RCT of Chaplaincy: Lexy Torke, Karen Steinhauser, LaVera Crawley

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We have some terrific guests today, Eric. We are delighted to welcome Lexy Torke, who is Professor of Medicine at Indiana University School of Medicine, where she’s section chief of palliative medicine. Welcome to the GeriPal podcast, Lexy.

Lexy: Great to be here.

Alex: We are delighted to welcome Karen Steinhauser, who’s a social scientist, a professor of population health sciences and of medicine at Duke and also a health scientist at the Durham VA Health System. Welcome to the GeriPal podcast, Karen.

Karen: Thank you. Glad to be here,

Alex: And we’re delayed to welcome LaVera Crawley, who is systems vice president for spiritual care at Common Spirit Health and a chaplain. Welcome to the GeriPal podcast, LaVera.

LaVera: Thanks.

Eric: I am super excited. We’re going to be talking about a lot of different things here, including… Oh, what’s the title that we’re going to be calling this, Alex? This is…

Alex: More on chaplaincy… [laughter]

Eric: Chaplaincy part two?

Alex: To what extent can you study spiritual care interventions?

Eric: Yeah.

We’re going to be talking about a randomized controlled trial on a chaplaincy intervention. But before we jump into all of those topics, who has the song request for Alex?

LaVera: I believe I do.

Eric: Oh, boy.

LaVera: I requested the song River Man that was originally recorded by Nick Drake. Yeah. And the reason, I want the listeners to get their own sense, and I would invite the listeners to pay attention to at least two things or three things. First, the lyrics, that’s the main reason why I chose it. The theme is death. It’s interesting the way the artist describes death or approaches it. And then the second thing to listen to is the music itself, the time signature and the switching back and forth from major to minor, major to minor. And as you’re listening to that, imagine the life of Nick Drake, who I believe recorded this first sometime in 1969 and five years later committed suicide.

Eric: Oh.

LaVera: So be aware of that as you’re listening to the lyrics.

Alex: That is wonderful context. Now, I’d only heard of this song because my kids music teacher got them to play it together. So one of my kids on guitar, on the other in ukulele. So I got my kid who plays his guitar to play this song so I could accompany it. And this time, so he’s a ringer because he’s much better than me, a guitar. So here’s a little bit of river man…

[Alex Singing]

Betty came by on her way.

Said she had a word to say.

About things today.

And fallen leaves.

Said she hadn’t heard the news.

Hadn’t had the time to choose.

A way to lose.

But she believes.

Going to see the river man.

Going to tell him all I can.

About the plan.

For lilac time.

If he tells me all he knows.

About the way his river flows.

And all night shows.

In summertime.

LaVera: Can I just say another word or two about that song first? So for those who aren’t aware that the river referred to as the river sticks, and the river man is the one who guides people. And the river sticks is that river that enters from living life to underworld. And the river man is the guide that guides those who are living into the underworld. So again, given that Nick Drake was severely depressed most of his life and OD’ed on antidepressants five years after that, he was clearly struggling. And it’s sort of this back and forth, do I want to live? Do I okay, maybe I’ll change the plan or I don’t know. And it’s all in the lyrics if you just sort of read that. It’s very poignant.

Alex: Very powerful.

LaVera: Yeah.

Alex: Thank you. I have a new appreciation for that song, LaVera.

Eric: Thank you too. I’m just going to jump right into this topic. And we’re going to start off with, was it JPM or JPSM, Lexy that published?

Lexy: JPSM.

Eric: JPSM published a paper. It was a randomized trial that was looking at a chaplaincy intervention. I don’t see a lot of those out there. Randomized controlled trials of chaplaincy interventions. Lexy, why did you and your group decide to do this project?

Lexy: Yeah, so I can say that I became about, in 2014, I had the opportunity to lead a center at our health system called the Evans Center that focuses on religion, spirituality, and health. And I can talk a little later about how my interest in this topic developed, but when I got into this role, I’ve been interested in surrogate decision making for most of my research career. I just think that some of the hardest things we face are coping with and making decisions for patients when they can’t decide for themselves. And as I came into this role and was thinking about where we could have an impact, just the surrogate situation came to mind. And so we got together with a really great interdisciplinary group of chaplains, chaplain leaders, other researchers, and developed this intervention by meeting weekly for several months and reviewing the literature, reviewing what our chaplains did in their ordinary practice, and then also just thinking about what would be a rigorous intervention that we could test in the ICU setting with family members.

And that’s how we came up with this intervention, the spiritual care assessment and intervention framework or SKY we call it for short, because it’s great to have a cool acronym. [laughter]

Eric: I feel like there are a lot of cool chaplaincy acronyms. I guess FICA is not as cool as SKY. What’s involved in this? Is it an assessment? It is a screening? What’s the SKY?

Lexy: Great. So, we developed it to be, I guess we were balancing a couple things. One is we wanted it to be consistent with chaplains’ usual practice and why it was so essential that we had chaplains and chaplain leaders integral to the development. And so we wanted it to feel pretty natural to the chaplains and to be what they would do in their ordinary practice, and so it involves some important components. Chaplains can do an assessment of the spirituality of the individual and then they use interventions that are part of their discipline and those interventions are tailored to the individual’s spiritual and religious needs of the person that they’re caring for.

That’s why we use the terms assessment and intervention and we think of assessment as a skill of a very advanced skill that chaplains have of doing an in-depth evaluation of a patient or family member, and then the interventions should certainly follow naturally from that. That was our goal, but we had to balance that natural practice the chaplains have with developing something that was rigorous enough that it could be reproducible, that we could have fidelity, adherence to fidelity, just like you do in any other behavioral randomized trial, and so we had to balance those things and that’s why we added some aspects of structure.

Eric: Okay. And is so part of this intervention, so there was a proactive component of getting chaplaincy involved. There was an assessment that was focused on four spiritual domains. What were those spiritual domains?

Lexy: The domains were meaning and purpose, relationships, transcendence and peace, and self-worth and identity, and we developed those. There have been a number of ways to try to take the scope of spirituality and divide it into a number of categories, and there are frameworks with seven categories and three categories. We just couldn’t find one that quite fit our needs, and I’m sure that they differ to some extent by the clinical context, so we reviewed a bunch of categorizations that were in the literature and this was the most parsimonious group that we could come up with, that I thought captured the core elements of spirituality.

Eric: And are there set questions for each domain or do you just give them, this is what you’re going to be talking about address this issue?

Lexy: Yeah. That is the semi-structured part, is that we came up with a list of questions for each of the four domains. And when the chaplain is doing their initial assessment, which is the most in-depth one, we ask them to read at least one question from each domain verbatim. And that’s the part that’s structured and they literally check it off on a card they have with them, but then they can take that conversation wherever it may lead. So they might ask something like, “What’s most important to you now?” or something along those lines, but then the conversation will naturally emerge from that and will go in whatever direction is important to that particular person.

Eric: LaVera, you’re a physician, you’re a chaplain, you’re a bioethicist, you’re a researcher. From a chaplaincy perspective, how does this sound to you?

LaVera: It sounds fine. It’s distinguishing between the kinds of structured questions you use as an assessment in a research context is going to be very different compared to the bedside. In addition to that long list, I was also a chaplain educator. So, I taught chaplaincy, and when I teach assessment, there are so many models out there. And as Lexy mentioned, some of them are contextual, so you use something if someone is in a crisis versus something that’s more general, and there is so many models out there. And my approach to it is apply the right model to the right context. So, learn as many as you can and what they’re all about. And the other thing is that verbatim question for research, that’s fine, but that might not be the way to enter into a spiritual relationship with a patient with that kind of question.

You have to read what’s in the room and start with that. It might be, “Oh, that’s a beautiful picture. Is that your grandchildren? Tell me about your grandchildren.” And you start entering into a conversation about support or relationships and things of that nature. So yeah, right great for a research context and a very different approach you might want to have at the bedside. Let me say, that said, one caveat is we are now, we meaning the chaplaincy profession, are now in an opportunity to enter into a different level of recognition with new CMS codes for chaplains.

Eric: Really?

LaVera: Yeah. They’ve been in effect for the VA. For those of you who work in the VA know that and very recently, the wording got changed and CMS took the VA context out. It’s now available. These hick pick codes are available to any chaplain in a healthcare system. And the problem with that, one of those codes is about spiritual assessment, so for me, in a system that has hundreds of hospitals that are now trying to come together as one, we’re the result of a merger of two major health systems. And one health system would use one set of criteria for coding and another for another, so we’ve got to create one, which means one way of looking at spiritual assessment. So, we’ll be borrowing from the research context to figure out how we could more standardize how we’re going to approach spiritual assessment.

Eric: This means chaplaincy made bill. So, it’s not just a cost center.

LaVera: That’s down the road. Initially, we just want to show that we were there.

Eric: Okay.

LaVera: So they can code that we actually did something, that we assessed, that we intervened, and that there were some outcomes. If we can get that recognized, then hopefully the dollars could follow later on.

Eric: I’m going to take one more tangent because I’d love to hear from this. You started off as a physician, right?

LaVera: Yes.

Eric: Now, do you mainly practice as a chaplain?

LaVera: I trained at UCSF in family medicine. I left there and went and practiced on the Navajo Indian reservation for a number of years. Absolutely loved it. Now, the part about the chaplaincy is I’ve always been deeply, deeply spiritual and I can say working on the Navajo reservation was a dream come true because I could do my Western medical stuff in the context of a very spiritual environment, really wonderful, but ended up leaving and coming back to the Bay Area and was trying to figure out. Okay, I don’t necessarily want to stay clinical, but I really love that spiritual work and what’s the closest profession. So I ended up training in ethics at Stanford for a study looking at health disparities at the end of life for low income African Americans, and that just started a whole new level of career for me in end of life health disparities.

Loved it, loved being at Stanford, but still had this longing for more integration with the spiritual. Took a sabbatical one year from Stanford and did chaplaincy training for that year with the intentions of going back to Stanford and revitalizing my scholarship to include more spiritual care. But I’m really glad I got bit by the chaplaincy bug and I ended up shifting careers and moving into the direction of fully into spiritual care.

Alex: I just want to note for our listeners, I told LaVera this when we just had a conversation a couple weeks ago before doing this podcast. And I told her I quote LaVera every year when I teach the geriatrics fellows, the palliative care fellows, I would love for you to tell the story that I quote because you experienced it. I’m talking about when you were talking about palliative care and you were confronted about palliative care in the African American community. I wonder if you could tell that story for our listeners.

LaVera: Yeah, if I could just go back a little, so the time I was writing that, I was a Soros scholar. George Soros had the project on Death in America. I’m sure you know many of the big names in palliative care now were a part of those cohorts, and I would show up. RWJ, Robert Wood Johnson was doing a lot work in that area as well and there was just this renaissance, this new explosion of palliative care grants were just being given. It was really a rich time.

Alex: Was this late nineties?

LaVera: Yeah. That is exactly when that was. And I would show up to meetings and organizations and I would be one of a few, if there were any others, African Americans in the room and we’re talk. And my scholarship, as I mentioned, had been about inequities at the end of life. So I’m saying, okay, “Of we’re really wanting to improve the care of the dying in my community, in the Black community, where are my peers? Where are my colleagues?” I went on a campaign, we got funding, and we were looking at how to educate African American physicians because that group of physicians cared proportionally for more Black patients, so why not start there to improve the end of life?

So, one of my strategies was to make presentations nationally and one of those presentations, and here now I’m to your story, Alex, was at the National Medical Association that year. And I made a presentation from, I had done an ethnographic study at Stanford and I used one of my cases to show the journey of that this one woman had taken and how important it would’ve been to have more physicians aware of what was going on in the life for her, and my goal was to rally the troops in that audience.

The National Medical Association, for those who don’t know, is a predominantly African-American version of the AMA, started when the AMA refused to allow, historically, Blacks into the organization, so they started their own. It’s almost as old as the AMA itself. And so it’s a big conference every year, a lot of African-American, a lot physicians in general, but a lot of African American physicians. I was there to rally the troops, start them on the road of educating for better end of life for their patient populations. And in the audience was Dick Gregory, who recently passed a few years ago. Those of you who were too young to know, Dick Gregory was a satirist. He was a comedian and he used comedy and satire to talk about the racial issues of the 50s and 60s.

And so he was pretty well known, in fact, really, one of the first, if not the first Black comedian to break through and was able to be appreciated by white audiences as well. Really important person, who later in his life got very interested in healthcare. So he would show up to these National Medical Association meetings every year and he was in the audience. After I had done this, what I thought was a great rallying call, he stands up and he says, and all eyes are on him. He’s a celebrity and all eyes are on him. And he says, “So now, Dr. Crowley, we’re trying to get Black folks comfortable with dying.” And his point was, we die disproportionately from things we shouldn’t die of, that care is denied. Basically, he was saying upstream so that there’re going to be more people dying prematurely and not getting the kind of care they need. And he was questioning whether I was inviting people to just let them roll over and die or continue the battle that he took on as a civil rights activist in thinking about, do we really want to die comfortably?

Alex: So, yeah. I love this story and the way that it brings up for trainees when I’m teaching them this issue of, oh, palliative care sounds wonderful. They’ve all drunk the Kool-Aid, as Ken Kavinsky likes to say, “They’ve drunk the Kool-Aid” and yet, and yet, this is so complex and the intersections between culture and medicine have this deep legacy that we need to explore. And as you’ve written in your work, there is a justified mistrust of the healthcare system and an ethic of struggle that needs to be appreciated. We’re getting off-topic, but I’d love to get back into it and relate it to your chaplaincy work. I’d love to bring Karen into this because Karen, you’ve been studying spirituality and assessment of spirituality and would love to hear your thoughts on Lexy’s study, as we’ve heard so far, as the domains that were covered. How does this sound to you? What’s missing? What’s in there? How does this fit in the historical context of what we know?

Karen: Yeah. Well, first of all, congratulations to you, Lexy, for the great work that you’ve done and for the really systematic approach to thinking about what’s the intervention, first of all, so the chaplaincy version of what’s in the syringe, what’s in the, to use AGJO Christian metaphor, what’s in the chalice? What’s in the intervention? And so I think in your work, you’ve really tried to identify what happened in those interactions with surrogates. That’s one thing that I thought was really helpful and appreciate. And also, really like the way that you have identified different kinds of outcomes, spiritual wellbeing with the facet SP, as well as then impact on mental health outcomes or emotional distress outcomes of anxiety and depression. And we don’t know very much about how all of those overlap. I would say, probably LaVera could speak much more to this, how that shows up clinically, but from a research perspective, we don’t have good data pulling those apart and disentangling and knowing what relates to what.

So I feel like this is, it’s a really nice step forward in the chaplain interventions that have been in the literature. There really aren’t a lot of them. And when they have been, they are really describing a visit and we don’t get much of a window into what’s happening inside that visit. So your team has really addressed that. Of course, I have questions about what you’re thinking about what’s next, but happy to pause there for a minute.

Eric: Before we talk about what’s next, we should talk about what Lexy actually found in this study. So, you had chaplains do these proactive visits, ICU patients. They followed them during the course of their hospital stay. You had them follow SKY, this semi-structured protocol. Did it have any impact?

Lexy: Yeah. We compared patients. We randomized individual patients either to the SKY framework or to usual care. And we do have a really strong chaplain department in IUP Health, and so the units where we did the study did have a chaplain, but of course, the chaplain is pulled in many directions. And since patients and families often can’t be in the unit due to, well, personal responsibilities, children, jobs, and then the pandemic, we did find in fact, that people in the SKY intervention got more chaplains, more time with the chaplain and more visits. Our primary outcome we looked at was anxiety and we chose our primary outcome. We debated a lot about whether it should be spiritual wellbeing or anxiety, and in the end, it was interesting. One of our chaplain leaders focused on anxiety because he said there are better measures for it that are responsive to change and so you’ll have a better [inaudible 00:24:25], but we were able to show differences in both.

And the way we did our analysis, we both compared the scores on our measures, the generalized anxiety disorder seven scale and the facet SP. We compared the raw scores on those measures, but we also were interested in making sure that the differences were clinically meaningful. So we identified what we call them minimal clinically important difference for the G87 and the facet SP. And then we looked at the proportion of patients who had that change, that improvement, and we found that it was significantly more patients in the intervention group had an improvement in their anxiety compared to the control group. And more patients in the intervention group had an increase in their spiritual wellbeing. And then the third outcome that we found a difference in just in raw scores was a measure of satisfaction with spiritual care, which was much higher in the intervention compared to the control group. So those were our statistically significant differences.

Eric: Does this come as a shock to you LaVera?

LaVera: No, no. The only thing that I think could possibly be shocking is why do we always need research to prove what’s common sense? What you did was you gave a family who’s in complete distress attention asking specific questions, not being afraid to go where it’s very painful to go. A lot of times in healthcare we are not trained to sit with suffering and do all kinds of ways of avoiding it by just doing things, okay, let’s prescribe this or let’s, as opposed to just going there as a chaplain can and just sitting there with the pain, asking the hard questions and knowing how to just hold a person as they’re just sharing their heart and duh, of course that’s going to help someone feel better. I’m a researcher, I believe in evidence-based practices. And it’s sometimes a bit frustrating though that we have to prove what’s obvious in order to get changes in the healthcare system.

Eric: So, let me ask this then. Does it have to be a chaplain? Could it be the bedside nurse? Could it be the palliative care team? Could it be someone else?

Lexy: Well, I want to say I whole, sorry, LaVera. I wholeheartedly agree with you LaVera, that it’s too bad that something that we sort of know in our hearts are so valuable, needs to be proven. But I think I mean there are two things. One is just a movement for evidence-based practice in all fields where we do healthcare. But the second is that unfortunately chaplains tend to get, how do I put it, tend to sometimes be cut when times get tough. And I just think having the evidence that this matters, the evidence, the actual empirical evidence to compliment the stories that we all know. So I just want to say that I agree with you that it is frustrating that we have to prove our worth.

Alex: Can you stick on this for a second. I’d love to get Karen’s thoughts on this. On the one hand people have said research is the meticulous documentation of the blatantly obvious, which is kind of LaVera’s point here. And Einstein famously said, not everything that counts can be counted and not everything that can be counted counts. So, these are like important notions to keep in mind as we think about studying spirituality. Karen, you’ve studied this spirituality for a long time. You’re developing an assessment, I spirit, I believe. Why study this? What is your justification? How would you respond?

Karen: Well, one of the things that I wanted to return to for a second if I could, and then jump back to that is Eric’s question, which was, does it have to be a chaplain or could it be somebody else? And that is an empirical question and possibly a scary question too, right? Because what are the unintended consequences of the answer? But I would be curious to know if we had attention as LaVera described it, but from a social worker versus a chaplain, for example, what, beyond the attention, what about the different depth of expertise that each of those profession brings may change outcomes? And do they change different kinds of outcomes beyond anxiety? Do we get more, for example, with regard to spirituality into meaning and purpose, relationships, transcendence and peace, self-worth and identity, those aspects of the assessment? So that’s something that I think about in terms of who delivers the intervention.

LaVera: And if I can, and I really do want to hear the answers to your question, Alex. But let me just say that the point is, if we could do things like palliative care does them, that is in a team, then each person is holding that piece of it. And I think outside of parent’s care and some of the other specialties there, there’s not really this interdisciplinary connection that’s really working well. And so then it would be nice to have those other than the chaplains, be aware of the spiritual component and then just ask some basic screening questions. And the screening questions would just allow you to know that. Well, this person is maybe under some distress in that realm of religion or spirituality. And it’s beyond my specialty to really deep dive into what they’re doing.

I’m going to be out of my lane if they start telling me things about God and I’m not a theologian. So that’s the time then to call in a chaplain for those deeper dives into the spiritual components. But everybody might, when I was a chaplain educator, I taught medical students as summer chaplain interns because everyone needs to know how to be able to recognize spiritual distress. They don’t have to be experts in it, but to recognize it, acknowledge it, and then get the resources needed for interventions.

Lexy: I want to add though, I think that those of us, I mean the palliative care team model is so good because we do have overlapping expertise. And really, I mean, so for example, if a social worker were doing this listening, perhaps there are family dynamics or psychosocial needs that they would be attuned to, whereas I as a physician might have something else I pay attention to. But all of us need to be able to listen deeply. So, I do think that we have, I think of our team as an overlapping venn diagram or anyone not to be able on, the team ought to be able to listen deeply and provide some of this, but then the chaplain does have these special domains.

And so perhaps maybe if one of our family members had, for example, negative religious coping where the chaplain’s expertise was especially needed. But honestly, I mean, I suppose later we could do a comparative effectiveness trial of different disciplines, but I’m not sure that’s the most important question because we just acknowledge that we have these overlapping skills and that whoever’s at the bedside at the moment could probably do most of this. But that there are certain specific things that a chaplain could do that really no one else is qualified.

Eric: Yeah, I like in our last podcast about chaplaincy, the analogy was if the chaplain comes in and identifies that somebody is having pain, they’re not going to be the ones prescribing an opioid for that individual, but they can do both. Some more assessment also potentially some interventional around total pain, including spiritual suffering that actually may worsen physical pain. So there is this overlap. For me that kind of was able to put my head around that. And I also wonder, I would love to hear from all of you, I’ll start off with Karen because this is the part I’m still forgetting from our last podcast. So there’s these screening tools that we have around spiritual distress, spiritual coping, there’s assessments and there obviously interventions in this study. What’s the right terminology for all? Who does the assessments, who does screening?

Karen: Sure, I was going to say, I’ll talk about that and then maybe I’ll step back and talk about even how we talk about spirituality more broadly, because I think that’s a really important distinction to make too. So typically when we talk about a spiritual screening that is done by, and either of you, please correct me if you want to say more about how you think this works or if I’ve got it right or not, that the screening really can be done by anybody on the team. And as a brief way of assessing, does this person need additional more in-depth assessment? Are they expressing a distress that needs to be attended to a spiritual history, learns a little bit more in depth about what their person’s practices and affiliations might be, coping style, et cetera, that also can be performed by someone who’s a non-spiritual care specialist, a non chaplain. And then we think of assessments as typically being a very in-depth assessment by someone with healthcare chaplaincy training, theological training.

Those often take, not always, but often take a more narrative format. And as LaVera said, there are lots of those within the chaplaincy tradition. George Fette seven by seven, and Paul Prizer, Susan Lyons, lots of different kinds of assessments that parse spiritual needs and resources into different numbers of domains and have different language for it, but cover many similar things. So those are the distinctions in what we might evaluate and who might do it. But if I’m to step back for a minute, I think one of the challenges that we have, and I often use the analogy that when we talk about spirituality, we’re not often in our public and even interdisciplinary discourse, very refined. We talk about it, we talk about the weather. How’s the weather today? As if it’s this one gross thing where actually spirituality is a multi-dimensional construct that might include the relevance and importance of spirituality to this person’s life and their coping.

It might include their practices and affiliations, which may be religious or not. It might include the impact of their beliefs on the decisions that they make about their care. And it might include spiritual needs such as grief, despair, anger, et cetera, as well as resources that they have to bring to bear. And so that’s just one way to parse it or with some of those categories that I’ve mentioned. But I think until we can get more refined in our conversation, we don’t become as refined in our measures of each of those aspects and our interventions around each of those aspects. And who would be appropriate to attend to those? That’s a lot of information [inaudible 00:35:43], but I share some of that.

Alex: I would love to get into what the next steps are. And I know that Lexy, you have some thoughts about next steps, and I think you may have even involved LaVera a little bit in some next steps or something.

Lexy: Yeah.

Alex: So, love to hear about that. Love to hear from Karen about I spirit, and maybe we’ll start with next steps. Lexy, you want to start?

Lexy: Yeah, absolutely. So yeah, I mean, this is one of the small number of studies, randomized trials that are out there. And actually I want to give a shout-out to Karen actually for having one of the other few studies that focuses on family members as she has studies of caregivers in the outpatient setting. And I’m working in the inpatient setting, but very few studies that focus on family members. But our study had some limitations. We did it in one center in the Midwest. And so our patients were all in the, about 80% Christian, 10% none and only a smattering of other religious or spiritual practices and beliefs. And it was about 20% African American, 80% white. So we had some black white diversity, but we didn’t have other types of diversity. And so I want to do a larger study that is diverse actually in two ways.

One is we’re actually going to very deliberately sample African-American and black patients. So we can look at what the effect of this intervention on disparities. And I think reducing health disparities has been something that’s important in my work. I spent my early time at Brady, and by the way, LaVera, your early article was pivotal for me when I came upon it, when I was working in that setting. But it’s very important to me to that we develop interventions that not only improve care for everyone, but also narrow disparities. And so that’s something I particularly want to look at. So we’re going to over sample for that. And then we just want the whole sample to be more diverse. So we’re going to deliver it in Spanish so we can improve our Hispanic and Latinx population and do it in cities where there are more Asians, Hindus, Muslims, and Jews. So we’re going to have it be more diverse in a variety of ways. And so we’re planning a multi-center study and hope to submit that in June.

Alex: Great. And Karen, we’d love to hear from you about I spirit, and if you could tell us, I think that’s ongoing work.

Karen: Sure. That’s some work that we started a few years ago. My interest in spirituality has, excuse me, been from early on predating my work in beginning research in palliative care. But of course early in trying to understand what was important to patients and families, this became a central kind of feature that people spoke about. And so following that stream, sort of some of the most recent work was funded by the VA, first of all to develop a measure of spirituality for those in serious illness. And we ended up having a five domain measure on the topics I mentioned just a bit ago, importance of spirituality, practices and affiliations, the impact of beliefs on decision making, and then spiritual needs and resources and the needs and resources.

The questions for that actually map onto several narrative frameworks within chaplaincy assessment with the idea being that if this measure were delivered prior to care, preferably in the outpatient setting, it would feed information to the chaplain about what needs might be delved into further as well as to the other parts of the interdisciplinary team who might be focused on how beliefs impact healthcare. So that’s kind of something that we’ve really been interested in most recently and just have a pilot implementation study funded to get it implemented into the stream of care and are figuring out how do we get this information summarized quickly and into the electronic health record.

Eric: LaVera, I got a question for you. Alex, is it okay if I ask?

Alex: Yeah.

Eric: So is there a concern at all from the chaplaincy sphere that the quantification of everything in chaplaincy is going to remove the heart or the spirituality in chaplaincy as we try to, because this is, it sounds very biomedical the way we’re approaching this. Is that a concern at all?

LaVera: Well, you’re only talking about a randomized controlled trial, and there are all kinds of research. There’s research that is much more, say the action research family of methods. It’s how chaplains are actually trained. So this is not a podcast on methodologies, but I always get a little concerned when I get that question and I get it from inside the profession a lot. And it really shows that the hegemony of the randomized control trial and systematic reviews the top of that pyramid in terms of robustness of data. Whereas there are a lot of other narrative approaches and qualitative approaches that can yield information that it’s much more natural to what chaplains do.

So that’s often my strategies to bring them in through that door and then let them know. Secondly, even if it is the sort of typical chaplain and there’s no such thing, but the typical chaplain who is so deeply spiritual does not want to ever add a number to anything, doesn’t want to quantify anything, that person’s going to need a job. And chaplains, as Lexy said, in cost-cutting times, soft things tend to go, and as long as we keep representing ourselves as very soft, chaplains are going to get cut. So it’s kind of a requirement that we move into the evidence-based practice world, and we are with people like Lexy and Karen.

Eric: So, well, I guess that brings up the next point is the next steps because the cynic looking at the palliative care literature would say, yeah, it’s great that improves satisfaction and symptoms and all these other measures. But brass tacks, what made palliative care grow was probably because it decreased length of stay in hospitals and it helped bottom lines with hospitals. Did your intervention Lexy actually have any effect on utilization, which again, somewhat argue is the reason that services palliative care get funded?

Lexy: Well, so no. Basically we did look at that, it was planned as a, kind of exploratory outcome. But one of the issues is that we only had 40 deaths. And I think that was a result of our methodology of wanting to get people enrolled early before we really knew their prognosis. I will say that actually other communication interventions in the ICU have had better success at moving those metrics of care, like time in the ICU among patients who die. So we were not able to move that. But I guess a couple things. One is that I hope that especially as we move in the direction of caring about public health, of caring about populations, that it will matter that the mental health outcomes of our family members are bad.

And you think about the tens of thousands of people who are admitted to the ICU and all of them have families and all of those families are suffering. And so if we look at things from either a managed care or a population health point of view, there is a huge impact of the distress that these family members face. And I will say that I think palliative care has thrived for two reasons. One is cost, but others is when policymakers realize how important it is. And sadly, that’s often if they have a seriously ill or dying family member is that they have their stories. And I truly believe that kind of as LaVera said, that narrative and those experiences are powerful too.

Eric: I want to be mindful of the time. I wonder if we can do one quick lightning round. If you had a magic wand, what one thing would you wish we changed around this issue is spirituality chaplaincy could be anything. I’m going to start off with Lexy.

Lexy: I think chaplains should be required in many more settings. I know it in hospice for example, it’s one of the few areas where there’s actually a requirement for spiritual care, but I wish that it were required as a part of other parts of care, including ICU Care.

Eric: Karen.

Karen: I wish that there were, I think the palliative care team does it well. But in other parts of the hospital, the relationships between chaplaincy and a lot of physicians in our interviews have showed there’s not a great understanding of what each other does. And yet the physicians we’re speaking to say they know that spirituality is very important to their patients. And so helping physicians have more fluency in general spiritual care and how to make referrals to specialists when needed.

Eric: And lastly, LaVera.

LaVera: Well, I would take Karen’s wish and I would operationalize it by saying I believe everyone in the healthcare field, physicians, nurses, therapists, social workers, anybody who has patient contact or family contact, they need to take one unit of clinical pastoral education. That is the training that chaplains get. I have an MD, I have a master in public health. I went to seminary and then I did a year of chaplaincy training. That year was the best education I got on being a human being with others. So I think that everybody needs at least one unit of CPE to learn if nothing else to learn how to sit with suffering.

Eric: That was lovely. But before we end, and speaking of sitting with suffering, Alex, do you want to play a little bit more? Was it River Man is the title?

Alex: River Man, here’s a little more.

[Alex Singing]

Betty said she prayed today.

For the sky to blow away.

Or maybe stay.

She wasn’t sure.

For when she thought of summer rain.

Calling for her mind again.

She lost the pain.

And stayed for more.

Going to see the river man.

Going to tell him all I can.

About the ban.

On feeling free.

If he tells me all he knows.

About the way his river flows.

I don’t suppose.

It’s meant for me.

Eric: Lexy, LaVera, Karen, thank you for joining us on this GeriPal podcast.

Lexy: Thank you.

LaVera: Thank you.

Karen: Thank you.

Eric: I’v got to say also how honored I am to have all three of you on, because I actually cite all of your previous studies to. For example, like Karen, I can’t believe, I think this is the first time you’ve had on your podcast and what was it, JAMA 2000. You had like what’s important to people at the end of life? And I still cite that study over and over and over again. So really thank you for all three of you for the amazing stuff that you do.

And I want to thank all of our listeners for supporting this podcast. Good night, everybody.