Archive for March, 2013

A Chaplain Reflects on the AAHPM Conference

Much is properly made these days of the role of spiritual care in palliative and hospice care and the lead role that professional chaplains need to play in that domain of care. Many palliative care teams and professional chaplains have risen to this challenge. The newly released version of the NCP Guidelines makes that standard even clearer. However, I would maintain that, for this integration to fully mature, chaplains need to become more involved in the greater palliative care community just as they need to be involved in the professional chaplaincy community. Put another way, for chaplains to grow their identity as members of palliative care teams, they need to live in the palliative care culture nationally as well as locally.

While there are several options for how to do this, one that has been highly worthwhile for me over the past four years is the American Academy of Hospice and Palliative Medicine (AAHPM) which just concluded its yearly conference. I would immediately acknowledge that there are several barriers to chaplains being involved here- mostly involving money and time. Dues and attendance at the conference are expensive by chaplaincy standards although I do run into chaplains attending AAHPM whose way is being paid by their teams. And the time to go, especially if one is also attending one’s professional chaplaincy association meeting, often winds up cutting into vacation time. Thus, I’m not claiming that this integration will be easy to accomplish. I am claiming that unless we find ways over these barriers, the continuing integration of spiritual care and chaplaincy care into palliative care will be seriously impeded.

Some of what chaplains might imagine as barriers are not. Two “barriers” I know some chaplains presume are “This is an organization mainly for doctors so I won’t be welcome there” and “There will be no content at the meeting relevant to my work”. Both of those assumptions are decidedly false. Remember- these are palliative care and hospice people. By and large, they appreciate and welcome the inclusion of the spiritual dimension of care. And this is a very large organization so the range of offerings in any one time slot at the conference is very wide and deep. My problem in most time slots is picking between the several offerings I want to go to.

The number presentations involving chaplains is still small but increasing. I’ve been part of a team that has presented a very popular pre-conference seminar for the past four years. Tim Ford (VCU), Edie Meyerson (Mt. Sinai-NYC), and this year Terry Irish (City of Hope) and Denise Hess (Providence Health, Torrance, CA) have all made excellent contributions. One of the interesting parts of AAHPM culture is that it is almost impossible to get a workshop accepted unless there are presenters from more than one discipline. This supports the value placed on team work in palliative care. For chaplains, this means that the place to start if you want to present is to talk to your team and be part of a team presentation or a presentation with at least one other member of your team. This year Terry presented with a social worker and Denise with a physician from their respective teams. Note- the deadline for workshop submissions for next year’s conference in San Diego is April 19th. Now is the time! You don’t have to be a member to submit.

Another feature of AAHPM is that it heavily promotes social media. Even if you are not an AAHPM or NHPCO member you can follow various palliative care and hospice blogs and tweets. Pallimed and GeriPal are two of my favorites along with following AAHPM itself and palliative care luminaries like Diane Meier on Twitter. These will give you a good sense of the conversation and hopefully incent you to respond or comment occasionally. This is a major way the voice of chaplaincy and spiritual care is more often heard in the conversation. And it only costs a little time! I recently signed up to contribute to the AAHPM blog itself again to get the chaplaincy voice into the conversation.

For me the highlight of this AAHPM conference was the official release of the 3rd edition of the Clinical Practice Guidelines for Quality Palliative Care from the National Consensus Project which is a consortium of the major palliative care and hospice groups in the US. The guidelines can be downloaded free at Notably, Domain 5 (Spiritual, Religious, and Existential Aspects of Care) is tremendously expanded with significant chaplaincy input. The guidelines present powerful evidence for the necessity of professional chaplaincy on these teams. This set of guidelines is now the standard for palliative care and hospice teams and will hopefully become incorporated into the advanced certification standards for the Joint Commission as the 2nd edition was.

So, talking to each other as chaplains is essential. But if those are the only conversations we have, we are in danger of remaining pretty insular as a profession and worse, spiritual care will not be fully present in palliative care. We have to find a way!

George Handzo, BCC, CSSBB
President, Handzo Consulting

Another Amazing Assembly

Everyone knows that I look forward to the AAHPM & HPNA Annual Assembly the way a child eagerly awaits Christmas. There are so many things happening at any given time that there is never a dull moment. I’m also very lucky because I think that we have the most compassionate, enthusiastic and wonderful attendees. When among them I instantly feel like I am surrounded by family. This year I was excited to be working in a new position and I would be doing a variety of new things at the Assembly.

I had the privilege of managing the scholarship program for physicians in developing countries. Through this scholarship the Academy was able to bring 6 physicians to the Assembly. The stories about what these amazing people are doing in their communities are truly inspiring. Over the course of several months leading up to arriving in New Orleans I was able to get to know them all. They are some of the most remarkable people that I have ever met.

During the plenary sessions I sat behind the curtain while coordinating the questions that were being asked through Twitter. The amount of coordination and skill that goes in to making the presentation appear seamless is mind boggling. There are scripts that need to be written, slides have to be shown, videos coordinated, lights maneuvered, cameras positioned and a (very complex) control panel has to be manned. I was in awe of the production guys and our staff. They made it look so easy.

Being at the Assembly this year granted me the opportunity to meet many members and volunteers that I communicate with over social networks in person for the first time. It is such a strange but wonderful feeling to meet someone in person that you already know. At times I found myself skipping formal introductions opting for a big smile and saying “It’s so great to finally meet you!”

While I’m sad that the Assembly is over for 2013 I am looking forward to San Diego. The countdown has already begun!

Jen Bose
Marketing & Membership Coordinator

Hospice and Palliative Medicine Commit to ‘Choosing Wisely’

by Larry Beresford

On February 21 AAHPM, on behalf of its members and the specialty of hospice and palliative medicine, joined with 15 other medical societies to introduce Round Two of Choosing Wisely, a major national health care quality initiative sponsored by the ABIM Foundation. In a health care system undergoing rapid reforms, serious turmoil and escalating demands to raise quality and reduce costs, palliative care is often offered as a solution for providing appropriate care more in line with patients’ and families’ goals, with fewer unwanted and unhelpful treatments and, frequently, lower overall costs. But increasingly, HPM will be asked to show the evidence for the quality and efficiency of its own services, just like other sectors of health care.

The Choosing Wisely campaign challenges participating medical societies to name five treatments that are frequently performed but often unsupported by the medical evidence—and to share this list with their members and the public. AAHPM accepted that challenge, and took its place at the podium on February 21 with other societies concerned about their place in the health care value equation. The latest issue of AAHPM’s Quarterly newsletter describes how the academy developed its list, who participated in that work, and how academy members can join in the campaign in their own communities and facilities.

Now we’d like to hear from you. What do you think of the Academy’s Choosing Wisely list? Are there other treatments of questionable value that you think are equally deserving of quality improvement interventions to target unnecessary utilization? What is being done in your work setting to promote the goals and values of the Choosing Wisely campaign?

Larry Beresford is a freelance medical writer from Oakland, CA, who specializes in hospice and palliative care issues.

Spiritual Assessment Tools

At one of the workshops this morning, a speaker made the statement that chaplains were using scripted and particularized spiritual assessment “tools” that may project the chaplain’s assumptions and block the particular expression of the patient’s spirituality. When I sought to correct that assertion during the Q&A, I was told by one of the speakers and several members of the audience that I was incorrect.

The facts of the case are as follows. The standard definition of “spiritual assessment” used in professional healthcare chaplaincy in North America is.

A more extensive [in-depth, on-going] process of active listening to a patient’s story as it unfolds in a relationship with a professional chaplain and summarizing the needs and resources that emerge in that process. The summary includes a spiritual care plan with expected outcomes which should be communicated to the rest of the treatment team.

Fitchett, G., & Canada, A. L. (2010). The Role of Religion/Spirituality in Coping with Cancer: Evidence, Assessment, and Intervention. In J. C. Holland (Ed.). Psycho-oncology, 2nd Edition. New York: Oxford University Press.

This definition clearly does not support the use of a “tool”. This does not mean that no chaplain uses a tool. It only means that this use does not conform to best practice.

There certainly is a substantial lack of clarity here.

The Joint Commission and others do suggest a spiritual assessment. They do not require over even suggest the use of a “tool” which means that the definition above works. Any groups who are requiring the use of a tool are misreading the standards.

The fact is that several institutions that I know of have received advanced accreditation in palliative care without a spiritual assessment “tool”. One of those received a perfect score.

There is a widespread misunderstanding between spiritual “screening”, “history”, and “assessment” tools. For instance, FICA and HOPE are history tools, not assessment tools. They are not recommended for use by chaplains.

At the end of the day, there is a lot of misinformation out there on this topic. I would hope that practitioners would read the regs closely and draw their own conclusions about what is and what is not actually “required”.

George Handzo, BCC, CSSBB
President, Handzo Consulting

A Quiet Place and Labyrinth Room 215

This is my second AAHPM-HPNA conference and I have gravitated to the Wounded Healer talk both years. The care and treatments we provide to our patients and loved ones, can take a toll on us as providers. But as Henri Nouwen states our woundedness we can become a source of life for others.

I provide primary and specialty care to persons with ALS, their loved ones and caregivers. I have been the one to provide comfort and guidance. This year death became significant as I lost my mother three weeks ago. When loss becomes personal, everything changes. The daughter, nurse and individual all wrestled with the lack of control over all of it.

I completed a palliative care certificate course at the University of Colorado School of Nursing this past year. The academics of the course and the support of my colleagues helped me through my mother’s subsequent death. I also realized how little information on Palliative Care with Parkinson’s disease exists.

As I sit through the Plenary Session Friday morning “Our Exit Strategy: Denying Death its Strangeness” David Oliver and Debra Parker Oliver I am learning how death has become a teaching moment, at teaching us how to live.

We must take time to read, research, ask questions, reflect, pray, and support and talk to each other. Communication is the key. This George Bernard Shaw quote is at the bottom of all my e-mails: “The biggest problem with communication is the illusion that it has taken place.”

I never knew that Palliative Care would be my passion. But you only get one chance to die well…so let’s do it well.

Patricia Reisinger MS, CRRN, FNP, GNP
Nurse Practitioner
Spinal Cord Disorders Clinic – ALS
Denver, CO


Some time ago, my AAHPM teammate (and social media maven) Jennifer Bose asked me if I’d write a blog post on my experience at the Assembly today. I’d be lying if said I was anything less than brimming with excitement about the prospect. You see, this is my second Assembly as a member of the AAHPM staff, and my first came just about a week after I was officially hired last year. Because I was brand new, I was able to experience Denver as an attendee might. I was given cart blanche and attended whatever session or meeting I desired. I saw everything. I met everyone. It was staggering and remarkably educational.

It was also decidedly different than my experience this year.

This year, I have been static, essentially posting up permanently at the Resource Center Advocacy Kiosk (you should check it out!). And, if I’m going to be honest, I have to say that I was a little worried about how my perception of this year’s Assembly might stack up after the exhilaration of last year’s. And if I’m going to be even more honest, I was really, really worried about identifying something interesting to put in a blog post. On its face, my activity at the Assembly thus far has really just amounted to sitting on a stool, behind a desk.

Fortunately, I was reminded today why the phrase “on its face” exists. It is a nod to the simple, yet essential truth that life must be lived to be understood, a warning against prejudgment. I was shown again that this Academy and the members who volunteer their time are, fundamentally, deeply dedicated to the field. I was shown again that I am lucky to work for such a special group of people, that hospice and palliative medicine practitioners are not like other providers.

Where policy and advocacy conversations at other specialties’ annual meetings may focus on increasing reimbursement or protecting turf, HPM practitioners seem to have one, core consideration in the issues they hold dear – the quality of care and life for patients and families facing serious illness. Almost every conversation I had with Assembly attendees today focused on what can be done to increase access to hospice and palliative medicine, to assess and improve the quality of care, to express to health policymakers and health system administrators how hospice and palliative medicine is systemically beneficial, and to increase the HPM workforce. Unsurprisingly, the focus was always outward, always on the needs of others.

I feel sometimes that a part of my job is to fret. The scope of policy activity at the state and federal level is daunting, and the list of areas in which I feel a responsibility to help AAHPM members make an impact seems to grow exponentially. Maybe this is a natural feeling in the information age, with its unsettling ability to turn unknown unknowns into (the far more frightening) known unknowns, but it’s unpleasant nonetheless.

Fortunately, though, I have an antidote – action. I always feel better when we are advancing the ball on an issue. I love listening in on a Public Policy Committee call or helping a member draft a letter or developing a project outline. I love it. It is the only way to turn those known unknowns into known knowns, and working with known knowns is really the only way to get your hands around an undertaking as vast as the one facing hospice and palliative medicine.

And that’s what I saw today – I saw the genesis of that action. I saw people who have been involved in advocacy for years, people who are just beginning and filled with all the zeal you’d expect, and I saw people who are primed and already planning how they are going to step up and advocate for their field. So, even though I was static pretty much all day, I was in the middle of a huge amount of activity. It was a cycle of sorts – Potential energy. Activation. Kinetic energy.

Patrick Hermes
Manager, Health Policy & Advocacy

Release of NCP Guidelines, 3rd edition

The release today of the 3rd edition of the NCP Guidelines was a wonderful occasion for everyone involved in palliative care, but especially for chaplains. While the palliative care model emphasizes all four dimensions of care- physical, emotional, social and spiritual, it is often the case that the spiritual dimension is neglected in practice. As Betty Ferrell said today, if you are not doing exceptional spiritual care, you are not doing palliative care. The point here is that lots of institutions are claiming to do palliative care without any kind of spiritual care- let alone spiritual care that could be called exceptional.

There are multiple causes of this situation. In general, health care providers are least comfortable dealing with the spiritual dimension of care. It is also clearly true that there is less evidence for the efficacy of spiritual care in the palliative care process than for any of the other domains. Finally, chaplains themselves have contributed by often being unwilling to be team players and be accountable for their practice to a team. Connie Dahlin was correct today when she emphasized the point of how training for palliative care teams has progressed by emphasizing that even chaplains now have certification in palliative care. As usual, we are the last to the party.

The new guidelines give all of us, but especially spiritual care providers, new “evidence” to support our contention that spiritual care should be a full partner in palliative care. Domain 5 which covers spiritual, religious and existential care has been vastly expanded to reflect the results of the National Consensus Project in 2009 and other efforts. The professional chaplaincy organizations in the US have responded by endorsing these guidelines. On behalf of professional chaplains and all who value the spiritual dimension of care, thanks to Betty Ferrell, Connie Dahlin, Diane Meier and the whole task force for their efforts on behalf of the care of the spirit.

George Handzo, BCC, CSSBB

Feeling Sick?

I was sitting in the airport ready to board the plane to New Orleans yesterday and felt ill. OMG I realized I had been masking several symptoms for over a week. This was my first trip to NOLA I couldn’t be sick! Quickly I started web surfing for urgent cares and pharmacies near the Convention Center. All of these locations were less than a one-mile walking distance.

Concentra Urgent Care
318 Baronne Street
New Orleans, LA 70112

900 Canal Street
New Orleans, LA 70112

CVS Pharmacy
800 Canal Street
New Orleans, LA 70112

I feel better now. I hope you all stay well during your visit during the AAHPM and HPNA Annual Assembly.

Patricia Reisinger, MS, CRRN, FNP, GNP
Nurse Practitioner
Spinal Cord Disorders Clinic- ALS
Denver, CO

Behind the Scenes: Lessons in Leadership, Part I: Dancing with Doctors

As I write this post, the AAHPM & HPNA Annual Assembly hasn’t officially started, but I learned important lessons in leadership today. Some I anticipated – others were unexpected – but when I reflect on my day, here’s one that sticks with me (I will share another soon).

I had the opportunity to sit in on a portion of a special pre-course offering entitled, “You’re Not Just a Doctor Anymore: Finding Influence Through Effective Physician Leadership.” This session was sponsored by the AAHPM Leadership Development Committee and the American College Physician Executives (ACPE). The facilitator, Kevin O’Connor, shared a YouTube video featuring an unemployed guy named Matt who set out to do something simple – travel the world and videotape himself dancing at various locations where he visited. Matt’s 14 months and 42 country journey was later edited into a powerful 4 minutes video entitled, Where the Hell is Matt? which has now been viewed by more than 45 million people via YouTube. Since that time, he has returned to many of the same countries to dance again, this time, however, he has replaced his folksy stomp with more culturally appropriate steps taught by locals (see his 2012 video montage for more of Matt dancing, also available on YouTube).

What do Matt’s travels and this unexpected Internet dance sensation have to do with physician leadership? Quite a bit, it turns out – at least according to the pre-course participants. O’Connor suggested dance is a metaphor for leadership and influence which generated an interesting discussion among session participants. Some of the conversation centered around the following concepts and reflections:

· Doing something simple can inspire other to join in – it’s contagious
· Actions motivate; words aren’t always required
· What you set out to do may result in something positive and bigger than you imagine
· There is much to be learned from others if and when we take the time to watch and listen

This prompted further thoughts:

· Who is the “Matt” in your work environment?
· Does this person realize the impact he or she is having?
· How does this apply to the work of physicians in hospice and palliative medicine?
· Does our “happy dance” attract others? Is it sustainable? Does it inspire others to join in?

Sometimes the simple things we do reach people in ways we don’t expect. So keep on dancing.

Steve Smith, CAE
Executive Director/CEO
American Academy of Hospice and Palliative Medicine (AAHPM)

Just One More Degree

You’re Not Just a Doctor Anymore: The New Art of Leadership is a pre-conference workshop I had the pleasure to attend. Everything you didn’t learn in medical and nursing school you learn from Kevin O’Connor, is how it all
started. Mr. O’Conner led with a metaphor that informed and shaped the content for 5 hour session. “What a difference a degree makes! From 211 to 212, water goes from being hot to powering a train. What matters if we add an extra degree to what we do everyday? That email, conversation, or phone call…just one more degree.:”

Mr. O’Conner offered a practical approach and a reframing of mindfulness to our roles as leaders in the organizations we all serve. Not surprisingly the entire session was about relationships.

The Extra Degree Starts Here

These are my take home notes, not to be place in a folder in a box in the basement. Rather these are action points to be incorporated in my daily life and shared in this blog for others who may have like interest in this practical approach to a reframed leadership mindfulness to our own relationships and social styles; personal or professional.
1. Paraphrase as a first response. Shine your light on the other person.
2. Consider questions first before conclusions.
3. Encourage: Affirm what you heard that you liked: You know what I like about what you said… Remember you can build a fire on embers……..focus on their pilot light and perhaps it will glow more
4. Link and connect with the word “and” and not “but”. I also avoid the word “just”.
5. Respond with a thank you or a paraphrase
6. Ask and listen…..everyone loves hearing a good listener
7. Listen in meetings, pause, summarize the content and add in a new thought
8. Know, understand and align with the language of other social styles.
9. Think about the product of the product. The obvious product from the American Girl store is the doll. The
product of the product for the parent is the day of memory making with their daughter. What is the product
of the product of a palliative care consult?
10. Use emotional narrative to get around the prevailing winds of organizational talking points.
11. Demonstrate interest, support and encouragement in others.
12. Be a student and not a teacher.

This workshop has been a transformative experience that lends itself well to the practical implementation in my daily work. I welcome comments and questions about the workshop.

Cory Ingram, M.D.
Assistant Professor of Family and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director – Palliative Care
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System