Advance Directives:Opportunities for Aultman and

Clergy CollaborationJeffrey Marsh, M.D.

October 29, 2015

Case example76 year old widow with sudden cerebral

hemorrhage.Family from out of town gathered and

uncertain of her wishes.What is role of the clergy at this point?Was there a role before this event?

Are you comfortable answering these questions?What is our religion’s stance on the medical

treatments I am addressing in my advance directives?

What is your opinion about the choices and values I’m addressing in my advance directives?

I’m a little unsure about some of the issues in advance directives. Do you have any advice for me?

Does our religion have a position statement on advance directives?

What is an Advance Directive?Living WillHealth Care Power of AttorneyMOLST

Forms revised in Ohio in 2015.

Rate of AD completionCommon belief that only 10-20% of adults have completed them.

Rate of Americans who have Completed Advance DirectivesDK Morhaim et al, American Journal of Public Health, 2013

Cross-sectional study from MarylandOf adults surveyed:

60% wanted their end-of-life wishes to be respected.

About 30% had advance directives completed.

Reasons for not having ADsDid not know about ADs.Too young or healthy to complete them.Too expensive.Don’t have the forms.Too complex.Too much time to complete.Wanted to obtain information from their

doctors.

Racial differencesWhites were twice as likely to have ADs than

African-Americans.Cultural differences in family-centered decision

making.Distrust of the health care system.Poor communication with health care

providers.

Role of the Clergy in Medical-Ethics Decision MakingChaplain Ralph Ciampa – Hospital of the University of Pennsylvania

Decision makingPastoral careOngoing teaching Voice of conscience

Respecting choicesGundersen Lutheran Health SystemInitiated in 1991Multi-tiered approach to provide answers to

questions regarding goals of care at important stages of life

Rate of Completion of ADs:85%

Promoting Signing of Advance Directives in Faith CommunitiesLJ Medvene et al, Journal of General Internal Medicine, 2003

Caring from Generation to GenerationLongitudinal study over four years with

implementation and revision of program that fostered discussion and completion of ADs.

Seventeen faith communities in Wichita, Kansas.

Facilitated by parish nurses.248 congregants completed program (69%)

140 did not have an AD before program.

Promoting Signing of Advance Directives in Faith CommunitiesLJ Medvene et al, Journal of General Internal Medicine, 2003

Twelve Activities to Encourage the Participation of Faith Communities in End of Life Care

1. Ongoing education of members on beliefs about meaning of life, suffering, illness, healing, dying and death, and afterlife.

2. Raise awareness about fundamental religious values vis-à-vis medicine.

3. Offer educational forums on specific issues related to end-of-life such as advanced directives, funeral and burial customs, legal matters and estate planning, hospice care, etc.

4. Be an advocate within the medical system for respect of religious beliefs, practices, and prohibitions as well as for the importance of spiritual care at the end-of-life.

5. Help members clarify specific goals of medical care that are in keeping with religious beliefs and values.

6. Assist patients and families with difficult decisions regarding the direction of medical treatment and ethical dilemmas about withdrawal of life support, artificial nutrition, use of antibiotics, etc.

Twelve Activities to Encourage the Participation of Faith Communities in End of Life Care (Continued)

7. Provide spiritual care and counseling to patients who are terminally ill and to their families.

8. Mediate divine presence and affirm value and personhood.

9. Provide assistance in sustaining religious practices and rituals for patients in the hospital or unable to leave home.

10. Provide practical assistance such as respite for caregivers, meals, running errands, and housekeeping.

11. Ensure proper disposition and treatment of the body at the time of death, and conduct funerals, memorial services, and burial rites.

12. Offer bereavement counseling and grief support groups.

What is MOLST/POLST?Medical/Physician Orders for Life Sustaining

Treatment.

Discussion What can we do together to help

document decisions and ease the burden on decision-makers?

“As Catholics we believe that our life is a gift from God over which we have limited power. We have been called to protect and cherish human life and not destroy it. Saint Paul asks us,

57 ‘Do you not know that you are the temple of god and that

the spirit of god dwells in you?” Our response is our gift to God.

“By the same token, we are not morally bound to prolong our lives by means which will inflict serious financial, physical, or emotional hardships on ourselves or our loved ones. Therefore, there is no need to prolong the dying process by every means available to medical science. A person may appoint a family member or friend as attorney-in-fact in an advance directive to see to it that extraordinary means are not used.” (Catholic Priest)

“People come to me in the eleventh hour when there is little time for discussion and when decisions must be made. These kinds of decisions should not come at the last moment but rather when people are alive and clear-headed. I try to tell my congregants that it is when they are healthy that the family must open up to each other and have honest conversations. Tragically, without family discussions and advance directive documents, I see families fighting over which sibling loves papa best, and whether the child who would ‘turn off the switch’ is the callous one or whether the one who refuses to act is the compassionate one. These situations are surely the furthest from the will of the dying and not in the interest of the family. Now is the time to rehearse for that which is inevitable.” (Jewish Rabbi)

“Christians should seriously consider completing advance directives because we have a responsibility to take care of our bodies. We are created in the image of God (Genesis 1:26- 27) and we are endowed with free will and choice. It is important to exercise these God- given abilities in a responsible way, particularly when it comes to our health. When we complete advance directives, we decide for ourselves, diminishing or eliminating guilt or anxiety for family members at a time of serious illness.” (Protestant Minister)

The Role of Clergy in Medical-Ethics Decision MakingChaplain Ralph Ciampa Clergy remain one of the professions with the greatest freedom to take initiative in responding to

individual crisis situations and in addressing pressing social and community concerns. Clergy also retain a rather high level of respect by the community at large, and their voice is valued on important issues. Medical interventions have become so complex and are woven into such complicated personal and social fabric, that clergy will find an infinite range of roles they may play in ministering to these situations.

Four major roles might be the following: Decision Making. When patients' families and medical teams are making decisions about

medical treatments, clergy are often in a unique position. They may be much more familiar with the medical system and issues than the patient or family; and they may be much more familiar with the patient's and family's concerns, values and resources than the medical team. Although clergy are occasionally deliberately excluded from these discussions, most clergy tend to underestimate how much their input would be valued by both the patients and families and the medical teams. Clergy can be important liaisons and advocates. Taking initiative to offer these services to both patients and staff can open many doors.

Pastoral Care. Even when the very best possible decisions about medical care have been reached, there may be much grief and hardship to be lived through by the patient, family, and medical staff. The clergy's role as a non-judgmental and skillful listener, and as a comforting voice can hardly be overestimated. The sensitive and timely use of sacraments, rituals, scripture, and prayer are a great blessing in times of loss and transition. Keeping the patient and family in touch with their spiritual community, and offering long term follow-up after crises are important gifts of ministry.

Ongoing Teaching. Clergy are recognized as teachers by their congregations. We have a marvelous opportunity to equip our flock to meet the challenges of chronic and acute illness, difficult decisions, and painful losses. Sermons, Sunday school classes, special seminars, workshops, pamphlets and books, casual conversations, ministry at the bedside, and countless other ways are available. Clergy can help to anticipate the choices that may face all of use as fragile and finite human beings. We can begin to lay the theological and spiritual groundwork for these difficult times well before they overtake us.

Voice of Conscience. There are many challenging and complicated decisions to be made by our society regarding how health care will be offered in our country. Many vested interests are competing to shape the system to their advantage. There are many marginalized individuals and groups in our society with little voice to speak for their needs. Clergy and churches form an important bridge between those who may be least able to speak for themselves and those who wield power in our society. To be knowledgeable about the issues and to seek a just and equitable society falls in the honored prophetic tradition of ministry.