-term cases to assist in discharge facilitation, particularly in cases involving non-English-speaking families. This trend reflects both the expanding role of chaplains and the pressure on departments to demonstrate their tangible value in a time of financial strain for healthcare systems. I call this strategic deployment of chaplains “capitalized hope.”
Language barriers add a layer of complexity to challenging cases. As historian Harriet A. Washington suggests in her seminal book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, one need only study the history of medicine to understand why those in historically marginalized communities maintain a distrust of medical care (Washington, 2008). A 2023 study found that Unilateral Do Not Resuscitate (UDNR) orders were 21% more likely to occur in non-English speaking patients, citing higher risk of hospitalization and communication errors as primary reasons for the discrepancy (Piscitello et al., 2023).
Every day, healthcare practitioners offer hope, even in seemingly hopeless situations. Research suggests, however, that non-English-speaking families receive fewer visits and worse quality care than their English-speaking counterparts (Pandey et al., 2021); and families tend not to see chaplains as directly involved in healthcare decisions (Harris, 2018). Recognizing this, I argue that hospital management views (especially multi-lingual/cultural) chaplains as a unique ‘wildcard’, capable of building relationships outside the immediate circle of primary decision-makers in a patient’s care. Within this context, these chaplains face the challenge of balancing their therapeutic role amid competing institutional interests and pressures. The cases of UDNR in Ms. L and Mr. V reveal an example of the subtle mechanisms by which chaplains might, perhaps unknowingly, become aligned with institutional power, underscoring the potential for unintended complicity.