A Day in the Life of a Hospice Chaplain

 By J. R. Peyton, MDiv., June 2010©

I paused outside of the room to gather my thoughts and breathe a prayer for the job that was ahead.  The hospice nurse had called and informed me of a new patient that had a fast-growing cancer (b cell type lymphoma) on her face, neck, and head.  She was not expected to live very long.   A month ago she had been 100% healthy, living independently, and had no visible symptoms.  The nurse had tried to prepare me for a rather unsightly situation and the considerable difficulty in controlling the pain.

            On entering the room, darkened because of the closed drapes and dimmed lights, my eyes slowly adjusted to the darkness.  Withering in pain on the bed was a terribly disfigured woman with multiple, open, weeping tumors on her head, of which some were as large as a football; dozens of other tumors ranged in size from a marble to a golf ball.  Significant amounts of morphine had been administered sublingually, but had little effect on her pain.  Her chart said that she was not a practicing Christian, but had expressed a desire to see the chaplain on admission (some days ago prior to being on hospice).  She is elderly, but her body seems to be rather healthy compared to her head.  She has a decreased level of consciousness (due to medication and disease) and is alert only to herself, her pain, her end-of-life concerns…

Kim[1] was every bit as bad as can be imagined.  She tossed and turned on her bed, her skin was moist and clammy, the sores on her head were… (well, some things can’t be described), and the smell…  I pushed up the chair as close to the bed as it would go and sat down.  When I took her hand, I could feel the grip tighten around mine (somewhere inside she was still reaching out for community).  She whispered a word (one of two words she said while I was there) to me before I could say anything, “Scared!”  I told her who I was and did not receive any response other than her hand gripping mine.  Her collar-length hair was matted, wet, and hanging in her face.  I reached out my other hand and began moving the hair out of her face and running my fingers through her hair and over the tumors that were claiming her life.  Her response was almost immediate as she calmed down and began to more comfortably fall asleep.  The nurse came in and said, “Thank God you’re here.  We haven’t been able to do anything for her.”  Amazing what a hand can do when time is given and the effort is made!  Over the next few hours I said my prayer, even told the story of how Jesus touched the leper, played some hymns on my iPod, but mostly just held her hand and touched her head and hair. 

An hour later, her arm relaxed as her coma deepened, and I was able to go.  The pager on my phone beeped as I walked down the hall, troubled once again over my last visit.  Now the phone was beeping again: a beep that I had learned to associate with crisis.  A beep that pulled me from my troubled reflection, “Was I doing enough?  Were the songs/scriptures/prayers meaningful?  Had I briefly been able to highlight the joined hands of God and man?”

            The text message read, “New pt in Gerald, Mo, may die at any moment.  Can you come today and do intake/assessment?”  A few phone calls later, I had rearranged my schedule, postponed less critical appointments, picked up a lunch for the 160-mile, round-trip journey, and headed down the road in my car to a new unknown crisis.  Would I be able to provide comfort?  Could I extend the hand of Christ to care for the sick, diseased, and/or demented?

            While I drove out to the house, I received a call from the hospice social worker with a briefing on what was known.  She was an 82-year-old woman with an inoperable cranial aneurism that could burst at any time.  As well, she had an implanted pacemaker/defibrillator that kept firing irregularly whenever the heart failed to fire on its own.  She had several children of varying involvement.  Finally, she also had some form of dementia.

            When I arrived at the house, the front door was ajar, so I walked on in (only done in the country) and found the family room crowded with family and hospice workers trying to provide initial services to the family and client.  As is often the case, other than a precursory greeting and/or examination, the demented patient is then ignored and the attention is given to the family.  It is the chaplain’s job to ‘spend time’ with the patient (time I love to spend).  I knelt next to the wheel chair and put my arm on the back of the chair.  The patient immediately gave me a sloppy hug and laid her head on my shoulder.  She welcomed me warmly and denied any pain.  We talked of her family, of whom she could provide little information to the number or names of her children.  She did not know the day, month, or year.  She was unable to tell where she was other than “Home!”

            Finally, I asked the questions I am forced to ask about her faith tradition for her records.  She immediately stated that she was Catholic.  When asked if she had always been Catholic, she stated, “No! I just changed a few weeks ago!”  A family member in the background stated, “More like 50 years ago!”  When asked what she was before she became Catholic (seeing that it felt so fresh and recent to her) she again answered quickly that she grew up Mormon.  When asked if she thought of herself as either Catholic or Mormon, she stated she wasn’t sure.  When asked if I could contact a Catholic Priest or Mormon Elder for her, she said, “No!  The first one didn’t approve of my first marriage, and the second didn’t approve of my divorce and second marriage!  Besides, my husband is United Church of Christ!”  When asked if she ever went to church with her husband, she again informed me, “He doesn’t go to his church either, because they didn’t approve of me!”  She then, without prompting, drops a bomb shell on me, “Besides, we have you now (gives me a little, slobbery hug and kiss on the cheek)!  You will be our pastor now!”  When I asked her husband if I could contact someone for him to act as a spiritual advisor, he too affirmed his wife’s words, “No, we have not attended church in 40 years, and I am sure that you can take care of any religious needs we have!”  It is worth noting here that while she could not remember the names of her children, she could quite accurately relate the painful history of a rather fractured faith background.

It would be easy sometimes to just “walk away” after a week of daily death, heartbreak, and mayhem.  But someone must do this work… I believe Jesus would do this work… and I want so desperately to be Jesus to them.  Sometimes I feel like I am close… but other times I know I am a million miles from the mark.

What do I do for these ladies?  What can I offer them?  What does the ecclesia have to offer them?  How can the gospel be presented to them this late in the situation?  What form would the kerygma take, and what should it look like?  In this context I do not stand at a podium, take a text, and pontificate about some aspect of the scripture, a format that anticipates an allotment of time in which to reflect, incorporate, and by which to become empowered.  On the other hand, my actions become the kerygma for the patient, and therefore this lived sermon[2] must be a major consideration (and the result of) any research that is to be done on ministering to people at the time of death. 

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[1] Names of patients and their situation changed enough to protect the privacy and dignity of the patient and their families.

[2] See Attachment One for sample sermon outline that is intended to be lived rather than spoken from a pulpit.

Attachment One

The Hand that Touched

Text - (Mark 1:40-42) (The Message)

            “A leper came to him, begging on his knees, "If you want to, you can cleanse me." Deeply moved, Jesus put out his hand, touched him, and said, "I want to. Be clean." Then and there the leprosy was gone, his skin smooth and healthy.”

Point#1

            The beggar’s situation seemed hopeless.  Set apart in a dark place, alone, and certainly he was afraid.  His hand reached out…  (This will attempt to meet the patient where she/he is at this time – I see you! I hear you!).

Point#2

            Jesus recognized that the leper was after more than physical healing.  If that were all there was to this story, then Jesus could have spoken the word from a distance and accomplished the same.  No, Jesus recognized the outreached hand that said, “Can anybody love me just the way I am!  I am so all alone in my pain, my disability, and my hopelessness!”  So Jesus did what was important first – He touched the leper, He accepted the stigma of becoming a leper, and bridged the gap between heaven and hell!  The healing of his body was secondary to the healing of his self image.  (This will attempt to provide the patient with validation of life, faith, and meaning – I feel/touch you!)

Point#3

            How long had it been since he had been touched by anyone?  Can you imagine with me for a moment how it must feel to not know the touch of man (or God)?  Even a hand of hatred is better than total seclusion (an Eskimo proverb)! The gift of touch, regardless of the physical healing, created a feeling of wellness and wholeness in the man’s life.  (This will hopefully infuse the patient with a sense of worth and accomplishment – I value you!)

                 

Conclusion – The lived moment!

            * (Matthew 28:20b) “And remember, I am with you each and every day until the end of [your life]." (my paraphrase)

            * It is my desire in the lived sermon to join the diseased body of humanity and the divine hand of God together! 

Pastoral Prayer

            Dear God we stand here in our weakness in need of your hand.  We don’t pretend to understand the ‘why’ or any other of the deep questions of life.  We do recognize the need of community… the need for someone to be here.  Let my hands, the hands of the nurses and aides, and the hands of all who visit here be the hands of God.  Let her community bring blessings, peace, and contentment in these hours of pain and passing.  We ask all these things with our faith firmly in the mystery of your Son, Jesus Christ.  As Jesus provided mediation between God and humanity – Let Kim’s community now mediate to her the endless love of the Master’s touch.  Amen!

Explanation of Clinical Chaplaincy given at the UGST Symposium 2013

Personally, I have completed four units of CPE and, after working for over 5 years full-time as a chaplain, I am now a board certifiable chaplain.  A Board Certified Chaplain (BCC) is very expensive and requires a minimum of four units of CPE (two must be Level Two CPE), 2000 clinical hours of work after completing CPE, a Master’s of Divinity, a lengthy application process, and then sitting for a consultation/review by other BCCs.  After being hired by UGST, I walked them through the year-long process of becoming a Member School of ACPE.  I then was the natural and only potential candidate for the cluster board to appoint to the St. Louis Cluster Board that governs CPE training in the St. Louis, MO, and the Springfield, IL, area.  The St. Louis Cluster is the only remaining Cluster board in the ACPE; at one time such cluster governance dominated the ACPE.  This Cluster has survived because it is dedicated to unity, tolerance, and a commitment to be inclusive to a wide variety of faith backgrounds.  In this Cluster, United Pentecostal Church (UPCI) chaplains have found a warm welcome and mentoring by CPE supervisors who are dedicated to making a place at the table for them.

It would be helpful to start with an overview of clinical chaplaincy and how chaplaincy training takes place.  CPE training is given in a succession of levels, and the level you complete will determine the job opportunities.  It is also worth noting that the requirements for employment are different from state to state, and even from county to county, depending on the strength of enforcement by state and local officials.  For example, Missouri law states that no one can work in any clinical chaplaincy position without at least one unit of CPE.  However, in rural areas state regulators ignore this requirement because there is no CPE training available (although someone with CPE would be preferred in a hiring process).  On the other hand, in population centers like St. Louis and Kansas City you would probably not even be considered for an entry-level position without two units of CPE. 

As a final note on employment, it is the expectation of ACPE, most educators, and even state regulators that the Federal Government will likely establish rules on the education requirement of chaplains, because both Medicaid and Medicare are now billed for and reimburse for chaplains’ visits in a hospice setting.  In 2010 the Medicare Hospice Guidelines made the chaplain and/or a counselor a mandatory part of the Hospice Team. As in the case of other medical providers that are part of the Hospice Team, a minimum standard will probably be set in the near future.  When this happens it is the hope of ACPE that this will be set high (M. Div. and four units of CPE) (which is in keeping with social worker requirements) to improve the quality of care that chaplains are providing.  When this happens present day chaplains will be given a time span to come into compliance before being allowed to work for a company that accepts Medicaid and/or Medicare.

While I have no official data, there are only a handful of licensed or ordained ministers in the UPCI that have any CPE at all.  As far as I know, there are only a couple of people who are board certifiable (I am the only one I know of for certain).  Further, there are no Oneness Pentecostal supervisors or any Oneness Pentecostal students in supervisory training.  Crystal, if she gets a supervisory training slot, will be the very first to have been accepted into such a training program.

After a lengthy application is filled out ($50 fee) and the student is selected, all CPE students start with Level One training at a hospital that is licensed by ACPE to provide the training.  The cost for a unit of CPE varies between locations, but is usually around $600.  ACPE gives priority to people with an M. Div. and students in a similar program.  However, if slots are available, supervisors will fill the slots with anyone interested in chaplaincy.  The clinical method of training in CPE units require between five and eight students to be effective.  Each unit of Level One or Level Two CPE require 300 hours of clinical time, 100 hours of didactic and group supervision, and sometimes a variety of other responsibilities such as on-call work.  Each unit is usually made up of students at a variety of levels, and the cohort supports each other through the process.  Units can be done over different periods of time (10 weeks @ 40 hours a week and often called an ‘Intensive Unit’, 20 weeks @ 20 hours a week and is often referred to as an ‘Extended Unit’, etc).

Anytime after a single unit is completed and either the student or the supervisor feels that the student has completed all of the Level One objectives (objectives are listed in the ACPE Handbook), the student can apply to sit for a Level One Consultation.  A Level One Consultation is a written and verbal examination by supervisors and other important hospital employees or Cluster board members to determine if they are ready to begin working on Level Two objectives.  Many students will work for many units on Level One and never sit for a Level Two Consultation.  One reason for this is that supervisors will rarely tell students what is clearly written in the ACPE Handbook (students are required to sign that they have read the handbook), and I have known students who have completed six units of CPE and, when asked, had never heard of Level Two CPE.

Another opportunity for those seeking training is to be hired by a medical facility as a ‘resident’.  It is required that residents have at least one unit of CPE before becoming a resident.  As a resident they will do four Intensive Units back-to-back over the course of a year.  During that time the resident is expected to devote their entire attention to CPE learning and working at the medical facility that hired them.  While resident students are still required to pay for their CPE units, they are paid a stipend that again varies between location (between $23,000 and $32,000 a year).  Occasionally hospitals will hire a Second-Year Resident that will serve as a resident and mentor to other residents.

The next level of training would be a supervisory candidate training.  Because of the number of clinical hours one accumulates doing CPE, it is not required (as in other programs) that those seeking supervisory training have a clinical period (or become BCC) between finishing Level Two training and starting supervisory candidate training.  Supervisory training is provided by a supervisor who is qualified to do so and a medical center that is licensed to provide the training.  Supervisory training takes between three and five years after completing Levels One and Two CPE.  Therefore it would not be considered unusual if the entire process (Level One to Full Supervisor qualified) took about ten years to complete.  Currently in the United States, chaplain supervisors have been ageing and retiring at a faster rate than new supervisors have been trained.  There is therefore an increasing shortage of supervisors available.  Currently in the St. Louis area there have been two supervisor positions and a supervisor trainee position open for almost a year.  The before-mentioned shortage, coupled with ACPE’s dedication to inclusion of under-represented groups (especially Pentecostals, who now make up 1/12 of the world’s population), opens a space for a golden age of opportunity for Pentecostal chaplains.

My vision when I started out in chaplaincy was to have an influence on chaplaincy education throughout the Oneness movement.  By being appointed to the St. Louis Cluster Board as a representative of UGST (and by extension representing all Pentecostal chaplains), I have in some ways jumped over the need to have supervisory training in order to have this influence. I envisioned that this would only be possible by becoming the first UPCI supervisor and training UPCI’s future chaplains.  However, by sitting on the Cluster Board, I can influence the decisions of the Cluster as it determines who gets the scarce training slots in the St. Louis area.  Further, because of this position, I am sought out to consult on matters that affect or include Pentecostals in general.  I am also asked to sit on Level One Consultation Boards, Supervisory Candidate Mock Boards, meet with and/or interview potential job applicants around the city and give feedback, give presentations at chaplaincy training events and conferences, provide hospital training for chaplains and social workers, and only God knows the influence I can have over CPE and chaplaincy training in the remaining years of my life.  My chaplaincy journey has been one of faith, and God has surely opened the doors so that, as His vessel, I might be used to bring glory to His Kingdom.