One chance to get it right! A personal view by Martin Abrams
Revd Martin Abrams, full time hospital chaplain (Southport and Ormskirk Hospital Trust)
Martin is a core member of the Palliative Care Team, attends their regular Multi-Disciplinary Meeting and works with the team within the hospital, hospice and community. He is also a former Methodist representative to the Churches’ Funerals Group
Good Practice, Spiritual Assessment and Communication Skills in Palliative and End of Life Care
In 2013 and 2014 two significant documents were published reflecting on the strengths and weaknesses of the Liverpool Care Pathway (end of life care). The first (in 2013) was the findings of an independent review chaired by Baroness Julia Neuberger and entitled More Care Less Pathway. The following year, the Leadership Alliance for the Care of Dying People published a document entitled One Chance to Get It Right.
Both these documents have influenced greatly the emerging good practice within palliative and end of life care, with One Chance to Get It Right becoming our palliative care team’s working mantra.
It was the Greek philosopher Epictetus (55 – 135 AD) who is attributed with the wise saying, appropriate to all pastoral care: “We have two ears and one mouth so that we can listen twice as much as we speak.”
If a multi-disciplinary palliative care team is to have any chance of fulfilling the principle of one chance to get it right, it clearly has to do a lot of listening with a patient, their family and others important to them.
Part of the listening process involves a spiritual assessment, which enquires about what spiritual, psychological and religious support a patient, and those important to them, may appreciate.
If, following a spiritual assessment, spiritual needs are identified, the chaplain, minister or pastoral carer responding clearly has a lot more listening to do to understand a person’s needs.
The spiritual carer’s response should never be a prescription of set prayers and readings, but a person-centred encounter in which the aim is to understand what is important to a person in those moments. This may lead to a traditional religious blessing with prayers and readings, but it may not.
Health care professions are also encouraged to recognise that a person’s needs and responses can change very quickly, and “no support required” one day can very quickly become something quite different the next.
Within the toolbox of listening skills, open questions have a key role. Sometimes out of nervousness, fear of the situation, or what might be said in response, it is all too easy for a carer to make a statement or ask a closed question. This will inevitably elicit a one word, or very short, answer. For example, the statement: “I imagine you are feeling fairly down at the moment?” Or asking: “Are you feeling down at the moment?” which, as well as suggesting how we think a person may feel, will simply prompt a one word answer. However, saying and asking something like “I really want to offer you the support that is best to you, so please tell me your story?” or “How are things at the moment?” can prompt a lot of very helpful responses, which can be followed by other open questions.
Open questions also show a genuine interest in a person and what they are thinking and feeling. Of course, listening to the answer is very important, as is picking up the cues a person gives as to what is important to them in those moments. All this enhances the opportunity of offering the right response to the person.
One of my well used questions is: “What would make a difference to you now?” The strength of this question is that it can quickly help assess what is significant to a person in that moment.
We may, for example, visit a person of great faith, who we know well, and expect an ongoing conversation debating the theological issues relating to suffering, death and dying in the context of prayer and hope-filled bible readings. If the answer to the above question comes back as “a drink”, or “shut that window,” or “how do I tell my partner what I am feeling?” or “help me, as I have lost all my faith”, immediately this becomes a person-centred encounter with the conversation agenda set by the person.
The above question has, as well as the above replies, prompted many other responses, some predictable and some surprising, including:
- A Rapid End of Life Transfer to the person’s home, or another Preferred Place of Care, which, if practical can be arranged in hours, 7 days a week. This is in fact a regular occurrence
- A relationship blessing of a patient’s relatives in a hospital room, so a patient can be part of the celebration and the security of their commitment
- The wedding of the patient and their partner (which can be arranged in days, or sometimes hours) or a marriage blessing and prayers said for the future of the dying partner and the surviving partner
- Drinking Champagne and celebrating life with family and friends as the patient wanted to be at their own “wake”
- Arranging for pets to visit
- Traditional prayers and blessings
- Support for a committed atheist, who always said when his time came he would want to meet the chaplain
- Funeral or Life Celebration planning
- Other ways of creating memories including photographs with family and friends, special films watched together and significant music listened to.
Little of the above happens without good communication skills and a real commitment to the recognition that there is only one chance to get it right.
For all involved in palliative care and supporting people at the end of life, in which faith communities have a significant part to play, it is important to make a priority of the privilege offered and recognise that palliative care is not only support for dying well but also for living well in whatever time is available.