SHIFTS IN CHAPLAINCY 1 The Integrative Assessment Tool by Corinna H. Chung Upaya Buddhist Chaplaincy Program Graduate (2010) Follow Me, and I will make you become fishers of men (John 21:17). The Integrative Assessment Tool casts the net as wide as possible. It was created by the author as a sensitive method aimed at identifying spiritual distress and coping skills of as many patients as possible, independent of their faith or lack thereof. Although patients in the United States will predominantly be Christian, the word God does not appear explicitly. Instead, a more inclusive language is used in order to encompass both vertical (concerned with relationship to God and concern in earthly activities affecting an afterlife) and horizontal belief systems (concerned with social relationships and a concern with the effects of activities in the community). In this way the tool is not overtly religious but does not exclude religion either. The set of questions offers a framework eliciting thoughts, memories and experiences that give coherence to a person s life, and help locate their source of strength or distress (be it intrapersonal, interpersonal or transpersonal). It is the author s hope that patients will be encouraged to name anything that lends support at this vulnerable time and to have their needs (identified in a previously mentioned study) met: to feel free to express true feelings without being judged, to speak about important relationships, to discuss unresolved issues, to have time to prepare for death. The other research cited in the discussion under the heading Secular Chaplaincy demonstrates that patients questions mainly pertained to general existential issues; only 8% were overtly religious in nature. This is reflected in the author s The Integrative
SHIFTS IN CHAPLAINCY 2 Assessment Tool. At the same time The Integrative Assessment Tool covers what Stoll describes as the four essential areas for spiritual assessment: 1. Concept of God/transcendence 2. Source of hope and strength 3. Religious practices 4. Relationship between spirituality and health On one hand, the set of questions in The Integrative Assessment Tool help the chaplain to effectively collect objective data, such as faith denomination and the impact of the patient s faith on medical care. On the other hand, and in contrast to most existing tools known to the author, The Integrative Assessment Tool focuses on deeper, more subjective data. The different sets of questions provides a framework for the chaplain and the patient to explore the two basic categories of spiritual assessment 44 : 1. Functional information, the How of spiritual life, because most people can relate to these common human quests, even if the patient has found no answers: (cognitive) search for meaning/ purpose; (experiential) feeling hope/joy/peace/comfort; (relational) relationship between health and beliefs/practices; relationship to family/ friends/ community; coping skills. 2. Substantive information, the What of spiritual life: past spiritual/religious background and present spiritual/religious affiliation;
SHIFTS IN CHAPLAINCY 3 beliefs about self/others/ transcendence; present personal practices, rituals, faith community; the level of involvement/support they provide. 44 The Integrative Assessment Tool also contains a section for palliative care patients to facilitate end-of-life planning, once a patient has reached the level of acceptance that allows addressing these issues directly. The set of questions aid the chaplain and patient to explore subjects such as end of life reaction, terminal event arrangements, afterlife beliefs and reconciliation with self/others/spiritual Source. Instruction to the Chaplain on how to use The Integrative Assessment Tool : Chaplains can use The Integrative Assessment Tool as a guide to support them in conducting semi-structured interviews. Not all questions have to be asked; they represent available options for the chaplain to invite reflections, memories and stories, slowly mapping this individual s resources and the barriers to using them. The author assumes the religious denomination has already been determined during the screening protocol. This information, together with answers about faith community and who the patient would like to contact to talk with about religious or other matters, will come up naturally as the chaplain poses the questions that explore resources and how the patient finds meaning. Besides establishing rapport and trust in whatever way is appropriate, chaplains need to determine how best to preface the questions themselves. For example, by beginning with If you are comfortable talking about this topic, would you please share some of your beliefs about.
SHIFTS IN CHAPLAINCY 4 With minor modifications (not included here) The Integrative Assessment Tool can be used for assessing family, friends or medical staff. It is of course crucial to follow up, explain, reassure and counsel the patient s loved ones. While with the patient, it is recommended to keep note-writing to a minimum in order to give as much undivided attention as possible to the patient. Even if notes have to be made, the chaplain aspires to provide an atmosphere of communion rather than that of an interview. Listen to where resources stem from / who or what gives meaning; listen to what might be source of distress; listen to clues for effective interventions: 1. intrapersonal / self: recognition of positive traits, healthy self-esteem in spite of physical disabilities, being in touch with oneself, quiet time, ability to relax, ability to tolerate stress, ability to endure loss/vulnerability/uncertainty/ambiguity, accepts and embraces the impossibility to find meaning, completion of tasks, finished business, feels involved in decision-making, has some degree of control, positive outlook, gratitude, forgiveness. 2. interpersonal / relational: love, sense of belonging, closeness, closure with others, significant other, family, friends, pets, social networks, fellowship spiritual, cultural, professional or other. 3. transpersonal / religious / contemplative: God, deities, ultimate reality, sense of the sacred, set of values, connectedness with or feeling looked after by Higher Power, surrender into God s hands, sacred scriptures, sacraments, spiritual community, clergy, faith, worship, hymns, prayer, guided imagery, meditation, spiritual/religious practices, rituals. 4. environmental / creative / therapeutic: experience nature, music, literature, poetry, beauty, creating collage or other art projects, journal-keeping, life review.
SHIFTS IN CHAPLAINCY 5 THE QUESTIONS: (a) Securing and Strengthening Resources (past coping skills) How has your attitude to life, spirituality or religion sustained you during difficult times in the past? What in your life has brought you joy or peace? (present - resources) What could nurture your inner strength or your spirit while you are here? How does your faith, relationships or other resources you have, help you during this illness? What can I do to make you feel more comfortable? (future retaining hope / goal setting) What inspires you with hope? What kind of goals do you look forward to? (consider short, medium and long-term goals) (b) Opening to a higher perspective/finding meaning (past) Looking back over your life, what moments, people or experiences stand out as important? What did you consider the most meaningful things in life? (present) What really matters to you now?
SHIFTS IN CHAPLAINCY 6 What helps you make sense of being here? How has your relationship changed to important things in your life? Where does your sense of what to do, or how to look at things come from? (future) What is important for you to happen in the next few days or weeks? What would help you find peace of mind? What do you wish for? (c) Impact on Medical Care and Decision Making 46 How do your beliefs influence the way you think about your health? How do your beliefs influence how you look at your disease? How do your beliefs impact your decisions about your treatment and medical care? What would you like your caregivers to know and pay special attention to? (d) Special Considerations TV on/off, curtains open/closed, lights bright/soft, temperature higher/lower, frequency of visitors more/less, display of religious or cultural symbols, personal photo frames, flowers, wall decoration, special blanket and other personal items, CD player, DVD player, writing or art supply, room with a view of sky/mountains if desired and possible.
SHIFTS IN CHAPLAINCY 7 (e) Cultural / Interfaith Considerations Interfaith and cultural considerations become particularly important toward end of life and require awareness of the chaplain s own ethnocentricity. Although it is unrealistic to expect a chaplain to be fully competent at intercultural communication skills and to know the customs, taboos, etc. of all cultures, an effort in behavioral flexibility and interfaith education has to be made to avoid major missteps. It might be helpful to solicit the patient/their loved ones as teachers regarding faith/cultural practices by saying, for example, I am not very familiar with your culture / faith, could you help me understand. (f) End of life Planning Terminal event planning is intended for patients with grave illnesses. It can only be undertaken if the patient / family is not overwhelmed by the fear of dying and has reached a sufficient level of acceptance of dying. Care: How do your beliefs impact your hospital care, treatment or medical procedures? What aspects of your religion or spirituality might impact how you would like or would not like to be cared for? Do you have an advanced directive to let caregivers know what treatments you wish them to withhold? What would you like your caregivers to know and pay special attention to? Regrets / Forgiveness / Closure: What do you feel you have lost in the course of this illness?
SHIFTS IN CHAPLAINCY 8 Is there any kind of unfinished business you would feel comfortable sharing with me? If you had your life to live over what would you like to be the same and what would you like to have done differently? In terms of your relationships (or whatever issue causes distress) what would you like to be the same and what would you like to have done differently? Whose visit would mean a lot to you now? Are there people you would like me to contact for you now, even if you have not seen them in a long time? (For example, to say that you forgive them, or to ask for their forgiveness 69 ) Are there people who you would like to call and come visit (so that you can say good-bye and I love you 69 )? How can I support you in finding a sense of closure as you approach the end of your life? Even if your body should not get cured, what would help you now to find peace of mind? Life review What would you say were the milestones in your life? Would you be interested in drawing or writing a timeline of your life (or spiritual history) including remarkable encounters and important events? Some say wisdom is what floats to the top like cream after a rich life What kind of wisdom or legacy would you like to share or leave behind for others? Would you like to tell me about X as a person?
SHIFTS IN CHAPLAINCY 9 Preparation: Where would you like to die? What does death mean to you? What does it mean to you that this is happening? Actual death: What is important about how others will care for your body before and after you die? What is important about how others conduct themselves at time of your death? What specific instructions do you have about the care of your body after you die? Funeral arrangements: Where and how would you like to be buried or cremated? What kind of ritual or funeral service would you choose? Is there someone special you would like to officiate? Is there something special you would like to be said at your funeral? After death / Afterlife: How do you want to be remembered? What do you believe happens after death? If your health should decline, how does your faith - or other resources - prepare you for what is ahead?