Episcopal Chaplain at the Bedside

General Convention 2009: How Health Measures are Faring

2009-07-14T02:03:00.002-05:00

As I’ve been at General Convention, I’ve been following some of the resolutions related to health, including those I have blogged about. Some of those matters have already been passed in General Convention, with perhaps some small changes.

Most important to me was Resolution D011, “End of Life: Principles for Decisions at the End of Life.” This was the same resolution I wrote for the 2006 General Convention, that was lost uncompleted at the end of business. (You can find the final version here; and my 2006 blog post here.) It was passed in the House of Bishops first, and was so strongly supported that it was presented in the Consent Calendar, as a resolution that should pass and isn’t subject to debate. While I would have loved to speak to this in the House (and did in the Legislative Committee), I was pleased that the Committee thought this so worthwhile. Among other things, it commends chaplains in AEHC and health ministers in NEHM, as well as chaplains and counselors certified by APC, ACPE, AAPC, and CPSP, as resources for the Church in areas of health care and ethical issues.

Another was Resolution A077, “Episcopal Health Ministries.” This was proposed by the Standing Commission on Health, and “urges the congregations of The Episcopal Church, which have not already done so, to explore and implement health ministry as an organizing concept or vital component of outreach and pastoral care of the congregations by 2012….” It was also passed as part of the Consent Calendar. (You can find the final form of the Resolution here. You can find my blog post here.)

In addition, three of the resolutions from the Executive COUncil Committee on HIV/AIDS have been adopted. Resolutions 159, 160, and 161 have all been approved in both houses. (I wrote about them here.)

This is just a brief update, but I’m trying to follow these issues. Last Convention was a tough one for health issues, because many were squeezed out by the time spent on responding to the Windsor Report and the wider Anglican Communion. This Convention is looking a whole lot better. Keep watching this space.

Reflections on the Voting on D025 - or Getting Past B033

2009-07-13T01:04:00.000-05:00

From the floor of Deputies:

We have come on Sunday of all days to discuss the ordination of bishops in the Episcopal Church – or, really, the ordination of partnered gay and lesbian bishops, for there is no other issue in general regarding the ordination of bishops. Indeed, we aren’t really discussing that, either. We’re actually discussing D025, titled, “Anglican Communion: Commitment and Witness to Anglican Communion.” The real issue is a resolution from 2006, B033. That was the resolution that called for bishops and Standing Committees of dioceses to “exercise restraint” in consenting to the election of a bishop whose “manner of life” would displease Anglicans elsewhere.

The legislative committee on World Mission considered three sorts of resolutions. Some would simply repeal or rescind B033. Some would make a positive statement about not allowing discrimination in admission to discernment for any office, ordained or lay. Some would make a broader statement. They chose D025 as the broadest response.

Interestingly enough, D025 doesn’t speak to 2006-B033. It doesn’t repeal or rescind it. Rather, it speaks of openness in discernment. It also speaks of maintaining as best we can our relationships with other Anglicans around the world, including financial support. It also speaks of the ministries we already see of gay, lesbian, bisexual, and transgendered persons in the Church, and the way that folks in those ministries have demonstrated the gifts of the Spirit.

As when we heard so many voices two days ago, there aren’t really any new points being made. Once again the points made are made with passion, and with clarity. One could speak of “the usual suspects;” that is, voices from dioceses that have been pushing the Church toward inclusion support the resolution. Voices from dioceses that have been anxious, both about Scriptural issues about inclusion of glbt persons and about relations with those parts of the Anglican Communion that are unhappy with us, do not support it.

Interestingly enough, folks from both ends speak of sacrifice, and about who within our own ranks will be lost – some literally, driven to leave the Episcopal Church because it is too slow in embracing all the baptized or because it is too fast in incorporating all the baptized. Several times reference has been made to the image of a plane, requiring two wings to fly. The image is clear, of course, as is the concern: just who can we “afford” to lose – and I put that in quotes because any loss isn’t good or even acceptable, even if comprehensible.

And yet now and again there is something more positive. There has been a person who read the story of Jesus healing at the pool at Bethesda, and ended by calling for the House to “sin no more so that nothing more bad may happen to us;” but although she self-identified as being against the measure, I have to admit I wasn’t clear on how she meant that. There has been a person supporting the measure whose tone was not simply earnest but hopeful. There was the person who stated, “In the first place readiness for many has nothing to do with our baptismal vow,” which seems a rather odd thing to say; or, better, an odd way to say that baptism in and of itself doesn’t qualify one for ordination, which I think is what the person meant.

We’re operating under a special order, and not simply the Rules of the House of Deputies. So we’ve had thirty minutes of testimony before anyone might offer an amendment.

There has been a call for a vote by orders. When we vote, then, the clergy deputies of our diocese and the lay deputies will confer separately, and will each offer a single, separate vote. In an interesting constitutional maneuver, there has been a request to divide the resolution into two parts. That is, each part would be voted on separately, and could stand or fall independently. Essentially, the point chosen would separate our affirmation of our life in the Anglican Communion from our affirmation of the glbt persons in our midst and are accession to our Constitution and Canons in opening discernment for ministry. So, the first part could pass (and it almost certainly would), while the second part could fail (which I doubt it would, but it would be much closer). Moreover, there has been call for a vote by orders on the motion to divide.

And of course all this takes time. We’ve already clarified that the time for these voting machinations aren’t taking time from time for debate or amendment. We haven’t discussed how much energy it’s taking from the members of the House.

I will spare you the machinations. I expect they will in fact carry on for a while. Suffice to say that something will happen, and many of you will see it in the news before you see my comments here. But I want to tell you two things. First, everyone is quite serious. No one is casual, and no one is flippant. The house is intent, if not yet intense.

Second, it is hard to hear in the midst of so much talk of sacrifice those voices that speak of mission. No one considers mission irrelevant. Every person thinks this will in one way or another affect our ability to do God’s work. But few are actually speaking of that.

But then few are actually speaking. Most of us are paying attention, voting when called upon, and hoping: hoping that we can indeed focus again on mission. Most of us indeed seem to want “to get past this.” We’re just not agreed on what we’ll find past this when we get there.
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And now we’ve voted – and while we wait for the results of the vote by orders, we’re trying to get on with the business of the house. There is certainly other business to do, and even important business. Still, our attention is divided while we wait….
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The motion has passed, and passed with a margin of roughly 70% to 30 %. The rules of the House of Deputies do not allow for applause, and there is none. That may be due as much to exhaustion as to the rules. Rather, there is prayer and departure, for the legislative day has ended.

I was a visitor in the House of Deputies in 1976 when the change to Canons allowed for the ordination of women to the priesthood. I was an exhibitor in 1979 when the Prayer Book was approved. I was a visitor in 1982 to see the debate and approval of the Hymnal. I was sitting in the Alternate gallery in 2006 when B033 was approved. And now I was a Deputy, voting on this. I have a feeling that this is another event in the life of the Church that I will be talking about in years to come..

Reflections on the Conversations on B033

2009-07-11T10:58:00.002-05:00

Matins

Even as I write, I sit in the House of Deputies. We are meeting as a Committee of the Whole, hearing how many among us have seen the results of passage of B033 at the end of General Convention in 2006. I say “hearing” rather than “discussing,” because while many are speaking, it is not technically “debate.” I am not among those planning to speak. I simply feel others will say what I would say, and perhaps say it better. I am happy to listen; and listening, let me share some reflections.

First, I am not particularly struck by the opinions. Oh, they’re articulate and well thought through. It’s just that there’s nothing new in them. We’ve heard them before. I don’t say this to be dismissive but descriptive. While some are speaking from microphones who have not spoken so publically as those of us in the blogosphere, they’re saying things that have been said here. Oh, there are the occasional surprises. There was the deputy who spoke of just how resilient our Communion is, with bonds of affection based on the personal relationships shaped by the Millennium Development Goals. There was the deputy who chose an interesting image of B033 as “the crucible of adaptive change.” But most of the statements made familiar points.

So, what strikes me is the continuing passion, the audible pain and anxiety that were quite clear. Many speak of sacrifice – of the sacrifice of people, the sacrifice of relationships, the sacrifice of the Communion. Many speak of cost – of cost in lives, of cost in relationships, of cost in ministries and vocations lost. No one speaking – no one - is casual, and no one is dismissive. Of course, the pain being what it is, I don’t know that those most engaged don’t still feel dismissed. I rather expect they do.

At some point, we will address this with a resolution. It will be a clear instance in which we will do that because it is our process, and not because it’s ideal. It would perhaps be ideal to seek consensus. It would also be a clear sign of the presence of the Spirit. It would be a sign of the coming of the Kingdom, and I for one would be waiting for the roof to roll back and the heavens to open and the dead in Christ to rise. We are not sufficiently in one place to come to consensus, common thought and feeling. The voices are making that clear. There are perhaps more speaking of, in some sense, moving beyond B033 than there are speaking of staying where we are. But, the number calling, sometimes pleading to stay where we are, is enough to indicate a significant, and not a tiny minority. Where shall we go from here? Yet, the one thing we cannot do is stay here.
_____________________________________________________________________________ComplineThe Compline

The day has passed, and I’m back in my hotel room. However, this morning’s discussion took me back a few days. My first day of Convention started early, and not in Anaheim. I began with a morning flight. I roused early, and made my plane. My only mistake cost me my pocket knife – again. However, I had chosen the particular pocket knife specifically because I wouldn’t be devastated if I lost it.

As the ground below me went from green to tan to red, I did some studying – studying that I hadn’t been able to do up to this point. Oh, I’ve had the materials. I just haven’t had the time. While folks in the hospital wouldn’t disapprove of me taking time to study for Convention ahead of time, the patients simply wouldn’t stop coming. What can one say? And so my time was committed to matters more immediate.

The theme of this Convention is “ubuntu.” Of course, in all my convention material the word is capitalized. However, I haven’t done so here because the word is first a concept, and not a title. It’s most common meaning – common in the sense of most often quoted – is “I am because we are; and because we are, I am.” The real meaning is broader than that. It really encompasses a statement that personhood is only known in community. I can’t be me apart from participation of and with others. It might be called a “communitarian” position, somewhere between our sense of Western individualism and cultures in which the community is all in all.

We first heard it in context of the Lambeth Conference. It was intended to give us some sense as Anglicans of interdependence. It was tied to the Gospel of John, who spoke of us being in Jesus as he is in the Father and the Father in him; and to Paul’s image of the Body: “The eye cannot say to the hand, ‘I have no need of you.’”

All of which made it rather hard for everyone to really embrace. Oh, great statements were made, but few changes. There were those who weren’t there, functionally saying, “I have no need of them.” There were those who were there but saying, “I have need of you, as soon as you fall in line.” There were those who were there but saying, “I really want to be with you, but if need be I’ll do without.”

And now it is the theme of the 76th General Convention of the Episcopal Church. Some things are the same. There are those who were with us three years ago who have departed, saying, “I have no need of you.” There are those present prepared to say, “I really want to be with you, but if need be I’ll do without.” And while no one said, “I have need of you, as soon as you fall in line,” some said, “I fear they will have no need of us if we don’t fall in line.”

We do not do community well in America. Some talk about our militant individualism, as if we’ve lost touch with what it means to be defined in relation to a community. I can see that, but I sometimes think it’s just the opposite: that many of us have experienced what it has meant to be defined by a community – call it our small town, or our family, or our class – and defined as outcast, and we’ve wanted to flee away. We are not so much individualists because we have no sense of community, as much as we believe we are recovering from community by being individuals.

And so this morning voices were heard, all of whom felt they were speaking of being included in an important relationship. The many who spoke moving beyond B033 did so to feel included, or to include another, in the Body of Christ in the Episcopal Church. The smaller number who spoke of staying with B033, believing we could do so without abandoning GLBT Episcopalians, almost to a person spoke of being included in the Body of Christ in the Anglican Communion. And everyone – virtually everyone – spoke of sacrifice.

“Ubuntu” – the idea that we are who we are most fully in the context of community, and the community is most fully complete with we are all in it – is more than the theme of Convention. It is a Gospel value. It is the Biblical norm, both for Israel and for the early Christian community. We are indeed called to it, however confusing and confounding it may seem to us. The difficulty, a difficulty that is clearly painful, is to figure out how we can embrace it. For many have come to a point of knowing that this must involve sacrifice and risk, while feeling that they have already risked more than they can afford to lose.

Daily Notes on General Convention

2009-07-11T01:43:00.004-05:00

I haven't written a lot here about General Convention. In part, that's because I've been writing elsewhere. A colleague and I are alternating writing on our diocesan web site about General Convention. If you'd like to see those, check out things here. I'm writing reports for even days (Days 2 and 4 so far), while my colleague is writing the odd numbered days. Feel free to read both.

If you're looking for other sources, the ones I recommend are the Episcopal News Service and the Episcopal Cafe. I would encourage also to look at other diocesan web sites. Many dioceses have someone writing regularly, whether bishops, deputies, or both; and that variety of writers will give a better perspective on feelings and perceptions, and not just the news items.

General Convention is a significant event every three years, and a lot of people are involved. Take some time to hear those voices.

Acceptable Sacrifices

2009-07-10T11:10:00.002-05:00

I have to admit that I haven’t had as much time to post here, what with the other things I’m doing this week. I’m especially aware of that as I hear bits and pieces on the news of other events in the business of health care.

One item that caught my attention was the report that representatives of the American Hospital Association had told the White House and Congress that hospitals would accept significant cuts in Medicare and Medicaid over the next ten years in support of a plan for universal access to health care.

For years now hospitals especially have struggled with the Medicare and Medicaid payments they’ve been receiving. That’s because the payments were set at a percentage of what the folks at the Centers for Medicare/Medicaid Services (CMS) thought costs ought to be (as opposed to paying fully what the costs actually were). While there are worse payers than Medicare and Medicaid, they’re big players; and their restrictions have helped make economics tight for everybody.

So, why would they accept these cuts? Because they’re hoping for a big jump in economies of scale. With roughly 40 million folks un- or underinsured, hospitals are losing 100% of the costs for many of those patients. If they can get something for those patients, even if it’s only, say, 60%, that will make up – perhaps more than make up – the lost increases from Medicare and Medicaid.

Remember that one of the ongoing issues in paying for health care is cost shifting. It’s basically the same consideration retail folks have for loss and petty theft: you know you’re going to have some marginal losses, so you raise the price of everything so that what you do sell will cover your costs. In health care the principle is the same, even if the dollar values are much greater. If hospitals are losing out entirely for some patients - and for some institutions this can run to millions of dollars – they have to raise their rates to cover the gaps. Since this raises all their rates, and since all institutions in a given economic area have the same pressures, that effectively raises costs, and so the value of the percentage they do receive from Medicare and Medicaid.

So, if there is coverage for those 40 million or so un- or underinsured, or even for a large percentage of them, that will provide revenue for hospitals that they aren’t getting now. With this new revenue where previously there was total loss, there will be less need to cost shift. So, the lower increases from Medicare and Medicaid will be acceptable.

That said, this all hangs on passing something like universal access to health care. If that doesn’t happen, the hospitals can’t accept the change. On the other hand, I think the hospitals will get enough to really help. After all, as we’re more and more aware, none of us will be able to accept the consequences of not changing.

It's Great, but It's Not Exactly the Same

2009-07-08T16:58:00.001-05:00

One of the best things about General Convention is worship. The daily Eucharists are thrilling. They reflect the diversity of the Episcopal Church. It’s initially a bit jarring, certainly, to go from a psalm in English to the Gospel read in Spanish. After that first moment, though, it’s intensely satisfying. We are a diverse Church, and yet we can worship together without losing anyone’s integrity.

The music is just as diverse. We will hear rhythms that few of us hear regularly. We will be exposed to texts and tongues that few of us would hear at all otherwise. I collect the worship booklets to take home and share with parish clergy, hoping it will inspire them to some experimentation – some modest, well considered experimentation – in worship.

One difference between the Eucharists this year and those in 2006 has been the absence of movement after the sermon. In 2006 each day once the sermon was over a noticeable group of folks would rise and work their way out of the worship space. They were, by and large, on their way to an alternative daily Eucharist offered by some who were dissatisfied with the direction they saw General Convention taking.

My reaction to their absence this year is mixed. On the one hand, I’m saddened. They aren’t leaving this year because they aren’t here in the first place. Many have found their ways to other ecclesial bodies outside the Episcopal Church and arguably unrecognized by the Anglican Communion. They have despaired of feeling a place within the Episcopal Church. They have despaired, in many cases, of us entirely.

At the same time, I have to admit that it’s a joy to be worshipping together as one without such public demonstrations of separateness. I could not help then but see it as a distraction. I am happy not to have the distraction now.

That said, I will have to reflect a little sadness. These actions were perhaps a distraction, but the people were not. They were members of the Episcopal Church, however dissatisfied; and they continue to be members of the Body of Christ. I don’t expect I will see it; but perhaps in a generation those after me will see some reconciliation. I still think things will be more complete when once again they feel they can worship with us.

Universal Access: More Than One Model

2009-07-04T22:22:00.002-05:00

I have commented before about the narrowness of the arguments about universal access to health care. What I mean is that most of the time the examples are limited to three. There are arguments about the Canadian model and the British model – usually discussions of their limitations – and about the American model – usually its strengths, although it isn’t really a model of universal access. I have commented before that other nations have other models, and manage to provide universal access to care, almost always at less expense as a percentage of GDP, and almost always with better outcome statistics.

An article in today’s Kansas City Star, my hometown paper, tries to address this. The author, Scott Canon, has looked at a variety of models. He’s also sought comments from a variety of experts on them.

This is a comment article in a paper, and not a scholarly review. On the other hand, it’s the first effort I’ve seen at least trying to show that other nations are using a variety of tools to offer provide universal access. Each model has its strengths and limitations. Each involves some hard political decision-making, and some rationing. On the other hand, our model also involves some hard political decision-making, and involves rationing, however hard we try to deny it.

Take a look at the article. It won’t resolve arguments one way or another. However, it will offer images of more than just three ways of addressing health care needs. That by itself is worth the time and trouble.

On Professionals Praying With Patients

2009-07-02T22:44:00.001-05:00

In an off-topic response to my last post, Frank asked this question:

My dad has been in a discussion on another blog about whether a doctor should ask a patient if he could pray for the patient. My mom and dad are very much opposed to a doctor asking a patient if he can pray for the patient. Others think it is fine for the doctor to ask that. Are there any rules at hospitals on this subject?

I have two experiences that I think about with this question. One is the story of a colleague, who spoke of a pre-op visit with a patient. The patient commented that she hoped her surgeon was a good Christian. He answered, “At the moment, ma’am, you’d better hope he’s a good technician.”

The second is the portion of my orientation of new staff that addresses our System’s policy, “Protection of Religious and Cultural Rights and Beliefs.” I comment that my goal is that the hospital be a “spiritually safe place;” which is to say a place where each person can be the same person spiritually in the hospital that the person would be elsewhere. I then note that I’m not the only person who pays attention to spiritual care. I note that many professionals pray for patients; while a few besides me also pray with patients.

Part of that discussion is the need to really think “protection” when we think of a spiritually safe place for patients and/or families. It might seem trivially true, but it has also been studied. Patients are anxious, and don’t want to upset the people taking care of them. That raises the risk that they will say what they think we want to hear. For the hospital to be a “spiritually safe place,” we really do need to think about protecting that space.

That said, I find in my own work that many folks can accept as an expression of good will the thought that someone might pray for them, even if they would not pray themselves or want the other person to pray with them. Sometimes, too, they will ask for prayer or indicate that they value prayer. My own thought is that if they ask, and the person asked is both free to accept or decline, and also feels appropriate participating, praying with the patient, or being present while the patient prays, is okay. Now, if you think that through, that in most circumstances suggests that the patient from his or her position of vulnerability can ask the staff; but the staff person from his or her position of power cannot ask the patient.

Now, there is another dynamic in play here. In the last decade or so health care professionals other than chaplains have been thinking about how the spiritual lives of both patients and professionals affect both relationships and outcomes in health care. Nurses have actually been including this in their professional discussions for some time. However, physicians, psychiatrists, social workers, and counselors have also been thinking about the effects of spirituality in their work. In most instances this isn’t a discussion of faith or miraculous healing. Rather, it’s recognition that for many individuals spiritual beliefs influence how they live their lives and make decisions.

One consequence has been that physicians of faith have felt less pressure to hide. They have been prepared to acknowledge that prayer is an important part of their lives, and that they pray for their patients, and for help carrying out procedures. Again, for many patients this is simply a statement of good intention, and they’re not offended. Some do indeed find it comforting. So, consider this conversation:

Patient: I know things are in God’s hands, and that things will be all right.

Physician: Well, I will be praying for that as we go to the OR.

Patient: I’m glad to hear that. Could we pray together?

Contrast it with this conversation:

Physician: I just wanted you to know that I pray before all my surgeries.

Patient: That’s good.

Physician: May I pray with you?

I think the latter conversation verges on manipulation. Again, if we consider that the patient might well say what we want to hear (and what patient wants to offend his surgeon, however slightly, just before the procedure?), the second conversation is questionable. But is the first? The doctor has responded to a comment from the patient with a statement about his own practice, with no expectation of the patient. If the patient then makes the request and the doctor feels comfortable participating, is this a bad thing? It arguably strengthens the doctor-patient relationship. It supports the patient’s hope and lowers stress, both of which have been shown to support health and wholeness.

There are some hospitals that have a culture that discourages professionals other than chaplains or clergy from praying with patients. Those institutions feel that’s necessary to respect and protect the spiritual beliefs of the patient. They may or may not have an explicit policy; but corporate culture can be very clear and very powerful. In some environments chaplains feel they have to be the clearest enforcers of such policies. They distrust the judgments of the other professionals around them, fearing that they will jump too quickly to suggest their own spiritual perspectives instead of respecting the patients’, mostly because they simply imagine that everyone will agree with them, or at least understand them.

In my own setting, I don’t have that fear. New staff members do get orientation from me on the subject, including explicit directions against evangelizing or proselytizing. They also get diversity training as part of their orientation; and I connect to this by noting that our religious and cultural beliefs are simply another category of diversity that the System expects us as employees to respect.

Now, doctors don’t have that orientation. At the same time, they are offered opportunities for diversity training, and hear regularly that respect for diversity is a central tenet of the System. My sense is, both in my own institution and in others, physicians praying with patients are uncommon (although I can well imagine that many are praying for patients). For those who do, if they do that in a context that’s not manipulative and that satisfies the patient, I’m comfortable. If I were to learn that is was manipulative, that would be another thing altogether – one that I’d probably find myself in the middle of, at least in my institution.

Like so many things that happen in health care, prayer with a patient is one that can be done appropriately or inappropriately. More doctors feel free to be authentic about their own faiths, and I think that’s a good thing. If they can be authentic about their own faiths, and also respect the faiths of their patients, that’s even better.

General Convention 2009: Pet Grief

2009-06-30T22:16:00.002-05:00

I continue to look through legislation submitted to General Convention, looking for resolutions on health care or otherwise of interest to chaplains. After all, new resolutions are being submitted every day.

While I haven’t found any new resolutions on health care, I have found some of interest to chaplains. One of those is Resolution C078, submitted by the Diocese of Montana. It is titled, “Liturgy for Loss of Companion Animal,” and reads as follows:

Resolved, the House of _______ concurring, That this 76th General Convention reaffirm that all animals are a part of All Creation, for which we are called to be stewards of God's gifts; and be it further

Resolved, That the Episcopal Church embrace the opportunity for pastoral care for people who grieve the loss of a companion animal; and be it further

Resolved, That this General Convention direct the Standing Commission on Liturgy and Music to develop a rite to observe the loss of a companion animal for inclusion in the next edition of the Book of Occasional Services and that it report its work to the 77th General Convention.

This resolution speaks distinctly to an important change that has taken place in our society. When most Americans were rural and agricultural, the animals around them tended to be either tools or hazards. There were the animals kept to produce meat or fiber. There were animals kept as tools, whether as beasts of burden or herding animals or controllers of vermin. There were animals that were simply hazards, whether to health or to crops. There were some animals that might be either hazards or food sources, depending on how they interacted with human agriculture.

Note, though, that none of these were pets. People might become quite fond of them – note how upset we all became about Old Yeller – but they were rarely confused about how they were to be treated and used. No matter how well tended or loved the bull calf, everyone knew from the beginning that eventually he would be slaughtered or sold. No matter how well loved the dog, she lived in the kennel at the back and not in the bedroom.

While that understanding of how humans and animals relate isn’t gone completely, it’s no longer the most common experience. Most of us have companion animals – pets – and not livestock. There are also service animals that share the lives of many. However, the relationships between service animals and those they serve reflect more often the intimacy of pets than the utility of livestock. For most of us, the animals in our homes are not tools but members of the family. We attribute a certain level of personhood to them. For many they are intimate companions, listeners who don’t interrupt, and providers of unlimited affection. For some they become like children, but children who never grow up and leave, who never move beyond their need of us.

With that in mind, I think it important to take seriously grief at the death of a companion animal. I know from both personal and professional experience that the sense of loss is real and significant in the lives of those who lose the animal. This is often heightened by a greater sense of responsibility; for, all too often, we discern suffering in our companion animals as best we can, and choose to end suffering with euthanasia. We have, as I said, attributed some personhood to these animals. We have taken responsibility for their lives, and frequently for their deaths. The grief that we experience in these relationships and these decisions is meaningful in our lives. We have to go through the same grief processes in these losses that we do in any other.

It is also true that often those around us are not as able to empathize for the loss of a companion animal as they are for the loss of a human companion or family member. It is also common that those grieving loss of a companion animal expect less empathy, and so make it so by being less ready to reach out for support. In either case, there may be a particular experience of isolation in grieving a pet or service animal.

These are all reasons for Episcopalians, both clergy and lay, to take seriously grief at the loss of a companion animal, and to offer compassion and support, as well as to seek support when we grieve ourselves. That said, we can consider as a separable question whether the Church ought to establish an official rite for this circumstance for inclusion in the Book of Occasional Services. The authors of the resolution offer this explanation for the resolution:

Various groups within the Church have shown an interest in developing inclusive liturgies for events that touch people's lives, for which there currently exists no authorized rite. The bond between humans and their animal companions can be strong, causing a deep sense of loss, grief (or even guilt) over the animal's death, especially when dealing with the loss alone, without the presence of their community of faith, or having the preconception that such an event falls outside the interest of their church. Our animal companions provide a unique connection to creation and expand our sense of God's diverse gifts in creation. In many cases they also join us as partners in ministry, in such capacities as assistance animals, i.e., seeing eye dogs, etc. as well as therapy dogs and cats used in health care facilities and for pastoral care. An authorized rite in the Book of Occasional Services would give clergy and others a resource for offering pastoral care at the death of a companion animal.

I would certainly agree with the assertions in this explanation. That said, I don’t know whether we really need an authorized rite for “a resource for offering pastoral care at the death of a companion animal.” First and foremost, as a chaplain I’m conscious that the most important act in pastoral care is quiet, sensitive listening. I am certainly prepared to offer a rite; but it’s not the first step. Moreover, while we understand clearly in our worship tradition that some services require clergy leadership while others decidedly do not, formation of a single “approved” rite would tend to narrow our response and to focus on what liturgical leaders do, instead of what we can all do. Parents have been formulating rites for years for the death of a pet. As we appreciate that the reality of grief at the loss of a companion animal isn’t only the experience of children, we can appreciate the capacity of adults to formulate appropriate prayers to honor the losses in their own situations. As an aside, I am not aware of discussion at this point of a revision of the Book of Occasional Services. Such a rite might be seen more quickly if proposed for trial use as a part of the literature of Enriching Our Worship.

I was a visitor to General Convention in New Orleans in 1982, and was present in the House of Deputies as the Hymnal 1982 was debated and tweaked. When a deputy moved to amend to add “He’s God the Whole World In His Hands” to the Hymnal, a member of the Commission noted that it had been considered and rejected. What was important was the reason it was rejected. That was because that much beloved hymn for children is at its best when those participating were customizing it, adding verses in the moment appropriate to the folks participating. He noted then that for our hymnody we were not restricted to the Hymnal, or to other music specifically approved by the General Convention. I would suggest we are in a similar case here. Burial of the Dead is not a sacramental rite, and we already read the rubrics for that rite with some significant latitude. We have latitude as well to create prayers for situations not addressed in the Prayer Book. I think we can use that latitude creatively to mourn the death of a companion animal, whether alone or in a congregation.

I would be interested to see how this gets through the committee process. I think the occasion for this resolution is real. I don’t know that this makes a specific, approved rite necessary.

General Convention 2009: Mental Health (Health Issues 7)

2009-06-24T13:21:00.002-05:00

In my last post on General Convention and health, I highlighted resolution C071, titled “Health Care Coverage for All,” submitted by the Diocese of East Tennessee. I also noted that there was a second resolution on health from East Tennessee. That resolution is C073, titled, “Re-evaluation of Care for Mentally Ill.” The resolution itself is brief enough to include in full.

Resolved, the House of _______ concurring, That the 76th General Convention recognize the urgent need to find a way to effect a re-evaluation by the appropriate federal, state and local agencies of the care and long-term treatment of the chronically mentally ill members of our communities; and be it further

Resolved, That this resolution be the beginning of a mission for our country led by the Episcopal Church to develop an action plan with the help of mental health professionals, government officials and church leaders, and other appropriate partners to find ways for communities to move forward with concrete steps to deal with these issues without moving backward into the abuses of the past.

In the explanation, the writers of the resolution made reference to the Community Mental Health Center Construction Act of October 31, 1963. The point of the act was to reduce the number of psychiatric patients were kept, and often simply warehoused, in state psychiatric institutions, and to make treatment available to those patients in their own communities. The thought was that this offered several benefits. It would make it possible for patients to have access to family support. With psychiatric care centralized in state hospitals, often far from family, this could be difficult (and still can be; in Kansas there are two state hospitals still open, both in the easternmost quarter of the state. For families living in the western half of the state, it can be a long drive.). Second, it was thought that with new medications many patients could function in society, well enough to live at home, and sometimes well enough to live alone and be gainfully employed.

I grew up in East Tennessee, and I well remember the state hospital in Knoxville, then known as Eastern State Psychiatric Hospital, or more often just Eastern State. I also well remember when some effort was made to implement the principles of the Community Mental Health Center Construction Act. In Tennessee that took place in the early 1970’s. The governor at the time, Winfield Dunn, was a dentist; and he appointed a psychiatrist to be his Director of Mental Health Services. There was great enthusiasm at the time.

Unfortunately, as the writers of the resolution note in the Explanation, “The mental health care centers that were developed lacked the resources necessary to accomplish their task, thus creating in these past 46 years a large group of people living in degrading homelessness where those with emotional and mental problems have few resources and services, very little follow-up care and no long-term care.” As I recall, state legislators found it exciting to save money by reducing expenses at the state hospitals. They just didn’t find it sufficiently exciting to spend that money in developing community mental health resources. Oh, the centers were built and programs were established; but never with enough staff and never with enough money. The results were in fact two-fold. On the one hand, there weren’t enough community mental health resources to really support those who could live in the community. On the other, there were no longer sufficient resources for those whose friends, families, and caregivers learned really couldn’t live in the community, because the programs of the state hospitals were so curtailed. That was the squeeze that resulted in the “degrading homelessness” the writers identify.

While there have been other issues, that homelessness has been a problem of particular note. It has resulted, I believe, not only in the significant percentage of the chronically homeless who have psychiatric needs, but also in the number of people incarcerated who need psychiatric care. And, notwithstanding the frequent comment that the largest providers of mental health services are now correctional institutions, it’s care that they don’t always receive.

This is a subject General Convention has addressed in the past. Resolution 1985-D127, “Support Ministry to the Homeless Who Are Mentally Ill,” directed

That the 68th General Convention instruct appropriate Executive Council staff to develop and make available to the Church educational resources regarding the plight of homeless people, including those who are mentally ill; to establish, in cooperation with dioceses, Jubilee Centers, local parishes, the social agencies of this Church, other social agencies and the mental health care delivery system, a means of providing assistance for these individuals who are without an adequate support system to meet their needs for care and supervision; and to develop a program of advocacy with other existing organizations on behalf of such homeless people.

Resolution 1991-D088, “Encourage Understanding of Mental Illness and Respond to the Needs of the Mentally Ill,” called for Episcopalians “to become knowledgeable about mental illness…, to reach out, welcome, include and support persons with a mental illness…, to equip the clergy and laity for ministry to the mentally ill and their families and that clergy and lay ministers seek out training and opportunities to minister to the spiritual needs of those who are affected by a mental illness…” among other steps. This was reaffirmed in resolution 2000-C032, “Urge Congregations to Commend and Support Mental Health Support Groups,” with the added suggestion that congregations offer facilities to such support groups. In addition, the important resolutions of past General Conventions on universal access to health care have consistently called for equal and adequate care for mental health as for physical health.

Adequate mental health care continues to be an important issue for our society, with many ramifications. If we can make progress toward universal access to health care, and especially toward parity between care for physical and mental health, we can hope for meaningful changes. This resolution would reaffirm the Episcopal Church’s support for adequate mental health care for all, and especially for those who are homeless or living in inadequate circumstances. Sounds worthy to me.

Published at PlainViews

2009-06-17T09:40:00.003-05:00

I have a new piece that has appeared in PlainViews, the online journal for chaplains. The subject will be familiar to my regular readers: being a research-informed chaplain. You can read it here.

If you're a chaplain who stops here and you haven't yet looked at PlainViews, I encourage you to spend some time reading there. PlainViews had information and opinions from and for chaplains on a wide variety of topics. You can read the current edition, certainly; but also scroll down to the bottom of the page and check out the Archives. There are many things there worth reading, and most will take only a few minutes.

If you're looking here having linked from PlainViews, welcome. If you'll look to the left column under "Labels," you'll see categories I've used to sort my posts. That can help you sort through and focus on topics you're interested in. Stay a while, read some, and leave me a comment.

General Convention 2009: Health Issues 6

2009-06-15T21:34:00.002-05:00

I have written a number of posts about resolutions to General Convention that related to health care, or that might be of interest to chaplains. To this point, those resolutions have been “A” resolutions coming from one of the Commissions, Committees, Agencies, and Boards (CCAB’s) of the Church. However, I have continued to review resolutions as they are posted on the General Convention’s web site to note any others that would be relevant.

To date I have discovered two, both “C” resolutions submitted by the Diocese of East Tennessee. The first is C071, titled “Health Care Coverage for All.” As I have noted, the Report of the Standing Commission on Health did echo the consistent statements of the General Convention in support of universal access to health care. However, the Report did not include a resolution on the topic. Thus, Resolution C071 speaks again to that concern. It reads as follows:

Resolved, the House of _______ concurring, That the 76th General Convention call on its congregations to undertake discussions within the parish of the issue of health care coverage in the United States, including:

a) recognition that health is multi-dimensional, with spiritual, social, environmental, and mental elements as well as physical,

b) reminder of personal responsibility for healthy life choices and concern for maintaining one's own health,

c) proclaiming the Gospel message of concern for others which extends to concern for their physical health as well as spiritual well-being,

d) responsibility as a parish to attend to the needs (including health-related needs) of others, both other members of the parish family and those of the wider community, the nation, and the world,

e) recognition that there are limits to what the healthcare system can and should provide and thus that some uncomfortable and difficult choices may have to be made if we are to limit healthcare costs; and be it further

Resolved, That, following up on the discussions within the parishes, communicants, individually and congregationally, be urged to contact elected federal and state officials encouraging them to:

a) create, with the assistance of experts in related fields, a comprehensive definition of "basic healthcare" to which our nation's citizens have a right,

b) establish a system to provide basic healthcare to all,

c) create an oversight mechanism, separate from the immediate political arena, to audit the delivery of that "basic healthcare,"

d) educate our citizens in the need for limitations on what each person can be expected to receive in the way of medical care under a universal coverage program in order to make the program sustainable financially,

e) educate our citizens in the role of personal responsibility in promoting good health with provisions of restricting to some degree treatments for disease in which the patient fails or refuses to comply with good medical practice; and be it further,

Resolved, That this resolution be distributed to all dioceses of the Episcopal Church of America for their consideration and support; and be it further

Resolved, That the 76th General Convention call upon the Episcopal Church to establish and fund a task force to develop action plans and educational materials for dioceses and parishes to conduct the above-described activities; and be it further

Resolved, That the General Convention request the Joint Standing Committee on Program, Budget and Finance to consider a budget allocation of $5,000 for the implementation of this resolution.

Past General Convention resolutions have addressed standards for universal access, including some understanding of what "quality health care" might mean, and approaches to political leaders. This resolution has some distinctive features. First, it focuses first on educating and involving members of the Church. Involving individuals in discussing these issues and contacting their political issues encourages ownership and accountability.

Second, this resolution calls for a specific action in establishing a task force to develop materials. With funding expected to be tight in the next Triennium, I don't know whether actual dollars will be approved.

Finally, this resolution addresses specifically and explicitly rationing of health care. While it doesn't use the term, it does speak of the necessity of limiting and restricting treatments. It speaks especially of educating both church and community members that some limitations will be necessary and expected if we are to accomplish universal access to health care. For many this has been a challenge, but the recognition that some personal responsibility and some limits will be necessary.

With its call for a task force and funding, and its acknowledgement of rationing, I will be interested to see how this resolution progresses. It is, however, consistent with the past resolutions of General Convention in calling for universal access to health care. It is timely, inasmuch as universal access to health care, or at least to health insurance, is a central goal of the Obama Administration. How much impact this specific resolution has won’t be known for a while. At the same time, it doesn’t hurt for General Convention to say it once again.

At Daily Episcopalian: More Thoughts on General Convention

2009-06-12T08:56:00.002-05:00

My latest piece is up at the Episcopal Cafe on the Daily Episcopalian page. It's also about General Convention, in the context of my "Second Sermon."

While you're looking at my piece, take a look at the work of my colleagues there, and feel free to leave a comment (I know it's a bit cumbersome, and requires joining TypePad; but TypePad is free, and the conversation is important to us). We want to offer some interesting news, commentary, and spiritual reflection from a progressive Episcopal and Anglican perspective. Come and see.

General Convention 2009: "Holy Women, Holy Men"

2009-06-09T14:59:00.004-05:00

I have posted on a number of health issues addressed in various Reports to this summer’s General Convention. However, there are a number of Reports that are not obviously related to health issues that may also be of interest to chaplains. One this year is the Report of the Standing Commission on Liturgy and Music.

The largest portion of this year’s Report is “Holy Women, Holy Men: Celebrating the Saints.” This is an extensive revision – some would say a replacement for - the well known “Lesser Feasts and Fasts” approved for the Episcopal Church. “Lesser Feasts and Fasts” has published the calendar of approved celebrations in the Episcopal Church, along with the approved lessons and collects and some historical information. I use it each year as I remember those worthies in the Episcopal Calendar who have some relationship with health care: St. Luke (October 18); Florence Nightingale (August ); and Constance and Her Companions, the Martyrs of Memphis. Luke was a physician, of course; and Florence Nightingale was arguably the founder of modern professional nursing. The Martyrs of Memphis are remembered as those Episcopal religious and clergy who stayed in Memphis, Tennessee, during the yellow fever epidemics of the 1870’s to care for those too poor to leave the city.

There has already been a good deal of discussion about “Holy Women, Holy Men.” It lays out principles for adding persons to the Calendar, including some new categories cor consideration. It greatly expands the calendar, adding many possible worthy individuals to remember. In those additions are new men and women, many persons of color, and a number of people significant in Christian history who were not – or who once were and then left being – Anglican. If you’re interested in broader discussion, I would suggest reading here or here.

What was interesting to me was the addition of a number of persons whose Christian lives were lived out or had some affect health care. New in the list in “Holy Women, Holy Men:

Cannon, Harriet Starr: First a member of the Sisterhood of the Holy Communion, she left with four other women to found the Community of Saint Mary. Not only were most of the Sisters among the Martyrs of Memphis members of CSM, but the Community continues to run health care institutions. (May 7)
Chisholm, James: Episcopal priest in Portsmouth Virginia, like the later Martyrs of Memphis, he remained with his congregation during an 1855 epidemic of yellow fever that depopulated the city. “He brought spiritual comfort, food, such medical assistance as he could minister, and even dug graves.” Toward the end of the epidemic, he died of the disease himself. (Sept 15)
Fr. Damien and Sr. Marianne of Molokai: Fr. Damien is famous for his work in the leper colony on the island of Molokai in Hawaii. He eventually contracted Hansen’s Disease himself and died. Sr. Marianne was Roman Catholic nun “who was asked to found a leper hospital for women on Molokai and to take over the work of Fr. Damien among the males.” (April 15)
Grenfell, Wilfred Thomason: “British medical missionary to Labrador and Newfoundland where he established hospitals and founded the first Seamen’s Institute.” (Oct 9)
Innocent of Alaska: Innocent was a Russian Orthodox missionary to the Aleuts in Alaska, and became the first Orthodox bishop in the New World. In his work with the Aleuts, he persuaded them to be vaccinated for smallpox and kept scientific journals of flora and fauna in the area. (March 30)
Mayo, William W., and Charles Menninger , with their sons: The Doctors Mayo are, of course, known for the Mayo Clinics and Hospitals in Minnesota, while the Doctors Menninger are known for the Menninger Psychiatric Clinic, initially in Topeka, Kansas, and now in Houston, Texas. Both clinics were noted for bringing the best clinical care and research to care for the bodies, minds, and spirits of their patients. (March 6)
Passavant, William:. As a Lutheran pastor and social reformer, he established the first Deaconess Hospital in Allegheny, as well as other hospitals in the Upper Midwest. (Jan. 3)
Vincent de Paul: Founder of the Vincentians, he established many charitable projects including hospitals, orphanages and ministry to prisoners. He also founded the Daughters of Charity. That community continues to be a major provider of health care today. In addition, a number of other communities that find there vocation in health care follow the Vincentian Rule. (Sept. 27)

There are others whose lives would be of interest to chaplains, including the four Army chaplains who died in the sinking of the USS Dorchester in World War II; Mother Ann Seton; and Bartolomé de las Casas. However, these I’ve mentioned have had some direct effects on health care.

It remains to be seen whether “Holy Women, Holy Men” will be approved in General Convention, or whether it might be approved with some changes. At the same time, these additional observances can offer some interesting possibilities. For Episcopal chaplains especially they might offer the opportunity to show in our various ministries how much history and interest the Episcopal Church has in contemporary health care. Certainly, this will be a topic of interest in this summer’s General Convention.

General Convention 2009: Health Issues 5

2009-06-03T14:40:00.003-05:00

I have written a number of posts on health care issues in the Report to General Convention of the Standing Commission on Health. However, there is another continuing body that has a stake in health care issues. That is the Executive Council Committee on HIV/AIDS.

As they have in past General Conventions, the Committee on HIV/AIDS has provided a report for General Convention, including a number of resolutions. However, the heart of the report is a section on “The State of HIV/AIDS Today,” which centers on three topics. The first points out that infection rates, both in the United States and abroad, continue to rise. The Committee points out that, “In the United States the general infection rate has stabilized at about 56,000 new infections per year (recently revised upward by 40% by the Centers for Disease Control).” Moreover, around the world “The HIV/AIDS pandemic globally also continues to keep pace with our efforts to curb it….For every two persons who receive treatment, an additional five persons become infected.” They note that a number of programs have increased their efforts to fight the disease, “but we remain behind the curve.”

The second concern is that there remains a stigma against those who are infected. The Committee comments,

This stigma keeps us from paying enough attention to the pandemic domestically. The United States does not have a comprehensive plan for addressing the pandemic although we require that of other countries to which we give aid. Good education about HIV/AIDS is lacking, and urban legends persist both domestically and overseas. People are reluctant to get tested and then reluctant to seek care. Those infected and affected are still bereft of the pastoral care and compassion from their communities that usually accompany illness.

Finally, and in light of the last sentence about the stigma, the Committee is concerned about the Church’s response. They acknowledge and honor a number of programs at home and abroad. “However, despite numerous calls for increased education of our young people about their responsibilities and the factual realities of sexual relationships, in many of our parishes this does not happen. We also too easily focus our attention on the pandemic overseas and ignore the people who are suffering in our own neighborhoods.”

In light of these concerns, and of their plans for the next triennium, they summarize the report,

Thus HIV infection rates continue to rise in the United States and globally, while poverty, invisibility and stigma lead to lack of care, lack of concern and lack of a coordinated response. However, we are living in a time of increased interest in public health and access to health care, and growing attention to the global HIV pandemic and the Millennium Development Goals. The church still has an opportunity to demonstrate a Christ-like response to the HIV/AIDS pandemic, particularly in our neighborhoods in the United States as well as with our partners overseas.

In response, the Committee proposes a number of resolutions.

RESOLUTION A159 ADDRESS THE ISSUE OF AIDS notes the rise in the infection rate, and the call of the Baptismal Covenant for our concern, and resolves specifically, “That the General Convention urges Episcopalians at all levels of the Church to engage in conversations with HIV/AIDS service providers, local health departments and other public and private resources to urge them to address this issue in direct and substantive ways that include the following prevention activities: accurate and explicit prevention information that is sensitive and specific to issues of culture, ethnicity, sexual identity, sexual orientation and the use of IV drugs and recreational drugs;
RESOLUTION A160 ACCESS TO ADEQUATE MEDICAL CARE FOR PEOPLE LIVING WITH AIDS “deplores the discrepancies in levels of care and treatment of people living with HIV/AIDS based on poverty, prejudice, ignorance and the lack of visibility;” and calls for the Church to “advocate strongly for access to adequate medical care not based on any factor other than the need for health care.”
RESOLUTION A161 AIDS EDUCATION AND RESOURCES calls on the General Convention to “[urge] rovinces, dioceses, congregations and worshiping communities to include accurate and comprehensive HIV and AIDS prevention in youth education programs [and] encourage its congregations and worshiping communities to offer educational programming to interested parents and grandparents on how to discuss sex with their children,” IT also calls for the National Episcopal Aids Coalition (NEAC) and National Episcopal Health Ministries (NEHM) to develop and share materials for the purpose.
RESOLUTION A162 DOMESTIC STRATEGY COMMITTEE ON AIDS CRISIS calls for “Executive Council with the assistance of the Committee on HIV/AIDS to convene a domestic strategy meeting for the purpose of developing a comprehensive response to the HIV/AIDS crisis by The Episcopal,” and report on the meeting and its results to the next General Convention.
RESOLUTION A163 MANDATE ON NEAC AIDS TUTORIAL calls for General Convention [to] mandate staff and leaders and all active clergy take the on-line tutorial on HIV/AIDS prepared by the National Episcopal AIDS Coalition (NEAC) during this last triennium,” and to monitor compliance.
RESOLUTION A164 COMMENDATIONS TO PRESIDING BISHOPS commends our current and most recent Presiding Bishops for their observance of World AIDS Day, and calls for observance of World AIDS Day in congregations.

There is one other resolution, that is indeed the first resolution. RESOLUTION A158 CONTINUING RESOLUTION calls for General Convention to “authorize the continuation of the Executive Council Standing Committee on HIV/AIDS for the 2010–2012 triennium,” and speaks of the work the Committee foresees in that time. This is in response to the work, if not the specific resolution, of the Standing Commission on the Structure of the Church. That body’s report includes the resolution, RESOLUTION A117 DISCONTINUE THREE COMMITTEES, including the Committee on HIV/AIDS. In their report, the Commission on Structure notes of their efforts that “Clearly these Executive Council Committees have accomplished important work…. The Commission believes it is time for the policy work to be intentionally taken up by existing Standing Commissions, whose mandates already cover the same subject areas.” Arguably, with the exception of the resolution on the NEAC tutorial, the resolutions from the Committee on HIV/AIDS are policy statements. With that in mind, the Commission on Structure says in the Explanation for resolution A117, “The policy work of the Committee on HIV/AIDS should be undertaken by the Standing Commission on Health, now that it has been reestablished and funded. The program work related to HIV/AIDS education and services will continue to be done by the National Episcopal AIDS Coalition (NEAC), which would work closely with the Standing Commission on Health regarding policy initiatives.”

This is not a new idea, and was discussed in and around the re-establishment of the Commission on Health in 2003 and its funding in 2006. However, the Committee was continued, and the change not made. Certainly, adding HIV/AIDS to the concerns of the Commission on Health is arguable; and adding the funding for HIV/AIDS would add to the budget considerations for the Commission. Whether this will happen in this Convention, however, remains to be seen.

Certainly, HIV/AIDS remains an important issue, and particularly as a health issue, both in the United States and abroad. As our understanding has changed from “dying of AIDS” to “living with AIDS,” from an acute to a chronic illness, so has our understanding of how HIV/AIDS affects care for the sick, from the institution of “universal precautions” to the issues of funding care for chronic conditions. Conversely, other issues affect how we address HIV/AIDS specifically. For example, as the Anglican Communion is reshaped, addressing the AIDS pandemic in Africa may well be affected by our relationships with Anglicans no longer in communion with the Episcopal Church. The work of the Committee on HIV/AIDS, both in their report and in their proposed resolutions, deserve close attention this July at the General Convention.

General Convention on Abortion

2009-06-01T13:19:00.003-05:00

The murder of Dr. George Tiller, a physician who provided safe abortions, will bring again to the forefront issues of abortion and of appropriate responses. Readers should be aware that the General Convention has spoken to abortion (most fully in resolution 1994-A054 here; to post-abortion stress (in resolution 2000-D083 here); and to violence against abortion clinics (resolution 1988-D124 here). I have written before about this in more detail, but I thought we might want again to recall how General Convention has addressed these issues.

Good Ethics Listening for Chaplains (and Others)

2009-05-24T15:16:00.001-05:00

I have already pointed to the Center for Practical Bioethics as a good resource on matters of biomedical ethics. There is a good deal of information on their web site, and some good ideas and discussion at the blog, Practical Bioethics.

Today I want to point to another resource they offer: The Bioethics Channel. The Bioethics Channel offers a series of podcasts with interviews on a variety of bioethics issues. Most are brief – fifteen minutes or less – and offer thoughts and opinions from experts both within and beyond the Center.

As a chaplain, I was interested in the recent podcast, “Religion and Medicine: Compatible?” Two physician ethicists, Drs. Farr Curlin and John Lantos, gave their thoughts about why physicians should be sensitive to the interactions of spiritual and medical concerns among their patients, and how they might learn about them. Their concern is not to obviate or displace chaplains or other religious professionals. Instead, they appreciate how important spiritual issues and beliefs can be for patients, and how those beliefs might impact a patient’s understanding of and compliance with health care. Thus, their interest is in how awareness of and sensitivity to spiritual concerns of their patients might improve doctor-patient relationships and, by supporting a more effective partnership, patient satisfaction and outcomes.

So, take a look at the Bioethics Channel, and see what you find there of interest. It’s an opportunity for some continuing education and intellectual stimulation that is relevant to chaplains and others interested in health care ethics.

Supporting the Hard Conversation: Paying for POLST

2009-05-22T12:50:00.004-05:00

Yes, I've been away for a while; good times! Now, back to work....

A colleague of mine has brought to my attention House Resolution 1898, “Life Sustaining Treatment Preferences Act of 2009,” introduced by Congressman Earl Blumenauer (Democrat of Oregon). The intent of the resolution is to require Medicare to reimburse for a patient’s time with a professional when the purpose is to document patient preferences about treatment at the end of life.

The language of the title and of the bill reflects the movement to develop Physician Orders for Life-Sustaining Treatment (POLST). The point of the movement is to develop forms for a physician and patient to use in recording a patient’s preferences, not simply as a statement of intent, but as an actual set of physician orders. Moreover, the intent is that area physicians and area healthcare institutions (especially hospitals, emergency medical services, Emergency Departments, and long term care facilities) will agree to recognize and carry out those orders, whether or not the specific physician has privileges in that specific institution. Most physician orders are on an individual facility’s forms, and stay in the patient’s records. In the case of POLST, the form stays with the patient, and the patient or the patient’s agent can produce it when a patient is dying, trusting that the doctor’s orders for the patient’s treatment will be followed. The hope is that POLST orders can be implemented more quickly and with less difficulty in interpretation than current Healthcare Treatment Directives.

That raises issues for both institutions and physicians of proper credentialing and privileges. In a metropolitan area of any size, few doctors try to obtain privileges in every institution. There are usually too many institutions, and too little time; and so physicians will focus their practices in one or a few institutions. Rural physicians will rarely have privileges in the metropolitan referral hospitals to which patients in extremis might be transferred. There are issues of standards and liabilities to be addressed. At the same time, those issues aren’t insurmountable, and programs have risen across the country to develop such tools.

What is more difficult, however, is arranging for a good consultation in which a physician or other professional has time to sit down, hear a patient out, explain to a patient the options and issues for care at the end of life, and come to mutual understanding for the orders. Neither public (Medicare, Medicaid, etc) nor private insurers reimburse for that use of a physician’s or other professional’s time. And yet it can take - indeed, it should take – longer than most physician visits. If the patient is to really understand the options, and the professional is to really understand the patient (at least enough to complete the order set), they need time together.

That is the issue that Representative Blumenauer’s bill is intended to address. It would amend relevant Medicare law to add “consultations regarding an order for life sustaining treatment” as an intervention for which Medicare could reimburse.

In adding these consultations it adds a new subsection in the law to describe characteristics of such consultations in some detail. Especially important are the definitions that amended law would provide. It begins with a definition of the consultations themselves:

The term ‘consultation regarding an order for life sustaining treatment’ means, with respect to a qualified individual, consultations between the individual and the individual’s physician (as defined in subsection (r)(1)) (or other health care professional described in paragraph (2)(A)) and, to the extent applicable, registered nurses, nurse practitioners, physicians’ assistants, and social workers, regarding the establishment, implementation, and changes in an order regarding life sustaining treatment (as defined in paragraph (2)) for that individual. Such a consultation may include a consultation regarding--
‘(A) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;

‘(B) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

‘(C) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

The Secretary may limit consultations regarding an order regarding life sustaining treatment to consultations furnished in States, localities, or other geographic areas in which such orders have been widely adopted.

Also important

‘(2) The terms ‘order regarding life sustaining treatment’ means, with respect to an individual, an actionable medical order relating to the treatment of that individual that--
‘(A) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order) and is in a form that permits it to stay with the patient and be followed by health care professionals and providers across the continuum of care, including home care, hospice, long-term care, community and assisted living residences, skilled nursing facilities, inpatient rehabilitation facilities, hospitals, and emergency medical services;

‘(B) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;

‘(C) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary);

‘(D) is portable across care settings; and

‘(E) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.

All of this is well and good. Also good are provisions for grants to establish and support programs for development of POLST-type documents. However, there is a provision that does concern me:

‘(3) The term ‘qualified individual’ means an individual who a physician… (or other health care professional…) determines has a chronic, progressive illness and, as a consequence of such illness, is as likely as not to die within 1 year. (Emphasis mine)

That restriction to those who a physician feels will probably die within a year becomes a significant restriction on POLST programs. After all, age per se is not considered “a chronic, progressive illness;” and yet a patient in his or her 90’s might well not be a good candidate for CPR. In my own setting we have elderly patients who arrive in ER with acute (and not chronic) concerns who request a DNR order, or point out that a Health Care Directive declines CPR.

It is certainly the case that staff see patients for whom they fear doing CPR will do more harm than good. Frail bones break under chest compressions. Inserting a breathing tube or using electric shock have their place, but are also matters of controlled violence. For the patient who’s had a significant stroke – which is, remember, an acute and not a chronic condition – staff don’t want to apply controlled violence when the medical evidence is that it will offer no benefit. Should Medicare not support a POLST conversation for a patient with that concern?And how comfortable with physicians be in determining likelihood of death within one year? One of the continuing issues in hospice care is difficulty physicians have making such a determination for a six-month time frame. All too often, by the time a physician is prepared to acknowledge and share with a patient that together they’ve reached the limit of what therapeutic medicine has to offer, the patient doesn’t have six months or even six weeks, but six days. One might think that one year offers more opportunity than six months; but it might just as well make “likelihood of death” that much harder to determine. Should Medicare not support a POLST conversation for a patient with that concern?

Finally, that’s complicated by the question of what constitutes “a chronic, progressive illness.” With good care patients with such chronic diseases as congestive heart failure, high blood pressure, or diabetes might live for years. However, individual patients may well not do as well; and any of those conditions might lead to related acute events that might well be life threatening. Should Medicare not support a POLST conversation for those patients?

This is a good effort, and one that should, I think, be supported. Reimbursing professionals and institutions for time spent with patients to determine their wishes and to insure that those wishes are followed is in keeping with the ethics lived out in health care today. It shows significant support for maintaining a good doctor-patient relationship, especially in addressing difficult decisions. However, the restriction of that reimbursement to the cases specified is a significant problem. It will leave out so many patients for whom such conversations are not only desirable but also medically reasonable that it will undermine one of the purposes of not only POLST efforts, but of Advance Directives generally: that all patients will have the opportunity to express their concerns and values, and expect that those concerns and values will guide the health care that they will receive.

So, folks, get to your computer or your fax machine. Let your member of Congress know how you feel about this effort; and if you support the effort, address the concern about the restrictions. We as a people have an opportunity to do good for many patients through Medicare reimbursement. I think we ought to do what we can to do good for more people, and not for fewer.

Grand Rounds Again

2009-05-12T08:22:00.002-05:00

I've had another article accepted to the health care blog carnival, Grand Rounds. The new edition is up at Health Blogs Observatory, and my recent post on problems with a research article on religious coping was accepted.

This is National Hospital Week, and follows National Nursing Week, and to this Grand Rounds starts with a tribute to Florence Nightingale. For my Episcopal readers (and others interested in church issues), remember that Florence Nightingale is remembered in the Episcopal Calendar of Lesser Feasts and Fasts (August 12). You can find here a concise biography, including how she lived out her faith in her work.

So, head over to Grand Rounds and see what folks in health care are writing about. The articles are interesting and the scope is broad.

Anglican Network for Health: Can the Net Be Strong Enough?

2009-05-06T10:37:00.003-05:00

At the current meeting of the Anglican Consultative Council (ACC) in Kingston, Jamaica, a great deal of attention is being paid to international Anglican networks, including the new Anglican Network for Health. The Rev. Paul Holley, the Representative of the Anglican Communion to the UN Offices in Geneva, Switzerland, and who was with us at the January meeting in Houston, was interviewed about the new Anglican Health Network. In the interview he speaks of his sense of the current and future work of the Network. He makes reference to the Houston meeting, as well as some of the results. You can find a podcast of the interview here (not quite eleven minutes). When you have a few minutes, it’s worth a listen.

In my most recent post at Episcopal Café, I expressed my concerns about changes in the Communion:

And my greatest qualm is that we have already lost forever the Anglican Communion that I knew, and that the Episcopal Church will soon follow. I don’t mean that the Church has departed from the Christian faith or the Anglican tradition. I don’t believe either of those assertions. It is, rather, that the shape and manner of the Communion has changed, and of the Episcopal Church will change.

I have to admit that I don’t have much hope. The Fellowship of Confessing Anglicans (FOCA: the GAFCON group) will want little to do with us, Covenant or no. Indeed, one of their favorite theologians has suggested that they should sign on to the Covenant as soon as possible, in hope that will persuade the Episcopal Church not to sign!

At the same time, I have expressed a concern in the past (here and here and here, at least) about Archbishop Williams’ commitment to a new, more centralized, "new-Rome-but-for-the-Papacy," ecclesiology. His comments so far at the ACC meeting only reinforce my opinion about what he thinks necessary. I fear that, FOCA or no, General Convention would have trouble signing on to that vision, either. For many of us that would be to embrace the influence of foreign prelates that we thought we had rejected in the English Reformation. The “brain trust” for this effort is to be the Inter-Anglican Standing Committee for Unity, Faith and Order, or IASCUFO. It occurred to me that IASCUFO could be an anagram for U-FIASCO – that is, attempts at “unity” by fiat will in the end be a fiasco. So, I don’t have much hope about this Communion of relationships holding, Instruments or no Instruments, with or without a Covenant.

And it is precisely ministry possibilities like an Anglican Network for Health that would be lost. My Best Beloved, who is much less interested in all of this than I am, asked me yesterday what mattered about it. My answer was that what would be lost, or at least seriously rearranged, would be the opportunities for ministry. The fact is we do have a lot of resources in the Episcopal Church, resources that we really want to share. In the past we’ve tried to share them by working with local Anglican groups around the world. Already some in Africa have refused to work with us, unwilling to take what they see as “tainted” money – tainted in part by what they see as our sinfulness, and in part by a “cultural imperialism” that we ourselves question and challenge, but that they see (largely accurately, I think) as a major threat to their own contemporary cultures. It’s harder for us to share our resources when the local contacts we have known will no longer have anything to do with us.

But perhaps the Draft Covenant and discussions around it offer a model for continuing, if not a useful tool per se. The Covenant speaks churches of the Anglican Communion and churches who sign the Covenant as, potentially, separate groups. Perhaps when other avenues fail, inter-Anglican networks could continue, supported by the two or three successor groupings of folks in the Anglican tradition. Being focused on ministries and not so much on ecclesiologies or ecclesiastical politics, perhaps networks like the Anglican Health Network can continue, allowing people to work together without having to agree on all, or even most things. Perhaps in the future, that could be a model for a different way of covenanting, one that could bring reconciliation among folks in the Anglican tradition.

One can only hope….

Once Again at Grand Rounds

2009-05-05T16:44:00.003-05:00

Periodically I point to the ongoing web carnival, Grand Rounds. This week's edition (vol. 5, no. 33) is now up on the blog at Ausmed, and my recent post on DNR and AND orders has been accepted. Click over and take a look at a selection of blog posts and articles on issues in medicine and health care.

Once Again at Episcopal Cafe

2009-05-04T09:02:00.001-05:00

My newest post is up at Episcopal Cafe. It's about loss - but not the sort of loss I usually write about as a chaplain. I hope you enjoy it. I hope you enjoy it enough to comment over your name, and let us know what you think.

Take some time while you're there to look at other parts of the Cafe. We'd like for you to read, and we'd like to hear from you. You'll need to set up a Typepad account, if you don't already have one; but it's quick and, like most such online accounts, free. So, please, leave a comment at the Cafe, and let us know what you think.

General Convention 2009: Health Issues 4

2009-05-02T22:09:00.001-05:00

Perhaps the most important, and probably the most controversial issue addressed in the Report to General Convention of the Standing Commission on Health is actually only briefly referenced in the Report. The topic is a Denominational Health Plan.

At the 2006 General Convention, Resolution A147, titled, “Study the Costs and Issues of Healthcare Benefits for All Clergy,” was passed in both Houses:

Resolved, That the 75th General Convention endorse the Church Pension Group’s proposal to conduct a church-wide study of the costs and issues surrounding the provision of healthcare benefits to all clergy and lay employees serving churches, dioceses and other church institutions and to report their findings to the 76th General Convention; and be it further

Resolved, That all dioceses, parishes and other church institutions are urged to cooperate with the conduct of this study by responding to requests for data regarding employee census and healthcare costs; and be it further

Resolved, That this study will include an analysis of the potential for a mandated denominational healthcare benefits program and other viable alternatives, culminating in a recommended solution and an actionable implementation plan.

The potential benefits of a mandated denominational health plan are potentially quite considerable. The first is simply making the actuarial risk pool much wider, and so spreading the risk. Since insurance rates are based on the average risk for any member measured against the total risks of all member, the more members in a group the better the average risk, and so the lower the cost of insurance. Historically, while the Church Medical Trust was willing to handle the negotiations, the costs were based on each diocese alone. That has made for some significant differences between dioceses with many clergy and those with few.

Mandating participation in the plan, and including lay employees, would also increase the pool. Historically, a diocese, or even an individual congregation could opt out of the plan, if Council or Vestry thought they could get a more economical deal. And since the plan to date has only included clergy, adding lay employees would certainly add members.

Let’s look at what the Church Pension Fund has proposed. The specifics are proposed in Resolution A177. The resolution, along with background and supporting information, is found in the Report to General Convention of the Church Pension Fund (it’s a long report, with a lot of valuable information; but keep scrolling down until you get to the discussion of the health plan).

The resolution is in three sections. The second section is a canonical change to implement the plan, while the third has to do with funding. The details of the proposed plan itself are in the first section:

Resolved, the House of _______ concurring, That this church establish The Denominational Health Plan of this church for all domestic dioceses, parishes, missions, and other ecclesiastical organizations or bodies subject to the authority of this church, for clergy and lay employees who are scheduled to work a minimum of 1,500 hours annually, in accordance with the following principles:

1. The Denominational Health Plan shall be designed and administered by the Trustees and officers of The Church Pension Fund, following best industry practices for comparable plans;

2. The Denominational Health Plan shall provide that, subject to the rules of the plan administrator, each diocese has the right to make decisions as to plan design options offered by the plan administrator, minimum cost-sharing guidelines for parity between clergy and lay employees, domestic partner benefits in accordance with General Convention Resolution 1997-C024 and the participation of schools, day care facilities and other diocesan institutions (that is, other than the diocese itself and its parishes and missions) in The Denominational Health Plan;

3. The Denominational Health Plan shall provide benefits that are comparable in coverage to those benefits currently provided by the domestic dioceses and parishes of this church;

4. The Denominational Health Plan shall provide equal access to health care benefits for eligible clergy and eligible lay employees;

5. The Denominational Health Plan shall provide benefits through The Episcopal Church Medical Trust, which shall be the sole plan sponsor for such benefits and continue to be operated on a financially sound basis;

6. The Denominational Health Plan shall have a church-wide advisory committee that is representative of the broader church and appointed by The Church Pension Fund, and such church-wide advisory committee shall receive an annual report about the status of The Denominational Health Plan;

7. For purposes of this Resolution, the term "domestic" shall mean ecclesiastical organizations and bodies located in the United States, including the Dioceses of Puerto Rico and Virgin Islands;

8. The Church Pension Fund shall continue to work with the Dioceses of Colombia, Convocation of American Churches in Europe, Dominican Republic, Ecuador Central, Ecuador Litoral, Haiti, Honduras, Micronesia, Taiwan and Venezuela to make recommendations with respect to the provision and funding of healthcare benefits of such dioceses under The Denominational Health Plan; and

9. The implementation of The Denominational Health Plan shall be completed as soon as practicable, but in no event later than by the end of 2012;…

Let me point out what I consider the most significant paragraph of this section, and, indeed, the most significant phrase in that paragraph:

2. The Denominational Health Plan shall provide that, subject to the rules of the plan administrator, each diocese has the right to make decisions as to plan design options offered by the plan administrator, minimum cost-sharing guidelines for parity between clergy and lay employees, domestic partner benefits in accordance with General Convention Resolution 1997-C024 and the participation of schools, day care facilities and other diocesan institutions (that is, other than the diocese itself and its parishes and missions) in The Denominational Health Plan; (emphasis mine)

So, there won’t be a single denominational health plan, in the sense that every eligible person in every diocese will be participating in the identical plan and paying the identical rate. There will be a single plan in the sense of being a single plan administrator and plan sponsor – the Church Medical Trust of the Church Pension Fund - but that’s not really a “single plan.” Moreover, look at all the things that an individual diocese can make choices about: “plan design options; cost-sharing guidelines; domestic partner benefits; and the participation of schools, day care facilities and other diocesan institutions.” That begins to look like there could be an awful lot of variation from diocese to diocese.

That doesn’t mean there aren’t simplifications and cost savings to be had. These are addressed in the Report itself, but some stand out. First, it would still bring all eligible clergy and lay employees into one large pool, or at least a small number of pools larger than we use now (according to the report at least one as small as 15 households!). It would further balance the risks in the pool by keeping younger, healthier participants in the pool with us graying members, instead of allowing individual congregations with younger folks to simply opt out, and skew the average age.

It will also reduce the number of plans, In conversation with an employee of the Church Medical Trust, our diocesan deputation was told that when first looked at there appeared to be more than 200 separate plans purchased in the Church. However, when characteristics were compared it turned out there were more like seven plans – but purchased from many different companies at many different prices. By focusing on the characteristics of the plans, the Church Medical Trust can negotiate with national companies and get national, or at least regional prices – and so better than an individual diocese might get.

Still, this will indeed be controversial. First, in the current optional plan there are certainly some dioceses doing quite well. They may find it hard to sacrifice for the benefit of dioceses doing more struggling. Small congregations will want to know as much as possible about how this will affect costs. Paying for heath insurance for clergy has become one of the most difficult costs for some congregations, and for dioceses that have a high percentage of such congregations. And of course there will be those who simply dislike the thought that the Church would mandate the plan (or anything else, for that matter).

And it probably won’t reduce what we’re paying now. The opportunity for savings – and it’s a big opportunity – is in reducing how fast our costs grow. That’s hardly insignificant. The Report estimates a savings over the first six years of the plan of $134 million. Still, that’s not immediate relief, but future savings.

This is an important plan for the Episcopal Church, and for the health of clergy and lay employees and their families. It is likely to be the most ambitious plan undertaken in this Convention, regarding health or anything else. I would encourage all Episcopalians to attend to this. Read the Report and the Resolution. Talk to your parish treasurer, and make sure he or she is also involved. Then, make sure to let your bishop and deputies know about questions and concerns. This will affect our life together in ways we will be much more aware of than most of us are of the Anglican Communion. It may not have the theological import or panache that other issues and resolutions have; but this Report and this Resolution will shape how the Church does business for a long time to come. We need to give it the attention that it deserves.

The Church and the Flu

2009-05-01T21:11:00.004-05:00

Right now there are a great many concerns about the new flu. We can call it the H1N1 flu, or the swine flu; but whatever we call it, it’s got people concerned. In the metropolitan area where I work there have been two “probable” cases reported (confirmation from the Centers for Disease Control takes time). That hardly seems overwhelming; but when I stopped by the drug store today, the shelves were almost emptied of hand sanitizer.

I’ve been looking at resources, and have even shared some with local clergy in my area. They include the following sites that my own institution has been sharing:

The resources MedlinePlus in Spanish may be especially helpful for some folks.

Episcopal Café, a web site of the Episcopal Diocese of Washington (D.C.) has a page with useful links, some of which address specifically how churches are addressing communion. You can find that here.

Another comprehensive site, addressing a host of questions, is on the site of Episcopal Relief and Development (ER-D) Their information includes material from CDC, and pandemicflu.gov, as well as some materials for developed for Canadian Churches during the SARS epidemic.

Our siblings in the Evangelical Lutheran Church in America (ELCA) have also posted resources. You can link to their information from here.

Remember that the most important steps to take are things we already know:

Wash hands early and often, and use appropriate sanitizers.
If you feel sick, stay home as an act of grace to others.
If you have a family member sick, keep that person home for the same reason.
Use discretion especially if you’ve recently been in Mexico, or have been with someone known to have this flu.
Follow guidelines from the CDC and the State Department about travel to Mexico.
Get your information from trustworthy sources: the CDC, local public health, or your health care provider.

This is, as many have said, a time for concern, but not for alarm. To some extent that’s because we’re not powerless, even in the face of illness, even in the face of pandemic disease. We have good sources of information, and we have some basic practices for self-care, the most important of which are, literally, in our hands. And, of course, we trust that we always have God as our helper.

Another Voice of a Chaplain

2009-04-29T12:48:00.002-05:00

Usually, when I'm pointing to Episcopal Cafe, it's usually to my own latest post there. Today, I'm pointing to someone else. As I find them, I post here links to articles from chaplains and about chaplaincy that I think are worth reading. Today's post at Daily Episcopalian is from the Rev. Joy Caires. Now a parish priest, she was early in her career a chaplain at Rainbow Babies and Children's Hospital in Cleveland, Ohio. Her post offers a reflection connecting one of her days in chaplaincy to the message of Easter. I encourage you to read and enjoy it.