Hospital Chaplains Providing Coherence Through Mediation: Insights from a Qualitative Study
Robert Klitzman, MD, Columbia University, NY, NY
Background: Mediation by bioethicists has been found to be highly effective in addressing conflicts among patients, families and providers (Dubler and Liebman, 2011), and involves several approaches and skills in which chaplains may also engage. Mediation involves creating an atmosphere of trust, having concerns for the patient’s best interests, and acting as an impartial, neutral third party. In a recent quantitative study of chaplains in Poland, around 30% had received requests to mediate between doctors and patients, 25% among family members and 16% among members of the medical team; 73% had accepts this role, but 46% reserved the right to decline (Głusiec & Suchodolska, 2023). Many questions arise, however, about whether, when and how U.S. chaplains engage in these roles.
Methods: In-depth interviews were conducted with 23 U.S. chaplains and systematically analyzed.
Results: These professionals’ activities include such mediation, but that the types of these roles vary widely. Chaplains possess relatively unique characteristics that help them at times serve in these functions – engaging in active listening and ministry of presence, communicating in open-ended, patient-centric ways, demonstrating interest, respect, support and empathy to patients and families, and having abilities to gain respect and trust as spiritual or religious figures. Additionally, chaplains have relatively more time to spend with patients, and less medicalized and rigid agendas. Consequently, chaplains can help understand patients’ and families’ perspectives, values and goals. Since chaplains are often in certain ways somewhat separate from the rest of the medical team, they can also convey medical providers’ points of view to patients and families and vice versa, provide “fresh eyes” and help reframe clinical conflicts. Such mediation can occur when patients are from religious or cultural traditions with which staff have less experience (e.g., by explaining Muslim families’ beliefs underlying hesitancy about doctors writing DNR orders). But these roles arise in other contexts as well, and take on a wide variety of forms. Such mediation approaches can, for instance, counter inaccurate staff, patient or family assumptions that may contribute to conflicts, including staff biases or “labeling” of certain patients (e.g., as “drug addicts,” in ways that may impede optimal communication and treatment and generate tensions). Chaplains do not always plan in advance to take on these functions, and are not always directly asked, but rather end up doing so. As one chaplain, for instance, reported, “An Orthodox Jewish family had a loved one die in the early morning on Shabbat…Yet the family couldn’t get in touch with anyone from their community to say it was ok to let the body go to the morgue in the interim. So, they literally barricaded themselves in the room.” This chaplain had established a relationship prior to the conflict, and therefore now served as the key negotiator, persuading the family to agree to have the body removed. “The way I tried to build a caring relationship with them worked.”
Chaplains vary, too, in how often, and in what they perform these roles, and feel comfortable doing so, at times taking on these roles informally, implicitly and de facto, rather than formally and explicitly. For example, when the family of a brain-dead ICU patient, wanted to continue aggressive treatment, causing conflict with providers, a chaplain said in a family meeting, “‘I hear how very much you love your mom. But [also] that the staff here also cares very much for your mom, so everybody is trying to do the same’…Suddenly, when ‘love’ was introduced, the whole mood in the room shifted. It became, ‘Ok. We’ve got some common ground here. We’re not on opposite sides of the fence!’ That was very helpful…Families say, ‘Ok, as long as the staff knows that we just need more time.’” Chaplains can thus serve here as neutral “go-betweens,” creating an important space or forum for addressing tensions. Yet doctors, nurses and administrators often do not formerly or explicitly recognize or encourage these functions. These activities of chaplains are also, in certain ways, outside traditionally-described roles of chaplains.
Conclusions: Given increasingly fractured healthcare systems, chaplains can offer valuable assistance and coherence in clinical conflicts by acting as mediators, and do so in varying contexts and ways, and should consider more fully and explicitly recognizing, developing and encouraging these skills and functions. Specifically, many chaplains may benefit from more explicit training to develop and refine these approaches. Medical education should also include enhanced recognition of how chaplains can assist in addressing such disagreements that arise. This presentation will explore these possibilities and the challenges involved.
Methods: In-depth interviews were conducted with 23 U.S. chaplains and systematically analyzed.
Results: These professionals’ activities include such mediation, but that the types of these roles vary widely. Chaplains possess relatively unique characteristics that help them at times serve in these functions – engaging in active listening and ministry of presence, communicating in open-ended, patient-centric ways, demonstrating interest, respect, support and empathy to patients and families, and having abilities to gain respect and trust as spiritual or religious figures. Additionally, chaplains have relatively more time to spend with patients, and less medicalized and rigid agendas. Consequently, chaplains can help understand patients’ and families’ perspectives, values and goals. Since chaplains are often in certain ways somewhat separate from the rest of the medical team, they can also convey medical providers’ points of view to patients and families and vice versa, provide “fresh eyes” and help reframe clinical conflicts. Such mediation can occur when patients are from religious or cultural traditions with which staff have less experience (e.g., by explaining Muslim families’ beliefs underlying hesitancy about doctors writing DNR orders). But these roles arise in other contexts as well, and take on a wide variety of forms. Such mediation approaches can, for instance, counter inaccurate staff, patient or family assumptions that may contribute to conflicts, including staff biases or “labeling” of certain patients (e.g., as “drug addicts,” in ways that may impede optimal communication and treatment and generate tensions). Chaplains do not always plan in advance to take on these functions, and are not always directly asked, but rather end up doing so. As one chaplain, for instance, reported, “An Orthodox Jewish family had a loved one die in the early morning on Shabbat…Yet the family couldn’t get in touch with anyone from their community to say it was ok to let the body go to the morgue in the interim. So, they literally barricaded themselves in the room.” This chaplain had established a relationship prior to the conflict, and therefore now served as the key negotiator, persuading the family to agree to have the body removed. “The way I tried to build a caring relationship with them worked.”
Chaplains vary, too, in how often, and in what they perform these roles, and feel comfortable doing so, at times taking on these roles informally, implicitly and de facto, rather than formally and explicitly. For example, when the family of a brain-dead ICU patient, wanted to continue aggressive treatment, causing conflict with providers, a chaplain said in a family meeting, “‘I hear how very much you love your mom. But [also] that the staff here also cares very much for your mom, so everybody is trying to do the same’…Suddenly, when ‘love’ was introduced, the whole mood in the room shifted. It became, ‘Ok. We’ve got some common ground here. We’re not on opposite sides of the fence!’ That was very helpful…Families say, ‘Ok, as long as the staff knows that we just need more time.’” Chaplains can thus serve here as neutral “go-betweens,” creating an important space or forum for addressing tensions. Yet doctors, nurses and administrators often do not formerly or explicitly recognize or encourage these functions. These activities of chaplains are also, in certain ways, outside traditionally-described roles of chaplains.
Conclusions: Given increasingly fractured healthcare systems, chaplains can offer valuable assistance and coherence in clinical conflicts by acting as mediators, and do so in varying contexts and ways, and should consider more fully and explicitly recognizing, developing and encouraging these skills and functions. Specifically, many chaplains may benefit from more explicit training to develop and refine these approaches. Medical education should also include enhanced recognition of how chaplains can assist in addressing such disagreements that arise. This presentation will explore these possibilities and the challenges involved.