Pastoral Care
Training Program
For Volunteer Visiting in Hospital,
Nursing Home and Community
Compiled and Edited by Chaplain Janet Stark,
BGH Spiritual Care Manager
Designed by the Spiritual Care Department
Brockville General Hospital
2015 Edition
Brockville General Hospital Pastoral Care Education
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About this manual……
This manual has been designed as a training resource to accompany a 30-hour
pastoral care training program. It touches on a number of topics and is not the
complete word on providing pastoral care! The manual alone does not replace the
value of in-class teaching, discussion and sharing.
A set of PowerPoint
presentations and suggested lesson plans may accompany the text material.
You are welcome to print out this manual, or individual pages from it. If printing it in
its entirety, I suggest printing double-sided, if possible, and using 3-hole paper in
your printer or photocopier.
You may share any of the pages, as long as the
footnote identifying The Brockville General Hospital remains.
About this course…..
Although we hope you can attend all sessions, you must attend 8/10 classes to get
your certificate, and you must sign in for each class. The first class is mandatory.
Let the trainer know if you have extenuating circumstances. Please turn off
cellphones and check messages at breaks. At each class we will have a lending
library of resources. You are encouraged to read at least one book on pastoral care
during the weeks of the course. If you have a good resource you would like to
share, please show it to the trainer first, then copy it on 3-hole punch paper for the
participants.
Janet Stark
Spiritual Care Manager
Certified Multifaith Chaplain,
Grief Services Provider & Pastoral Care Trainer
[email protected]
613-345-5649 x 1-4120
[email protected]
Brockville General Hospital Pastoral Care Education
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Table of Contents
Page Number
Course Information
Table of Contents ______________________________
Index _________________________________________
Booklist ________________________________________
Forms; Reflective Learning ________________________
Introduction to Spiritual/Pastoral Care _____________________
Faith, Religion & the Church ______________________
Christian Denomination Chart ______________________
Jesus’ Stories of Healing __________________________
Ground Rules, Code of Conduct _____________________
Privacy & Confidentiality ___________________________
Spirituality vs Religious Practice _____________________
Maslow’s Hierarchy of Needs _______________________
P.I.E.C.E.S Assessment Tool _______________________
Social vs Pastoral Visiting __________________________
Health Team ____________________________________
3
7
10
11
21
22
28
29
49
51
54
59
62
64
67
The Pastoral Visitor ____________________________________ 68
Professional Caregivers ____________________________ 69
Qualities of Effective Volunteers _____________________ 70
Spiritual Care Volunteer Job Description _______________ 79
Characteristics of Spiritual Health ____________________ 84
Volunteer Tasks __________________________________ 86
About the Visit ___________________________________ 87
Spiritual Practices for Volunteers _____________________ 92
Listening Skills ___________________________________ 97
Empathy vs Sympathy _____________________________ 101
Standard Precautions for Infection Control ___________________ 109
Music Therapy ________________________________________ 113
Care Clowning _______________________________________ 118
Recreation Therapy _____________________________________ 120
Physical Touch ________________________________________ 121
Recording life Stories ___________________________________ 122
Meeting the Person _____________________________________ 127
Visitation ________________________________________ 127
Communication “Do’s & Don’ts” ______________________ 138
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Communication Skills _______________________________140
Therapeutic Conversation ____________________________145
The Family Unit ____________________________________147
Family Conflict _____________________________________148
Bad News _________________________________________150
Communication Self-Analysis _________________________155
Case Studies in Communication _______________________157
Culturally-Appropriate Care ________________________________ 161
Aboriginal Issues ___________________________________ 167
Cross-Cultural Assessment ___________________________ 171
Multi-Cultural Directory _______________________________ 175
Spiritual Needs __________________________________________ 197
Spiritual Assessment _____________________________________ 204
Spiritual Distress _________________________________________ 211
Total Pain _________________________________________ 212
Spiritual Abuse __________________________________________ 216
Religious Addiction _______________________________________ 221
Palliative Care ___________________________________________ 225
Your own feelings about death _________________________ 227
Spiritual Care compliments Palliative Care ________________ 236
Domains in Palliative Care ____________________________ 237
Tasks for the Dying Person ____________________________ 241
Dying Person’s Bill of Rights ___________________________ 243
What the Volunteer can do _____________________________246
Communicating with the Dying __________________________249
Christian Spiritual Care of the Dying ______________________251
Tips and Tools Sheet _________________________________ 253
End of Life Stories ___________________________________ 255
Aging & Geriatrics _________________________________________ 263
Life’s Losses ________________________________________ 268
Needs of the Elderly __________________________________ 270
Challenges of Aging __________________________________ 276
Institutionalization ____________________________________ 281
Long-Term Care _____________________________________ 285
Bill of Rights Long-Term Care ___________________________297
Elder Abuse _________________________________________311
Depression _______________________________________________317
Cognitive Disorders ________________________________________ 325
Delirium ____________________________________________326
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Alzheimer Disease ____________________________________328
Dementia Illnesses ___________________________________ 332
Parkinson’s Disease ___________________________________ 335
Dementia Behaviours __________________________________ 337
Dementia & Communication _____________________________ 345
Dementia & End-of-Life ________________________________ 348
Dementia Case Studies ________________________________ 352
Parish Nursing _____________________________________________ 355
Hospital and Community Visits ________________________________ 357
Case Studies & Role-Plays ______________________________363
Ethics & Legal Issues ________________________________________ 371
Confidentiality/Privacy __________________________________ 371
Code of Conduct ______________________________________ 377
Bill of Rights __________________________________________ 378
Competency/Informed Consent ___________________________ 380
Ethical Dilemmas ______________________________________ 382
Euthanasia ___________________________________________ 383
Ethics Concern Form ___________________________________ 384
Proselytizing Policy _____________________________________388
Ethics Cases __________________________________________389
Grief & Loss ________________________________________________393
Anticipatory Grief _______________________________________403
Worden’s 4 Tasks of Mourning ____________________________ 406
Bereaved Families ______________________________________408
Grief Tips and Coping Strategies ___________________________409
Bereavement Myths _____________________________________420
Grief Tool for Healing ____________________________________421
Complicated Grief _______________________________________423
Different Kinds of Grief _________________________________________425
Pet Loss _______________________________________________425
Child Abuse ____________________________________________427
Sexual Abuse & Rape ____________________________________429
Abortion _______________________________________________429
Death of a Child & Infant ___________________________________431
Miscarriage _____________________________________________432
SIDS __________________________________________________435
Suicide ________________________________________________ 436
Murder ________________________________________________ 437
Grief Support _________________________________________________438
Death Support Practical List _____________________________439, 451
Grief at Christmas ________________________________________457
Funeral Outline; Christian & Non-Religious __________________________459
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Mental Illness & Spirituality ____________________________________ 461
Mental Health Bill of Rights _______________________________461
Stigma & Mental Illness __________________________________462
Recovery Model for Mental Illness __________________________463
Maslow & Mental Illness __________________________________468
Mental Health Practical Spiritual Care _______________________ 469
Teen Mental Health Issues ________________________________475
Mental Health and the Volunteer ____________________________477
Spirituality Circle for Mental Health __________________________479
Mental Health, Psychology & Sociology ______________________ 482
Mental Health Resources _________________________________ 489
Disability ____________________________________________________491
Developmental & Intellectual Disabilities ______________________494
Addictions: 12-Steps for Recovery ________________________________499
Spiritual Care After a Disaster ____________________________________501
Prayer _______________________________________________________507
Prayer Teaching _________________________________________507
Prayer Exercises _________________________________________518
Prayer Quotes ___________________________________________520
Prayers ________________________________________________522
Care for the Caregiver __________________________________________535
Family Caregiver Leave _________________________________________549
Inspiration, Poems, Stories ______________________________________551
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Index
Aboriginal Issues 167
Abortion 429
About the Visit 87
Addictions: 12-Steps for Recovery 499
Aging & Geriatrics 263
Alzheimer Disease 328
Anticipatory Grief 403
Bad News 150
Bereaved Families 408
Bereavement Myths 420
Bill of Rights 378
Bill of Rights Long-Term Care 297
Booklist 10
Care Clowning 118
Care for the Caregiver 535
Case Studies & Role-Plays 363
Case Studies in Communication 157
Certificate of Completion 19
Challenges of Aging 276
Characteristics of Spiritual Health 84
Child Abuse 427
Christian Denomination Chart 28
Christian Spiritual Care of the Dying 251
Code of Conduct 377
Cognitive Disorders 325
Communicating with the Dying 249
Communication “Do’s & Don’ts” 138
Communication Self-Analysis 155
Communication Skills 140
Competency/Informed Consent 380
Complicated Grief 423
Confidentiality/Privacy 51, 371
Cross-Cultural Assessment 171
Culturally-Appropriate Care 161
Death of a Child & Infant 431
Death Support Practical List 439, 451
Delirium 326
Dementia & Communication 345
Dementia & End-of-Life 348
Dementia Behaviours 337
Dementia Case Studies 352
Dementia Illnesses 332
Depression 317
Dev’t & Intellectual Disabilities 494
Different Kinds of Grief 425
Disability 491
Brockville General Hospital Pastoral Care Education
Domains in Palliative Care 237
Dying Person’s Bill of Rights 243
Elder Abuse 311
Empathy vs Sympathy 101
End of Life Stories 255
Ethical Dilemmas 382
Ethics & Legal Issues 371
Ethics Cases 389
Ethics Concern Form 384
Euthanasia 383
Evaluation Forms 15
Faith, Religion & the Church 22
Family Caregiver Leave 549
Family Conflict 148
Family Unit 147
Florence Nightingale 47
Funeral; Christian & Non-Religious 459
Grief & Loss 393
Grief at Christmas 457
Grief Support 438
Grief Tips and Coping Strategies 409
Grief Tool for Healing 423
Ground Rules, Code of Conduct 49
Health Team 67
Hospital and Community Visits 357
Inspiration, Poems, Stories 551
Institutionalization 281
Introduction to Spiritual/Pastoral Care 21
Jesus’ Stories of Healing 29
Life’s Losses 268
Life Stories 122
Listening Skills 97
Long-Term Care 285
Maslow & Mental Illness 468
Maslow & Palliative Care 245
Maslow’s Hierarchy of Needs 59
Meeting the Person 127
Mental Health and the Volunteer 477
Mental Health Bill of Rights 461
Mental Health Practical Spiritual Care 469
Mental Health Resources 489
Mental Health, Psychology & Sociology 482
Mental Illness & Spirituality 461
Miscarriage 432
Multi-Cultural Directory 175
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Murder 437
Music Therapy 113
Needs of the Elderly 270
P.I.E.C.E.S Assessment Tool 62
Palliative Care 225
Parish Nursing 355
Parkinson’s Disease 335
Pastoral Visitor 68
Pet Loss 425
Physical Touch 121
Prayer 507
Prayer Exercises 518
Prayer Quotes 520
Prayer Teaching 507
Prayers 522
Privacy & Confidentiality 371
Professional Caregivers 69
Proselytizing Policy 388
Qualities for Effective Volunteers 70
Recovery Model for Mental Illness 463
Recreation Therapy 120
Reflective Learning 13
Religious Addiction 221
Sexual Abuse & Rape 429
SIDS 435
Brockville General Hospital Pastoral Care Education
Social vs Pastoral Visiting 64
Spiritual Abuse 216
Spiritual Assessment 204
Spir. Care Compliments Palliative Care 236
Spiritual Care After a Disaster 501
Spiritual Care Volunteer Job Description 79
Spiritual Distress 211
Spiritual Needs 197
Spiritual Practices for Volunteers 92
Spirituality Circle for Mental Health 479
Spirituality vs Religious Practice 54
Standard Precautions for Infection Cont109
Stigma & Mental Illness 462
Suicide 436
Tasks for the Dying Person 241
Teen Mental Health Issues 475
Therapeutic Conversation 145
Tips & Tools Sheet for Spiritual Distress253
Total Pain 212
Visitation 127
Volunteer Tasks 86
What the Vol can do to help the dying 246
Worden’s 4 Tasks of Mourning 406
Your own feelings about 227
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Acknowledgements
The gratitude of Brockville General Hospital goes out to:
Contributers
Abraham Maslow, Albert Revell, Anna Seaver, Barbara Reeder, Benjamin & Rosamund Zander, Bill
Marrevee, Brenda Haggett, Brent Peery, C Adamee, Carolyn Murray, Cindy Morneault, David Dosa,
David Downing, David Silver, Dawn Chaitrim, Debbie Steele, Deborah Jenkins, Debra Wade, Dianne
McNamara, Donald Dunn, Elizabeth Kubler-Ross, Esther Walker, Fred Smith, Geoffrey Johnston,
George Hzando, Grace McBride, Grace Ross, Hilkka Aavasalmi, Janet Clapp, Jeanne Lambert,
John Kennedy Saynor, John McManamy, John Toews, Joyce Hamelin, Joyce Rupp, Katherine
Frommelt, Katherine Suter, Kathy Reis, Larry Dossey, Lea Hamblett, Marilyn Stoner, Mark Young,
Mary Slingerland, Marva Dalvin, Matthew Stanford, Maureen LeClair, Michael Webster, Mother
Teresa, Nancy Kehoe, Oscar Romero, Paul Gurr, Paul Wong, Pope John Paul II, Ray Houghton,
Robert Buckingham, Robert Buckman, Ruth Graham, Sandra Harrison, Stephen Kendall, Tom LIske,
Tracey Schofield, W & J Thomas, Virginia Lafond, William Worden
Clerical Support
Doris Albert, Doris Hallett, Gillian Fetter, Margo Judge
Agencies
Alcoholics Anonymous, Alzheimer Society of Canada, Brockville General Hospital, Canadian
Hearing Society, Canadian Hospice-Palliative Care Association, Centre for Addictions & Mental
Health, Connecticut Dept of Health, Community Care Access Center of South-Eastern Ontario, Grief
Watch: Tear Soup Series, Health Canada, HealthCare Chaplaincy, National Centre for PostTraumatic Stress Disorder, Ontario Ministry of Labour, Society of Biological Psychiatry, St. Mary’s
Hospital Montreal, United Church Observer, VISIONS: BC Mental Health Journal, Shepell Inc.
Southlake Regional Health Centre
Project Manager, Editor, Contributing Author
Janet Stark is the Spiritual Care Manager of the Brockville General Hospital and the former Palliative
Care Education Coordinator for Lanark, Leeds & Grenville, Eastern Ontario. She is a Certified
Multifaith Chaplain, Health Administrator, Grief Services Provider and Adult Educator. She has
published FINAL SCENES: 80 stories of Spiritual Care at End-of-Life and a chapter on Spirituality
and the Profession of Nursing in the textbook Nursing Leadership and Management, 2
nd
Canadian
Edition, Nelson Publishing, 2013. She is also a Senior’s Fitness Trainer and a Care-Clown—“JanAnne the Nutcase”! Janet is a Lay Minister in the Presbyterian Church of Canada. She can be
contacted at [email protected]
Brockville General Hospital Pastoral Care Education
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Suggested Booklist
Multifaith Information Manual 5th Edition, 2011 Toronto, Ontario.
Multifaith Council on Spiritual and Religious Care, www.omc.ca
ISBN 9781896377155
Callanan, Maggie & Kelley, Patricia Final Gifts, 1992, Toronto, Bantam Books
ISBN 0-553-37876-7
Dossey, Larry, Healing Words. Harper Collins 1993 ISBN 0-06-250252-2
Jacobs, Martha R. A Clergy Guide to End-of-Life Issues 2010 Cleveland Ohio.
The Pilgrim Press, Editor PlainViews
ISBN 978-0-8298-1859-8
Johnston Taylor, Elizabeth, What do I Say? 2007 Templeton Foundation Press,
Philadelphia, ISBN 978-1-59947-120-4
Nouwen, Henri, The Wounded Healer, 1972, Doubleday & Company, New York
ISBN O-385-14803-8
Stark, Janet Final Scenes: Bedside Tales at End of Life, 2010 Winnipeg, Word
Alive Press, ISBN 978-1-77069-125-4
Yancey, Philip, The Question that Never Goes Away, 2013, Grand Rapids,
Michigan, Zondervan, ISBN 978-0-310-33982-3
Brockville General Hospital Pastoral Care Education
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Pastoral Care Training Program Waiver
The Pastoral Care Training Program for lay volunteers is provided through the
direction of the Spiritual Care Department at Brockville General Hospital.
The goal of this program is to provide Christian volunteers the basic instructions for
pastoral visiting in health care and home settings.
All participants must have a sponsor (clergy/spiritual leader) in order to take part in
Pastoral Visiting in any one of these settings after completing the program.
Brockville General Hospital WILL NOT be held accountable for your visiting
activities unless you are under the direct supervision of the Spiritual Care
Department.
You will be asked to sign a form indicating that you have read and understand
these instructions.
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PASTORAL CARE COURSE
STUDENT NAME: ____________________________________(print)
DATE
HOMEWORK
COMPLETED
Student Initials
BOOK(s) READ
Title and Author
A minimum of 1 book is required
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Class 8
Class 9
Class 10
No homework
Final Session
This is an honour system. I certify by my initials noted above, that I have completed the
required weekly homework and have read 1 book related to the subject of pastoral care. I
understand these are the requirements for completing the Pastoral Care Course and that
completion of the assignments and reading a minimum of 1 book is a requirement is mandatory,
along with attending a minimum of 8 out of 10 sessions.
Please keep track of this information and submit this document to the course presenter at the
beginning of the last class.
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Reflective Learning
(Putting learning into Practice)
Process of exploring an issue and using an experience to clarify meaning
for oneself and resulting in a changed perspective
Awareness of feelings or thoughts (mindfulness)
↓
New Learning
↓
Critical analysis of feelings or knowledge
↓
New Perspective
The Reflective Journal
A Journal is a written collection of your thoughts, feelings, reactions and
impressions.
Why keep a journal?

It helps to process and personalize new information

It helps to understand and remember new ideas

It helps us STOP & LOOK at ourselves

It serves as a record of your own personal and professional growth.
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We are asking you to keep a journal throughout the course. This will not be
handed in! We hope that you will share some of your recorded thoughts and
ideas in the “Reflection Time” preceding each class. This time will be an open
forum for discussion.
Use the journal for:

notes you wish to take in class

“homework” assigned

“light bulb” moments

key learning points

thoughts, profound observations

action steps you would like to try

things that caused you stress

emotional moments

questions

problems

things I could teach others

things I would like to learn more of

things I would like to remind myself of
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Session Evaluation
Date:__________
Name of Presentation:__________________________
Name of Presenter:________________________________
What was good about the session? (What will you take & use from this session?)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
What could have been better? (How could we improve the content?)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
How would you rate the presenter? (Was the presentation clear and helpful?)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Thank you!
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Brockville General Hospital
Pastoral Care Volunteer Training Program
Final Course Evaluation Form
1.
Do you have a better understanding of pastoral care now? How?
___________________________________________________________
___________________________________________________________
2.
Was the information presented in an interesting fashion? Comment.
__________________________________________________________
___________________________________________________________
3.
Were your expectations of the course met? Please comment.
___________________________________________________________
___________________________________________________________
4.
General suggestions for improvement:
___________________________________________________________
___________________________________________________________
5.
If you have any suggestions for further topics please share them:
___________________________________________________________
___________________________________________________________
6.
On a scale of 1-10, what would you rate the course? _____________
Thank you for your time!
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Certificate of Completion
This is to acknowledge that
______________
Has completed the 30-hour training course in
PASTORAL CARE
for Spiritual Care Volunteers
Date:______________
Place:______________
______________________________________________________
Sponsored by
Trainer
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Brockville General Hospital Pastoral Care Education
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The Church as Pioneers In Health Care
These are examples of the religious roots of health care:

The parable of the Good Samaritan (Luke 10:25-37) and other parables of
Jesus.

Religious orders in the middle ages of Europe providing way-fare stations for
travellers—the original hospice concept

The Roman Catholic Church’s religious communities, such as: Order of Sisters
of Charity of Montreal, commonly known as the Grey Nuns, founded in 1738 by
Saint Marguerite d'Youville

Jean Vanier and Henri Nouwen pioneering the L’Arche communities for the
disabled

Early hospitals in South Africa were all mission hospitals, run by the church

Jewish hospitals for burn victims

Shriner’s hospitals and hospital clowning
What other examples can you add of the church providing health care?
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For Churches, Clergy, Pastoral Care Teams
“From Hospital to Home”
Consider educating parishioners of these spiritual health related matters by
preaching from the pulpit, and/or in the church bulletin, newsletters and
workshops.

We need to change & expand our thinking about what/who/how we provide
pastoral health care in the home. “Church” visits are not just an add-on. As a
community of faith, we need to see our role in home health care, in order to help
change the limited perception of the professional health team.

Consider hospice training as a valuable overlap to pastoral care training. It
covers more active physical care, which is very valuable in the home.

Expand pastoral care in the home beyond the active church-goer, caring also for
the family unit.

Patients in hospital can ask hospital staff to include their minister or pastoral
helper at a family meeting, or a discharge planning meeting. We need to
promote new ways for the health community to view spiritual caregivers as
members of the health team.

Suggest to your parishioners in the community that receive home health care,
that they use a log book or communication book to record visits from both
pastoral teams and health professionals. This is called charting in the home.
The health team needs to see the valuable contribution spiritual care can bring
to the patient. If a community nurse sees that a pastor has been visiting, then
there might be a better sense that spiritual care is part of this person’s multidisciplinary health team

Include health education and end-of-life decision-making in pastoral training
sessions. ~training should cover health-based spiritual care in all settings—
hospital, home and facility.

When hosting pastoral educational sessions at churches—please invite other
churches to participate if possible-- advertise any sessions that are open to
other church pastoral care teams—to the area ministerial association
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
Ask parishioners to let you know when someone is in hospital

Tell parishioners that on admission to hospital, they can have their religion and
their church recorded. This is most helpful for the spiritual care team

Upon admission they should also be asked, “Would you welcome a visit from
Spiritual Care”. Those that respond “yes” are put on the spiritual care list for the
spiritual care team to visit.

It is easiest to gain permission ahead of time to have access to their
name/circumstances of their hospital stay

Ask permission of the patient to share information with the spiritual care team

For Clergy who have a hospital ID badge: Know how to get the active patient
list from your church denomination at both hospital sites.

Make sure your pastoral volunteers follow the direction of the BGH spiritual care
department when in hospital. They may also wish to ask the BGH team if they
can be of use

Consider devoting one worship service/year to health care/pastoral care

Talk about the possibility of starting parish nursing—part-time, shared with
another congregation/ denomination etc.

Home visits/ phone visits/ prayer chains are all ways of providing pastoral care
Phone visits and prayer chains, provide care when one cannot always get out to
the person’s home. Some churches partner parishioners with home patients
and shut-ins for a daily phone call—check in.

Pastoral care also includes practical helps: errands, meals, drives

Consider inviting the youth of your congregation to do pastoral visiting and credit
them with volunteer hours toward their 40 mandatory high school hours.

Consider a church-based “respite” program to give family caregivers a break.
This could be a) at the church or b) sending pastoral volunteers out to the home
Janet Stark
Brockville General Hospital Pastoral Care Education
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About a Patient’s Religious Needs
For many people, religious beliefs play a significant role in personal spiritual
support. When one is ill, personal faith may be emphasized as one seeks to
make meaning out of suffering. For others, it is a time of crisis of faith, when one
cannot make sense of their situation. Some struggle to feel God’s presence and
to reconnect spiritually. A person may ask, “Why? Why me?” Real anguish is
experienced by one who has a belief in a loving God but feels abandoned. Often
this person can draw on his religious beliefs to bring him back to a place of
acceptance.
Someone who has weak or broken ties to a faith community may wish to
reconnect. Others may seek to form a new relationship with a spiritual power
and may welcome support and direction. Nurses can identify this need and help
make connections to the spiritual care team or community clergy.
To find inner peace, an ill person may need to identify, express, work
through, and let go of spiritual anguish such as bitterness, guilt, or regret. Belief
in a loving and forgiving spiritual power can help one let go and reach toward
spiritual wellness. This can be a process, and for some it may be a struggle not
completely settled at the time of death.
If prayer has been a part of the ill person’s life, it can be a valuable
resource. Prayer can acknowledge unspoken needs and desires and can be a
tangible expression of suffering. Once articulated, that is, spoken out loud, a
prayer can seek comfort, acceptance, and healing. Healing can be either
physical or spiritual, or it can be both. Prayer happens in many ways—through
the informally expressed word, meditation, touch, or more formal prayers and
scripture passages. Other faith practices such as songs, readings, or rituals may
often be a very comforting reminder.
The value of believing in life after death needs to be stressed, particularly
because those from all religious backgrounds who believe in heaven or paradise
or eternal life have a very strong asset in accepting impending death. Some may
even welcome death as an end to suffering, an opportunity to be reunited with
Brockville General Hospital Pastoral Care Education
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loved ones, seeing the face of God, or to have a new and healthy body. One
may not be afraid to die but still be afraid to suffer or experience pain. One may
also be afraid to be alone. Nurses can emphasize that the client will not be
abandoned. Excellent palliative care should help ensure that an ill person will be
as comfortable as possible in her final days. Nurses have shared many miracle
moments—the signs and wonders a dying person has experienced. These are
part of the profound experience of the mystery of spirituality.
Janet Stark 2011
Brockville General Hospital Pastoral Care Education
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Bible Answers re: the Problem of Suffering
that contain only part of the truth, yet are inadequate for dealing with the whole problem
notes from a lecture by Dr. Marva Dawn, July 20/98
There is suffering because of Satan, and the powers of evil.
But this answer, taken very far, leads to dualism.
Evil is the result of human free choice. But what about divine sovereignty?
Suffering is retributive (punishment). But what about the unfairness of
suffering (cf. passages like Psalm 37 or Psalm 73)? And what about Jesus’
unwillingness to connect misfortune with a person’s own sin (John 9)?
Suffering is disciplinary (God teaches us). But what about the suffering of
the innocent or of the very young?
Suffering is revelational – it reveals ourselves to ourselves. Suffering reveals
to us the state of our world, and even God. But this kind of thinking turns God
into a sadist. What about those who suffer who are too young to learn? What
about the fact that suffering turns many people away from God?
Suffering is probational (cf. Isaiah 48:10 or Zechariah 13:9, for example,
where it is said that we are tested in the fires of adversity). But why some and
not others? And why so unevenly? And why those not old enough to be “proven”
by it?
Suffering is just plain meaningless (cf. Ecclesiastes). But that is not enough
for most people!
This will all end when the final day comes. But it’s awfully painful in the
meantime! And this approach can be used to leave people hurting.
Evil is mysterious. It is bigger than we are. God alone is wise enough to know
the answer. But this response brings no comfort to the oppressed (though it is
part of the answer!).
All of these “answers” can be stretched too far.
All can be hurtful when given to people who are suffering.
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Jesus heals the Demonic
Mark 5: 1-20
Chaplain Brenda Haggett MTS
They came to the other side of the lake, to the country of the Gerasenes. 2 And
when he had stepped out of the boat, immediately a man out of the tombs with
an unclean spirit met him. 3 He lived among the tombs; and no one could
restrain him anymore, even with a chain; 4 for he had often been restrained with
shackles and chains, but the chains he wrenched apart, and the shackles he
broke in pieces; and no one had the strength to subdue him. 5 Night and day
among the tombs and on the mountains he was always howling and bruising
himself with stones. 6 When he saw Jesus from a distance, he ran and bowed
down before him; 7 and he shouted at the top of his voice, ‘What have you to do
with me, Jesus, Son of the Most High God? I adjure you by God, do not torment
me.’ 8 For he had said to him, ‘Come out of the man, you unclean spirit!’ 9 Then
Jesus asked him, ‘What is your name?’ He replied, ‘My name is Legion; for we
are many.’ 10 He begged him earnestly not to send them out of the country.
11
Now there on the hillside a great herd of swine was feeding; 12 and the
unclean spirits begged him, ‘Send us into the swine; let us enter them.’ 13 So he
gave them permission. And the unclean spirits came out and entered the swine;
and the herd, numbering about two thousand, rushed down the steep bank into
the lake, and were drowned in the lake.
14
The swineherds ran off and told it in the city and in the country. Then people
came to see what it was that had happened. 15 They came to Jesus and saw the
demoniac sitting there, clothed and in his right mind, the very man who had had
the legion; and they were afraid. 16 Those who had seen what had happened to
the demoniac and to the swine reported it. 17 Then they began to beg Jesus to
leave their neighbourhood. 18 As he was getting into the boat, the man who had
been possessed by demons begged him that he might be with him. 19 But
Jesus[e] refused, and said to him, ‘Go home to your friends, and tell them how
much the Lord has done for you, and what mercy he has shown you.’ 20 And he
went away and began to proclaim in the Decapolis how much Jesus had done
for him; and everyone was amazed.
Imagine with me for a moment that your life has been tragically struck by illness
that has for a variety of reasons left you emotionally, spiritually and even
physically isolated. You have lost your capacity to care for yourself in a way that
is socially acceptable and your behaviours, a direct result of your illness, leave
people who come near you frightened. People have ceased to see you as
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anything other than someone who needs to be controlled. They cannot see that
you are afraid too. Your spirit is tormented night and day by your illness; you
have tried to free yourself by the only means you know but nothing has worked.
You have cut yourself and cried out with agony but every day and night it is the
same only to be repeated day and week and month and year after year.
People used to treat you differently, but as your illness progressed you were
forced away from the general population. Occasionally people would come near
you but not for the reasons you desired. They did not come to comfort or
console you, nor did they come to feed and clothe you. They came only to try
and make you more palatable to them – to control you by various means. Long
ago you ceased to be human in the eyes of others. In fact they no longer even
refer to you by your name; instead they call you by your disease. It has been so
very long since you have had any positive human encounters; you are
suspicious of everyone – your past experiences have taught you to keep your
guard up.
But today is different. VERY different. A man, unlike any other has just arrived at
the isolated place you have come to call home and he doesn’t seem to be one
bit afraid of you. There is something about him that draws you to him and for the
first time, in God knows how long, you are not afraid – you are cautious but
somehow you sense that your encounter with this stranger is going to be
different. And then it happens…this stranger who speaks with a gentle authority
asks you your name. My name? What is my name? Nobody has used it for so
many years. Do I even have a name, you question yourself. And then it
happens, this stranger touches you in a way you have not experienced in a
lifetime. He looks beyond your isolation and your physically repulsive condition
and he begins to speak healing words over you. What happens next is
inexplicable. You have no words for it. The only thing you know is that this one
who has come near you has some how liberated you from everything that has
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kept you bound and isolated in this forbidden hell hole you call home. You have
been restored to wholeness.
Your first instinct and desire is to leave this place that has been the source of so
much misery and pain; to free yourself from the crowds who have tried to bind
and control you without pity. But instead of taking you with Him, this healer
commissions you to return to your community and let your healing be a witness
to your family and neighbors of the great things the Lord has done for you.
This is of course a paraphrase of the encounter of Jesus with the demonpossessed man who lived in the tombs in the region of the Gerasenes. What I
have often found intriguing about this story is that Jesus came to the Gerasene
region and returned to where he had come from for the sole purpose of restoring
dignity and wholeness to one man. Written in the margin of my Bible I have the
words, For the Sake of One.
When we enter the space of another human being, it may only be for a brief
moment but that encounter can have a lasting and possibly life-changing affect
for the other. As we consider this healing story of Jesus we cannot help but see
the parallel to bringing pastoral ministry to those with diminished mental
capacities. Of course we cannot do what Jesus did in bringing complete healing.
However we can approach those suffering from Mental Health issues as human
beings and ease their spiritual torments through effective and appropriate
spiritual care a little at a time simply by our willingness to treat them as humans
made in God’s image rather than as a feared disease. They have names, they
have fears, and they have longings and desires for human contact just like we
do. They are often afraid because of how people relate to them in their illness.
Our challenge as pastoral care givers is to be willing to enter the space of
another with care and caution and see the whole person before we see their
disease regardless of whether that disease is of body, mind or spirit. May the
Lord be our helper as we do!
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Jesus Heals the Hemorrhaging Woman
Mark 5:24-34
Chaplain Brenda Haggett MTS
“24 A large crowd followed and pressed around him. 25 And a woman was there
who had been subject to bleeding for twelve years. 26 She had suffered a great
deal under the care of many doctors and had spent all she had, yet instead of
getting better she grew worse. 27 When she heard about Jesus, she came up
behind him in the crowd and touched his cloak, 28 because she thought, “If I just
touch his clothes, I will be healed.” 29 Immediately her bleeding stopped and she
felt in her body that she was freed from her suffering. 30 At once Jesus realized
that power had gone out from him. He turned around in the crowd and asked,
“Who touched my clothes?”
31
“You see the people crowding against you,” his disciples answered, “and yet
you can ask, ‘Who touched me?’ ” 32 But Jesus kept looking around to see who
had done it. 33 Then the woman, knowing what had happened to her, came and
fell at his feet and, trembling with fear, told him the whole truth. 34 He said to her,
“Daughter, your faith has healed you. Go in peace and be freed from your
suffering.”
Even though Jesus was pressed in from every side by crowds of people, all
looking for something from him, Jesus knew that healing virtue had gone forth
from him. He was present to her, enough to stop everything and give her his full
attention.
This woman had taken the biggest risk of her life. Based on her physical
condition, according to Jewish Law, she wasn’t supposed to be out in public.
She had an issue…an unpleasant illness that had caused her a great deal of
pain; both physically and emotionally. But that was not the only cost of her
illness; there was also the financial cost…everything she had, she had used to
try to alleviate her pain. She was emotionally and physically bankrupt. Her
illness had left her devoid of dignity; for which she wore the standard garment of
illness - shame. And yet on this day she was willing to take one final risk.
She had heard of Jesus now famous abilities to restore broken physical bodies.
And in that incredible moment of merely touching the hem of his garment, she
experienced that physical healing first hand. But, Jesus, in His divine wisdom
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knew that what she needed just as much as healing for her body, was the
healing of her broken spirit. Maybe it was for that reason that Jesus called her
out of the crowd that day. She was already made well the moment she touched
Jesus clothes and yet Jesus purposefully brought her out of the background and
into the foreground. In that action Jesus restored her spirit. In front of everyone,
Jesus told this one who had been barred from active community worship
because of her illness that she was still highly valued – enough to call her a
daughter of Abraham. A degree of restoration of body can often be achieved by
the medical profession but only the spirit of a human can be completely restored
by God.
Every time I read this miracle story I am intrigued by Jesus’ willingness to place
this broken woman in the place of priority over what would seem to be a more
important situation – a little girl’s life was hanging in the balance. And yet Jesus
delayed going to meet the needs of someone else in order to be fully present to
the need directly in front of him.
As spiritual care providers there is no end to the number of people who are in
need of our ministry. On the way to one person, we may find ourselves
temporarily delayed by another’s immediate need and each person needs and
deserves us to be fully present to them because nobody’s spiritual need is less
or more important than another’s.
Pray: Lord Jesus we confess that too often we are distracted by our busyness to
complete the seemingly endless good works there are for us to do. Help us to
have the wisdom to know when to stop for one person as you did. We desire
wisdom. Please help us dear Lord to be fully present in every moment you call
us into – for each person’s life you call us to touch if even only for a brief time.
We are not adequate without your Spirit’s power. Grant us Oh God to touch as
you would touch and to be as you would be. Amen.
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Jesus Heals the Epileptic Boy
Matthew 17: 14-18
Chaplain Brenda Haggett MTS
14
When they came to the crowd, a man approached Jesus and knelt before him.
“Lord, have mercy on my son,” he said. “He has seizures and is suffering
greatly. He often falls into the fire or into the water. 16 I brought him to your
disciples, but they could not heal him.” 17 “You unbelieving and perverse
generation,” Jesus replied, “How long shall I stay with you? How long shall I put
up with you? Bring the boy here to me.” 18 Jesus rebuked the demon, and it
came out of the boy, and he was healed at that moment.
15
For centuries people (including God’s people) dealt with mental illness as
though the person were demon possessed – trying all kinds of exorcism
activities to relieve the afflicted person.

Trephining the skull – burrowing holes in it to let demons escape

Exorcisms, incantations, prayer, atonements/sacrifices, and other various
mystical rituals were used to drive out the evil spirit

Other means attempted to appeal to the spirit with more human devices-threats, bribery, punishment, and sometimes submission, were hoped to be an
effective cure

Hebrews believed that all illness was inflicted upon humans by God as
punishment for committing sin, and even demons that were thought to cause
some illnesses were attributed to God’s wrath. Yet, God was also seen as the
ultimate healer and, generally, Hebrew physicians were priests who had special
ways of appealing to the higher power in order to cure sickness.

Ancient Egyptians seem to be the most forward-thinking in their treatment of
mental illness as they recommended that those afflicted with mental pathology
engage in recreational activities such as concerts, dances, and painting in order
to relieve symptoms and achieve some sense of normalcy

In all of these ancient civilizations, mental illness was attributed to some
supernatural force, generally a displeased deity. Most illness, particularly mental
illness, was thought to be afflicted upon an individual or group of peoples as
punishment for their trespasses
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In today’s healing story we read about something that to us sounds like it could
be a form of cerebral palsy or epilepsy or maybe even a type of Asperger’s or
autism – either way to us in our highly educated world it sounds more like an
illness rather than demon possession. It is possible in the world of Matthew’s
day where all illness was thought to have some attachment to the demonic
world, that he simply did not have the language to convey this child’s illness.
But, that really is only speculation and could be argued till the end of time.
Please do not mishear me, I am not discounting the very real presence of
demonic activity in our world!
What I think is most relevant here is what Jesus says to the disciples after their
failed attempt to heal the boy; He calls them an unbelieving and perverse
generation. Jesus is very obviously vexed and frustrated with them for their lack
of understanding so much so that he voices it like this, “how long shall I put up
with you”? Possibly Jesus frustration with them was because they had
developed only one approach to dealing with the sick.
In many ways those suffering with mental illness in the church are just as vexed
and frustrated with the many well-meaning people around them who try to “pray”
their illness away through the laying on of hands and other Christian healing
practices. I myself have many times anointed the sick of body and mind with oil
and through the laying on of hands invited God’s healing – and I will continue to
do so. I’m not referring to those kind of prayers; rather I am referring to the
approach to the mentally ill person in the Christian Church that leaves them
feeling vexed and frustrated because of others’ lack of understanding that
conveys to them they are demon possessed (brought this upon themselves)
instead of sick.
It is something we must guard against. Sadly, I have a better understanding than
most when it comes to this because I myself have suffered with serious bouts of
depression in my life. I remember one such occasion when I was still as yet
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undiagnosed and my pastor said from the pulpit that if anyone came to him
because of depression the first thing he would do was address their sin issues
and lack of spiritual devotions. He closed the door in my face to getting help
from him because he did not understand. I left feeling misunderstood and
consequently did not receive healing from him in any form. Thankfully I had
physician who understood and helped to get me some much needed relief
through medication to correct an imbalance in my system.
Let us pray: Father God we come to you in the strong name of Jesus our savior,
our brother, our friend and we ask that you help us to be a people who always
demonstrate your grace and mercy to those who are ill of body and mind. May
we ever be people who seek to understand and with a gentle approach bring
your healing touch through whatever means you deem best. We recognize our
need for the gracious and generous gifts of your Holy Spirit to help us carry out
the works you have planned in advance for us to do. Help us to always be willing
to walk where you lead. Amen.
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The Good Samaritan
Luke 10:25-37
Chaplain Janet Stark
25
On one occasion an expert in the law stood up to test Jesus. “Teacher,” he
asked, “what must I do to inherit eternal life?” 26 “What is written in the Law?” he
replied. “How do you read it?” 27 He answered, “‘Love the Lord your God with all
your heart and with all your soul and with all your strength and with all your
mind’; and, ‘Love your neighbour as yourself.’” 28 “You have answered correctly,”
Jesus replied. “Do this and you will live.” 29 But he wanted to justify himself, so
he asked Jesus, “And who is my neighbour?” 30 In reply Jesus said: “A man was
going down from Jerusalem to Jericho, when he was attacked by robbers. They
stripped him of his clothes, beat him and went away, leaving him half dead. 31 A
priest happened to be going down the same road, and when he saw the man, he
passed by on the other side. 32 So too, a Levite, when he came to the place and
saw him, passed by on the other side. 33 But a Samaritan, as he traveled, came
where the man was; and when he saw him, he took pity on him. 34 He went to
him and bandaged his wounds, pouring on oil and wine. Then he put the man on
his own donkey, brought him to an inn and took care of him. 35 The next day he
took out two denarii and gave them to the innkeeper. ‘Look after him,’ he said,
‘and when I return, I will reimburse you for any extra expense you may have.’
36
“Which of these three do you think was a neighbor to the man who fell into the
hands of robbers?” 37 The expert in the law replied, “The one who had mercy on
him.” Jesus told him, “Go and do likewise.”
**
The gospel writer Luke was a follower of Christ and a doctor or healer of his
day. He tells us this story that Jesus told his disciples.
“There was once a man travelling from Jerusalem to Jericho. On the way he
was attacked by robbers. They took his clothes, beat him up and went off
leaving him half-dead. (we don’t know anything more about him except that he
was minding his own business, and he got ambushed, or swarmed) Luckily, a
priest was on his way down the same road, but when he saw him, he angled
across to the other side. (Maybe he was on his way to the temple and didn’t
want to touch the injured man, because that would make him ceremonially
unclean.) Then a Levite religious man showed up; he also avoided the injured
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man. (Maybe he was in a hurry, or maybe he just didn’t care.) Or—maybe they
both felt pity for the injured man, but the point is—neither of them stopped.
Perhaps the Priest and the Levite were also afraid of being bush-whacked. We
don’t know. But we are told about the choice made by the third man.
A Samaritan traveling the road came on him. (A Samaritan was despised by the
Jews. A Samaritan was an outcast and a good Jew would not have anything to
do with him and certainly not touch him for any reason.) When the Samaritan
saw the injured man’s condition, his HEART WENT OUT TO HIM. (That is the
fullest meaning of the word compassion) “His heart went out to him.” He did not
worry about rules; instead he followed his instincts, which says a great deal
about his character. Did he stop to weigh the odds of personal attack or
robbery? Did he remember that a Jew might not want him to touch him? We are
just told of his actions. He gave the man first aid, disinfected and bandaged his
wounds. (He could have stopped there and went on his own way… but no…)
He lifted him on his own donkey, led him to an inn and made him comfortable.
(Now that is quite a full package of intervention and the Gentile could have
left it at that with a fully-satisfied conscience. But no.) In the morning he pays
the inn-keeper 2 silver coins and tells him to take care of the injured guy and if it
costs any more he says “PUT IT ON MY BILL—I will pay you on my way back.”
Jesus then asks his disciples and particularly the religion scholar “Which man
became a neighbour to the attacked man?” Easy answer. Then he tells them
all to GO AND DO LIKEWISE.
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Jesus Heals the Paralytic
Mark 2:1-5
Chaplain Janet Stark
“When Jesus had come back to Capernaum several days afterward, it was
heard that He was at home. 2 And many were gathered together, so that there
was no longer room, not even near the door; and He was speaking the Word to
them.
And they came, bringing to Him a paralytic, carried by four men. And being
unable to get to Him because of the crowd, they removed the roof above Him;
and when they had dug an opening, they let down the pallet on which the
paralytic was lying. And Jesus seeing their faith said to the paralytic, "My son,
your sins are forgiven." And he got up and immediately picked up the pallet and
went out in the sight of everyone, so that they were all amazed and were
glorifying God, saying, “We have never seen anything like this.”
**
Which is easier, to say to the paralytic, ‘Your sins are forgiven’; or to say, ‘Get
up, and pick up your bed and walk’? Supposing you were the paralyzed man—a
paraplegic. “Jesus is in town,” your buddies say. “It’s no use. I don’t have a
ticket. I heard it’s a sellout,” you say. But your friends persist. “You gotta go.
Don’t give up. We’ll take you,” they say. The hall is crowded. There is standing
room only. Your friends lift you up, wheelchair and all, up a flight of stairs to the
upper balcony. They see Jesus speaking to a crowd, who are in complete
silence, hanging on every word. Then one of your buddies yell, “Hey, Jesus!”
He looks up—takes in the situation and slowly nods. Everyone is looking up at
you. Your friends lower you down, right in front of Jesus. He smiles. He says
to you, “Your sins are forgiven.” A weight is lifted. All the troubles and guilt and
sins ever piled on your shoulders over your whole life seem to lift. You are so
light you feel you could float, and feel so happy like you don’t even need legs at
all. He gives your buddies a nod of approval. He says: “Team, well done. You
have companioned your friend. You have been his legs for him. You have
multiplied your faith together. Your desire for his well-being will not go
unrewarded.” Then Jesus looks piercingly into your eyes. “Stand up, my
friend,” he says, “Your faith has made you well. Fold up your wheelchair and
walk home.”
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Discussion Questions
Which is easier, to say to the paralytic, ‘Your sins are forgiven’; or to say, ‘Get
up, and pick up your bed and walk’?
What are your thoughts on healing?
Is there a relationship between faith and health?
How does Jesus model “the Great Physician”?
What other Bible stories are you reminded of?
Describe what comes to mind when you look at the picture of “Jesus the Good
Shepherd” on page 23”.
Ecclesiastes 3: 1,2,4
There is a season for everything:
A time for giving birth
A time for dying
A time for tears
A time for laughter
A time for mourning
A time for dancing….
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Jesus Raises Lazurus from the Dead
John 11:3-44 (selected verses, NIV)
Chaplain Janet Stark
3
So the sisters sent word to Jesus, “Lord, the one you love is sick.”
(Jesus said), “Our friend Lazarus has fallen asleep; but I am going there to
wake him up.” 17 On his arrival, Jesus found that Lazarus had already been in
the tomb for four days. 21 “Lord,” Martha said to Jesus, “if you had been here, my
brother would not have died. 23 Jesus said to her, “Your brother will rise again.”
25
Jesus said to her, “I am the resurrection and the life. The one who believes in
me will live, even though they die; 26 and whoever lives by believing in me will
never die. Do you believe this?” 27 “Yes, Lord,” she replied, “I believe that you
are the Messiah, the Son of God, who is to come into the world.” 32 When Mary
reached the place where Jesus was and saw him, she fell at his feet and said,
“Lord, if you had been here, my brother would not have died.” 33 When Jesus
saw her weeping, he was deeply moved in spirit and troubled.
35
Jesus wept.
39
“Take away the stone,” he said. 43 When he had said this, Jesus called in a
loud voice, “Lazarus, come out!” 44 The dead man came out, his hands and feet
wrapped with strips of linen, and a cloth around his face. Jesus said to them,
“Take off the grave clothes and let him go.”
**
11
When Jesus did not come right away, the disciples, Mary and Martha thought it
was too late. It appeared that he was not answering their request, or not
answering the way they wanted. Jesus said, “He is dead” plainly. (We should
not be afraid to say the word “dead”) Jesus’ spirit—The Holy Spirit—groans for
us when we are in need and it prays to the Father on our behalf. Jesus wept.
This is the shortest sentence in the Bible. Jesus was humanly touched, and he
was sad at the death of his friend. Jesus had compassion and he was
grieving—even though he already knew what the outcome would be. If Jesus
can express deep emotion openly, then it is OK for us to express our
emotion too! Jesus may also have wept because he knew his friend Lazurus
would also have to die again, some day. He also knew his own suffering was
coming soon.
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Bible Passages for Healing
2 Cor. 12:10 (from the Apostle Paul) Three Translations:
“That is why, for Christ’s sake, I delight in weaknesses, in insults, in hardships,
in persecutions, in difficulties. For when I am weak, then I am strong.” NIV
“Therefore I take pleasure in infirmities, in reproaches, in needs, in persecutions,
in distresses, for Christ’s sake. For when I am weak, then I am strong.” NKJ
(God says) My grace is enough; it’s all you need. My strength comes into its own
in your weakness. Once I heard that, I was glad to let it happen. I quit focusing
on the handicap and began appreciating the gift. It was a case of Christ’s
strength moving in on my weakness. Now I take limitations in stride, and with
good cheer, these limitations that cut me down to size—abuse, accidents,
opposition, bad breaks. I just let Christ take over! And so the weaker I get, the
stronger I become.
The Message by Eugene Petersen
What do you think this verse means?
Life Application Bible explanation of 2 Cor. 12:10
When we are strong in abilities or resources, we are tempted to do God’s work
on our own, and that can lead to pride. When we are weak, allowing God to fill
us with His power, then we are stronger than we could ever be on our own. God
does not intend for us to seek to be weak, passive or ineffective—life provides
enough hindrances and setbacks without us creating them. When those
obstacles come, we must depend on God. Only His power will make us
effective for Him and will help us do work that has lasting value.
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A Sign
Mark 8:12
Chaplain Janet Stark
“Sighing deeply in His Spirit, Jesus said, “Why does this generation seek
for a sign? Truly I say to you no sign will be given to this generation.”
Ben and Bonnie were a very close couple and had a deep Christian faith.
When Ben was admitted to hospital with abdominal pains, they felt it was just a
temporary problem needing some quick attention. After exploratory surgery, the
Dr. gave them the bad news that Ben was full of cancer, and that little could be
done.
Ben and Bonnie were stunned.
overwhelming emotion.
They were thrown into a place of
Immediately, they called on their greatest spiritual
strength—their faith. Through a few days of constant conversation with God and
with each other, they came to a place of acceptance. Still Bonnie prayed for
healing. When their minister came to visit, Bonnie asked her if it was selfish to
pray for healing for Ben, if healing was not part of God’s plan. “Of course not!”
was her response. “He desires that you pray for healing.”
When I visited later that morning, I explained that healing happens in
different ways. A person’s body can fail and die, but the healed spirit does not
die but lives on. I saw the Bible on the bedside table and I pointed out a verse in
Hebrews 11:13. “These all died in faith, not having received the promises…”
I asked Ben how he felt and he said he was focusing on his wife and how
she was doing. Then he said she was focusing on God, and that God’s strength
comes through Bonnie and then to him.
Then Bonnie told me an amazing story. She is one who always asked God
for a sign, such as the number of steps to take or a four-leaf clover. Often she
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has experienced a sign that the Spirit was with her. Bonnie was praying for a
sign for Ben. She held her Bible and asked for a Bible verse that would speak to
her. She hoped to find some words of scripture that would give her comfort.
She opened the Bible at random and pointed to a verse. It was Mark 8:12.
Incredibly, it said: “But Jesus signed deeply in His spirit and said, ‘Why does
this generation seek a sign? Assuredly, I say to you, no sign shall be given to
this generation’.”
Bonnie was greatly encouraged by this verse and pondered on its meaning.
She feels that Jesus was telling her not to bother looking for a sign, because He
has been right with them both all along! She is now assured that a sign isn’t
necessary. Jesus will walk with them both, no matter what the outcome for Ben
is. She says the voice in the Bible verse is like a parent gently chastising his
child, saying, “Don’t keep asking for things, I’m in charge here, and I will take
care of you; in fact I already am.” I told them it was a wonderful way to frame it
in their mind. I prayed with them, giving thanks for their faith, and left the room
full of hope in a sad situation.
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Dear Friend:
Welcome to our Pastoral Care Training Program!
We are looking forward to spending ten classes together, during which we hope
to provide you with a better understanding of Spiritual Care and Pastoral
Visiting.
These sessions will give us a time to share some of our own stories with one
another. There will be an opportunity for questions provided at each session.
The teaching in this manual comes from a Christian perspective, that of being a
“Good Samaritan.”
However, just as the religious orders cared for all that
passed through the gates of the hostels of old, pastoral volunteers are taught to
care for all people of all faiths—or no faith.
Spiritual care is a ministry of caring offered to all our residents, patients, families
and the staff by our Spiritual Care Team. The purpose of the Spiritual Care
Service is to promote the “Total Wellness” of each individual entrusted to our
care. In health, there must be a balance between mind, body and spirit. We
strive to meet these needs through prayer, worship, and visitation. The persons
own belief systems and religious convictions dictate the type of care they wish to
receive.
In October, of 2006, our Brockville community was enriched by the joining of
the two long time standing health care facilities, the Brockville General acute
care and the St. Vincent de Paul long term care, complex care, rehabilitation
and palliative care hospitals. In 2012 the Elmgrove Acute Mental Health Site
joined BGH as well.
The combining of these entities now allows for all programs and services to
be united in their delivery. The roots of our current organization are very deep
and we, as partners, in health care and members of this community must ensure
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that the “philosophy of care” legacy will live on.
As Christians we are all “called” to be an extension of Christ’s healing mission.
We are a community of people with unique gifts to share with one another,
bonded by a common belief of compassionate care for all.
The spiritual needs of a person may affect their overall health and well-being.
As a Spiritual Care Volunteer it is essential to respect each person’s faith
choices and belief systems. Their spiritual preference must be respected and
honoured by all who minister to them.
Those individuals completing this pastoral care training program, who decide to
work with the BGH-Spiritual Care Team, will be asked to attend one of the
hospital’s orientation sessions. In addition, there will be a period of supervised
visits arranged by the Spiritual Care Manager.
Those who choose to volunteer at other facilities or parishes will be under the
direction of the spiritual care person specific to that organization.
“I held his hand while we talked, and we prayed together familiar
words of comfort, the Our Father. Knowing I might not see him
again, I gave him the Aaronic Blessing. At the end of our visit, I
turned to leave. He said, “Thanks, Sister.” I left feeling strangely
blessed. I am not a nun, nor am I Roman Catholic. However, if he
felt I acted as a nun toward him; if I acted for him as someone he
trusted and respected in his faith tradition; then I was honoured to
be filling that role. No corrections needed.”
Janet Stark, “Final Scenes” 2010 p108
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Florence Nightingale, the Lady with the Lamp 1820 -1910
Florence Nightingale was a Christian Universalist. She went against the wishes
of her wealthy parents and defied social custom when she took up a career that
no respectable woman of that day would even consider. She became a nurse.
History knows her now as "The Lady with the Lamp." Night after night she
walked among the cots of wounded soldiers, carrying her kerosene lamp to light
the darkness and wearing her cape to keep out the cold. She was always ready
to bandage the wounds of a bleeding soldier, give a drink of water to a thirsty
patient, or write a letter home for a private on his deathbed. Up until Florence's
time, the hospitals in England were a disgrace. Could she help better the
conditions? She would have to overcome the resistance of high officials, the
apathy of the public, and even the ignorance of doctors. Throughout her life,
Florence remembered the entry in her diary when she was still a seventeenyear-old girl: "God spoke to me and called me to His service."
The first official nurses’ training program, the Nightingale School for Nurses,
opened in 1860. The mission of the school was to train nurses to work in
hospitals, work with the poor, and to teach. This intended that students cared for
people in their homes, an appreciation that is still advancing in reputation and
professional opportunity for nurses today.
Florence Nightingale carried a lamp as she walked the halls of the battlefield
hospital and became known as the "lady with the lamp". She saved thousands
of lives. People called her a ministering angel in the hospitals, but she herself
became ill with a disease she got there. Her lasting contribution has been her
role in founding the modern nursing profession. She set an example of
compassion, commitment to patient care, and diligent and thoughtful hospital
administration.
Paraphrased with information from http://www.gardenofpraise.com/ibdnight.htm
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Spiritual Care Services
BROCKVILLE GENERAL HOSPITAL
Standards of Spiritual and Religious Care for
Health Services in Canada
Objectives
The primary objectives of the Spiritual and Religious Care Services’ health and
healing ministry are:

to be available and accessible to care recipients and care providers (staff, family
and friends) within the continuum of care, especially those experiencing spiritual
distress;

to assess the spiritual and religious needs of the care recipient within the
continuum of care;

to develop and implement a spiritual and religious care plan to meet the care
recipient’s needs;

to empower individuals to understand the relationship between spiritual,
religious, physical, psychological and mental well-being;

to provide appropriate opportunities for worship, prayer, sacraments and other
rituals;

to facilitate experiences of supportive community;

to encourage follow-up that meets ongoing spiritual and religious needs
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GROUND RULES
 THIS IS AN OPEN FORUM FOR COMMENTS
 RESPECT EACH INDIVIDUAL’S UNIQUE AND DIVERSE
EXPERIENCES & BELIEFS
 PARTICIPATE & EMBRACE IN THIS TIME OF SHARING
 WHAT’S SHARED IN THIS ROOM STAYS IN THIS ROOM.
 ALLOW TIME FOR EVERYONE TO SPEAK
 USE YOUR SENSE OF HUMOUR!
 RELAX & ENJOY
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Hospital Code of Conduct
Our Code of Conduct sets out the behaviours that we expect from all persons
within the Brockville General Hospital.
Our Code of Conduct applies to any
individual (patient, client, visitor, staff, physician, community partner, volunteer
or student) who gives or receives service in this organization.
The Code of
conduct sets the boundaries by which we treat each other as well as those we
serve.
Brockville General Hospital is committed to a safe working environment.
Abusive/aggressive behaviour and/or coarse language are not acceptable.
1. We will treat everyone with courtesy and respect.
2. We will not tolerate discrimination in any form.
3. We will respect the privacy and confidentiality of others.
All individuals using the Brockville General Hospital facility for all purposes will:

maintain confidentiality

treat everyone in a professional manner, demonstrating compassion and
caring, respect, integrity and dignity.

communicate with everyone in a clear, timely, truthful manner,
demonstrating attentiveness and choosing an appropriate environment.

offer assistance to anyone within the building or on the hospital grounds
who appears distressed or in need of help.

work in a safe manner, following safe work practices.
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Statement of Commitment to the Code of Conduct and Confidentiality
Affiliation: Volunteer
I understand that in my association with Brockville General Hospital (BGH) as
indicated above, I will have access to information and material relating to BGH
patients, clients, employees, and other individuals that is of a private and
confidential nature.
I have reviewed the BGH Code of Conduct and understand that this will apply to
all my interactions in my association with BGH.
I will at all time respect the
privacy and dignity of patients, clients and their families, and employees and
other associated individuals.
All Brockville General Hospital administrative, financial, patient, client, employee
and other records whether written, verbal or electronic format, are confidential
material and I will protect it to ensure confidentiality.
I will not read records,
discuss or use such information, unless there is a legitimate purpose to do so in
my BGH duties and responsibilities.
I understand that a breach of any of these conditions will result in disciplinary
action up to and including dismissal, loss of privileges or similar action.
Print Name
Signed
Witnessed
Date
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Privacy and Confidentiality
The PHIPA (Personal Health Information Protection Act, 2004) made the need
for maintaining patient confidentiality even more important for employees and
volunteers. Now that you have reviewed the current Brockville General Hospital
Confidentiality Pledge, please answer the following questions:
While volunteering you learn that another volunteer is a patient in the hospital.
Can you inform the volunteer coordinator about this? Circle correct answer:
YES/NO
While volunteering you learn that your neighbour is a patient in the hospital.
Can you inform your family that they are in the hospital?
Circle correct answer:
YES/NO/only with the patient’s permission
Are volunteers permitted to talk about patients they have seen, with other
volunteers?
YES/NO
Are volunteers permitted to contact a patient’s family members outside the
patient environment?
Circle correct answer:
Yes, I would call the family directly.
No, because the patient and the family members have a right to privacy, I
would consult the appropriate staff member, e.g. nurse in charge or
Spiritual Care Manager
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BROCKVILLE GENERAL HOSPITAL
MISSION STATEMENT
To provide an excellent patient experience
guided by the people we serve,
delivered by people who care.
SPIRITUAL CARE DEPARTMENT
MISSION STATEMENT
In keeping with the Mission Statement of the Hospital, the Spiritual
Care Team commits itself to Holistic spiritual ministry. We will strive
to provide spiritual and emotional support to each person entrusted
to our care, while respecting the diversity of the individual’s faith
connection for the enhancement of their quality of life.
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What is Spiritual Care?
Group Activity
What does the word “spirituality” mean to you?
What does the word “religion” mean to you?
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Spiritual Needs and Religious Practice.
Spiritual Needs:
1. To love and to be loved.
2. To forgive and to be forgiven.
3. To have meaning and purpose in life. (Why do I exist?)
4. To have worth. (To be remembered)
5. To be creative; to be all we can be, and artists of our own future.
Religious Practice:
1. Organized expression of our spirituality.
2. Practicing our beliefs through rights, rules and doctrines that are set down.
3. Participating in rituals, tenets, activities and traditions that reinforce our
beliefs.
4. Structured patterns that one follows in a community/parish setting.
Pastoral Care is a Ministry of Caring, that…..

Promotes spiritual and emotional healing for all

Provides Multifaith (world religions) and Ecumenical (Christian denominations)
support, and support for those of no professed faith.

Provides comfort and support to patients and their families and the staff that
care for them.

Is respectful of the sacredness and dignity of human life.

Is an important component of holistic care, promoting the healing of the mind,
body and spirit.
Spirituality is the energy within each person that looks for meaning and
purpose in life. It is a unifying and integrating factor among humans.
Spirituality is expressed through a vast array of means, both formal & informal.
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Spiritual Care is the opportunity to explore the issues of meaning and purpose
in one’s life, to establish personal identity, to believe, to love, to hope, to forgive,
to experience healing, to experience community, to serve and to be able to see
beyond one’s present circumstances.
Spirituality is at the very core of our
human existence. It is where the most basic questions concerning our existence
are raised.
Add your thoughts here:
Religion is one expression of spirituality reflected in beliefs and practices
uniting its adherents in the community. Religions are expressed through
sacred writings, codes of behavior, rituals and ceremonies
Religious Care is the opportunity to participate in the common practice and
rituals of one’s faith groups, as defined by the faith group and by the needs of
the individual.
Religion is one expression of spirituality through our faith
traditions, religious rites and practices.
Add your thoughts here:
Pastoral Care is the opportunity to assist individuals of all ages, groups and
communities – at all times and phases of life – to connect with God, to grow in
relationship with God and to live in cooperation with God’s vision for a just,
healed and flourishing world, by paying attention to the whole person, body,
mind and soul.
Add your thoughts here:
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Spiritual Healing, at its core is grounded in a set of ideas that it shares with
most of the world’s great spiritual traditions. It promotes the ever-renewing
possibility of hope. It holds the belief that the various travails of our life have real
meaning and faith that in some final analysis, our existence matters.
The spiritual healer is called to recognize the sufferings of her/his client in
his/her own heart. Our service will not be authentic until it comes from the heart
which has been wounded by the sufferings about which we speak. A spiritual
healing ministry demands an understanding of ways in which the healer can
make her/his wounds available as a source of healing.
Terms
Pastor: Minister, Priest or Chaplain
Pastoral: Care that focusses on needs of faith
Hippocratic Oath: Hippocrates, the Father of Medicine, 5th C B. C. Doctors and
nurses take the oath to “do good and not to do harm” in their practice.
Hospital: A medical facility for acute health care
Hospitality: welcoming care
Hospice: noun- a place where end of life care is given; verb-the act of providing
end of life care.
Palliate To relieve symptoms
Palliative A physical condition where the focus is on comfort rather than cure.
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Spirituality vs Religion
All persons are spiritual in nature. However, not all persons are religious. Look
at the small circle on the inside—imagine the small circle in many different sizes.
It could be very small for a person of Christian background who observes
Christmas and Easter, but very little else of the Christian faith. Or it could be
larger—for someone who has a stronger faith practice. It could be a circle
almost as big as the outer circle—for one where their religious faith is central to
their very being (e.g., a faith leader, rabbi, or priest). The visual is of two circles
where every person is fully spiritual in nature, with varying degrees of inner
circles. It is quite reasonable to have a client who has no inner circle or religious
nature; however, the outer circle depicts that spirituality is inseparable from the
person.
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Janet Stark 2011
“Maslow’s Hierarchy of Needs”
An interpretation of Maslow's hierarchy of needs, represented as a pyramid with
the more basic needs at the bottom. Maslow has classified the basic needs of
man into five broad categories:
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Maslow’s triangle includes all aspects of the person. Spirituality touches each
part from the most basic physiological needs through safety and upward to selfactualization. In health care, the focus is most often on the lower levels. When
clients have acute illnesses, we can help them get well, and this means they
move up the hierarchy, regaining their independence, and eventually they are
discharged or empowered to manage chronic illness. When health care
providers focus on basic needs, we are providing care. Helping people is a
spiritual act, sharing part of oneself with another.
Maslow’s model teaches that we must start to care for the ill person by providing
for the basic needs first. Starting on the bottom level, we need to meet the
physical needs such as food, water, sleep, and shelter. Next, the patient must
feel secure—that he will not fall out of bed or that he is safe in the nurse’s care.
When we move up toward love and belonging, we increase the opportunity for
supportive care: companioning, affection, and spiritual care. The spiritual needs
reside in the top three levels: belonging, confidence, comfort, hope, creativity,
acceptance, and legacy. Maslow’s model illustrates well the basic spiritual
needs and shows that all aspects of care have a spiritual component.
Janet Stark 2011
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1.Physiological Needs These are necessary for our basic survival. They
include the need for food, drink, clothing, shelter, sex, and the avoidance of
injury, pain, discomfort, disease, or fatigue. Physical needs must be met first
before trying to meet higher needs. For example: pain and symptom must be
dealt with before supportive measures like listening and understanding can be
effective.
2. Safety Is this a safe place? A person needs to feel secure; he needs to
know if he feels safe in the hospital or nursing home. Does he trust he will not
fall out of bed? Does he trust his care team and his family who take care of him?
3. Love and Belonging A person needs to feel that they belong
somewhere…for example, it is OK for him to be in this hospital room, or staying
at your house right now. A person needs affection and warmth ranging from a
friendly smile of acceptance to the physical embrace of a hug… to knowing one
is loved.
4. Esteem A person needs a sense of peace and satisfaction, knowing that
they are less than perfect and that is OK, knowing that they have right
relationships, and that they have made peace with God or whatever they believe
him to be.
5. Self-Actualization This highest level is very profound. Many do not reach
this level of self-understanding and growth. It is reaching the concept of how
you fit in the world; understanding your sense of purpose and value and having
accepted your journey and fate. We sometimes refer to this as ‘being right with
the world.’
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P.I.E.C.E.S. Assessment Tool
P.I.E.C.E.S. assessment offers a way of looking at each person as a whole
person in a systematic way. This tool has been designed for the dementia
population, but can be used to assess other conditions as well.
Major areas and issues to be assessed are as follows:
P (Physical)
Delirium
Disease
Drugs
Discomfort
Pain & Symptom
I (Intellectual) Memory
Reasoning
Abstract thought
Insight /Judgement
Language
Perception
Orientation
Concentration
E (Emotional) Feelings
Mental Health
Loneliness
Wellbeing
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C (Capabilities)
Functional abilities
Functional dependence
Task demands
E (Environmental)
Noise, over stimulation/ under stimulation
Relocation, changes in environment
Environment demands
Lighting / Colour Schemes
S (Social/Spiritual/Sexual) Social Network
Life Accomplishments & Story
Interactions with caregivers
Spirituality and Pastoral Needs
Sexuality, needs and practice
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What is the difference between…
Social Visits
Pastoral Visits
Conversations
Active Listening
Lighthearted
Serious
Trivia
Intense
External
Introspection
Weather
Memories
News
Personal Stories
Friends
Reflection
Neighbours
Self disclosure
Problems, needs
Worries, Fears
Focus is on
Focus is on
Objective & General
Subjective & Individual
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Pastoral Visiting
Pastoral visits attempt to bring solace, comfort and relief to the person. It helps
one to face realities and fears by speaking about them in a ‘safe’ environment.
It concentrates on the person’s specific thoughts and feelings and encourages
them to share and express themselves.
The visitor MUST be empathetic, not sympathetic
Empathy:
The ability to identify oneself mentally with a person in order to
understand his or her feelings or meaning.
Sympathy: The ability to share another person’s emotions.
It can include
feelings of pity toward one suffering pain, grief or trouble.
“A burden shared is a burden lightened”
The Difference Between a Social and a Pastoral Visit
In the conduct of patient visitation, it is extremely important for the volunteer to
keep in mind the difference between a social and pastoral visit. While social
visits are not unimportant, and indeed, are often crucial for the welfare of the
patient when they are conducted by his or her family members and friends, it is
with the pastoral visit that he or she must be primarily concerned. For it is in the
context of the pastoral visitation that the volunteer truly “attends” the patient and
offers significant assistance to him or her. It is in that context that the truly
personal and transcendental needs of the patient are addressed and met. It is
here that the volunteer ministers to the patient and can truly assist in the healing
process.
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To help distinguish between a social and pastoral visitation, the following
characteristics of both should be kept in mind:
The conversation of a social visit, focuses on essentially pleasant, external or
non-essential and even inconsequential subjects, such as the weather, local or
world events, family or person trivia, etc. It is intended to initiate or maintain a
pleasing or congenial atmosphere through mutual sharing of experiences,
stories, or relatively unimportant information. It usually is intended to be
pleasant, enjoyable, “light”, entertaining, and diversionary, and it is often marked
by a great deal of generalizing or universalizing on what should or may happen
to others. It is not designed to be serious, deep, or focused on crucial or
potentially disturbing subjects.
The pastoral visit, on the other hand, is intended to concentrate on a person,
and on his or her problem, concerns, conditions, fears, worries, needs and so
on. Its focus is subjective and individual, rather than objective and general. It
attempts to bring solace, comfort, and relief to the patient by helping him or her
face realities rather than by avoidance of them. It encourages the patient to
share himself or herself, together with all his or her fears, concerns, misgivings,
etc., rather than to share mere entertaining stories or anecdotes.
It requires the volunteer to be understanding and empathetic, not just pleasant,
and to encourage the patient to be concerned with what is in terms of his or her
condition and its consequences, rather than what ought to be.
It concentrates on the patient’s specific thoughts and feelings rather than on
generalities, and is intended to help the patient express and share thoughts and
feelings. It allows the patient to set the agenda and often discusses health
concerns, his or her relationships with family members and his or her relations
with God rather than entertaining pleasantries or diversions.
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Who May be on the Health Team?
Can you think of any others?
Activity Director / Therapeutic Recreation Worker
Chaplain / Clergy / Spiritual / Pastoral Care Volunteers
Community Care Access Centre Case Manager
Dietitian / Food & Nutrition Manager
Funeral Director
Occupational Therapist
Palliative Care / Hospice Volunteers
Personal Support Worker (Health Care Aide/Community Support Worker)
Pharmacist
Physician
Physiotherapist
Registered Nurse
Registered Nurse / Registered Practical Nurse
Respiratory Therapist
Speech Therapist
Volunteers
A
Family
Person
(patient,
client,
resident)
Friends
Who is in the Circle of Care?
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Care Giver Exercise
Fill in the blanks:
My spiritual/religious affiliation is:
My faith practices are:
I believe….(one sentence or two about what your religion or spiritual practice
means to you)
I don’t tell my “neighbours” about my beliefs and practices because I am
afraid…..
I think they will make the following judgments about me:
I do tell my “neighbours” about my beliefs and practices when:
It is easier to talk about it when:
It is harder to talk about it when:
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Professional Caregivers
On any given hospital nursing team you may have:

an older nurse who was trained by the Catholic nuns,

a nurse with aboriginal roots who often feels that traditional medicine is at odds
with his customs and practices,

a young nurse who proudly claims to be an atheist,

a middle-age nurse who is an evangelical Christian and attends every worship
service held in the hospital,

a nurse who is of Asian background and Buddhist in practice,

a nurse who seems angry at the church and fights against any personal
connection with organized religion, and

a nurse who is very spiritual and finds strength in sports and nature.
In reviewing their nursing backgrounds, you realize that there has been a vast
range of educational experience when it comes to spiritual health. Some have
had very little spiritual education, others have had the basics on chaplaincy
services and religious care, and yet others have had a more current, broader
focus on spirituality. How are we to expect all staff to have a comfort level with
the topic of spirituality? Can we educate and sensitize them to ensure that
clients are provided with best practice spiritual care?
The topic of spiritual care is often misunderstood and poorly addressed in health
organizations. We may profess to provide holistic care—body, mind, and spirit—
but are we all “on the same page” when it comes to “spirit” care? If not all on the
same page, how can we provide “spirit care” to a consistent standard?
Janet Stark 2011
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Do We Know Ourselves Well?
Finish these statements:

One of my biggest challenges is..........

The social setting in life I find the most difficult or troublesome is……..

The type of person I have most trouble with is……

I don’t cope very well with………….

I am anxious when……………

I am afraid to …………

I don’t have the skills to………………..

A problem that keeps coming back is………..

If I could change just one thing in myself it would be………..
Once you have finished:
1) Put a (√) next to the issues you are willing to discuss.
2) Circle the issue(s) you believe are most closely related to becoming an
effective visitor.
3) Bring the issue(s) that are both checked and circled to a group discussion
or to discuss with your mentor or another person with whom you are
comfortable sharing.
Identify our strengths and gifts
Finish these statements:

One thing I do very well is………

I communicate most effectively with others when……..

People can count on me to………

A recent problem I handled well is……..

A value I try hard to practice is………

One thing I like about myself is………
What areas of myself can use some work?
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Qualities of an Effective Caregiver
 Warm, compassionate, empathetic
 Aware of feelings related to death and grief
 Aware of personal value and belief system
 Acceptance/non-judgment
 Promotion of dignity & respect
 Strong ability to listen & communicate
 Aware of different beliefs, culture and worldviews
 Ability to assess needs of patient/resident/client
 Ability to appropriately respond to needs
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The Volunteer as Spiritual Caregiver
by Tracey Schofield, Assistant Editor, Long Term Care
A person is much more than skin and bones, blood and muscle. Beneath the
physical shell lies a complicated and complex emotional, psychological and
spiritual being. Intuitively more than scientifically, we know the soul hungers for
spiritual sustenance as the stomach hungers for food. Indeed, the spirit of a
person who is sick or troubled often needs as much spiritual care as the physical
body needs medical attention.
The awareness that spiritual care is basic to the wholeness of every human
being is now so fundamental that it is considered an essential component of
long term care.
Indeed, tailor-made pastoral care is as important as
individualized medical or psychosocial care for many residents, even those with
no specific religious faith.
But who is to minister to the individual spiritual needs of every resident?
Certainly the requirements for personalized pastoral care far exceed the
ordained clergy’s ability to provide for it. Fortunately, for thousands of residents
who benefit from this soul service, ordained clergy are not the only authentic
ministers of spirituality.
There is as growing awareness that laypersons minister as effectively at their
level as clergypersons do at theirs. Ergo, the pastoral care volunteer, properly
trained and motivated by a healthy faith, can play a critical role in the
nourishment of a resident’s spiritual self. The ministry of volunteer pastoral care
is broad and incorporates the disciplines of healing, sustaining, guiding and
reconciling. At its heart is love and compassion, with those who need care.
The pastoral caregiver can come from any walk of life: they may be a regular
volunteer seeking to broaden their horizons by adding a spiritual component of
care to their work and using their normal activities as a springboard to deeper
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concerns’ or they may come from within a place of worship itself. But whatever
their background, they must be thoroughly and properly trained.
According to local or parish conditions, many clergy will train laypeople to do
ministry that is within the theological and policy practices of their denomination,
matching the gifts and talents of caregivers to the specific needs of residents.
As well, volunteers may seek training through workshop seminars on pastoral
care visitations and programming.
There is a great deal to learn. Volunteers must be aware of the range of
emotions experienced by residents who have come to live in a nursing home
and must have a basic understanding of institutional life. They must be trained in
crisis intervention and pastoral care. They must be able to communicate with
residents and to establish functional relationships. They must be capable of
providing one-on-one care. They must understand the psychodynamics of grief
and be trained in palliative care and ministering to the dying. As well, pastoral
care volunteers must learn how to relate to staff, how to fit within the long term
care system and how to facilitate visitation in a cross-denominational setting.
Many facilities need the voluntary services of piano players, soloist, chorus
leaders and instrumentalists. Staff often require assistance in bringing residents
to worship centres. As the “hand and feet” of spiritual caregiving volunteers can
speak about the need for pastoral care in their area, visiting residences to
explain the work of pastoral care.
It is important that the trained and practicing pastoral care volunteer not be cut
adrift. The establishment of the support group for lay caregivers is one way to
help prevent volunteer burnout. As well, volunteers should be assigned a
pastoral care guide to supervise their work and provide encouragement,
understanding and gentle direction where needed.
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It has been said that “the future of the world is in the hands of those who care
with unlimited caring.” With their love, compassion, understanding and
devotions, who better to cradle the world than the spiritual caregiver?
The Pastoral Caregiver’s Code of Ethics

Residents/clients/patients trust you to fulfill your promises. Integrity must be
recognized as the practice standard of the caregiver.

Honour your Lord and respect the resident by giving your best efforts when
ministering.

Be submissive to those who carry the ultimate responsibilities of care.
Remember: you are a member of a caregiving team.

Confidentiality is a paramount virtue and an absolute necessity. However, it
must be balanced with responsibility.

Liaise with resident, family, staff or other support people.
Caring for Seniors: A Model of Pastoral Care for the Elderly in Long-Term Care, Albert Revell 1992
Personal Qualifications of a Pastoral Care Visitor

Motivation

Emotional Maturity

Non-judgmental

Warmth, Empathy, Tact, Discretion

Confidentiality

Flexibility

Dependability

Good Listening/Communication Skills

Ability to Work as a Team Member

Talents & Skills

Sense of Humour
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Teamwork: A Little Stuck Truck
Chaplain Brenda Haggett MTS
One recent, snowy morning, I was making my 45 minute drive into work. About 10
minutes into my drive, I saw in the distance a small truck in the snow bank; rather than
taking the turn to take to stay on course, I made my way towards the little stuck truck.
The driver was a young man – likely on his way to high school. How he got stuck where
he did is beyond me! Either way, regardless of how it happened, he needed help. The
thought crossed my mind “what can I do?” I certainly couldn’t push…but then it
occurred to me that if he would allow me to, I could get behind the wheel so that he
could push. Fortunately for us, it wasn’t long before a couple more vehicles came by
and I gingerly flagged them down to help. The young man seemed to be too
preoccupied with his embarrassment to ask for help. Thankfully two strong men
stopped at my frantic arm-waving (maybe they thought I was a helpless damsel in
distress) and soon we were working together to get the young man out of his situation
and back on track. The young man was relieved to be supported by hands of
experience as each of us took on a task for which we were best suited. I manoeuvered
the steering wheel while the two older men each took a front corner with the young man
suitably sandwiched in the middle. Our combined efforts accomplished something that
could not be done alone. In very little time, the stuck truck was free and each of us was
back in our own vehicles on our way to wherever we were going before stopping to
help.
That brief encounter with a stuck truck demonstrates for me quite well the work
done in spiritual care. We are part of a team; “T-together E-everyone A-achieves Mmore”. I meet people every day who are stuck in circumstances; sometimes of their
own making and other times just victims of circumstances. Either way, they need help
becoming “unstuck”. As I have come to appreciate, it usually takes more than one
person – in fact, it takes a team of trained people, each with areas of expertise, to get a
sick person ‘unstuck’.
I think it is natural to occasionally ask “what can I do?” when faced with a
challenging situation. But, if we as spiritual care providers trust that “the steps of the
righteous are ordered by the Lord”, then we can be confident that when we walk into a
situation, God has already gone before us to prepare the way.
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Conducting a Personal Spiritual Audit
12 Questions to keep your personal audits in control
Fred Smith, Leadership, Winter, 1998
Am I content with who I am becoming?
Not what I do, but who I am.
Am I becoming less religious and more spiritual?
Religion is something I control.
Spirituality is an experience that controls me.
Does my family recognize the authenticity of my spirituality?
Can your family say, “There is something of God in you?”
Do I have a flow-through philosophy?
We are blessed to be a blessing.
Do you see yourself as a pump, or a pipe?
Do I have a quiet center to my life?
There is an important difference between the fast track and the frantic
track. Peace is the evidence of God.
Have I defined my unique ministry?
Opportunity is not mandate.
Do I know and regularly do the things I do well?
Is my prayer life improving?
Oswald Chambers defines the essence of prayer as “finding the mind of
Christ.”
Have I maintained a genuine awe of God?
Awe isn’t learned; it is realized.
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Is my humility genuine?
Accept your strength with gratitude knowing that what you have comes through
you, not from you.
Is my “spiritual feeding” the right diet for me?
We are all different. We have different character traits that need developing or
removed.
Is obedience in small matters built into my reflexes?
Is obedience out of love?
How do I handle disobedience? Excuses? Confession? Carry guilt?
Punish myself? God alone can forgive, and He will.
Do I have joy?
Based on God’s Sovereignty.
Umbrella Question:
Am I working for progress or pride? What is my motive? Most often it is some
of each.
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What about Sharing my Faith?
To provide spiritual care do your best to understand the patients and meet them
on their own ground. Consider what to do when asked questions about your own
religious beliefs. It is usually appropriate to share and even beneficial when two
conditions are met:
1. when the client and caregiver share the same faith and
2. when the caregiver is asked.
When volunteers, staff or clergy seek to convert patients to their own faith group,
this is called ‘proselytizing’ and is unethical. In most health facilities, community
clergy are not allowed to make random hospital visits with the intent of
converting clients.
(see policy against Proselytizing in the Section on Ethics, p. 388)
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Brockville General Hospital
Spiritual Care Department Volunteer Visitor Job Description
Purpose:
To provide compassionate pastoral visiting to the sick.
Objective:
To strive to meet the spiritual, cultural and religious needs of those entrusted to
our care through individual visitation.
Qualities:

Committed to the policies and procedure of the hospital and the department

Ensures complete confidentiality of any information received while serving the
department

Respect for privacy of the patient and family

Desire for ministering to the sick and dying

Comfortable within a hospital setting

Good physical and emotional health

Motivated by a healthy faith

Good interpersonal and listening skills

Dependable and responsible

Respectful of the diversity of religious faiths and ethnic cultures
Duties:

Visiting assignments will be arranged by the Spiritual Care Coordinator with the
consent of the person being visited or their designate.

Reports to Spiritual Care Coordinator any problems or concerns arising from the
visit and any information that would improve the person’s quality of life.

Actively listens to the individual to assess immediate needs.
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
When appropriate, offers resource materials and information to support the
spiritual and religious needs of those being visited. (Large print and multifaith
resources available at both hospital sites)

Time permitting, and in the absence of family, assists the person being visited
with miscellaneous tasks that would improve their spiritual and emotional wellbeing. (ie letter writing, assisting with phone calls, reading to them etc.)

Remains current to the activities of the department by reviewing information
provided, newsletters and attending ongoing education sessions.
Training Requirements:
Spiritual Care visitors will be strongly encouraged to complete the Pastoral Care
Training Program offered by the Spiritual Care department or an equivalent
program that is recognized by the department.
Reports to:
All spiritual care volunteers report directly to the Spiritual Care Manager or to the
Chaplain in the Manager’s absence.
Revised
July 7 2011
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Ordinary People
Just ordinary people, God uses ordinary people,
He uses people just like you and me who are willing to do as He
commands.
God chooses people, who will give their all,
No matter how small your all may seem to you,
Because little becomes so much as you place it in the Master’s
hand.
Just like that little lad, who gave Jesus all he had,
How a multitude was fed with two fish, five loaves of bread.
Oh, what you give may not seem much but as you yield it to the
touch
Of the Master’s loving hand, then you will understand
How your life could never be the same.
Just ordinary people, God uses ordinary people,
He uses people just like you and me who are willing to do as He
commands.
God chooses people who will give their all,
No matter how small your all may seem to you.
Because little becomes so much as you place it in the Master’s
hand.
Copyright 1977, Birdwing Music/Danniebelle Music/Cherry Inae Music Pub.Co.,Inc.
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Desirable Qualities in a Volunteer
Motivation:

desires to serve, share, and interact with others

desires to learn and grow or a way to make a meaningful contribution to society–
and the personal gratification that comes with this

should not be seeking to resolve past losses, relieve guilt, or convert
Emotional Maturity:

a fully developed sense and appreciation of emotions in self and others

compassionate and sensitive

perceptive: a sense of when to be present and active and when to withdraw and
passively support

self-confident and takes oneself ‘lightly’ rather than being self-critical

past personal crises that have been resolved can be a valuable resource,
helping one to understand and support others through a current loss
Warmth, Empathy, Tact:

sympathetic, cordial

ability to identify with another person

skillful in dealing with others or with difficulties arising from personal feeling

forms a helpful relationship with residents and families
Confidentiality, Discretion:

respects confidentiality of all information relating to residents and families with
whom they come in contact or become knowledgeable about

discreet, unobtrusive
Flexibility, Dependability, Adaptability:

provides support when needed (various hours of the day or night) and in a
variety of settings

uses past experiences in a variety of ways to enhance their role as a palliative
care team member

reliable and punctual

adapts to different cultural, racial, sexual, spiritual and intellectual needs
Good Listening/Communication skills: willing to listen quietly
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Top Ten List of Things A Volunteer Should Know
10. List your dreams and talents. Where do you excel? What have you always
dreamed of doing? What do you really enjoy or would like to try? Is there a way
to prepare, learn or try it as a volunteer?
9. Pick your duration. One size doesn't fit all, just like volunteer opportunities.
I've found that volunteer projects come in three sizes: one-time, short-term, and
"whad'ya doing for the rest of your life?"
8. Make a commitment. Sometimes a volunteer project is an acquired taste.
Give yourself a chance to have good days, bad days and in-between days. If
after three months you see no redeeming value, then at least you can feel you
gave it a fair chance.
7. Watch and learn. Seasoned volunteers can teach you the "ropes" so to
speak. Observe them and follow their lead. Have confidence in the knowledge
that you are capable and trainable. Balance that confidence with a dose of
humility, also.
6. Ability, need and desire. You must have the ability to do the service, there
must be a need for the service, and you must have the desire to be of service.
5. Unpaid doesn't mean unprofessional. "Anything worth doing is worth doing
well." All that we do, we need to do with our most sincere effort. Anything less is
a disservice to those we are helping and ultimately to ourselves.
4. Balance is key. Priorities add balance. Charity begins at home-- keep the
priorities straight. Balance out family, work and volunteering. If you become
overwhelmed, stress will set in and you won't enjoy doing anything.
3. Stand back and admire. Sometimes people forget to say "thank you," so you
will need to reward yourself. Be proud of your accomplishments-- take the time
to smell the roses, hear the raindrops on the pane, feel the snow on your nose,
taste the cool clear water.
2. Find a home or make a change. Are you stale or still fresh? Are you learning,
enthusiastic or approaching burnout? Check yourself periodically and act upon
your honest answers.
1. Have fun! Life has enough drudgery; volunteering shouldn't be one of
them. Giving of yourself should be uplifting and joyful. We are at our best
when: we learn, grow, play and serve each other with love and respect.
Donald Patrick Dunn
Chicken Soup for the Volunteer's Soul
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Characteristics of Spiritual Health

Is mostly free of addictive habits

Finds fulfillment in self, others, work and leisure (work-life integration)

Accepts the limitations of humanity

Takes time to meditate or communicate with the Holy and Spiritual

Knows mortality to be inescapable but redeeming

Investigates and interprets illness within the context of meaning

Balances dependence and freedom

Uses health to serve others

Balances the spiritual with the physical and emotional

Takes responsibility for one’s own health
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The Pastoral Care-Giver Limitations
The role of the pastoral care-giver is at once a modest one and an
awesome one.
It is modest in the sense that none of us will ever be in a position to give an
explanation for why people suffer. It is modest in the sense that the assistance
we may be asked to give or which we may think we can offer, is beyond our own
abilities. It is also modest in the sense that none can claim to have the magic
formula or the easy recipe that will do in all circumstances. In other words, there
will always remain huge holes in whatever we may try to stammer in the face of
suffering.
The pastoral care-giver is not the answer person who in the name of God
has answers for all the questions.
Rather, the pastoral care-giver tries to hear and to listen to and to respect what
the person who suffers has to say. And, perhaps even more importantly, at
times that pastoral care-givers may need to help the person to say what needs
to be said. Real pastoral care must aim for something else: for what happens
between this person and his or her God. What we may hope for is the presence
of God to the person who suffers, who despairs, and who feels abandoned. The
awesomeness of the role of the pastoral care-giver lies in trying to bring the
person into communication with God whom we may represent or point to in spite
of and with all our limitations. For God alone is the source of all healing. By
means of our journeying with the person who suffers, we try to create a space
where glimpses and signs, traces of God’s presence can be detected, so that
hopefully that person may entrust the self to this God, cling to Him and
persevere in having confidence in a God whose full glory will still need to be
revealed.
Bill Marrevee
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Volunteer Task
Emotional Support
Practical Support
Hold the patient’s hand
Be a quiet presence at the
patient’s bedside
Listen to the patient’s
memories and life stories
Listen to the patient’s fears,
concerns or worries
offer grief and bereavement
support to the patient’s
loved ones after a
patient’s death.
Give the patient a back/foot rub
Help the patient with letter writing &
telephone calls
Run errands for the patient (e-g pick up
medications, groceries)
Drive the patient to the doctor, hospital
or to visit a friend
Provide respite/relief for loved ones (be
with the patient when they can’t be;
provide short breaks for them)
Shovel the patient’s driveway or cut the
grass.
Help with the patient’s pet (walk the
dog)
Provide hands on care (help with
feeding, lifting, turning in bed)
Social Support
Spiritual
Play cards/board games
with the patient
Read to the patient (books,
magazines,letters,
newspapers)
Talk to the patient
Share hobbies and interests
with the patient
Go for a walk with the
patient
Provide friendship and
compan-ionship
Brockville General Hospital Pastoral Care Education
Invite all patients to share spiritual and
religious beliefs and to define what
spirituality is for them and their spiritual
goals
Learn about the patient’s beliefs and
values
Assess for spiritual distress
(meaninglessness, hopelessness as
well as for sources of spiritual strength
(hope, meaning, and purpose).
Provide an opportunity for
compassionate care.
Empower the patient to find inner
resources of healing and acceptance.
Identify spiritual and religious beliefs
that might affect the patient’s health
care decision-making.
Identify spiritual practices that might be
helpful in the treatment or care plan.
Identify patients who need referral to a
board-certified chaplain or other
equivalently prepared spiritual care
provider.
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“Caring Friend” Pastoral Visitation
1. Briefly centre yourself in prayer before visiting
2. Knock on the door and ask if you may enter. Greet the resident/patient by name
and identify yourself (and the spiritual care department).
3. Please keep in mind that Spiritual Care Volunteers are there to listen.

Do Not – tell a resident/patient how you perceive they are feeling.

Do Not – offer advice

Do Not – tell a resident/patient “you should not feel that way”

Remember, there are no right or wrong feelings from the patient perspective.

Do Not – have an agenda, allow the person being visited to lead the visit.
4. Try not to ask too many questions. Often times a patient is too weak to talk &
would appreciate a quiet presence. Silence is OK.
5. Please remember each person is an individual:

His/her fears, hopes, dreams are real to him/her.

Don’t assume it is a comfort to hear, “I know what you are going through, my
aunt had…” or “I know how you feel”

Try to affirm for the person that his/her feeling is okay.
Remember, silence can be therapeutic!
6. Sometime during your visit, if and when you feel prayer would be appropriate,
you might want to ask the resident/patient/family if you do so. Be sensitive to
whether the resident/patient wants prayer at all. You may say, “I’ll be praying for
you,” or you can always pray silently.
7. If appropriate, you can remind/inform the person where the chapel is located and
about the Spiritual & Religious resources available.
ALWAYS WASH YOUR HANDS THOROUGHLY AFTER EACH VISIT
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Visitation Ministry Training
http://mintools.com/visitation-ministry.htm
Chief among the reasons why your church should have a visitation ministry is
that people matter to both God and to you. Visiting them lets them know you
care.
Who Needs to Be Visited:
Anyone needing encouragement, comfort, or a sense of belonging would profit
from a visit. While that could include everyone, there are certain individuals who
especially need to be reminded that they aren’t forgotten. These are people who
can feel rather lonely at times.

elderly people still living independently especially if they are shut-ins

elderly or disable people living in nursing homes

people who are sick for a prolonged period of time

people who are hospitalized

bereaved people

prisoners

people in shelters

people in crisis
Who Should Do The Visitation:
Many a pastor has fallen under criticism for failure to do enough visitations.
Realistically, however if the pastor is to adequately prepare sermons, counsel, &
provide general leadership for the church, little time remains to visit everyone.
Some churches have hired a visitation pastor to bridge the gap. Some churches
have a visitation committee or team to share the load.
The biblical reality, when you look at the one another passages of
Scripture, is that visitation is a corporate effort not just the pastor’s or
committee’s job. If we are truly going to express care for one another, then we
must sometimes go where the people are. We must lay aside our busy
schedules and excuses and make people a priority.
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How nice it is if the pastor from the church visits in our time of need. How
encouraging if another member also visits during this time of crisis. But to have
numerous people visit over the course of time, now there’s a caring church.
To be sure, visitation will come easier for some people than others. While
we all should be visiting one another on occasion, especially in time of need,
people with a more outgoing personality or with the gifts of hospitality,
exhortation, and/or mercy will be more prone to make visitation a part of their
regular ministry. Visiting is a viable ministry for people with this kind of gifting
and/or personality, especially if their heart reaches out to people who are
hurting, lonely or in need.
What Should Happen in a Typical Visit:
Fear of not knowing what to say or do is one of the big stumbling blocks to going
out on visitation. You don’t have to have a planned program to visit someone.
Just being there matters more to them than what you do or say Your presence
communicates that you care and that is the bottom line in visiting someone in
need. If you go with an obvious agenda, or planned out speech, people could
feel that your agenda matters more than they do.
1. Spend most of your time listening. Let them talk, Get to know them better. Learn
about their needs. You don’t always have to throw out pearls of wisdom into a
situation. A person could find great relief simply by being allowed to talk. Don’t
change the subject when they talk about something you find uncomfortable.
Learn how to be a better listener
2. Remember that you are there for them and not for yourself. You are their guest
so respect their space – don’t push your ideas on them; let them minister to
you, respect their property – don’t rearrange things without their permission,
and respect their time – don’t overextend your welcome.
3. Be sensitive with the kind of stories you tell. A person with cancer or with a loved
one dying from cancer does not need to hear everybody else’s hardship or
remedy for cancer.
4. Extend the gift of touch. A hug, a hand on the shoulder, or holding their hand
breaks through the barriers and communicates warmth. (remember to use hand
sanitizer)
5. Offer to pray with or for them. Even non-Christians will often welcome prayer in
their time of need.
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Companioning
Companioning is about going to the wilderness of the soul with another human
being; it is not about thinking you are responsible for finding the way out.
The only map that does the spiritual traveler any good is the one that leads to
the centre.
Listen and attend with the ear of your heart - St. Benedict
Listening and responding from the heart, you are patiently empathetic to the
needs of the mourner.
Companioning is about bearing witness to the struggle of others; it is not about
judging or directing those struggles.
Too often we underestimate the power of a touch, a smile, a kind word, a
listening ear, an honest compliment, or the smallest act of caring, all of which
have the potential to turn a life around – Leo Buscaglia
Companioning is an expression of compassion, being involved in the feeling
world, going beyond. “I know how you feel,” overcoming the temptation to try
and “fix things” and embracing the feelings of loss.
The most familiar models of who we are (doctor & patient, helper & helped)
often turn out to be major obstacles to the expression of our caring instincts.
They limit the full measure of what we have to offer one another. True
compassion arises out of unity – Ram Dass
Companioning means discovering the gifts of sacred silence; it does not mean
filling up every moment with words – Buddhist tenet
The companionship of silence has the ingredients that can bring some peace in
the midst of the wilderness. The forces of grief weigh heavy on the heart.
Silence serves to lift up the mourner’s heart and create much-needed space to
give attention to grief. Being in silence helps restore energy and inspires
courage to explore the many facets of transformational grief.
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Companioning – Attending on a Visit
Introduction (ground rules for visitors)
1. Keep yourself safe. It’s okay to expect to feel comfortable in a visit.
2. Stay in your lane. If you’re in over your head, get out. (Refer, as appropriate)
3. It’s okay to ask for what you (BOTH) need, in order to have a productive visit.
You may need to take some control in order to set up for a productive visit.
4. Don’t take it personally. To be a visitor is to make sacrifices. You will walk
through some dark valleys; it will sometimes be painful.
5. Try not to take offence (even as you shudder or cringe internally)
Show up and shut up.
As members of a body, part of a community/church, we have resources, and are
thus better equipped to face difficulties. This is what pastoral visiting is all
about…Keeping God’s people connected with their church/community. When
someone is walking through a dark valley, “the valley of the shadow of death”
the greatest need is to NOT BE ALONE. They need a friend to walk with them.
Your call is to be a companion on the journey.
Your resources:
1. Yourself (time and presence)
2. Faith
4. Pain (your own woundedness)
5. Prayer
3. Experience
Four Levels of Communication:
1. Casual, Social Interchange (How are you? Fine, thank you.)
2. Personal, Social Level (mutual interests – How ‘bout them Leafs?)
3. Information Level (Intellectual, with some emotion – I love it when the spring
flowers bloom)
4. Intimacy and Disclosure Level (Sharing, Empathy, Emotional, Expression)
Guiding Principle: Walk with them. Stay with them. Let them set the direction
and the agenda. Let them talk about what they need to talk about. Help and
support them when they are finding it difficult. This is what it really means to
“show up.”
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Spiritual Practices Volunteers can Adopt
Chaplain Janet Stark
Show up! The presence of a caring person has immeasurable value!
Agapé love Have positive regard for all—the term means “love for all mankind.”
Mercy and grace Show compassion and empathy while providing nonjudgmental, non-preferential treatment. The volunteer shows grace by allowing
the client to be human: imperfections and all.
Develop trust The therapeutic relationship between client and care provider can
greatly assist healing. Sometimes a relationship is driven more by personality
than by professional competence. A client who is experiencing vulnerability
needs to feel safe.
Eye contact and smile These are your first “words” to your client, and they help
the initial connection. A warm smile often paves the way for meaningful
discussion.
Active listening It is so important to hear the stories of the clients. Perhaps this
is more important than saying the right words. Listening, hearing, and accepting
are very helpful, even when this doesn’t always result in direct action
Sincere words Communication skills are important, as are a few words chosen
intuitively. Often fumbling words are accepted because of the tone and the
intent. A reflection or acknowledgment of what you are hearing is often helpful.
Gentle touch A light touch of the hand or shoulder is often appropriate, and can
convey what words alone cannot. Hand-holding can be a great comfort, but
caregivers need to wash their hands frequently and carefully to prevent the risk
of spreading infection.
Simple reflection/prayer/ meditation A reflective statement, prayer, poem, or
reading a card are ways to offer spiritual practice. There are many creative ways
to help while, at the same time, meeting the comfort level of the volunteer.
Be rather than do Just the opposite of what we think! We have been taught
“Don’t just stand there, do something!” Sometimes it is more appropriate to
“Don’t do something, just stand there.”
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Chaplaincy 101: Show Up. Shut Up. Offer Help
A few decades ago I played on a pretty good high school basketball team.
Looking back, I see we were good not because we possessed any extraordinary
athleticism. I think we were good because we had been trained for six years in a
program that consistently drilled into us the fundamentals of basketball. We did
the basics well.
I have given some thought over the last few years to the question of what are
the fundamentals of good chaplaincy care. What are the basics that when done
well will lead to care that makes a positive difference for patients, families and
the healthcare team? One way of summarizing them might be: Show up: Shut
up, and offer help.
Chaplaincy care is intensely personal work carried out through the medium of
relationships. Showing up is the first step toward building an effective helping
relationship. In our department we stress proactive chaplaincy. This is in
contrast to reactive chaplaincy, responding to the initiative of others. There is a
certain amount of this in any chaplain’s work. But, there is real danger in others
defining our work for us if this is our primary approach. Proactive chaplaincy
care involves making rounds in assigned clinical areas and attending
multidisciplinary rounds meetings for the purpose of initiating relationships with
patients, families and the healthcare team. It is hard to be of much help if we do
not first show up.
Frequently the foundation of relationships is laid by explaining who a
chaplain is and how we can help. Though simplistic, in most cases it is sufficient
to say, “We are specially trained clergy who offer spiritual and emotional support
in the hospital.” Longer explanations can be provided as needed. There is
typically some introductory conversation. This is often relatively shallow in
content, but valuable as a means of establishing trust that leads to the possibility
of more substantive interaction.
It is then that we shut up. We move into a primary mode of eliciting the
other’s story and listening. We listen with trained ears, eyes, heart, and mind.
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What are this person’s needs? Hopes? Resources? What is her concept of the
Holy? What is the shape and quality of community in her life? [1] All of our
listening combined with our training and experience provides the material out of
which we form an assessment. It is based on our assessment that we offer
help. [2] We identify the chaplaincy care interventions which we deem to offer
the greatest potential for assisting this person. If he/she grants us the privilege
of being his helper, he/she can expect to benefit from both our personal concern
and professional capability. Accepting and benefiting from our help does not
require a person to even begin to comprehend all of the years of education,
clinical training, personal growth, and life experience that contribute to it. He/she
just needs to know we care.
These are the fundamentals of what we do. Day in and day out. With person
after person. We show up. We shut up. We offer help. On the surface, these
rudiments are no more impressive than the innumerable hours my high school
team spent in dribbling and passing drills or in running through offensive and
defensive sets ad nauseum in practice. To the ignorant it is about as exciting as
a musician practicing scales. But, to those of us who have trained to master the
essentials, this is the stuff out of which grows some of the most meaningful work
a person could ever hope to invest a life in. When we get it right, patients, their
families and the whole healthcare team wins.
Brent Peery, D. Min. Reprinted from Plainsviews, e-newsletter for Chaplains Feb.2010
Footnotes
[1] VandeCreek, Larry and Lucas, Arthur. Eds. The Discipline for Pastoral Care Giving:
Foundations for Outcome Oriented Chaplaincy, New York: Haworth Press, 2001. 8-18
[2] We offer; we do not impose. To do the latter would risk violating the medical ethics principle
of patient autonomy, not to mention the inherent dignity of another human.
Brent Peery, D. Min., DCC is chaplain director for Memorial Hermann Hospital – Texas Medical
Centre in Houston. Brent is an ordained Baptist minister, endorsed by the Cooperative Baptist
Fellowship. He is husband to Karen for over twenty years and father to Garrett, Brooke, and
Anna Carol. He is profoundly grateful for the joy and meaning that his family, faith, and work
bring to his life.
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Chaplaincy 101: There’s More to it than Showing Up and Shutting Up.
As always, I appreciate Chaplain Brent Peery’s thinking and even more, his
proactive willingness to put it out there for the rest of us. I don’t disagree with
Chaplain Peery as much as I want to look at the same practice model from a
slightly different angle and make sure that some of its facets are not ignored.
In general, the titles, Show up and Shut up, imply much more passivity than
Chaplain Peery may intend. If is important for the reader of his article to pay
attention to all the activity that goes on while the chaplain is just “being there”
and how much training it takes for the activity to be done well. Showing up leads
to very active education of the staff, looking for patients who could use
chaplaincy care, and active and intentional building of relationships. Shutting up
leads to a very disciplined assessment and formation of a treatment plan. As
Chaplain Peery points out, it is not just “listening”; it is “eliciting’ – definitely an
active process that presupposes training and skill.
I agree that the chaplain who is not visible and a fully present and integrated
part of the health care team are not going to be utilized. It is the major way that
a chaplain and chaplaincy care becomes known and staff knows when to call us.
I also agree that it is dangerous to let others set the chaplaincy care agenda.
However, protocols for making chaplaincy referrals designed and in serviced
with chaplains in the lead, pro-actively hard-wire our agenda into the business of
the health care institution. We can’t be everywhere all the time. Since these
protocols tend to involve and are developed by several disciplines, this process
gives chaplaincy an opportunity to both teach about what we do and
demonstrate the particular contribution of spiritual care. Further, to the extent
that the protocol development process forces us to have other disciplines come
to agreement on what chaplaincy should be doing, we raise our value and the
support for our contribution.
I am concerned that Chaplain Peery’s use of “offer help” can imply that good
intentions are sufficient in the current world of health care. Granted, sometimes
offering alone gives the patient great comfort and support.
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However, it is
increasingly clear that we have to be able to demonstrate that outcome. I would
call this “Being of Help”, and as Chaplain Art Lucas would have reminded us, if
we make the claim that we have been of help, we also need to be able to
answer the question “how do you know?"
I agree with Chaplain Peery that it is easy to witness the seeming
effortlessness with which a trained athlete and the team execute in a way that
appears natural without appreciating that no one can play any game at a high
level without extensive training and practice. Likewise, good chaplaincy care
should seem to emerge naturally from the person of the chaplain. It should not
be apparent to the patient how many verbatims and excruciating IPR’s the
chaplain had to go through to get to this point. Thus, it is all the more critical,
especially with other disciplines in the field of health care, for us to use language
that makes it clear how informed, active, intentional and disciplined the practice
of chaplaincy care truly is.
Rev. George F. Handzo is HealthCare Chaplaincy’s Vice President, Pastoral Care Leadership and
Practice and runs its Consulting Service which is devoted to strategic assessment, planning and
management of chaplaincy services. He has spent over three decades in the field of multifaith
clinical chaplaincy care. An APC Board certified healthcare chaplain, Certified Six Sigma Black Belt,
and Lutheran Pastor, George served as president of the Association of Professional Chaplains
(APC) from 2002-2004. He also served as chair of the Spiritual Care Collaborative (previously the
Council on Collaboration), which is comprised of the six major pastoral care organizations in the
United States and Canada.
Which points of view do you naturally gravitate toward?
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Listening Skills
How Do We Actively Listen? We listen with our whole BODY
Presence: Ministry of your presence-- the being there.
Body language: Will tell the person whether you are comfortable in being with
them. For instance...are you in a hurry, is your foot rocking, is your body tense,
are you trying to sneak a look at your watch? etc.
Tone: Is it anxious due to nervousness, time constraints, angry, apprehensive,
uncomfortable, shy, shocked...
Eye contact: Maintain eye contact -this means you are WITH the person.
Indicates you are comfortable, secure and trustworthy.
Positioning: Don't stand over. Sit facing at same level. Pull up a chair when
possible beside the person. Do not have a barrier (such as a desk) between
you. Do not talk down to a person. If in wheelchair, get down to person's level.
Touch: The power behind a simple hand on the shoulder, a held hand, a hug, is
extremely powerful and beneficial to a hurting, grieving person. Because this is a
controversial subject, you need to use discretion.
Relax: Empty yourself of your own life contents. Use of prayer prior to a visit is
most helpful, especially just prior to entering.
Enabler: Your responsibility is to make it easy for the person to be at ease and
relaxed -this enables the person to trust you and will be more likely to open up to
you. Keep in mind it is always the other person's agenda -sometimes the person
just does not want a visit at this time -respect that right. You are an ENABLER
not a MAKER.
Focussed: Your task of listening is made more difficult if YOU are under stress
or grief -important to be aware of this and stay focussed on the person's pain
rather than your own. Also if other distractions in room, i.e. T.V., children, radio.
See where you can make a change to keep focussed.
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Probe: Gentle prodding to get to know person is O.K. Ask about home life,
children, family, school, career-- enough to get to know something about the
person and set an atmosphere.
Clarification: Unless you can convey the fact that you are listening, it is of little
value. Report the product of your listening by making regular perception checks
of WHAT YOU HEARD. Only then do you afford the person the luxury of feeling
understood, even if your perception is not completely accurate. Don't be shy
about this. This is an area where your listening skills will be most needed.
Honesty: If something appears beyond your capabilities or limitations –be
honest --simply state “I do not have an answer to this,” but you might want to
offer some alternative. Grieving people sometimes ask questions that they really
do not want an answer to. EX: Why is this happening to me? Be honest -you do
not have an answer.
Supportive: Shows you accept the person exactly how they are at this
particular stage in their journey. Accept the feelings, i.e. guilt, anger, frustration.
Be supportive by listening to the feelings behind the situation, not building on it.
Evaluate: The ability to assess a visit is important. Assess the person's needs,
feelings, so you can be alert as to whether the person is able to cope or whether
you need to refer quickly or down the road.
Advice: Never give advice, even when asked. It's fine to say that such and such
has been helpful in some cases, or even better, gently turn it back to the personstating "What Do You Think or Feel"….OR What are the alternatives for you?
Judging: Be shockproof. If person feels they are being silently condemned,
they will not be able to express themselves freely.
Perfection is impossible --be gentle with yourself.
The ministry of listening is truly A LABOUR OF LOVE.
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Some Guidelines for Creative Listening

Look at your attitude and how you feel about the person who is talking to you.
Are you looking down on them? Can you accept the person totally?

Listen for feelings behind what is being said, to the tone of voice, and the body
language as well as the words themselves.

Be attentive and try not to let your mind wander in your own thoughts and
reactions. Good Listening requires a quiet atmosphere without distraction.

Test your understanding by feeding back what you have just heard and felt. This
helps focus and clarify thoughts and feelings.

Interpret questions as door-openers. If an answer is really being sought, the
question will be repeated. Most questions require no answer except to share
feelings behind them.

Remember that the person speaking is in control, and that the listener can help
only as much as allowed. If you follow the mood of the person, you will have no
difficulty laughing together over the absurd events of the day, or seriously
considering some of the mysteries of life.

Examine your own feelings. Too often, we are sympathetic to others. Sympathy
in the listener may not be helpful to the person. In contrast, an empathic
response hears the feelings of the other, and seeks to understand. It is centered
in the other person and can lead to further understanding.

Are you projecting your own feelings onto the other person? Projection distorts
the accuracy and depth of understanding and leads to many errors in listening.
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Steps for Listening
Physical 1.
Mental
Sit facing your friend
2.
Watch eye contact
3.
Be aware of nonverbal clues
4.
Establish a comfortable distance
5.
Focus physically
6.
Relax
7.
Focus mentally, shutting out own thoughts and distractions
8.
Suspend judgment
9.
Listen
10.
Wait before responding
Barriers to Listening
1. Did you stop listening because you started making assumptions?
2. Were you so worried about how well you should do that you stopped listening?
3. Did you hear something that struck a personal emotional chord?
4. Did you begin to feel overwhelmed?
5. Were you unable to understand the topic and “lost track”?
6. Was the message coming through confused?
7. Were you unable to ask for clarification?
STOP
Before you speak!
LOOK
At the nonverbal signs!
LISTEN
To the Words!
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Sympathy or Empathy
Individuals react to life experiences from their own point of view. Caregivers
possessing the ability to experience another person’s pain are able to lift or at
least share the burden. We know that caregivers can easily become drained of
energy from emotions experienced in palliative care.
Sympathy refers to the sorrow one feels for the person in pain. Although it is
often a natural response, it is not a very productive response in that the
individual experiencing the loss/pain often feels responsible for the feelings of
the caregiver.
Empathy is the ability to understand what another person is feeling without
losing one’s self in the other’s pain. The experience is shared in that the
caregiver can see the experience through the griever’s “own eyes”. Empathy,
which by definition implies acceptance as well as support, allows the griever to
feel understood.
For the caregiver, it is better to be able to react to the patient with empathy.
However, it is recognized that as humans, we give better care when we invest of
ourselves. As Healthcare professionals and workers, we tend to be nurturers.
Therefore it is a very fine line, and often difficult for the caregiver to find that
balance. It is important, to always be aware of our own emotional health, so we
can be of benefit to someone else.
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Empathy
When to listen with empathy:
1. To begin a relationship of trust and caring.
2. To help other persons understand themselves better & get more closely in touch
with their feelings and attitudes.
3. When you find it hard to understand what another person is saying, or don’t
know what they mean by what they say.
4. To learn more about a person, especially feelings & reports of socially
unacceptable behaviour or ideas.
5. When your ideas and the ideas of the other person are different. Empathic
listening will help you fully understand their views.
When not to listen with empathy:
1. When the other person is seeking information only, or needs immediate action.
2. When the other person is inappropriate (abusive, seductive, aggressive).
3. When the other person is not in touch with reality, is suicidal or intoxicated.
4. When empathic listening no longer produces new information (feeling or
content) from the other person.
Make it easy for others to be themselves
1.
Use good attending skills (look at the person, turn your body toward the
person, and pay attention to spacing).
2.
Listen closely to what the person is saying and how he is saying it.
3.
Watch for nonverbal clues to feelings.
4.
Remember the content (what the other person is talking about) and the
feelings (how they feel about what they are talking about).
5.
Reply! Use words that describe the content and feelings in what you say.
Give lots of attention to the person’s feelings.
6.
Keep listening. If you want to help, give all your attention to the other person.
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Why empathic listening works
1. The other person sets the pace. You let them take the lead in the conversation.
You don’t push them faster than they want to go. This builds trust.
2. The other person is completely free to be natural. That’s a rare opportunity. The
other person will probably take advantage of it by relaxing and behaving in the
ways that are most real and honest. When you show that you can be trusted,
other persons are free to tell you about their hurts, their secrets, and their
ambitions. The result – you can really know them.
3. The other person gets more understanding. In a mirror you can see things
about your physical self that cannot otherwise be seen. In the way, Empathic
Listening serves as a mirror in which persons can see their behaviours and
attitudes more completely. This helps them understand themselves better and
forces them to decide whether or not they like themselves the way they are, or it
they want to change.
4. To empathically listen gives something of value. Empathic listening is hard work
and the other person knows it. When you listen with empathy, you prove to the
other person that you care.
5. It keeps you out of trouble! While you are engaged in empathic listening you will
not do anything that is punishing, painful, or hurtful to the other person.
6. Empathic listening clarifies and reduces confusion.
7. Empathic listening creates a relaxed, trusting atmosphere and reduces threat.
8.
Empathic listening encourages “connected” communication
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Helpful Empathic Listening Practices:
nodding, “hummm”, “I see”
Listening noises
Reflecting
saying back what the person has told you – perhaps
paraphrasing “You say you haven’t been out of the house for a week…”
Understanding reflecting feelings: “Its sounds like you are very angry with me”
Summarizing
brief summary of what has been said (Keeps the conversation
on track “So… your son is an architect & your daughter is a firefighter”
Supporting
“It’s okay to feel that way.” “I’d feel angry myself if I were in your
shoes”
Probing seeking more information about a subject: “Tell me more about what
you did in the war.”
Referring
“It might be best if you talked to the doctor about that”
Common Mistakes in Empathic Listening
1. Sounding like a parrot or a robot.
2. Talking about content only, ignoring feelings
3. Giving cheap advice.
4. Using poor attending skills. You sound good, but you look like you don’t
really care or don’t have the time.
5. Shifting attention to yourself. Talking instead of listening.
6. Having no energy. You must be as intense in your words and emphasis
as the other person.
7. Sliding into non-helpful replies such as joking, making judgments, reassuring
Blocks to Empathic Listening
Most people block communication some of the time. Our tendency is to run
away from painful realities or try to change them as soon as possible. Unless
empathic listening has preceded, there is often a block rather than a connection
made between the two people.
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Responding to another person with a block can:

Cause the other person to feel unaccepted, judged, blamed, rejected, or not
listened to.

Cause the other person to defend himself.

Promote dependent behavior.

Show the other person that you do not respect him.

Overlook or fail to acknowledge the feelings of the other person.
In conversation we sometime respond to others in well-meaning but ineffective
ways. The following responses are examples of communication blocks between
people that prevent real understanding. (Carr, Saunders, 1979)
Advising and Giving Solutions: “What I would do is….,” “Why don’t you….,”
This can imply that the person is unable to solve his own problems. It may
prevent the person from thinking through a problem, considering alternative
solutions, and making his own best choice. It may lead to dependency or
resistance.
Probing and Questioning:
“Why…?” “Who….?,” “What did you do….?”
The person asking the questions takes the lead in directing the conversation
rather than responding to the other person’s feelings and ideas. This may
distract the person from this/her concern because he/she is answering questions
that reflects the other’s concern. Asking questions may lead to the person
becoming passive, sharing half-truths, and feeling anxious (of course there are
times when questions are appropriate and necessary, however only a small
percentage of talk time should be used for questioning).
Minimizing:
“Don’t Worry..”, “You’ll feel better..”
This ignores how the person is feeling and can cause him to feel misunderstood
and very alone. The person may pick up the message that is not O.K. to feel
badly, or it may cause strong feelings of hostility, i.e. “That’s easy for you to say.
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Ordering and Preaching: “You must….” “You should….” This can cause a
person to feel judged. He/she may become angry and resist the other person.
When someone asks you what you would do, put the question back to them.
Diverting and Withdrawal:
“Let’s talk about things”, or not saying anything,
or turning away, or avoiding issues like sexuality, religion. This can stop the
person from sharing his/her concerns and feelings. It may imply that a “stiff
upper lip” is preferable to sharing concerns. It may also imply that the person’s
problems are not important or valid.
Judging:
“You can’t expect to be able to ….” This person may feel
watched and judged, causing feelings of anxiety about how they are being
perceived. If the praise or criticism does not match his/her self-perceptions,
he/she may feel discomfort.
Arguing:
“Yes, but….” The person may not feel understood and listened
to. It can lead to counter-arguments. The person may feel inadequate and
inferior. If you feel defensive, or find you are rationalizing and explaining
yourself, stop and check out what is going on with You!
Telling Your Own Story: “My experience is just the same….” This implies that
I’m more interested in my life than yours, or I can teach you by my experience.
Confronting: “Everything you say to me is negative.” Facing the person with
the reality of their negative behavior or attitude:
Ignoring: Not paying attention to what the person says – acting as if you did not
hear it.
Judging: “That was the wrong thing to do.”
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Please Listen…
When I ask you to listen to me,
And you start giving me advice,
You have not done what I asked.
When I ask that you listen to me,
And you begin to tell me that I shouldn't feel that way,
You are trampling on my feelings.
When I ask you to listen to me,
And you feel you have to do something to solve my problems,
You have failed me, strange as that may seem.
Listen; all I ask that you do is listen,
Not talk or do - just hear me.
When you do something for me,
That I need to do for myself,
You contribute to my fear and feelings of inadequacy.
But when you accept as a simple fact
That I do feel what I feel, no matter how irrational,
Then I can quit trying to convince you,
And go about the business
Of understanding what's behind my feelings.
So, please just listen and hear me
And, if you want to talk,
Wait a minute for your turn - and I'll listen to you.
Adapted from Dr. Ray Houghton
Trinity Reformed Chimes
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Standard Precautions for Infection Control
The idea behind Standard Precautions is that all persons are potential
carriers of any number of infectious diseases. There is no way that you can tell
by just looking at a person if s/he is carrying hepatitis, AIDS, tuberculosis,
intestinal parasites or any other disease. Therefore, the rules to protect you
apply to everyone. We must be careful when handling blood or body fluids
(urine, feces, vomit, saliva, tears, drainage from wounds or sores, vaginal
secretions, semen etc.) Following are the rules you must follow when doing
pastoral visits. In order to maintain a trusting relationship with the ill person and
the family, you ought to explain the reason you are taking these precautions is
for their protection as well as yours.
What is a “nosocomial” infection?
This is a hospital-acquired infection that a person did not have before entering a
health facility.
What are some common viral and bacterial infections?

Methicillin-resistant staphylococcus aureus (MRSA)

Clostridium difficile (C.Diff)

Vancomycin-resistant enterococci (VRE)
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Hand Washing
Policy
1. Hand washing is the single most important procedure for the prevention of
nosocomial infections.
2. Hand washing is indicated: After visiting and touching a patient.
3. Before and after touching wounds or drainage, Ideally, before and after any
body contact/performance of personal care.
4. After contact with mucous membranes, blood and body fluids.
5. After touching inanimate sources that are likely to be contaminated with body
substances: e.g. urine measuring devices, soiled linen, waste, furniture, door
knobs, hand railings.
6. After removing gloves.
7. Before and after using the toilet.
8. Before eating.
Procedure:
1. Remove Jewelry
2. Wet hands under running water.
3. Keep hands lower than elbows; apply soap or antiseptic
4. Use friction to vigorously clean between fingers, palms, backs of hands and
wrists. Do this for a minimum of ten seconds.
5. Rinse hands under running water.
6. Dry hands well with paper towels.
7. Use paper towels to turn off faucet.
Protective Eyewear
Policy
Protective eyewear (glasses, goggles or shield) are worn to protect one’s eyes
in situations where splashes of blood or other body substances are likely to
occur.
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Procedure
1. Put on eyewear prior to entering [resident’s] room or commencing procedure.
2. Remove eyewear following procedure.
3. Wash eyewear with soap and water and dry well immediately following
procedure.
4. Replace eyewear in proper storage area.
Masks
Policy
Masks are worn to prevent exposure of the mucous membranes of the mouth
and nose during procedures that are likely to generate aerosol droplets or
splashes of blood or other body fluids.
1. Apply mask to cover both the nose and mouth, and fit snugly under the chin and
over the bridge of the nose.
2. Discard mask immediately following procedure for which it was required.
3. Discard mask when it is obviously moist or soiled.
4. Wash hands after discarding mask.
Never carry mask in pocket for use or reuse. Never wear mask around the neck
Aprons and Gowns
Policy
Plastic disposable aprons and/or reusable long-sleeved cloth gowns are worn
during procedures where clothing and skin are likely to be soiled by splashes of
blood or body substances.
Procedure
1. Put on gown before engaging in procedure.
2. Remove gown immediately after procedure by holding the back edges and
turning it inside out.
3. Immediately discard: plastic aprons into garbage, cloth gowns into the laundry.
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Handling of Soiled Linen
Policy
All used linen is contained in leak-proof, sturdy, clear plastic bags.
Procedure
1. When bags are 2/3 full, tie securely and place in laundry pick-up area.
2. Double bag soiled laundry when the outside of the bag is visibly soiled with
Blood or other body substances.
Spills
Clean up any spills of blood, urine, vomit or feces as soon as they happen.
Wear Gloves
Use warm soapy water. If blood has spilled, a weak solution (1 part bleach to 10
parts water) of bleach and water should be used for cleaning up. Be careful or
you might bleach out carpeting. Cold water often works best with blood spills to
avoid staining.
Sharps and Needles
You need to know how to keep yourself and others safe in a caregiving situation
which involves the use of needles and other sharps.
You must be very careful.
After using the needle. DO NOT RECAP the needle. DO NOT TRY TO
REMOVE THE NEEDLE FROM THE SYRINGE. DO NOT TRY TO TWIST OR
BEND THE NEEDLE OR SYRINGE. DISPOSE of the needle and syringe in a
heavy container (made of hard plastic or glass) which is clearly labeled.
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Music Therapy for Spiritual Care
What is music therapy?
It is the intentional and compassionate use of music to improve or maintain
psychological, cognitive, social, spiritual and physical health of people with
special needs. When someone is terminally ill, one or more of these dimensions
is usually compromised. Music can tap the remaining ability or life-force of the
person and enhance the sense of well-being. Our goals are to enhance the
quality of life and decrease suffering.
Music Therapy includes assessment, development of goals specific to needs,
application of program and regular evaluation of effectiveness.
Why use music?
Music is not often used in the clinical setting, in part because we equate it with
health, activity and entertainment. We need to take a look at music in another
contest – that of music therapy as an adjunct to other existing treatment
modalities. Older adults did not grow up listening to professional musicians.
Making music was normal – parlour pianos, sheet music, kitchen bands etc.
Music improves the atmosphere, for staff as well as patients. There is a halo
effect – patients often function better in music session, staff sees patient as a
real person, spends more time with him. Personal access to a CD player,
anytime of day or night, gives the patient some control.
Assessment
1. Has some aspect of music played a significant role in this person’s life?
2. What difficulties is the patient experiencing?
3. How can music help to alleviate these difficulties?
Pain? Difficulty with expression of feelings? Insomnia? Anxiety?
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We don’t have a music therapist. What can we do?

Listen to music – the patient’s choice, not the staff’s.

Find a good radio station, with gentle music. Monitor it – turn it off sometimes.

CDs and tapes - a tape library – sign out and in.

Categories: relaxation; C&W (be careful); classical, (adagios, largo etc.)
orchestral sacred; ethnic; easy listening.

Tape favorite records for personal use. Music can provide structure for dressing
bathing, and difficult procedures.

Listen with the patient, talk about the music, sing along, make it part of your
treatment.

A CD player with auto-reverse and quiet turnoff for sleep inducement – light
comfortable earphones for 24 hour use.

Make use of the talent – e.g. volunteers and staff who play piano could play
while residents are waiting for mealtime or at staff change.

Tape TV programs like Lawrence Welk, Let’s Sing Again, specials like the
Grand ol’ Opry 60th.

Physical rehab: use musical activities to create interest and motivation.

Try these activities for 5 -10 minutes while listening to music: massage with
body lotion – facial muscles; hold hands, stroke, pat, sway to music, clap, tap
toes, etc.; gentle exercises; deep breathing – groan.

Remember that continuous music can be NOISE.

Subscribe to Eldersong, the Music and Gerontology Newsletter email;
[email protected]

Keep a music therapy booklet at the nursing station to list individual musical
choices, instrument skills, etc. – see checklist.

If a patient is in a coma or near death, play or sing his favourite song. Hearing is
the last sense to go.

Playing music – some patients may enjoy making music on small percussion
instruments, monochords, harmonicas etc.
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Insomnia
What is the reason for the insomnia? Is it fear of not waking up, or does he/she
have too much to think about?
1. Relaxation tapes
2. Guided Imagery – imagining a familiar and desirable place or feeling. The
music alone may provide the stimulus, or the music therapist could make a
tape, guiding the patient through the images.
3. Processing of dreams – encourage the patient to talk about dreams.
Anxiety
The goal is to break the pain cycle of “fear-anxiety-pain. The fear may be of
physical pain or death, future of loved ones, the unknown, or of isolation.
1. Relaxation techniques: The structure of a relaxation session can be
reassuring and “grounding” for the anxious patient. It is also an intervention
in which the patient can participate to his/her potential, thus enhancing a
sense of control. For example, the patient may choose the time of day, the
place and the type of relaxation to be used, the music or environment sounds
for accompaniment.
These choices are important since our impressions of a relaxing experience
may differ greatly from those of the patient.
2. Matching respiration rate: In the case of hyperventilation, the music therapist
would match or mirror the patient’s state by breathing or singing in rhythm
with him, and then slowly alter this rhythm to a more comfortable one. This
technique is used in an attempt to help him to express the source of distress.
3. Imagery: the degree of success with this technique depends on some prior
patient experience with it.
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4. Listening to music – tapes of music that are familiar and comforting can be
played to make the patient feel more calm.
Pain
Relaxation:

active – tense/release

passive – slow deep breathing, repetition of phrases, regular rhythm, predictable
melody unchanging dynamics and pleasing harmony.
Listening to music: responses to music include complex brain chemistry changes.

some types of music produce endorphins which can reduce the amount of pain
we feel.

music raises pain tolerance by providing an external source of diversion
or by providing a stronger stimulus than the pain itself.
Massage: for those who feel comfortable with the intimacy of touch, music may add
to the comfort of massage for chronic or dull pain. A music or massage therapist
would massage in time with the patient’s breathing or chosen music, and may
gradually slow the rhythm in order to encourage the patient to breathe more slowly
and deeply. The music should be carefully selected – approximately 60 beats per
minute to match the heart rate. Largo and andante movements from classical works
and environmental sounds work well, but familiar favourites are the most relaxing.
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Difficulty with expression
1.
For those with aphasia or dysphasia, melodic intonation may help to relearn
words to communicate needs.
2.
Use of song: Often the words of a chosen song seem to fit the preset situation
and express the unspoken thoughts of the patient or his family. Do not interpret
– let the patient process it in his own time. Chosen songs could be recorded and
used as a catalyst for life review. Songs can inspire memories which may help to
answer painful spiritual questions such as “What has my life meant?” Memories
become important as a bridge to wholeness – putting present difficulties in
perspective with more positive live events. Songwriting can be an enjoyable
experience for some people.
3.
Art & Music – collage, painting to music; working with clay.
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Care Clowning
Clown Qualities:
friendliness, kindness, sensitivity, gentleness, compassion, fun-loving
Greeting “I’m happy to see you”
(you don’t need to know or remember their name)
-ask permission to enter/participate
Speak-
say “there is a friendly clown here” so not to scare or surprise

clearly, loud and slow, repeat key words if hard of hearing

give the person space and an avenue to disengage if he/she chooses

use eye contact, touch, smiles & laughter to reach demented &
uncommunicative patients

don’t talk down or use baby talk with elders
Listen –

from the heart and be spontaneous, go with your intuition
See--

if you see something embarrassing, focus on the patient’s eyes.
Body Language

try matching your breathing to theirs or slow it down

keep a “soft stomach” and a relaxed posture

allow yourself to be vulnerable, accept that you will see pain & suffering

touch shoulder or arm whenever possible, (safer to touch clothing) rather than
hand unless you can use hand-wash unobtrusively before touching the next
person

SMILE! it takes 17 muscles to smile but 44 to frown
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Songs—

songs are good, let patients decide if they wish to participate, you can carry on
singing alone if necessary and still be enjoyed
Skits and Gags—

when clowning with a partner, make sure it is all about the patient and not just
each other

puppets work well to make “conversations”

play in a child-like not child-ish manner

wear foam knee pads if you expect to drop to your knees to meet someone at
eye level

for music choose upbeat music at least 70 beats/minute because it replicates
the human heart

say “There’s a smile that’s been lost, and I’m looking for it….”
A show

should be “with” and not “for” patients and last no more than 20-30 mins.

best times in hospital or nursing home are: 10:30-11:30 or 3:30-4:30

An old remote control makes a great prop, you can point it and get it to “do”
almost anything!

use toy automatic violin to make yourself an instant musician

get a hand-held doorbell, or bicycle horn

you can do wonders with a roll of toilet paper, a mirror
Medical gags: CAT Scan;
Stool Sample
Skits: How to grow taller (by standing on a big book)
Take my case to court (briefcase—I lost my case)
Attach a tea bag on a string to your earring, to “keep you out of hot water”
“Jan-Anne the Nutcase”—Janet Stark
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Misunderstood (Recreational Therapy)
It was not long ago, when an old friend of mine asked, “How am I doing?” How
do I spend my time? I told him I’m busy, I have lots to do being a Rec. Therapist
(at a Home) in Saskatoon.
He thought for a moment, then scratched his head – “A Rec. Therapist?” What is that?”
He said. To answer this question. I thought for a while, put my hand on his shoulder,
and said with a smile.
A Rec. Therapist puts “life into living”; puts “share” into sharing and “give into giving.
We knock out the “dis” in disability and plan for our clients with creativity.
We probe programs for people with needs. We cultivate ideas but they plant the
seeds. We’re part of a team that provides total care. Where there’s laughter and
song, you know we are there.
For some we are legs to those that can’t walk. While others depend on our voice
to talk. I’m proud to be working in Rec. Therapy. My reward is the client who
smiles back at me.
You can find us in rehab, and in hospitals too. We’re in long term care, offering
so much to do. Most people don’t realize that we’re here for good. Our jobs and
this field is so misunderstood.
My friend seemed impressed but still somewhat confused. He still scratched his
head and stared at his shoes. “Oh I get it now—“He said in his ‘lingo.’ “You’re
one of those people who knit and call bingo!
Tom R. Liske
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The Power of Touch
By the Rev. George Handzo, BCC, CSSBB.
Vice President, Pastoral Care Leadership & Practice
In a recent article in The New York Times, Benedict Carey
note:
“Momentary touches, they say – whether an exuberant high
five, a
warm hand on the shoulder, or a creepy touch to the arm – can
communicate an even wider range of emotion then gestures or
expressions and sometimes do so more quickly and accurately
than
than words.”
In the field of hospital chaplaincy, we’ve long been aware of the power of touch.
A comforting touch on the arm or a reassuring pat on a patient’s hand can
significantly increase the level of connection between a chaplain and a patient.
A touch can say ”I know what you’re going through.” It can say “You’re going to
be all right,” or “I’m here for you.” To the elderly, in nursing homes, caring touch
creates a sense of security.
The Times noted that “a sympathetic touch from a doctor leaves people with the
impression that the visit lasted twice as long.” The reason? “ A warm touch
seems to set off the release of oxytocin, a hormone that helps create a
sensation of trust, and to reduce levels of the stress hormone cortisol.”
Touch also has a cultural component. Some cultures find it offensive to be
touched by anyone but a close friend or a relative.
And of course, touch is also a gender issue. A woman can touch a man or
another woman much more easily and with more acceptance than a man can
touch a woman. All in all, when done appropriately and with heart, touch has the
power to lift the spirit.
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RECORDING LIFE STORIES
Janet Stark
“When an old person dies, it’s like a library has been burned.”
Alex Haley, author of Roots
Why would it be helpful for a caregiver to help someone who is dying tell their
life story?
Needs of the Dying
 Need for meaning and purpose in life: it was worthwhile to be here
 Need to be remembered: leaving a legacy behind
Great comfort for family members left behind
Geneology or Family Tree:

Is not a Life Story

Is factually correct

Is a history or family lineage

Includes records in libraries, newspapers, archives, cemeteries, land registry
office

Can be structured easily by computer software programs

Several Internet tools available
“Memoirs”: Personal stories & anecdotes which can be part of a Life Story.
Memoires are usually ones perspective from memory and do not need to be
validated by proof.
Autobiography

Is a life story written by oneself

May be chronological or laid out by theme, a narrative.

Is true from the writer’s perspective
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Journal or Diary-Writing:

Is intended as a completely selfish work; may be very private.

Can be very therapeutic ; usually unstructured and unedited
A LIFE STORY
What it is:

an autobiography or biography

memoirs

a series of stories, anecdotes
What it is not:

a genealogy

an historically-perfect documentary

a time to "reveal all"
How is the Life Story made?

A series of visits, interviews, with conversation recorded

Interviewer is a facilitator, keeps the story flowing

The goal of the interviewer is to make the person as relaxed as possible

If a written copy is desired, the oral stories can be edited, organized

Photos and documents would then be chosen and strategically placed.
To Prepare for the Life Story Interview:
a) Things to have available, preferably chronological:

selected photos

genealogies (family tree)

certificates, documents, maps

letters & cards

diaries, journals

memorabilia & souvenirs
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b) Bring a digital tape recorder and also take a picture of the person at the time
of the interviews.
c) Life Stages List:
Make up an ordered list of life stages.
Historical School vs. Creative School
A historical perspective can give lots of information and facts, but may lack
warmth, humour and creativity. The creative approach seeks to find out “what
makes a person tick” and includes funny stories, both sad and happy
experiences and personal perspectives.
Questions: W5: What? Who? When? Where? Why? Good ways to start
conversation
Some Difficulties

Allow the person to talk about their losses.

This can be very therapeutic.

Always try to finish the session with a happy thought or memory

The story is always from the perception of the storyteller.

The person may refuse to talk about certain events
Use a digital “voice-activated” tape recorder that goes on and off itself

Best feature is in hearing the person’s own voice!

Copy audio files directly onto your computer

Label each file (audioclip) with the name of the person and date it was recorded.

Include a photo in the computer file

Electronic files can be easily copied to make copies for family members.

Do a sound test before you do the interview

Keep recorder close to person

Keep all extra background noise out
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
Give the person a list of suggested topics ahead, or interview them to make a
list of “life stages” together.

Can give a list of questions ahead, but don’t overwhelm.
The Interviewer

Needs a clear, pleasant voice

The interviewer is more like a listener but helps facilitate the direction of the talk.

Smiles and nods to provide rapport

Prompts the teller with a comment or question

Asks questions

Handles all the technology
Home Videos

Short video clips can now be done easily with a portable phone

Can videotape a person telling stories

Can videotape close-ups of pictures

Can use a camera set up ahead on a tripod for more formal still shots

Important to use a remote microphone when recording sound

Can be easily transferred to computer and copied to make copies

Can be professionally edited it desired
Written Stories: Book Format

Can be a person’s own handwriting

Books are now easy to print in small quantities at most print shops or on-line

Easy to produce with home computer and desk-top publishing

Books can be made from typing out an orally-recorded tape.

When typing out a recorded story, you can abridge something, but you cannot
edit or paraphrase the content

You may divide the work into segments: chapters or stories

Consider getting permission to put single stories in a church newsletter, the local
newspaper, sending them to the local historical society, Women’s Institute etc.
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Dementia and Story-Telling

The person often remembers the past more clearly than the present

It is a good time to record these stories, it can be a fun thing to do

Use storybooks to prompt memories, old songs

Look through old photo albums together.

They may still see themselves as young

Be prepared to hear the same story over and over.
The Presentation of the Life Story

Make an attractive package, organized, labeled and dated

A sheaf of papers in a drawer, and a shoebox of old photos is not very inviting.

Be sure to page number them

Make copies to give out, but keep the original if handwritten.
Common Misconceptions
1. Don’t assume you’re not important or famous enough for people to be interested
in your story.
2. Don’t feel you must start with your ancestors, your parents, then your birth and
proceed chronologically through your life
3. A life story must cover all the stages of one’s life.
4. You must “tell all.” Sometimes getting things “off your chest” can lead to regrets
later.
5. You must know a great deal of history to write an autobiography.
6. A life story is not a journal or diary, where events are recorded daily or regularly.
7. You must be good at spelling, grammar and punctuation.
8. Family & friends will always be delighted with your work.
9. Those with dementia cannot tell their life story. Often the opposite is true.
10. Your work, of course is never going to be published. Who knows?
Janet Stark 2003
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Ten Useful Tips for Visiting the Sick
It’s a situation most people have been in at some point in their lives: visiting a
seriously ill friend or relative. Many people avoid such encounters because they
feel they “don’t know what to say.” What do you say to someone with a serious
illness without sounding trite or hollow? How can you turn such a visit into a
healing encounter? Here are ten suggestions to help make the visit a positive
one---for both you and the sick person.
1. Be There.
Fear of saying the wrong thing often keeps friends or relatives from visiting. The
first step is to realize that it is your presence, not your words, that means the
most. Remember, there is no magic formula, there are no magic words. Just
being present for that moment will go a long way toward helping the person
heal, if not physically, then at least emotionally.
2. Know the Power of Touch.
Holding a person’s hand or giving a comforting pat on the arm can mean a great
deal to someone fighting fear and loneliness. Naturally, it depends on your
closeness to the person and on his or her willingness to be touched, but a visitor
who stays at arm’s length from the patient may be unconsciously exacerbating
the sense of separation that a seriously ill person already feels. A gentle touch
tells the person you’re willing to be with them.
3. Listen.
Come to the visit with an open agenda. Let the patient lead in telling you what
his or her needs are. If he or she wants to recount favorite stories---even if
you’ve heard them several times before---listening with enthusiasm can validate
the person’s sense of self-worth.
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4. You Don’t Need the “Right” Answer.
A person confronted with a life-threatening illness often asks, “Why me?” Many
visitors feel they are supposed to have an answer, one that will make the patient
“feel better.” But the familiar clichés one uses to make sense of the tragedy (“It’s
part of God’s plan.” “Everything happens for a reason.”) can sometimes do
more harm than good. The ill person frequently isn’t really looking for an answer
but is expressing his or her confusion. So the best thing to do is to repeat the
question in your own words, indicating that you understand the person’s anxiety.
“I see you’re really troubled by this” is a more helpful response than “God is
testing you.”
5. Validate the Person’s Emotions.
Too often, because of our own discomfort, we try to avoid the subject of illness
or death and don’t allow patients to discuss their feelings. If they say, “I know I’m
not getting better,” responding with “Don’t talk that way” does not help them
come to grips with the situation. Instead of suggesting that they keep their
feelings to themselves, encourage them to express their fears or concerns; this
way they know that you’re willing to journey with them, and that you understand
their thoughts and emotions.
6. Don’t Be Afraid of Tears.
Again, saying to a person, “Don’t cry,” is more hurtful than it is helpful. Tears
help heal, and bottling up one’s emotions is unhealthy. You don’t have to say
anything; you can just hold the person’s hand. And don’t be afraid of your own
tears. Let them flow.
7. Be Compassionate.
We can be better prepared to handle a patient’s emotions if we know something
about what he or she is experiencing. Terminal patients in particular experience
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a variety of moods and emotions, among them anger, depression, denial, false
hope, peace, and acceptance. There is no one formula for how and when they
will experience these, but they are all common emotions among the seriously ill.
Try to be open to whatever they are at any given time so that you can respond
with understanding and compassion.
Keep in mind, too, that anger and
frustration may sometimes be directed toward loved ones. Visitors need to
realize that this is not personal, but part of the response to the illness. Also, not
every sick person experiences peace and/or acceptance. However, your visits
will go a long way toward helping the person reach this goal if you are able to
offer compassion, love, and acceptance.
8. Monitor What You Say. Even if patients are unconscious or seem unaware
of what’s going on around them, they may be able to hear what is said to them.
Thus visitors should not only guard against saying negative things, but should
continue to express words of love and encouragement.
9. Keep Your Visit Brief. Seriously ill people tire easily but may feel obliged to
put on a good face for visitors. Frequent brief visits are better than infrequent
long ones. Find out the best time to visit, and plan your call accordingly.
10. Be Yourself. If you have always been an optimistic, upbeat person and
carry that tone naturally into the sickroom with you, fine. But trying to put on a
show of cheerfulness when you don’t feel it, will immediately strike a false note
the patient will detect. Don’t put pressure on yourself by feeling you have to
“accomplish” something during the visit. You’re there just to provide support,
which the patient will appreciate more than any platitudes or jokes you may
offer. As one hospice director says, “Remember, anything is the right thing to
say as long as you’re sincere.
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Suggestions for Patient Visitation
1. Knock on the door and ask if you may enter. Greet the patient by name and
identify yourself.
2. Please keep in mind that Pastoral Care ‘Caring Friend’ volunteers are here to
listen.
Do Not – tell a patient how you perceive he/she is feeling.
Do Not – offer advice
Do Not – tell a patient “you should not feel that way”
Remember there are no right or wrong feelings!
3. Try not to ask too many questions. Often times a patient is too weak to talk
and would appreciate a quiet presence.
4. Please remember that each patient is an individual – his/her fears, hopes,
dreams are real to him/her. Don’t assume it is a comfort to hear, “I know what
you are going through, my aunt had…” or, “I know how you feel”. Try to affirm
for the patient that his/her feeling is okay.
Remember silence can be therapeutic!
5. Sometime during your visit, when you feel prayer would be appreciated; you
might want to ask the patient/family if you may do so. Be sensitive to whether
the patient wants prayer at all.
Always use hand wash after visiting each patient
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Tips for Pastoral Visiting
1. Be clear about your purpose in visiting.
2. Minister to the resident’s needs, not your own.
3. Relate to the resident as a person
4. Before the visit, find out what you can about the resident.
5. Pray before your visit if you find it comforting.
6. Recall God’s presence.
7. Make a conscious break with whatever you have been doing before the visit.
8. Recall that you are part of a caring team.
9. Survey the room before you enter. (What do you see?)
10. Knock before entering and enter slowly.
11. Be observant.
12. Be careful in your grooming.
13. Greet resident and introduce yourself. Don’t keep them guessing.
14. Don’t lean over the resident.
15. Sit or stand so that the resident can easily hear and see you. Don’t sit on the bed.
16. Be genuine.
17. Decline to give medical service.
18. Avoid discussing the value of the doctor’s diagnosis.
19. Don’t let a resident’s moral faults repel you.
20. Don’t stay too long. Don’t overstay your welcome.
21. Avoid crippling sympathy.
22. Don’t raise alarming topics with the resident.
23. Don’t be an amateur psychologist.
24. Don’t let a resident’s apparent insults or outrageous comments affect your attitude
toward him/her.
25. Share your time equally.
26. Avoid gossip (never reveal knowledge of another resident’s condition).
27. Keep a positive attitude.
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Observer Check List
Eye Contact

nodding that is continual

looking directly

nervous ticks

breaking eye contact

affirming nods

looking down

continual smiling and/or frowning

looking away

staring

shifting eyes

chewing gum

squinting and/or frowning

tapping

playing with
Distracting Habits
Body Posture
hair/clothing/papers/book/pen

moving closer/moving away

drinking

arms crossed

smoking

touching

relaxed position

tensed position

too loud/too soft

facing other person

harsh

slouching

too slow/too fast

rigid

expressionless

too close/too far away

excited

body turned

use of slang/jargon

use “you know” “ah” “ah-um” too
Voice
much
Facial Expression

calm

appropriate smiling, laughing

crying
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shaky tone
Chaplain/Spiritual Care Visitors
A. Preparation for Visitation Ministry:
1. Familiarize yourself with essential background information and current needs
relative to individual visited (church/clergy etc.)
2. Prayer –





Wisdom in dealing with potentially sensitive issues which may surface during the
visit.
Compassion
Empathy
Sensitivity
Guidance relative to words spoken
3.




Attire and Hygiene –
No perfumes (allergies)
Cleanliness
Neatly dressed/appropriate to setting and individual being visited (
Wearing identification badge of institution – indication of authorization
4. Gender Related Factors –
 Ability to relate to individual being visited
 Gender-matched if this is more helpful to the person being visited
5. Pre-visit
 Call to establish mutually convenient visitation time (home)
6. Appropriate Ministry Materials
 Person’s own clergy; Chaplain; pastoral/spiritual care visitors
 Awareness of institution visitation regulations, and mission statements
(especially concerning proselytizing)
Notes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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B. The Pastoral Care Visit - Institutions
1. Check for isolation notifications at door of room first

Put on protective gown and gloves

Frequent use of hand sanitizer
2. Patient/Resident Unprepared for Visitors

If privacy curtain is pulled –check with nurse first

If uncovered, attire is inappropriate to receive guests

If currently experiencing nausea or severe pain

If currently using washroom or bedpan

If sleeping (do not wake a sleeping patient in most cases—especially if they are
very ill)

If staff are attending to needs of patient

If busy reading, watching TV—you may interrupt and ask
3. Patient currently with other visitors

Return later – monitor time of visit accordingly

If family is visiting, introduce yourself and determine desirability of a combined
visit
4. Entering the Patient’s/Resident’s Room

Use a quiet, gentle approach – don’t startle

Give your name and role

Ask permission to visit
5. Possible openings

General comments, weather, the view

Flowers in the room – photos/cards

Associates from the past i.e. family, friends
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6. Appropriate Conversation

Until a trusting therapeutic relationship has developed, use safe – non
controversial topics such as drawing upon shared experiences, where they have
lived, travelled, etc.

You may ask how they are feeling today and talk about their illness if initiated
by patient/resident

Do not introduce discussion on specific religious beliefs and practices
7. Appropriate Ministry Tools

Small Bible, New Testament or other faith scriptures

Poetry, Devotional readings, Prayer books

Rosary for Roman Catholic

Appropriate, approved literature from the church which they normally attend.
8. Sensitivity to Needs During the Visit

Request that the resident/patient inform you if experiencing illness, weariness or
discomfort during the visit (step out or conclude the visit)

Visitation time varies according to the setting, personal familiarity, physical
conditions and environmental conditions (other patients/residents in the room)

Facility staff must be free to administer care to the patient. This takes
precedence over visitation. Step out or conclude visit if necessary.

Cooperation between pastoral visitor and staff is essential.
9. Readings and Prayers

Prayer may not be appropriate

Patient may express no interest in religion or be openly opposed to it

Timing may not be right or may need to become more acquainted

Sensitivity and perception of the visitor relative to readiness or openness toward
spiritual matters during the visit.
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
Age of resident/patient – guides your topics and language and be aware that the
younger generation frequently has NO faith history

Inclusion of other patients in the room may need to be considered

Volume of prayer for the hearing impaired – consideration of others

Relative to the patient’s/resident’s faith and tradition

Meaningful (uplifting, comforting, inspiring, a source of hope and appropriate to
the resident/patient circumstances)

Consideration given to expression of gratitude for the care the hospital is
providing
10. About Physical Touch:

Sensitivity relative to physical contact during prayer; one may hold or touch a
patient’s hand if the visitor senses an invitation; or may touch a patient’s
shoulder during prayer.

Dependent upon the comfort zone and cultural tradition of those involved

Patient initiated – patient offering his/her hand to the visitor

Pastoral initiated – if familiar with the patient and sufficiently aware of
background and beliefs

Placing hand on theirs may be more appropriate - sensitivity to this is paramount
when visiting.
11. Inappropriate Responses

Providing or administering medication, food or beverage (exception is helping a
patient with a drink of water if it is already on their bedside tray)

Providing access to walkers, wheelchairs

Assisting patient/resident to the washroom

Helping out of beds or chairs

Going for a walk or to another room
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
Be aware of Hospital Policies. Be prepared to be reprimanded by the
patient/resident when not responding to their request and be prepared to offer
assistance, instead, by notifying the nursing staff
Potential Stressful Situations in Visitation
You may experience:

Uncertainty as to how you will be received

Concern about how you have responded to sensitive moments during the visit

Being burdened by the apparent pain experienced by the patient/resident and
your inability to alleviate in a meaningful way

The intensity of providing care and support to a dying person as well as
distressed family members during final moments

Having been faced with physical ailments i.e. Wounds, nausea, smells or other
difficult issues relative to the patient’s illness.
The anecdote for all of these potentially stressful feelings is prayer. You may
begin your visitation by seeking God’s direction and praying for the individuals
whom you visited. Now is the time to pray for your own needs and let God do
the rest. Another suggestion is to share your burden with your supervisor,
another pastoral volunteer, a caring friend and/or your sponsor.
Summary:
Pastoral visitation fulfills one of the most essential significant needs of a
patient/resident. The relationship between exercising one’s faith and the healing
process should not be underestimated. When combined with professional
medical opportunities, the physical, emotional and spiritual well-being of an
individual can be significantly enhanced.
A consequence of this for the spiritual care visitor is a sense of fulfillment and an
assurance of God’s blessing upon their ministry.
BGH Volunteer Chaplain Dave Downing 2009
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The “Do’s” of Visiting

Do make the visit short and commit to returning.

Do try to visit at the same time every week (they will anticipate your visit.

Do always address the person by the name they prefer.

Do always identify yourself and the church you represent (if applicable).

If reading scripture: Do give the person a Bible to hold; if praying give them a
cross or rosary to hold; if singing a hymn let them hold the hymnal.

Recognize and use humour, affection and praise.

Do sit close and away from the glare from windows.

Do use eye contact.

Do reassure them that they are loved.

Do allow for periods of silence.

Do consult with sponsor or staff.

Be comfortable in your approach.

Do let the person being visited have control of the visit.

Do be yourself.
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The “Don’ts” of Visiting

Don’t rush visits, push, or give orders, advice or platitudes such as “God never
gives us more than we can handle”.

Don’t take insults or inappropriate behaviour personally

Don’t stare away, look at your watch or look bored.

Don’t use baby talk, talk too loud or get too close to the person.

Don’t interrupt the person or judge their behaviour.

Don’t argue, confront, contradict or try rationally to explain their beliefs.

Don’t always feel you have to talk – silence is golden and allows the person to
reminisce. The time may allow him/her to think and tell you a story.

Don’t use lengthy prayers, unless the person requests this.

Don’t insist on visiting if this is not a good time for the person.

Don’t make promises you cannot possibly keep.
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Rate Your Communication Skills
Communication Skills
1.
Be brief and concise, get to the
point.
2.
Use body language, gestures
and stance to support my words.
3.
Use a tone and inflection
consistent with the message I
want to send.
4.
Use words that accurately
describe what I want to say.
5.
Consider the time, distractions
and place that I deliver the
message.
6.
Ask others to repeat (playback)
what I have said to them.
7.
Let others know when I don’t
understand something they’ve
said.
8.
Listen to understand rather than
preparing my next remarks.
9.
Before I agree or disagree or say
anything, check to make sure I
understood.
10.
Fake listening when I am not.
11.
Be honest. Tell others when I
can’t or won’t listen.
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Need
Doing
Need
to Do
All
to Do
Less
Right
More
Communication Skills
12.
Need
Doing
Need
to Do
All
to Do
Less
Right
More
Ask questions to help me
understand.
13.
Check out with others what I
think they are feeling rather than
assuming I know.
14.
Listen to and acknowledge
negative feelings and ideas.
15.
Observe non- verbal messages.
16.
Set aside time to communicate.
17.
Share good feelings (praise,
happiness, appreciation.
18.
(any others?)
19.
(add your own)
20.
Skills I want to practice:
1. __________________________________________________________
2. __________________________________________________________
3. __________________________________________________________
4. __________________________________________________________
Notes
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Perception Checks
I’m getting the impression that ….
It appears to me that …..
It seems to me that ….
I’m wondering if ….
It sounds to me as if ….
Is it possible that ….
I have a hunch that ….
I sense that ….
I perceive that ….
I get the feeling that ….
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Clarifying
Phrases that are useful when you are having some difficulty recognizing what
the other person is feeling or saying, or it seems that the other person might not
be receptive to your communications.
I wonder if ….
I’m not sure if I’m with you, but ….
What I guess I’m hearing is ….
Correct me if I’m wrong, but ….
Is it possible that ….
Does it sound reasonable that you ….
Could this be what’s going on, you ….
This is what I think I hear you saying ….
You appear to be feeling ….
It appears you ….
Perhaps you’re feeling ….
I somehow sense that maybe you feel ….
Is there any chance that you ….
Maybe you feel ….
Is it conceivable that ….
Maybe I’m out to lunch, but ….
I’m not sure if I’m with you; do you mean ….
I’m not certain I understood; you’re feeling ….
It seems that you ….
As I hear it, you ….
…. is that the way it is?
…. is that what you mean?
…. is that the way you feel?
Let me see if I understood; you ….
Let me see if I’m with you; you ….
I get the impression that ….
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Tips for Communicating with Someone with a Hearing Loss
1.
Pick the best spot to communicate: avoid noisy background situations and areas
that are poorly lit.
2.
Get the person’s attention before you speak – look directly at him or her.
3.
Don’t shout! Speak clearly and distinctly.
4.
Do not put obstacles in front of your face (i.e. your hands), or in your mouth (i.e.
gum, cigarettes).
5.
Speak clearly and at a moderate pace.
6.
Use facial expressions and gestures.
7.
Give clues when changing the subject.
8.
Rephrase when you are not understood.
9.
Be:
10.
Talk TO a hard of hearing person, not ABOUT him or her.
11.
When in doubt, ASK the hard of hearing person for suggestions to improve
PATIENT
POSITIVE
RELAXED
communication.
The Canadian Hearing Society
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Roadblocks to Therapeutic Conversation:
What Assumptions Are we Making when we…?
th
Source: Mark E. Young, Learning the art of helping: Building blocks and techniques (5 edition).
Upper Saddle, NJ: Pearson
1.





Ordering, Directing, Commanding
You must do this
You cannot do this/that
I expect you to do this
Stop it
Go apologize to him/her
2. Warning, Admonishing,
Threatening
 You had better do this, or else
 If you don’t do this, then…
 You better not try that!
 I warn you, if you do that…
3.






Moralizing, Preaching, Imploring
You really should do this…
If you don’t do then, then…
It is your responsibility to do…
It is your duty to do…
I wish you would do…
Isn’t that a sin to do that?
4. Advising, Giving Suggestions,
Offering Solutions
 What I think you should do is…
 Let me suggest…
 It would be best for you to…
 It worked for me…
 The best solution is…
5. Persuading with Logic, Lecturing,
Arguing
 Do you not realize that…
 The facts are in favor of…
 Let me give you the facts…
 This is the right way to do…
 Experience tells us that…
6. Judging, Criticizing, Disagreeing,
Blaming
 You are acting foolishly
 You are not thinking straight
 You are out of line
 You didn’t do it right
 You are wrong
 That is a stupid thing to say/do
7. Praising, Agreeing, Evaluating
Positively, Buttering Up
 You usually have very good
judgment
 You are an intelligent person
 You have so much potential
 You’ve made quite a bit of progress
8.




9. Interpreting, Analyzing,
Diagnosing
 You are saying that because you
Brockville General Hospital Pastoral Care Education
Name-calling, Ridiculing, Shaming
You are a sloppy person
You are a fuzzy thinker
You’re talking like an idiot
You really screwed things up this time
10. Reassuring, Sympathizing,
Consoling, Supporting
 You’ll feel different tomorrow
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




are angry
You are jealous
What you really need is…
You have problems with authority
You are in denial
You are just being paranoid
11. Probing, Questioning,
Interrogating
 What in the world did you do that
for?
 How could you let it get this bad?
 Haven’t you done anything to try to
fix this?
 Have you consulted anyone?
 Who influenced you to do, say, feel
that way?





Things will get better
He/she will be okay
It is always darkest before dawn
Behind every cloud there is a silver
lining
It is not that bad
12. Distracting, Diverting, Kidding
 Think about the positive side
 Try not to think about it
 You really should just let it go
 That reminds me of a time when…
 You think you have problems…wait till
I tell you about the time when…
FELOR Communication Technique
F
E
L
O
R
Friendly
Empathetic
Lean forward slightly
Be Open
Relax
Visiting Fears

I don’t know what to do

I don’t know what to say

What if they do not want me there?

What if I say something wrong?

How long should I stay?

What if I cannot hear them or worse understand what they are saying?

What do I do then?

Who will help me? I’ll stay very busy. I do not want to BOTHER them.

I don’t think I was of any help at all.

I made that person cry.
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Illness in the Family
Changes the Interactive Unit
Father
Mother
Mother
Brother
Brother
Sister
Sister
Sister
Sister
The remaining family members
will now struggle to once again
complete the circle by assuming
the father’s roles or a temporary
or permanent gap may result.
The father dies thereby
interrupting the family system.
I believe there is no such thing as a model family. Families are different: There
are 2-parent, single-parent, blended families, with married, divorced, commonlaw parents and step, adoptive, half children and siblings. There is also no such
thing as a truly dysfunctional family, as all families live with some level of
dysfunction. Think of your own family. Surely there are some relationships that
are wounded and some dynamics that are less than healthy. Families struggle
to maintain homeostasis, even at the best of times. Illness, and certainly death,
change the family dynamic. Even when providing the very best of pastoral or
palliative care, relationships may not be healed. Sometimes illness presents a
great opportunity for reconciling and healing, and it is a privilege to witness such
a thing. At best, we can help provide prayer support and opportunity for healing.
Janet Stark
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Common Causes of Family Conflict

Workload / demands / responsibilities

Communication Breakdowns

Substance abuse

Personality Styles/ Relationship Dynamics

Lack of interpersonal and problem solving skills

Conflicting values

Undefined Roles / Responsibilities

Power Struggles

Lack of respect

Unrealistic Expectations

History of unresolved conflicts
The Family Meeting

Usually facilitated by nurse, social worker or chaplain

Establish ground rules of mutual respect

The health professional should start by stating the current facts about
the patient’s medical condition or case, and identify what care
decisions need to be made at this time

All family members are encouraged to speak in turn

Ill person may or may not be present, and may or may not speak

Hear from every family member, not just the loud or aggressive ones

Acknowledge this is a difficult time for the family

Focus on the needs and wishes of the ill person

Use simple, clear communication and information sharing,

Compromise: it should not be a win-lose situation

Discuss next steps, trial them if necessary

Make a plan to review and adjust as necessary
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Strategies Toward Family Conflict Resolution

Negotiate ground rules of respect

Encourage a presence of faith in each other’s problem solving abilities

Empathize with differing perspectives

Maintain eye contact and a soft expression

Show you take concerns seriously by listening carefully

Don’t agree, apologize, or argue

Make sure all family members or voices are heard

Share facts

Ask open ended questions

Provide a supportive response – reflecting both feeling and content

Seek feedback of everyone involved

Facilitate belief in the validity of different positions and the other perspectives

Emphasize the commonalities and minimize the differences between (or
among) the parties.
 Promote people’s strengths

Avoid getting defensive

Maintain self- control and self- care

Maintain a presence of confidence and self- respect

Don’t take conflict, words or behaviours personally

Work toward compromise, not a win or lose situation

Thank each one for coming
Janet Stark
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Breaking Bad News
It is never a volunteer’s responsibility to break bad news. However, you may
encounter this situation with your own family, or you may be the next on the
scene to support a person after they have been given bad news. “Bad news” is
clinical information about a person’s diagnosis and prognosis and is usually
given by the physician. Sometimes the Dr. will tell a family member or power of
attorney for health care and that person will tell the patient the news. Bad news
should never be given over the phone and there should always be a support
mechanism in place.
The person receiving the “bad news” should have three choices of whether they
want to hear this information:
1. Yes, I want to know
2. No, I don’t want to know
3. Not now, maybe later
If a patient, who is of sound mind, wants to know medical information about their
own condition, the Dr. is legally obligated to tell them the truth, regardless of
what family members may say.
Janet Stark
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Supporting After Bad News
 Prepare information, setting
 Have tissues ready
 Watch body language
 Find out what they already know
 Ask how much they want to know
 Share information
 Observe for and allow emotional reactions
 Say you are sorry this has occurred
 Respond to the patient’s emotions
 Listen carefully
 Use appropriate touch
 Spend time with upset person
 Reassure person he/she is safe
 Give some private time
 Don’t take anger or other emotion personally
 Express your desire to understand and assist
 Offer help with practical tasks
 Negotiate a concrete follow-up plan
Janet Stark
Naming the feeling “I know this is upsetting…”
Understanding
“It would be upsetting for anyone”
Respecting
“You’re asking all the right questions”
Supporting
“I’ll do everything I can to help you through this”
Educating
“I’ll help you understand
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Hearing Difficult News
Divine Companion,
The harsh voice of reality
thrusts its dagger into my heart.
Statements and Facts
I do not want to hear
get lodged in my memory
and scrambled in my mind.
Help me not to panic,
I need to be patient
with what is before me,
To take one day at a time,
Grant me courage
to face the consequences
that may come from this situation.
May peace of mind and heart
soon return to me.
prayer by Joyce Rupp
Feeling Shock at the News
Faithful Shelter,
My life has suddenly changed,
I feel numb and unbelieving,
stunned and alarmed.
It does not seem possible that my life
Could be so quickly turned upside down.
Comfort me, Abiding Companion,
wait with me while I try to grasp the truth.
Slowly reveal to me what I need to accept.
As the layers of the days ahead unfold
keep me safe in the shelter of your love.
Abide with me, comfort me.
prayer by Joyce Rupp
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Criteria for Presenting Bad News
Sat down – the physician should move the chair near patient and sit down.
Assumed a comfortable interpersonal distance – physician should sit at
approximately arm’s length from the patient.
Made eye contact – physician should keep good eye contact with patient
throughout interview.
Was easily understood – the physician should use a tone of voice that is
clearly understood.
Asked what the patient already knew. Ex. “What is your understanding of the
situation?”
Gave a “warning shot” – the physician should preface giving the bad news by
some warning statement – e.g., “I’m afraid I have some bad news”
Avoided the use of medical jargon – no or minimal use of technical terms.
Listened attentively – Provide information at the desired level – physician
should pay attention to patient’s reaction, allow time for silence, not rush into
treatment options when spouse indicates the are not ready for that information.
Invited questions – the physician should give the patient an opportunity to ask
questions.
Suggested a follow-up plan – physician should initiate discussion concerning a
follow-up visit or future treatment plan discussion.
Appeared empathic – physician should indicated by body posture, tone of
voice, facial expressions and choice of words, that they care about the patient
and have some sense of understanding of the impact of the bad news.
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Bad News Statements….. What Do You Say Next?
1. Patient has just seen the neurologist. When you enter the room, she says:
“I just found out I have the beginning stages of Alzheimer’s. You might as well
put me down now.”
2. Dr. Lewis just told me he thinks the lump in my breast may be cancer!! I can’t
face this, I’ve got 2 young children at home……
3. A young woman has just been told her husband is brain dead, and has been
counseled about organ donation. She is still in a state of shock when she sees
you.
4. A middle-age man who is a champion swimmer has just been revived from
cardiac arrest. The physician has counseled him to cancel all competitive
swimming in the near future
5. An elderly woman has just been told that her husband needs to undergo
emergency surgery, but that the surgery is risky and he might not survive the
operation.
6. My Mother has told me she won’t take any more treatment. We can’t just sit by
and watch her die.
7. I just found out Sam’s prostate cancer has spread to the bone. I thought
prostate cancer was treatable!!! Now it’s a death sentence!
8. They told me if I don’t consent to my little’s girls leg amputation, the flesh-eating
disease will spread..
9. What would you think if they told you your wife has HIV?
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Personal communication Self-Analysis Questionnaire
For each statement listed below, encircle the number that best indicates how you
perceive your behaviour on a continuum from one extreme to another. The numbers
1, 2, and 3 represent the negative end of the continuum – they suggest a need for
work on the item; the numbers 5, 6, and 7 represent the positive end of the
continuum – they suggest a perceived competence in terms of the behaviour. The
number 4 represents a mid-point between the extremes. A rating of 4 may also
indicate that you are not sure where you stand.
I do not pay full attention
1 2 3 4 5 6 7
when I listen so I miss
I am very attentive listen
carefully
words and ideas
When I’m not sure
When I don’t understand
1 2 3 4 5 6 7
something, I act as if I do
whether I understand, I
seek clarification
The way I respond to
The way I respond to
1 2 3 4 5 6 7
others seems to
others makes them react
encourage them to talk
defensively – they feel as
with me openly and
if I’m attacking them
honestly
I have trouble in phrasing
1 2 3 4 5 6 7
my ideas precisely
I speak clearly in specific
and concrete language
I speak fluently without
My speech is cluttered
1 2 3 4 5 6 7
interjecting meaningless
with meaningless like
expressions like “uh,”
“uh,” “well uh,” and “you
“well uh,” and “you
know,” or I stumble and
know,” or without
grope for words.
stumbling around for the
right word.
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I either keep quiet about
my negative feelings
I describe objectively to
1 2 3 4 5 6 7
others my negative
about other’s behaviour
feelings about their
toward me or I blow up at
behaviour to me without
what they’ve said or
blowing up or
done
overreacting.
I am seldom interested in
what others think of me
I am willing to hear what
1 2 3 4 5 6 7
or my actions
attitudes and behaviours
I am usually careless
about aspects of my
others think of my
I am usually very careful
1 2 3 4 5 6 7
about my clothing and
dress and grooming
grooming
I am unaware of or
I am conscious of and try
uninterested in others’
1 2 3 4 5 6 7
attitudes toward time
to adapt to others’
attitudes towards time
I try and convey
I often say things I don’t
1 2 3 4 5 6 7
information that I mean
and feel “real” about
really mean or care
about
I often interrupt and
leave person without an
I allow person time to
1 2 3 4 5 6 7
opportunity to get
fully express their ideas
and listen throughout
message across
I never consider events
or people in the past who
If I get unusually hurt or
1 2 3 4 5 6 7
angered by discussions I
may be influencing what I
try and understand why I
say and hear
felt so strongly
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Case Studies in Communication
1. Mr. Jones , age 40, the father of three active school-age children: “There’s no
reason I should die in the hospital. My wife can take care of me here at home.” Mrs.
Jones has already told the volunteer that she can’t cope any longer with her husband’s
deteriorating health.
Volunteer Response
2. Nancy, age 18, at the bedside of her mother who has inoperable cancer: “Doesn’t
Mom look better today? I just know she’s going to get well.”
Volunteer’s Response:
3. Young man in his 20’s dying of leukaemia: “Why me? I just got married. Suzie and
I have so much we want to do together.”
Volunteer’s Response:
4. 70 year-old gentleman, whose children are very protective of him: “I know I’ve got
cancer. Why won’t somebody tell me?
Volunteer’s Response:
5. Mrs. Kelly, a 60 year-old widow whose ill health has made her a shut-in: “I wish my
daughter would come and visit me. She just lives in Kemptville but she always has
some excuse about being too busy with grandchildren.”
Volunteer’s Response:
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6. Young mother of a little boy with a brain tumour: “What kind of a God is this to
make my child suffer so?
Volunteer Response:
7. Mr. Arnold, 52-year old construction worker with a serious heart disease: “I’ll be
stronger, you’ll see!! I should be able to get back to work by the end of the month.”
Volunteer’s Response:
8. Miss Ross, a 50 year old career woman with terminal cancer tearfully admits: “I’m
afraid to die.”
Volunteer Response:
9. Mr. Smith is in the final stages of kidney failure. His 36 year old son asks: “Dad’s
been sleeping all morning. Do you think it’s okay for me to go down to my office to get
some work done?”
Volunteer’s Response:
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Communication Summary
•Be yourself!
•Be sincere!
•How is the message perceived?
•Non-verbal is as important as the words
•Touch is valuable
•The last sense to go is hearing
•Take our cues about comfort level from the client
•Help make a comfortable setting
•Remain non-judgmental
•Don’t assume!
•Be patient
•A sprinkling of humour is healthy!
•Conflict is normal
•Don’t give advice
•Empathy is better than Sympathy
•Do more listening & less speaking
•Just be there!
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Cultural Care Theory
Janet Stark
Culturally-appropriate care extends the scope of spiritual and religious care. The
term cultural care is a good one and a concept that Canadians are tolerant of.
Culturally-appropriate care includes the customs, traditions, and practices that are
shared among a group of people. Sometimes by teaching this concept a way
becomes open for discussing spiritual care.
Culturally-Appropriate Health Care
Meaning of the word “Culture”:
 ethnic background or nationality
 inclusive of religion or spiritual practice
 local community lifestyle
 family heritage and traditions
Multiculturalism in Canada
Canada is known as a cultural mosaic, having people of many different ethnic
backgrounds across the nation. Urban ethnic diversity in Canada gives us
large areas of ethnic groups living together in cities. Local culture often
manifests as a more homogenous group living in a local area. For example, in
rural Quebec, the local culture is francophone. In northern areas of each
Canadian province, the local culture may be Aboriginal. In small towns and rural
areas, there may be cultures almost entirely of English, Irish, and Scottish
descent.
It is important for volunteers to recognize that the Canadian population is
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transient, and staff travel far and wide as well. In a large city one can expect to
care for ethnically diverse clients. Even in homogenous areas, accidents occur
on major highways, bringing clients of all backgrounds into small-town
emergency departments.
To be culturally sensitive, a care provider needs to be open and inquiring.
A volunteer does not need to know everything but, instead, know where to find
information. A multi-faith manual could be a key resource. The spiritual care
department should keep a current list of local practising clergy and leaders of all
ethnic and faith groups. If copies of this list are kept in clinical areas and nurses
are made aware of this list, they can be encouraged to contact the appropriate
person without having to refer to the spiritual care department.
A culturally appropriate care plan is proactive, not reactive. A harmreduction model suggests that we give a spiritual-cultural assessment early on,
preferably on admission. The nurse needs to know right away who is going to
speak for the client. Always assume that clients speak for themselves unless
they are incapable or have made another directive. The nurse also needs to
know if there are special considerations required in providing care, which also
includes care upon death, handling of the body, and burial or cremation
practices.
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Objective in being “Culturally Sensitive”
 prevent the occurrence of events that will distress the patient/client or family
(preventive)
 develop appropriate health care plan for that culture (proactive)
Immigrants
 Seniors may have physically moved to Canada from their country of origin in
their own lifetime
 What was the reason for coming to Canada? (may have emigrated voluntarily,
because of famine, religious persecution, or refugee)
 Have already had to adapt and change a great deal to fit in, language being only
one of these changes
Assumptions in Western Medicine
Patients are expected to:
 Understand a bio-medical perspective
 Be punctual
 Be future-oriented
 Accept truth-telling as a basic principle of care
 Be willing to work on therapeutic goals
 Be motivated by the prospect of change
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What are Different Beliefs about Suffering?
 Belief that the illness may be caused by a misdeed
 Some cultures may value a “stoic demeanor”
 Others are more expressive and encourage moaning and wailing to express
discomfort
Physical Touch:
 Who may touch whom?
 How is bathing handled?
Privacy:
 Must certain family members be present when being physically examined?
 May be extremely modest
 May consider left hand for toileting duties (Middle-eastern cultures)
 What clothing must be worn—veils, turbans etc?
Pain:
 Do the person feel free to express pain?
 What meaning does suffering have?
 What is the attitude toward opioid use for pain?
 Do they promote certain complementary or alternative therapies?
Room arrangements:
 Muslims may need to turn the bed to face the East (Mecca)
Rituals:
 Required prayer times, burning of incense
 Ritual bathing
 Cords tied around waist or wrist (or other practices)
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Dietary Requirements:
 What is the meaning of food?
 What person may and may not eat
 How food is prepared
 Jews eat “Kosher”; food must be blessed by Rabbi
In Control of Care
 Who may advocate for care?
 What is the role of women in that society?
 Whom do you address during a family conference?
 Who is the decision-maker?
 The family may request secrecy in not telling the ill about the seriousness of
illness. North Americans put a high emphasis on telling the truth; this is
consistent with our philosophy in providing good palliative care. (This may
cause distress in the health-care team, if not allowed to discuss the truth.)
Last Stages of Living
 Must someone stay with dying person at all times?
 Continuous prayers, required prayer times
Rituals & Ceremonies After Death
 Goal is to help provide intervention for safe passage of the soul
 Cords may be tied around the waist or wrist
 Grief may be demonstrated by chanting or wailing
 What is the practice for covering and transporting a dead body?
 Staff may not be allowed to touch, bathe or dress the body
 Does the body go to the morgue?
 Is it buried or cremated? How soon after death?
“Dying is a very private and unique event for each senior and family. We should intrude as little
as possible and assist as much as we can”
Dr. Elizabeth Latimer, Hamilton
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As Volunteer Caregivers, what can we do?
Attempt to understand the personal values of the person first, and the beliefs and
practices of the family and culture second.
 Encourage family to share information as to what is allowed and what is not
 Find out if the patient is making the care decisions, and if not, whom?
 Be interested enough to find out information about that culture
 Find out what spiritual care might be helpful to the family
 Treat the family as a unit of care
 Remember about “total pain” (psychosocial and spiritual pain, as well as
physical pain)
 Accept refreshments as part of the ritual
 Some families insist on giving gifts to a caregiver
Communication
 Western societies like to talk things through, share emotions
 Non-verbal communication: people avoid direct eye contact. They feel it could
be interpreted as rude or disrespectful
 Latin cultures have a shorter personal space
 When patient speaks a different language, take time to communicate, use
simple words
 Get an interpreter if possible
 Watch for non-verbal communication
 Check to see if information has been understood
Non-Verbal Communication
 Sitting quietly at the bedside
 Sharing tea within the family circle
 Respectful body postures, gestures, facial expressions
 Eye contact? Valued in Western cultures, may be considered rude by others
 What is the personal space—comfort zone? Some cultures stand much closer
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Summary
 Treat each patient as unique with their own personal set of values
 We are walking into an intimate place when we enter the family’s world
 Remember that we are the guest in their space, tread sensitively
 Respect cultural rites and ceremonial practices that accompany death and dying
 Know where to go for information, to provide resources
Aboriginal Issues in Health Care
Who are Aboriginals?
 First Nations People
 Inuit (not called Eskimo)
 Métis (French-Canadian Indians)
 Innu (natives of Labrador)
Statistics:
 Only 3-5% reach the age of over 55 (this is a senior)
 “Seniors” are called “elders”
 there is disability in 30% of Aboriginals
 alcohol and smoking play a larger part in health needs
 high rate of diabetes
Spirituality:
 nature is holy
 the 4 directions are representative: north, south, east, west
 smoking of “sweetgrass”
Role of Elders:
 Elders, or seniors are given much respect
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 Elders are a valuable resource, consulted for decision-making
 Younger people are expected to look after their elder’s needs
 Elders may be very sensitive to personal questions, and see them as impertinent
 Discussion of “sex” is taboo
 May not want to “bother” health care providers
 Will not complain or ask for help
View of HealthCare:
 suffering may be seen as a special gift the Creator bestows on only a chosen
few
 “Aboriginal people value their independence to the extent that they will ignore
health problems in order to stay closer to home. The history of treatment and of
communicable diseases in remote and isolated areas is that people and children
were removed to southern hospitals. Some people never returned home. Thus,
nursing homes are still viewed by Aboriginal people as places where one goes
to die.”
A guide to end-of-life care for seniors; Health Canada
Lifestyle
 many live in poverty
 live together with other members of the family
 abuse is very difficult to prove
 instructions for wills may be verbally stated
 may have no power of attorney
Traditions
 may make use of traditional healers or “medicine men” (Shamans)
 a large extended family gathers around the sick
 use of herbs and natural medicines
 healing tools: stones, pipes, feathers, cloth etc.
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After Death
 a ‘wake’ is held before burial
 songs, prayers and stories of the deceased are offered at the ceremony
 a fire is kept burning for the duration of the wake, to keep the soul warm for it’s
transformation from one state to the next
 may cut their hair as a manifestation of grief
What health caregivers can do:
 respect wishes to remain in the home, even if it seems inadequate
 watch for non-verbal signs of pain
 Treat personal matters very delicately
 Try to find spiritual care in their own language
 Accept small tokens of thanks, this may be food or tobacco
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Medicine in Words
Chaplain Brenda Haggett MTS
I attended an event in Ottawa entitled Sacred Trust: Healing in Aboriginal
Culture. One workshop was led by a very gentle, soft-spoken native woman in
her 60’s named Morning Star. She told her story of brokenness, abuse, hatred,
loss of identity, unforgiveness, and ultimately of her healing.
She called her talk Medicine in Words and she likened it to the practice of
alchemy (a process of turning base metals into precious metals); she spoke of
her journey of self-transformation as sacred alchemy – taking the brokenness
and using it to bring healing and transformation. As she said, for every negative
there is a complementary healing process, but it requires a life-long journey of
healing and a commitment to being transformed.
Her broken life began at age 3 when she was taken from her native home and
placed along with an infant brother into the care of a Norwegian white family in
Alberta. The family took in several native children but also several white children
and the two groups were treated very differently. She grew up hating both whites
and natives alike. It was not until she was in her early 30’s that she found herself
in a native retreat setting in the Green Mountains of Vermont. She found herself
drawn towards wholeness by the elders’ sense of identity, love, peace, and
serenity. In rediscovering her native identity she was able to reclaim her
spirituality. She spoke about the power of the human self to use everything that
the Creator has given to bring healing. And ultimately she said it took the power
of medicine given in words of love and hope for her to exchange her brokenness
for healing and wholeness.
I could not help but think about the work that spiritual care does within the
hospital. We do not bring physical medicine but we bring something often just as
important - the medicine of words (love, joy, peace, and hope). As Morning Star
said in her talk - it was the power of love that healed her broken spirit. May we
be empowered by our Creator to carry the medicine of words to all we come in
contact with in the course of work in spiritual care.
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Culture Change
Commit to these values:

Know each person.

Each person can and does make a difference.

Relationship is the fundamental building block of a transformed culture.

Respond to spirit, as well as mind and body.

Risk taking is a normal part of life.

Put person before task.

All people are entitled to self-determination wherever they live.

Community is the antidote to institutionalization.

Do unto others as you would have them do unto you.

Promote the growth and development of all.

Shape and use the potential of the environment in all its aspects: physical,
organizational, and psycho-social / spiritual.

Practice self-examination, searching for new creativity and opportunities for
doing better.

Recognize that culture change and transformation are not destinations but a
journey, always a work in progress.
www.pioneernetwork.net
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Cross-Cultural Assessment
Dawn Chaitram, BA, BSW (Winnipeg)
(used with permission)
1.
How do you describe your culture?
2.
Do you adhere to traditional, contemporary or bi-cultural values?
3.
Is there a specific ethnic group that you relate to?
4.
Is there more than one group that you identify with?
5.
What aspect of your culture is important to you?
6.
What languages do you speak? Which are you most comfortable with?
7.
Do you adhere to any food restrictions or practices that are culturally dictated?
8.
How are illness and pain regarded in your belief system?
9.
Are there cultural explanations of the illness?
10. When you are ill, do you consult a medical doctor or another type of practitioner
or healer?
11. What are your feelings related to dying at home? Hospital?
12. What are your feelings related to personal care?
13. What do you and your family expect from those providing care?
14. Are there cultural factors that need to be incorporated into care plans?
15. Do you adhere to a particular religion?
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16. How closely do you subscribe to the beliefs, rituals and traditions of your
religion?
17. Are there mourning patterns and rituals that need to be understood by care
providers before death occurs?
18. Are there other care practices that you believe in that you would like to tell me
about? i.e. prayer/healing
19. In an ideal world, what would you want us to do related to your health?
20. What are other options?
21. Tell me about your family.
22. Who makes most of the decisions in your family?
23. Is there anyone else who should be involved in making decisions regarding
care?
24. Are there any concerns that you would like to share with me or anything else
that you would like to tell me about yourself that would help me in developing a
plan of care for you?
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CARING across cultures
Multicultural and Multifaith Considerations in Dying and Death
St. Mary’s Hospital Center
Montreal Québec
Pastoral/Spiritual Care Services
Cindy Morneault, M.Div
Spiritual Care Professional
[email protected]
This document was produced with the support of the
Hélène Derouin Renaud Educational Series in Palliative Care Endowment Fund.
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Table of Contents
Introduction
Caring Considerations for the Dying ...............................................................177
Worden’s Four Tasks of Mourning ..................................................................178
Care Plan for the Bereaved ............................................................................178
Origins
Blacks ..............................................................................................................179
Chinese ........................................................................................................ 179
Greek ...............................................................................................................180
South Asian ................................................................................................... .181
Southeast Asian ..............................................................................................182
Italian ............................................................................................................ ..182
Jewish ..............................................................................................................183
Polish ...............................................................................................................184
Portugese ........................................................................................................185
Ukrainian ..........................................................................................................186
Faiths
Baha’i Faith ......................................................................................................187
Buddhism .........................................................................................................188
Christianity .......................................................................................................189
Hinduism ..........................................................................................................190
Islam ...............................................................................................................191
Judaism ...........................................................................................................192
Sikhism ............................................................................................................194
Foreword
The information included in this presentation has been gathered from different sources and may
or may not be applicable to your present situation. This is intended as a general, but by no
means absolute, guideline bearing in mind the ever changing outlook of succeeding generations.
This volume is produced by Public Relations in collaboration with Pastoral/Spiritual Services and
Social Services.
This booklet was produced in an attempt to lessen the stresses on staff during the process of a
patient’s dying and death. As stated previously, these are guidelines only but we hope that they
help staff to be more comfortable in dealing with patients and families of different cultures and
faiths.
The Pastoral/Spiritual Services department is available to staff for consultation and/or relevant
information. There is someone on call at all times. During regular office hours they may be
contacted by calling local 3361. After office hours please contact locating at 3232 and ask for
the Chaplain on call. There is also a list of community bereavement resources available upon
request from the Pastoral/Spiritual Services department.
We have endeavored to include cultures and faith reflective of our hospital population.
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Caring Considerations for the Dying
Situation
Approach
1. Staff is aware of
specific customs
and traditions
patient and family
may follow.
1. When appropriate, encourage the
family to be open and honest with the
patient in discussing illness and
impending Death.
2.
Family and
patient will carry
out rituals according to their
beliefs during the
dying period.
2a. Establish with patient and family
any specific customs or rituals they
would find comforting.
b. Explore ways of facilitating the ability
to practice the identified customs and
rituals.
3a. Encourage patient to remain as
functional as possible and as in control
3. Patient and family
express
satisfaction with
the care and
consideration
shown them by
staff.
of the situation as is comfortable for the
patient. If patient is the head of the
family continue to let the patient make
decisions.
b. Assess need for an increased
supportive care network: extended
family, friends and other professionals;
e.g. Pastoral/Spiritual services.
c. Enhance the provision of emotional
and spiritual support by participating in
selected readings or prayers, if
appropriate. 177
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Worden’s Four Tasks of Mourning*
In bereavement literature, professionals frequently refer to Worden’s Tasks of
Mourning. This provides an excellent framework to address the grief work»
patients and their families may be experiencing during the mourning process.
1. To accept the reality of the loss
2. To experience the pain of grief
3. To adjust to an environment in which the deceased is missing
4. To withdraw emotional energy and reinvest it in another relationship
* Grief Counseling & Grief Therapy: A Handbook for the Mental Health Practitioner» J. William
Worden Springer Publishing. N.Y. 1982
Grieving and mourning have no time limits. There is no right or wrong way.
Each individual grieves at his/her own pace and in their own manner. What is
important is respect.
Care Plan for the Bereaved
Goal
To enable the survivor(s) to cope with the loss by moving through the process of
grief and mourning.
Approach
a) Anticipate the beginning of the mourning process before death and provide
privacy which may be needed for the expression of grief.
b) Anticipate the possibility of a heightened expression of emotion at the time of
death and into bereavement.
c) Provide appropriate support.
d) Be aware of mourning rituals.
e) Facilitate bereavement follow-up if a need is expressed by the family. Such
resources are available through Pastoral/Spiritual Services.
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Origins
Blacks
Immigration of the Caribbean Blacks to Canada began in the 1950’s with a
dramatic increase in the 1960’s and 1970’s. The Black population is comprised
of a great number of widely differing cultural groups. For example, a Black
Muslim from Ethiopia has little in common with a Black Christian from Trinidad.
Blacks from the Caribbean come from several different countries within that
geographical area, like Jamaica or Guyana, among others, each with its own
unique history and culture. Therefore, even the Caribbean Blacks cannot easily
be discussed as a single group.
Among the Black peoples there are followers of each of the major religions. The
majority of Caribbeans are of Christian background and there are some
followers of the Rastafarian movement. Funeral and bereavement practices vary
according to the specific religious tradition followed.
Chinese
There were three major waves of Chinese immigration to Canada: in the early
1900’s, male Chinese labourers came to work on the railroads; in 1947 a few
students and relatives of those Chinese already in Canada immigrated; in the
late 1960’s and 1970’s many young Chinese adults (mostly from Hong Kong)
came as landed immigrants with their elderly parents.
Within traditional Chinese society the family (based on an extended or clan
structure) played a strong central role. The family was male-dominated and the
primary relationship was father-son. While the Chinese continue to place a high
value on the family, many factors (both in China and in Canada) have
contributed to the erosion of that traditional extended family structure.
For
example, marriages are no longer «arranged» and the primary relationship has
shifted to husband-wife. In addition, many wives are now in the work force.
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Longevity is also valued and the elderly are respected for both their age and
wisdom. Traditionally the elderly were cared for by their children but this too is
changing and more elderly Chinese are using the social services and institutions
available.
Chinese society, in general, values education. It is seen as the key to economic
and social success. Three medical systems co-exist within Chinese society:
1. Folk medicine.
2. Classical Chinese medicine based on the Taoist «Yin-Yang» principle
3. Western health care.
It has been found that two sensitive subjects which are rarely discussed,
especially among elderly Chinese, are hospitalization and the need to make a
will. Admission to hospital is often associated with death and to make a will may
be considered a bad omen. Generally the subject of death may also be regarded
as a taboo topic.
The religious affiliation of the Chinese community is diversified. The two largest
groups are Buddhist and Christian (in its various forms). There are also a few
Muslims.
Greek
While Greek immigration to Canada began in the early 20th century, the major
influx has occurred since the early 1960’s with the majority of Greek immigrants
being of working class background.
The Greek community is now well-
established and many more people, especially second generation Greek
Canadians, are moving into the professions. That is, in part, due to the high
value Greeks place on education which they feel is the key means for social and
economic mobility.
Traditionally Greeks share a strong sense of family life.
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This structure
encompasses an extended family unit which tends to be close and spend much
time together.
The traditional Greek family is male-dominated and follows
clearly defined sex roles for both husband and wife. While these basic values
remain, family life is changing as more and more women work outside the home.
The Greek Orthodox Church is an influential force within the Greek community.
Death is usually viewed as a great tragedy. Generally, euthanasia is strongly
opposed. Many Greeks feel that every effort should be made to preserve life
until it is terminated by God. During the dying process and after death, feelings
of grief may be openly expressed, especially by the women. A wailing and
sobbing response is often exhibited to demonstrate the depth of their grief.
Greek people usually discourage autopsies and prefer burial to cremation. The
traditions followed immediately after the death include a wake and funeral
service in the Church. After the graveside service when the grave is sealed, a
memorial meal is held where it is believed the person who has died is spiritually
present. The first forty days of bereavement are especially significant because it
is believed that the spirit of the deceased remains on earth for forty days.
South Asians
Among South Asians we see people from India, Pakistan, Bangladesh, Sir
Lanka, Nepal as well as others.
As with many other cultural groups, the
traditional South Asian values and customs are slowly changing as they become
more exposed to Canadian lifestyles. A South Asian’s conduct and behaviour
was traditionally governed by a strict set of religious values and beliefs.
Parental authority was absolute and children’s conduct was strictly governed by
their parents, including the arranging of marriages. At present, the extended
family system still remains central to all Asian cultures and has a very strong
influence on behaviour and outlook. Each member considers himself or herself
a part of the extended family group rather than as an independent individual.
Where possible, important decisions are not made without consultation with the
whole family.
As a rule, the elderly are respected and their dependence
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accepted - rarely would the family consider not caring for them at home.
Traditionally, illness is considered to be the responsibility of the whole family.
Thus the family usually expects to play a major part in supporting the sick
person and may want to undertake much of the bedside care. It is common for
South Asians to feel that the sick should stay in bed as long as possible with
minimum activity (they may therefore become very distressed when encouraged
to mobilize). There may be a great fear of catching a chill when ill (consequently
they may wrap up well, decline cold drinks and be reluctant to bathe). Generally
they expect a sick person to express anxiety and suffering openly - not to be
cheerful or active.
Most South Asians follow one of the Muslim, Hindu, Sikh, Buddhist or Christian
faiths. Religion tends to be considered a natural part of life and most cultural
traditions have a religious significance by which people judge themselves and
others.
South East Asia
South East Asia is made up of peoples of Thailand, Vietnam, Cambodia,
Philippines, Indonesia, Burma (Myanmar), Timor-Leste (East Timor), Malaysia,
Brunei, Laos and Singapore. The three main religions in these countries are
Muslim, Buddhism and Christianity.
Italian
The first major Italian immigration occurred in the 1880’s when thousands of
Italians were recruited for railway labour.
Beginning in the mid 1940’s, a
wealthier, better educated and business-oriented group began immigrating and
there are a substantial number of second, third and even fourth generation
Italians in Canadian communities.
It is impossible to describe Italians under a single ethnic label because the
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regions of Italy from which they come are so culturally diverse. While Italian
communities are loosely structured and diversified, they are strong and well
established and have developed a rich cultural, political, and social support
network.
In general, Italians value both education and the work ethic. They also place a
high value on the family and have a history of a strong authoritarian family unit.
The vast majority of Italians follow the Catholic faith. While the church is thought
to be losing some of its dominance as a cultural institution, religion continues to
be very important to most Italian Canadians.
For many Italians, there may be a tendency not to tell the dying person about
the seriousness of their illness, or to admit they are dying.
This may be
perceived as a way to protect the patient. The mourning process may begin
before the actual death and may be marked by a heightened emotional
response such as wailing. Immediate family members and close friends usually
assume charge of the household. There is a two day visiting period before
burial. Shortly after death, the women of the immediate family wear black; the
men may wear a black armband. The parent of the deceased wears black from
head to toe for up to two years. The spouse may wear black forever. There is a
‘lifting’ process by which, at certain points in time, the mourning colour changes,
e.g. from black to blue to brown.
There may be a stigma attached to not
following the traditional mourning rituals; however, the person’s age and length
of time in Canada affect this adherence to custom. Young children may be
exempt from the usual rituals. Bereavement follow-up may be appropriate and
welcome, especially by the senior citizen.
Jewish
The Canadian Jewish community is made up of Jews with roots in many
different countries and with many different cultural backgrounds. The first wave
of Jewish immigration was in 1920 as East European Jews fled the pogroms in
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Russia, Romania and Poland. The next wave, before World War II, brought
German, Austrian, Czech, Polish, Latvian and Hungarian Jews as Nazism was
spreading across Europe.
Since the 1950’s, another group namely the
Sephardic Jews from Egypt and North Africa, immigrated to Canada.
There is a well-developed and extensive structure of social, religious and
cultural organizations within the community and participation in these groups is
high. The practice of three distinctly different types of Judaism also adds to the
community’s diversity.
Consequently, there are organizations such as the
Canadian Jewish Congress which attempts to bring the various components of
the community together. The religious and cultural aspects of Judaism are so
interconnected that it is impossible to distinguish one from the other - the cultural
community is linked to the synagogue which is the heart of the religion. Most
Jews, regardless of the religious commitment, share the following basic values:
• A belief in the family as the basic unit of society.
• A view of the practice of charity as a legally binding obligation.
• A commitment to education, learning and the work ethic.
• A belief in the importance of ceremony and tradition.
The loss of Jewish identity through assimilation is one of the community’s
greatest concerns as it struggles to be part of the indigenous society while at the
same time maintaining its cultural identity.
Polish
Immigration to Canada has been closely tied to the history of the nation of
Poland.
The first wave of immigrants arrived before World War I, with the
majority settling in western and central Canada. After World War I another wave
of immigration was prompted by the shortage of land available to divide between
the children, as was the Polish custom. During and after World War II foreign
occupation of Poland prevented numerous soldiers and other citizens from
returning to their homeland. Many of these people came to Canada. Today,
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many continue to arrive in Canada in the hope of providing a better future for
their children. In 1966 the Polish people celebrated one thousand years of
Christianity. Worship generally follows the Catholic tradition. Day-to-day life is
closely tied to the Church, and practicing the Christian faith means a great deal.
Social events revolve around the Church and, therefore, Feast Days such as
Easter, Christmas, Ascension Day, etc. have great significance.
Belief and practices surrounding attitudes to death and dying are noted under
the Christianity section (see pg. 9). Frequently Polish families participate in
prayer for the dead at the funeral home. This service is conducted by the priest
and is called Rozaniec (the last prayers).
Portuguese
The Portuguese, in general, place a high value on hard work and the family unit.
Their concept of family is one of reciprocal rights and obligations within an
authoritarian structure. Relatives often live within a few blocks of one another
(especially in downtown cores). Social activity tends to be centered in the home
and mutual assistance among family members is common. Traditionally, gender
roles within the family are highly segregated. The father plays the dominant role
and is the bread winner. The mother’s role centers on the family - homemaking
duties and raising the children.
As in other cultural groups, many of these
traditional structures are changing as more Portuguese women enter the work
force, and as their children become more exposed to the less structured and
more permissive Canadian lifestyle. These factors, among others, result in a
high degree of stress on immigrant Portuguese families, especially for the
women who are expected to maintain their traditional roles in addition to their
new ones.
Generally, the Portuguese are comfortable consulting a doctor and usually
expect medication to be prescribed. Many will use folk healers in conjunction
with traditional health care. There is a general belief that a good diet and plump
appearance are synonymous with good health.
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The predominant religion of the Portuguese is Catholicism and the Church is
often the focal point for family and social life. The role of the Church within the
community appears to be less influential here than it is in Portugal.
The
Portuguese share many of the same rituals and concerns as the Italians
regarding death and dying (See Italian, pg. 6).
Ukrainian
There were two major waves of Ukrainian immigration to Canada. The first
occurred between 1900 -1918 when many settled in the Prairies. The second
wave occurred shortly after World War II with the new immigrants settling in
communities across Canada including Edmonton, Winnipeg, Montreal and
Toronto.
The Ukrainians work hard to purchase their own homes in order to provide a
sense of security.
This is important to them because of the hardships and
uncertainty of their lives prior to immigration.
Close to the hearts of Ukrainians are the many expressions of their native
culture.
Traditional dancing in skillfully embroidered costumes, Easter egg
painting, as well as preparing unique and delicious foods remain an integral part
of their lives in Canada.
Ukrainians belong to the Catholic Church, as expressed in the Byzantine
tradition, or may be members of the Orthodox faith. The significance Ukrainians
attach to their faith in everyday life is reflected by the fact that their
neighbourhoods invariably surround a church.
Beliefs and practices surrounding attitudes to death and dying are noted under
the Christianity section. Ukrainian families participate in prayers for the dead at
the funeral home.
This service is conducted by the priest and is called
Panakhyda.
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WORLD RELIGIONS (FAITHS)
Baha’i Faith
Basic Beliefs
• The oneness of God, the oneness of religion, and the oneness of humanity.
• The purpose of religion is to unify humanity.
• All great religions and prophets are divine in origin.
• All great religions represent successive stages of divine revelation throughout
human history.
• The eradication of racial and religious prejudice.
• The search for truth as an individual responsibility.
• The harmony of religion and science as complementary aspects of the truth.
• The establishment of an international auxiliary language.
• Basic education for all children.
• Abolition of extreme wealth and poverty.
• Equality of the sexes.
Beliefs and Practices Regarding Death
Beliefs: An individual’s essence or reality is spiritual, not physical; the body is
seen as the throne of the soul, worthy to be treated with honour and respect
even though it may be dead.
After physical death, the soul continues to
progress; it proceeds on to the next stage of existence, closer to God, free of
physical limitations.
Practices: The body should be buried, not cremated; preferably without
embalming (unless embalming is required by law). It must not be transported
more than one hour’s journey from the place of death. For a Baha’i over 15
years old, the Prayer for the Dead is to be recited at burial.
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Buddhism
It is estimated that there are approximately 180,000 Buddhists in Canada.
Founded in India in the 6th Century B.C. by Siddhartha Guatama (The Buddha),
Buddhism seeks «the truth» through a middle way between the two extremes of
asceticism and self-indulgence. Essentially a monastic religion, it teaches that
right living will enable people to attain Nirvana, the condition of the soul that
does not have to live as a body and is free from all desire and pain. The
underlying principle of all Buddhism is belief in reincarnation of the soul. There
is great emphasis on meditation to relax the mind and body in order to see life in
its true perspective.
There is a firm belief in non-violence; women are considered inferior (a woman
must await rebirth as a male before she can attain Nirvana); there is a strong
emphasis on individual effort - “Look within, Thou art the Buddha”.
It is important for a patient to be allowed quietness and privacy for meditation.
Great importance is also attributed to the state of the mind at death which
should be calm, hopeful and as clear as possible. To this end some patients
may be reluctant to take drugs, which must be respected. There are no special
rituals regarding the body and cremation is common. However, when the
individual is pronounced «dead» the body should be gently covered with a
cotton sheet, with care taken not to create any disturbance to it. It must not be
touched, manipulated or moved around by another person’s hand or body. Do
not close the eyes, mouth etc.. Leave the body just as it is.
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Christianity
Christianity is a religion dating back over two thousand years.
There are
approximately one billion Christians spread over all continents and comprising
dozens of cultures and languages. This makes Christianity the largest religious
group in the world as well as the prevailing religion in the Western Hemisphere.
Christianity was founded upon the life and teachings of Jesus Christ, who is
believed to be the Son of God.
This faith must be taught, proclaimed and
passed on to later generations - this is the responsibility of all Christians.
Christianity proclaims that God created the world and that everything that exists
depends on God. A belief in an after life and the soul are both integral parts of
the Christian Faith. Sundays are observed as the holy day. Their holy writings
include the Old and New Testaments of the Bible.
Today there are three major divisions of Christianity:
1. The Catholic Church consists of Roman Catholics and Eastern Catholics:
The head of the church is the Pope, who is seen as infallible. Catholics are
obliged to participate in a Holy Mass each Sunday and on designated Holy Days
(e.g. Christmas Day, New Year’s Day, Easter). They can also attend Mass on
any week day. Their source of spiritual guidance is the parish priest. During
illness, one is encouraged to receive the Sacraments of the Sick.
These
Sacraments include Confession, receiving the Holy Eucharist and the anointing
with Holy Oils.
This Rite is symbolical of a new life with God and can be
received as often as necessary.
2. The Protestant denominations: The Protestant Church is comprised of many
denominations including Anglican, Lutheran, Presbyterian, United, Baptist, etc.
Protestant denominations are not under the jurisdiction of the Pope and each
has its own regulating body. Participation in Sunday worship is encouraged but
not obligatory.
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3. The Eastern Orthodox churches: These are comprised primarily of the Greek,
Romanian, Russian and Ukrainian cultures. A magnificence of ancient tradition
and ritual is incorporated into their formal church worship. The setting is often a
Byzantine designed church, highlighted with icons and mosaics.
Upon death there are no specific rituals required but respect is expected at all
times. After death the bereavement rituals may include:
• visitation to the bereaved at home or in a funeral home over a two to three day
period, prior to the funeral
• funeral or memorial service in church or funeral home chapel to celebrate the life
of the deceased and the departure of the soul to an afterlife.
• burial or cremation usually occurs after the funeral service. These rituals provide
the bereaved with an opportunity to express their grief and to prepare for the
«grief work» ahead.
Hinduism
Hinduism evolved in India around 1400 B.C. and is defined as a wide variety of
beliefs held together by an attitude of mutual tolerance, and by the
characteristically Hindu conviction that all approaches to God are equally valid.
The individual Hindu is, in effect, free to believe or disbelieve what he wants.
He regards his religion as a total way of life.
The goal of every Hindu is to break free of this imperfect world and achieve
reunion with Brahman. Brahman is literally everything physical, spiritual and
conceptual - hence the belief in reincarnation and in the transmigration of souls
until the soul is reunited with Brahman. The cycle then ceases.
Vegetarian diet is preferred; the killing of any living thing is outlawed and cows
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are considered sacred. As followers of the caste system, they believe one’s
membership in one of the four main castes is determined by birth.
Hindu women wear a nuptial thread around the neck and sometimes a red mark
on the forehead - these should not be removed. A male may have a sacred
thread around the arm indicating attainment of adult religious status - it will
cause great distress if this is removed. In the case of a dying patient the Hindu
Priest will tie a thread around the neck or wrist to indicate that a blessing has
been given - again, this should not be removed. Readings from the Bhagavad
Gita give great comfort to the dying person. It is important to the Hindu that his
last word or thought be of his God. This will ensure his rebirth in a higher form.
A Hindu would usually prefer to die at home and may wish to be on the floor
near to Mother Earth.
The eldest son is responsible for the funeral
arrangements, so it is very important to a Hindu to have a surviving son to
perform these rites. If no appropriate family member of the deceased (e.g.
spouse, children) is available to wash the body nursing staff may do so.
Cremation is usual and the ashes are traditionally scattered on water. The
Ganges is the Hindu’s holy river and some devout people may wish the ashes to
be sent home to be scattered on the Ganges.
There is a set pattern of mourning with relatives and friends visiting regularly to
comfort the family and to offer gifts of money, food and clothes. A final service,
called the Kriya, is held approximately two weeks after death.
Islam
Islam is a complete way of life and followers of Islam are called Muslims. They
believe all people are created by God, (Allah), live by His grace, die by His will,
and by His command they shall return to Him. Islam teaches that death is part
of life and a rebirth into another world.
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Pork and intoxicating substances are forbidden by Islamic law. Friday is the
Holy Day for congregational prayer. A cleansing ritual is performed prior to
prayer and one’s head must face towards Mecca. Their holy book is the Koran.
When symptoms of death appear the patient should be turned on his/her side
and his/her head slightly raised. If possible, they should face east, the direction
of the Quiblah, the Central Mosque in Mecca. The person attending the dying
should continue reciting appropriate verses from the Koran. This is done gently
so that the dying person is not disturbed. If the patient is rational and able to
speak, they are encouraged to repeat the verses as their last words.
After death, the body should be washed and prepared by a trusted relative of the
same sex, or the spouse. After death, the individual’s eyes should be gently
shut, his or her mouth closed with a bandage running under the chin and tied
over the head, and arms and legs straightened. Burial takes place as soon as
possible. No coffin is used and the grave is simple without dome or raised
structure. Mourning is limited to three days except in the death of a spouse,
when four months and ten days are required.
Judaism
Judaism is one of the world’s oldest major religions and the first to teach a belief
in one God. It is a practical religion and is strongly focused on the family. Jews
believe in a God who has a special Covenantal relationship with all the Jewish
people so that if they obey God’s laws, they may achieve salvation.
They
believe they are chosen by God to be examples to the world - a position of great
responsibility, not of special favour. They also believe a «Messiah» or saviour
will come to bring this world to perfection. Their holy writings include:
• The TORAH (the law) - the first five books of the Bible.
• The TALMUD (commentary on the law) - a collection of all Jewish laws and
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teachings taken from scriptures and oral tradition.
The Sabbath (holy day of rest) begins at sundown Friday and ends at sundown
Saturday. The Synagogue (or temple) is their house of worship and also the
center of Jewish education and community activities.
The Rabbi serves as
spiritual leader, teacher and interpreter of Jewish law. Worship is conducted
both at home and in the Synagogue and there are many special holy days and
festivals throughout the year.
There are three major divisions of Judaism:
1. Orthodox Judaism - places Jewish traditions above the values and mores of
the general society; incorporates only those aspects of the general culture
compatible with Jewish law.
2. Conservative Judaism - aims to synthesize the values of the general society
and Jewish law and tradition; the past is always the starting point but the present
must be taken in to account.
3.
Reform Judaism - places general values above Jewish tradition; thus, the
individual Jew decides what will be observed and what is meaningful to him or
her.
The traditions and practices that have evolved around death, dying and
bereavement vary greatly depending on the person’s adherence to Orthodox,
Conservative or Reform Judaic beliefs. However, all practices attempt to accomplish three tasks:
1. To honour the dignity of the human body. Therefore no act or deed may be
performed that might desecrate, mutilate or in any way dishonour the body before or after death.
2. To assist the bereaved through their grieving process using the comprehensive
laws of the whole mourning ritual.
3. To affirm the basic belief that life and death are part of God’s plan.
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According to Jewish law the body must not be left unattended from the time of
death until burial. The body should be lying flat, completely covered, with eyes
and mouth closed. Some families will insist on staying with the deceased until
the body is picked up by the funeral chapel. A light should be on at the head of
the bed. Jewish burial should take place «without undue delay» i.e. within
twenty-four to forty-eight hours. Therefore pre-planning of the funeral is helpful.
The family of the deceased sits SHIVA for seven days. During this time friends
and relatives visit the bereaved and bring gifts of food. The family remains
socially withdrawn for thirty days and the official mourning period is over after
one year for parents, 30 days for other relatives.
There are four specific
services of remembrance for the deceased during each year and an additional
observance upon the anniversary of the death. There is also a special service
at the time of the unveiling of the tombstone (thirty days to one year after death).
Sikhism
Sikhism, founded by Nanak in the 15th century A.D., was a combination of the
Islamic belief in one God with the basic ethical beliefs and world view of
Hinduism. Over the years, Sikhism developed its own doctrine and rituals based
on the Granth - the Holy Scriptures of Sikhism. This is made up primarily of
Hindu and Islamic writings and the thoughts of special Sikh holy men. Sikhs
believe in a common God for all mankind and preach religious tolerance. They
continue to be strongly influenced by Hinduism.
There are five traditional symbolic marks which all practicing Sikhs should wear;
1. Kesh - long, uncut hair and unshaven beards.
2. Kanga - A comb to keep the hair in place and symbolize discipline.
3. Kara - A steel bangle worn on the right wrist to symbolize strength and unity.
4. Kirpan - A sword, the symbol of authority and justice, often worn as a brooch.
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5. Kachha - A pair of shorts initially to allow freedom of movement in battle, now a
symbol of spiritual freedom.
It would cause distress for any of these symbols to be removed from the dying
person. The Sikhs favour cremation for disposal of the dead with the ashes
being thrown on water. There is no objection to medical staff handling the body.
For a period of ten days following death, relatives and friends take part in a
series of services, either in the home of the deceased or in the temple. A final
service marks the end of the official mourning period.
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Care for the Spirit
When we speak of "care for the spirit", we are referring to needs and
opportunities in an area that is hard to talk about. "Spirit", "soul", or "life force"
are terms we use to try to capture something of our deeper natures. Religious
belief and practice, or a philosophy of life, may represent the way to the spirit for
some. Others may not have a formalized way that captures their own sense of
their essential self, or "what it is that is really me".
Living with a final illness may bring a time of self-searching and selfassessment. Many things are changing for the dying person. As they move
through their illness, it will be important for them to try to make sense of what is
happening. This may challenge their beliefs and what has previously given
meaning to their lives. The purpose now is letting go.
In this turmoil, are there ways to work toward completion, forgiveness, love, and
peace? Are there ways to accept the times when such fulfilment does not occur?
People may seek forgiveness from others or from God, or offer it to those who
have hurt them. They may offer thanks and appreciation for what they have
been given, and acknowledge their depths. The work that people do in
considering the "big" questions of life, finding value and meaning in their life
experiences, and acknowledging their strengths and weaknesses can lead to a
period of acceptance.
This process may occur through quiet thought, meditation or prayer, or through
dialogue with others.
The following guidelines are points for you to consider when supporting your
clients and their families as they explore issues of the spirit.
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Needs of the Human Spirit
1. Need for Meaning and Purpose in Life
Examples of Distress




expresses having no reason to live
questions meaning in suffering and death
expresses despair
expresses anger at God
Examples of Comfort




feels happy to have whatever life is left
expresses having had a good, productive life
expresses having felt it worthwhile to be here
feels thankful to God for life
2. Need for Giving and Receiving Love
Examples of Distress





worries about family members after death
feels loss of faith in God
can't discuss death
feels lack of support
fears separation from others or God
Examples of Comfort





trusts family will carry on the heritage
feels God is loving and waiting to welcome
talks openly of death
accepts help and love from others
feels close to family and confident in faith
3. Need for Hope and Creativity
Examples of Distress





fears loss of control
has lost interest in life
feels a burden
denies reality of condition
has no hope
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Examples of Comfort






aware of small successes
looks forward to grandchild's upcoming wedding
accepts loving care
accepts death, values living
plans funeral
sees more to life than what is here on earth
Spiritual Needs of the Sick
 spiritual support may help some people make sense of their illness and give
them the strength to continue
 there are many different systems and each one has its own practices, myths,
rites and symbols
 spiritual beliefs are highly personal and vary among individuals
 it is important to respect other people's spiritual beliefs and not impose one's
own spiritual beliefs on others.
 we all have a spirit and need to express our spirituality, however, not everyone
has an organized religion to express it
Janet Stark
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Ho'oponopono
The Ho’oponopono is an ancient Native Hawaiian method of stress reduction
(release) and problem solving. Common translations: to make right, setting
matters right; correcting and restoring relationships; to correct; to restore; to
rectify an error. This is accomplished through prayer, discussion, confession,
apology, forgiveness and perhaps most importantly, release.
Say or meditate on the following:
I Love You, I'm Sorry, Please Forgive Me, Thank You.
When you add the fifth thing—saying Good-bye, you now have all five things
that one needs to hear or feel to have emotional wellness at end of life.
Old Hawaiian Tradition
1. I forgive you
2. Do you Forgive Me?
3. Thank You
4. I love You
5. Good-bye
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Suggestions for Individuals, Families or Volunteers
 Spend some time looking at photo albums together. Create one.
 Reminisce. Write down or tape record special stories, thoughts, memories
 Create a more formal piece, such as a life history, an ethical will (e.g. what one
believes is important to know about life.) This does not have to be long to be
significant.
 Read from favourite books, scriptures, poetry etc.
 Share music (recordings, singing, playing)
 Help the person to keep connections with things or activities that have held
meaning for him e.g. sunsets, art, particular TV shows or movies, the sea.
 Identify rites and rituals that may be helpful such as communion, sacraments,
prayer, blessings. Contact the appropriate person.
 Pray or meditate together if this is comfortable for the parties involved.
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Guidelines for Care of the Spirit

Be respectful of each person's particular beliefs, values, faith.

Stop. Look. Listen. Ask permission. Does the person want to share with you in
this area?

Use your senses to give you information about what is important to this person.
What books, music, religious symbols, photos are part of the environment?

Pay attention to family rituals and who initiates them. Is there prayer before
meals, meditation, prayer time, reading from holy books? Are all family members
involved actively or passively, are some members absent?

Check out your perceptions with the person who is ill. Ask permission to make
suggestions or to participate.

Use your good communication skills. Listen carefully. Be comfortable with
silence. Ask for clarification if you are receiving unclear messages.

You do not have to fix anything. Be with the person where they are on their life
journey. Be a companion who is not afraid or hurt by the feelings and the
struggle of another person. There may be strong feelings of aloneness, anger,
despair when these spiritual questions are being asked.
Refer issues of concern to your supervisor for help.
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Examples of Spiritual Interventions
Therapeutic

Compassionate presence
Communication

Reflective listening.
Techniques

Support patient’s sources of spiritual strength

Open-ended questions to illicit feelings

Inquiry about spiritual beliefs, values

Life review, listening to the patient’s story

Continued presence and follow-up

Guided visualization for “meaningless pain”

Progressive relaxation

Breathing practice or contemplation

Meaning-oriented therapy

Referral to spiritual care provider as indicated

Use of story telling

Dignity-conserving therapy

Massage

Reconciliation with self or others

Spiritual support groups

Mediation

Sacred / spiritual readings or rituals

Yoga, tai chi

Exercise

Art therapy (music, art, dance

Journaling
Other Therapy Practices
Self-care
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Spiritual Assessment
1. Is there a purpose to their life as they suffer?
2. Are they able to transcend their suffering and see something or someone
beyond that?
3. Are they at peace?
4. Are they hopeful or do they despair?
5. What nourishes that sense of value of themselves?
6. Do their beliefs help them cope with their anxiety about death,
with their pain,
and with achieving peace?
Five components of a successful spiritual assessment tool:
1. The spiritual assessment should encompass both religious and non-religious
beliefs.
2. The language of the assessment needs to address more than religious affiliation
or the presence of psychological problems.
3. Spiritual pain may not be separately identifiable from psychosocial pain until it
reaches a certain level of discomfort.
4. Caregivers need to recognize each patient has the capacity to heal spiritually.
5. The assessment process should focus on the premise that spirituality occurs
within our religious spiritual community
Enhanced spirituality increases our inner resources for dealing
with the challenges of life and daily living
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Spiritual-Cultural Assessment
Name of Patient/Client/Resident: ___________________________________
Faith Group/Religion/ Ethnic Background: ______________________________
Spiritual Contact:___________________________Phone #________________
Spiritual-Cultural History:
Do you have a faith practice or religion? _______________________________
How would you describe your culture?_________________________________
Do you have any rituals you wish to practice?___________________________
What spiritual practices gave you support in the past?_____________________
(Sometimes concrete examples need to be suggested: prayer, nature, reading,
pets, art, music, worship services, visits from family, clergy etc) _____________
________________________________________________________________
Who gives you support? ___________________________________________
Tell me about your family___________________________________________
Is there anyone else who should be involved in making decisions about your
care?___________________________________________________________
Goals of Care:
What is really important and meaningful to you right now?__________________
Is there anything the care team needs to know about health practices or
restrictions important in your culture/faith group?_________________________
What do you believe about your illness? _______________________________
Spiritual Distress:
Is there anything bothering you right now?______________________________
Is there anything you are afraid of?____________________________________
How are your loved ones coping right now?_____________________________
What would help?_________________________________________________
How can we include this in the hospital setting?__________________________
Are there any other concerns you would like to share with me?______________
Janet Stark 2011
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Long- Term Care Spiritual Assessment
Carol Brophy
Resident’s Name
Room
Date of
Follow-Up
Assessment
What is your source of Strength when you feel afraid or need special help?
What gives you Hope or on what hope do you build your life?
What would you let go of for a moment in order to feel really good and happy
right now?
What gives you the greatest sense of belonging?
What is significant in your life right now?
What inspires you to cope with change?
What was your faith background and can you share your beliefs?
Can you share with me about your relationship with your family and your
friends?
Discussion.
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Sources of Spiritual Support
Identify the sources from which you now receive spiritual support. Then check
the resources you would like to use in the future.
Activity
Now use
Would like to use
Worship services
Visit with clergy
Talk with friends
Prayer
Meditation
Music
Poetry
Scripture
Other books
Rosary
Sacraments
Other people
Other symbols
Other rituals
Place a plus sign next to the sources that are most important to you. Place a
minus sign next to those that are least important to you.
Look over your responses and write your observations, questions, and
comments about what you notice.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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Spiritual Assessment Examples
Diagnoses
Key Feature
Example Statements
Lack of meaning /
“My life is meaningless”
questions meaning
“I feel useless”
(Primary)
Existential
about one’s own
existence / Concern
about afterlife /
Questions the meaning
of suffering / Seeks
spiritual assistance.
Abandonment
Lack of love, loneliness /
“God has abandoned
by God or others
Not being remembered /
me”
No Sense of
“No one comes by
Relatedness
anymore”
Anger at God or
Displaces anger toward
“Why would God take
others
religious representatives
my child…it’s not fair”
/ Inability to Forgive
Concerns about
Closeness to God,
“I want to have a deeper
relationship with
deepening relationship
relationship with God”
Deity
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Conflicted or
Verbalizes inner
“I am not sure if God is
challenged
conflicts or questions
with me anymore”
belief systems
about beliefs or faith /
Conflicts between
religious beliefs and
recommended
treatments / Questions
moral or ethical
implications of
therapeutic regimen /
Express concerns with
life/death and/or belief
system
Despair/
Hopelessness about
“Life is being cut short”
Hopelessness
future health, life
“There is nothing left for
Despair as absolute
me to live for”
hopelessness, no hope
of for value in life
Grief/Loss
Grief is the feeling and
“I miss my loved one so
process associated with
much”
“I wish
a lossI could
of person,
run again”
health,
etc.
Guilt/Shame
Guilt is feeling that the
“I do not deserve to die
person has done
pain-free”
something wrong or evil.
Shame is a feeling that
the person is bad or evil.
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Reconciliation
Isolation
Need for forgiveness
“I need to be forgiven for
and/or reconciliation of
what I did”. “I would like
self or others
my wife to forgive me”
From religious
“Since moving to the
community or other
assisted living I am not
able to go to my church
anymore”
Religious
Ritual needs / Unable to
“I just can’t pray
Specific
practice in usual
anymore”
religious practices
Religious/
Loss of faith and/or
“What if all that I believe
Spiritual
meaning / Religious or
is not true?”
Struggle
spiritual beliefs and/or
community not helping
with coping
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Spiritual Distress
You walk into a patient’s room on 5th floor and find him lying on the bed in a fetal
position. Before you can ask him how he is today, he says to you,
“My God has abandoned me.”
You discover his body hurts all over, he is in pain.
What do you say or do?

Come close and take his hand

Say, “Tell me about that”

Say, Let’s talk to God”

Say “That must feel lonely”

Tell the story of “Footsteps”

Ask if he would like prayer
All may be good choices. Use the Spirit’s leading, and your personalities and
gifts and choose the ones that are right for you.
What would not be helpful:
“There must be a blessing in all this suffering”
“God allows suffering because of our sin”
“Be strong”
Speak to a nurse; describe what you see with no judgments: For example-“He is lying in a fetal position and reporting pain all over.”
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What is Spiritual Distress?

Spiritual distress is a disruption in one’s beliefs or value system. It affects a
person’s entire being. It shakes the basic beliefs of one’s life

What are the Signs and Symptoms of Spiritual Distress?

Questions the meaning of life

Afraid to fall asleep at night or other fears

Anger at God/higher power

Questions own belief system

Feels a sense of emptiness; loss of direction

Talks about feelings of being left by God/higher power

Seeking spiritual help

Questions the meaning of suffering

Pain and other physical symptoms can be expressions of spiritual distress as
well
What to Report to the Health Team

Any signs of behaviors listed above

Side effects of medications

Report any behaviors that are out of character for the patient at this time

Report any symptoms that are getting worse

Talking about suicide

Known history of spiritual distress

Not caring about self and life in general

Sudden rejection or neglect of previous practices or beliefs
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What can we do for a person experiencing spiritual suffering/distress?
1) Look for interventions to assist with spiritual healing
2) Communicate without judgement
3) Listen, Listen, Listen
4) Refer to pastoral care or another spiritual leader or group
5) Encourage reconciliation and forgiveness
6) Identify a spiritual support system (individual, group, place)
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What can be done for Spiritual Distress?
For Patients and Family

Do not feel that you are bothering the team by asking questions

Asking questions means that you care enough to ask the question

Look for ways to keep and honour desired rituals and ways of life

Remember not everyone has spiritual distress

Allow the person to be angry. Try to talk about that anger

Try listening to devotional tapes or music without words

Meditation can be helpful

Write poetry or work on an art project

Provide calm, relaxing setting

Be willing to be present without having to “do” something

Treat the patient with dignity and respect

As much as you can, enjoy this time together and look for ways to make
memories

Do not say “I know how you feel” because you do not. Instead, offer empathy for
the continual loss of familiar meaning and identity associated with the illness

Try not to “help,” rather provide support

Support any desire to maintain links with friends and family

Be willing to listen and reminisce

Be open to giving spiritual support if asked or contact person’s minister, rabbi,
priest, etc.
http://www.hpna.org/PatientEducation.asp
Approved by the HPNA Board of Directors October 2005
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Spiritual Abuse
What the pastoral care provider needs to know…
Chaplain Brenda Haggett MTS
What is spiritual abuse?
Spiritual abuse occurs when those in power use that power to control other
people for their personal gain. It is tantamount to bullying, and can leave victims
feeling disillusioned with the church, with clergy, and with God and often results
in people leaving their faith completely. Spiritual abuse is not limited to sexual
abuse; it can also include financial abuse.
Spiritual abuse is the misuse of a position of power, leadership or influence to
further the selfish interests of someone other than the individual who needs
help. Sometimes abuse arises out of a doctrinal position. At other times it occurs
because of legitimate personal needs of a leader that are being met by
illegitimate means. Spiritually abusive religious systems are sometimes
described as legalistic, mind controlling, religiously addictive and authoritarian
Spiritual abuse has many names: legalism, manipulation, and cult-like control.
The abuse however does not have to be dramatic to leave a mark; abuse,
however experienced, is always destructive and leaves its victims in a state of
spiritual distress and distrusting of those who legitimately come offering healing
in the name of God.
Spiritual abuse can cause significant emotional damage to the vulnerable,
especially to young children and those suffering from mental illness.
Cases of spiritual abuse occur in cults, communal communities that deny
individual rights and freedoms, abusive sexual relationships between clergy and
children (paedophilia), sexual relationships between therapist and client.
Common characteristics of abusive religious communities include an
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over-emphasis on authority, secretiveness about doctrine, fundamental
perfectionism, and suppression of criticism.
When a volunteer or other health-care provider suspects a client has endured
spiritual abuse, it is best to refer to chaplaincy and describe your observations.
When privy to a story of spiritual abuse, the volunteer should ask permission of
the client to share this with the chaplain. Often these concerns are best handled
by mental health practitioners and counselling. When one suspects abuse from
within the client’s own faith group, it is not recommended to consult with their
leader.
Some clients have been hurt by the church or by their past religious experiences
and carry a deep resentment to any expression of organized religion. The
church has helped many, but, historically, it has hurt many as well.
How to identify a potentially spiritually abusive leader
Spiritual abusers put themselves in positions over the vulnerable and often claim
to be God’s advocate with special spiritual authority to get favours from God for
a fee. Spiritually abusive leaders are driven by narcissism, self-will, and selfglorification. Without fail such leaders attempt to wear the façade of false
humility but always have a very well-polished charismatic exterior and possess
the ability to draw a crowd around them. They demand and command
unquestioning loyalty from those they lead and consider themselves
accountable to no human agency, only to God. Questions are not permitted, and
those who question the authority of the leader often find themselves being
disciplined harshly by the leader and may include being ostracized from the
community for not being a team-player. Often in a spiritually abusive
environment there will be rigid standards of behavior that attempt to control all
aspects of the members’ lives; finances, time, work, relationships, etc.
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The experience of spiritual abuse
The church should be a safe place for people, but sadly it is too often a place
where people’s beliefs in the sacred and holy are shattered beyond repair
leaving them in a place of spiritual desolation. According to Pargament, MurraySwank, and Mahoney (2008) when the individual’s deeply held beliefs and
values are damaged by spiritual abuse, it causes the person to become
spiritually disoriented. This occurs because “the sacred is an organizing force,
because people build relationships with the sacred, and the violation of the
sacred is an event that may shatter the individual’s world”. (Pargament, et al.,
2008, p.403). Sadly for those who experience spiritual abuse there is a negative
spiritual transformation that includes the loss of all they have known and
believed to be sacred and they are left feeling violated.
How to distinguish healthy leadership from potentially abusive leadership
Healthy Spiritual Leadership


Toxic Spiritual Leadership

Leadership recognizes, and is sensitive
to power issues
dismisses them due to narcissistic
Leadership accepts the individual due to
rewards through symbolic authority

their intrinsic human worth


detriment of the other facets of our
Leadership seeks to cooperatively
humanity


member within the same group
Leadership recognizes and
Spiritual needs are exploited to satisfy
the narcissistic needs of the leader
Leadership encourages a spirituality that
can be expressed uniquely by each

A spiritual lens takes priority to the
integration
address the spiritual needs

Acceptance by leadership dependent
upon performance
Leadership seeks to incorporate a
healthy bio/psycho/social/spiritual

Awareness of power issues, but
Spirituality is narrowly built around selfcentred perspective of the leader

Leadership has poor self-awareness
acknowledges their own personal flaws
and little to no self-evaluation; the group
and limitations
becomes an extension of the leader’s
narcissistic ego
Ward, D. L.(2011) The lived experience of spiritual abuse. Mental Health, Religion & Culture 14(9) 899-915
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A true story of spiritual abuse
“This guy had my soul in his hand. It was devastating to know that someone
would step out of the powers of spiritual liberty to take over someone else’s
soul…I still have anger about a lot of that and I think more of the anger is about
the spiritual loss than anything to do with the sexual abuse” (Fater & Mullaney,
2000 as cited by Pargament, 2008, p. 403).
What then can be done to help those who have been spiritually abused?
God has grace and mercy to heal the brokenness caused from living in a
fallen world however for those whose lives have been shattered by spiritual
abuse, it can be difficult to provide healing in the name of God for those who
hold the belief that God is to blame for their suffering.
For those who are willing to come alongside those who have been spiritually
abused, there is a great need for gentleness and patience; guiding them into the
truth of God’s loving character requires that they experience unconditional
positive regard – love in action! Trust that is violated is difficult to rebuild and
requires an authentically Biblical response.
Creating spiritual dialogue with those who have been spiritually abused
The first and foremost thing is to let the person tell their story in a way that
helps them know they have been genuinely heard. Tell me more…without
interruption or pat-answers is a good place to start. Spiritual abuse is referred to
by Pargament et al. (2011) as an “emotional landmine, a subject capable of
eliciting the full range of explosive affects [emotions], from shame and despair to
grief and anger” (p. 407).
The victim of spiritual abuse must be allowed time and permission to lament
their experience before they can ever begin the journey of healing which
involves forgiveness and letting it go.
Flaherty (1992, as cited by Pargament et al., 2011, p. 410) suggests that
victims of spiritual abuse need images of God that brings him close to their
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human experience. One suggestion offered is to think of God as one who suffers
with us, joins us in our weeping, sharing in our brokenness; finding a way to see
God as being one with us in the tragedy of our suffering. This is a stretch for
some caregivers but it is necessary for the one who needs God’s healing to
imagine afresh the humanity of Immanuel, God with us.
What not to do
Never claim to know how another person feels and never tell another person
how they should feel. Do not shut them down when they begin to express their
anger with God. God allowed the lamenting, imprecatory Psalms to be included
in His Word and they are there for a reason. A season of Lament was part of the
history of God’s chosen people and for those dealing with spiritual abuse they
need permission to lament.
Do not try to fix the situation by getting the person to pray or go to church as
this is likely to be met with extreme resistance. Empathize with them, be a safe
and confidential listening ear. Do not judge them or condemn them for being
angry with God.
Conclusion
There is solace for the soul that only our loving God can bring in His good
time but often he uses the human agency; therefore do not hesitate to refer the
person to a professional for help in dealing with the shame, grief, and trauma of
the abuse.
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Religious Addiction
Chaplain Janet Stark
Although it can be judgmental to label someone as a “religious addict”,
unhealthy beliefs and practices have been promoted by the more
“fundamentalist” religions. Ultra-conservative churches that take biblical
passages literally can lack the compassion and grace that a healthy spirituality
fosters. Lack of confidence and discernment can result in one becoming a
follower or “sheep”
Religious addicts ….

Have a poor sense of self and look to others for self-definition

May believe in the literal translation and interpretation of the scriptures.

May become compulsive in their religious practices

Believe that only they hold the “real truth” and have no tolerance for diversity
and personal choice.

Are discouraged from free individual thinking and opinions

Idolize their leaders, and follow them blindly, even when they make mistakes.

Conform to the social structures and customs of the group they are in.

Are at the extreme “religious fanatics” or members of a cult.

Believe that God will always work miracles if one’s faith is strong enough.
Spiritual Abuse is…..

Not allowing one to read and question whatever they wish!

Controlling who one can talk to or befriend; censoring certain relationships

Telling someone that their illness or pain is the result of sin or not praying
enough

Telling someone that they should stop taking their meds, stop seeing their Dr.
etc. because God will heal them if he wants/if they have enough faith etc.
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Healthy Faith….

Is compatible with maturity, and self-esteem

Is flexible and free

Grows and deepens—does not stay static

Can be challenged—it allows doubt, question, study, discussion

Is not compulsive or dogmatic

Is respectful of all

Allows one to cares for people of all faiths and those of no faith

Knows what one believes personally, but judges no one

Takes responsibility, allows mistakes, apologizes when necessary

Know that its’ leaders are fully human and fallible.

Is not black-and- white thinking

Values uniqueness and individual personalities
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Suffering: Compassion as Spiritual Practice
1. Learning Balance & Simplicity: Sit in stillness (Be, not Do) Live in the “Now”
Find the still point in the centre of the hurricane
2. Deepen Intimacy: Let your barriers down. Join in the suffering. More people
“burn out” from resistance to suffering
3. Foster Presence: Be anchored in yourself, what is our motivation for doing this
work? “Enlightenment” means noticing the light, but also the shadows
4. Open the Heart: Allow your heart to break. Open up to our clients, and also
open up to the spirit source of all love which is God. Our heart is a vehicle of
God’s love. We must love ourselves.
5. Encourage True Expression. Jesus encouraged a “dialogue with the beloved”.
We want to connect. Speak up against injustice. Take risks.
6. Develop “Mindfulness”. Witness consciousness by watching yourself. The mind
quiets, creates balance just by being. Detach from negative mental feelings.
7. Realize God in Everyone: The interconnectedness of all things. We can reach
peace, compassion and purpose. It isn’t all up to us. Pain and love can both be
present. We can be given courage and energy to prevent burnout.
Grace Ross RN MSc
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What is Palliative Care?
Palliate: means to provide comfort or relief for a distressing condition or symptoms.
Palliative care is the active, total care of persons whose disease is not responsive to
curative treatment.
When cure is no longer possible, care is. The goal of palliative care is achievement
of the best quality of life, as defined by the patient & family.
Palliative care is compatible with active treatment (acute care)
Who is the Palliative Patient?

Anyone with a life threatening illness.

Patients needing psychosocial support helping them to better deal with the
emotional and physical deterioration of the illness.

Palliative patients that need pain and symptom management involving a
multidisciplinary team approach. Care ought to be based on the symptoms and
needs, and not on how many days the person has to live.

Palliative individuals that would benefit from a Volunteer visitor or respite for the
family.
Principles of Palliative Care
Sanctity of Life
Quality of Life
Autonomy
Dignity
Myths of Palliative Care
•
There is a distinct dividing line when someone becomes palliative
•
Palliative care is a “hand-holding” service
•
Palliative care focusses just on pain control
•
Palliative care is the “death service”
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(older model of care)
(model of care)
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Topics for Reflection
1. What experiences have you had with a palliative patient?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
2. What do you hope to learn more about to better work with palliative patients?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
1. List three things you would need or want if you knew you had only one year to
live?
2. What is the one thing about your death you are most afraid of?
3. What are two things you would want to do before you die?
4. What do you want people to remember about you after you die?
Twenty-Four Hours to Live
You have just been told you have only 24 hours to live.
1. List the feelings you may have:_____________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
2. List what you would want to do before death.
________________________________________________________________
________________________________________________________________
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Janet Stark
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Do you Accept Death?
Paul Wong, clinical psychologist
“I believe the best way to die well is to live well, and the best preparation for
death acceptance is to live a fully meaningful and productive life. We need to
answer these 10 questions:”
1. If I were to die next month, how would I live differently?
2. I don’t want to take anger and resentment to my grave. How can I forgive those
who have hurt me?
3. What do I need to reconcile with my loved ones, so that I will have no regrets at
the end of my life?
4. What unfinished business do I need to take care of before I go?
5. What are the most important life lessons that I have learned, and how will I pass
them on to others?
6. Have I taken stock of my life and counted all my blessings from God?
7. How will I express gratitude to all those who have been most helpful and kind to
me before it is too late?
8. What should I do with my life before death comes knocking? What is my calling?
9. What would be the best legacy I can leave behind? What will my children or
family think of me?
10. What have I done to help others and glorify God?
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Frommelts’ Attitudes Toward Care Of The Dying Scale.
Please complete the following questionnaire according to your attitudes at
this time. Be honest with yourself. This is not a test. It is confidential. In these
items the purpose is to learn how caregivers feel about certain situations in which
they are involved with patients. All statements concern the giving of care to the
dying person and/or, his/her family. Where there is reference to a dying patient,
assume it to refer to a person who is considered to be terminally ill and to have
six months or less to live. For the purpose of this questionnaire the term
“caregiver” means professionals and paraprofessionals.
1. Giving care to the dying person is a worthwhile learning experience.
2. Death is not the worst thing that can happen to a person.
3. I would be uncomfortable talking about impending death with the dying
person.
4. Care for the patient's family should continue throughout the period of grief
and bereavement.
5. I would not want to be assigned to care for a dying person.
6. The caregiver should not be the one to talk about death with the dying
person.
7. The length of time required to give care to a dying person would frustrate
me.
8. I would be upset when the dying person I was caring for gave up hope of
getting better.
9. It is difficult to form a close relationship with the family of a dying person.
10. There are times when death is welcomed by the dying person.
11. When a patient asks, “Am I dying?” I think it is best to change the subject
to something cheerful.
12. The family should be involved in the physical care of the dying person.
13. I would hope the person I'm caring for dies when I am not present.
14. I am afraid to become friends with a dying person.
15. I would feel like running away when the person actually died.
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16. Families need emotional support to accept the behavior changes of the
dying person.
17. As a patient nears death, the caregiver should withdraw from his/her
involvement with the patient.
18. Families should be concerned about helping their dying member make the
best of his/her remaining life
19. The dying person should not be allowed to make decisions about his/her
physical care.
20. Families should maintain as normal an environment as possible for their
dying member.
21. It is beneficial for the dying person to verbalize his/her feelings.
22. Care should extend to the family of the dying person.
23. Caregivers should permit dying persons to have flexible schedules.
24. The dying person and his/her family should be the in-charge decision
makers.
25. Addiction to pain relieving medication should not be a nursing concern
when dealing with a dying person.
26. I would be uncomfortable if I entered the room of a terminally ill person
and found him/her crying.
27. Dying persons should be given honest answers about their condition.
28. Educating families about death and dying is not a caregivers’
responsibility.
29. Family members who stay close to a dying person often interfere with the
professionals or paraprofessionals job with the patient.
30. It is possible for caregivers to help patients prepare for death.
1988, Katherine H. Murray Frommelt
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Perspectives on Dying
A Personal Questionnaire
1. My first personal involvement with dying was with
a.
c.
e.
g.
grand-parent
brother or sister
friend
public figure
b. parent
d. other family member
f. stranger
h. pet
2. When I was young, the subject of dying was talked about in my family
a.
c.
d.
e.
openly
b. with some sense of discomfort
only when necessary and then with an attempt to exclude me
as though it were a taboo subject
don’t recall
3. My childhood concept of what happens after death is best described as
a.
c.
e.
g.
heaven-and-hell
a sleep
mysterious and unknowable
no concept
b. after-life
d. cessation of all activity
f. something other
h. can’t remember
4. Today, my concept of what happens after death is
a.
c.
e.
g
heaven-and-hell
a sleep
mysterious and unknowable
no concept
b. after-life
d. cessation of all activity
f. something other
5. My present attitude toward dying has been most influenced by
a.
c.
e.
g.
death of someone close
religious upbringing
ritual (e.g. Funerals)
longevity in my family
b. specific reading
d. introspection and meditation
f. TV, radio, movies
h. my health or physical condition
6. The role that religion has played in the development of my attitudes about dying
a. very important
c. somewhat, but not major
f. nothing at all
b. rather important
d. relatively minor
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7. I think about dying
a. very frequently (at least once a day)
c. occasionally
e. never
b. frequently
d. rarely (no more than once a
year)
8. To me, death means
a.
b.
c.
d.
e.
the end, the final process of life
the beginning of a life after death
a joining of the spirit with a universal cosmic consciousness
a kind of endless sleep; rest and peace
a termination of this life but survival of the spirit
9. To me, the most disagreeable aspect of my death would be I’d
a.
b.
c.
d.
e.
f.
g.
no longer be able to have experiences
be afraid of what might happen to my body
be uncertain of what might happen to me if there is a life after death
no longer be able to provide for my family
cause grief to my relatives and friends
not be able to complete all my plans and projects
die painfully
10. I feel that most deaths
a. results directly from the conscious efforts of the persons who die.
b. has a strong component of conscious or unconscious participation by the
persons who die (in their habits, use or abuse of drugs, alcohol, cigarettes,
medications etc.)
c. is not discernible; they are caused by events beyond our control
11. I believe that psychological factors can influence or even cause a person to
begin dying
a. firmly
c. do and don’t
b. tend to
d. don’t
12. When I think of dying or when circumstances make me aware of my own mortality,
I feel
a. fearful
c. depressed
e. resolved
b. discouraged
d. purposeless
f. pleasure in being alive
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13. I feel that the degree of effort that should be made to keep a fatally ill person
alive is
a. all possible effort
b. efforts that are reasonable for the person’s age, physical condition, mental
condition and pain
c. after reasonable care has been given, a person ought to be permitted to die a
natural death
d. a person should not be kept alive by elaborate artificial means
14. If my physician knew I had a terminal disease, I ______ want him to tell me
a. would
b. would not
15. If I had a terminal illness, I _______ want to talk to someone about dying
a. would
b. would not
16. I would most want to talk to __________about my dying
a. spouse
c. relative
e. physician
b. immediate family member
d. clergy
f. nurse
17. I probably would feel ________about talking with someone about my dying
a. embarrassed
c. willing
b. distressed
d. at ease
18. If someone close to me had a terminal illness, I would want that person told
a. would
b. would not
19. If someone close to me knew that he had a terminal illness and wanted to talk to
me about his dying, I would feel
a. embarrassed
c. willing
b. distressed
d. at ease
20. When I think of dying, I mostly fear
a. a long term illness
b. a painful death
c. that I’ll be mentally disoriented
d. physical disability
e. what lies after death
f.having others take care of my personal needs
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21. The sight of a dead body is
a. horrifying to me
c. neutral
b. natural
d. unsettling
22. When notified of a funeral, I
a. usually decline gracefully
c. am happy to attend
b. attend, if at all possible
d. dread it but usually go
23. The fatal illness that I am mostly afraid of getting is
a. heart disease
c. kidney failure
b. cancer
d. other
24. So far in my life, I feel
a. satisfied
b. fortunate
c. wish I could start over
d. I’ve worked too hard
e. I’ve wasted too much time
f. I’ve been cheated out of lots of good things
g. I’ve made some bad decisions, but basically been happy
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Spiritual Care Compliments Palliative Care
Spiritual Care
Palliative Care
A sense of presence by compassionate
Active involvement in the care of
caring
palliative patients and families.
Promotes spiritual and emotional healing,
Compassionate care based on
prayer, worship, visitation and
clinical skills and expertise.
sacramental ministry.
Ecumenical service provision
A specialized service directed
toward sustaining the quality of
life for the dying.
Provides comfort, counseling
Focused on providing for
and team support to all resident/patients/
symptom relief
clients, their families and staff that care
for them.
Respectful of the sacredness and dignity
of human life
.
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Life affirmation.
Canadian hospice Palliative Care Association 2002
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The Spiritual Nature of Death and Loss
Since ancient times there has always been a select group of people who help
members of the community deal with spiritual matters. Whether shamans, ministers,
rabbis or priests, these individuals help to interpret, support and care for the
members of the community. Religious faith and spirituality can help to sustain
people through life and death crises in many ways. Religion is one way to explain
the experience of spirituality. Spirituality does not need a religious community.
Spirituality is an important aspect in the lives of many non-church people.
Religious faith and spirituality helps control fears and anxieties by revealing not only
the tragedy and sorrow of life but also the blessings and rich experiences.
Faith and spirituality helps people to turn their best thoughts and feelings into
constructive action. It allows us to transform the tragic events of life through the
power of hope and the power of love.
Religious faith and spirituality leads people to a deeper sensitivity of spirit, higher
aspirations of service. Although grief is painful, it does not lead to despair.
Some religions contain a belief in immortality, or life after death, or a further life
experience. These beliefs may relieve some of the guilt that would be present if it
were thought that at no point in time or eternity could wrongs be righted or injustices
rectified.
Religious faith and spirituality gives courage to the present and direction for the
future. Through community religious rituals, it provides evidence of group strength
and comfort, recognizes the dignity of life and the validity of feelings prompted by
facing death.
The spiritual dimension is crucial in the lives of many people, yet it is most often not
addressed. Often, spiritual care is ignored or placed on the outside edge of the
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health care system. Often, the only member of the care team that is missing is the
spiritual caregiver.
Although we probe into all aspects of a person's life, we may disregard the religious
beliefs, values and experiences. Moreover, the absence of a connection to a
religious community does not mean the absence of concern and caring for spiritual
matters. Only about 25% of Canadians identify themselves as belonging to a
religious community, but 60% of Canadians describe themselves as being religious.
Many health care workers including chaplains are unfamiliar with multicultural needs
and requirements. One such area of life that is often overlooked is the spiritual
needs and requirements of peoples of differing faiths. Indeed, there is a false
assumption that all persons who adhere to a particular faith all have the same
beliefs and the same religious rituals.
Within the palliative care movement, spiritual concerns are of great importance, no
matter the country of origin or religion of the people involved. In communities and
institutions were there are people of differing religious and/or ethnic backgrounds,
the members of the palliative care team should make the effort to be aware of these
differences. In each religion there are groups with different emphases or differing
sects or denominations, just as found within the Christian religion. It is not important
that you be able to identify all these differences. With a sense of caring, you can
identify and respect the particular preferences of the person who is dying and the
family.
It cannot be over-emphasized that people from other backgrounds have practices
and beliefs which differ from Western Christianity, also it must be understood that
religious traditions are part of culture. The practices of the Asian Christian may be
very different from the practices of the Greek or Dutch or Aboriginal Christian. There
are cultural distinctions as well as specifically religious variations to living. Thus, the
practices of a Vietnamese Christian will differ from those of a Vietnamese Buddhist.
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Further, there are practices that c Roman Catholic will desire that a United Church
person will not want.
When it comes to practices surrounding illness, dying and death, there are certain
areas that need to be considered by the palliative care team. These involve diet,
fasting, names, symbols, care and touching of the dying person, handling the body
after death, grief and bereavement practices.
Integration to Canadian dominant cultural practices will vary depending on the
individual, the family and size of the cultural community, and how long the person(s)
have lived in Canada. You cannot assume anything. Ask.
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Four Tasks for a Person who is Dying
1. The need to find meaning in life, review:

What was this life all about?

What did I learn in my life? .

What did I do with it?

What did I give to others and what did I receive from others?

Did I live according to my beliefs and priorities?

What are my priorities now?
2. The need to heal relationships, to deal with unfinished business, make a deep
connection and let go.

Acknowledging difficulties, joy, love, resentment, anger, good and bad, aiming for
forgiveness and acceptance

Learning forgiveness and compassion for self and others

Working through and sharing grief

Reaching and sharing joy

Opening up to the present

Living in the moment

Settling practical affairs

Making a will
3. The need to understand the meaning of suffering and have a means to
transcend the unavoidable suffering of dying.
Understanding that a lot of the pain experienced is psychological in origin.

What are you learning from this crisis? Can you see anything positive in this?

Has this crisis become an opportunity for you?
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
Have you through this experience been able to make a deeper connection to life?

Do you have a means to alleviate anxiety?

Do you use meditation/ prayer/ relaxation exercises/ inspirational readings/ music to
help you in this process of letting go, of your body, of your life as it had been?
4. The need to understand what death is and to prepare for it in the best way
possible.

What do you believe death is?

What do you believe happens at death?

Do you have a spiritual belief and what is it?

How can l or others help and support you in this?

Prepare for death and let go?
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The Dying Person's Bill of Rights and Responsibilities
I. You have the right to considerate, respectful service and care, with full recognition of your
personal dignity and individuality, without regard to gender, age, ethnicity, income level,
lifestyle, educational background, or spiritual philosophy.
2. You have the right to be dressed as you wish and not to be disrobed or uncovered any
longer than necessary for your care.
3. You have the right to privacy and the assurance of confidentiality when receiving care, to
refuse visitors or persons not directly involved in your care, and to choose who will receive
information about your condition.
4. You have the right to request the presence of a person of your choice during interactions
with health care professionals.
5. You have the right to experience all emotions, including anger, sadness, confusion, guilt,
depression, impatience, fear, and loss.
6. You have the right to have your end-of-life choices respected by health care
professionals, including continuing or discontinuing treatment.
7. You have the right to die with your loved ones present and to request the presence of a
health care professional, if desired.
8. You have the responsibility to treat your caregivers with respect and to follow their
directions when consistent with your wishes.
9. You have the right to honest, accurate, and understandable information about your
current diagnosis and prognosis; the recommended treatment and what it is expected to do;
the probability of success; and the possible risks of complications and side effects,
including the probability of their occurrence.
10. You have the right to be informed about alternative forms of treatment, including
Hospice and home care, and to participate in all decisions affecting your care.
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11. You have the right to request and receive a second opinion. When curative care is no
longer indicated or desired, you have the right to access palliative care, including pain
medication in whatever dosage or schedule the palliative care team deems necessary.
12. You have the right to make your own decisions regarding what constitutes your human
dignity, as long as you are mentally competent and continue to have basic decision-making
capacity. You will be considered mentally competent if you can understand the nature of
your condition, the treatment alternatives available, the likely outcomes of treatment versus
non-treatment, and can accept responsibility for your decisions.
13. You have the right to access information in your medical record and to know if your
health care providers believe that your condition or course of disease will result in death.
This information may be needed to make informed decisions about your future.
14. You have the right to forgo eating and drinking naturally in order to permit the process
of dying to proceed unencumbered.
15. You have the right and responsibility to complete an Advance Directive to Physicians
(Living Will) and to execute a Power of Attorney for Health Care so that someone you
choose can make health care decisions for you, if needed.
16. You have the right to competent medical, nursing, and social services care.
17. You have the right to know who is responsible for coordinating and supervising your
care and to know how to contact that person.
18. You have the right to be informed about who owns and controls the agency or facility
involved with your care and the right to referral to institutions, facilities, or practitioners who
can provide the care you need.
19. You have the responsibility to choose a primary care physician who is able and willing
to carry out your wishes.
20. You have the responsibility to communicate your end-of-life wishes to family, friends,
and health care providers.
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Techniques to Help Patients and Families Deal with Palliative Illness

Let patient/family share in decision-making; all mentally competent people have this
right.

Give information to patient/family about cancer and the dying process. It reduces
uncertainty which can fester into anxiety and fear.

Let family help with physical care, if they so wish.

Help families to see this as a time for maximizing life rather than focusing solely on
death (intimacy, sharing, support).

Remember & respect individuality of each family member. Don't assume or jump to
conclusions when it comes to understanding families!

Be available when patient/family need you; concerns, feelings, and fears aren't on
schedule.

Be accepting of patient's changing body. Patient and family will watch you for cues
as to how to deal with bodily functions, disfigurement, etc. e.g. eye contact -physical
touch -humour .

Remember to return to patient, especially when you've promised. Patients
(especially elderly patients) fear being left alone.

Do life reviews with patient. Their past is what gives them feelings of self-worth and
meaning.

Don't be afraid to try out a new idea. As long as your basic premise is that of caring,
follow your intuition and never be afraid to backtrack, apologize and start over if it is
not received well.
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Palliative Caregivers Must Remember….

that no two families are alike; some are loosely organized while others are "tightly
knit"

that many families have long histories of troubled relationships

to avoid "taking sides" in a family situation

to try to foster communication and understanding among family members

remain non-judgemental

resist imposing personal standards and values

respect cultural and religious differences

to be aware that feelings of anger, grief or depression are unique
to the individual and manifest differently

establish boundaries early (i.e., what are you willing/not willing to do?)

report any suspected abuse immediately to supervisor
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The Meaning of Spiritual Caregiving at end of life

Dying is spiritual work. It is the spiritual part of us that responds to the physical and
emotional happenings in our bodies. Spiritually, we experience losses, separation,
suffering, pain, isolation, loneliness, depression. Spiritually, we see, relate to and
live every aspect of created life.

When listening to and dialoguing with patients or residents and families, it is
important to recognize the difference between expressions of what is spiritual for
them and what is of religious importance. Spirituality and religious faith may be very
separate things or they may overlap in a person's life.

Spiritual support can range from writing a letter (very personal and intimate time), to
playing some special music, or reading from a favourite book or scripture. Sharing
time looking at the sky, the clouds, the sun, or just being outdoors can be a spiritual
experience.

Listening to the story of the dying person will often help them define their own
spirituality and what they need at this time. Every time we listen to another person's
experience or life story, we are involved in "spiritual caregiving."
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Communicating with those that are Dying and their Families
The central principle of good communication with people who are dying, with their
family members and friends and with other caregivers is to act in the best interest of
the person who is dying as defined by that person.
Some people choose not to co-operate or communicate; therefore you cannot help
everyone to die in the way you think is best. It is difficult for some families and
friends to give the person choices, hoping that the person will make the “right”
choice, and then watching the person suffer needlessly. However some people will
choose not to have pain medication because they want to die without the aid of
artificial drugs. Some people will choose not to resolve family problems even
though the family is ready to talk openly about the past.
The most that you can expect from yourselves is to provide people with an
opportunity to talk, an opportunity to make decisions and the constant opportunity to
change their minds. You can assist patients and families to improve communication
skills by your example and by specific skills you pass along to them. The person
and their family are the people most affected when communication is done very well
or very poorly.
Some thoughts to consider when you are communicating: Who are you
communicating for? Does the person want to communicate with you? Is it all right if
someone chooses not to talk? If you can answer these questions and accept that
people will not always do what we think is best for them, then you will have the kind
of communication attitude that encourages people to speak openly and honestly
with you.
When you communicate, keep the following goals in mind. Try:
1) to reduce uncertainty,
2) to help the person act for themselves
3) to improve relationships,
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4) to be truthful,
5) do not give people too much information at once.
Remember that the person and their families are often intimidated by "authority
figures" and overwhelmed by well-intentioned people.
When you achieve your communication goals you can expect some of the following
results for both you and the person you are communicating with:

less time spent communicating because you are a more effective communicator,

better comprehension

less stress

mutual support

less fear and anxiety

more control

improved symptom-pain management for the person who is dying.
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Christian Spiritual Care of the Dying
A. Jesus Christ as a model for suffering
 He experienced loss and grief: He wept at the death of Lazarus
(John 11: 33-36)
 He was afraid and lonely: Garden of Gethsemane
 He suffered physically, experienced pain and suffering: his crucifixion
B. A “good death” or peaceful death may include attitudes of:
acceptance
joyful spirit
surrender
contentment
comforted by God trust in God
a clear conscience
reconciliation
hope
peace
insight
appreciation
thankfulness
courage
certainty
C. Forms in which death manifests itself:
a. Physical Death: separation of spirit and body
Inevitable, definite, beyond our control
b. Clinical or reversible death: cessation of heart and lung activity
Possibility of resuscitation with human intervention (CPR)
c. Legal, biological or irreversible death
Tissue death, flat EKG, EEG
Would require divine intervention (miracle) to bring back from death (Lazarus)
d. Spiritual Death: Separation/alienation from God
For unbelievers, a permanent condition
D. Eternal Life: (Heaven) Each human being will live on in eternity,
either in heaven or in hell (Matthew 25:46) Eternal life vs. eternal punishment (John
17:3, Romans 6:23, John 5:24, 1 John 1:1-3, Romans 14:17)
Paradise Revelation 21:1-22:5 For believers in Christ (saved)
Hell: a place where a dead unbeliever will be separated from his Maker for eternity,
a place without a second chance.
E. Needs of the Dying Person
To find help and comfort when dealing with:
Loss and Grief
Loneliness Fear Guilt Stress
Pain
Loss of: physical comfort, mobility, dignity, self-control, physical strength, mental
capacity, financial security, social status, possessions, identity, relationships, future,
Grief: (mourning) for self, for the past, loss of hopes. Mourning is repeated with
each new loss. Value systems change, and focus may leave temporal things as
vanity
Loneliness: Isolation, due to nature of illness. May be in hospital, away from things
familiar
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Fear: Insecure about the nature of the illness, fear of what is to come, fear of
suffering, fear for the future of the family, fear of being helpless, loss of control
Guilt: past lifestyle, broken relationships, mistakes, unmet promises
both real (a conviction of wrongdoing) and false guilt (someone else’s expectations)
Stress: confusion, frustration and struggle, may result in reactions:
Denial
anger
rebellion
criticism
sadness
Depression
despair
fear
guilt
disappointment
distrust
bitterness
doubt
Pain: with the help of proper assessment and medication 95% of patients can be
reasonably pain-free.
Christian Principles of Preparing for Death
a.
b.
c.
d.
e.
total surrender as to where and when and how the Lord works
Live as a disciple of Jesus Christ: bear much fruit to God’s glory (John 15:8)
Die unto self (Galations 2:20)
Be filled with the Holy Spirit (Ephesians 5:18)
Be filled with the Word of God (Colossians 3:16)
Answers to Spiritual Needs
a.
b.
c.
d.
e.
victory for the battle over death
eternal life
forgiveness and reconciliation
trust in God
assistance in saying Good-bye
F. The Practice of Care for the Dying
a.
b.
c.
d.
e.
f.
g.
h.
i.
Agapé love
Mercy
Build a trust relationship
Attentive listening
Eye contact
Wise words
Comforting touch
Prayer
Serving Feet
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Spiritual Needs at End of Life
“When Cure is not possible, Care is….”
Tips & Tools for teaching & ruling elders, and spiritual care teams
Spiritual Distressors
Losses
Fear
Guilt
Pain
Loneliness
A “Good” Death
When one:
-is at peace
-is ready to “go home”
-is finished preparations
-has no regrets
-has a “healed” spirit
Our Spiritual Nature
Social
Emotional
Physical Intellectual
Our Holistic Self
The 5 Tasks:
Spiritual Wonders
To say to loved ones:
I Love You
I forgive you
Do you forgive me?
Thank You
Good-bye
Mini-Miracles
Apparitions & Signs
Near Death Awareness
Near Death Experiences
Giving permission to
“let go”
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Spiritual Reminiscence
Do NOT say...
Encourage story-telling
Let them know they will be
remembered
Remind them of their value
Affirm legacy
You have to “hold up”
“Be strong”
“It’s all in God’s will”
“There must be a blessing
in all this” (suffering)
Helpful
Practices
Listen!
Listen, Respect
Listen, Respond
Listen, Share
Listen, Encourage
Listen, Refer
Gifts of Self
Show Up!
Agapé Love
Mercy & Grace
Develop Trust
Eye Contact
Sincere Words
Gentle Touch
Simple Prayer
Serving Feet
“Be” rather than Do”
Life After Death
Explore their
beliefs
How do they frame
it?
Heaven?
Paradise?
Eternal Life?
Everlasting Life?
Do they welcome
going to this
place? Are they
afraid?
Helpful Tools
Prayer
Readings
Music
Nature
Ritual
One can die healed
We do not have to walk alone
Good-Bye: “God-be-wi’-ye”
Janet Stark 2009
South East Ontario Palliative Care Education Coordinator
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Beauty at the End of Life
by Geoffrey P. Johnston
Friday, February 28, 2014 The Kingston Whig-Standard
Geoffrey Johnston’s mother recently passed away and demonstrated great courage
in the face of death, enjoyed the love and support of loved ones, and was comforted by her
faith.
Philosophers have long posed the question: If a loving God exists, why does he
permit good people to suffer? “This is the problem of pain in its simplest form,” writes British
novelist C.S. Lewis in his 1940 treatise The Problem of Pain. Lewis, author of The
Chronicles of Narnia and one of the most influential Christian thinkers of the 20th century,
argues that pain is a necessary part of life.
“That God can and does on occasions, modify the behaviour of matter and produce what
we call miracles, is part of Christian faith,” he writes. “But the very conception of a common,
and therefore stable world, demands that these occasions should be extremely rare.”
We are born, feel pleasure and pain, and inevitably die, and it’s our mortality that
defines us and makes life precious. “Try to exclude the possibility of suffering which the
order of nature and the existence of free wills involve, and you find that you have excluded
life itself,” Lewis concludes.
Nobody wants to suffer. After all, says Lewis, “pain hurts.” And the anticipation of
suffering and death can sometimes be even more intolerable than actually experiencing
physical pain.
Like Archbishop Desmond Tutu, my mother drew strength from the Christian faith.
During her final illness, she and I would discuss Bible scripture. “And remember, I am with
you always, to the end of the age,” I would say, quoting Mathew 28:20. That simple
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passage, a promise made by Jesus Christ to his followers, comforted my mother before my
father died of cancer in 2012, and throughout her own battle with the disease.
Why do good people suffer? Why did my mother — who selflessly served her
church, family and community — suffer from a crippling autoimmune disease and then get
cancer?
Lewis’s views on suffering may infuriate some folks. He argues that it is through
suffering that God imposes divine humility on people, so that they may “discover their need
of God.” He goes on to say that the “illusion of self-sufficiency may be at its strongest in
some very honest, kindly, and temperate people, and on such people, therefore, misfortune
must fall.”
Pope Francis has said that “suffering is not a virtue in and of itself, but it can be
virtuous, depending upon the way in which we deal with it.” Similarly, Thomas Aquinas
declared that mere suffering is not good; however, he maintained that something good
could come of suffering in certain circumstances.
Beauty at the end of life
However, in the apparent rush to avoid the suffering of a terminally ill person, society risks
missing the many opportunities to experience and embrace love, compassion and
forgiveness at the end of life. “I have seen great beauty of spirit in some who were great
sufferers,” Lewis writes. “And I have seen the last illness produce treasures of fortitude and
meekness from most unpromising subjects.”
Dying is hard, and cancer is cruel. Throughout Mum’s final illness, my siblings and I cared
for her, ensuring that she could live out her final months in the house that we grew up in.
While living at home, she felt safe and secure. She received palliative care services there,
including house calls from nurses and a palliative care physician.
In the middle of the night just after Thanksgiving of 2013, Mum suffered a terrible
fall. I was at her side within seconds, but the damage was done. Her hip and leg were badly
broken; she had to undergo orthopedic surgery to relieve excruciating pain. At the same
time, her cancer was accelerating.
As soon as she was stable, we decided it was time for Mum to be transferred to the
palliative care unit at the Brockville General Hospital, where she would receive excellent
compassionate care in a home-like setting. Her single room was a pleasant change from
the sterile surgical ward. The walls were painted royal blue, and the room had a wooden
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cabinet with shelves for family photographs, flowers and a flat screen television. And for
visitors, there was a large, comfy recliner.
When I first stepped into my mother’s room in the palliative care unit, I felt a wave of
sadness and panic sweep over me; I knew that she would never go home again. But I
realized that Mum would require a great deal of care in the coming weeks, and that she
needed me to be strong. So, I pushed my feelings aside, summoning what little courage I
possessed and pretended to be calm and confident.
To be honest, the weeks that followed remain a blur to this day. My siblings and I
made sure that Mum was almost never alone. I would arrive in the morning, take her hand,
smile and say, “I’m glad to see you.” No matter how much pain she was in, she would
return my smile and reply, “glad to see you, too.”
When Mum and I were alone, I would sometimes read the Bible to her. And
sometimes she would ask me to lead her in prayer. At night, we would watch hockey games
on television. (Mum especially enjoyed watching Don Cherry on Hockey Night in Canada.)
One morning, Mum and I were alone together, sitting quietly. Perhaps sensing that
my calm exterior was just a I, she broke the silence. “When I finally slip away, I don’t want
you to be sad. I’ve had a good life.” I was speechless. Here was my mother facing imminent
death, and she was more worried about me, trying to ease my emotional pain.
The nurses on the palliative care unit made sure that Mum received regular doses of
pain medication, fluids, ice cream, and always took the time to chat with her. They always
treated her with compassion and great respect, and I will always be grateful to them.
Facing the end
Late one night, Mary, a tall and extremely-efficient nurse, entered the dimly lit room.
I stood back, allowing her to do her job. It had not been a good day; fluid had started to
build up in Mum’s legs and she was coughing. “I hope the doctor can do something,” I said,
my courage evaporating. Mary turned and gave me a sympathetic smile. We both knew that
time was growing short.
The day before Mum died, she was unresponsive and appeared to be unconscious. No one
thought that she would ever regain consciousness. Late in the day, I spoke gently to her,
telling her to squeeze my hand if she could hear me. And to my surprise, she did.
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An hour later, she opened her eyes to see her granddaughters standing at her
bedside. They had come home from university to say goodbye. They sang her a song that
she had sung to them in childhood, and Mum even hummed along!
That night, her pain was terrible. My older brother and I stood vigil until the
breakthrough pain medication finally got the pain under control about 2 a.m.. I spent the
rest of the night in the comfy recliner next to her bed as she slept.
Family members were with Mum throughout Saturday. Around the dinner hour, the others
went for supper while I stayed with Mum, who again appeared to be unconscious; her
breathing was laboured. I washed her hands, face and neck, and told her that she wasn’t
alone.
For the next 40 minutes, I sat beside Mum, reading the newspaper and listening to
her deteriorating breathing. As 7 p.m. approached, her breathing suddenly changed, she
gulped for air. Then she stopped breathing for a few seconds and then started again. I
sprang to her side, pressed the nurse call button, and took Mum’s hand.
Mary responded quickly, and I told her to call my older brother. But I knew the end
was at hand. I continued to hold Mum’s hand with my right while putting my left on her
shoulder. I repeated that she wasn’t alone and told her that I loved her. The other nurses
and nursing assistants on the unit came into the room, so that I wouldn’t have to experience
my mother’s passing alone.
I continued to speak quietly to Mum, tears rolling down my cheeks. Mary put her
hand on my forearm. Even after Mum had taken her final breath, I continued to talk to her,
just in case she could somehow still hear me.
Mum died with dignity. She demonstrated great courage in the face of death,
enjoyed the love and support of loved ones, and was comforted by her faith. Except for a
miraculous cure, we couldn’t have asked for more.
Given that suffering is inevitable, how can we endure it? Lewis perhaps said it best:
“When pain is to be borne, a little courage helps more than much knowledge, a little human
sympathy more than much courage, and the least tincture of the love of God more than all.”
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Coming Home
Dad was dying. He was a retired farmer from Southern Ontario and he was
dying of lung disease. One spring day we got the call. It was my Mom, asking us to
come to Hamilton to the hospital. Dad had gone on oxygen a few days before, at
home, and now his condition was worsening. At one point his heart had stopped,
and with a flurry of activity, he was revived. At the time, the doctor didn’t know he
had a hand-written advanced directive with a do not resuscitate order.
In
retrospect, my Mom said it was just as well, as giving him a few more days of life
allowed us to say our good-byes. All five children made it home, and at one time all
of us were in the hospital room with Dad. We’re spread out now, and it’s not often
we are all together. Dad knew he was dying. I had written him a poem, thanking
him for all of the things he taught me over the years.
To Dad
Dad—over the years you taught me many things—
To play euchre, checkers and crokinole
To dance, and enjoy fiddle music
To make homemade ice cream
To like black licorice and humbugs
How to braid bindertwine for a calf rope
To swing on a rope in the barn
How to write a speech about Wilf Carter
To sing to the cows: “Mares Eat Oats”, “Little Brown Jug”,
“Turkey in the Straw” and “Cheer Boys Cheer”
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To enjoy a country picnic
How to feed a dog from the table
A strong work ethic; (I picked stones)
To take interest in my family history
To take pride in the love of the land
For all these things I am grateful—
I love you Dad,
Janet
My Dad was not an emotionally-expressive man, but as I read him the poem
that night, he squeezed my hand so hard. Without words, I knew he loved me, and
he had given me the blessing. He said “thank you” and it was more than enough.
One afternoon, we all went down to get a snack and give Dad some quiet time.
When we returned, his minister was there. The minister had my poem in his hand.
They must have been chatting about us kids, because I heard my Dad say “I guess
we didn’t do too bad, because all my kids came home to see me”. The minister was
doing what we call in palliative care: giving meaning and purpose by a life review.
Over the next few days, there was lots of family going in and out of that room, and
at one point we thought he had rallied and was improving.
When the doctors
discussed palliative care with my parents, it was then Dad said he wanted to go
home. The weekend was coming, and it was going to be hard to arrange his
discharge with home nursing care. It was month end as well, and the doctors were
on monthly rotation. He was getting a new doctor. We promised him we would get
him home. He held on, weak with very laboured breathing, and not able to eat
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much.
Late Tuesday afternoon, the ambulance brought him home.
As the
attendants carried the stretcher into the old stone home, he had them stop and he
took a long last look at his farm. He looked at the fields and the rolling hills, the
barn and the home where he had brought my Mom as a new bride fifty-five years
before. Again he said “thank you”. They put him into the hospital bed, which had
been prepared in the living room. Then it quieted down. My Mom was with him,
and also my sister, a geriatric nurse. Perfect. His breathing changed, and with my
Mom and my sister holding his hands, he died about an hour and a half after he got
home. It was perfect. He had come home, to his beloved farm, to die.
Janet Stark 2010
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What Do You See?
What do you see nurses? What do you see?
Are you thinking when you look at me –
A crabbit old woman, not very wise,
Uncertain of habit, with far away eyes.
Who dribbles her food and makes no reply
When you say in a loud voice: I do wish you'd try..
Who seems not to notice the things that you do,
And forever losing a stocking, a shoe.
Who unresisting or not, lets you do as you will
With bathing and feeding, the long day to fill.
Is that what you are thinking? Is that what you see?
Then open your eyes nurse --you are not looking at me.
I'll tell you who I am as I sit here so still,
As I rise at your bidding and eat at your will,
I'm a small child of 10, with a father and mother,
Brothers and sisters who love one another;
A young girl of sixteen with wings on her feet,
Dreaming that soon now a lover she'll meet.
A bride soon at twenty, my heart gives a leap,
Remembering the vows that I promised to keep.
At twenty-five now I have young of my own,
Who need me to build a secure happy home.
A woman of thirty, my young now grow fast,
Bound to each other with ties that should last.
At forty my young sons now grown up have gone.
But my man stays beside me to see I don't mourn.
At fifty once more babies play at my knee,
Again we know children, my loved one and me.
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Dark days are upon me, my husband is dead.
I look to the future, I shudder with dread.
For my young are all busy rearing young of their own.
And I think of the years, and the love I have known.
I'm an old woman now, and nature is cruel'Tis her jest to make old age look like a fool.
The body it crumbles, grace and vigour depart.
There is now a stone where I once had a heart.
But inside this old carcass a young girl still dwells
And now and again my battered heart swells.
I remember the joys, I remember the pain
And I'm loving and living life all over again.
I think of the years all too few -gone too fast.
And accept the stark fact that nothing can last.
So open your eyes nurse! Open and see
Not a crabbit old woman, Look closer -see me!
This poem was among the few possessions found in the locker of a psychiatric - geriatric patient
following her death at Prestwich Hospital, Manchester, England. Shortly after the discovery of the
poem, it was published in that hospital staff’s journal, The Magpie, and has been published in several
other journals since then.
“10 Can-Do Qualities for Slower Aging”
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
Healthy lifestyle
Confident self-image
Feisty character
Wisdom
Laugh at self/Sense of humour
Flexibility
Life-long Learning
Positive attitude
Personal support system
Meditation/prayer/spiritual practice
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Beatitudes for Friends of the Aged
Blessed are they who understand
my faltering step and palsied hand,
Blessed are they who know that my ears today
must strain to catch the things they say.
Blessed are they who seem to know
that my eyes are dim and my wits are slow,
Blessed are they who look away
when coffee spilled at table today.
Blessed are they with a cheery smile
who stopped to chat for a little while.
Blessed are they who never say
“You’ve told that story twice today.”
Blessed are they who know the ways
to bring back memories of yesterdays.
Blessed are they who make it known
that I’m loved, respected and not alone.
Blessed are they who know I’m at a loss
to find the strength to carry the cross.
Blessed are they who ease the days,
on my journey home in loving ways.
Esther Mary Walker
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Minnie Remembers
My hands are old,
I’ve never said that out loud before
But they are.
I was so proud of them once,
They were soft, like the velvet
Smoothness of a firm, ripe peach.
Now the softness is more like worn-out sheets
Or withered leaves.
When did these slender, graceful hands
Become gnarled, shrunken claws?
When, God?
They lie here in my lap,
Naked reminders of this worn-out
Body that has served me to well!
How long has it been since someone touched me? Twenty years?
Twenty years I’ve been a widow.
Respected
Smiled At
But never touched.
Never held so close that loneliness
Was blotted out.
I remember how my mother used to hold me, God.
When I was hurt in spirit or flesh,
she would gather me close,
stroke my silky hair
and caress my back with her warm hands.
O God, I’m so lonely!
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I remember the first boy who ever kissed me,
We were both so new at that!
The taste of young lips and popcorn,
the feeling inside of mysteries to come.
I remember Hank and the babies,
How else can I remember them but together?
Out of the fumbling, awkward attempts of new
lover’s came the babies.
And as they grew, so did our love.
And, God, Hank didn’t seem to mind
if my body thickened and faded a little.
He still loved it. And touched it.
And we didn’t mind if we were,
no longer beautiful.
And the children hugged me a lot.
O God, I’m lonely.
God, why didn’t we raise the kinds to be silly
and affectionate as well as
dignified and proper?
You see, they do their duty.
They drive up in their fine cars:
They come to my room to pay their respects,
They chatter brightly, and reminisce.
But they don’t touch me.
They call me “Mom” or “Mother” or “Grandma”.
Never Minnie, My mother called me Minnie.
So did my friends. Hank called me Minnie, too.
But they’re gone. And so is Minnie.
Only Grandma is here. And God! She’s lonely!
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Five Stickies
As we travel through life we grieve many losses. We grieve losing our first tooth, or
our favourite primary school teacher. We grieve losing our ability to skip and jump
as we grieve losing our youth. Some of us grieve losing our hair, and maybe again
we grieve losing all our teeth! At some point, we face the loss of our health. The
normal life cycle consists of a series of losses.
To illustrate this point, I have the members of a class take five small yellow stickynotes, and on each one, write something they have in their life that is very
meaningful to them. It could be their new car, their flower garden, their ability to
play golf, or their dog. Most often, it is more profound things such as: spouse,
family, health and faith. I ask them to put these five stickies on each finger of their
left hand. With their right hand, I ask them to take a sticky from their neighbour. I
tell them they don’t care which one they take, as they aren’t really interested in what
it is. They set it down in front of them, and then they turn to their neighbour again,
and take something else. Now each one has only three stickies left. Once more,
they do the same thing, removing a sticky from their neighbour. When finally they
each have only one thing left, I tell them they can stop.
Then I describe this scenario: You are eighty years old, and have been coping fairly
well at home on your own, until one day you have a stroke. Your children try to take
care of you for awhile, as best they can. One day they gather together and tell you
how sorry they are, but you will need to move into a care home. You have arrived
at the new nursing home, lonely and bewildered and suffering from limited
movement from your stroke.
This is where the stickies come in. I ask the class what things they have lost. As
they describe the kinds of things they lost, I add to the story. Now you can’t get out
to church and you miss it so, and all your church friends too. No longer can you
drive, as your license has been taken away. You miss your old farmhouse where
you spent many happy years, and your prize-winning flower garden. You miss your
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home-cooked meals because now you can’t chew and swallow properly and are
getting a minced diet. You are not over the loss of your husband, who died two
years ago, and not only do you miss him, but you miss your cat, Spooky. Then the
Doctor comes in and tells you that the stroke has left permanent damage, and you
will not walk again. The next week more test results come in and the Doctor comes
back in with more bad news. You also have a chronic illness, the beginnings of
Parkinson’s disease.
That’s quite enough losses. I now ask the class members how they feel. The
answer is “pretty bad.” I ask them to respect a person’s losses when they are
caring for them. It is not just about the physical condition you are caring for today, it
is also about a series of losses that led up to this point. This helps sensitize staff
and volunteers in understanding the complex needs of a person with declining
health. Then I ask the class members to share what last item they were left with;
the last sticky on their finger. Then we discuss how to foster a sense of hope,
having at least something of value left on which to build spiritual strength.
This story of loss is not rare; these are real cases of real folks we deal with every
day. Let us learn more loving ways to provide care when the one we are caring for
is so vulnerable.
Janet Stark
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Some Needs of the Elderly
1. They prefer to be independent and live in their own houses as long as possible.
2. They need family support. Accommodation and socioeconomic factors are even
more important than health services in keeping the elderly independent.
3. They should always be given the opportunity of participating in decisions
affecting themselves.
4. They need to feel useful. They need activities in keeping with their abilities.
5. They need adequate income for food, clothing lodging, health care, and some
miscellaneous purposes.
6. The need to continue to grow through mental stimulation, keeping up with the
times and learning new facts.
7. They may need financial and legal counsel and, when they do, the role of the
family member will be to encourage them, in a non-threatening manner, to get such
help.
8. They need to be an integral part of the normal life of the family, church, and
community.
9. They need to feel that friends and family members do things WITH them, not just
FOR them.
10. They often need transportation for a variety of purposes. Ex: groceries
delivered, medical appointment, drug stores, and church services.
11. They need their spiritual needs fulfilled and developed if they are a Christian
family. Many older adults feel cut off from regular church activities and church
family, sacrament of communion, bible study because of illness or lack of
transportation.
12. They need to love as well as be loved. They need to be touched & felt cared for.
13. They need to have a sense of self-esteem and value.
14. They need to be listened to without criticism, judging etc. They need to
be
able to express their strong feelings of anger, sadness, failures, unfulfilled dreams,
fears, etc.
15. They need to be able to share their joys, share their past experiences, their
values, how it was in “the good old days”, etc.
16. Recognition and sense of self-worth are just as important to aging people as it is
in younger generations.
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Grandma’s Hands
Grandma, some ninety plus years, sat feebly on the patio bench. She didn't move,
just sat with her head down staring at her hands.
When I sat down beside her she didn't acknowledge my presence and the longer I
sat I wondered if she was OK
Finally, not really wanting to disturb her but wanting to check on her at the
same time, I asked her if she was OK. She raised her head and looked at me and
smiled. "Yes, I'm fine, thank you for asking," she said in a clear voice strong.
"I didn't mean to disturb you, Grandma, but you were just sitting here staring at your
hands and I wanted to make sure you were OK," I explained to her.
"Have you ever looked at your hands," she asked. "I mean really looked at your
hands?"
I slowly opened my hands and stared down at them. I turned them over, palms up
and then palms down. No, I guess I had never really looked at my hands as I tried
to figure out the point she was making.
Grandma smiled and related this story:
"Stop and think for a moment about the hands you have, how they have served you
well throughout your years. These hands, though wrinkled shriveled and weak have
been the tools I have used all my life to reach out and grab and embrace life.
"They braced and caught my fall when as a toddler I crashed upon the floor.
They put food in my mouth and clothes on my back. As a child, my mother taught
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me to fold them in prayer. They tied my shoes and pulled on my boots. They held
my husband and wiped my tears when he went off to war.
"They have been dirty, scraped and raw, swollen and bent. They were uneasy and
clumsy when I tried to hold my newborn son. Decorated with my wedding band
they showed the world that I was married and loved someone special.
They wrote my letters to him and trembled and shook when I buried my parents and
spouse.
"They have held my children and grandchildren, consoled neighbors, and shook in
fists of anger when I didn't understand.
They have covered my face, combed my hair, and washed and cleansed the rest of
my body. They have been sticky and wet, bent and broken, dried and raw. And to
this day when not much of anything else of me works real well these hands hold me
up, lay me down, and again continue to fold in prayer.
"These hands are the mark of where I've been and the ruggedness of life.
But more importantly it will be these hands that God will reach out and take when he
leads me home. And with my hands He will lift me to His side and there I will use
these hands to touch the face of Christ."
I will never look at my hands the same again. But I remember God reached out and
took my grandma's hands and led her home.
When my hands are hurt or sore or when I stroke the face of my children and
husband I think of grandma. I know she has been stroked and caressed and held by
the hands of God.
I, too, want to touch the face of God and feel His hands upon my face.
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My World Now
Life in a nursing home, from the inside
by Anna Mae Halgrim Seaver
This is my world now. It's all I have left, you see, I'm old, and I'm not as
healthy as I used to be. I'm not necessarily happy with it but I accept it.
Occasionally, a member of my family will stop in to see me. He or she will bring me
some flowers or a little present, maybe another pair of slippers --I've got eight pairs.
He'll visit for awhile and then they will return to the outside world and I'll be alone
again. Oh, there are other people here in the nursing home. Residents, we're called.
The majority are about my age. I'm 84. Many are in wheelchairs. The lucky ones are
passing through -a broken hip, a diseased heart. Something has brought them here
for rehabilitation. When they're well they'll be going home.
Most of us are aware of our plight --some are not. Varying stages of
Alzheimer's have robbed several of their mental capacities. We listen to endlessly
repeated stories and questions. We meet them anew daily, hourly or more often.
We smile and nod gracefully each time we hear a retelling. They seldom listen to
my stories, so I've stopped trying.
The help here is basically pretty good, although there's a large turnover. Just
when I get comfortable with someone he or she moves on to another job. I
understand that. This is not the best job to have.
I don't much like some of the physical things that happen to us. I don't care
much for a diaper. I seem to have lost the control acquired so diligently as a child.
The difference is that I'm aware and embarrassed but I can't do anything about it.
I've had three children and I know it isn't pleasant to clean another's diaper. My
husband used to wear a gas mask when he changed the kids. I wish I had one now.
Why do you think the staff insists on talking baby talk when speaking to me?
I understand English. I have a degree in music and am a certified teacher. Now I
hear a lot of words that end in "y”. Is this how my kids felt? My hearing aid works
fine. There is little need for anyone to position their face directly in front of mine and
raise their voice with those "y" words. Sometimes it takes longer for a meaning to
sink in, sometimes my mind wanders when I am bored. But there's no need to
shout.
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I tried once or twice to make my feelings known. I even shouted once. That
gained me a reputation of being "crotchety." Imagine me, crotchety! My children
never heard me raise my voice. I surprised myself. After I've asked for help more
than a dozen times and received nothing more than a dozen condescending smiles
and a "Yes, deary, I'm working on it," something begins to break. That time I wanted
to be taken to a bathroom.
I'd love to go out for a meal, to travel again. I'd love to go to my own church,
sing with my own choir. I'd love to visit my friends. Most of them are gone now or
else they are in different "homes" of their children's choosing. I'd love to play a good
game of bridge but no one here seems to concentrate very well.
My children put me here for my own good. They said they would be able to
visit me frequently. But they have their own lives to lead. That is normal. I don't want
to be a burden. They know that. But I would like to see them more. One of them is
here in town. He visits as much as he can.
Something else I've learned to accept is loss of privacy. Quite often I'll close
my door when my roommate --imagine having a roommate at my age --is in the TV
room. I do appreciate some time to myself and believe that I have earned at least
that courtesy. As I sit thinking or writing, one of the aides invariably opens the door
unannounced and walks in as if l'm not there. Sometimes she even opens my
drawers and begins rummaging around. Am I invisible? Have I lost my right to
respect and dignity? What would happen if the roles were reversed? I am still a
human being. I would like to be treated as one. The meals are not what I would
choose for myself. We get variety but we don't get a choice. I am one of the
fortunate ones who can still handle utensils. I remember eating off such cheap
utensils in the Great Depression. I worked hard so I would not have to ever use
them again. But here I am.
Did you ever sit in a wheelchair over an extended period of time? It's not
comfortable. The seat squeezes you into the middle and applies constant pressure
on your hips. The armrests are too narrow and my arms slip off. I am luckier than
some. Others are strapped into their chairs and abandoned in front of the TV,
Captive prisoners of daytime television; soap operas, talk shows and commercials.
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One of the residents died today. He was a loner who, at one time, started a
business and developed a multimillion-dollar company. His children moved him here
when he could no longer control his bowels. He didn't talk to most of us. He often
snapped at the aides as though they were his employees. But he just gave up;
willed his own demise. The staff has made up his room and another man has
moved in.
A typical day. Awakened by the woman in the next bed wheezing --a
former chain smoker with asthma. Call an aide to wash me and place me in my
wheelchair to wait for breakfast. Only sixty-seven minutes until breakfast. I'll wait.
Breakfast in the dining area. Most of the residents are in wheelchairs. Others use
canes or walkers. Some sit and wonder what they are waiting for. First meal of the
day. Only three hours and twenty-six minutes until lunch. Maybe I'll sit around and
wait for it. What is today? One day blends into the next until day and date mean
nothing.
Let's watch a little T.V. Oprah and Phil and Geraldo and who cares if some
transvestite is having trouble picking a colour-coordinated wardrobe from his
husband's girlfriend's mother's collection. Lunch. Can't wait. Dried something with
pureed peas and coconut pudding. No wonder I'm losing weight.
Back to my semiprivate room for a little semiprivacy or a nap. I do need my
beauty rest, company may come today. What is today, again? The afternoon drags
into early evening. This used to be my favourite time of the day. Things would wind
down. I would kick off my shoes. Put my feet up on the coffee table. Pop open a
bottle of Chablis and enjoy the fruits of my day's labour with my husband. He's
gone. So is my health. This is my world.
SEAVER’s son who lived in Wauwatosa,Wis.
found these notes in her room after her death.
(Reprinted with permission of Newsweek, Inc. 06/27/94)
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Challenges of Aging
Adamec, C.; The unofficial guide to eldercare, 1999 MacMillan General Reference
Think of eldercare as a continuum. It may come into play simply to make life more
comfortable, or absolutely necessary when it becomes difficult/impossible to carry
out some of the necessary tasks of daily living. As a person becomes older, he/she
may develop difficulties in performing certain activities necessary to day-to-day life
without assistance like eating, getting in and out of bed, getting around inside their
home, dressing, bathing, using the toilet or taking their medications.
It’s most often a gradual decline; they may have no trouble handling the basics, but
certain more complicated task – such as managing money, cooking meals or coping
with several medications – have become difficult. So the bills maybe aren’t getting
paid on time; nutrition is being ignored; they can’t tell you which medications are for
what or when they are supposed to take them. They may seem depressed; old
pastimes or interests seem forgotten and nothing seems to make them brighten up.
Personal hygiene has deteriorated, and their home is starting to look unkempt.
Deterioration in personal hygiene is a common problem for the elderly, and can be
due to either physical or mental impairment. Fear of falling may make a person
unwilling to shower or bathe, or severe pain from arthritis may make it difficult to
wash hair or brush teeth. Getting help with these intimate activities can be
extremely embarrassing.
Some ailments afflict the elderly in far greater numbers and with far greater severity
than others. These include heart disease, arthritis, various forms of cancer,
diabetes, high blood pressure, diseases of the eye, prostate trouble and
osteoporosis.
Some elders are impaired by dementia. (See handout on dementia) In many forms
of dementia, episodes of confusion alternate with periods of lucidity. The elder
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person is aware that, at times, s/he becomes lost and confused and feels distressed
and depressed at the likelihood that this condition will only worsen over time.
Paranoia is common in memory-loss ailments and may present a particularly
difficult situation to care providers. It’s commonly said that you need less sleep as
you get older… so the elder may wander at night.
Social support is not only an important determinant of health throughout life, it
influences an individual’s outlook on the end of life. Remaining days may be seen
as a waiting period before death or as time left to continue living. Good social
support helps dying people find ways to say goodbye, and may assist people to find
meaning in their lives.
Seniors often have fewer social resources to draw on; they have lost friends and
family members; many do not have anyone to provide care or to support them; and
spouses are often frail and only able to provide limited assistance.
The dying person may exhibit withdrawal from family and friends. It may be their
choice to disengage from social life as death draws near, possibly to focus on
internal or spiritual concerns. Increasing fatigue may also limit the person’s capacity
to maintain relationships. Social withdrawal, however, can also be a sign of distress.
For instance, if they are distressed by their appearance or disability, or are in
depression, they may shun the presence of others.
Elders who won’t ask for help or acknowledge and accept their limitations may be
going through a fear of change. (Changing appearance, physical decline, memory
loss, narrowing of interests.) My Dad told the joke of the 100-year old man being
interviewed in nursing home and asked “I bet you have seen a lot of changes in
your life.” “Yes”, the man answered, “and I have been against every one of them.”
Physical: Normal physical decline due to aging is also compounded by many
chronic conditions. According to Atchley, the most prevalent conditions are:
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diabetes, visual and hearing loss, orthopedic impairment, and arthritis. 1 The top
diseases are heart disease cancer, Alzheimer’s. Most over 85 years of age have
more than one deficit or illness. A look at the medications list on a resident’s chart
gives an idea of the number of conditions—a resident may be taking 8-10 different
drugs. These topics will be covered: the importance of regular pharmacy review,
“poly-pharmacy”, occupational therapy, physiotherapy, exercise and activation.
Memory loss will be covered in the dementia unit.
Adjustments to having personal care done by different personal support workers or
“strangers” can be very difficult for both elderly men and women.
Emotional: A move to a nursing home involves grief and loss. McPherson, in
“Aging as a Social Process” written in 1990, calls moving into a nursing home being
“institutionalized.”2 Today in 2004, we are not only calling these residences ‘care
homes’ we are moving toward holistic care and the desire to better meet individual
needs. To help a resident feel worthy and retain dignity when they can no longer
care for themselves, we must be firm believers in the value of ‘being’ as opposed to
‘doing.’ The resident may be suffering from perceived uselessness.
Fears of
progressing illness and pain, fears of dying and the unknown, need to be identified
and addressed by the care team.
Intellectual: Even a healthy brain shrinks with age. However, in the absence of
dementia, there may be no measurable intellectual decline for a person even into
his eighties.3 Studies have shown that stimulation and activity will help and elder
retain his intellectual capacity. (I’ve noticed many elderly residents can complete
the daily crossword faster than I!)
Social: Moving into a nursing home often causes difficult adjustments for losses
that may occur too quickly due to: loss of a spouse, compounded with the loss of
friends, neighbours and loved ones, home, neighbourhood and social activities.
1
Atchley (2000, p. 87)
McPherson (1990, p. 283)
3
Complete Guide to Caring for Aging Loved Ones (p. 160)
2
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Although care homes are very good at providing a variety of social activities, it may
be a slow process to adapt and participate socially in these planned activities.
Spiritual: Studies have shown that those with a strong sense of spirituality handle
life crises and dying better than those without this groundedness.4 In the nursing
home, there is grief due to loss of regular church attendance, and the church family.
Sexual: Do not assume that all seniors lose their libido. It varies greatly. It has
been said that at age 50, 50% may lose their desire for sexual activity, at age 60 it
is 60% and so on. The elderly may lose their ability for sexual intercourse, but may
still have great need for physical affection. It is important to recognize the deep
human need for physical touch that is apart from physical medical care, and
affection that is apart from the requirement of employment.
Often a person with dementia may lose their social inhibitions and this results in
being found in a situation that to others, and especially family, may be socially
unacceptable. A person with limited or declining cognitive capacity may not have
the same social filters for nudity, sexuality, elimination etc. Family and caregivers
need to understand the context and not to over-react.
Isolation: Can result from a loss in social or familial role, frequent hospitalizations
and restrictions due to the illness. The dying may withhold discussion of their
experience for fear of alienating others. Withholding information from them also
isolates them and denies them control over decisions-making and creates barriers.
Dying in a long-term care facility can also separate them from others. The
knowledge that one ultimately dies alone can result in overwhelming loneliness.
Finances: Financial considerations are important for seniors. Financial worries are
associated with heightened distress and are an additional element of suffering.
Finding meaning and personal growth: When people feel their lives have
meaning or importance to others, they face death with a greater sense of calmness.
Life review and reminiscence can help seniors to consider what the dying process
means to them in the context of their past life and what it will mean to those left
behind.
4
Atchley (2000, p.306)
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Loss of control: is a predominant fear among many dying seniors. It is important
for them to maintain control over the areas that are still manageable. The way we
approach everything we do with a senior can promote or take away control; it is
important to be aware of this at all times.
Vulnerability to abuse and neglect: Poor health, increasing dependence on
others, isolation and caregiver burden are factors that can lead to increased
vulnerability.
Some common fears and concerns:
 Losing their independence
 Becoming a burden
 Losing control due to physical or mental deterioration
 Choking or suffocating, sensory loss, paralysis and the inability to communicate
 Fearing that the pain will not be relieved; or that they will be overly sedated
 Being easily forgotten
 Suffering with dignity
 Losing one’s self and the grieving process that accompanies it
 Dying alone or without anyone caring. This is particularly true for seniors who have
outlived their friends, disengaged from community life, and who are geographically
distant from their families.
Fisher, R., MacLean, M., Ross, M., Editors;
A guide to end-of-life care for seniors, 2000. Ottawa;
Universities of Ottawa and Toronto.
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Institutionalization
Chaplain Janet Stark
The typical long-term care resident in Canada is 85 or older and living with chronic
illness or co-morbidities. This may make one wonder-- Are they living or are they
dying? Our palliative perspective would be that they are living, while having medical
conditions palliated.
30 % of elderly hospitalized patients said they would rather be dead than living in a
nursing home. What are the two greatest fears? 1. Falling and not being able to
get up. 2. Institutionalization. Even though the terms nursing home and long-term
care facility are no longer used—the term is long-term care home—many are very
afraid they will end up there. At best—they may call it “heaven’s waiting room, and
at worst—the “death house.” Many feel it is the last stop before the morgue. How
sad this is when knows that there are strict regulations in place for the quality of
homes and the protection of residents. Many folk who would otherwise be living
alone, and lonely—possibly being neglected and poorly nourished are well takencare of in long-term care homes. Many staff treat residents with both respect and
affection and although we hear about the abuse cases, the incidence is relatively
rare.
I visited an elderly patient recently who had a very similar outlook to the wise old
man in this next story. He acknowledged that the retirement home he had chosen
would give him hot meals, wash his clothes and help him bathe. No longer would
he have to buy his own groceries, do the cleaning and so on. He was looking
forward to making new friends and having an active social life once again. He was
looking forward to music and art and merriment of all sorts. His outlook was very
refreshing, but unfortunately, rare.
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A Wise Old Man
A man of 92 years, very well-presented, who takes great care in his appearance, is
moving into an old people’s home today. His wife of 70 years has recently died, and
he is obliged to leave his home. After waiting several hours in the retirement home
lobby, he gently smiles as he is told that his room is ready. As he slowly walks to
the elevator, using his cane, I describe his small room to him. "I like it very much",
he says, with the enthusiasm of an 8 year old boy who has just been given a new
puppy.
"M. Gagné, you haven’t even seen the room yet, hang on a moment, we are almost
there. " " That has nothing to do with it ", he replies. "Happiness is something I
choose in advance. Whether or not I like the room does not depend on the
furniture, or the decor – rather it depends on how I decide to see it." "It is already
decided in my mind that I like my room. It is a decision I take every morning when I
wake up." "I can choose. I can spend my day in bed counting all the difficulties
that I have with the parts of my body that no longer work very well, or I can get up
and give thanks to heaven for those parts that are still in working order." "Every day
is a gift, and as long as I can open my eyes, I will focus on the new day, and all the
happy memories that I have built up during my life." "Old age is like a bank
account. You withdraw in later life what you have deposited along the way." So, my
advice to you is to deposit all the happiness you can in your bank account of
memories. Thank you for your part in filling my account with happy memories,
which I am still continuing to fill…
author unknown
The next story gives the opposite perspective. The story was told me by a health
administrator, the daughter of the elderly patient facing possible long-term care
admission. Even to the health professional, the prospect of living in an institution
seemed revolting.
What must be done to change the perception and/or to change the reality that longterm care is this way?
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“Warehoused” in Nursing Homes
Janet Stark, Final Scenes 2011
I received this story by e-mail from a distressed daughter. The fact that she
was a high level health administrator who knew the health system through and
through did not make her distress any easier. She described this situation of her
elderly mother.
Mrs. Osborne was ninety-three years old. She was in hospital after having
surgery to repair a broken hip due to a fall. Many times a broken hip in an elderly
person can put the body into trauma, and if it is not strong enough, the organs can
shut down, starting with the kidneys. What might be a major injury in a younger
person sometimes proves fatal in an older patient.
When the daughter went in to see her mother for the first time, she found her
heavily medicated. After a few days, Mrs. Osborne was well enough to sit up and
converse. She still, of course, could not put her weight on the injured leg. One
afternoon, the charge nurse met the daughter on her way in to visit her mom. She
spoke about the next steps for Mrs. Osborne. She suggested short-term rehab
followed by admission to nursing home. At hearing this, the daughter was most
alarmed. “Mom took care of herself,” she said, “She has always managed very well.
After she recovers we fully expect her to go back home”. The nurse then said that
her assessment of her mother showed confusion, mild agitation and perhaps the
beginning stages of dementia.
She couldn’t speak clearly or put on her own
clothes. Surely it would not be safe for her Mom to live on her own any more.
The daughter thought for a few moments and then she said, “Can’t you give
mom some more time? Give her a few more days to recover and some rehab
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therapy. Although Mom was getting very slow, she could wash and dress herself
and make simple meals. We helped to do the housekeeping and other chores. You
need to remember a few things about my Mom. She is in a strange environment,
she still has anesthetic in her system, not to mention high doses of pain-killer and
she does not have her hearing aids in, her glasses on, or her teeth in. In that
situation, wouldn’t you come across as being a bit confused too?” The nurse smiled
and let her go on. “Mom is a very proud and independent lady. She would lose her
spirit if we put her in a nursing home. If Mom loses her spirit, then I know she will
die.” They agreed to send Mrs. Osborne to a short-term rehab bed in the hospital,
and reassess her later after she was more mobile.
The daughter finished her e-mail with a distressing question. She asked,
“Why are we so in a hurry to warehouse our older adults.”
I have thought a great
deal about that question.
**
Family members often take on guilt for placing their parents in care against their
will. One study suggested that more than half of caregivers interviewed agreed that
placement was the most difficult problem they had ever faced, even though 95% of
them had no alternative. Long-term care is designed to give an elderly person
dignified wholistic care—supplying the most basic needs like food and shelter, while
at the same time, keeping them safe when it may no longer be safe for them to live
at home. Newer homes provide more privacy as it is understandable that an elderly
person does not choose to live in such intimate space with a complete stranger.
Residents need autonomy—choices. The resident or patient-centred model is
slowly becoming the norm. We must advocate for this for our elders and eventually,
for ourselves!
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Quality of Life Survey in A Long-Term Care Home
http://www.dad.state.vt.us/Reports/Programs/chapter2.htm
Yes
Somewhat No
1. I feel safe in the home where I live. Would you say:
2. I feel safe out in my community. Would you say:
3. I can get where I need or want to go. Would you say:
4. I can get around inside my home as much as I need to.
5. I am satisfied with how I spend my free time. Would you say:
6. I am satisfied with the amount of contact I have with my family and friends.
7. I have someone I can count on in an emergency
8. I feel satisfied with my social life and with my connection to my community.
9. I am concerned that I don’t have enough money for the essentials.
10. I feel valued and respected.
9. I am concerned that someday I may have to go to a nursing home.
10. Overall, how would you rate your quality of life?
Excellent Good Satisfactory Unsatisfactory
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Issues from Placement in Long-term Care
Janet Stark
Challenges of Eating
Eating is such a pleasant and important function for all of us. For the resident in
LTC, eating can become very difficult, and toward end of life, food will eventually not
be tolerated or needed. The volunteer can help with those that need feeding
assistance. Watch for these symptoms: loss of appetite, nausea, vomiting,
constipation/diarrhea, sore mouth/dry mouth, swallowing problems and taste
changes. Nutritional supplements can be tasted and tube feedings explained.
Volunteers need to be taught by the nutrition manager or dietitian and can practice
proper positioning and safe feeding methods with each other.
When long-term care residents lack stimulation and even more so when they lack
cognition, they may spend their time waiting for the next meal. Meals may represent
more of a social function than a need to satisfy hunger. All meals in long-term care
meet stringent regulations, and even when they don’t please a resident, they are
certainly nutritious and often provide a much better diet than a senior may be
preparing for himself at home.
Sometimes food complaints are appropriate, and sometimes they are an indication
that a person has lost control over many aspects of his life. If he can still express his
food choices, then it is an indication of a certain amount of personal autonomy.
Volunteers may need to familiarize themselves with different types of diets: soft,
fluid, minced, puréed etc. Physical things that affect diet are: medical conditions
(dysphagia—hard of swallowing is the most common) allergies, diabetes, well-fitting
teeth,
Although it is certainly not necessary for a volunteer to bring a gift, often special
foods and treats can bring a smile to one living in long-term care. The volunteer
should check with the resident, the facility personnel or the family in order to make
safe choices as to what goodies to bring when visiting.
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Cases for Eating in Long-Term Care
Resident #1
You are 87 years old and have trouble hearing and seeing. This is part of tile normal
process of aging. You hate being fed but you cannot express this verbally. Half the
time you just do not want to eat and you get up from the table and leave.
Resident #2
You are 92 years old. You are continually slipping down in the chair. You love to eat
and are always hungry but you will need to be fed. You also have trouble hearing
and seeing as a normal part of aging.
Resident #3
You are 83 years old and have trouble seeing and hearing. You can feed yourself
but are very slow because of muscle weakness. You have lots of complaints about
the food.
Resident #4
You are 86 years old, have difficulty hearing and have tunnel vision. You are very
sociable and like to talk with other residents. Mealtime has always been a social
time for you. You eat very small amounts. You are on a minced diet but insist you
are able to eat regular food.
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Communication
"What do I say, how do I respond?" when a distraught family member or person
with dementia poses a difficult or unanswerable question. Remember the
importance of validating the person, of identifying with the emotions being
experienced, and then finding ways of opening the door to allow the person the
opportunity to talk about his/her fears and feelings. Let's look at some possible
responses to the following statements which a volunteer may hear.
Why did this have to happen to my mother? This is a plea for help. The most
important thing would be to stay close and not back away from this. This may well
be the time for a hug and to say something like, "I can see that you love your
mother a lot."
I'm going to die in this place you know... (cognitively-impaired person)
"How does that make you feel? Are you afraid of death? What part frightens you?
Would you like me to stay with you?"
He had so much left to do!
"What things did he still hope for? Tell me about his accomplishments." ,
I have so many regrets. I just wish he could understand so that I could say I'm
sorry. "Why don't you tell him anyway? Maybe he will understand."
He's not dying, is he?
Be clear on just what is being asked. Ask, "What has the doctor told you about the
illness?" And although we can't predict the exact time of death, we do need to be
truthful if this person is dying.
I want to stay near, but I'm afraid of death.
"What part do you find most frightening? How can we help you?"
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Cultural Differences
The best quote comes from Dr. Elizabeth Latimer of McMaster University, Hamilton:
“Dying is a very private and unique event for each senior and family. We should
intrude as little as possible and assist as much as we can.”5 Care for the culturally
diverse is basically two-fold:
1. to prevent distress of the resident and family
2. to provide a proactive appropriate care plan
Although in Lanark, Leeds & Grenville, it is estimated that only 10% of the
population is non-Christian, many have family that have emigrated from another
country.
Teaching culturally-sensitive care highlights the principle to treat all residents as
individuals first, and members of a cultural group second. In other words, don’t
assume that because one is from a certain cultural group, that they will want things
a certain way. Depending on family traditions, beliefs and the extent to which they
may have assimilated western culture, each individual’s needs and expectations
concerning death and dying may be different. It is the job of the care team to find
out and provide personally appropriate care.
Refer to the section on Culturally-appropriate care on page 173
5
A Guide to end-of-life care for seniors (p. 166)
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Dementia & Alzheimer Disease
Approximately half of the residents in a nursing home will have some degree of
cognitive impairment. It is helpful to learn some basic facts and myths of Alzheimer
disease and other dementia illnesses. (Remember when these illnesses were once
called “senility”?) Refer to this section starting on page 343
Exercises such as wearing blurry glasses, earplugs, putting corn in the shoe and
sitting on rocks can be a fun way to illustrate what it might be like to have these
deficits, but have the frustration of not being able to explain them.
Volunteers should focus on activities that those with cognitively-impaired can still do
well: encouraging residents to share history by telling stories about the past can be
very rewarding for both parties. Long-term memory is often preserved when short term memory has gone. “Older generations benefit from reviewing their lives and
placing them in perspective. When people have the opportunity to articulate and
‘share’, it helps them to place value on their past.”6
Sometimes it is the family who seem to suffer more than their loved one who has
dementia. ‘Clara’ remarked: “The geriatric social worker said something
interesting. She said there is a kindness in the loss of memory. As an elderly
person’s universe gets smaller, it allows that person to be content. Despite his
circumstances, my Dad seems content.”7
Volunteers will need to practice how to approach a resident, how not to overstimulate and to go with “what works” for each individual resident with dementia.
The staff can be a great help here in orienting the volunteer to individual behaviour
and needs.
6
7
Campbell-Rempel, p. 45
Caring for Aging Loved Ones (p. 146)
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Elder Abuse
The article “An Easy Mark” identifies six characteristics that leave elders vulnerable
to abuse: Accessibility, Trust, Loneliness, Gender Vulnerability of Females,
Disposable income and Intimidation.8
Research shows that older women are less likely to report abuse. “Shame and
humiliation about being a victim may keep a woman from revealing that her spouse,
child or other family member abuses her.”9 (Also included here are the rare but
serious incidences of LTC staff abusing residents.) Victims may fear further abuse,
emotional blackmail etc.
The section on Elder Abuse (pages 327) explains types of abuse, factors
contributing to abuse; signs to watch for; and neglect as a form of abuse. When
suspecting something—even when not sure—ask for the nursing home policy and
procedure for reporting suspected abuse.
End-of-Life Decision-Making
All long term care homes post the “Resident Rights in Long-Term Care” (p 313) and
many subscribe to the The Dying Person’s Bill of Rights10 (p 259) DNR, (do not
resuscitate orders) invasive therapies; tube-feedings, artificial hydration, consent,
capacity, right to receive information and right to refuse treatment, advanced
directives and Power of Attorney are discussed in the section on ethics (starting at
p. 387). Case studies using a decision-making model will familiarize volunteers with
the kinds of difficult decisions that staff and families are faced with.
8
Carter B. (2003)
Hightower, J. (2004)
10
LL&G Palliative Care Manual (2004. p. 133)
9
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Palliative care includes the right to deny or withdraw treatment. It also includes the
right to change one’s mind! Suicide, assisted suicide, euthanasia are explained to
clarify terms that are often misrepresented by individuals and the media.
The basic principles of health-care ethics are:11

Respect for autonomy

Beneficence & Non-malificence

Justice

Sanctity of life
Realistic case studies and role-plays, where a distressed resident wishes to die—
and begs for help to end his/her life -- may help provide the volunteer with possible
responses.
Family Dynamics
Family conflict is normal. In health care we (should) say there are no difficult
patients, just patients facing difficult circumstances. As well in long-term care, there
should be no difficult residents or families, just residents dying and families living
under difficult circumstances.
When the normal ‘parenting the child’ becomes the (adult) child ‘parenting the
parent’, the natural order of family role becomes reversed. The family members will
have many feelings. Adult Children often face guilt, putting Mom or Dad into a
home. “Older parents make their children vow to never put them in a nursing
home…. The children feel beholden to their promise, but may be at risk caring for
an ill parent at home….They need to understand that admission to a nursing home
is not failure on their part or an indication of abandonment. It may be the only way
to ensure the individual receives appropriate care and is in a safe and secure
environment.”12
11
12
LL&G Palliative Care Manual (2004. p. 127)
Gordon, M. (2003)
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Adult children often face the obstacle of caring across the miles. According to Lisa
Petsche, there are eight million North Americans involved in caring for a mature
adult—usually a parent—who lives in a different geographic area.13 The stress of
caring can be confounded by distance, financial cost and crises. At the other end of
the spectrum are those residents who have no family or whose family never visits.
Volunteers can be a valuable help in filling a void.
Older individuals may have lived at one time in a home with their own parents and
grand-parents. They may have preferred to live with an adult child rather than come
to the nursing home and be resentful of society’s change away from 3-generation
households. According to McPherson, the trend away from keeping frail elderly
parents at home began when more daughters and daughters-in-law began to work
full-time.14 Many adult children have been caring for an elderly parent even when
the parent lives in their own home, and will continue to do so when the parent
moves into nursing home. Sometimes the family member has reached the point of
exhaustion before bringing a parent to the nursing home.
How a family meeting works is explained on page 158—the role of the nurse or
social worker as ‘peacemaker’—working toward compromise and avoiding the ‘winlose’ situation with conflicting siblings.
Financial: Financial status varies among the elderly: many are concerned about
whether their finances will last their lifetime. Others live frugally because they prefer
to leave money to their children rather than spend it on their own needs. Many
worry about the high costs of health care. It is important to know that the Ontario
government provides the right for long-term care to all regardless of financial status.
A power of attorney for financial matters should be assigned while an elderly person
is still cognizant. Sometimes an elderly person in long-term care is vulnerable to
being taken advantage of financially. (see financial abuse, page 328)
13
14
Petsche, L. (2003)
McPherson (1990, p.283)
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Grief & Loss
There are many losses when one moves into long-term care. Grief and loss is
covered in detail starting on page 409. The concept of ‘anticipatory grief’ discusses
the preparatory sadness of the family as they anticipate the eventual loss of their
loved one. It also relates to the grief of a long-term care resident as he anticipates
his own death. Many long-term care homes have palliative care teams, pastoral or
chaplaincy care and bereavement follow-up to help hurting families
Worden’s Four Tasks of Grief15:
1. to accept the reality of the loss
2. to experience the pain of the loss
3. to adjust to the environment in which the deceased is missing
4. to invest in new relationships and activities
Most nursing homes have meaningful practices to help family, fellow residents and
staff deal with the loss of a resident. These include candle-lighting rituals, memorybook displays, memorial services, follow-up cards and phone calls.
Pain & Symptom: Comfort Measures
Pain & symptom management must be achieved first, so that all other supportive
care measures can be effective. Pain assessment is done by registered health staff
and volunteers will not be assessing pain or administering medications. However, it
is helpful for them to understand the basics in pain management, because they can
always report on what the resident asks them to do and can also report on what
they observe. Pain in long-term care can not only be caused by cancer, but from
arthritis and many other chronic conditions.
Check the PIECES model (p 67) will be reviewed again with emphasis on total pain.
(p 228)It is an easily-understood tool used in long-term care to assess for ‘whole
pain’ (body-mind-spirit) of a resident16:
15
Worden (1978) LL&G Manual (p. 154-159)
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Physical:
pain & symptom control & comfort measures
Intellectual:
abilities and needs
Emotional:
psychological mood or state
Capabilities: helps needed for ADL (activities of daily living)
Environment: living conditions and resources available
Social/Spiritual/Sexual: need for human contact, spiritual well-being
Basic principles of opioid therapy, can help to dispel the myths about morphine
addiction. Residents in long-term care experience such distressing symptoms as
anorexia, breathing problems, confusion, constipation, delirium, diarrhea, fever,
headaches, mouth soreness, restlessness, skin care, sleep, vomiting etc. Other
discomforts can be bunions, toothaches, headaches and other common ailments
that a resident with dementia may not be able to verbalize.
The volunteer can often, and with permission, provide comfort measures—back and
foot rubs, lotions, soothing music and other non-pharmacological interventions.
Complementary therapies (therapeutic touch, reflexology, reiki etc.) may be offered
by qualified practitioners, as long as the costs involved are clear and acceptable.
A volunteer can sit with a lonely, frightened or non-communicative resident, just
smiling, listening and hand-holding, assuring him/her that they are being cared for
and will not be abandoned.
Volunteers can also help relieve distress as the following activities may help to
promote the resident’s well-being through recreation, art, music, laughter, and
relaxation.
16
LL&G Palliative Care Manual for Healthcare Professionals (2004)
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Signs of Approaching Death
Volunteers need to be prepared for the physical changes the body will go through
along with actions and comfort measures they can provide.
They will also learn
how to recognize when death has occurred, and what they can do until the
nurse/family arrive. (see section on palliative care starting on p 241)
The family will often spend a great deal of time with their dying loved one and may
need support. “Every resident whose death is likely to be imminent has the right to
have members of the resident’s family present twenty-four hours per day.”17
Optimum care includes moving the resident to a private room or “palliative suite”.
The family will need more privacy. The volunteer can help make the family
comfortable and provide refreshments.
Spirituality
Everyone is a spiritual being! Long-term care homes should have clergy lists and
pastoral care resources available. Spiritual care emphasizes sensitivity and
meeting the resident where he/she is at. These are basic spiritual needs of all:

need for meaning and purpose in life

need for giving and receiving love

need for hope and creativity
The spiritual care volunteer simply needs to ask the resident, family or staff what
might provide comfort. Reading a favourite prayer, poem or bible reading can help
increase comfort because the repetition of familiar words can be very soothing.
There are many stories of spiritual experiences at the time of death. The book “Final
Gifts” is filled with stories of the experiences of hospice nurses Maggie Callahan
and Patricia Kelley. They tell of profound experiences in the final hours, where the
dying have been visited by loved ones (long gone) or angels. They call this
“nearing death awareness.”18 (see section on spiritual needs & distress p. 209)
17
18
Every Resident: Bill of Rights (2001)
Callahan, M. & Kelley, (1992)
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Ontario Bill of Rights for Residents in Long-Term Care Homes 2012
1. Respect and dignity
"Every resident has the right to be treated with courtesy and respect and in a way
that fully recognizes the resident's individuality and respects the resident's dignity."
In other words...You have the right to be treated with respect. The staff at your longterm care home must be polite to you. They must recognize your dignity and rights
as a person. For example, you can choose what you want to be called. If you would
rather be called "Miss Lee" instead of "Angela", tell the staff. They must respect
your wishes.
2. No abuse
"Every resident has the right to be protected from abuse."
In other words...No one is allowed to abuse you physically, financially, sexually,
verbally, or emotionally.
Physical abuse is when someone assaults you, handles you roughly, or slaps,
pushes, or beats you. It is also physical abuse when someone refuses to give you
medicine that you should take, or gives you medicine that you should not be taking.
Financial abuse is when someone takes your money or property by fraud, theft,
force, or by tricking you. If anybody forces you to sell or give away your property, or
takes your money or possessions without your permission, what they are doing is
financial abuse.
Sexual abuse is when someone forces upon you any type of sexual activity that
you do not want. It may be inappropriate touching, sexual exploitation, or
comments. Sexual abuse happens if, for example, a staff member or other person
in authority has a sexual relationship with you, shows you pornographic materials,
or looks at your naked body when that is not part of their job.
Verbal abuse is when someone calls you names, yells at you, or speaks to you in a
way that scares, belittles, or threatens you.
Emotional abuse is when someone threatens, insults, or frightens you, or says or
does something that humiliates you. This kind of abuse may make you feel lonely,
ignored, or as if you are being treated like a child.
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3. No neglect
"Every resident has the right not to be neglected by the licensee or staff."
In other words...The owner and the staff at the home are not allowed to neglect you.
Neglect is when the home fails to give you the treatment, care, services, or help that
you need for your health, safety, or well-being. Neglect also happens when
someone, by not taking action, puts your health, safety, or well-being at risk. For
example, you have the right to get medication that is prescribed for you. If you need
help getting to the toilet, you should be taken to the washroom instead of being
forced to use incontinence products such as diapers, pads, or plastic pants.
4. Proper care
"Every resident has the right to be properly sheltered, fed, clothed, groomed and
cared for in a manner consistent with his or her needs."
In other words...You have the right to receive the care you need. Your care should
include:




a proper place to live,
enough good food to eat,
clean clothes to wear, and
help with looking clean and tidy.
The staff at your long-term care home should look after any special needs you
have.
5. Safe and clean home
"Every resident has the right to live in a safe and clean environment."
In other words...You have the right to have a clean and safe place to live in. The
long-term care home must be safe and everything should work properly. Smoke
alarms must work, fire exits must be clearly marked, and stairways must be clear.
The building must be clean. Garbage should be taken out regularly. There should
be no bad smells and the building must have a good air supply.
6. Citizens' rights
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"Every resident has the right to exercise the rights of a citizen."
In other words...You keep all your rights as a citizen. These include:






your democratic rights, including the right to vote,
your equality rights, including the right to be protected against discrimination,
the right to practice your religion,
the right to express yourself,
the right to meet with anyone you wish, or to join any organization or group, and
the right not to have your possessions looked through or taken without your
permission, except as allowed by law.
As a citizen, you also have responsibilities. For example, you are expected to:


respect other people's rights and freedoms, and
obey Canada's laws.
7. Knowing your caregivers
"Every resident has the right to be told who is responsible for and who is providing
the resident's direct care."
In other words...You have the right to know who is looking after you no matter who
they work for or how they are employed. For example, they could be staff from an
agency or volunteers, they might work full-time or part-time, or be permanent or
temporary staff. You still have a right to be told who they are if they take care of you
directly.
People who are responsible for your medical and personal care include:





doctors,
the Director of Nursing and Personal Care,
registered nurses and registered practical nurses,
personal support workers, who are also called health care aides, and
volunteers.
8. Privacy
"Every resident has the right to be afforded privacy in treatment and in caring for his
or her personal needs."
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In other words...You have the right to privacy. You should feel that you are being
treated with respect when you are given medical care. For example, when your
doctor is examining you, the door to your room or curtain around your bed should
be closed.
You should also have privacy when your personal needs are being looked after. For
example, when you are being dressed or bathed, the door or privacy curtain should
be closed. When you use the washroom, the door should be closed if that is what
you prefer.
9. Participation in decisions
"Every resident has the right to have his or her participation in decision-making
respected."
In other words...You have the right to be involved in decision-making about all
aspects of your life in the home. You get to make the decisions about your
treatment or care. (There is more information about this in Right 11.) In other
decisions about life in the home, such as what is on the menu, or what
entertainment will be available at the home, you may not have the final decision. But
you still have the right to express your opinion or your wishes and to be involved in
the decision-making.
The home should respect your right to participate by:





making sure you are told about any changes they are considering,
giving you all the information you need to help you understand the issues,
giving you a chance to speak
listening to what you have to say, and
trying to make room for your wishes.
Other parts of the Residents' Bill of Rights talk about your right to make certain
decisions for yourself or to take part in decision-making in other areas. Right 9 is a
reminder that, in all these areas, your opinions and your right to participate must be
respected.
10. Personal belongings
"Every resident has the right to keep and display personal possessions, pictures
and furnishings in his or her room subject to safety requirements and the rights of
other residents."
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In other words...You have the right to keep personal things in your room. This is
your home. As in any home, it is important to have personal items around that are
special to you or make you feel more comfortable. For example, you might have a
favourite quilt, cushion, or books. You might have pictures of your children or
grandchildren, or other important pictures. You might also have your own furniture,
computer, or television.
Talk to the staff about what you would like to have in your room. It is your choice, as
long as your belongings do not interfere with the safety or rights of other people in
your long-term care home.
11a. Plan of care
"Every resident has the right to participate fully in the development, implementation,
review and revision of his or her plan of care."
In other words...You have the right to be fully involved in your plan of care, from the
making of the plan, right through to when it is being carried out or changed. A plan
of care is a written document that says what kind of care you need and how that
care will be provided. It covers not only medical and nursing care but also things like
personal support, nutrition, social activities, recreation, and religious practices. Your
plan of care is unique to you.
You have the right to be at meetings with your doctors and others who provide you
with care to talk about the plan of care. You have the right to ask questions and to
say what you want to have in your plan of care.
11b. Consent to treatment
"Every resident has the right to give or refuse consent to any treatment, care or
services for which his or her consent is required by law and to be informed of the
consequences of giving or refusing consent."
In other words...If your doctor suggests a way to help you, you can decide to:



do what the doctor recommends,
not take the doctor's advice, or
talk to another doctor or qualified person to get a second opinion.
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You must be told what will happen to you if you agree to have a treatment or take
prescribed drugs and what will happen if you do not. If there are alternatives to the
recommended treatment or drug, you must be told about them. You need to know
these things in order to make an informed decision.
No one else can make decisions about your treatment if you are mentally capable.
You can have someone help you make decisions, but that too is your choice. You
are mentally capable if you understand and appreciate both what you are doing and
the consequences of your decisions.
If you are not mentally capable of making certain decisions, your substitute
decision-maker must make them for you. A substitute decision-maker is a person
who has the legal right to make decisions for you during times when you are not
mentally capable of making them yourself.
11c. Care decisions
"Every resident has the right to participate fully in making any decision concerning
any aspect of his or her care, including any decision concerning his or her
admission, discharge or transfer to or from a long-term care home or a secure unit
and to obtain an independent opinion with regard to any of those matters."
In other words...You have the right to take part in all decisions about moving into the
long-term care home, leaving it, or moving to another room within it. These kinds of
decisions cannot be made unless you or your substitute decision-maker agree.
You have the right to talk to someone outside your long-term care home to get a
second opinion about the kind of care you need. You have the right to have a family
member, friend, or advocate with you when you meet with doctors and nurses. If
you like, you can ask this person to help you decide what to do.
11d. Privacy of health information
"Every resident has the right to have his or her personal health information within
the meaning of the Personal Health Information Protection Act, 2004 kept
confidential in accordance with that Act, and to have access to his or her records of
personal health information, including his or her plan of care, in accordance with
that Act."
In other words...The law says your health and medical records must be kept private
and confidential. Only the people responsible for your care are allowed to see
these records. Other people can see them only with your permission. Your records
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must be kept in a secure place where others cannot see them. You have the right
to see and get copies of your own records and to show them to other people, if you
wish.
12. Independence
"Every resident has the right to receive care and assistance towards independence
based on a restorative care philosophy to maximize independence to the greatest
extent possible."
In other words...You have the right to get help to become as independent as you
can. For example, you have the right to get help to improve your ability to walk or go
to the bathroom on your own. You have the right to participate in programs at your
long-term care home that can help you keep or improve your independence. For
example, you might be able to do exercises, play games, make crafts, and take part
in other activities that are available. You have this right even if you have cognitive
or other disabilities, or you are unable to leave your room.
13. Restraint
"Every resident has the right not to be restrained, except in the limited
circumstances provided for under this Act and subject to the requirements provided
for under this Act."
In other words...You have the right to be free of restraints, except in the few
situations where the law allows restraints to be used. A restraint is anything that
limits your movement and prevents you from doing something you might want to do.
Some examples of restraints are:





medication or drugs,
wheelchairs with lap belts,
mittens, to keep you from scratching yourself,
bed rails, to keep you from falling out of bed, and
locked doors.
But there are some types of restraints that homes are never allowed to use.
Examples of banned devices are:


roller bars on wheelchairs, commodes, and toilets,
restraints that can be released only with a separate device such as a key or
magnet, and
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
sheets, wraps, or other items used to wrap you to prevent you from moving.
If you are mentally capable, no one can restrain you, put you in a locked unit, or
prevent you from leaving if you do not agree. You may want a friend, family
member, or advocate to help you decide whether you should allow restraints to be
used on you. If you are not mentally capable, your substitute decision-maker must
decide for you.
Sometimes, you may need a restraint for your own safety.
Restraints should not hurt you or make you uncomfortable. If you are put in
restraints, your healthcare providers must check on you frequently. And you must
be assessed at regular intervals by:



a doctor,
a registered nurse, or
registered nurse in the extended class, who is sometimes called a nurse
practitioner.
Your doctor must tell you about any plans to use a restraint on you and explain how
it would be done. You must be told what will happen if you agree to the restraint and
what will happen if you do not.
The only time you can be restrained without consent is during an emergency, if
there is no other way to prevent serious bodily harm to you or someone else.
Medication or drugs can be used as a restraint only during an emergency situation.
14. Communicate and visit in private
"Every resident has the right to communicate in confidence, receive visitors of his or
her choice and consult in private with any person without interference."
In other words...You have the right to meet and talk with people in private.
Because this is your home, you can invite your family, friends, or anyone else to
visit you. You get to choose who visits you. Your family or substitute decision-maker
might not want certain people to visit you and might even tell the home not to let
them visit you. But the home cannot stop anyone from visiting you if you wish to see
them.
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If you want to speak to someone alone, you have the right to do this. Tell the staff at
the home if you do not have enough privacy in your room. They should make
arrangements if you give them notice.
You have the right to keep your mail private, whether you are sending or receiving
it. No one is allowed to open your mail or read it unless you want them to.
15. Visitors during critical illness
"Every resident who is dying or who is very ill has the right to have family and
friends present 24 hours per day."
In other words...You have the right to have your family and friends with you when
your health is critical. If you want them there, they can be with you day and night
and can stay as long as they want.
16. Designated contact person
"Every resident has the right to designate a person to receive information
concerning any transfer or any hospitalization of the resident and to have that
person receive that information immediately."
In other words...You have the right to choose a person your long-term care home
must call right away if you ever go to a hospital or move to another home.
17. Raising concerns
"Every resident has the right to raise concerns or recommend changes in policies
and services on behalf of himself or herself or others to the following persons and
organizations without interference and without fear of coercion, discrimination or
reprisal, whether directed at the resident or anyone else,
a.
b.
c.
d.
e.
f.
the Residents' Council,
the Family Council,
the licensee [the management of the home],
staff members,
government officials,
any other person inside or outside the long-term care home."
In other words...You have the right to speak freely. No one is allowed to punish you
for speaking out or making a complaint. You can talk about things that concern you
and suggest changes to your home's rules and services. You can do this for
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yourself or for others. There are many people who make decisions that affect you.
You may want to give them suggestions or tell them your concerns. Some of these
people are members of the Residents' Council or Family Council, staff at your longterm care home, and government officials.
18. Friendships
"Every resident has the right to form friendships and relationships and to participate
in the life of the long-term care home."
In other words...You have the right to make friends and to spend time with them.
You have the right to be involved in any activities offered at the long-term care
home, if you wish. This can be an important part of your life at the long-term care
home. For example, you may want to participate in exercise classes, be a member
of the Residents' Council, or join in other programs where you can meet other
people and do things together. No one can stop you from doing these things.
19. Lifestyle and choices
"Every resident has the right to have his or her lifestyle and choices respected."
In other words...You have the right to live your life in the manner you wish.
For example, no one can stop you from having a romantic or sexual relationship if
that is what you want. The home should respect your personal preferences and
habits.
20. Residents' Council
"Every resident has the right to participate in the Residents' Council."
In other words...You have the right to participate in the Residents' Council. Every
long-term care home must have one. The law gives these councils certain powers
over how the home is run. Only residents of the long-term care home can be
members of the Residents' Council. Joining the Residents' Council is a good way to
meet people and to have a say in the running of the home.
21. Intimacy
"Every resident has the right to meet privately with his or her spouse or another
person in a room that assures privacy."
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In other words...You have the right to be alone with your spouse or a person who is
important to you. It does not matter whether you are married or not, and it does not
matter whether the other person is of the same sex as you or the opposite sex. The
long-term care home must have a place where you can meet in private and be
intimate, if you wish.
22. Sharing a room
"Every resident has the right to share a room with another resident according to
their mutual wishes, if appropriate accommodation is available."
In other words...You have the right to share a room with another resident, so long
as you both agree and space is available at the home.
The person you share with could be just a friend or someone you are romantically
involved with. You can choose to share your room with someone of the same or
opposite sex. It does not matter whether you are married to each other or not.
23. Personal interests
"Every resident has the right to pursue social, cultural, religious, spiritual and other
interests, to develop his or her potential and to be given reasonable assistance by
the licensee to pursue these interests and to develop his or her potential."
In other words...You have the right to do things that interest you and things that are
important to you, either inside or outside the home. You do not stop being the
person you were before you moved into the long-term care home. You may want to
continue your hobbies, follow your religion, and do other activities. The home
should make it possible for you to do these things, within reason. For example, the
home could:



set aside a special area for prayer,
help get you ready on time for outings, or
contact outside organizations that may be able to help you.
24. Written policies
"Every resident has the right to be informed in writing of any law, rule or policy
affecting services provided to the resident and of the procedures for initiating
complaints."
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In other words...You have a right to be told in writing how to make a complaint about
problems in the home. If you are expected to follow a rule, the home must tell you
about the rule in writing. For example, you must be told in writing about increases
in the basic fee of your long-term care home or in fees for extra services such as
ironing, mending, and hairdressing. All policies about vacations, visiting hours,
discharge, and the use of restraints should be explained to you. The home's policies
must follow the law.
25. Your money
"Every resident has the right to manage his or her own financial affairs unless the
resident lacks the legal capacity to do so."
In other words...You have the right to manage your money while you are in the longterm care home if you are mentally capable of doing so.
Being able to manage your money includes deciding how you will pay your bills at
the home and whether you will have a trust account. It also means understanding
what can happen if you keep large amounts of cash on you or in your room. Even if
you are not capable of making other kinds of decisions, you might still be capable of
looking after your financial affairs.
26. Going outside
"Every resident has the right to be given access to protected outdoor areas in order
to enjoy outdoor activity unless the physical setting makes this impossible."
In other words...You have the right to go outside to enjoy nature, fresh air, and
outdoor activities whenever possible. If the home has a protected area no one can
stop you from using it. You have the right to come and go from the home as you
wish if you are mentally capable. If you are not mentally capable you have the right
to use the protected outdoor area if you wish, as long as the home has one.
27. Bringing people to meetings
"Every resident has the right to have any friend, family member, or other person of
importance to the resident attend any meeting with the licensee [the management]
or the staff of the home."
In other words...You have the right to bring along people who are important to you
when you have meetings with the staff of the home. You have this right whether the
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meeting is an admission conference, a care conference, or any other meeting with
staff.
You may choose to bring friends, family members, or people who advocate for you.
A lawyer is an example of an advocate. Having people to support you at meetings
can be helpful for many reasons. For example, you may want someone to ask
questions or take notes to help you remember all the details. Or, you may need to
meet with the staff to talk about your plan of care or about complaints, but may not
be comfortable doing this by yourself.
**
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Elder Abuse
Janet Stark
What is Abuse?
To misuse, maltreat or insult
What is Elder Abuse?

Elder abuse is harm done to an older person that is violent or abusive.

Elder abuse is often a crime
Who is at risk?

The elderly

More women than men

Young children

The cognitively-impaired

Physically disabled
Types of Elder Abuse
Physical Abuse

Physical assault, such as slapping, pushing or beating an older person

Forced confinement in a: room, bed, or chair
Sexual Abuse

Any unwanted form of sexual activity

Sexual assault
Psychological

Humiliating, insulting, frightening, threatening, or ignoring an older person

Treating an older person like a child
Medical

Denying a person medical care

Withholding medications

Giving extra medications to sedate or control behaviours

Making medical decisions not in keeping with the elderly person’s wishes
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Verbal Abuse

Being confrontational or “talking down” to an elderly individual

Name calling, swearing or using coarse language when addressing the client
Financial

Forcing an older person to sell personal property

Coercing an older person to sign legal papers

Stealing an older person’s money, pension cheques, or possessions

Committing fraud, forgery, or extortion

Misusing a Power of Attorney
Neglect

Abandoning an older person, or withholding food and or health services

Deliberately failing to give a dependent older person what they need

lack of personal care

lack of medical attention

isolation, social & emotional

inadequate living conditions

poor diet

Active: intentional failure of a caregiver

Passive: unintentional

Self-Neglect: assess for cognitive impairment, depression
Who might cause elder abuse?

A family member or friend

Someone the older person relies on for basic needs

Staff in group residential settings, such as care homes, long-term care facilities and
chronic care hospitals

Older persons may be abused by a family member as a result of a previous conflict
in earlier years. It may be “a form of getting even”
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Contributing factors

Alcohol or substance abuse

Financial hardship, greed

Family history of abuse

Lack of communication/agreement

Isolation & lack of support

Dependency

Lack of caregiver recognition
Examples of elder abuse in care facilities:

Confining a resident to a chair or bed by means of a restraint (unless prescribed by
a physician and with family/caregiver consent)

Rough handling when transferring a resident from the chair to bed or vice versa

Feeding a resident either in a hurry or in too large of an amount at one time

Making decisions for a resident without their consent

Leaving a resident isolated in an area they are not comfortable in (neglect)

Accepting gifts from a non-cognitive resident on an ongoing basis

Name calling—especially degrading terms that make the resident feel like a child

Any form of physical contact that is unwarranted such as slapping, shoving etc.

Stop the abuse immediately!

Ensure the resident is safe to leave alone

Report abuse immediately. In a care home it is your professional responsibility

Make sure you have all the pertinent facts and report to your immediate supervisor
and follow-up as necessary
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If older persons are abused by staff in care homes it may be:

due to lack of training

frustration or lack of time to do the care well

caregiver burnout
Who can you call to get help?

your pastor or priest or your volunteer coordinator or supervisor
If you are not getting action you can:

call your area police and ask for the person looking after suspected elder abuse

call the MOHLTC Action Line @

call Advocacy Center for the Elderly @

call CCAC in your local area for advice and information
1-866-434-0144 to report abuse
1-416-598-2656 for legal services
If you are a caregiver and find that you are in a difficult situation or about to cross
the line of safe and compassionate care you can:

ask a colleague to switch resident assignments to offer a quick solution

discuss difficult residents at report or care conferences to come up with solutions

determine if there is a cause of the conflict such as new medication, possible stroke
etc.
Abuse is not always intentional

A situation may have been created that has caused you to “cross the line.” This
may not have been intentional, just a reaction to a situation that was not going well

If this happens to you, tell someone you trust and get help
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Signs to watch for:

Unexplained injuries, marks

Withdrawal, low self-esteem

Passivity, frightfulness

Lack of personal hygiene

Discrepancy between income & standard of living
Therapeutic Relationships
The therapeutic relationship is grounded in an interpersonal process that occurs
between the nurse and the client(s). Therapeutic relationship is a purposeful, goal
directed relationship that is directed at advancing the best interest and outcome of
the client
Developing Therapeutic Relationships

treat people as you would like to be treated (the golden rule)

reflective practice, self-awareness and empathy

Phase of the relationship—has a trust been built? Do I understand the needs and
wishes of the other person—resident, colleague or family member?

Developing therapeutic relationships is part of your professional practice and should
be on-going in your work and life experiences

Older adults need our help and support to live the remainder of their days in a
comfortable and safe environment
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Depression
Risk Factors:

Female gender

Past psychiatric history

Cognitive impairment

Severity of physical illness

PAIN

Degree of functional disability

Loss events
Is it Depression?

Loss of concentration

Difficulties with memory

“I don’t care” responses

Importuning: “attention-seeking behaviours”

Increased somatic symptoms

Fatigue, sleep pattern disturbances

Changes in appetite - (wt loss)

Guilt, helplessness, hopelessness

Symptoms present for at least 2 weeks
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Disappointment: When things are not as one had hoped: “I can’t go to my granddaughter’s wedding because I fell and broke my leg.” This person, can however,
find enjoyment in lots of other things. This person needs support for a temporary
loss.
Demoralization: This term means to undermine the confidence or morale of; to
dishearten. It is when one has lost their spirit. It can be expressed in sadness due
to a loss of health-- “I’ll never dance again after having my foot amputated.” “I had
just retired and planned to tour Europe, when my heart gave way.” This person
may eventually accept the loss and adjust to a new reality. This person needs
support and possibly counseling. Uncared for, this condition may lead to
depression.
Depression: this condition requires more support and intervention to prevent from
becoming a prolonged or chronic condition. The person may appear melancholy or
flat. Things that might normally interest a person do not, and signs of depression
point to a drop in general health. The term depression is often over-used when
what we are describing is disappointment or demoralization
Dementia & Depression
10-50% of patients with dementia have symptoms of depression.
Untreated depression with dementia -worsens cognition and the ability to perform
ADLs (activities of daily living).
Changes in mood, motivation and apathy vary throughout the stages of dementia
Janet Stark
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Screening Tool: Cornell Scale for Depression in Dementia (CSDD)
Scoring System: a = unable to evaluate 0 = absent 1 = mild or intermittent 2 =
severe . Ratings should be based on symptoms and signs occurring during the
week prior to interview. No score should be given if symptoms result from physical
disability or illness.
A. Mood-Related Signs
1. Anxiety
0
1
0
1
0
1
a
0
1
a
0
1
a
0
1
a
0
1
a
0
1
a
0
1
a
0
1
a
0
1
a
2
anxious expression, ruminations, worrying
2. Sadness
a
sad expression, sad voice, tearfulness
3. Lack of reactivity to pleasant events
a
4. Irritability
2
2
2
easily annoyed, short-tempered
B. Behavioral Disturbance
1. Agitation
2
restlessness, handwringing, hair pulling
2. Retardation
2
slow movements, slow speech, slow reactions
3. Multiple physical complaints
2
(score 0 if GI symptoms only)
4. Loss of interest
2
less involved in usual activities
(score only if change occurred acutely, i.e., in less than 1 month)
C. Physical Signs
1. Appetite loss
2
eating less than usual
2. Weight loss
2
score 2 if greater than 5 lb. in one month
3. Lack of energy
fatigues easily, unable to sustain activities
(score only if change occurred acutely, i.e., in less than 1 month)
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2
D. Cyclic Functions
1.
Diurnal variation of mood
a
0
1
2
symptoms worse in the morning
2.
Difficulty falling asleep
a
0
1
2
later than usual for this individual
3.
Multiple awakenings during sleep
a
0
1
2
4.
a
0
1
2
E. Ideational Disturbance
1.
Suicide
a
0
1
2
feels life is not worth living,
has suicidal wishes or makes suicide attempt
2.
Poor self-esteem
a
0
1
2
self-blame, self-deprecation, feelings of failure
3.
Pessimism
a
0
1
2
anticipation of the worst
4.
Mood-congruent delusions
a
0
1
2
Early-morning awakening
earlier than usual for this individual
delusions of poverty, illness or loss
Scoring:
A score >10 probably major depressive episode A score >18 definite major
depressive episode
(reprinted from Biological Psychiatry, volume 23, Alexopolous GS, Abrams RC, Young RC,
Shamoian CA, “Cornell Scale for Depression in Dementia,” page 271-284, copyright 1998, with
permission from the Society of Biological Psychiatry.
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Depression in the Elderly - Tips for Caregivers
The pastoral care worker provides a caring relationship that can often prevent
depression setting in or escalating into a crisis that requires hospitalization or
results in suicide.
1. Be on the alert for symptoms of depression. Encourage them to talk about it.
Let them know there is no stigma to being depressed, nor stigma related to
the requirement of mediation for their depression.
2. Learn as much as you possibly can about Depression.
3. Let the person know you feel no stigma towards Depression by your responds,
body language, tone, etc.
4. Encourage & give permission to the expression of anger. Listen attentively to the
possibility of unresolved experiences in their lives.
5. Keep in regular contact – give a clear time & date of your next visit & make sure
they are informed as soon as possible if you are unable to keep your
commitment.
6. Encourage and facilitate membership in a group.
7. Display sincere interest I the person, their days activities, their families, their
interests.
8. Seek the person’s advice or help in something he/she can do.
9. Comment favourably on person’s performances (past ones if present ones are
slipping) Encourage past or present accomplishments (the depressed person
can’t usually see any
accomplishments being positive).
10. Listen without judging. Encourage persons to share feelings of guilt. Encourage
person to express anger. (Suppressed hurt turns to anger. Suppressed anger
turns to depression)
11. Encourage person to make decisions for him/herself, if possible, in order to
bolster self-esteem and self-confidence.(with sensitive guidance and support)
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12. Cater to person’s strengths, by encouraging recounting of successful part of
their life. (or playing an instrument, doing handcraft, etc.) Invite them to do
something for someone else.
13. Remember to use touch.
14. Encourage come form of exercise & fresh air. They don’t usually feel up to it.
Encourage proper diet. Encourage person to seek professional help.
15. If they appear to be struggling with identification of their illness – help them to
identify some of the warning signs of Depression.
16. Be creative in finding ways to stimulate interest, (e.g. animals, children,
cooking, family album.)
17. Don’t claim their pain – it’s theirs. Remember you’re a support person. It is easy
to get caught up in the same feelings yourself.
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About the Eden Alternative
The Eden Alternative is based on a set of guiding principles, as set forth by its
founders, Dr. William and Judy Thomas. The Principles are eloquently illustrated in
Dr. Thomas' book Learning from Hannah, and are summarized below.
The Eden Alternative Ten Principles
1. The three plagues of loneliness, helplessness and boredom account for the bulk
of suffering among our Elders.
2. An Elder-centered community commits to creating a Human Habitat where life
revolves around close and continuing contact with plants, animals and children. It is
these relationships that provide the young and old alike with a pathway to a life
worth living.
3. Loving companionship is the antidote to loneliness. Elders deserve easy access
to human and animal companionship.
4. An Elder-centered community creates opportunity to give as well as receive care.
This is the antidote to helplessness.
5. An Elder-centered community imbues daily life with variety and spontaneity by
creating an environment in which unexpected and unpredictable interactions and
happenings can take place. This is the antidote to boredom.
6. Meaningless activity corrodes the human spirit. The opportunity to do things that
we find meaningful is essential to human health.
7. Medical treatment should be the servant of genuine human caring, never its
master.
8. An Elder-centered community honours its Elders by de-emphasizing top-down
bureaucratic authority, seeking instead to place the maximum possible decisionmaking authority into the hands of the Elders or into the hands of those closest to
them.
9. Creating an Elder-centered community is a never-ending process. Human growth
must never be separated from human life.
10. Wise leadership is the lifeblood of any struggle against the three plagues. For it,
there can be no substitute.
www.edencan.com
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Cognitive Disorders
Cognitive disorders consist of two main types: Dementia and Delirium (an acute
medical emergency, also referred to as a reversible dementia or pseudodementia).
Delirium: Delirium is a medical emergency that presents as a psychiatric problem.
Possible causes:

Medications: sensitivities, interactions, toxicity e.g. digoxin

Infections e.g. UTI- urinary tract infection, pneumonia

Thyroid deficiency

Dehydration and electrolyte imbalance

Vitamin deficiencies e.g. Vitamin B12

Metabolic disorders e.g. hyperglycemia

Post-op / general anesthetic delay in recovery e.g. hip repair

Hypoxia- restricted oxygenation

Substance abuse

Withdrawal from meds eg. bezodiazepines (Ativan), antidepressants

Dialysis

Head injuries: brain trauma

Sensory overload or deprivation
Signs and Symptoms:

Acute sudden onset is typical

Fluctuating symptoms that can change throughout the day or hour

Disturbance in sleep-wake cycle e.g. awake, restless at night

Fluctuations in activity, from drowsy and stuporous, to restless and agitated
(pulling on IV, catheter, picking at linen, calling out…)

Decreased attention, easily distracted.

Change in cognition with memory loss, disorientation, languagecommunication difficulties, perceptual disturbance, misinterpretations

Hallucinations and delusions (false fixed ideas or beliefs)

A significant finding in a lab report or medical examination may provide the
cause of the underlying medical problem.
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Delirium
Delirium is an acutely disturbed state of mind that occurs in fever, intoxication, and
other disorders and is characterized by restlessness, illusions, and incoherence of
thought and speech. Delirium is NOT dementia, and many times is reversible with
proper medical assessment and care.
Risk Factors for Delirium
 Cognitive Impairment
 Sleep Deprivation
 Immobility
 Visual or Hearing Impairment
 Dehydration
 Anaesthetic
Conditions that may present with Dementia-like symptoms

Infections (eg. UTI, respiratory)

Dehydration

Metabolic imbalances (e.g. B-12, hypothyroidism)

Medication including anesthesia

Head injury, brain tumors, trauma

Cardiovascular or respiratory disease

Depression

Visual &/or hearing loss
If Delirium is suspected always:

Act immediately to identify and correct the underlying medical cause.

Ensure adequate hydration and nutrition, and elimination.

Optimize hearing and vision by using hearing aids, glasses.

Familiar surroundings and environment. Reduce environmental noise.

Encourage and support exercise as tolerated.

Use orientation cues as clocks and calendars in a well-lit room.

Provide consistent staff or family member(s) to provide care.

Avoid restraints, and restraining equipment if possible, e.g. catheters
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Dementia
The term Dementia refers to a group of disorders that exhibit symptoms
similar to Alzheimer disease (e.g. memory loss, disorientation, etc.), which are often
progressive and so severe as to lead to impairment in a person’s daily functioning.
The areas affected in the central nervous system (CNS) define the different types of
Dementia. Alzheimer disease is the most common.
Dementia Breakdown:
Alzheimer disease accounts for more than 50% of dementias.
The other dementias include:

Vascular Dementia

Lewy Body Dementia

Frontal lobe Dementias

Alcohol Related Dementia e.g. Korsakoff’s
Alzheimer Disease
Alzheimer disease is a chronic degenerative, irreversible organic brain disorder.
Beginning with what may at first be almost imperceptible changes such as
forgetfulness and confusion, leads to severe intellectual and physical impairment,
ultimately leading to death. At present there is no known cause or diagnostic test.
Diagnosis is made after a comprehensive assessment and natural history.
In Alzheimer disease there is an overall shrinkage of brain tissue due to loss of
neurons, with amyloid plaque formation, neurofibrillary tangles and localized
inflammation. This pathology is seen on autopsy. In general the course of the
disease progresses through a series of predictable stages with so-called typical
symptoms, over a period from several years to twenty years.
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Stages of Alzheimer Disease
The staging of Alzheimer Disease has been described in a variety of ways from the
three stages of early, middle, late, also called mild, moderate and severe, to the
seven stages developed by Dr. Barry Reisberg in the Global Deterioration Scale.
t is important to remember that the disease affects each person differently. The
order in which the symptoms appear, and the length of each stage will vary from
person to person.
Early Stage:

loss of short term memory pertaining to recent events, conversations

difficulty remembering the right word or “mixing up” words (word finding
difficulties)

awareness of changes in their abilities

may become passive or withdrawn from activities

shorter attention span

out of character behaviours

difficulty making decisions of finding routes while driving a car

difficulties in learning new things, or changes to an established routine.

poor judgment

not reading as much as before

signs of depression (loss of appetite, poor sleep, physical complaints)

sporadic loss of ability to do complex, familiar daily activities such as writing
a cheque, playing cards, following a recipe.
Interventions:

Obtain thorough medical assessment. Monitor medication administration. Avoid
use of over-the-counter medication and herbal remedies unless approved by
physician.
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
Specialty referrals to Memory Disorder Clinics, neurology, geriatric psychiatry, if
required.

Seek counseling and education (Alzheimer Society and VON Alzheimer
Outreach)

Family conferencing

Seek legal and financial advice- Advanced Care Planning: appoint Power of
Attorney

Adjust lifestyle as required: retirement, driving, etc.

Contact the ACCC to register for future needs and obtain information on
community supports & programs.

Establish a support network of family, friends, and supportive partners

Maximize physical status: optimize nutrition, hydration and exercise, rest and
sleep.
Middle Stage:

memory becomes increasingly impaired

individual may lose awareness of his/her personal history

personality and behaviour changes

changes in mood and emotions may occur

anxiety , fear and restlessness may be apparent

misinterpretations may lead to frustration, fear and anger

visual hallucinations, delusional behaviour may be evident.

increased confusion and disorientation to time and place

loss of functional abilities requiring assistance with daily tasks such as bathing,
dressing and grooming.
Interventions:

Seek in-home help: register with the CCAC (Community Care Access
Center)

Investigate Day Programs and Respite programs through the CCAC
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
Future planning: including the person with dementia, family, substitute
consent giver(s) and supportive agencies.

Focus on safety inside and outside the home; including driving, use of power
tools, farm equipment, kitchen appliances..

Compensate for deficits and maximize assets.

Avoid unnecessary changes in environment or routine.

Continued use of glasses and hearings aids to help ground the person in
their environment.

Continue to have physical health monitored by physician.

Optimize nutrition and hydration. Monitor for urinary tract infections and/or
constipation.

Provide for time for exercise, rest and comfort.
Late Stage:

obvious cognitive impairment

significantly impaired memory

significantly impaired communication

significantly impaired ability to care for oneself

“fear” a common emotional undertone

marked behaviour challenges

physical problems may arise, e.g. incontinence

visual or auditory hallucinations may become more evident

may misinterpret what is seen and heard.
Interventions:

Minimize stress

Seek help from all sources

Focus on health of person and caregiver

Continue with support and education systems for caregivers
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
Access respite care

Be prepared for placement

Focus on remaining abilities!
Terminal ~ End of Life:

complete withdrawal: the person appears to have lost the ability to speak or
understand language

usually maintains a sense of self and emotional memories

the person requires total care for ADLs.

Emaciation and high risk for infection often leads to death.
Interventions:

maximize comfort and warmth

ensure the person is free from pain or pain is well managed.

provide for visits by clergy according to person/family wishes

provide for pleasurable activities known to be enjoyable by the person with
dementia e.g. type of music playing, prolonged visits by family, diet of
pleasurable tastes e.g. chocolate: guarding against risk for choking,
hyperglycemia etc.

continue all systems of support

rest and regroup

support family

arrangements after death: possibility of autopsy
The person living with dementia still has many experiences they can respond to and
derive pleasure from such as: sensory events (smell, sight, touch, taste and sound)
and social situations. Their emotional memories are retained till the end stage. The
person is an adult and with the loss of functional abilities they must be treated with
dignity and respect.
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Vascular Dementia
Vascular dementia is a term that encompasses cognitive impairment secondary to a
number of conditions that compromise circulation of blood to the brain, including
small vessel disease and multi-infarct dementia. Unlike Alzheimer disease the
cause of vascular dementia is known. If blood vessels in the brain burst (cerebral
hemorrhage), if arteries becomes blocked by clots or plaque (thrombosis or
embolism), or it there is insufficient blood flow to the brain (ischaemia or infarct)
brain tissue will die. This is often referred to as a stroke or (cerebral vascular
accident or CVA), or mini-stroke (transient ischaemic attack or TIA). Recognition of
an underlying risk factor for vascular dementia: high blood pressure, often leads to
specific treatment that may modify the progression of a vascular dementia.
Vascular dementia progresses in a step-wise fashion: a loss of cognitive or
functional abilities may follow a cerebral vascular event, then stabilize until the next
event. With continued cerebrovascular events the steps become so small- the
decline appears gradual.
The individual’s progression of symptoms depends on the part of the brain affected.
Individuals with damage to the left hemisphere are more prone to impairments in
communication and are at a higher risk for post-stroke depression. There may be
emotional swings with periods of laughter, or tears referred to as “emotional
incontinence”. Epileptic seizures or partial/total paralysis may result from brain
damage.
Binswangers’ Disease
Binswangers is a rare form of a vascular dementia characterized by lesions in the
deep white matter of the brain (subcortical arteriosclerotic encephalopathy). It is
characterized by loss of memory, impaired cognition and mood changes. Abnormal
blood pressure, stroke, disease of the large blood vessels in the neck and disease
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of heart valves are common. Symptoms may include: urinary incontinence, difficulty
walking, Parkinsonian-like tremors, slowness, lethargy, and depression. These
symptoms occur early in the disease with progressive cognitive impairment
developing later, which may be accompanied by delusions and agitation. A
diagnosis of Binswanger’s is rarely seen.
Lewy Body Dementia
Lewy Body Dementia is the result of degeneration in key areas of the brain
associated with abnormal structures (Lewy bodies) affecting the brain stem- which
result in symptoms similar to Parkinson’s Disease, and the cortical areas of the
brain which produces symptoms similar to Alzheimer Disease.
A combination of key features distinguishes Lewy Body Dementia from other
dementias. Features similar to Alzheimer disease are present such as difficulties
with organizational skills, word finding, and visuospatial abilities. Some of the
features exhibited can be confused with a Delirium.
* Remember with Delirium the onset is sudden and parkinsonian symptoms are not
characteristic.
Classic features of Lewy Body Dementia:

Fluctuating confusion and cognitive performance in the early stages of the
disease, for example a client may be able to hold a conversation one day,
and the next, be lethargic and mute.

The presence of parkinsonian features including shuffling gait, flexed
posture, reduced arm swing, tendency to fall, and rigidity. Presence of a
tremor is the least common parkinson’s feature of a client with Lewy Body
disease.

The presence of visual hallucinations, which may or may not be disturbing to
the client. The client may have some insight into reality.
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
Clients with Lewy Body dementia have a sensitivity to antipsychotic
(neuroleptics) medication (e.g. Haldol, olanzapine, risperdol). Administration
of antipsychotic medication further reduces the dopamine levels resulting in
exacerbation of parkinsonian features. Use of anticholinergic medication
such as Exelon or Aricept has shown to be a better treatment choice.
Frontal Lobe Dementia (FTD)
Frontal lobe dementia is also referred to as frontotemporal dementia (FTD) and
includes Picks disease. Frequently staff label this client as “difficult” or
“manipulative” as their presentation is not typical of a dementia.
The first symptoms of frontal lobe dementias are not memory loss and cognitive
decline. Instead there is a history of changes in behaviour .The age of onset is
younger than with Alzheimer disease. Features may include social
inappropriateness, insensitivity, lack of attention to personal hygiene and grooming,
disinhibition, impulsiveness, sexual misadventures, loss of insight, poor judgment,
obsessiveness, hyperorality (compulsive overeating, often craving sweets, and/ or
putting inedible objects in mouth) or pica (ingesting inedible material), echolalia
(repeating what is heard), difficulty with word finding, and use of “jargon”.
Frontotemporal Dementias are insensitive to the Folstein Mini Mental state Exam
(MMSE) as it tests memory and orientation, features relatively preserved in FTD.
Testing of insight and judgment will reveal impairments.
Treatment options vary with presentation. Frontotemporal dementias often exhibit a
deficiency in serotonin levels therefore the SSRI class of antidepressants may be
considered as a choice of treatment.. Use of cholinesterase inhibitors (Aricept and
Exelon) and the newer antipsychotics (olanzapine, risperdol) are other options, in
addition to a well structured care plan with full team compliance.
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Alcohol Related Dementia: Korsakoff’s
Korsakoff’s Dementia is the most common cause of alcohol related dementia.
Thiamine deficiency can lead to Wernicke’s encephalopathy and Korsakoff’s
syndrome or dementia. It is also associated with malnutrition.
Korsakoff’s Syndrome can also be caused by toxic or infectious brain disease
(anterior posterior polioencephalitis).
Both disorders are characterized by severe memory loss, especially short-term
memory with a tendency for confabulation: filling in memory gaps with fabricated
ideas, often in great detail.
All “alcoholics” or individuals suspected of steady alcohol use should receive
thiamine supplements (IM /po), especially during the critical period of time after
cessation of alcohol use/ withdrawal, usually post admission.
Normal Pressure Hydrocephalus (NPH)
Normal Pressure hydrocephalus (NPH) is an uncommon disorder that involves an
obstruction in the normal flow of cerebrospinal fluid. This blockage causes a build
up of fluid in the ventricles of the brain. The cardinal signs of NPH are difficulty
walking, urinary incontinence, followed by dementia. Diagnostic investigations such
as a CT scan or MRI can diagnose the problem. If detected early and corrected by a
neurosurgical procedure (insertion of a shunt), the symptoms can be reversed.
Parkinson’s Disease
Parkinson’s Disease belongs to a group of conditions called motor system
disorders. The four primary symptoms are

tremor in hands, arms, legs, face, and jaw

rigidity or stiffness of limbs and trunk
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
bradykinesia or slowness in movement

postural instability or impaired balance and coordination.
Often the patient with Parkinson’s disease bears a “masked facies”, and appears
apathetic, expressionless or depressed. The disease is both chronic, meaning it
persists over a long period of time, and progressive, meaning its symptoms grow
worse over time.
Parkinson’s disease occurs when certain nerve cells in the brain (substantia
nigra) die or become impaired. Normally these cells produce a neurotransmitter
called dopamine that is responsible for transmitting signals to produce smooth,
purposeful muscle activity. A large percentage of patients experience visual
hallucinations, which are related to the disease and the treatment, ( e.g. Sinemet,
Requip). The hallucinations are a side effect of increasing the available dopamine in
the brain. Most patients generally have insight and recognize the visual
hallucinations as “unreal” and tolerate their occurrence - when the hallucinations are
not disturbing or distressing.
Only 30-40% of Parkinson patients develop dementia. The majority of which present
with Alzheimer-like symptoms. A smaller percentage appear to have a Lewy Body
type dementia. Patients with Parkinson’s disease are at a high risk for depression,
especially in the early stages.
Other Dementia Related Disorders

Alzheimer Disease and Down’s Syndrome

Aids Dementia Complex

Huntington’s Disease

Creutzfeldt Jacob Disease (Mad Cow Disease)

Progressive Supranuclear Palsy

Multiple Sclerosis

Brain Injury including Pugilistic (Boxer’s) Dementia

Tertiary Stage Syphilis
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Behaviours May Include:
Agitation
Catastrophic Reactions
Demanding
Denial of Problems and of need for Help.
Hallucinations and Delusions
Inappropriate Sexual Behaviour
Insulting
Physical Aggression
Repetition
Rummaging, Pillaging and Hoarding
Shadowing Staff
Sundown Syndrome
Wandering
Withdrawal and Depression
Source: Excerpted from Pieces of the Puzzle.
Reproduced with permission from the Alzheimer Society of Nova Scotia, 1996.
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Symptoms and Behaviours
Memory Loss... May Result In:

Difficulty in learning new material

Difficulty in adjusting to new situations

Inability to concentrate

Disorientation -time, place, person

Denial, concealment, confabulation, cover-ups

Depression, apathy, withdrawal

Repetitiveness, rummaging

Suspiciousness, paranoia, hiding things

Losing items, wandering
Intellectual Loss…

Shortened attention span

Lack of reasoning ability

Loss of ability to abstract and to do simple math

Impaired judgement/making decisions

Loss of inhibitions/compulsiveness

Loss of ability to follow directions

Deterioration of conversational and social skills
Perceptual Loss…

Misinterpretation of senses

Difficulty reading and watching television

Fear /insecurity / clinging
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Language Dysfunction…

Inability to understand and misinterpretation

Difficulty finding words

Using wrong, but perhaps related, words
Motor/Sequencing Loss…

Sleep disturbance --insomnia

Restlessness/nervousness

Difficulty in starting/stopping a task

Inability to follow a logical sequence, components of task get mixed up

Incontinence
Delusions and Hallucinations…

Anxiety , fear

Confusion, inappropriate behaviours
Personality Changes/Mood Swings

Anger, aggressiveness, combativeness

Catastrophic reactions
Feelings Remain Intact…

Embarrassment, shame

Hurt feelings/sadness

Feelings of rejection
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Strengths…

Ability to perform habitual tasks

Ability to continue with a simple task for a long time

To recall long term memories

Sense of humour and fun
Anyone of these symptoms/behaviours may result in unbearable frustration, fear,
depression or anger. Many symptoms may precipitate a catastrophic reaction or
uncooperativeness. Certain symptoms occur frequently enough to be called typical
of the disease, but some are less common than others.
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7 A’s
Anosognosia
 Loss of knowledge of illness
 Forget that they forget, so blame others when things go wrong
 Spouse compensates
Amnesia
 Memory loss
 May not remember recent conversations, comments, questions
 Lose things
 Short term memory loss
 Long Term memory usually intact
Agnosia
 Loss of recognition of sensory information (sight, sound, smell, touch, taste)
 May misinterpret what is seen and heard etc..
Aphasia
 Loss of language (both speech & comprehension)
 Word finding difficulties
 May not participate in conversations
 May revert to first language
Apraxia
 Difficulty with complex tasks ie. making a pot of coffee, dressing..
 Difficulty directing body parts to do familiar tasks
 Difficulty understanding directions
Apathy
 Loss of drive
 Reduced or no initiation of activity
 Little or no emotional response
Altered Perception
 Misinterpretation of sensory information
 May lead to illusions &/or delusions
 Loss of colour & visual perception
 Loss of depth perception
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Effects on the Family
The Alzheimer person requires continuous care, and the caregiver's job has been
aptly referred to as a 36-hr. day. The daily demands of caring for someone who is
chronically ill, with its many-sided responsibilities, is itself a form of chronic illness.
The unrelenting emotional stress and physical strain are augmented by the
realization that the condition is degenerative and untreatable. Families must deal
with one set of problems, only to be confronted with new ones. Nothing is static,
circumstances are always changing unpredictably and uncontrollably. Add to this
the "stigma" that still exists for brain dysfunction disorders and the result is a
pressure-cooker existence.
Alzheimer Disease is definitely a family problem. All family members must cope with
the ongoing sense of loss and feelings of empathy for the person who is
"intellectually" dying.
Family dynamics are threatened. Interpersonal tensions arise, magnify or
reactivate between members. Role-reversal problems are common and changes in
the relationships alter a family's structure and equilibrium. Teenagers or spouses
may justifiably feel neglected by the person absorbed in caring for the A.D. patient.
There is the undeniable fear of hereditary considerations.
Often one or more members of the family are misguided in their assessment of the
situation and the impaired relative usually due to lack of education or denial of the
disease. It is necessary to understand the disease and the afflicted relative in order
to avoid inappropriate expectations and misinterpretation of his behaviour.
Various family members may be at different stages in the process toward
acceptance. Acceptance can come only after relatives have understood the disease
process and come to terms with the fact that their loved one is and no longer will be
the person they once knew. A delicate balance between overprotection and
insufficient attention is hard to achieve. Sadly, family members must watch the slow
disappearance of those characteristics that make up the unique personality of their
relative.
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Reactions of families coping with the disease may be similar to the reactions
of families coping with death. It is natural to try to deny the reality of this insidious
disease and extremely difficult to accept such a horrible prognosis. Denial that
anything is seriously wrong is usually followed by over-involvement of the family,
including desperate searches for treatments and cures. Anger follows once the
seriousness of the disease is appreciated. "WHY ME?" feelings can lead to
depression, remembering how things were and what could have been, and
anticipation of more loss. Finally comes the resolution or acceptance, which
involves a certain degree of sadness and continuous mourning.
This process of mourning is very like the process described by Kubler-Ross,
author of On Death and Dying. Since the bereavement process is anticipatory and
painfully on-going, some family members may emotionally and/or physically
withdraw too early. The mourning process can go on for years, and anticipated grief
can reoccur with each decline in the person’s condition.
Relatives may also experience fear of the unknown cause of the illness,
despair over personal inadequacies and an inability to cope, guilt when they feel
negative emotions, resentment when the impaired relative fails to respond to TLC,
and the always present sadness that accompanies mourning.
Families exhibiting excess denial can be helped through education. In some
cases confrontation is necessary in order for families to reach the stage of
acceptance needed to make realistic plans for maintenance and management.
Individual or group psychotherapy may be recommended.
It is much more productive for the family to acknowledge the illness and
accept the fact that there is nothing that can be done to reverse the condition.
However, families can still care for the person and make him/her as comfortable as
possible by showing kindness and affection. Each family must realistically assess its
own situation and decide what to do about it.
Experienced caregivers and professionals offer good advice: Take one day
at a time! The magnitude of the whole process is such that the caregiver can only
effectively cope with life one step at a time. It is necessary in some matters,
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however, to plan ahead. Certain legal matters, institutionalization, and death
preparation are best done before the need actually arises.
In order to cope with the dynamic changes that occur, it is helpful to adjust
and accept each moment as it comes, to make life liveable right now. Enjoy as
many "little things" as possible. One husband states "There are not that many
rewards but learn to enjoy them...you change along with her...find things funny
together that would not have been funny before".
In their need to "care so much", caregivers often lose sight of their own
personal needs and interests and future. Some caregivers, particularly spouses,
refer to themselves as "prisoners of love". Obviously life must change for the family
who cares for an A.D. relative at home and social isolation and loneliness are the
problems most commonly expressed by the primary caregiver. The caregiver must
actively work to avoid an unhealthy preoccupation with the A.D. person at the
expense of his own needs. As the loved one's memory fade farther away, the
caregiver carries many battle scars that may remain vivid in his own memory ...with
guilt, the caregiver may welcome some respite from the burden of loving. They
must accept the fact that protecting themselves is also protecting the person who
depends upon them.
We can help families and patients understand and make sense of what they
are experiencing. We can help them realize that they are capable of enduring what
they initially found to be unbearable. We can help then find the tools to get through
the process to minimize the pain.
Suffering is experienced by persons, not merely bodies. A person can suffer
enormously at the distress o another, especially a loved one. One family caregiver
is quoted, "A.D. shows no mercy, has little grace, and leaves most families
devastated".
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Communication with Dementia Patients
Communication is the way we share information or exchange ideas. When one
person conveys a message the other expects a response. This is how we interact
with each other. As human beings we need contact with others and the support that
comes from that. Communication is two way, requiring two people. When one of the
two is impaired, communication becomes difficult.
When we think of communicating we usually think of language, and Alzheimer
Disease has a profound effect on language. The disease affects speech and the
use of words, as well as the understanding of the words heard. As the disease
progresses, language as a means of communicating becomes less and less
effective. You need to use different ways of getting the message across and
staying in touch.
Communication with a person with Alzheimer Disease requires belief, creativity,
understanding, patience and skills.

Belief -that every person, regardless of disabilities, maintains a core of self that
can be reached.

Creativity -in expressing both your feelings and your message.

Understanding -of the effect of the disease on communication.

Patience -to slow down, listen, watch, wait for a response, repeat a phrase.

Skills -to convey messages or feelings effectively.
Getting a message across
Set the stage
Communication is always easier if other things are not happening at the same time.
When trying to get your message across, make sure that there are few distractions.
For example, if the TV or radio is distracting the person, turn it off.
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Get his/her attention
Approach the person slowly and from the front. Gently touch a hand or arm to help
get attention. Wait until he/she seems ready to listen before talking.
Make eye contact
Sit facing or standing in front of him/her, if possible. Keeping eye contact will help
the person know who is speaking and may assist the person in concentrating on the
message.
Speak slowly and clearly
Use simple words and short sentences to make the message clear. If the person
has hearing problems lowering the pitch of your voice is often better than increasing
its volume.
Give one message at a time
Keep a conversation simple. Too many thoughts or ideas at one time can be
confusing. Limit choices: questions which can be answered with a "yes" or "no" are
easier than open-ended ones.
Pay attention
The person's reaction to what you say can give you some idea of how much is
understood. Watch facial expressions and body movements. Respond to moods
and emotions even when the words don't make sense or are inappropriate.
Repeat important information
If you are uncertain the message was understood the first time, repeat it using the
same words.
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Show and talk
Use actions as well as words. For example, if it is time to go for a walk, point to the
door or bring the person's overcoat or sweater to illustrate what you mean.
Take time
Allow the individual time to respond. Interrupting can discourage further
communication.
always remember...

That feelings remain despite the losses caused by Alzheimer Disease. Feelings
may be the only way an individual understands what is going on.

That we all communicate by emotion, expression and touch. Holding a hand, or
smiling when talking can convey more than any words.

To be aware of your body and facial expressions. Harsh glances can be just as
negative as harsh words.

To include the individual. It is painful to be ignored because of your difficulties in
communicating.
The quality of life of individuals with Alzheimer Disease is largely dependent on their
interactions and relationships with others. Maintaining a connection can be a
complex and challenging process. Some days it may seem that nothing is
understood, while on others much is exchanged and felt. Try to make the most of
the good days--let them help you through the tough ones. Common sense helps, for
no one has all the answers...keep trying. You are doing the best you can.
In addition...
We are learning more about Alzheimer Disease and its care everyday--much of it
from caregivers like yourself who find solutions to problems and share them with
others. You can call you local Alzheimer Society to find resources in your
community. You can also exchange ideas by visiting the Caregiver Forum on our
Web site, www.alzheimer.ca There is information. There is help. You are not alone.
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End of life care in Alzheimer Disease
Even though Alzheimer Disease can persist for decades, it is a terminal
illness. The care of the dying demented patient should be guided by his/her wishes
as much as possible. For individuals with Alzheimer’s disease, advance planning is
essential. During the earlier stages of the illness, patients often retain the capacity,
and should be asked for direction as to what they would like to see done in the
future if they cannot provide direct input. They can be asked for their choices about
future medical decisions and they can also be asked to designate a surrogate or
agent who will be entrusted with the responsibility of making treatment decisions for
them. As much as possible, decisions for incompetent individuals should be based
on what it is felt the patient would have wanted. It is important for physicians to
know the relevant laws in their provinces with regards to this issue.
An individual has the right to refuse or withdraw from any treatment, including
treatment of life-threatening conditions. These choices must be respected. If the
patient lacks decision-making capacity, it is important to determine whether the
patient has made any advance directives and who is the decision-maker for the
patient. Generally there is an agreement on the appropriate approach between the
patient (or legal representative), other family members, and the attending physician.
The legal surrogates of the patient have the right to consent to medical therapies.
The care of the dying patient focuses on the relief of any distressing symptoms. The
Fairhill Guidelines on the ethics of care of those with Alzheimer disease hold that in
the terminal stages of Alzheimer disease the provision of comfort care only, is an
appropriate approach. The Alzheimer Society of Canada has endorsed this.
Aggressive medical treatment may be extremely onerous to the individual. Often
issues arise with regards to hydration and nutritional support. Management options
would include hypodermoclysis (subcutaneous drip), and percutaneous
endocscopic gastrotomy (PEG) tube placement.
A consensus-based approach to providing palliative care to patients who lack
decision-making capacity has been described. The identified steps to providing
palliative care to these patients are as follows:
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
Identifying the main participants in the decision-making.

Allow the participants to narrate how the patient has come to this stage of the illness
or update the physician in those cases where the physician has an extended
relationship with the patient and family.

Teach the decision-makers about the expected clinical course of the patient’s
disease.

Advocate for the patient’s quality and dignity of life.

Provide guidance on the basis of existing data and clinical experience.

A decision should be based on patient’s preferences, the balance of burdens and
benefits of each option & its ability to relieve suffering, and maximize dignity and
quality of life.
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The Final Stage
When the mind is lost we encourage important strategies to ensure the comfort of
the dying person through these areas:
~ Hydration
~ Nutrition
~ Massage
~ Spiritual Care
~ Respect
The goal is to assist and support the family and friends in achieving a serene
passage from life to death. We encourage families to be with them through the final
mysterious stage of life.
Families are helped to reach the person on a sensory level
through the use of strategies such as massage with lotion, holding them, rocking
them or cradling them.
Effects on Family When end-of-Life Occurs
Often when there is little or no response from the dying person, family members feel
discouraged, grief stricken, or even foolish in their efforts.
Those of us in the profession of supportive care need to role model and encourage
efforts to reach the person who is dying.
There is evidence at some level, the person with dementia can be reached and
afforded a sense of peace. Families who engage in such activity through the dying
time of dementia feel comforted and effective.
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An Experience Captured by A Support Worker
I was privileged to be present at the dying time of a man whom I had worked
with, and had been with the family through the experience of dementia. He and I
had shared a love of dogs, and had spent many lovely times together swapping
stories and playing with my dogs.
As he lay curled up in the final stages of life, the grief and loss of his family
was devastating. They felt unable to reach him in anyway. No vestige of the man
they loved remained.
With the family’s consent, I decided to bring in my big beast Michael to visit.
As the man lay curled up on the bed, we placed the dog in his arms beside him. Big
Mike, of course, loves to cuddle, and made the most of his comfortable place.
Gradually as the dog’s warmth and softness permeated his skin, the man began to
slowly, ever so slowly stroke the dog’s fur. How could this be, when no purposeful
movement is possible at this stage?
And yet, as the family watched the tiny familiar gesture, they were flooded
with the memories of their loved one – in different times, in better times. Suddenly
he was with us again.
Moving On
Moving on with your life will not be easy. Even though you began the grieving
process long ago, there may be a hole in your new life alone that will never be filled.
Take comfort in knowing that you provided the best care, love and support to the
person with Alzheimer disease that you could.
Remember the Person:
Reminiscing about happy times may bring comfort.
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Case Studies
Frontotemporal Dementia:
Mr.Simpson, age 58 years, was diagnosed with a Frontal Lobe Dementia by the
Geriatric Psychiatry Outreach Team. He lived on the farm with his wife of 32 years.
She and her family had noted changes in his behaviour over the last 2-3 years. Last
spring he sold their herd, below market price, without discussing it with his wife or
son, and planned to raise prize bulls. This alarmed the family. Although Mr.
Simpson had discussed a lot of “get rich quick” ideas in the past several years, he
never acted on them. Prior to this period he was very frugal and conservative with
his decisions.
When neighbours visited, especially Mrs. Simpson’s female friends, he was either
rude or flirtatious, embarrassing everyone but himself. The family had assumed the
changes in his behaviour were due to alcohol and suspected he may be hiding his
drinking. He consumed a moderate amount of alcohol in the past but always after
chores were finished for the day.
His driving was becoming more of a concern as he acted impulsively. Mr. Simpson’s
son would not allow his children in the car when his father was at the wheel. One
night he never came back from town and was found in the neighbouring farmer’s
field asleep in his truck. Alcohol was not a factor.
During his assessment he scored well on the Folstein Mini Mental State Exam with
29/30 losing one point on the 3 stage command: when asked to fold the paper in
half he folded it into the shape of a kite. He was well oriented to time, date, year and
place. When asked to list 7 words starting with the letter “F”, he listed 4 with
difficulty (farm, Ford, fist, food, then repeated “Ford”, then went on to list two other
car makers: “Chev” and “Dodge”.
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Later when his wife was interviewed she was quite anxious, as her husband’s
actions were distressing to her. Several months prior, while in church he grabbed
her buttock, and loudly declared “That is still a nice piece of ass!” - completely out of
character. Friends and family were avoiding the couple. His hygiene was another
concern. His wife had a difficult time getting him out of his filthy coveralls to bathe
and change clothes even once a week, and resorted to her son’s coercion to get
him to bathe.
Mr. Simpson’s son noted his father had neglected the accounts for the farm and
was not concerned with paying bills or doing the banking. The son was a support to
his mother and was easily accessible as he lived down the road at a neighbouring
farm. The wife held Power of Attorney for finances and personal care.
Mrs. L
Mrs. L. is a 66-year old widow who lives with her 32- year old daughter and her 25
year old son. Her husband was killed in a construction accident. Mrs. L. has been
diagnosed with Pick's Disease. Mrs. L. is a very active person. When she escaped
from the Day Away Program, she was found near her home by a volunteer. Mrs. L.
had only been away from the Day Away Program for a very short period of time.
Early one morning, Mrs. L. found a step ladder and climbed it to reach the sugar
that had been hidden from her. She stumbled on the second step, lost her balance,
and landed with her full weight on both feet on the floor. In the afternoon, Mrs. L's
daughter noticed that her mother had not moved since lunch. Mrs. L's brow was
deeply furrowed.
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Parish Nursing
Jeanne Lambert, Parish Nurse
What is a Parish Nurse?
The Parish Nurse is a Registered Nurse who, in response to God’s call,
applies nursing knowledge and healing gifts within a faith community. It is a step in
one’s faith journey that brings the nurse to parish nursing ministry. The parish
nurse undertakes additional education for this specialized role.
Parish nursing is an arm of the congregation’s ministry which concentrates on the
specific needs that relate to the mental, physical, emotional and spiritual health of
its members.
Primary Roles of the Parish Nurse
Health Advocacy: The parish nurse helps parishioners ensure their health needs
are being met, helps them navigate the complex health system, may act as liaison
between health service and individuals and help work through difficulties and
complaints.
Health Educator: The parish nurse presents and arranges educational programs
and information dealing with health and wellness issues including cancer and other
diseases, nutrition, exercise, hand washing, or stress management.
Health Counselor: The parish nurse meets with parishioners to discuss and listen
to concerns. These concerns may be of a mental, physical, emotional, or spiritual
nature.
Resource Referral: The parish nurse is aware of related health, social and faith
services available in the community and serves as a link to local health agencies
such as the Heart Association or the Cancer Society and service providers in the
community.
Volunteer Coordinator: The parish nurse recruits, trains and supervises volunteers
that are asked to assist with the overall health and pastoral care ministry in the
congregation.
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Would your congregation benefit from a parish nursing program?
1. Are there members in your congregation who are not able to participate in
ministry because they are less than healthy?
yes
no
2. Do you have members who are chronically ill and due to their illness are not able
to hear God’s word regularly?
yes
no
3. Do you have children or youth in the congregation who are not getting Christ‐
centered information on various health issues — for example, sex, nutrition, self‐
care, relationships or leaving home?
yes
no
4. Do you have shut‐ins who need more visitation, encouragement and assistance?
yes
no
5. Is your Pastor spending more time visiting the sick and caring for the physical
needs of the members than sharing the gospel?
yes
no
6. Are members talking to the Pastor about serious health issues but refusing to see
a medical professional about those issues?
yes
no
7. Do you have health care professionals in your community who provide care or
advice that directly contradicts the principles of God’s word?
yes
no
8. Is there evidence that some members are not seeing positive results from their
medications, and is there a sense they are not taking their medications properly?
yes
no
9. Do you suspect that there are members who rely too heavily on medication to get
through their daily activities?
yes
no
If you answered “yes” to any of the previous questions, a parish nursing
program might be appropriate for your congregation.
Christian Life Resources
Canadian Association for Parish Nurse Ministry
www.ChristianLifeResources.com
http://www.capnm.ca/fact_sheet.htm
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Hospital and Community Visits
Alleviating Visiting Fears
Remember, you are doing good work. You have been called to do God’s work to be
an extension of church, community and of God’s healing ministry-- one human
spending time with another. Therefore, you are doing good work, God’s work.
Having anxieties and fears before visiting, is a normal reaction. You will be entering
into the unknown and this can be a cause for nervousness.
Believe in yourself, in the very fact that you care enough to give of yourself.
STOP and remember…
This is not about me – It is about the person I am visiting.
I am there:
to be THERE (presence)
I am there:
to offer my time, without expectations (no agenda)
I am there:
because I said I would be (trust)
I am there:
because I promised to return (commitment/accountability)
I will be myself (authentic)
I will allow the visit to unfold as it is meant to be (acceptance)
I will allow the person I am visiting to direct and guide me through the visit
(dignity/respect)
I will try my best in meeting the Spiritual & Religious needs of the person. (caring
ministry)
I will believe in myself enough to know that I do make a difference (faith)
I will honour myself to know my limitations and I will remember that it is indeed a
privilege to be able to journey alongside this person. I will take time to pray about
my visits.
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Some helpful prayer examples:
Before:
“Bless me Lord, and guide my steps along the way. Amen”
“Lord, help me to be present to this person and to bring them the comfort and
support they need at this time.”
“Dear Lord, bless my spirit with the courage to be open to their needs.”
“Heavenly Father, guide me and help to protect my generous heart.”
After:
“Thank you Lord for this precious time, bless me and help me to leave these needs
in your hands.”
“Thank you God, for being with me throughout this visit and I pray that you will
continue to guide my steps.”
“Lord, I need you. I pray for your strength, support and comfort.”
Group Work Questions
1. How would you arrange to meet with a person (patient, resident or client).
2. List how would YOU prepare for the visit.
3. On arrival how would you ensure the best possible atmosphere for a quality visit?
4. This being your first meeting with this person what would you do to make this a
comfortable and meaningful initial visit?
5. How would you bring the visit to a close?
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What Not to Say When the Unthinkable Happens
When tragedy impacts those we love, we naturally want to help. And if we can't
help, we at least want to offer comfort, hope, and reassurance. All too often,
however, our eagerness to say the right thing or to fix things blinds us to how our
words might be received and perceived by the person suffering. The following
commonly offered words of counsel sound helpful, but often feel like salt-in-thewound to the person on the receiving end.
When the unthinkable happens, resist the temptation to say these things, no matter
how good they sound to you:
1. "It could be worse."
This statement minimizes a person's loss and pain by essentially saying what
they're experiencing is not that bad. The last thing a hurting person (who, by the
way, already knows "it could be worse") wants to hear is that his/her pain isn't
legitimate. For example, let's say Jane's husband experiences a debilitating stroke
that impairs the use of one side of his body, but does not impair his thinking,
reasoning, or speech. Jane is already well aware that her husband's condition could
be worse (he could be dead or further disabled - she doesn't need to be reminded).
But that doesn't meant that what she's experiencing isn't frightening, nor does it
mean that she won't grieve her husband's deficits and their lost dreams.
Let's offer the kind of grace to hurting people that allows them to hurt without
minimizing their pain.
2. "You can be thankful that..." or "Look at the bright side."
Though it may sound similar to the first, this statement takes the opposite approach.
Instead of minimizing a person's suffering by offering scenarios that could be worse,
these words minimize (and can even dismiss) a person's heartache by looking at
what is good in the situation. Using Jane's example from above, of course she's
thankful that her husband isn't dead or further impaired. Do we really think she
wouldn't be? But by telling her to be thankful for her husband's speech or intact
mind, we're actually saying "Don't feel bad." But it's okay for Jane to feel badly
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about what's happened and about her husband’s genuine (and life-altering) losses.
Being thankful for our graces and blessings during tragic times is important, but it
doesn't take away the need to recognize, experience, and work through real
emotional pain.
3.
"Something good will come of this, you'll see," or the similar, "Every
cloud has a silver lining."
How do we know? And should we presume to know? The truth is we may never see
good come from certain situations. Not in this lifetime, anyway. We may never
understand the "why" factor or see how something terrible can be used to
accomplish something good. Does God work all things for good for those who love
Him and are called according to His purpose (Romans 8:28)? You bet. Absolutely.
But His definition of good may differ from ours. And His ways are not our ways. And
we can't see eternity, as He can. We can't see or predict the future. Even if
something good does come of a current tragedy (as we hope and as it often does),
the person in pain may not be able to see that far ahead just yet. People in pain
need us to allow them to walk through their pain honestly and without criticism first
before they can move on to embrace any positive outcomes that might result from
their experiences.
4. "You'll get over this in time," or its variant, "Time heals all wounds."
Another minimizing strategy, this counsel tells the hurting person that his/her
pain is no big deal because it will soon pass. So what is wrong with this counsel?
First, this statement may not be true! Some things simply won't heal in this lifetime
(parents of missing or abducted children, for example, rarely reach closure; they
hurt and wonder for the rest of their earthly lives). Second, it dismisses the reality of
the present pain. A person in pain doesn't care what this will feel like ten years from
now or even next year; all he knows is what he feels now.
5. "Well, this wouldn't have happened if...."
A blaming technique, these words attempt to cast responsibility on other people,
policies, or actions (or inactions). Again, to begin with, how can we presume to
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know what any outcome would have been (we simply don't know)? And beyond our
inability to know, second-guessing doesn't help the person in pain; all it does is give
vent to our need to blame.
6. "This is a difficult, I know. I felt the same way when...."
When the unthinkable happens we often want to offer our experiences as comfort.
But when pain or crisis is new, the last thing a hurting person wants to hear is our
horror stories. It feels like a one-upmanship: "Yes, your situation is bad, but wait till I
tell you what happened to me." To the hurting person, this feels as uncaring and
self-centred as it really is.
7. "What's this world coming to? Before you know it we'll all...."
The onset of the unthinkable is NOT the time rant. A person in pain doesn't need to
hear our opinions or fears or politics or philosophy. The tragedy isn't about us; it's
about those involved and their pain.
8. "I understand what you're going through" (unless you have actually gone
through the same circumstance).
How dare we presume to understand the grief of a father who's just lost a son when
we've never lost a child ourselves! How can we even begin to know the suffering of
a wife whose husband just announced an affair and his intention to divorce her
when our marriage is thriving? How can we say "I know what you're going through"
when we've never been through it? Yet, in our love-motivated attempts to help, we
often do.
Instead, we can be honest. "I can't possibly know what this is like for you, but I want
you to know I love you, support you, and am here for you."
9. "If you just pray with enough faith, God will...."
Another blaming technique, this statement implies that the person in crisis is partly
responsible for the tragedy or its outcome because she isn't praying enough or with
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enough faith. Not only do these words not offer comfort, they compound the
person's suffering by adding guilt to the mix.
Not only does this statement imply blame, it also suggests we know the mind of
God. Can any of us say we know what God will do in a given circumstance? At best,
we can know only what we hope He will do.
10. "I just read an article [or just finished a book] about this and it says to...."
People experiencing fresh pain don't want or need clinical information; not yet,
anyway. There will be a time for offering helpful resources and education, but when
tragedy strikes, people first need comfort; they need to be held and heard; they
need to know they aren't alone.
www.lighthousenetwork.org
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Cases
Examine all aspects of possible PIECES needs (p 67) & suggested interventions
(physical, intellectual, emotional, capabilities, environmental, social-spiritual-sexual)
1. A 33-yr old woman with MD on disability pension living with her brother & his wife
2. An elderly gentleman recently widowed with an alcohol problem and a recent
palliative diagnosis of …………
3. A 83 year old gentleman with middle-stage dementia making sexual advances with
nursing staff
4. A 17-year old girl facing complicated grief over the loss of her twin sister in a car
accident
5. A 63-year old woman with breast cancer who has just lost her only son in military
action
6. A 47-year old man misses sexual intimacy from his wife who has just had a
colostomy due to bowel cancer
7. A top level marathon runner finds bone cancer in his leg just before a key
international race.
8. A 92-year old dying man remembers the hurt he has caused his 2 daughters from
years of sexual abuse
9. A grandmother with lung cancer is refused to visit the grandchildren unless she
quits smoking.
10. A 9-year old child with leukemia is petrified of a scheduled bone marrow transplant
11. The day a 58-year old woman signs retirement papers, she suffers a major heart
attack
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12. Patient has just seen the neurologist. When you enter the room, she says: “I just
found out I have the beginning stages of Alzheimer’s. You might as well put me
down now.”
13. Dr. Lewis just told me he thinks the lump in my breast may be cancer!! I can’t face
this, I’ve got 2 young children at home……
14. A young woman has just been told her husband is brain dead, and has been
counseled about organ donation. She is still in a state of shock when she sees you.
15. A middle-age man who is a champion swimmer has just been revived from cardiac
arrest. The physician has counseled him to cancel all competitive swimming in the
near future
16. An elderly woman has just been told that her husband needs to undergo emergency
surgery, but that the surgery is risky and he might not survive the operation.
17. My Mother has told me she won’t take any more treatment. We can’t just sit by and
watch her die.
18. I just found out Sam’s prostate cancer has spread to the bone. I thought prostate
cancer was treatable!!! Now it’s a death sentence!
19. They told me if I don’t consent to my little’s girls leg amputation, the flesh-eating
disease will spread..
20. What would you think if they told you your wife has HIV?
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Role-Play Scenarios
In your table group, choose two “actors” (the visitor and the client) and one of the
following scenarios to role-play. The client gets the last word. Observers watch in
silence; take notes. 1. Role-play for five minutes. 2. Table group debriefs (five
minutes, among themselves). 3. One observer shares learnings and insights with
the whole group (not more than five minutes).
1. Client is unresponsive (A Blank Stare)

No eye contact; No expression
2. An elderly client has recently moved into Long-Term Care




3.
Client is despondent, lacking the desire to live



4.
Appears fearful, agitated
Wants “to go home”
Asks visitor to “take me home” (quite insistent)
Expresses fears that grown children are “Spending everything in the bank
account.”
Talks of “miserable life,” being unloved, unwanted
Feels like they are a burden on the family
Wants to die, to relieve family of the burden.
Client is resistant, suspicious, argumentative


Asks: “Who are you?” Why are you here?” “Who sent you?”
“What Church are you from?” (but does not tell the visitor to go away, get
lost, etc.)
Observers—
Listen to the words (of the client, of the visitor) What are the words saying?
What are the words NOT saying?
What is being said WITHOUT words? Watch the non-verbal, body language.
Pay particular attention to the eyes. What is being said? What does this mean?
What ACTIONS, INTENTIONS did the visitor employ? (Helpful, not-so-helpful)
What was the reaction of the client?
What were you thinking and feeling…about what the visitor did?..about what the
client did?
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Case Studies
Identify and discuss some of the client’s needs as they to the PIECES model:
Physical Needs:
Intellectual Needs:
Emotional Needs:
Capabilities:
Environmental Needs:
Social/Spiritual/Sexual Needs:
Scenario 1
Complex Continuing Care Site – 67 year old woman diagnosed with MS 10 years
ago and only has movement in her lower arms and hands. Has no family and no
friends who visit, but enjoys the recreational sessions provided at the hospital.
Needs continual stimulation or becomes depressed.
Scenario 2
Acute Care Hospital Site – 45 year old woman, seriously injured in car accident 8
months ago and has only just been removed from the critical list. Desperately
misses her church and friends. Husband and son visit, but both work full time and
can only visit evenings and weekends. Nursing staff unable to sit with woman.
Scenario 3
Long Term Care Home – 85 year old man, can walk slowly with walker, but can be
bitter and angry at times. Staff feel he would benefit from visits and have convinced
him to accept someone, with some reluctance. Family is concerned about his
increasing agitation.
Scenario 4
Home setting – 16 year old girl, with new baby. Used to attend church regularly
and was a member of numerous church groups. Since her pregnancy she has left
all that behind, says she feels guilty. Girl is attending school but is not enjoying it
and her friends have drifted away. Loneliness and depression are an everyday
reality. Family have requested additional support.
Scenario 5
Palliative Care Floor or Hospice – 73 year old man with large family, diagnosed
with cancer and given only 3 weeks to live. Family will not accept this and continue
to try and convince the man to try different things to stop the cancer. Man has
accepted his fate and wants family to do the same. He needs a visitor with no
agenda.
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Case Study
What are the spiritual, physical, intellectual, emotional and social needs of
this person, and how well are they being met?
I am totally bed-bound, I have extensive disease, unable to do anything for
myself. I have total care provided by the community support worker and the
homecare nurse. I am not eating much, and am mostly conscious and coherent,
with periods of drowsiness and confusion. I am on several meds for pain and
symptom control.
I know I am dying, and have accepted this. I have spoken freely to all
members of my family and they are in various stages of acceptance. All are
supportive, but handling it differently. My husband is great, and we talk about
everything. He is very sad, but compassionate and provides much of my care when
the nurses are not here. He will fall apart when I am gone.
I am in a hospital bed in my sunroom. I can see the back yards and fields
beyond. I can hear the birds, and the neighbor’s dog, and a plane flying overhead.
Occasionally I hear a car on the gravel lane, and wonder who has come to see me
today.
Even though there are pretty flowers on my bedside table, I can smell the
taste of death all around me; the smell of sickness, stale air and sweat. I smell the
soaps and antiseptics and I can imagine I can even smell the medications. Maybe it
is my imagination. I wonder if my family can smell it too; although they don’t say
anything. I bet even the dog smells death, but he also is too polite to protest, and
he lays beside my bed on the mat. He misses our walks.
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I try to enjoy bits of food, and sometimes I take in a bit, and sometimes it
comes back up. Often even looking at food is hard. Everyone tries to encourage
me to eat. At first I worried about hurting their feelings when they brought my
favourite foods, so I would try…But now, I think they get it—I just won’t be eating
much anymore. A few sips of water or ginger-ale seems like a luxury.
I am thinking all kinds of things. I imagine all kinds of scenarios. My mind
imagines my death in various ways, and the funeral. I can even imagine my loved
ones sad and lonely after I am gone. Why can’t my mind be still? I ask God for
peace, and sometimes when I am alone I can feel peace, even taste it. Sometimes
I feel so ready to let go, and at other times…I am scared.
I don’t like a lot of fuss or noise, and ask that my house not turn into chaos. I
can’t stand chaos, it makes me feel like I’m not in charge. People come and go and
I ask for my favourite music, not all the time, but a little each day. I have my photo
albums beside me, and we take turns looking at them together. At first I did the
commentaries myself, but now I am too tired and weak, and someone else must
speak the stories. I can only manage ten minutes at a time.
My family asks nothing of me, I hope I have given them what they need. I
have given them the blessing and they have given it back to me. I am fortunate in
so many ways. I am ready now to be with the Lord. (Wow, I have heard that cliché
before!) But it is so true. I am so tired…
Janet Stark
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More Case Studies
1.
Mr. Brown is a 52 year old man, newly diagnosed with bowel cancer. He works out
of his own home as a career and family counselor. He and his wife separated in the
past year, their two daughters go back and forth between the two homes. The girls
are 10 and 12 years old. Mr. Brown’s elderly parents live nearby, but have health
problems of their own.
2.
Mrs. Smith is 76 years old and has end stage heart disease and diabetes. She lives
with her daughter who has a full time, high pressure job. Mrs. Smith has severe
pain in her legs due to poor circulation but manages to walk short distances around
the apartment. She is very short of breath and is sleeping for longer periods
throughout the day. Although her husband died seven years ago Mrs. Smith has
left all her banking/legal affairs unchanged.
3.
Mrs. Black is a 61 year old divorced lady with a long history of alcoholism. She is
estranged from her four adult children and has recently been admitted to hospital
with a brain tumour.
4.
Ms. Lee is a 17 year old high school student who has recently had her leg
amputated for bone cancer. She is an “A” student, active in several sports and a
very popular cheerleader in her school.
5.
Mr. Jones is a 91 year old man admitted to hospital with a massive stroke. His
condition is poor. His 90 year old wife is distraught. The Jones’ have been married
for 71 years and have never been apart once in all those years. Mrs. Jones doesn’t
drive and Mr. Jones has managed all of their finances throughout their marriage.
They have two sons: the youngest lives nearby in a senior’s apartment complex,
the other son lives in a group home for mentally disabled adults.
6.
Mrs. White is a 26 year old lady with leukemia. She is midway through
chemotherapy treatments and is in hospital with a lung infection. She and her
husband have three small children ages: 5, 21/2, and 11 months old. The Whites
moved here from B.C. shortly before Mrs. White’s diagnosis so that her husband
could start a new job. Neither of them have family here, nor have they had much
time to get to know many people in their community.
7.
Mr. Lewis is a 60 year old widower who lives alone in a one bedroom apartment.
He has been living in the same apartment building for over 12 years. Mr. Lewis was
diagnosed with colon cancer a year and a half ago, he was recently told his cancer
is life threatening. Mr. Lewis underwent surgery which has left him with a
colostomy. He has constant diarrhea. He finds the odour embarrassing as well as
the need to rely on strangers for help with personal care. Since his illness he has
isolated himself from his friends at the local YMCA and no longer participates in the
weekly bingo at his local parish.
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Psychosocial Scenarios
How to help provide pastoral care… in each of these settings:
1. A resident in a nursing home
2. A client in their own home
3. A patient in the hospital
A. An elderly man who is depressed because he knows he is dying
B. The children & grandchildren of this Grandpa, (A above)
C. A grieving husband who sees no reason to live after his wife has died.
D. A daughter with anticipatory grief for her mother who has dementia
E. An angry brother who is arguing with his sister at the bedside of their dying mother.
F. An elderly man who has “inner turmoil” but does not know how to express it or
what’s wrong.
G. Make up a situation of your own:
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Rule for Maintaining Confidentiality
Anything you see,
Anything you hear,
Anything you read,
Anything you observe with your five senses and
Anything you already know about a patient must be kept
Confidential
...Unless you have the express verbal consent by the patient to share information
about that specific issue to the person(s) they have given you permission to talk to.
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Confidentiality
Personal Information- Information about an identifiable individual, but does not
include the name, title or business address or telephone number of an employee of
an organization.
Privacy- The right to control information about oneself, personal autonomy.
Confidentiality - The legal obligation of the institution/organization
Confidentiality as defined in the "Health Ethics Guide" CHAC 2000 Pg 95
'Confidentiality is a quality of human communication that protects a person's right to
privacy by fostering trust between the care provider and the person receiving care.
Confidentiality excludes unauthorized persons from gaining access to information
concerning the person receiving care and that people who have such information
refrain from communicating it to others.
The Three ways that patient confidentiality is most often violated are through:
1. Print or electronic patient-related information that is left exposed where visitors or
unauthorized individuals can see it.
2. Discussions of patient information in a public place or with inappropriate,
unauthorized individuals.
3. Unauthorized people hearing patient -sensitive information
Ask permission if you feel something might be shared. “Am I free to discuss this
with….?” “May I speak to your daughter about….?” Does your minister know you
are in hospital? Would you like me to call him?”
Take your direction from the individual you are providing care to. Some things are
quite appropriate to share. Some families are very open and some are not. Do not
make assumptions! Some church families are very tight-knit and close. Asking
about privacy wishes fosters respect.
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Confidentiality Pledge
C
I will be careful about what I say and do.
O
I will repeat things of importance only to those who absolutely need to know.
N
I will not intrude on privacy of information.
F
I will faithfully respect others right to confidentiality.
I
I will ignore idle gossip about others.
D
I will devote my energies towards keeping information to myself.
E
I will earn the right to be a part of the team.
N
I will not repeat what has been told to me in confidence.
T
I will be trustworthy by keeping confidences.
I
I will imagine how I would feel if my trust in confidence was broken.
A
I will act in a way that brings trust.
L
I will leave what I have heard within these walls.
I
I will illuminate the vision and values of this institution.
T
I will think before I speak or repeat something.
Y
I will not yield to the temptation to discuss confidentiality matters.D. Boshuck
Hospital Volunteers are not expected to participate in these treatment
decisions:


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
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



Disclosure—“truth-telling”
Informed consent
Substitute decision-making
Advance care planning
Confidentiality
Withholding and withdrawing treatments
Resuscitation orders
Food and water
Pain control
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Privacy PHIPA
Personal Health Information Protection Act

Governs the manner in which personal health information may be
collected, used and disclosed within the health care system.

PHIPA will also regulate individuals and organizations that receive
personal information from health care professionals.
"Identifying information about the individual in oral or recorded form"






physical or mental health
family health history
medical benefits
laboratory tests
X-Rays and results
health card number
Agents of health information at BGH include:




physicians
clinical and non-clinical staff
persons contracted to provide services to BGH where the person has access
to personal health information (e.g. copying or shredding service, records
management service)
volunteers or students who have any access to personal health information
How can a breach of privacy occur?






Accessing a client's chart when we are not in the "circle of care"
Releasing patient's personal health information by phone
Discussing personal health information in a public area such as the
cafeteria, elevator, hallway
Allowing access to patient information on the computer
Leaving patient labels or armbands in public areas
Providing personal health information to the wrong patient
Case: Family members often ask you for information on how their loved one is
progressing and may become angry when you inform them you need to obtain the
patient's consent prior to providing information. What do you do?
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A Sense of Trust
A patient's husband asks you the results of his wife's pregnancy test. Can you give
him the results?
You wish to send a sympathy card to a co-worker. Is it all right to look up his
address in the medical records system?
Do you, as an employee and a parent, have the right to look up your own child's
record?
Is it a breach of confidentiality for staff or volunteers to openly and publicly discuss a
patient's care?
Can medical information be given to an employer who calls to inquire about an
employee's medical appointments or to request information about an employee's
absence?
If an employee who is a patient schedules an appointment, is it all right to ask what
they are being seen for?
Can a breach of confidentiality be grounds for termination of employment or
volunteer assignment?
If you overhear a conversation outside the clinical area regarding sensitive patient
information, should you let the offenders know immediately that they are violating
the confidentiality policy?
Does a clinician have the right to access any patient's medical record?
If you call to confirm an appointment or to relay test results, should you be very
specific?
If you need to locate a patient, should you page him or her over the house speaker
system?
Should parents always be given access to the medical record of a minor child?
If you know someone from your church is in hospital, should you phone the
priest/minister?
If a nurse asks you to tell her what is causing your patient emotional distress, do
you tell her?
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Respond either "TRUE" or 'FALSE to the following statements
True False
□
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□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Patient satisfaction studies reveal that the concern you show for a
patient's privacy means nothing to a patient.
Everyone in a hospital must maintain the confidentiality of patient
information, no matter where it comes from.
Computerized patient information is protected by the rule of
confidentiality.
Talking up front about the exceptions to a patient's confidentiality
helps the patient form realistic expectations about how private
information will be used.
When there is an exception to confidentiality, the patient should be
told that his or her privacy simply cannot be protected.
When an outside agency has a legitimate need to see a patient's
records, the patient must still give written permission.
Patient information may be shared by the patient with any interested
health care worker.
Hospital workers who do not need to know patient information have a
responsibility to consciously avoid it.
Volunteers need to know the AIDS or HIV infection status of patients
in order to protect themselves.
If a situation falls outside hospital policies and you are unsure whether
you should or should not report private patient information to hospital
or outside authorities, report it.
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BROCKVILLE GENERAL HOSPITAL
CODE OF CONDUCT
Our Code of Conduct outlines the behaviours that we expect from all persons within
the Brockville General Hospital. Our Code of Conduct applies to any individual
(patient, client, visitor, staff, physician, community partner, volunteer or student)
who gives or receives service in this organization. Our Code of Conduct sets the
parameters by which we treat each other, as well as those we serve. All employees,
staff and volunteers will uphold the core values of the Hospital and will sustain a
community characterized by inclusiveness and civility.
1.
We will maintain confidentiality.
2.
We will be mindful of what is said, where it is said and the impact it has on
others."
3.
We will treat everyone in a professional manner that demonstrates respect,
dignity, caring and compassion for each individual."
4.
We will communicate with everyone in a clear, timely, honest manner and
demonstrate attentiveness through choosing the appropriate environment,
responding and using a calm and helpful tone."
5.
We will offer assistance to anyone within the building or on the hospital
grounds who appears to be in need of help."
6.
We will not tolerate discrimination in any form."
7.
If we do not have the answer to a question or an issue, we will obtain the
information as soon as possible."
June 3, 2013
Tony Weeks, President and CEO
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BROCKVILLE GENERAL HOSPITAL
PATIENT’S BILL OF RIGHTS
You have a right to considerate, respectful care from your doctors and other health
care providers, free from discrimination. You are expected to treat your health care
workers and other patients with respect.
You have the right to accurate and easily-understood information about your plan of
care including having your questions answered.
You have the right to privacy in personal care, and confidentiality in information.
If you speak another language, have any type of disability, or don't understand
something, help will be given so you can make informed health care decisions.
You have the right to know who is looking after you while in hospital. You have the
right to talk privately with your health care providers.
You have the right to know treatment options, and take part in care decisions.
Parents, guardians, family members, or others who you choose can speak for you if
you are unable to make your own decisions. Having you involved in your care
increases the chance of the best possible outcomes and helps support a high
quality, efficient and effective health care system.
You have the right to have spiritual and cultural needs addressed including
having a spiritual care provider as part of your care team.
You have the right to read and copy your own medical record in the presence of
your health care provider. You have the right to ask your doctor to change your
medical record if it is incorrect or incomplete.
You have the right to a fast and objective review of any complaint you have about
your treatment, team member or the health care facility. This includes complaints
about wait times, hours of operation, action of health care personnel.
January 12, 2011
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The Dying Person’s Bill of Rights
I have the right to be treated as a living human being until I die.
I have the right to maintain a sense of hopefulness, however changing its focus may
be.
I have the right to express my feelings and emotions about my approaching death in
my own way.
I have the right to participate in decisions concerning my care.
I have the right to expect continuing medical and nursing attention even though cure
goals must be changed to comfort goals.
I have the right not to die alone. I have the right to be free from pain.
I have the right to have my questions answered honestly.
I have the right not to be deceived.
I have the right to have help from and for my family in accepting my death.
I have the right to die in peace and dignity.
I have the right to retain my individuality and not be judged for my decisions which
may be contrary to beliefs of others.
I have the right to discuss and enlarge my religious and/or spiritual experiences,
whatever these may mean to others.
I have the right to expect that the sanctity of the human body will be respected after
death.
I have the right to be cared for by caring, sensitive, knowledgeable people who will
attempt to understand my needs and will be able to gain some satisfaction in
helping me face my death.
Created by the South-Western Michigan In-service Education Council and published by the American Journal of Nursing.
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Ethics
"The study of the rightness or wrongness of human conduct"
Healthcare Ethics
"Healthcare ethics is the application of human values of right or wrong to
making meaningful and moral choices in healthcare delivery."
Principles of Ethics
1. Beneficence and non-maleficence (to do good and not to harm. The basis
of the Hippocratic Oath, part of physicians and nurses professional code)
2. Individual Autonomy (whenever possible, the person gets to decide, among
the legal and do-able choices)
3. Justice (all persons are equal, there is no preferential treatment for any)
4. Sanctity of Life (where there is breath, there is life, where there is life, there
is value.
Dilemma
A situation necessitating a choice between two equally undesirable alternatives. A
problem that seems incapable of a solution.
Legal Capacity
Understanding Relevant Information Or/And Appreciating the reasonably
foreseeably consequences of making or not making a decision.
Informed Consent for Treatment
Treatment must be:
Relevant to condition
Be voluntary
Be informed
Patient must know:
Nature of treatment
Benefits
Side affects
Alternative treatments
Consequences of not proceeding
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Legal Terms
Advance Directive:
Includes a “Living Will”. Your instructions on your choice
of health care, should you not be competent to speak for yourself. Only to be in
effect while you are alive. This can be changed at any time.
D.N.R. “Do NOT resuscitate” order. Must be kept with patient at all times. No
C.P.R. (cardio-pulmonary resuscitation)
Estate Trustee:
(after death only)
Person who settles the estate according to terms of the will.
Attorney under Power of Attorney: Person who handles one’s affairs when one
is incapacitated. (only while alive)
Will: Last Will and Testament is a legal document with instructions to handle the
estate of deceased. (only after death)
Power of Attorney for Personal Care
(Made in accordance with the Substitutes Decisions Act, 1995)
a. health care
b. nutrition
c. shelter
d. clothing
e. hygiene
f. safety
g. consent or refusal of consent to treatment
h. cessation or continuation of measures whereby life is artificially prolonged.
Factors Involved in Decision-Making

the interdisciplinary assessment

the diagnosis and prognosis

professional standards of care

legal statutes and policies

the competence of the individual

the person's expressed wishes and their family's understanding of
their wishes

cultural and religious practices
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Dissension Results from…

Lack of information

Misuse of information

Inadequate communication

Conflicting moral, religious and legal stances

Personal wishes and beliefs
Common Misconceptions
I cannot refuse treatment
Once I decide on treatment, I cannot change my mind
Treatment must prolong life
DNR = Do not treat
Dissension may result from….





Lack of information
Misuse of information
Inadequate communication
Conflicting moral, religious and legal stances
Personal wishes and beliefs
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Ethical Issues at End-Of-Life
Euthanasia
An action or omission of an action, which of itself or by intention causes death in
order that all suffering may be eliminated. Euthanasia, whether passive, or active
carries a fixed minimum of 10 years in prison.
Assisted Suicide
It is a criminal offence to aid or counsel someone to commit suicide, (or physicalassisted suicide) even if the person voluntarily requests such assistance.
Both euthanasia and assisted suicide are against the law in Canada. The senate
willnot re-visit the issue until good palliative care is available to all in Canada
Physician-assisted suicide
Recently, the issue of physician-assisted suicide has come to the fore. Although
suicide is no longer a criminal offence, assisting or counseling a person to commit
suicide is. In struggling with this issue one must take into account not only the
patient’s rights and autonomy but also those of the medical profession and the
individual physician. Kass argued strongly against physician-assisted death of any
kind on the basis of the historical mandate of medicine and the ethics of medicine
as outlined in the Hippocratic Oath.
When hearing cases in the media, have they reported fairly?
What is the ethical issue?
What principles are involved?
What does the law say?
What does good health care mean in this case?
Was this issue handled ethically?
What are your own thoughts?
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ETHICS CONCERN FORM
Please state your Ethics Concern by completing and submitting this form by e-mail or
hard copy to the Chair of the Ethics Committee.
1. Is this a current, ongoing or past concern? ________________________________
2. Please state your concern and explain why you think it is an ethical issue:
_____________________________________________________________________
_________________________________________________________________
Please provide your name and contact information. A member of the Ethics Committee
will contact you for clarification. Your identity will remain anonymous.
Name: ___________________________Department: _________________________
Signed: ________________________Date: _____________________________
ETHICAL PRINCIPLES
Promote freedom of choice
Do no harm
Do or promote good
Respect all
Treat all fairly
VALUES
Legal Requirements
Professional Codes of Ethics
Primary loyalty to the organization
Social/Cultural values
Confidentiality
Informed Consent
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Principles
Promote freedom of choice, is the principle of autonomy, it means the patient gets
to decide, within the options available
Promote good and Do no harm is the principle of beneficence and nonmaleficence. The Hippocratic Oath is based on this principle and all health
professionals promise this in their professional codes.
Respect for all means that we provide best practice compassionate care to all
regardless of one’s background culture or creed.
Treat all fairly is the ethic of justice; that no one gets preferential treatment, and no
one gets substandard treatment.
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Values
Legal requirements means that our ethical decisions must adhere to the law in
Canada.
Professional Codes of Ethics means that our decisions must be compatible with
our regulated health professional standards that we accept when we begin our
health practice
Primary loyalty to the organization means that we accept and adhere to BGH
policies and procedures
(It is helpful to note that the above three values may at times trump our own
personal morals and values. When this happens, it is good to discuss the issue
with your supervisor.)
Social/Cultural values means that we provide care that respects the patient’s
values, their ethnic background, sexual orientation and spiritual and religious needs.
Confidentiality and privacy are protected under the PHIPPA act.
Informed Consent means that the patient must understand their diagnosis, and
treatment options, including side effects and consequences of treating or not
treating. The patient must give written consent, free from all coercion.
BGH Framework for Ethical Decision-Making
Step 1—Recognize an Ethical Issue
Could this decision or situation be damaging to someone or to some group?
Does this decision involve a choice between a good and bad alternative, or perhaps
the better of two “bads”?
Is this issue about more than what is legal or what is most efficient? If so, how?
Step 2—Collect Information

What are the relevant facts? What facts are not known?
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
Can we learn more about the situation?

Do we know enough to make a decision?

What individuals and groups have an important stake in the outcome?

Are some concerns more important? Why?

What are the options for acting?

Have all of the relevant persons and groups been consulted?

Have the creative options been identified?
Step 3—Evaluate Alternative Actions
Evaluate the options by asking the following questions:
Which option will produce the most good and do the least harm? (The Utilitarian
Approach)
Which option best respects the rights of all who have a stake? (The Rights
Approach)
Which option treats people equally or proportionately? (The Justice Approach)
Which option best serves the community as whole, not just some members? (The
Common Good Approach)
Which option leads us to act as the sort of person we want to be? (The Virtue
Approach
Step 4—Make a Decision and Test It.
Considering all the approaches, which option best addresses the situation?
If you tell someone you respect, or told a television audience which option has been
chosen, what would they say?
Step 5—Act & Reflect on the Outcome
How can our decision be implemented with the greatest care and attention to the
concerns of all stakeholders?
How did our decision turn out and what have I learned from this specific situation?
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BROCKVILLE GENERAL HOSPITAL
MANUAL:
Clinical Policies
SECTION:
CATEGORY:
Spiritual and Religious Care
Services
CODE:
TITLE:
Proselytizing
APPROVED BY:
VP Clinical Services, CNE
SIGNATURE:
Spiritual Care Department
ORIGINAL DATE:
REVIEWED/REVISED:
SUBCODE
2
Oct
2006
Aug
2011
STATEMENT:
Brockville General Hospital does not allow proselytizing in the facility at any time.
Proselytizing is the initiation of, suggestion of, or promotion of ideas by any Clergy,
staff or volunteer of any denomination who attempt to challenge or change a
person’s belief or religious preference to that of their own beliefs and/or practices.
3.1
Remind individuals who appear to be proselytizing of the proselytizing policy.
3.2
Notify the charge nurse or Spiritual Care Manager of the situation.
3.3
Spiritual Care privileges may be withdrawn from a person for violating this
policy.
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Ethical Cases for Volunteers
1. One of our volunteers, a Registered Nurse, has been asked by a family to provide
private nursing care during the time she is not volunteering for Spiritual Care. How
should this be handled?
2. What should a volunteer do when he/she knows that another volunteer on the care
team is not following hospital policy?
3. The family of one of our clients has advised the Volunteer Co-ordinator that the
patient has been giving the volunteer gifts and buying her all sorts of things
including furniture. The family have no problem with this. The family and patient
really like the volunteer and the family feel that as long as the patient is happy doing
this everything is okay. Is everything okay?
4. One of our clients has revealed that her spouse, who is a physician, is treating her
(giving her medications).The patient and volunteer do not think the spouse is
communicating this to the doctor or the nurses. The volunteer wants to advise the
rest of the team but is afraid this will upset the patient’s husband. Any suggestions?
5. The family of one of our patients (they are new Canadians) insists that the patient
must not be told about their cancer diagnosis or prognosis. The patient is a
religious person and we are concerned that the patient is not getting the kind of
spiritual care she needs at this stage of her life. Any suggestions?
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6. One of our clients has asked our volunteer to drive him to a motel where he has
arranged to meet a prostitute. He then wants the volunteer to drive him home
afterwards. What do we do?
7. One of our clients occasionally uses marijuana to help with her pain. She does not
have approval for the medicinal use of marijuana. Is the volunteer breaking any
laws if they just there when the client “lights up”?
8. A client who is in a wheel chair has requested the volunteer to “bump” her down,
and back up a flight of stairs to her garden. The client gains an enormous amount of
pleasure out of seeing her flowers and she looks forward to this “excursion” each
week. The volunteer has been instructed to stop and the client is now angry at the
hospice and threatening to “fire” her care team and volunteer. What to do?
9. One of the volunteers would like to bring her child to the client’s home when she
visits. The volunteer thinks her son would be good company for the client’s son.
What do you think?
10. What should a volunteer do if they feel the client’s home is not safe to go into?
11. During a visit to a client who is now in hospital, the client asked the volunteer to
perform a task that a nurse did not agree with. The volunteer complied with the
nurse but felt very strongly that this robbed the client of choice and wasn’t
consistent with the philosophy of palliative care. Once the client is in hospital or
LTC how can we protect our clients?
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12. It appears that the only family caregiver for our client has a drinking problem. She
keeps asking the volunteer to drive her to the liquor store. Since she is the only
caregiver in the house overnight we are concerned about the client’s safety. What
do we do?
13. One of our patients has revealed to our volunteer that she is experiencing a lot of
pain but does not want to bother the doctor. The patient is also concerned about
increased side effects if her medication is changed. When the volunteer said she
could speak to the Dr. on the client’s behalf the client made the volunteer promise
not disturb the Dr. Would it be a breach of confidentiality to just go ahead and tell
the Dr.?
14. Can volunteers take food (home baking, casseroles) into the client’s home?
15. Following the death of a client, one of our best volunteers has become romantically
involved with client’s widow. We are beginning to hear gossip relating to our
volunteer’s actions. Should we let the volunteer go?
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Blessed are those who mourn,
for they will be comforted. – MATTHEW 5:4
After Mary’s husband died, she felt angry and
alone. She still came to church and found some
comfort in the fact that, Sunday by Sunday,
Eleanor would sit beside her.
Then, on Sunday morning after several months
had passed, Eleanor wasn’t there beside her any
more.
This upset Mary, until she looked across the
church and realized that Eleanor was sitting beside
Linda, whose husband had died just a week earlier.
Watch Linda being quietly and silently
comforted by Eleanor helped Mary to realize how
much grace she had received and how much she
had healed.
Perhaps you know an Eleanor.
Perhaps you are an Eleanor.
The Rev. Stephen Kendall serves as Principal Clerk of the
General Assembly of the Presbyterian Church in Canada
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Grief is the price we pay for love
Chaplain Brenda Haggett MTS
I had the privilege of attending a Grief Service Provider certification course run by
the American Grief Academy in Kingston. It was three full and very intense days,
immersed in the subject of grief. Here are a few nuggets of learning

Grief happens because of loss…(regardless of whether it is a death, job loss, or a
divorce)

All grief is about self-identity – Who am I now that my husband is dead? Am I still a
wife?

Grief is a cataclysmic storm – for even an expected death is a sudden and
unexpected death. The head may be able to prepare but the heart can never
rehearse the hurt and pain that comes with grief

Mourning is grief gone public – grief is the internalization of loss and it is a personal
experience – everyone grieves, but not everyone mourns their loss in the same way

We need to be generous with one another and allow each person to navigate
his/her own way through the journey of grief

There is comfort in the rituals…

Our family of origin, ethnicity, religious beliefs, and society in general all play a part
in how we mourn and in many ways dictate what is “acceptable” thereby providing
for us a template, of sorts, to guide us through things that need to take place

We all need to be cautious with the words we use when offering sympathy to
someone who has experienced a loss. Avoid words like “you should”. We should
never judge someone else’s decisions and choices around grief…it is their
journey…not ours. One size never fits all!

Our individual temperament will determine much of how we go through grief and
what supports will or will not work for us

There are many myths of grief that are held onto with emotional intensity – so much
so that they become “truths” for us

We need to help each other face the myths…because not everyone needs a good
cry…
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Symptoms of Grief
There are many symptoms that may be manifested throughout the grieving process.
Psychological & Emotional Manifestations
crying
sadness
despair
guilt
loneliness
anxiety
shock
emptiness
relief
numbness
yearning
anger
withdrawal
mood swings
irritability/hostility
depression
hopelessness
`
fear
Cognitive & Social Manifestations
disbelief
inability to concentrate
disorientation
difficulty completing tasks
confusion
inability to make decisions
sense of presence of the deceased
restlessness
preoccupied with thoughts of deceased
social withdrawal
seeing, hearing the deceased
loss of interests
Physiological & Somatic
tightness in the chest/pain
over sensitiveness to noise
irregular heartbeat/palpitations
weakness
stomach emptiness & GI disturbances
dry mouth
lack of energy & fatigue
disturbed sleep patterns
changes in appetite (anorexia)
shortness of breath
constipation, diarrhea, nausea, vomiting
sexual changes
Spiritual Manifestations
search for meaning and value in life
loss of control
feeling of abandonment by God
fear of the unknown
feeling of anger toward God
lack of direction and purpose
wanting to die to join the decreased
continued blaming
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Factors Impacting Grief Work:

Characteristics of bereaved

Characteristics of relationships

Nature of the death

Physiological factors

Treatment Issues

Familial Issues

Social Factors

Secondary Losses

Limited Resources / Community Supports
Secondary Losses

Loss of roles

Changed identity

Change of environment

Loss of status

Change in relationships

Loss of hopes, dreams, unfulfilled expectations

Loss of autonomy

Loss of predictability

Loss of social contacts

Loss of self-esteem

Loss of mobility
Tasks of Anticipatory Grief

Fluctuate back and forth between denial and acceptance

Establishing-trusting relationships with health care professionals

Meeting changing needs of dying person

Maintaining normalcy and functional family unit

Live with emotions
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
Work through dynamics with other people

Anticipate new reality after the death

Find appropriate hope

Allow dying person to be at risk

Make decisions for dying individual

Take care of oneself
Complicated Grief / Atypical Grief

Absence of Normal Grief

Nonexistent

Inhibited/Abbreviated

Delayed

Prolongation of Normal Grief

Chronic grief

Inability to let go of deceased

Need to keep deceased alive

Distortion of Normal Grief

Exaggeration of one or more manifestations

Excessive anger, guilt

Conflicted – to grasp implications of death
Basic Tasks of Mourning

To accept the reality of the loss

To experience the pain of grief

To adjust to an environment in which the deceased in missing

To re-invest our energies into new tasks and relationships
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Factors Impacting Psycho – Social – Spiritual Distress in Grief Work
Physical Issues

Stage of illness particularly advanced stage & type of illness.

Functional limitations.

Symptoms particularly pain & weakness.

Anorexia/cachexia syndrome.

Neurological dysfunction.

Endocrine disturbances.

Organic psychological disturbances such as delirium and depression.

Changes in body image.
Treatment Issues

Medications including opioids, chemotherapy, corticosteroids.

Dependence on life-support machinery or other aids.

Radiotherapy.

Multiple physician care providers with lack of coordination and/or communication.
Familial Issues

Previous psychiatric history and family dysfunction.

Individual and family coping strategies.

Substance abuse.

Family abuse and violence.

Unresolved grief.

Post-traumatic stress disorder.

Lack of preparation for death.

Spirituality.
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Social factors

Socioeconomic status.

Financial issues.

Culture and ethnicity.

Religion and/or belief system.

Family history of illness.

Lack of supports.

Availability of medical support services such as palliative/hospice care, home care
or other components of health care.
Characteristics and Meaning of the Lost Relationship

The unique relationship that has been severed

The role and function that the deceased filled in your family or social system

The characteristics of the deceased

Amount of unfinished business

Perceptions of the deceased’s fulfillment in life

The number, type and quality of secondary losses the death brings
Personal Characteristics

Coping behaviours, personality and mental health

Past experience with loss and death

Social, cultural, ethnic and religious / philosophical backgrounds

Sex-role conditioning

Your age – Level of maturity and intelligence

The presence of concurrent stresses or crises in your life

Circumstances of Death

The timeliness of death

Perception of the preventability of the death

Sudden vs expected death

Length of illness prior to death

Your anticipatory grief and involvement with dying loved one
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Possible Grief Reactions
Denial
Anger
Bargaining
Depression
Acceptance
Bargaining
Dr. Elizabeth Kubler-Ross
These possible reactions are found both in anticipatory grief and in the grief
experienced after a sudden or expected death. There is no time frame given in
working through these feelings. These “stages” of grief may come in a different
order, and one or more stages may be skipped entirely. A person may or may not
reach acceptance in anticipation of their own death.

What grief reactions have you experienced in the loss of a loved one?

Did these feelings come in any particular order or stages?

Did you move toward acceptance?
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Responses to Grief
With the development and evolution of newer philosophies, there is now wider
recognition and greater acceptance of the concept dealing with responses to grief.
These responses do not follow in succession but move back and forth, much like
the action of ocean waves and are as individual as the person experiencing the
grief.
Shock or Numbness Shock is experienced immediately following a death. This
phase may last minutes or weeks. Strong physical reactions accompanied by
feelings of panic or of being overwhelmed are not uncommon. Whether expected or
sudden, the reality of the death comes as a shock. Denial is used by some people
as a protective mechanism from the pain associated with grief.
Guilt Feelings of Guilt commonly felt after someone has died may be accompanied
by a sense of relief. Questions of "what if and thoughts of "if only" frequently surface
but are not usually met with definite answers.
Anger Anger, a frequent reaction to death, is usually directed at the person who
died and may present as mild irritability or extreme rage. Unexpressed or
unresolved feelings of anger may lead to deeper physical and psychological
problems.
Depression Along with the feelings of great sadness and loneliness that come with
the loss of a loved one, Depression must be recognized as a natural response that
needs to be experienced. The grieving process cannot and should not be hurried.
Once the loss has been accepted, the loved one can be remembered with joy rather
than pain.
Resolution The process of Resolution allows the integration of the loss into the
activities and routines of daily life.
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Tasks of anticipatory grief for families of the dying person
When someone close to you is diagnosed with a life-threatening/terminal illness,
everyone begins to grieve. This anticipatory grief process can be confusing and
difficult. On the one hand, you are attending to the needs of the ill family member
and maintaining involvement with them. On the other hand, you find that you begin
to reinvest emotional energy towards how life will continue after the person dies.
There is never enough time or energy to attend to these opposing needs.
The steps that you take to cope are called tasks. You can find that you are
engaged in all of these tasks to varying degrees at the same time. However, looking
at each of these tasks separately will help you to understand more exactly the
demands of the situation and how to make the best use of family time and energy.
Understanding the importance of these tasks can enhance each family member’s
coping ability.
Fluctuating from denial to acceptance of the illness and death
Some denial of reality is healthy and necessary for you to function. It allows you to
take in information at a more tolerable pace, and gives you a break from the
emotional stress of a situation. Acceptance of what is happening will not necessarily
bring peace.
Establishing a relationship with health professionals
You may need to learn how to be constructively assertive, as well as find a way to
deal with frustration. Family and health professional conferences can help to reduce
your anxiety by opening communication lines and giving you direct information. It
may help to write your concerns down before meeting with the health professionals.
Meeting the needs of the dying person
As the illness progresses the individual’s physical and emotional needs will change.
Your task will be to help in the best way you can without taking away his/her control
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or independence. Remember to ask your loved one what he/she thinks he/she
needs or wants.
Maintaining a functional family unit
When someone is sick it means that everyone has to take on new roles and
responsibilities. At the same time it is really important to maintain some of the
normal family routines. This gives you some security in the midst of chaos.
Living with the emotions of anticipatory grief
During this time both individuals and family experience intense swings in emotion.
Having information about these feelings and being aware of your own reactions help
you begin to cope. It is important to let each other know how you are feeling and
what you need. There may also be things that you prefer to discuss with someone
outside the family.
Dealing with people outside the family
You have little energy at this time for outside relationships and everyone's reactions
are unpredictable. Friends may avoid the sick person or make inappropriate
requests. You resent others' stability and good fortune. People don't understand
what you are going through.
Anticipating the family's new reality after the death
It is impossible to imagine the future. However, estate planning, dealing with
different kinds of unfinished business, and building in emotional supports are things
that can help you to prepare. The important thing is to do the best you can.
Finding appropriate hope
What you hope for throughout this time will change. Long term plans need to be
replaced by short term plans; you find yourself giving up treatment aimed at cure for
that which relieves symptoms. As you are able to accept the goal of comfort you are
taking a step toward acceptance of the inevitability of death.
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Allowing the dying person to be at risk
Refusal to take medications or accept personal help may be very difficult for you to
deal with, but it is important to recognize the individual’s right to choose activities
that may put him/her at risk. His/her choices should not put you at risk.
Making decisions for the dying person
There may come a time when your loved one is unable to make decisions for
himself/herself. Prior discussion, the use of a living will, or your knowledge of the
person will help you represent his/her best interests.
Taking care of yourselves
When you are focused on caring for someone else it is hard to have energy for
yourself and to see this as important. Building in time for self-care is crucial.
Recognize that you have needs … physically, emotionally and spiritually.
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Worden’s Four Tasks of Mourning
Mourning is the process that helps people cope with grief. The four progressive
tasks related to mourning are the active way by which we incorporate grief into our
lives and discover how we are changed by it.
Task #1
Acknowledge
To accept the reality of the death by talking about the dead person and the
circumstances surrounding the death. This helps to soothe and dispel feelings of
shock and denial - to come full face with the reality. Short-term denial is very
natural and normal. Grief counseling goal is to accept the reality of the loss.
Task #2 Experience
To work through the pain of grief, while difficult to bear, allows the grieving
person to understand that this suffering will pass. Work through the grief - it is
necessary to acknowledge and work through this pain or it will manifest itself
through some symptom or other form of aberrant behavior. Getting in touch with
your feelings regarding the loss. It is like peeling an onion - layer by layer, by
admitting the pain, verbalizing the pain, naming it, and finally owning it. Goal is to
help bereaved deal with both experienced & latent affect.
Task #3
Detach
To adjust to an environment in which the deceased is missing comes with
understanding the relationship with the deceased and the part he/she played in the
life of the survivor. The survivor of a deceased spouse may not be aware of all the
roles played by the deceased until after the loss occurs.
In time, one usually
decides that they must fill the roles to which they may be unaccustomed and
develop skills they never had or never used. A new sense of self emerges as the
adjustment is integrated.
Grief counseling Goal is to help bereaved overcome impediments to readjustment.
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Task #4 Memorialize
To re-invest energy in the future and move on This is perhaps the most difficult
task to accomplish. People may fear that they are dishonouring the memory of their
loved one by moving on with life and new relationships. It is a time to find renewed
meaning. Emotionally relocate the loss and move on with your own life. e.g. “My
spouse is not going to return.
I will make a new life without him/her.”
“My
son/daughter has died - I must put my attention on myself and other family
members.”
Characteristics of families who are more open in handling loss

Loss of role is recognized but no single family member is expected to fill it

Reorganization enables the carrying out of tasks previously connected to the
deceased’s role without the role itself actually being taken over by another
family member

Thoughts and feelings about death are expressed without expecting others to
act

Each family member is allowed to express his/her own way of grieving and
having that expression accepted by others
Characteristics of families who are more closed handling loss

Make as few changes as possible and try to maintain life as if the death had
not occurred

Feel the need to maintain certain roles in the family

Freedom of expression is not allowed
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Bereaved Families
“We’ve had the same loss, why don’t we have the same grief?”

Grief will be found in families, but grieving will not be done by families.

Families do not grieve, only individuals grieve.

The degree to which family members are able to anticipate and prepare for
the
death is a factor that can put family members at different places in their
resolution of the loss.

Gender acts as a discriminating factor.

The age and/or development stage of various family members will affect the
ways in which they grieve.

Members may find each other’s idiosyncratic grief style difficult to cope with.

Earlier socialization differences in cultural background may affect grief style.

Issues surrounding the loss may never be resolved completely.
An Offer to Enter into the World of a Grieving Person
“How are you doing?”
“What’s it like?”
“If you would like to talk, I’m willing to listen, if you don’t, that’s OK with me.”
“How did it happen?”
“Tell me about _________________(the deceased)”
“Tell me what it is you see death or loss as?”
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Coping with Grief
One of the major factors influencing the mourner’s movement toward reconciliation
is that he/she be allowed to mourn in his or her own unique way and time.

Proceed gently. Do not rush too much. The body needs energy to repair.

Keep decision-making to a minimum.

Don’t assume new responsibilities right away.

Accept help and support when offered.

Ask for help.

Search for support from others. Consider meeting new people.

It is important to find someone who cares, understands, and listens.

Be patient. Healing takes time. Understand anniversary reactions.

Lean into the pain. It cannot be ignored. It must run its course.

Crying does help.

Try to find or schedule comforting activities during holiday times or Sundays.

Look for help from a counselor or clergy.

Avoid relying on caffeine in coffee, tea and colas.

Get enough rest.

Try to eat balanced meals. Good nutrition is important in the healing
Family and friends are not mind readers.
process.

Keep a journal. It is a way to understand thoughts and feelings.

Read. There are many helpful books that deal with grief.

Moderate exercise helps to work off frustration and promotes sleep.

Don’t feel guilty when enjoying good times with family and friends.
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Tips for the Griever

Give yourself permission to grieve the loss

Accept social support and tell others what you need

Be realistic in expectations of grief work

Make sure you are satisfied with information about death

Be prepared for negative feelings and volatile reactions

Recognize grieving will be unique

It doesn’t make any difference what other people think

Be realistic in your expectations of others

Do not let others needs determine your grief experience

Do not let anyone minimize your loss

Your pain will subside if you continue grief work

Identify secondary losses and resolve

Look for appropriate ways to resolve unfinished business through closure

Identify, accept and express all your various feelings over the loss and it’s
consequences

Must allow for repeated crying and talking and reviewing without interruption of
anyone else’s sanity

Differentiate clearly between your various feelings of grief so that each one can
fully processed and your grief can be better managed

Look for those who can listen to you non-judgmentally and with permissiveness
and acceptance

Remember deceased and review relationship

Keep certain shared routines

Identify and work to resolve secondary losses and unfinished business

Be patient – don’t expect too much

Give yourself time alone

Get support for practical problems (I.e. finance)

Give yourself breaks from your grief

Find a way to replenish lost energy from grieving
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be

Avoid making major changes suddenly

Engage in some form of physical activity

Work to maintain good physical health

Decide about appropriate ways to keep memory alive

Decide which roles you are going to take on or give up

Decide which skills you need to develop

Do not equate the length and amount of your suffering as some kind of
testimony for deceased

Find some ways to make death meaningful

Think small – goals, pleasure, progress

Find appropriate – people, things to do, beliefs and causes to invest in
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Some Helpful Tips for Caregivers of Grieving Persons

Keep in mind YOU are only ONE channel for God’s presence

Christians do not grieve the same as those who have no hope. As Christians, we
have Hope.

It’s YOU making yourself available by: being present in person, a note, a telephone
call – a thinking of you card.

Help with practical matters, i.e. errands, fixing food, caring for children. Good
wording is:” I’m going to the store – can I get something for you?”

Don’t be afraid to cry openly if you were close to the person experiencing a loss.
This lets the person know you care and are sharing their pain – then they don’t feel
so alone.

Never say “I know just how you feel.” OK to say “I have experienced a similar
situation and have an idea of what you are experiencing.”

When they ask WHY – they are not asking for an answer – a simple reply may be, “I
don’t know why.” I wish I had and answer – I’m here with you.

Never use platitudes like: “A lot of people are in the same boat as you” or “You are
better off without him/her”.

When anger is present – encourage them to express it.

Patience – don’t say – “You will get over it in time.” Encourage them to be patient
with themselves as there is no timetable for grief.

Grieving people’s self-esteem may be very low.

When they express guilty feelings, encourage them to express the guilt – not helpful
to say: “You shouldn’t feel guilty” – turn it around and say – “It’s okay or normal to
have these feelings” or “I personally don’t feel you are guilty – you did the best you
could at the time, but I would like to hear more about how you feel about this.”

Depression is often a part of grief. It is a scary feeling for the person. Again, indicate
this is part of grief. You are much needed here.

Give special attention to the children in the family.

Encourage counseling if grief is getting out of hand.

Suggest exercise, walking, etc. to work off tension and anger.
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
Practice unconditional love. Feelings of rage, anger and frustration are not pleasant
to observe or listen to but it is necessary for the grieving person to recognize and
work on these feelings in order for them to work through the grief, rather than
become stuck in on particular phase of the process.

Assess on regular basis – how the is person today – because it can change
dramatically on a weekly basis.

No judging – families have a tendency to want quick healing and fixing. Good
Healed Grief cannot be fixed – only nurtured.

Encourage – when you see even a hint of progress – let them know. A grieving
person cannot make this assessment on their own.

Faith Test – whichever way their faith is going try to stay with it – no condoning it
but accepting it for now.

Use of prayer is vital to rid yourself of your own pain, thoughts, your own things in
your life so you can be present to the person.

Do not avoid the person – this adds to their loss. One person I know whose
husband left said “I not only lost my husband but I have lost some family respect
and friends. They avoid me and I have the feeling of being alone.

Special occasions are difficult for grieving people.
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New Beginnings for the Bereaved
Finding Hope in Grief
Does it seem odd to you for someone to talk about finding hope in grief? That’s
because one doesn’t often read about rediscovering hope in the midst of grief.
However, it has been one of the foundation stones of my work with bereaved people
during the many years that I have been doing this work. In this article, I would like
to address two aspects of hope and grief. First, I want to think about what hinders
people from finding hope in grief. Then I would like to talk about how it is possible to
find hope in the midst of our grief.
There are many things that hinder us from finding hope, especially in the early days
after the death of a loved one. Here are some of them.
An inability to grasp what “hope” means.
Perhaps it is because it is difficult to define hope. Or maybe it is because, in every
day conversation, we use terms like “positive attitude”, or “wish” or “look forward to”,
instead of talking about being hopeful. The American journalist and author, Norman
Cousins wrote, “The capacity for hope is the most significant fact of life. It provides
human beings with a sense of destination and the energy to get started.” Perhaps
this quote may help us to focus on how hope relates to the grief process.
The initial impact of grief dictates against our being hopeful.
In the first place, the shock of grief literally affects your ability to think clearly. The
future as you knew it has been lost. Notice I didn’t say your future has been lost.
There is still a future, but it will take time for you to see into that future.
Most bereaved people experience a period of disorientation.
It is a time when you are unable to focus and to make clear decisions. It is a time of
confusion and, often, of being unable to see outside your own situation. It is difficult
to be hopeful in these circumstances.
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Grief often robs you of your motivation or drive.
This is a normal phase of grief and, with time, it will pass. However, it is difficult to
find hope when you lack either the energy for, or the vision of what life could
become.
Many bereaved people experience a loss of self-confidence.
People who are normally self-motivated and confident will find themselves saying
things like, “I don’t think I can do this!” or “How will I get through this?” Again, it is
difficult to assume you’re normally, “positive” or “hopeful” approach to life when you
don’t think you can make it.
As sure as the sun comes up each morning,
And Spring returns after Winter,
So life returns after a season of grief
The ability to be hopeful is often hindered by the loss of identity of the closest
survivor or survivors.
When a person becomes spouse-less, child-less or parent-less, there is often a loss
of identity. “I don’t know who I am now!” is something I often hear. This is probably
one of the most difficult aspects of the grief process and, like everything else, it
takes time to adjust. Eventually, one regains an understanding of who the new
person is and with that comes a rebirth of hope.
Hope is often diminished following a series of crises in life.
It is common for a person to experience a succession of deaths, illnesses, financial
crises, or other losses. That person may come to the end of their rope. They may
give up on hoping things will ever get better-that there is light at the end of the
tunnel.
One of the greatest assaults on hope is the loss of faith in a God or in the
basic goodness of life.
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I think it is safe to say most people place their hope in either God or an outlook on
life that makes sense and helps them get through the difficult times. When that faith
is lost, hope I also lost and the person is adrift in a sea of uncertainty and despair.
You may be able to identify with some of the above reasons why people are unable
to be hopeful. But there will also be other reasons in your life why you may have lost
hope. Identifying them will help you to understand what is standing in the way of
finding hope again. Then, in time, you will with some effort rediscover hope in your
life.
So, then how do we regain our hope?
Be patient!
These are the most difficult words for a bereaved person to hear. Most of us want
this period of grieving to be over in a hurry! However, there is no shortcut. It takes
time for you to process what this loss means to you. Even as you are doing that,
your hope will return.
Look for any sign of a return to life.
You may be surprised the day you laugh out loud for the first time. There will be
days when you experience genuine joy or pleasure. This may happen when visiting
friends, seeing the face of a young child, or enjoying a walk with your dog. The day
will come when you will begin to dream again. Your new future will emerge out of
the fog of your grief. You will hear yourself say, “Someday I would like to do this.”
Don’t resist any signs that life may be retuning for you.
I believe human beings are essentially survivors and it is that instinct that has kept
you going. Although there may be been days you wished you could have joined
your loved one, you wouldn’t have done anything to make it happen! As sure as the
sun comes up each morning, and Spring returns after Winter, so life returns after a
season of grief. As William Cowper, the English poet once wrote, “The darkest day,
if you live to tomorrow, will have passed away.” When you feel life returning, don’t
feel guilty about moving on.
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Find someone who is objective with whom you can speak openly.
It is quite natural for a person who is grieving to begin to think about what life might
look like a few weeks or months after the death of a loved one. You will find it
helpful to share your thoughts and dreams with someone who isn’t involved
personally with your grief. The right person will encourage and support you in your
journey. You need to find someone who will not hold you back.
Keep a journal for these days.
You will find a great deal of support and encouragement meeting with people in the
same situation as you. There is often a level of openness you may not find among
you family or friends.
Recognize you successes.
Often newly bereaved people are required to learn new things. A man may have to
learn to cook, or a woman may have to learn how to do the finances. Of course, the
opposite is often true as well! When you have done something for the first time that
you have never done before, give yourself a pat on the back and congratulate
yourself.
By John
Kennedy Saynor
He was ordained a priest in the Anglican
Church of Canada in 1989 and began an
active ministry to bereaved people which
included the publication of his first book,
Saying Goodbye. After a number of years in
parish work, his bishop appointed him to work
at the Rosar-Morrison Funeral Home in
Toronto. Here the first GENESIS Bereavement
Resource Centre was established in 1993
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WHAT CAN WE DO TO HELP GRIEVING PEOPLE?
LISTEN!!….
People in grief need someone to listen while they tell their story.
Grief recovery requires the telling and retelling of their experience.
Listening takes the force out of anger
Listening can even make anger funny
Listening can help ease worries
A good listener is a walking, touching personal intensive care unit!
Listening can turn grief into growth. We do not take grief away from people; we
simply help them walk through it — by talking it out. They need to talk to a good
listener.
People learn while they talk. The articulation of grief diminishes the intensity.
The whole world is waiting to be heard. This need is especially deep during grief.
The ability to simply listen is the greatest help possible, in every phase of grief.
The caring supportive presence of another person is the most effective way to help
someone who is bereaved. What is always important is the human connection.
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Ten Commandments for a good Listener
1. Stop talking. You cannot listen if you are speaking.
2. Put the speaker at ease. Establish a permissive environment to help the person
feel free to talk.
3. Show the person that you want to listen. Look and act interested, and listen to
understand
4. Remove distractions. Do not doodle, tap fingers or shuffle papers. Close the door
for privacy and quiet.
5. Empathize. Try to see the person’s point of view.
6. Be patient. Allow plenty of time. Do not interrupt.
7. Be sensitive. Recognize the value of non-verbal communication
8. Go easy on argument and criticism. The person will get defensive or withdrawn
9. Ask questions. It helps to develop points further, encourages the speaker, and
shows that you are listening
10. Stop talking! The person cannot talk if you are.
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Bereavement Myths

Time takes care of grief

Grief lasts six months to a year

It’s more helpful if the loss is not mentioned

Grief brings people closer together

Try not to think of your loss

All losses are the same

Children don’t grieve

Children are too young to understand death

People who have had time to adjust to a death cope easier

It’s better to get involved in another relationship quickly

To feel angry or guilty is abnormal

People who show their grief are having more problems coping

Don’t give in to your grief

If you hear their voices or think you see them you are going crazy

Grief gets better every day

When someone dies your relationship with them is over

How long and difficult your grief is, equals how much you loved them

Everyone grieves the same
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Elders’ Institute
Tool for Pastoral Visitors
Dealing with Loss & Grief: A Tool for Healing
How do we support each other in Christian community during the most difficult times
of loss and grief? Janet Stark, an elder at St. Paul’s Presbyterian Church in
Kemptville, Ontario, and Certified Grief Services Provider, has adapted the work of
Kris Munsch (www.thebirdhouseproject.com) to offer this tool for all pastoral visitors.
The series of questions under eight categories offer a guide for everyone who is
moving through the process of grief to a new “normal”. This tool can be used both in
our personal grief work and as a guide in our pastoral conversations as we support
others in their healing journeys. (Remember, loss takes many forms and can
include the loss of a partner, job, independence (age, illness, empty-nesters), pet,
mobility, financial security, etc.) These questions offer a journey of self-discovery
and healing that require time and patience. It is important that pastoral visitors
maintain confidentiality and seek the counsel of the minister when overwhelmed by
their pastoral conversations.
ME
Who are you? Establish your identity. (I am a bank manager, a college
student, etc.) Establish your identity and role(s) as others see you and need you. (I
am a favourite aunt, a trusted friend, a good neighbour, etc.). These questions build
self-esteem.
FOUNDATION
What are your core strengths? What are your assets and gifts?
What are you particularly good at, interested in or passionate about? What gives
you spiritual energy, (such as, your loving spirit, sense of humour, deep faith,
generous giver, lover of nature etc.)? It is important to spend time thinking about
these questions and answering them in detail.
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LOSS What is your loss? What has happened that causes you sadness? What is
the crisis? Expressing this fully from your own perspective helps you to process
and try to make sense of what happened. This is the tough part. This is personal
and may be private.
REGRET
What do you regret? Would you have done anything differently?
What have you learned? These questions invite you to express the deep sadness of
your loss. This part of the journey may be quite difficult but necessary.
The next steps help you to move forward in positive ways.
AFFIRMATION Identify an inspiring phrase, Bible verse, mantra, deeply held belief,
line from a favourite poem, etc. Memorize it and recite it often until you own it and it
owns you.
GOALS What are some small, positive steps you can take today that help you
move ahead? What are some small tasks that need to be done? Name those
things that nurture you and commit yourself to draw on at least one of those things.
Those things that nurture you might include a visit to a grandchild, adopting a pet,
yoga lessons, a Bible study group. Be positive, and live in the moment!
SHELTER
Who will I keep safe, (partner, child, myself)? Do I have the strength or
resources to keep someone else safe? Can I keep myself safe, by trusting my own
instincts? Can I ask and allow God to shelter me?
TRUST Who do I trust? Can I allow myself to be vulnerable again? What do I put
my trust in? (Do I trust that God will take care of me, that the sun will come up
tomorrow, that I will move toward healing?)
~Better to have loved and lost than never to have loved at all ~ Shakespeare
Janet Stark is the Spiritual Care Manager and Multi-faith Chaplain at the Brockville General Hospital.
(printed with permission)
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Clues for Assessing Complicated Grief
Certain clues can give indications of complicated grief. If you identify that there
appears to be a great deal of pain or abnormal emotion, confirm this with the
following:

Person is unable to talk about the deceased, the loss or circumstances and
details of the funeral.

Do symptoms return on anniversary or at age of the deceased? This is
particularly so with traumatic deaths. The image of their loved one’s death is
often more horrible than the reality.

Does the person avoid visiting the grave, attending the funeral or subsequent
funerals?

Appearance of symptoms such as prolonged depression (more than 2
years), persistent guilt (ie. “I made him have surgery”), or low self-esteem.

Continued searching for the deceased. Seeing them in public/private.

Do relatively minor events trigger a severe grief reaction?

Are you hearing a recurrent theme of loss? (ie. Saying they’ll never love or
get close to anyone again.)

Is there relationship breakdown within the family or with close friends? This
is often seen after the loss of a child.

Is there increased use of alcohol, prescription drugs or street drugs?
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Complicated Grief is Identified By:
The presence of some or all of the following may indicate the presence of
complicated grief:

The extended length of time of the symptoms (+2 years).

The interference caused by the symptoms. ie: denial, anger, depression.
Normal lifestyle is interrupted.

The intensity of the symptoms. ie: intense suicidal thoughts or acts.

Being hung up on any of the normal stages of grieving.

Setting up of shrines that keep things the same as before the loss.

Development of physical symptoms like the deceased’s cause of death.

Compulsion to imitate the deceased.

Self -destructive impulses like excessive or increased alcohol consumption,
risk taking, hazardous behaviour.
If you suspect complicated grief refer to an appropriate professional for
assessment and treatment.
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Different Kinds of Grief
Grief not only has many faces, it also has many causes. In this lesson we will
examine some alternate losses that cause intense grief in some people while others
are unaware of the depth of the loss felt. Similarly, we will also discuss some forms
of grief which are accepted by mainstream as “legitimate” causes of grief. It is
imperative to note that while some forms of grief are stigmatized by society in
general, such as loss of a loved one due to suicide, it does not matter how a loss
came about; the ensuring pain and resulting grief are just as real for the individual
experiencing it, whether those on the outside looking in find the cause of the grief
“legitimate” or not.
The Loss of a Pet
To many the loss of a pet is a grief as deep and painful as to others the loss of a
loved one may be. Pets oftentimes take the places of loved ones who have either
passed away or moved on in life, such as ex-spouses or grown children. Offering
unconditional love, pets accept their human companions for who they are, not for
whom they might change them into. Similarly, many a person who still has much
hands-on love to give, yet no longer has children in the house upon whom to lavish
such affection, finds comfort in the dependence a pet will have upon its human
companion. Lastly, oftentimes a wagging tail or an excited chirp are the only sounds
of welcome a person will hear when coming home; often for weeks or years. It is no
surprise, therefore, that the loss of a pet can be as traumatic to some as the loss of
a person would be.
With the loss of the pet come feelings of self-doubt, guilt, and amplified loneliness.
Sadly, many do not take the grief over the loss of a pet seriously, since many
project how they would feel in a similar situation. Overtly or covertly, they relay the
message to the grieving person that the intensity of their grief is silly or
unreasonable, some will suggest to go down to the Pet-Store and buy another
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animal to replace the lost one; some will simply tell the grieving person to “get over
it.”
If you know someone who intensely grieves for his or her pet, or if you have lost
your animal companion and feel embarrassed about your grief, please remember
that not everyone can understand the bond between a person and his/her
companion animal. Yet, simply because others do not understand, does not mean
that you should hide your feelings and allow them to build up inside you with no way
out.
If you are the friend of someone who has lost a pet, please remember these simple
yet much appreciated gestures;

Gently ask the person about the circumstances of the pet’s death. If a decision was
made to euthanize the animal, reaffirm the person’s decision.

Offer empathy, support and compassion. Do not convey the message that the
person needs to “get over it”’, or should go out and “buy another pet”. Remember
that the other person lost a relationship, not simply an object.

Write a card to acknowledge the loss of the pet, and also to encourage the human
companion left behind. Remember, just because you are not the one grieving the
loss does not mean the other person is not feeling it!
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The Loss of Self …Child Abuse
The most traumatic event in a child’s life is abuse – sexual, verbal, physical or
emotional. Children will carry the scars of these incidents into their adulthoods, and
oftentimes through their entire lives. While someone on the outside looking in may
not understand reactions that appear out of context or exaggerated, for the survivor
of such abuse it often is the only coping mechanism s/he believed to have to
overcome the hole the abuse has left in her/his life; the loss of self.
If you are battling with the loss of the childhood you never truly had, the loss of trust,
the loss of relationships, and the overall loss of self, please remember that you are
not alone;

Remember that you are a fighter and a survivor!

While the past cannot be undone, the future holds a promise of happiness and
continued healing.

Healing may take on a variety of forms, such as journaling your experiences,
dealing with them within the context of a support group or perhaps one on one with
a counselor, yet, what all these forms of healing have in common is the decision to
not let the perpetrator’s actions control one more second of your life!
The scars of abuse are something that will never go away completely: they may
fade, and the influences on a person’s life may lessen, but they will remain. In cases
where they are more pronounced, one might find a person who suffers from severe
depression or a variety of personality disorders. Sometimes substance abuse
dependency can aggravate these conditions. Sadly, in a few cases the vicious cycle
appears unbreakable, and a survivor may yet succumb to the pain of abuse and
take her/his life.
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If you are someone who has experienced the loss brought on by child abuse and
you do not know how to cope with the grief, anger, hatred, and sheer agony please
know that you are not alone and that other people have made it through it before
you. Learn from them! Seek out a support group or an individual counselor who will
be able to help you through the worst of the upheaval.
If you know someone who has experienced the loss of self brought on by child
abuse, please know that even if s/he may push you away at times, s/he needs you!
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Sexual Abuse and Rape:
Rape is a crime of power, control, and extreme violence where sex is used as a
weapon against someone weaker. It is not normal reciprocal sex.
Please don’t……Tell us “it’s just sex”.
Don’t tell us it was God’s will we are raped or it was God’s will that we survived!
Don’t say, “It happened on a date, that’s common.” When you say that it belittles me
and my feelings about the assault. It’s not common because it happened to me and
I’m not a statistic.
Don’t tell us to “get over it’” We would if we could and we are trying our best.
Support us as we struggle to find our way again.
Loss by Choice…Abortion
No other choice one makes has the potential to bring on the amount of grief as the
choice over life and death, especially the life and death of a child. What starts out
with the intention of making an informed decision and informed choice about a
woman’s reproductive rights, will suddenly, for some women and also for some
men, spin out of control into the pain of post-abortion grief.
It is important to note that this is not an isolated incident, and while it does not affect
each woman who ever had an abortion, it does affect a large number of women,
with the numbers of women who speak out growing daily. What the women who
speak out seem to have in common are not only the emotions of grief, but also often
time the feeling of self-doubt, self-loathing bordering on self-hatred, intense shame,
and, for those who are already mothers, problems interacting with their children.
A woman who experiences post-abortion grief may feel alienated from the
connection with the sisterhood she felt with other women. Some women feel
betrayed by the pro-choice movement, when the particular circles in which they
move fail to support her grief, or may even feel threatened by the notion that a
woman experiences agony over the choice of an abortion. Similarly, some women
feel betrayed by the pro-life movement, when a particular group will berate them for
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having an abortion in the first place, rather than extending a helping hand and a
listening ear.
If you are a woman who underwent an abortion only to now realize that you made
the wrong choice, take heart! Understand and accept that the grief you feel is real
and needs to be dealt with. It will be beneficial to find a support group of women
who are in similar circumstances, to have a support network when you feel your
pain all but choking you. Avoid groups/counselors who will seek to minimize your
pain or explain it away. Similarly, avoid those that will seek to have you join the prolife or pro-choice movement first prior to receiving any help or who will claim that
you will need to do so in order to heal.
Another group whose voice is heard far less often in the context of the loss of a
child by abortion is the voice of men. Many carry the burden of the bloodguilt,
having been the instigators and supporters of the decisions, only to later on find that
they cannot let go of the shame, guilt, and overwhelming pain this “choice” exacted.
Similarly, some may feel pangs of envy when they see fathers with strollers or little
children balance precariously on their hips as they buy groceries away. Perhaps
they cry silent tears when they hear the children in the neighbouring apartment
squeal when someone is spraying them with water. Some may ask themselves daily
if perhaps they could have done something differently to dissuade their mates from
aborting their children.
Traditionally, men are seen as the big bad wolves of the abortion tragedy, the users
of women who not only got them pregnant but then abandoned them to their
uncertain faiths, condemning them to make a life and death decision that could
potentially weigh on their consciences for all of their mortal existence.
And, truth be told, the men who fit this description are legion! Yet, there is another
group as well. They are the ones who begged and pleaded with the women to
please allow the baby to be born; the ones who offered a ring in pledge of their
sincerity; the ones who were willing to let the women and the children go their
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separate ways, willing and able to support both financially, if only the children were
allowed to live; the ones who suggested adoption, made appointments with the
agencies, only to be stood up; and also the ones who sought to protect their unborn
offspring with legal challenges, only to be helplessly ordered to stay away while
their child was sucked into a sink, never knowing s/he was wanted by at least one
parent.
The Loss of Hope…Death of a Child
The death of a child is every parent’s most dreaded nightmare. Whether the child is
already grown and out of the house, still in infancy, or maybe even still in-utero, this
kind of grief is impossible to prepare for, and also impossible to overcome. The child
will always be a part of the family’s life, and while the pain may dull after a while, it
will be a constant companion. Not surprisingly, the death of a child is one of the
hardest occasions a family may ever have to face, and many a marriage has fallen
apart under its strain. Additionally, no other death brings as much seclusion as this;
friends with children will avoid the bereaved, for fear of deepening the pain, but
perhaps also for fear of facing their own worst nightmare. Similarly, those without
children often do not understand the depth of this pain and may even feel that a
parent should get over it, since they could have another child either by birth or
through adoption.
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When Hello Becomes Goodbye ~ Honouring the Life of Your Baby
Grief is the price we pay for love…
Without a doubt, the birth and death of your baby has had a significant impact on
you and your family. The following are ways that other parents, just like you, have
chosen to make their baby’s life and death an event that will always be honoured
and memorialized.
Have a funeral or memorial service for your baby.
This is a very significant way for those around you to come together to pay their
respects to you and your family and to share in your grief. A funeral does not have
to be a formal event, it can be something simple and private in your home or
backyard, or it can be formal in a church or funeral home chapel. What is important
is that you decide together what it is that YOU want. Nobody else knows what you
need at this time and you may find yourselves being told a lot of “you should” or
“when I…” or even “if I were you…” statements. Your family and friends mean well
but they cannot make those important decisions for you. You do not need to feel
rushed, you can do these things when you are ready and only if you want to. Take
time to speak with your spiritual community leader or speak with one of our hospital
chaplains as they have resources that can help you make a decision that reflects
your family’s values and beliefs. Remember – even if you choose to have a ritual at
the time of birth and death, these do not have to replace something you may want
to do later with other family members present. Do what feels right to you. Only you
know what you truly need to begin to heal.
(Our Spiritual Care Chaplains have many resources about funeral planning that you
can access).
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Do something meaningful ~ leave a legacy
Some people find it helpful to put their grief into action. There are many things that
you can choose from and none of them is a “you should.” Below are a few of the
things that other families in grief have done to help them learn to live with their loss.
We encourage you to involve other family members in these activities as they too
are grieving…
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Plant a memorial garden in your backyard or at the baby’s gravesite
Buy a locket and place a snippet of your baby’s hair in it, with a photograph
Donate money to a special charity (if your baby had a congenital illness)
Donate grief teddy bears to your local hospital to give to other grieving people
Begin a grief journal, write a poem or a story that inspires hope
Scrapbook some of the special mementos you have of your baby (hospital
bracelet, basinet card, booties, hand/foot print, lock of hair, photographs, baptismal
or dedication certificate, naming certificate, etc.)
Donate your baby’s clothing, crib, etc. to a home for pregnant women in crisis
Get a small tattoo (the name and date of your baby’s birth and death, a heart, a
butterfly…) the choices are endless and very personal
You may want to dedicate a piece of playground equipment in the neighborhood
park where your baby would have played as an older child
Have a special piece of jewellery made that holds the baby’s birth-month gemstone
Have photographs of your baby framed and hung on the wall with other family
photographs
Plant a tree in honour of your baby
Engage in random acts of kindness
On what would have been your baby’s first birthday or Christmas (or other
significant holiday) you may want to donate toys to a local charity.
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Miscarriage
Both parents feel the loss, but the mother is probably the most affected, since she
had the physical and emotional connection with the unborn child. The father had
this connection to a lesser extent, and so he sometimes may feel very left out of the
grieving process. It is not uncommon for women to rally around the mother and
seek to comfort her, while the father is summarily ignored or expected to move on
by himself, and get back to his regular routines, i.e. work, right away. It is important
to note that both parents are bereaved, and that both need support and help,
perhaps even counseling. While it is true that the physical connection was stronger
for the mother, that father, too, has to face the prospect of entering the nursery and
slowly beginning to pack up all the carefully laid out bedding, outfits and other items
purchased in anticipation of the birth. Similarly, he, too, will have to face that the
only photo he may ever have of his child is the ultrasound picture.
A loss through a miscarriage cannot be healed or made to go away, yet it can be
dealt with by openly talking about feelings, seeking professional help, and allowing
time for grief for both parents involved. There is no hard and fast set of rules to
overcoming the grief caused by a miscarriage. Instead, there is a list of don’ts…

Don’t accuse your partner of not wanting the baby, simply because s/he is not
expressing grief like you are.

Don’t listen to “friends” who chide you for not being “over” it.

Don’t blame your partner or yourself for the loss.. miscarriage is not something
either one of you could control.

Don’t keep your pain bottled up inside you; instead, let it out!
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SIDS
Sudden Infant Death Syndrome is, next to a miscarriage, the most traumatic event a
parent may ever experience. A modern-day scourge neither eradicated nor its
causes found, many a parent will suffer greatly from feelings of inadequacy (of
keeping their baby alive), guilt (for engaging in behaviours that have been identified
as being possible contributors to the likelihood of SIDS), and anger (often at
physicians and other medical personnel). Just like a parent surviving a miscarriage,
a parent faced with the unavoidable death of an infant will oftentimes find
her/himself alone. Friends and family don’t truly understand and are even a bit
afraid of the rawness of the emotions; while others offer well-meaning yet
inappropriate advice, such as “have another child right away”. Please know that it is
perfectly normal that you should think of your child constantly, and do not feel guilty
about missing her/him so much! Even if you will have other children, you will
continue to miss your dead child, to think of her/him and also remember her/him on
birthdays, holidays, etc. This is a normal part of the grieving process. The best
advice for those seeking to overcome SIDS is to network with those who are in a
similar situation.
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Death of a Loved One by Suicide
Suicide is one of society’s most stigmatized forms of death. Being decried in many
religious practices as being hell/hades bound, and being seen within society as
cowardly individuals, the dear are often judged by the living and found lacking.
Similarly, the bereaved, left to pick up the pieces after a suicide, will often feel the
stigma of this death; friends and family speak in whispers, often second-guessing
the reasons for the suicide, and very often seek to either gloss over the fact that the
death occurred by suicide, or simply refuse to acknowledge the death altogether.
In addition to the foregoing, a suicide is not usually done with malicious intent of the
deceased, but instead is a desperate act of a pained individual who did not see a
solution/way out in a moment of darkest despair. The bereaved is oftentimes aware
of the situation, and quite possibly is actively involved in helping the deceased.
Thus, the suicide is even more devastating, in that it elicits feelings of extreme guilt
within the survivors, who second-guess their every move, wonder what they
should/could have said/done differently that could have prevented this tragedy. The
next most likely emotion is one of anger. Most likely, the bereaved will be angry with
the deceased for not asking for help, yet also angry with her/himself for not seeing
the need for help much clearer. This personal anger may often be turned inward,
resulting in self-destructive behavior, and also in a seeming inability to get close to
others.
It is imperative that friends and family do not treat the grieving individual as a
second-rate mourner, and the dead as person devoid of morals and worth. The first
order of business must to the removal of the stigma of suicide from within the family
and circle of friends. This is best done through education, commitment to the
bereaved, and love for the deceased.
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Death of a Loved One by Murder
Those who lose a loved one through the violence of murder not only face the
normal issues of grief, but the added trauma of facing the fact that their loved one
was a victim. Anger oftentimes becomes an all-consuming rage and a need for
information very often turns into an almost self-destructive search for each intricate
detail of the victim’s suffering. These emotions are compounded by the legal
proceedings that follow the apprehension of the criminal, or the lack thereof, and the
lack of closure that goes alongside the failure to apprehend the murderer.
Friends and family will readily rally to the side of the bereaved, but may feel
uncomfortable by the intensity of the pain and anger s/he is experiencing. It is
important to remember that this is not a time to judge the “appropriateness” of the
expression of the grief, but instead a time to simply be there. Please understand
that emotions of the bereaved may run the gambit of a variety of emotions, yet all
with a startling intensity.
1. Anger may be directed at people (i.e. friends of the victim), the criminal, and
even a deity. Such anger may sometimes be expressed in fantasies of exacting
retribution, revenge, or physical pain of the person against whom the anger is
directed. This is a normal reaction to a world left shattered by the acts of another,
and should not be chided. The only time that friends and family should intervene in
this anger are the times that it either becomes self-directed, or that the bereaved
appears as though s/he will take action.
2. Fear is also a normal response to an action which should not have happened
and which stands against everything this society expresses and believes in.
3. Self-blame is another normal response. It often occurs if there is an unresolved
situation between the murdered victim and the bereaved, or if the victim was a child.
The bereaved second-guess her/his actions and, much like in the case of a suicide,
seek to find where s/he went wrong in failing to prevent the event. Such self-blame
may give way to self-destructive behavior, such as self-medication, and friends and
loved ones should be aware of such warning signs. Unlike anger, self-destructive
behavior should be dealt with immediately. It is a fallacy to assume that the
bereaved will “get it out of her/his system” and will feel better in a short while.
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Helping Others to Overcome Personal Grief
This section will speak directly to you, the friend of the grieving person. Having
discussed the various forms of grief, and also some of the causes of grief, the
question that overwhelms many a friend in the aftermath of a death is “What can I
do?” It has been observed that many will stay away from a woman who has suffered
a miscarriage, simply because they do not know what to say and what not to say.
Being There Without Feeling Awkward
Intense emotions have a way of attracting or repelling others. Intense love or an
intensely positive outlook on life, for example will attract other, while intense hatred
or negativity will repel them. Intense grief is the kind of emotion that will put others
in limbo; they know someone needs help and they want to be there but the rawness
of the emotion, the ambiguity of the societal expectations of the grieving process,
and other factors, such as discomfort with the topic of death, may quite often keep
friends away or send them to the sidelines. This is not necessary. Here are some
hands-on practical tips on how to be someone’s friend in a time of grief without
feeling awkward or out of place.

You don’t have to do the talking. Hugs and holding hands speak louder in a time of
grief, and the bereaved will not expect you to have all of life’s answers. Instead, be
willing to just listen.

Initiate contact. Don’t expect your bereaved friend to call you or come to visit you.
Instead, call her/him very frequently. Stop by and see if they are up for a game of
checkers (or whatever past-time they may enjoy) or bring by a pie and some hot
chocolate and a couple of plates. Invite yourself to tea – and then bring it yourself.
Even if you sit together in silence, your presence is what counts; so is the
opportunity you give your friend to talk to you if they wish.

Don’t squirm. When the bereaved begins pouring out their heart to you about the
deceased and any unresolved issues they feel are there, listen and nod. If you need
to find someone else to pick up your child from soccer practice and get her/him
some dinner, so be it.
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
Don’t seek to urge the bereaved on toward “getting over it”. In the midst of the most
intense grief, even the perception that there will be a light at the end of the tunnel
appears unrealistic to the bereaved.

Tread lightly when seeking to rationalize the death. Avoid such statements as “he is
no longer suffering’’. There is no comfort in those words.
While there is no one-size-fits-all method of being the friend of someone who just
experienced a personal loss, these suggestions should help you to fit into the world
of the bereaved without feeling out of your element yourself. As you can see, it is
much more important that you are there as a physical presence, rather than seeing
yourself in the position of a therapist whose job it is to help someone to move on
with her/his life.
Being Practical … When Others Cannot Be
Any practical help you can offer your bereaved friend will be very much appreciated.
If you see something that needs to be done, ask if you could do it for you friend.
Don’t ask if there is anything s/he would like you to do around the house (unless the
house itself is in an immaculate condition) – astonishingly, the most practical
individual will not know what help s/he needs in a time of extreme grief. Instead,
open the refrigerator, if it is empty, let the bereaved know you will be running to the
store for her/him and ask if there is anything special they would like.
Other practicals include:

Returning books to the library

Picking up the dry cleaning

Mowing the lawn and doing some overall yard work

Walking the dog; taking it to the groomer/vet

Doing some laundry

Cooking some meals

Cleaning the house

Helping the kids with the homework or taking them to school
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Other items with which a friend will heed help deal with the funeral, its planning as
well as the notification of relatives. Here you can shine and take the responsibilities
on your shoulder.

Ask whom you can notify of the death and plans for the wake/funeral and keep a
record of whom you informed and when

Offer to arrange housing for incoming friends and relatives, and inform them of the
plans made.

Pick up/return out-of-towners from/to the airport.

Do the lion’s share of the “Thank you” notes
Of special consideration, and already touched upon, is the care of children. If the
bereaved appears unable to help the children in their grieving, volunteer to stay
over and find someone trusted and known to the children who can do so and who
can help them express their grief. The same is true for the funeral; find someone
who can accompany the children and be their exclusive support during that event.
Another situation requiring special sensitivity is that of an elderly person losing
her/his life partner. Not only has a life-time of companionship come to a close, but
very frequently the bereaved may now face the inability to continue living the
environment to which s/he had become accustomed, be it for financial reasons or
simply because the loved one was a major care provider to the bereaved, who,
without this assistance, will be unable to care for her/himself. If you find your friend
in such a situation, you may very likely need to make some personal decisions, how
far you will be able to help your friend. For example, if the issue is one of financial
inability, you may be able to help your elderly friend with the phone calls and
paperwork needed to enlist government financial assistance. Similarly, if a caregiver
is needed, you may wish to confer with the family and offer to help out with finding a
suitable helper; however, be prepared that sometimes the wishes of the bereaved
and the wishes of the family may be opposed to one another. In such instances it is
best to simply support your elderly friend as unwanted changes to her/his living
situations are made.
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Giving Space… Some Mistakes to Avoid
Now that we have discussed the ways in which you may be helpful to your friend,
here are some commonly made mistakes that need to be avoided.

Don’t expect the bereaved to be “over” their loss at any time. It does not matter if
you do not voice this; your attitude will show what is on your mind. Please
remember that there is no time limit on grief. Similarly, don’t seek to impose your
opinion of what the proper grieving process should be onto the other person. Please
remember that grief is a highly personalized emotion, which is experienced and
dealt with differently by each person whom it affects.

Don’t attach value to a lost one; i.e. don’t say (or think), “Well, it’s not like you guys
were married”, or, “You are young; You can have more kinds”; or “You’ll fall in love
again”. Similarly, don’t seek to set up a widow(er) on dates. Not only is this
disrespectful to the bereaved, it also sets up the other person for a bad experience.

Don’t accuse the bereaved of using her/his grief as an excuse to withdraw or let
responsibilities slide. Similarly, avoid judgment on her/his behavior, such as staying
in bed all day or crying all day.

Avoid platitudes. While you, personally, may believe and feel comforted on a daily
basis by “God’s plan”. The deceased’s being in “a better place”’ or “the ways of the
circle of life”, do not impose these beliefs on your friend, s/he may not share your
faith, or who may be struggling through a spiritual crisis her/himself, seeking to
reconcile their faith in a deity with the loss s/he just suffered.

Don’t make promises you can’t/won’t keep. Don’t commit to helping with yard work
every week, and then find yourself unable to do so when soccer season starts.
Similarly, don’t be the daily homework helper for the children only to suddenly quit
when your school schedule picks up again.

Watch your words. “I am so sorry for your loss…I love you” goes a long ways.
Comparing the bereaved’s loss to a loss you experienced a while ago is not helpful.
Remember that each person grieves differently, and if the bereaved just lost a
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husband, yet you are recalling the loss of your great-uncle this comparison will not
help.

Ignoring warning signs. While there technically is no right or wrong way to grieve,
there are a variety of unhealthy grieving patterns, such as substance abuse or selfmedicating. There is also the threat of suicide.
Do not turn a blind eye if you see warning signs; similarly, do not turn a deaf ear if
the bereaved speaks of their own death or committing suicide.
Even if you suspect it might be on the bereaved mind, ask! Be direct, for example a
question such as “Have you been thing about killing yourself?” asks for a specific
answer. If you think that there is a danger of suicide, or if the bereaved answers
with a “yes”, “maybe” or “sometimes”, please do not wait and hesitate to seek help!
Explore the section on Suicide in this course, as it offers some resources for suicide
prevention. Err on the side of caution and use them!
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Tear Soup Cooking Tips
(Reprinted from Tear Soup, a recipe for healing after loss)
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Grief is the process you go through as you adjust to the loss of anything or anyone
important in your life.

The loss of a job, a move, divorce, death of someone you love, or a change in
health status are just a few of the situations that can cause grief.

Grief is both physically and emotionally exhausting. It is also irrational and
unpredictable and can shake you very foundation.

The amount of “work” your grief requires will depend on your life experiences, the
type of loss, and whatever else you have on your plate at that time.

A sudden, unexpected loss is usually more traumatic, more disruptive and requires
more time to adjust to.

If your loss occurred through violence, expect that all the normal grief reactions will
be exaggerated.

You may lose trust in your own ability to make decisions and/or to trust others.

Assumptions about fairness, and religious beliefs are often challenged.

Smells can bring back memories of loss and a fresh wave of grief.

Seasons, with their colours and climate, can also take you back to the moment in
time when your world stood still.

You may sense you have no control in your life.

Being at work may provide a relief from your grief, but as soon as you get in the car
and start driving home you may find your grief come flooding back.

You may find that you are incapable of functioning in the work environment for a
short while.

Because grief is distracting it also means you are more accident-prone.

The object of grieving is not to get over the loss, or recover from the loss, but to get
through the loss.

Over the years you will look back and discover that this grief keeps teaching you
new things about life. Your understanding of life will just keep going deeper.
Reprinted with permission from Grief Watch, 2002. www.griefwatch.com
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Tear Soup Cooking Tips
(Reprinted from Tear Soup, a recipe for healing after loss)
If you are the cook…

This is your grief – no one else’s. Your friends can’t feel your loss in the same way.
It will not affect their life the way it affects yours, and you may resent them for that.

At first you may think dying would be preferable to having to go through this pain.
Just try to stay alive. Sudden mood wings are normal. You may suddenly be
unreasonable and short.

Try your best to educate your friends about what you need and how they can help.
Be as honest as you can be about how you are feeling.

Don’t give up on your friends if they let you down. But if they continue to be
insensitive to your grief you may need to distance yourself for a while until you get
stronger.

At first you will probably want to talk to as many people as possible, but after a
month or so, find one or two people whom you can count on for the long haul to just
be there and listen when you need to talk

Write your thoughts in a journal. It will help you to process and also to remember
the new insights you are learning.

Consider attending a support group. Go at least three times before deciding if it is
helpful to you.

Exercise, sleep, drink plenty of fluids, and eat a well-balanced diet.

Pamper yourself. Take bubble baths, Get a massage.

Try not to compare your grief with another’s. You don’t earn points for having a
more painful experience than someone else has. And you won’t feel less grief if
someone else’s loss is worse.

You deserve to feel happy again. Being happy doesn’t mean you forget. Learn to be
grateful for the good days.

Long after everyone else has forgotten your loss, you will continue to remember.
Learn to be content with your private memories.
Reprinted with permission from Grief Watch, Portland, Oregon USA www.griefwatch.com
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Tear Soup Cooking Tips
(
(Reprinted from Tear Soup, a recipe for healing after loss)
If your friend is the one who is making Tear Soup

Be a source of comfort by listening, laughing, and crying.

Be there for your friend, even when you don’t understand.

Stick close to your friend and defend their right to grief.

Allow your friend to make mistakes, or at least to grieve differently from the way you
would grieve.

Send flowers. Send money if you know this would help.

Send Cards. The message doesn’t need to be long. Just let them know you haven’t
forgotten them. Send one every few weeks for a while.

Call your friend. Don’t worry about being a bother. Let your friend tell you if they
don’t want to talk about their loss right now.

Answering machines and e-mail are great ways to keep in touch, allowing the
bereaved person to respond only when they feel up to it.

Try to anticipate what your friend may need. Bereaved persons sometimes don’t
know what to ask for.

Avoid offering easy answers and platitudes. This only invalidates grief. Be patient.
Don’t try to rush your friend through their grief.

Give you friend permission to grieve in front of you. Don’t change the subject or tell
them not to cry or act uncomfortable when they do cry.

Ask them questions, but don’t tell them how they should feel.

Invite your friend to attend events together, as you normally would. Let them decide
if they don’t want to attend.

Don’t assume because your friend is having a good day that it means they are over
their loss.

Be mindful of holidays, birthdays and anniversaries.
Reprinted with permission from Grief Watch, Copyright Grief Watch 2002.
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Tear Soup Cooking Tips
(Reprinted from Tear Soup, a recipe for healing after loss)
Soup Making and Time

Grief work takes time. Much longer than anyone wants it to.

If a child or spouse dies it may be a year before the bereaved begins to gain a
sense of stability, because the loss is highlighted by each season, holiday,
anniversary or special day. The second year is not so great either.

You may be okay one minute but the next minute you may hit bottom.

Nighttime can be particularly difficult. Some people have trouble getting to sleep
while others have trouble staying asleep…and then there are those who don’t want
to wake up.

Most people can tolerate another’s loss for about a month before wanting the
bereaved person to get back to normal.
Reprinted with permission from Grief Watch, Portland, Oregon USA www.griefwatch.com
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Tear Soup Cooking Tips
(Reprinted from Tear Soup, a recipe for healing after loss)
If a child is the cook
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Be honest with the child and give simple, clear explanations consistent with the
child’s level of understanding. Be careful not to overload them with too many facts.
This information may need to be repeated many times.
Prepare the child for what they can expect in a new situation such as, going to a
memorial service, or viewing the body. Explain as best you can how others may be
reacting and how you would like the child to behave.
When considering if a child should attend a memorial service, consult the child.
Their wishes should be the main factor for the decision. Include the child in
gatherings at whatever level they want to participate. Helping to make cookies for
the reception may be all they want to do.
Expect them to ask questions like, “Why does he have his glasses on if he’s dead
and can’t read?” Or, “Why is her skin cold?”
Younger children are more affected by disruptions in their environment than by the
loss itself.
Avoid confusing explanations of death, such as “gone away”, or “gone to sleep”. It
might be better to say, “His body stopped working.”
Avoid making God responsible for the death. Instead say, “God didn’t take your
sister, but God welcomed her. “ Or, “God is sad that we’re sad. But now that your
sister has died, she is with God.”
Don’t assume that if the child isn’t talking about the loss it hasn’t affected them.
Be consistent and maintain the usual routines as much as possible.
Encourage the child to express his/her feelings and to ask questions.
Children may act out their grief in their fantasy play and artwork.
If children have seen adults cry in the past they will be less concerned about tears
now.
Show affection and let them know that they are loved and will be taken care of.
Each child reacts differently to loss. Behaviours that you may observe include,
withdrawal, acting out, disturbances in sleeping and eating, poor concentration,
being overly clingy, regression to earlier stages of development, taking on attributes
of the deceased.

Sharing your grief with a child is a way to help them learn about grief.
Reprinted with permission from Grief Watch, Portland, Oregon USA www.griefwatch.com
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Tear Soup Cooking Tips
(Reprinted from Tear Soup, a recipe for healing after loss)
If you are a male chef

The world may not see you as the bereaved person that you are. Because of your
gender, in our society you may be seen only as the support person – a role you
probably play very well.

If you have been taught from an early age that “big boys don’t cry,” you may feel
ashamed of your own tears. Other people may also be uncomfortable with your
tears.

Don’t hold your grief in. Find a safe place or someone who is not afraid of your
grief.

People may tell you how strong you are when you hold in your grief. Don’t confuse
grieving with weakness and not grieving the strength. In fact, holding grief in is very
hard on your body and can weaken your health.

Gender does not determine your grieving style, but it may affect the way you grieve.

Assume that your initial response to grief is the right response for you at the time.
Try not to behave as other think you should, but as you need to.
Reprinted with permission from Grief Watch, Copyright Grief Watch 2002.
Tear Soup Copy Right Grief Watch 1999, Portland, Oregon USA www.griefwatch.com
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(From Me, the One Who Died)
To my dearest family, some things I’d like to say.
First of all to let you all know that I arrived okay.
I am writing this from heaven where I dwell with God above
Where there are no more tears or sadness, there is just eternal love.
Please don’t be unhappy or sad just because I’m out of sight.
Remember that I am with you every morning, noon and night.
I had to leave you that day because my life on earth was through,
God picked me up and hugged me and He said “I now welcome you.
It’s good to have you back again; you were missed while you were gone,
For your dearest family, they will be here later on.
I need you here so badly as part of my big plan,
There’s so much that we have to do to help our mortal man.”
Then God gave me a list of things he wished for me to do
And most of what is on my list is to watch and care for you.
So I will be beside you every day and week and year,
And when you’re sad, I am standing there to wipe away the tear.
When you lie in bed at night and the day’s chores put to flight,
God and I are closest to you in the middle of the night.
When you think of my life on earth and all those loving years,
Because you’re only human, they are bound to bring you tears.
Please do not be afraid to cry, it does relieve the pain,
Remember there would be no flowers unless there was some rain.
I wish that I could tell you of all that God has planned,
But if I were to tell you, you wouldn’t understand.
But one thing is for certain, though my life on earth is over,
I am closer to you now than I ever was before.
And to my very many friends, trust that God knows what’s best,
I’m still not far away from you, I am just beyond the crest.
There are rocky roads ahead of you and many hills to climb,
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But together we can do it, taking one day at a time.
It was always my philosophy and I’d like it for you too,
That as you give unto the world, so the world will give to you.
If you can help somebody who’s in sorrow or in pain,
Then you can say to God at night, “my day was not in vain.”
And now I am contented that my life was worthwhile on earth,
Knowing as I passed along the way, I made somebody smile.
So if you meet somebody who is down and feeling low,
Just lend them a hand to pick them up as on your way you go.
When you’re walking down the street and you’ve got me on your mind,
I am walking in your footsteps, only half a step behind.
And when you feel that gentle breeze or the wind upon your face,
That’s me giving you a great big hug or just a soft embrace.
And when it’s time for you to go from that body to be free,
Remember you are not going- you are coming here to me.
And I will always love you from that land up above.
We’ll be in touch again real soon. P.S. God sends His love.
Author Unknown
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What To Do When A Loved One Dies?
When a loved one dies, it is an understandably stressful time. It can be even more
stressful trying to remember all of the details that must be taken care of related to a
person's death. If you are in charge of handling the affairs of the person who has
died, here is a checklist of some of the more important considerations:
Checklist of duties
Organ Donation If the deceased has consented to be an organ donor, or the family
is willing to consent to organ donation and the individual dies at home, the
paramedics should be called immediately. Be sure to let the dispatcher know that
the person is a potential organ donor as time is of the essence. If consent has been
given for the body of the deceased to be an anatomical gift, follow the instructions
provided by the institution or organization receiving the gift.
Notify Immediate Family. As soon as possible and practical, notify immediate
family and friends about the death of the loved one. This will assist them in making
arrangements quickly to be with you during this time. If a family member or close
friend can be designated to make these contacts, this could relieve you of a great
deal of stress. In order to assist them, have prepared an accurate listing of the
names, addresses and telephone numbers of family members and/or friends to be
notified in the event of such emergencies.
There are a number of tasks with which family and friends can lend a hand, such
as:

answering the phone

collecting mail

caring for pets

locating important items such as keys, insurance policies, claims forms,
addresses for magazine subscriptions, etc.
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
staying at the home during the wake, funeral, and/or memorial services to
guard against break-ins that commonly occur during that time

organizing food for family and friends after the services
Notify the Clergy. Contact the deceased's Pastor, Rabbi, Priest or other
designated religious leader if there is one, in order to facilitate counseling for family
members and members of the deceased's congregation, synagogue or parish. They
will also be involved in making arrangements for any final religious services.
Funeral Home If no arrangements have been previously made, contact the funeral
home or mortuary of your choice to carry out the final preparations and/or burial
instructions. Any advance preparation in this area alleviates a lot of stress during an
already stressful period. Most funeral homes are happy to talk with individuals to
provide helpful pre-needs information and arrangements. Someone will have to be
authorized to make the decisions concerning the disposition of the remains of the
deceased. A final resting place should have already been secured and the proper
person will need to be notified of the date of interment as soon as a date is set.
Monument Inscription: Check with the funeral home about who looks after this
Obtain Death Certificate. A death certificate must be completed and signed by
either an attending physician, the medical examiner or coroner or in the case of
persons dying in a hospice program a registered professional nurse employed by
the hospice. Certified copies of the death certificate can be obtained after the death
certificate has been filed with the local registrar. The certified copy must display an
official seal.
Copies of the Death Certificate. Once the death certificate is available, copies
need to be sent to all insurance companies, in order to receive the proceeds from
any insurance policies.
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Notify Employer Notify the employer of the deceased so that the proper paperwork
can be completed. This may affect payroll and benefits, as well as the general
morale and work schedule of the deceased's co-workers.
Pension Plans Notify the local office of Canada Pension and any other pension
sources immediately. There may be survivor’s benefits. The surviving family
member or estate is entitled to a one-time death benefit of $2500. from Canada
Pension. Pensions, annuities and other income sources will have different rules.
Check the plan or contact the administrator of those plans for further details.
Notify the Guardian/Power of Attorneys. If there is a guardianship, a power of
attorney for finances, or a power of attorney for healthcare, those persons need to
be notified that their responsibilities are at an end.
Contact the Deceased’s Lawyer to start estate proceedings
Documents to locate. There are some documents that may be needed or at least
helpful in settling the estate of the deceased. These documents should be located
and kept together in one place until they can be turned over to the person in charge
of carrying out this part of the affairs of the deceased. Included in the list of
documents to be sought:

funeral and burial plans/contracts

safe deposit rental agreement and keys

trust agreements

pre-nuptial agreements/marriage licenses/divorce papers

life insurance policies or statements

pension, retirement statements

income tax returns for the past three years

gift tax returns

birth and death certificates

military records and discharge papers
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
budgets/bookkeeping records

bank statements, checkbooks, check registers, certificates of deposits

deeds, deeds of trust, mortgages and mortgage releases, title policies,
leases

motor vehicle titles

stock and bond certificates and account statements

unpaid bills, notes

health/accident and sickness insurance policies

bankruptcy papers: filings and releases
Bank Accounts. If there are bank accounts on which someone is a "surviving
owner", a death certificate needs to be provided to the bank so that the surviving
owner can now take ownership. Joint accounts are frozen because of a death.
Otherwise, access to the accounts may be blocked until someone is appointed as
an official agent on behalf of the estate.
Cancel: Ontario Health Insurance, Driver’s License, Credit Cards, club
memberships, hospital cards, prescription drug plans, home insurance if home is
now unoccupied
Notify Canada Post (if person lived alone)
Notify land-lord if deceased was renting
File Life Insurance Claims
Wills. If there is a Will, when the person dies, the law requires that it be filed (the
law does not require that it be probated) with the Probate Court in the County where
the decedent lived. The Clerk will provide the executor or executrix of the Will with
the necessary paperwork. Expenses of the last illness and funeral should be paid
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from the estate before any additional disbursements are made. All remaining assets
and properties can be disbursed through the probate process.
When there is no Will. If there is no Will, and an administration of the estate is
desired, this is also done in the County Probate Court. Expenses of the last illness
and funeral or final arrangements should be paid from the estate before any
additional disbursements are made. All remaining assets and properties can be
disbursed through the administration of the estate.
Creditors. Letters should be sent to all creditors informing them of the persons
death. If any life insurance coverage exists on open accounts to pay off the
remaining balances, a copy of the death certificate will be required. Do not agree to
personally be responsible for paying the balances on any outstanding account. The
estate is liable, not individual family members unless that family member was a
named account holder, regardless of the insistence of the creditors. If nothing
remains in the estate to pay off debts, then creditors should be so informed.
Utility Companies. Local utilities (telephone, gas, electricity, cable) should be
notified only if someone else wants to be substituted on the accounts. Otherwise
wait until you decide whether or not and when the utilities are to be discontinued. In
any event, the utility bills must be paid in order to keep the utilities on.
Newspaper and Mail. The newspaper subscription will need to be discontinued if
no one else resides at the home of the deceased and the Post Office may need to
be contacted about a forwarding address for mail, if no one will be at the home to
receive it.
Tax Refunds. Any Tax refunds that arrive after the decedent's death will be a part
of the estate and will have to be distributed according to the Will or the
Administration process. Check into GST rebate
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Taxes Owed. Any taxes owed will have to be paid out of the estate or voluntarily by
a surviving family member.
Personal Property. Things like ownership to automobiles, automobile insurance
and house insurance will have to be changed eventually. Homeowner's insurance
policies should be reviewed carefully for instructions concerning coverage of
unoccupied premises.
Out-of-State Property. If property is owned out-of-state, the Will should be
probated, or the estate Administrated in the state of residence first and the Letters
Testamentary or Letters of Administration (they may be called something else in
another state) used to handle the property in the other state.
No Property. If there was no property left in the decedent's name and no other
assets that need to be transferred, then there are probably very few estate matters
to be handled. Georgia requires that a Will be filed with the Court if there is one,
whether or not it is actually probated.
Disposing of Personal Items and Clothing. Although one of the most
heartbreaking tasks when a loved one dies, as soon as emotionally possible, every
effort should be made to dispose of those items which will no longer be used by the
survivors. The timing of this is handled differently from person to person. If too soon,
it may prevent survivors from having adequate time to grieve, while if it takes too
long, it may seriously delay the ending of the grieving process, acting as a very
painful and constant reminder of the person's death. Only a few items should be
retained as mementos.
No items should be moved, sold, given away or otherwise disposed of if they have
been identified in the person's Will as items to be distributed as a part of the estate.
Only the legal beneficiary of those items is entitled to make the decision as to their
disposal.
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HOPE During Christmas
by Janet Clapp RN
This can be the most joyous time of the year or the most painful days of the year,
and much of how we experience them is how or if we’re prepared for them. As we
all know, holidays are especially difficult if you’ve recently lost the love of another
person. Whether this holiday is the first or the 25th that you’ve faced since losing a
loved one, these days can continue to be difficult ones to get through. Although the
literature says it’s the first years after the loss that is so difficult, I’m sure many of
you have found that as time goes on, sometimes we miss these loved ones even
more. As you all know a loss requires adjustments in our life.
I’m no expert at all, but I’d like to give you just a few suggestions that might help, or
not, to cope with the holidays. First of all there is no right or wrong way to handle
the different activities during the holiday season. Be gentle with yourself and don’t
expect too much. When someone tells you, well meaning, that you ‘should do’,
remember there are no ‘shoulds’. So remember to be careful of the ‘shoulds’. Get
lots of rest and be gentle with yourself.
Take time to remember your loved one. Maybe light a candle, or make a donation
to honour your loved one. Share your concerns and your feelings and your
apprehension with someone. Accept offers of help. Allow yourself to experience
the sadness that comes. It’s OK to cry.
What I’d really like to give you for Christmas is a STAR….Brilliance in a package!
Something you could keep in the pocket of your jeans or in the pocket of your being.
Something to take out in times of darkness. Something that you would never snuff
out or tarnish. Something you could hold in your hand. Something for wonderment,
something for pondering, something that would remind you what Christmas has
always meant: God’s Advent light into the darkness of this world.
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But stars are only for God’s giving, and I must be content to give you words and
wishes and packages without stars. But I can wish you life as radiant as the star
that announced the Christ Child’s coming and as filled with awe as the shepherds
who stood beneath its light and I can pass on to you the love that has been given to
me, ignited by countless others who have knelt in Bethlehem’s light. Perhaps if you
ask, God will give you a star.
So as we light the candle of HOPE, let us seek hope for all of us who long for
friendship, meaningful relationships, and hope for those of us who long for meaning
in life. As we open ourselves to God’s awesome presence with us here, even now,
allow your soul the freedom to sing, dance, praise and love. It is there for each and
every one of us.
The Carol says: “Hope is a Star” and my STAR for you is HOPE!
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Sample Christian Funeral Order of Service
Prelude Music
Welcome & Introductory Words
Brief Biography
Prayer or Poem
Hymn or Music
Family Tribute
Scripture Reading
Message/Reflection
Music
Additional words/poem/readings
Commendation
Blessing
Postlude Music
A Non-religious funeral ceremony is likely to include:
Music
A non-religious reflection on death
Readings of poetry and prose
Reminiscences about the dead person
A eulogy or tribute
(A talk focussing on the deceased, and the meaning of their life.)
Ritual actions: Candle lighting, sharing reminiscences with the people alongside
you, moments of silence and reflection.
Formal words of goodbye
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Mental Illness & Spirituality
CAMH Bill of Client Rights
The Bill of Client Rights has been developed to assert and promote the dignity and
worth of all of the people who use the services of the Centre for Addiction and
Mental Health (CAMH). The Bill of Client Rights expresses the truth that clients are
first and foremost human beings with the same rights as every Canadian. The
clients, families and staff of CAMH who have worked together to develop the Bill of
Client Rights want it to be a living document that will grow and change as it helps to
create an organizational culture of mutual respect. The Bill of Client Rights is
intended to emphasize the rights of clients rather than organizational convenience.
Policies at CAMH should be consistent with the Bill of Client Rights.
CAMH is committed to upholding all the rights of people under the law. The rights
outlined in the Bill of Client Rights may be restricted by law or by order of a court or
Review Board; or, they may be restricted reasonably to ensure the protection of the
rights and safety of the individual and/or others. The restriction of some rights
leaves other rights intact.
Right #1: Right to be Treated with Respect
Right #2: Right to Freedom from Harm
Right #3: Right to Dignity and Independence
Right #4: Right to Quality Services that Comply with Standards
Right #5: Right to Effective Communication
Right #6: Right to be Fully Informed
Right #7: Right to Make an Informed Choice, and Give Informed
Consent to Treatment
Right #8: The Right to Support
Right #9: Rights in Respect of Research or Teaching
Right #10: Right to Complain
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Mental Health Teaching on Stigma
Prejudice is negative feelings
Discrimination is negative actions
Which words carry stigma?
Single Mother
Alcoholic
Addict
Insane
Homeless
Psycho
Old
Homosexual
Immigrant
Handicapped
Schizophrenic
Negro
What are some other words you have heard?
When language is used to stigmatize people, it is hurtful and can lead to
discrimination and exclusion. A simple thing like negative word choices can reduce
the ability of people to live, work and recover in the community.
Stigma can have many layers. People may face stigma because of their substance
use and mental health problems in addition to stigma because of their race, culture
or religion. Multi-layered stigma can create enormous barriers for people who seek
treatment or support for substance use and mental health problems.
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Centre for Addiction and Mental Health website
Treatments: Medication/counseling/ritual/spiritual resources
What Helps:

Reducing stigma, increasing sensitivity

Encouraging creativity

Focusing on successes and in-the-moment pleasures

Fostering hope

Providing acceptance, affection, - being careful here –not to touch, to
encourage feelings of intimacy or Dependence. This can be a very fine line.

Encouraging laughter
Recovery Model
US Department of Health and Human Service
Self-Direction; Individualized & Person-Centred; Empowerment; Holistic; NonLinear; Strengths-Based; Peer Support; Respect; Responsibility; Hope
The patient needs to be pro-active in the ways in which they can take responsibility
for their ongoing recovery and well-being.
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Connecticut Department of Mental Health and Addiction Services,
Dimension: Supportive Relationships
Supportive Relationships is an important dimension of Recovery. We must educate
staff. Family education & support is available through the NAMI course/group
sessions.
Dimension: Renewing Hope & Commitment
As a service provider we must focus on strengths and use a language of hope and
possibility. Staff must believe in the ability of people to recover.
Dimension: Finding your Niche in the Community
Being knowledgeable of the full range of rehab and community services that can
help people reach their social and employment goals. Work toward community
integration.
Dimension: Redefining Self
Not allowing a label or diagnosis to take control of one’s life. Being responsive to
cultural/spiritual and sexual values.
Dimension: Incorporating Illness
Knowing when to ask for help. Taking one day at a time. Invite people in recovery
to share stories.
Dimension: Overcoming Stigma
Confronting personal prejudices. Teach others how to advocate for themselves.
Dimension: Assuming Control
Offer choice. Allow people the right to make mistakes. Avoid the “professional
knows best” attitude. People in recovery can choose & change their service provider
Dimension: Managing Symptoms
Encourage questions. Learn about other tools than medication. Symptoms do not
have to be eliminated before recovery can begin.
Dimension: Becoming an Empowered Citizen
Encourage opinion. Encourage being a responsible citizen. Understand mental
health and disability law.
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Respect, Recovery, Resilience
Recommendations for Ontario’s Mental Health and Addictions Strategy, MOHLTC Dec. 2010

Mental health and addictions are often long-term chronic conditions that can be
managed, but not cured

Patients must be active partners in their care

More focus on the whole family

Mental health and addiction strategies must go hand in hand, as many mentally-ill
patients have a co-existing or causal addiction.

We must deal with social issues, not just medical issues

We must foster a sense of belonging

In the recovery model the “expert” becomes the “coach” or “partner”

A “harm-reduction” strategy does not insist on total abstinence of an addicted
substance in order to receive care & treatment

A “trauma-informed approach” – Integrating care for physical/sexual abuse

When working with youth, it is essential to have youth peer-support

Prevention: healthy habits, coping skills, support systems, work-life balance,
sharing problems

Under the Human Rights code, employers cannot discriminate for mental health or
addictions

Maslow’s Hierarchy of Needs*: mentally-ill need housing, income for basic needs
etc. Many homeless people have mental illnesses and/or addictions and are not
being treated.

Early intervention is a key to ongoing mental health management, therefore we
need excellent assessments

An increase in youth suicides speaks to untreated mental health conditions.

Routinely screen for anxiety and depression. Depression is often over-looked

Assist as much as possible, while intruding as little as possible.

Better community care lowers ER & hospital crisis stays.
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Spirituality and Recovery for Mental Illness
VISIONS, British Columbia Mental Health Journal. (Spring 2010)

Spiritual Needs for Mental Wellness: hope, acceptance, peace, connectedness,
meaning,

Helpful Practices: religious observance, relaxation, meditation, creative expression
-John Toews, MD

Spiritual Healing has been practiced by Christians, Jews, Buddhists, Hindus, New
Age Studies have shown that religious expression helps depression, reduced
hospital stays,--people with no religious affiliation spent an average of 25 days in
hospital compared to 11 days for patients with some religious affiliation.

99% of family physicians believed that personal prayer can enhance medical
treatment.

75% felt that prayer from others could promote a person’s recovery.

Meditation & yoga are spiritual practices that are atheist-friendly. John McManamy

Encourage a personal daily spiritual practice

“Why me?” can get one stuck, instead we should promote “What now?”

We should not dismiss a person’s beliefs, but help them work out the meaning.

Questions about the spiritual nature of their experience are often avoided by health
professionals.

What can make a profound difference in the mental health experience of a troubled
youth, is finding one adult who is willing to accompany them on their (spiritual)
journey in the long-term.

It is helpful when an ill person gets to the point of leaning on God not to ‘fix things”
but to provide strength in a desperate situation.

Studies have shown that prayer and regular church attendance have resulted in
shorter hospital stays and lower levels of alcohol abuse for psychiatric patient.

Studies have shown that caregivers, who have a spiritual practice, can cope better
with the stresses of caring for cognitively-impaired elders.
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
Deeply spiritual experiences can be misunderstood and diagnosed as psychotic
experiences. (Victoria Maxwell) Mental Health professionals need to fully
understand spiritual experience, without always pathologizing. (Kundalini
experience-- Sanskrit)

Spiritual Practice may be called “Contemplative Practice”—including prayer,
meditation, journal or poetry writing, drawing etc.
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“Maslow’s Hierarchy of Needs”
An interpretation of Maslow's hierarchy of needs, represented as a pyramid with the more
basic needs at the bottom. Maslow has classified the basic needs of mankind into five
broad categories:
1. PHYSIOLOGICAL NEEDS –these are necessary for survival. They include the need for
food, drink, shelter, sex: avoidance of injury, pain, discomfort, disease, or fatigue, and the
need for sensory stimulation. If physiological needs are not satisfied, they are stronger in
their motivation than any higher needs.
2. SAFETY NEEDS –these focus on the creation of order and predictableness in one’s
environment. They include preference for orderliness and routine our disorder, preference
for the familiar over the unfamiliar.
3. LOVE NEEDS –are of two types: love and affection between husband and wife, parents
and children and close friends; and the need for belonging-identifying with larger groups
(church, club, work organization, etc.)
4. ESTEEM NEEDS –refer to the desire for reputation, prestige, recognition, attention,
achievement, and confidence. Some sociologists believe that esteem needs are powerful
motivators in North America.
5. SELF-ACTUALIZATION –the fulfillment of one’s capabilities and potentialities. Selfactualization needs take on a strong motivation power only when other more basic needs
have been fulfilled.
According to Maslow, high needs act as motivation forces only when preceding them on the
hierarchy have been satisfied.
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What do we need to know to provide helpful spiritual care?
Grace McBride, Chaplain Elmgrove 2011

Study the Mental Health Act

Staff and Volunteers need training in stigma reduction and sensitivity

Supplying information to outside clergy requires the consent of the patient.

EXCEPTION; Confidentiality can be broken when the criteria for: Duty to inform” is
met – (when a patient is at risk to harm themselves or others, sexual abuse, child
abuse etc.)

Church clergy not always comfortable and sometimes inadequately prepared to
deal with Psychiatric Patients.

Patient will not necessarily be local and often there is no family support.
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“Wrestling with our Inner Angels
Nancy Kehoe 2009 Jossey-Bass
A – always ask about spiritual beliefs and practices
B – be curious – foster discussion
C – consult
D – don’t make judgments
E – enjoy the exploration (and smile)

Some health professionals believe that a patient will use religion to deny illness

Many health professionals ignore spirituality but delve into everything else

Common thinking: If you talk to God – it’s prayer. If God talks to you – you’re crazy

Freud’s work downplayed religion as a symptom of immaturity or crutch

Mental health professionals have higher rates of atheism and agnosticism than the
general public

The fear that any discussion of religion was perceived as “proselytizing”(to induce
someone to convert to one’s faith)

The Catholic church no longer teaches that suicide is a mortal sin

Ignoring a mentally ill person’s faith or spirituality can miss out on a huge resource
for wellness

Attending a worship service can help one become part of a larger community and
can reach out to the sacredness, or special-ness of us all, can see beyond oneself

Nancy Kehoe developed a non-denominational, non-religious “service of light”

To reflect, honour, grieve, thank and pray for the mentally ill community and broader
world.

Nancy started the first open spirituality support group with the mental health patients
at her hospital about 35 years ago. It became a tremendous source for strength for
those who felt safe in the group, safe to express, safe not to be judged, allowed for
all expressions of faith.
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How Nancy Kehoe responds to a mentally ill person’s assertion that they have
heard the voice of God:

Ask about the experience

How does the patient frame this?

Does the name the patient gives it affect how we hear it?

Does the patient deny that he has an illness?

Where does this experience lead? --helpful/hopeful behaviour or destructive?

Can I ask the patient questions about the experience?

I am not primarily concerned whether the “voice” is of God or their own. I am more
concerned with how they interpret it and use their experience for good.
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Grace for the Afflicted
Matthew Stanford 2008 Paternoster, Colorado Springs
(Keynote at Comfort & Hope conference, Brock University, August 2010)

Matthew Stanford is a Texas neuroscientist and professor of psychology with a
Christian world-view. He is one of few who are expert in the field of mental illness,
while incorporating the strengths of Christian spiritual support quite publicly.

The church must not counsel the depressed to “pray more”, “turn from sin”, “get rid
of demons”, or stop taking medication

Clergy for the most part need a better understanding of mental illness, and how
medicine and faith can work together rather than at odds.
Psychology/Psychiatry/Spiritual Care have not always worked well together, and
expect to find some reluctance from both perspectives

Stanford said that clinical psychologists are historically far less ‘religious’ than the
general population. Nancy Kehoe also said that mental health professionals are
also in this group. There has to be a gentle persuasion in the field of spiritual care
to adopt a delicate balance between the two.

How do we discern: What is from God? What is from self? What is from mental
mis-perception/illness?

When these patients were once called “mad” or “insane”, and then more recently
“mentally ill”, perhaps we can move on to calling this group of patients, “mental
health patients”

Faith practices should always be deemed good if they result in improved behaviours
& coping skills—so it is the results of the belief that can be helpful/harmful and not
necessarily the belief itself.
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Get Growing
Ruth Graham Conference, Sept. Brockville 2010

The conference focused on the “marginalized” in society—the addicted, mentally-ill,
those with a criminal record, the homeless, etc.—any demographic that challenges
our comfort level.

Would we give the same health care in BGH emergency to the Queen of England
that we would give to the delusional, addicted, mentally-ill street person?

These issues challenge ourselves to study our own personal spirituality,
professional ethic and cultural world-view.

It’s about sensitivity, dignity, respect, acceptance, non-judgment and all the things
we are taught in professional ethics – these things work together to form us as
compassionate, spiritually-grounded caregivers.
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Grieving Mental Illness
Virginia Lafond Royal Ottawa Hospital

As professionals we need to reduce stigma around mental illness—for one reason-as many health professionals themselves are touched to some degree with mental
health issues, and are able to function very well

Accepting mental illness does not mean giving up, it means reaching a sense of
control—or recovery and may always be in process.

Understand and have insight into the triggers of a psychotic episode

Realize that professional caregivers are affected from working in a field of “chronic
loss”

Denial occurs when a wound is too intense to be felt all at once. (self-preservation)

If one see-saws through stages of grief, but reaches acceptance, even if only
temporarily, then one knows he can reach this point again.

It is perfectly acceptable to “feel sorry for oneself” for having mental illness

Lafond recommends God of Surprises Gerard W Hughes, 1985 –using spirituality to
recover on your journey with mental illness

Fears for those with mental illness: fear of never recovering, fear of missing one’s
dreams,
becoming
ill
again,
damage
to
reputation,
relationships,
being
unpredictable, fear that the illness is obvious to everyone. Fear, if not confronted,
hampers efforts to heal.

Family dysfunction rarely causes mental illness. Resist the impulse to “blame the
mother” for being over-protective, inattentive etc.

Mental illnesses have a life of their own even in the presence of state of the art care
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Mental Illness & Youth Lecture
Joyce Hamelin MSW Ottawa Pastoral Care Council May 3 2011 Ottawa

1 in 5 youth have a mood disorder or emotional instability of some sort; of those,
only 1 in 6 are being treated.
 We no longer refer to mental illness—now it is mental disorder
 Mental disorders cannot be cured, they are lifelong—they can be managed
 Substance abuse is often concurrent with mental disorders
 Don’t patronize youth, don’t give unsolicited advice
 Don’t label, lay blame; Talk openly about it

Most common disorders for youth: anxiety disorder, obsessive-compulsive,
schizophrenia (1 in a 1000), depression, bi-polar
 Having a mental disorder has nothing to do with level of intelligence
 This is a behavioural/psychological/biological condition
 Ill individuals are at greater risk of harming themselves than others
 Suicidal comments need to be taken seriously
 1st cause of death in teens is accident (often risk-taking behaviour) 2nd cause is
suicide
 Anorexia nervosa and bulimia are on the rise in teenage girls—often accompanied
with perfectionism and low self-esteem
 Conduct disorders-- hard time following rules, risk-taking behaviour, inappropriate
expression of anger, sexually inappropriate conduct—exacerbated by depression
 Remember genetic factors of mental disorders—“familial disposition”
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Signs of Teen Mental Health Issues

absenteeism

drop in school performance

excessive use of alcohol/drugs

change in sleeping/eating habits

depression

unexplained headaches/stomach aches

low energy—boredom

violation of other’s rights

neglect of personal appearance

opposition to authority

loss of interest/enjoyment of favourite activities

fear of body image—weight

vandalism

withdrawal

thrill-seeking behaviour

personality change

low self-esteem

suicidal-type comments

rage
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What do we need to do to screen & train Spiritual Care
Volunteers for working with mental health patients?
Chaplain Janet Stark

“Help & Not to Harm” model for spiritual care means that a patient’s religion should
be a helpful practice, not one that exacerbates psychotic behaviour or distress. –
more on this for training volunteers

Different approach to grieving a suicide—with a Christian one may find hope in
heaven, but with one that is suicidal or mentally-ill, we don’t want to focus on going
to a “better place” or being healed by being (dead) in heaven. –this idea could
become a goal to end suffering

Volunteers can be very helpful in developing creative spiritual health through—music, pet, art, reading, clowning therapies.

Empower patients by dealing with what they do well, what they enjoy, the
successes of today rather than deficits, failures or long-term agendas

Might be able to facilitate a support group – studies have shown that a model much
like the 12-step AA support group can be very helpful. Although it started out with
Christian concepts, it is now considered “spiritual concepts”, and the helping parts
are: love and acceptance, support and accountability.

Private spiritual counseling/pastoral care available (most rooms will be private
rooms)

Volunteers will need to be screened for willingness, comfort level to work with
mental health patients and have a minimum of the pastoral care course, and accept
other training opportunities.
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
Some patients will have a criminal record. At least 50% of inmates have a major
mental illness

For fear of judgment and past experience, some patients will remain silent. The
trusting therapeutic relationship is very important.

The past sex abuse within the church has hurt or scared many. We will need to be
sensitive to those who see the “collar” or male clergy as a threat and have a
balanced team—male and female; lay and ordained.

Religion has been at odds with Psychiatry and many mental health practitioners do
not assess or intervene in spiritual health at all. It is only recently that the mindbody-spirit understanding sees these fields as supportive and integrative and not
necessarily conflicting.

Past damage by some churches that teach that one can be freed from mental
illness by increasing faith, or that mental illness is a result of sin, or that depression
can be healed by praying etc., and some clergy have counseled patients not to take
medications or to comply with psychiatry.

Some patients are “Angry at God” for not helping them, afflicting them, punishing
them. We need to allow them to express these feelings without trying to change
them

Reconciliation can have any or all of these pieces:
o Personal—about relationship
o Moral—about deeds & beliefs
o Religious—about faith issues & peace with God
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Open Spirituality Circle Ideas

Open and close with non-denominational prayer

Lead in a brief meditation in the beginning

Read or ask for “Stories of Hope”

“Spirit Gatherings” with ritual can be an alternate to worship services—songs,
stories, poetry, readings

Can include music in the background or as a focus for generating discussion

Meditative walking, perhaps when there are few in the group

Encourage creativity, literally discuss the term “CREATOR’ as being the author of
creativity

Experiment with articulating dreams,—make up a song-- to elevate mood

Deep Breathing exercises to calm and ground

Explore: What does it mean to be “inspired”?

Look at the pieces of the Recovery model. How can each piece be spiritual?

Drawing/doodling can unleash one’s emotions and “inner voice”
Participant Goals

Become less dependent on the well-being of others

Become less concerned about others perceptions

Practice better sleep patterns and pre-bed routines

Find the ability to relax and enjoy living in the moment

Become less fearful

Use less negative self-talk

Achieve improved concentration
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Healthy Spiritual Practices

Concentrate and calm

Cultivate emotional wisdom

Awaken your spiritual vision

Transform your motivation

Live ethically

Express Spirit in action

Cultivate spiritual intelligence

Forgiving self

Practicing loving-kindness

Using truthful speech and actions

Cultivating gratitude

Giving back to society

Finding a supportive spiritual community

Practicing stress reduction techniques

Allowing one to grieve losses
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Questions for Open Spirituality Circle
1. What is on your heart/mind today?
2. What does wellness look like to you?
3. What gives you hope?
4. Are you lonely? What would make you less lonely?
5. What gives you peace?
6. What gives you meaning when you are upset?
7. Do you have a faith? Can you describe that?
8. What do you do to help with well-being/quality of life?
9. What helps you feel good about yourself?
10. How can you calm yourself when you are angry/upset? (self-sooth)
11. Who are supportive/safe people for you? How do they help you?
12. How can we support one another in this environment?
13. Have you had a spiritual experience? Do you feel comfortable sharing it?
14. How does this word or picture speak to you (variety of examples)
15. Can we make a prayer that works for you?
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How can we best integrate spiritual care therapies
with psychology and sociology?

It is helpful to get a Spiritual History (what they believe, practice and have been
through) as well as a Spiritual Assessment (what causes distress, what helps) for
those that will be in hospital for more than a few days.

Emotions may be more intense. – there may be self-sabotage, poor self-esteem,
embarrassment, terror, guilt etc.

Are we not asking about their spirituality because we are afraid of the answers?

Are we not asking because we are afraid they will ask us about our own spirituality?

Are we afraid that they might ask us to pray with them?

Remember Maslow: one must have pain & symptom under control, have shelter
food, safety & belonging before one can feel confident in opening up and dealing
with deeper, spiritual & existential struggles. As a health community, we can ensure
the environment is prepared for this to occur.

C.S Lewis said that Jesus was either insane, or he was right. How do we bridge
that gap from one understanding to another?

Submitting ourselves to the will of (God); allowing him to heal, sustain, encourage
etc. can be hugely powerful health practices when it is within the scope of what the
individual believes. Our role is to help the ill person, seek, explore, and define their
spiritual self, giving access to any requested resource, in order to develop this area
as a healing & sustaining practice. (this is not a direct quote, I have paraphrased
from what I have read)
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Mental Illness, Health and Spirituality
John Toews is a professor in the Department Of
Psychiatry at the University of Calgary.
He is the author, with Eleanor Loewen, of
“No Longer Alone”
Mental Health and the Church
Individuals and families continue to live with many conditions falling under the
umbrella term mental illness – stigma and discrimination often increasing the
burden. At times, in despair, many have questioned life itself as they struggle with
suicidal impulses. There is a universal longing for peace in those who experience
these diseases.
Those who have walked this path know that people with mental diseases are not
totally sick because there is always health within each individual, health that is often
not recognized by others. Those who struggle walk carefully for fear of what others
will think. The illnesses and the expectations of others add to the stress, each in
their own way.
Despite feeling all of these miseries and pressures, there is hope of improvement.
Improvement can take many forms; improvement can be a better place to live,
meaningful daytime activity, work, money, and/or respect. It could also mean
meaningful relationships, giving and receiving, and having a sense of peace and
self-worth. Some degree of improvement should be possible for every-one. While
most of us agree that the diseases are biological and require medical treatment, it is
what we and our families do with the illness that makes the difference. All of us can
strive toward personal growth: yet, in the face of disease, we so often despair.
There have been major advances in physical and psychosocial treatment, including
new psychotropic medications and rehabilitation services. Treatment services are
required to help us move from where we are to the maximum of our potential.
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Over the last decade, another major advance in knowledge has come about. There
is now good evidence that certain spiritual practices are associated with improved
health. The first of these practices was religious observance, possibly because it is
easy to count how many times on attends a religious observance.
Until recently we haven’t had good scales to assess spirituality directly. This is now
changing. For a long time sociologists have told us that the social connectedness
and healthy lifestyles associated with religion contribute to overall health. It has
even been noted that statistically the impact of mental illness is less for people who
practice a religious faith. We cannot use these findings to prove that religious
observance make us immune to mental illness or that it will actually make us better,
but if we analyze a large group of people with a particular disease, the religious tend
to do better. This may be precisely because they may have less bad habits and a
better social circle, and possibly a way of achieving peace. We all could speculate
on the causes. However, not everyone is religious nor does religious observance
necessarily make us spiritual. We are beginning to see research evidence that a
well-developed spirituality is helpful in and of itself. What are the characteristics of
this spirituality? Here I must speculate.
Hope
The first would be holding on to hope. We know that hope is key to survival in that it
keeps us going during the hard times. Hope is often associated with peace. Peace
is important to relaxation and acceptance. All of us who are connected to the field
of mental health know the importance of acceptance of the illness in the battle for
health. As long as we fight the acceptance, we waste a lot of energy that could be
used to make whatever gains are possible with the illness. Acceptance, then, is
another important step toward health.
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Connection to Self and Others.
Another spiritual attribute is interconnectedness with people. It is important to have
meaningful relationships with family and friends. Health is also often related to selfesteem.
This means that one recognizes the uniqueness of oneself as a person, and
recognizes that while the disease may affect a person, it is not who he or she is.
Self-esteem is helped by developing meaningful activities.
Meaning
Another aspect of spirituality that leads to health is to answer basic “meaning”
questions for ourselves. Much health is derived from serious consideration of
questions such as “what is my purpose in life?” In fact, Viktor Frankl noted that in
the extermination camps of World War II, those who retained or found meaning in
the face of the atrocities, tended to survive. These observations lead to logo
therapy, the groundwork for which was expressed in his book “Man’s Search for
Meaning”
So if spirituality is important, how does one get in touch with oneself spiritually?
Caring relationships, relaxation, meditation, and creative expression are important.
One can also add the more spiritual/religious practices open to anyone such as
prayer and, to use a phrase from a monk of Middle Ages, “practicing the presence
of God.”
Research is becoming available showing the health effects of all these practices,
some of which you’ll read in the coming pages. Spirituality is an area in which all
can grow and which can help make us better equipped for the stresses of life. Being
better equipped for stressors is surely associated with growth, peace and for some,
an easier journey through mental illness.
Visions: BC” Mental Health Journal
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Spirituality and Recovery
No. 12, Spring 2001
Mind Over Mind: The Health Effects of Spirituality
Jesus asked him, “What is your name?” ‘Legion,’ he replied. This was because so
many devils had taken possession of him…the devils came out of the man and went
into the pigs, and the herd rushed over the edge of the lake and were drowned...
The spectators told them how the mad-man had been cured” (Luke 8:30-37)
Jesus is saviour to many, and known as a healer to the many who pray to Him, or a
veritable pantheon of saints for release from their physical and mental afflictions.
The power of spiritual healing is not confined to Christianity. The great Jewish
prophet Elijah was also a healer, and the faith has long tradition of nabi’im who
have performed miracles.
One of the best-known Buddhist parables involves the Buddha refusing to use his
power to heal in order to teach the lesson of acceptance, though the Mahayana
branch of the faith as practiced by the Tibetans parallels Catholicism in its belief in
the healing power of held objects and petitions to saints. The mind-body movement
of Deepak Chopra is grounded in Hindu Ayurveda medicine, and the New Age
phenomenon is based in large part on the shamanic traditions of a whole range of
cultures.
Some three hundred years ago, the Age of Faith gave way to the Age of Reason.
Out the window went the power of prayer, to be replaced by the belief that the key
to physical and mental recovery resided the hands of medical science – amongst
learned men and women, anyway. The unwashed still persisted with their silly
superstitions.
Now science has done a complete 180. To date, there have been about 1200
studies on the healing power of faith and the health effect spirituality, according to
Dr. Harold Koenig, founder of the Centre for Study of Religion/Spirituality at Duke
University. Four studies he has been involved in include:


A 1998 study of nearly 4000 people aged 65 and older which found the risk of
diastolic hypertension 40 per cent lower among people who attended religious
services at least weekly and prayed or studied the Bible at least daily.
A 1997 study of more than 1700 older adults from North Carolina which found that
persons who attended church at least one a week were only half as likely as non486
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

attenders to have elevated levels of interleukin -6, an immune system protein
involved in a wide variety of age related diseases.
A 1998 study of 87 depressed older adults which found those who recovered from
depression the fastest corresponded to the extent of their religious belief.
A study of 542 patients aged 60 or older admitted to University Medical Centre
which found that attending religious services at least on a weekly basis reduced
hospital stays by more than half. People who had no religious affiliation spent an
average of 25 days in the hospital compared to 11 days for patients who had some
religious denomination. Patients who attended religious services weekly or more
also were 43 per cent less likely to have been hospitalized in the previous year.
Skeptics cite the placebo effect as a probable cause of the benefits of spiritual
belief, together with the fact that religious communities offer the kind of support
networks that reduce stress and cause mental anguish. Additionally, those who
attend religious services have better health habits, such as drinking and smoking
less. Finally, religions encourage marriage which is a reliable predictor of longer
life.
Still, the medical community is being won over. Even though no one is certain how
spiritual practice aids in recovery, it’s apparent that a number of processes in the
body are being enlisted in the cause, from the brain’s relaxation response to the
release of hormones to the strengthening of the body’s immune system. A.
Yankelovich survey found 94% of Health Management Organization (HMO)
professionals are 99% of physicians agreeing that person prayer can enhance
medical treatment. More surprising, 75% of the family physicians believed that
prayers of other promote a patient’s recovery.
According to Dr. Herbert Benson, president of the Mind/Body Medical Institute of
Boston’s Deaconess Hospital and Harvard Medical School, cited in a 1996 Time
cover story: “Anywhere from 60 per cent to 90 percent of visits to doctors are in the
mind-body, stress-related realm. “ In his book Timeless Healing (Scribner), Benson
contends that humans are actually engineered for religious faith: “Our genetic
blueprint has made believing in an Infinite Absolute part of our nature.”
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Needless to say, if you don’t believe in a higher power or belong to a religious
group, you may get depressed simply reading this. It’s always difficult, after all,
being left out. Be assured, the benefits of spiritual practice can still apply to you.
You simply have to find a non-religious way of going about it. Meditation and yoga,
for instance, are very atheist-friendly. It may be as simple as closing your eyes, and
chanting “Peace.”
And many religious works and services can evoke a strong inner response without
the necessity of having to believe.
John McManamy Visions: BC” Mental Health Journal Spirituality and Recover No. 12, Spring 2001
For Mental Health Recovery we are moving from “Why Me?” to What Now?”
.
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Resources for Mental Illness
Brockville General Hospital Resources:
Dr Rob Malone, Chief of Psychiatry
Linda Peever, Mental Health Manager, BGH
Dorothy Culhane, Manager Mental Health In-Patient Unit
All BGH Social Workers
Royal Hospital, Brockville location: Beth Smith, Chaplain
Leeds-Grenville Mental Health Services
25 Front Ave. Ave W BV
CAMH (Can. Addictions & Mental Health) 25 Front Ave. W BV
Books on Spirituality and Mental Illness: (In Spiritual Care library)
Dr. Nancy Kehoe, Psychologist, Harvard Medical School, author of
“Wrestling with our Inner Angels” Lecture at ROH, Ottawa Feb 2011
Matthew Stanford, PhD., Psychiatrist, Baylor University Texas, author of
“Grace for the Afflicted”: A Clinical and Biblical Perspective on Mental Illness (this is
a Christian resource) Viewing Mental Illness Through the Eyes of Faith Lecture at
Comfort and Hope Conference, Brock University August 2010
Virginia Lafond MSW ROH, “Grieving Mental Illness” 1994 University of Toronto
Press
BGH Training Programs:
NAMI –mental health professional training
NVCI—non-violent crisis intervention
ASIST – training in suicide prevention
GPA—Gentle Persuasive Approaches
Code White—BGH workshop
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Living with a Disability
Disability: a condition (such as an illness or an injury) that damages or limits a
person's physical or mental abilities.
Whether you're disabled, or a disability has affected a member of your family, a
mental or physical disability will change your life. As with any major life change, you
will face many challenges. Use the tips below to begin to come to terms with your
new normal and start living your life with balance, strength and optimism.
Don't allow yourself to be defined by your disability – Define yourself! It's easy
to fall into a state of discouragement, even despair. While it’s healthy to grieve for
your loss, do not allow your grief to consume you or permanently define who you
are. Despite the ups and downs inherent to the bereavement process, it will be
important ultimately to accept the new you.
Make appropriate accommodations at home – From wheelchair ramps and grab
bars to screen readers on your computer and voice-activated controls, home
modifications and technologies exist to make life easier. Funds to help pay for
assistive devices are available through the Ontario Ministry of Health and LongTerm Care's Assistive Device Program as well as from various organizations such
as The March of Dimes Canada. Your loved ones may also be able to help you
make your home more accessible. Whenever possible, take advantage of assistive
devices and optimize your living spaces. In addition to home modifications, consider
your home care options. Start by checking with the Canadian Red Cross which
provides personal support and homemaking services to help seniors and people
recovering from an illness or injury live independently.
Accept help but strive to become self-sufficient – At first, you will likely need
help from others. Accept help with grace, but try not to become dependent on
others. What skills do you need to develop? What aspects of your life do you want
back? Be creative and willing to adapt. For example, if you're wheelchair-bound and
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miss doing your own grocery shopping, try using the local shuttle bus and the
grocery store's motorized cart, or order your groceries online and have them
delivered.
Find meaningful work – Whether you're back on the job or getting ready to return
to work, finding meaning in your contributions, either on the job or as a volunteer,
can be extremely satisfying. It will also give you a sense of purpose and help you to
further develop your independence. Look for ways to make work more meaningful
to you. Whether it’s a contribution to others, a sense of accomplishment for a job
well done, or a feeling of belonging to a larger community, take the time to
appreciate the intangible value that work and volunteering bring to your life.
Take care of your mental and physical health –Make mental and physical health
your top priority by:

Paying attention to how you feel

Getting regular check-ups and preventive screenings

Exercising

Avoiding cigarettes and illegal substances

Limiting alcohol consumption

Sharing any concerns with your health-care provider

Seek inspiration from others
"It is a waste of time to be angry about my disability. One has to get on with life and
I haven't done badly. People won't have time for you if you are always angry or
complaining" – Stephen Hawking
"I have a Disability yes that’s true, but all that really means is I may have to take a
slightly different path than you" – Robert. M. Hensel
Living with a disability may not be the path you would have chosen for yourself or a
loved one, yet here you are on that path. It's up to you to decide what attitude to
adopt, and therefore influence where that path will take you. If you have a mental or
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physical disability and want to go back to work, take heart– it is possible to excel on
the job even with a disability.
Work performance and productivity
A growing body of evidence shows that workers with disabilities meet or exceed the
job performance of co-workers without disabilities. However, working with a
disability has its own unique set of challenges. For example, your disability may
require reasonable accommodations from your employer, or your co-workers may
prejudge your abilities based on misconceptions and stereotypes.
Accommodating a disability
Your employer may need to make changes based on your disability. In Canada,
employers are legally obligated to make reasonable accommodation through the
Employment Equity Act. An example of a reasonable accommodation is modifying a
work schedule or making available adaptive technology such as a screen reader for
the visually impaired.
Overcoming stigma at work
While you can't control what others think, you can fight stigma and lay the
groundwork for a successful working relationship with others. Unfortunately, many
conditions, including mental disorders, epilepsy, deafness, visual impairment and
others remain stigmatized. Some of your co-workers will be compassionate due to
their own experiences with mental or physical disabilities, while others will be
influenced by myths and misconceptions. It's helpful to be open about your
condition. Educating others both with facts and by your actions can make a big
difference in how you are perceived.
Your disability doesn't define who you are or what you're capable of, nor should the
misperceptions of others. Assuming you're otherwise qualified and ready to return
to work with reasonable accommodations, the future has great potential.
© 2013 Shepell·fgi
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Meeting the Spiritual Needs of those with Developmental
& Intellectual Disabilities
An interview with Sandra Harrison, Mgr. Community Living, Kemptville
The correct terminology for today would be to say people who have a
developmental or intellectual disability as opposed to the developmentally delayed.
It may be a matter of semantics, but it is seen as a label that best describes persons
as, people first. People who have an intellectual or developmental disability meet a
specific diagnostic criterion.
Developmental disabilities are neurologically based and have their onset before
birth or during early childhood, and which create long term difficulties in neurological
functions.
Intellectual disabilities originate before the age of 18 and are seen as limitations
in both intellectual functions and adaptive behaviour in social and practical skills.
At residential facilities and in the community group homes, there are residents with
physical disabilities and others with mental disabilities. Some of these residents
have both disabilities.
Our mandate at Community Living is to provide support for people with intellectual
disabilities and their families. It is sometimes true that physical disabilities are part
and parcel of a person’s challenges. There are also those who have concurrent
mental health issues as in the general population, and in our sector we say these
people have a dual diagnosis. There are several healthy lifestyle tools created to
meet the communication needs of people with an intellectual disability. I’m not sure
what specific tools might be available to inform people of the issues around
palliative care. These will be welcomed when developed.
We talk about the “ill person & family as a unit of care”. What about these
residents? Do you have different or less input and involvement from the family? If
this is so, does the staff fill in some of the role of family?
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With the closure of the large institutions, we are seeing families involving
themselves in each other’s lives in new and exciting ways. However, if the average
person returning to their community is mid- fifties, parents and siblings are often
unable to take on extensive roles as caregivers. It is important to families to remain
informed and to participate in care decisions concerning their loved ones. They
themselves become extensions of the support person’s circle of care, not unlike the
palliative care team within long term care.
In many cases, when there is no family, front line staff become family to those who
are aging and dealing with devastating illnesses. Paid staff, however, fall far short
of replacing family and this continues to be a challenge when it comes to assisting
people who would have nobody but staff to help them make informed decisions
about end of life care. Staff are limited by legislation as to the role they may play as
part of a person’s support systems.
What about decision-making? We know that individuals must have capacity for
consent. Who makes the decisions for the cognitively-impaired resident?
It is firstly important to remember that all persons have the right to make choices for
themselves with respect to medical decisions. The dilemma for support persons and
families would be to have confidence that a person comprehends the many facets
of treatment options including the option to discontinue treatment. There is no
universal standard for determining capacity, and this is made on an individual basis
by the physician and health practitioners. The ability to comprehend and recall
information as well as communicate the choice to others would be part of that
assessment. The follow through with a decision over time might also be
considered. Having the ability to access appropriate communication tools such as
an interpreter for the person with hearing impairment using sign language would be
essential to the process.
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The Consent to Treatment Act outlines the order of people who have the right to
make treatment decisions on behalf of a person deemed incapable. The person at
the top of the list has more authority.
The order is as follows;

Guardian of the person, or attorney for personal care which has been
validated. (Under the Mental Incompetency Act the “committee of the person”
becomes the guardian under the new act.)

Attorney for personal care which has not been validated. Validation is a
certification process available under the Substitute Decision Act. This is only
for use when making treatment decisions if the person becomes incapable.

A representative appointed by the Consent and Capacity Review Board with
authority to decide treatment.

Spouse or partner

Child over the age of 16

Parent

Brother or Sister

Other relative (includes a relative by marriage, such as a daughter in law).
Are the signs and symptoms of illness for these residents different from the general
population? Can the same type of assessments be used as we have developed for
example for the cognitively-impaired resident who has a dementia?
A person with an intellectual disability may not be able to articulate symptoms or to
qualify pain due to barriers in language and communication. All behavior is an
attempt to communicate. When difficult behaviours present in people we support,
we must consider what it is a person may be communicating and always there is an
attempt to rule out medical issues, including pain.
At the risk of generalizing, it is my experience that the people I work with seem to
have a high tolerance for pain. This may or may not be due to the relationship
between anxiety and fear and how it changes the perception of pain. Sometimes
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we are very surprised to find a person is physically injured and yet has not
complained to the extent you might think would be warranted.
People with intellectual and developmental disabilities present as others do, for the
most part, with recognizable signs and symptoms of illness. They are more likely to
experience poor health and are subject to the problems associated with specific
syndromes. People with intellectual disabilities are also vulnerable to abuse and
neglect by care givers and service systems.
Comment on the need for spiritual care. If a person is ever isolated or lonely as a
result of being shut in due to illness, you can expect this loneliness to be magnified
for the person with a developmental disability. All people are in need of spiritual
care. The issue is for the care giver to learn how to facilitate spiritual expression for
a person who many be exploring this aspect of their being. Traditional spiritual care
is appropriate but communication barriers may need to be addressed. Once again
due to the difficulty of facilitation, this too may be left to paid staff.
We have had two instances of people wanting to determine the resting places of
deceased parents. We have been able to do so and people have learned more
about themselves in the process. One might expect those types of unanswered
questions about self would be part of every persons need to settle certain issues in
their life. At the end of life, persons with developmental disabilities would also be
expected to have personal quests to which answers would be very elusive given
lack of historical information in many cases.
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12 Steps for Recovery
Alcoholics Anonymous
1. We admitted we were powerless over alcohol - that our lives had become
unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we
understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our
wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to
them all.
9. Made direct amends to such people wherever possible, except when to do so would
injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God
as we understood Him, praying only for knowledge of His will for us and the power
to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this
message to alcoholics and to practice these principles in all our affairs.
499
500
Preparing to Deliver
Spiritual Care after a Disaster
Preparation
Planning and preparation are important when working as a Psychological First Aid
provider. Up-to-date training in disaster mental health is a critical component in
undertaking disaster relief work. You may be working with children, older adults,
and special populations, all of which require in-depth knowledge. Before deciding
whether to participate in disaster response, you should consider the following:

What is your general comfort level with this type of work?

Have you reacted negatively in the past to working with situations of significant loss
where you weren’t able to assist others?

What is your comfort level with different age groups like toddlers, adolescents,
adults, the elderly, and those with disabilities?

What is your comfort level with mental health or emotional issues?

Are you willing to be accepting of others whose beliefs or life styles are different that
your own?

Do you have any health issues that would limit your ability to do this kind of work or
would put you at risk?

Do you have any family and/or work issues that need to be taken into account, such
as responsibility for the care of a family member or expectations of your
congregation?

How do you plan on taking care of yourself and/or your family in stressful
situations?
National Child Traumatic Stress Network - National Center for PTSD
501
Providing Service
Community religious professionals are able to be especially helpful to those in
spiritual distress. Spiritual distress is evident in individuals for whom religion is very
important but currently does not provide them with the support they need. An
example is the survivor who has long relied on prayer for support but now is feeling
unable to pray because of the impact of the disaster. Spiritual distress may also be
seen in some non-religious survivors who experience spiritual crisis because of the
incompatibility between their systems of beliefs and their perceptions of the disaster
situation. Below are some examples of signs of spiritual crisis:

Feeling a need to be cleansed

Feeling extreme guilt and shame

Feeling abandoned

Losing a sense of hope
Focus your attention on how people are reacting and interacting with other.
Individuals who may need assistance include those showing signs of acute distress,
including individuals who are:

Disoriented

Confused

Frantic or agitated

Panicky

Extremely withdrawn, apathetic, or “shut down”

Extremely irritable or angry

Exceedingly worried
502
Group Settings
While Psychological First Aid is primarily designed for working with individuals and
families, many components can be used in group settings, such as when families
gather together for information about loved ones and for security briefings. The
components of providing information, support, comfort, and safety can be applied to
these spontaneous group situations.
For groups of children and adolescents, offering games for distraction can reduce
anxiety and concern after hours and days in a shelter setting.
Psychological First Aid for Community Religious Professionals
Maintain a Calm Presence
People may look to you as a role model. It is important to maintain a sense of self,
to minister to survivors needs. Remember that your presence may remind people of
God, an awesome role, one to be taken seriously. You may remind those of nontheistic traditions of the presence of special wisdom and knowledge and be
perceived as a guide to forge a path through uncertain times.
Judge each situation individually. Sometimes your presence alone can provide
comfort and support. This ministry of presence may include prayer, reading, or
merely being silent. Be open to responding in whatever way is needed by survivors.
People take their cues from how others are reacting. By demonstrating calmness
and clear thinking, you can help survivors feel that they can rely on you. Others may
follow your lead in remaining focused, even if they do not feel calm, safe, effective,
or hopeful. Psychological First Aid providers often model the sense of hope that
survivors cannot always feel while they are still attempting to deal with what
happened and current pressing concerns.
Be Sensitive to Culture and Diversity
Providers of Psychological First Aid must be sensitive to culture, ethnic, religious,
racial, sexual orientation, gender and language diversity. You should be aware of
your own values and prejudices, and how these may coincide with or differ from
those of the community.
503
Training in cultural competence can facilitate this awareness. Helping to maintain or
reestablish customs, traditions, rituals, family structure, gender roles and social
bonds is important in helping survivors cope with the impact of a disaster.
Information about the community being served, including how emotions and other
psychological reactions are expressed, attitudes towards governmental agencies,
and receptivity to counseling, should be gathered with assistance of community
religious and cultural leaders who represent and best understand local cultural
groups.
National Child Traumatic Stress network – National Centre for PTSD
Be Aware of At-Risk Populations
Individuals that are at special risk after a disaster include:

Children, especially those:

Separated from parents/caregivers

Whose parents/caregivers, family members or friends have died

Whose parents/caregivers were significantly injured or missing

Involved in the foster care system

Those who have been injured

Those who have had multiple relocations and displacements

Medically frail children and adults

Those with serious mental illness

Those with physical or developmental disabilities, illness, or sensory deficits

Adolescents who may be risk-taker

Pregnant women and mothers with babies or small children

Disaster response personnel

those with significant loss of possessions (for example, home, pets, family,
memorabilia)

Those exposed first hand to grotesque scenes or extreme life threat
Especially in economically disadvantaged groups, a high percentage of survivors
may have experienced prior traumatic events (for example, death of a loved one,
504
assault, disaster). As a consequence, minority and marginalized communities may
have higher rates of pre-disaster trauma-related mental health problems, and are at
greater risk for developing problems following disaster. Mistrust, stigma, fear (for
example, of deportation), and lack of knowledge about disaster relief services are
important barriers to seeking, providing, and receiving services for these
populations. Those living in disaster-prone regions are more likely to have had prior
disaster experiences.
Psychological First Aid for Community Religious Professionals
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506
How do I Pray?
Pope John Paul II wrote: “We begin to pray believing that it is our own initiative
that compels us to do so. Instead, we learn that it is always God’s initiative
within us.”
Different Ways of Praying
1. Pray aloud or silently
2. Formal prayer - prayers from a faith tradition
3. Conversational prayer - informal conversation with God
4. Pray using Guided Imagery – praying with mental pictures
5. Rhythmic prayer – prayers with a cadence
6. Journal prayer – letters to God
7. Centering prayer – praying a scared word
8. Psalm prayer – praying scripture
9. Ask the Holy Spirit to pray on your behalf
10. Silent touch
11. Talking to your body parts/cells
12. Distance Prayer
13. Retroactive Prayer
14. Group Prayer
15. Holding Hands
16. Embracing the Pain/ Holding it
17. Laughter
507
About Praying with Others
Praying is:
A Mystery: An opportunity to step into the world of another. Do so gently
Being Present: A deep listening and comforting presence
Finding Sacred Space: Put your own agenda at the door and create room for
sacred space
Before

Pray for stillness, openness, wisdom and hope

Leave your agenda at the door

Ask yourself if this is a good time for you to visit

BREATHE
During

Be genuinely present

Recognize that you are in the presence of mystery

Attend with deep respectful listening

Keep your time short

Remember you are the guest of the other

BREATHE
After

Take a few moments to pray in thanksgiving

Recall the visit. Did you assume things?

Ask yourself what you learned about the mystery of life.

Offer a prayer of gratitude.

BREATHE
Sister Dianne McNamara,SP
Kingston, Ontario
508
Say a Little Prayer
Research has validated the power of prayer in health care. Here’s how you can
provider a spiritual dimension to your patient’s progress.
Edward Davis, 64, is undergoing a colon resection for cancer. After receiving report,
you begin assessing his vital signs. Suddenly, he looks up at you and asks, “Would
you say a prayer with me before I go into surgery?”
How would you respond?
Science and Faith
Nursing is both a science and an art. On One hand, we Implement technical
treatments that have been subjected to rigorous scientific method: on the other, we
listen and show that we care in intangible ways. We’re usually comfortable with this
duality. But when a patient expresses his religious or spiritual faith, we may feel
uncertain about our role.
Consider Mr. Davis’s request. Your own beliefs will colour how you respond. If
you’re not a religious person, you may doubt that praying will do him much good.
But prayer isn’t a matter of rubbing the genie’s bottle andhaving wishes granted. A
theologian once said, “God always answers prayers. It’s just that sometimes the
answer is “no.”
Research has shown that prayer can be helpful in times of illness. Why? Possibly
because when prayer isn’t a matter of begging and getting but rather of aligning
ourselves with our spiritual natures, we more easily accept what God already has
planned.
509
Can you do it?
You’re the only one who can decide whether or not to include prayer in your nursing
care.
If the idea of prayer makes you uncomfortable, then you should politely
decline a request like Mr. Davis’s. But you should still take his request seriously and
pass it along to someone willing to intervene, such as someone in pastoral services.
If you do decide to engage in prayer for a patient, think of your action as meeting a
spiritual need, not a religious one. Most religious beliefs share the common
denominator of prayer, so don’t worry if your religion differs from your patient’s.
In some instances, you may want to offer to pray for a patient even if he doesn’t
prompt you. If you’ve done a complete spiritual assessment as part of your nursing
history you can probably judge whether your patient finds prayer comforting.
But sometimes an illness creates a need for prayer that seemed minimal before.
This is where your intuition and good listening skills come into play. Watch for
symptoms of depression, such as apathy, statements of helplessness, withdrawal
from family and friends, and loss of appetite. Don’t be afraid to ask, “Would you like
me to pray with you?” if you think it could help. By acknowledging our patients’
spiritual dimensions, we practice holistic nursing at its best.
Carolyn Kresse Murray, RN. BA.
Pontevedra Beach, Florida
510
Tips for Praying During Spiritual Care
By Marilyn Stoner RN MSN
Assistant Professor of Nursing California State University

Start your own day with a few moments of silence, a prayer, or a favourite song.

Work purposefully with your patient, giving them your full attention whenever you
enter their room.

Touch them. Put a hand on their forehead or squeeze their hand.

Ask if they have a favourite spiritual reading, poem, or prayer. Keep their favourite
on your clipboard.

Be generous with silence. Simply meditating with a patient can comfort them.

Keep prayers realistic. If your patient is terminally ill, praying for a miraculous
recovery can instill false hope.

Acknowledge the spirit in everyone. By doing so, you acknowledge everyone’s need
to give and receive love.
511
Praying
For some people, the thought of praying can be intimidating. To speak directly
to God can leave you speechless, not sure what words to use, where to begin
or how to end. Often, prayer does not rely on words, but on a desire to be closer
to God, reminded of God’s love and abiding care, and hopeful that God will give
you the necessary strength to cope with life’s challenges and be healed.
A Patient’s Prayer
God, source of all life and healing,
Who can help us grow in wholeness:
Be with me in this time of physical and emotional need.
Help me rest and cope with the challenges I am facing.
Comfort and encourage those who love and care for me
whose lives have been unsettled and disrupted
by my illness and hospitalization.
Guide and give wisdom to the healthcare personnel
who are committed to my treatment and well-being.
In this special moment of my need,
I pray for healing and for inner peace.
I pray for patience and for understanding.
I pray for a deepening of my faith and belief in you,
my loving God. Amen.
This prayer is offered to you by your hospital chaplains who are also members of HealthCare
Chaplaincy
healthcarechaplaincy.org/care
512
A Personal Psalm
By Rev. Hilkka Aavasalmi, 2002 (used by permission, with gratitude)
Sometimes there are many questions…
Mostly about your ways with us.
It is curious, why it seems
You sometimes choose
Not to give us understanding.
Hard hearts do not easily crumble.
Why do you not change me, O God
In an instant…
You who can create a whale to swallow a man
Can you not create something to swallow…this?
Yet I forget that you are the burden-bearer
I forget that I have been changed
I forget and fail to remember
I am a new creation.
Help me to see what you see
And remind me again
That often the process is the point
That often the journey is the destination
As you reveal your image in me.
Sometimes there are many questions…
Help me to continue to trust
When the Heavens are silent
And to know that the answers may arise
In the Journey itself.
513
Five things I learned about ministry when I had cancer
United Church Observer, March 2014 By Michael Webster
I have always been healthy. My wife, Debbie, who is a nurse, warned me that if I
ever did get sick, I would be a terrible patient. She said that I had no patience with
being unhealthy, and no practice at it either. People who have been sick know what
it’s all about, she said. People like me make the worst patients.
Then, last year, I did get sick. Symptoms. Biopsy. Cancer. Surgery. Two
months off work and another month working part-time. Through it all, I was a model
patient — good-natured, optimistic, pleasant in every way. At least that’s how I
remember it.
Okay, maybe I got discouraged a couple of times, maybe even a little shorttempered now and then. The first couple of weeks post-op were the best. My
expectations were low, and I could see my progress — walk to the end of the
driveway one day, then to the telephone pole, then to the end of the block. After
that, my expectations sped up, but my progress didn’t.
I got dozens of get-well cards, but one stood out. On the front, it said,
“Recovery is a process. It takes time . . . it takes patience . . . it takes everything
you’ve got.” Those words became my mantra. I repeated them several times a day,
but truth be told, I never did learn patience.
What I did learn was what it’s like to be sick. And in my first experience of
being the pastoral visitee instead of the pastoral visitor, these are the five things I
learned about ministry.
1. Prayer matters. I have never been so prayed for and prayed over in my life.
Presbytery executive laid hands on me and prayed. My congregation prayed for me
on Sunday mornings. And of course, most of my visitors in the hospital prayed for
me as well. Overall, I found it to be a powerful and deeply spiritual experience.
Like a lot of United Church folks, I don’t believe that prayer changes God’s
mind about how the universe ought to unfold. I do believe prayer has the power to
effect change, that it is a precious gift from our Creator, and that we have hardly any
idea how it works or how to use it.
514
As a minister, though, I have not always acted as though I believe in prayer.
Sometimes when I visited someone, I would feel uncomfortable offering a prayer. I
took my own discomfort as a signal that the person didn’t really want a prayer.
Baloney! That discomfort says more about me than it does about them. And for
crying out loud, I’m their minister — they expect a prayer. Prayer changes the whole
tenor of a visit. Whether or not they want me to pray for them, they expect me to
ask.
2. All pastoral prayers are too long. I know what it’s like. It’s the end of a
pastoral visit, and it’s time for a prayer. Sometimes I ask, “What shall we pray for?”
Judging by their expression, some people consider this a dumb question, but for
others, it leads to a meaningful discussion. Often, I just say a prayer that tries to
cover all the bases. I’ll never do that again.
As I lay in my hospital bed, helpless, drugged and in pain, every prayer I
received seemed to drag on forever. Most of my visitors were other ministers, and I
was grateful for their company, but for the most part, they prayed like I did. They
gave thanks for this and that — for me and for the beauty of the day, yada, yada —
and then asked for a bunch of stuff, but it is hard to remember exactly what because
by that time I had already zoned out.
Here’s what I learned: Longer is not better. To the point is better. Heartfelt is
better. Three or four brief sentences will do just fine. God will get the idea, and so
will the patient.
3. It ain’t over till it’s over. I think I have a pretty good record of making
hospital visits. But I’ve done a terrible job of following up once people go home. At
some level, I guess I assumed that once patients are discharged, they are no longer
in crisis.
I now know that getting home from the hospital can be just the beginning of
one’s struggles, that recovery is the hardest thing of all, that it is a process . . . it
takes time . . . it takes patience . . . it takes everything you’ve got. And that includes
ongoing pastoral care from your minister.
515
4. Humility stinks. Okay, so I didn’t learn much about patience, but I sure rose a
few points on the humble meter. And not just because I was at the mercy of nurses
examining parts of me I usually keep covered up. I also realized how blessed I am
to live in a country that provides first-rate medical care without eviscerating my
savings. That was just the beginning.
Like a lot of caregivers, I find it fulfilling to show compassion to others but
difficult to be on the receiving end of kindness. I would rather pull out my fingernails
than admit I need somebody’s help. The Bible’s word for that attitude is pride.
Cancer gave me many opportunities to practise humility. Friends and
parishioners gave us rides and offered to sit with Debbie during my surgery. A
neighbour rototilled our garden. Later, another cleared the snow off our driveway. I
haven’t come close to getting rid of that pride of self-sufficiency, but I learned to
ease my squirming discomfort and accept with reasonably good grace the
kindnesses that were offered.
5. I’m humble, but I’m also important. I often say that ministry is a lot like farming,
only it’s all seeding and no harvesting; that is, clergy rarely get to see the results of
their work. That’s true enough, but it ignores the fact that, as a minister, I am a
character in people’s life stories. Long after I am gone, they will remember me as
the minister who did the baptism or the funeral or who said something that helped
them or challenged them or, God forbid, hurt them. In the same way that I can
remember all my grade school teachers, I remember all my ministers, and so I will
be remembered too.
That’s easy to forget when, as one of my professors used to say, “the
Sundays start coming at you like telephone poles.” But tell a congregation that
you’ve got cancer, and you begin to be reminded that ministry is not only an
awesome responsibility but also an awesome privilege. Cancer is not a learning
experience I recommend, but it certainly is an effective one.
Michael Webster is in team ministry at St. Martin’s United in Saskatoon. He is currently cancer free.
516
A Prayer
May the God of Stillness be with you
Calming your agitated heart.
Inviting you to meet your God
In the stillness of your being
And to come to know
The one who is there
As your God
And may your own inner stillness
Draw others tot the God of peace
May the blessing of Stillness Be upon you
UNIVERSAL PRAYER
(for those who have just died, and my be used at bedside)
OUR GOD, IN WHOSE PRESENCE WE COME INTO LIFE, IN WHOSE CARE
WE LIVE AND DIE, WE COME AT THIS MOMENT OF DEATH TO REMEMBER
WITH ONE ANOTHER THE LIFE OF _____(name of deceased)____________
WHO HAS LIVED WITH US. OUR LOVE GOES WITH HIM/HER AS WE NOW,
IN SILENCE COMMEND HIM/HER TO YOUR CARE.
(SILENCE)
517
Prayer Exercises
Here are some scenarios in which you might find yourself offering prayer. Write out
a prayer, in your own style, in your own words what you might say. It is helpful to
“pray back” the patient’s needs he/she has already articulated, using his/her words
of longing and loss, asking for God’s grace, healing, support, love and care and in
gratitude for his continuing care and support.
1.
You are visiting a young Mom who has three children and a troubled
relationship with a common-law husband. She misses her church family she left
when she moved here. She is very appreciative of your visit and you offer to pray
with her.
2.
You are in hospital visiting a 55 year old man who is dying of cancer. At first
he seems a bit gruff, but after some good conversation about the ‘good old days’ he
seems to soften a bit. He asks for you to say The Lord’s Prayer with him, and then
you sense he needs something more.
3.
You are visiting a 12-year old boy who broke his leg in a car accident. He
has recently been told that his mother died in the accident. He appears withdrawn,
but you feel God urging you to pray.
4.
You are at the nurse’s station getting some information about your patient,
when a nurse gets a phone message that her mother has died. You know this
nurse fairly well and immediately put your arm around her. After some silence and
tears, she asks for prayer.
5.
You are visiting a Catholic patient who regularly attends hospital mass, and
uses prayer beads daily. She missed her regular visit from her priest because she
was having physiotherapy. When you come in to visit, she asks you to bless her.
518
6.
You are visiting someone from your church that now lives in a nursing home.
You find her sitting in the sunroom with 3 other residents. Her face lights up when
she sees you, and she asks: “Have you come to pray with me?!” and the other 3
ladies look up at you expectantly.
7.
You are visiting a 40-year old woman who is dying of heart failure. She has
a very strong faith, but is most concerned for the future of her twin boys, aged 13.
She asks for prayer.
8.
You are visiting your retired minister who now lives in a nursing home. After
talk of many things, he says that all his life he has prayed for others, and now he
wishes someone would pray with him. You are a bit self-conscious because you
recognize he is more eloquent at prayers, but you want to help meet his need, so
you pray.
9.
You are visiting a 53-year old gentleman in hospital who is just scheduled for
heart surgery. He jokes about the risks of the operation, but you feel he is trying to
hide some of his fear. You offer prayer.
Janet Stark
519
Healing Words by Larry Dossey, M.D.
Harper Collins 1993
These quotes which appear in Dr. Dossey’s book, Healing Words validate the
relationship between prayer, faith and better health outcomes. Pages are
referenced.
Prayer occurred not only when people prayed for explicit outcomes, but also when
they prayed “Thy will be done”. xvii
The effects of prayer did not depend on whether the praying person was in the
presence of the (organism) being prayed for; healing could take place on site or at a
distance.
xvii
Prayer effects are not confined to the present or future; they may also affect past
events even though they seem already to have taken place.
8
God is present to some degree in all individuals, the Divine factor in prayer is
internal, not external to everyone.
8
Prayer need not always be “thought”; “unconscious prayer”—even “dream prayer” –
is thus possible.
8
Intercessory prayer has a tendency to ask for definite outcomes, to structure the
future, to “tell God what to do,” such as taking the cancer away. Prayerfulness, on
the other hand, is accepting without being passive, is grateful without giving up. It is
more willing to stand in the mystery, to tolerate ambiguity and the unknown. It
honours the rightness of whatever happens, even cancer.
24
Often a prayerful, prayer-like attitude of devotion and acceptance—not robust,
aggressive prayer for specific outcomes, including eradication of the cancer—
preceeds the cure. 31
Praying individuals can purposefully affect the physiology of distant people without
the “receiver’s” awareness.
45
Telesomatic events commonly occur between individuals with strong emotional
bonds.
51
No approach works 100 percent of the time.
59
Those who do not demand healing are the ones who frequently seem to receive it.
65
520
We must consider seriously that prayer and dreaming are very closely related, and
that we pray unconsciously night after night, dream after dream.
71
What people believe consciously about the desirability and effectiveness of prayer
may not matter.
80
Prayer does not involve any conventional form of energy or signal, that it does not
travel from here to there, and that it may not “go” anywhere at all. 83
Rather that complaining that this form of prayer is too passive to suit us, we should
give thanks that we do not have to furnish wisdom or foresight to the universe.
87
In the tests, nondirected technique appeared quantitatively more effective. One cooperated with the natural order instead of trying to change it. 97-8
Love is the power that makes it possible to reach out to heal at a distance. 111
Love (empathy, compassion, caring, bonding) is the fuel behind the healing. 113
Healing of another is in some sense self-healing.
115
Love is compatible with illness—in the same sense which Jesus said, “Love your
enemies,” not “Don’t have any.” 117
There is something in the human psyche that wants prayer to be helpful and benign
but never harmful. 157
Spiritual healers have a feeling of selflessness, a way of being instead of doing. 197
So pervasive will its use (prayer) become that not to recommend the use of prayer
as an integral part of medical care will one day constitute medical malpractise.
205
The recognition of a soul-like quality of consciousness—by science on the one hand
and by religion on the other—will constitute a bridge between these two domains.
This point of contact will help heal the bitter divisions between these two camps. No
longer will people feel compelled to choose between them in ordering their lives. At
long last science and religion will stand side by side iln a complementary way,
neither attempting to usurp the other.
206
No longer will be pray incessantly for things, such as our health, but our prayers will
be predominantly prayers of gratitude and thanksgiving.
207
521
A Small Collection of Christian
Prayers and Readings
For Family and Friends
Psalm 23
The Lord is my shepherd;
May God bless you with faith to quiet
I shall not want.
the fear of your hearts.
He makes me lie down in green
May he give you courage to face the
pastures:
adversity of this time.
He leads me beside still waters.
May he strengthen you in love that
He restores my soul:
grows through difficulties.
He leads me in paths of
May God grant you grace to praise
righteousness,
him in all this day’s events. Amen.
For his name’s sake.
Yea, though I walk through the valley
of the shadow of death,
Gracious God,
I will fear no evil, for you are with me;
We come to you seeking peace of
Your rod and your staff they comfort
mind for the family and friends who
me.
are concerned about ______. May
You prepare a table before me
they find comfort in each other and in
In the presence of my enemies:
the knowledge that _____ is in your
You anoint my head with oil;
care. Cast out fear and fill their hearts
My cup overflows.
with faith and love.
Surely goodness and mercy will follow
Amen.
me all the days of my life:
and I will dwell in the house of the
Lord forever.
522
Lord, we ask you to deliver us from
Abide With Me
the fear of the unknown future;
Abide with me, fast falls the eventide;
From the fear of failure and of running
The darkness deepens;
out of money;
Lord with me abide:
From the fear of loneliness, sickness
When other helpers fail and comforts
and pain;
flee,
From the fear of age and of death.
Help of the helpless, O abide with me.
Help us, O Father, by thy grace to
I need Thy presence every passing
love and fear you only;
hour;
Fill our hearts with cheerful courage
What but Thy grace can foil the
and loving trust in you
tempter’s power?
Through Jesus Christ our Lord.
Who like Thyself my guide and stay
Amen
can be?
From The Oxford Book of Prayer
Through cloud and sunshine, Lord,
abide with me.
Henry Francis Lyte, 1793-1847
Bless are those who trust in the Lord
and have made the Lord their hope
Dear Lord,
and confidence.
We give you thanks for the gift of this
They are like trees planted along a
day. We thank you for the wonderful
season of spring: the song of birds,
riverbank with roots that
the many shades of green. Most of all
reach deep into the water. Such trees
are not bothered by the heat
we thank you for Jesus and the
or worried by long months of drought.
assurance that he is with us in
Their leaves stay green
everything we face. Thank you Lord,
and they go right on producing
Amen.
delicious fruit.
Jeremiah 17: 7-8
523
Loving God, we thank you for the
of your great love for us. In Jesus’
time we have spent together today. I
name we pray. Amen
thank you for ______ and for the
friendship we share. Lord, we are
We shall see God as he really is.
concerned about ______. You know
Think of the love that the Father has
his/her needs and we ask that he/she
lavished on us by letting us be called
will feel your presence and your great
God’s children; and that is what we
love very close to him/her. You have
are. Because the world refused to
promised to go with us through every
acknowledge him therefore it does not
situation we must face. in Jesus’
acknowledge us. My dear people, we
name we pray. Amen.
are already the children of God, but
what we are to be in the future has not
Gracious God,
been revealed; all we know is, that
It is raining today, but how much the
when it is revealed we shall be like
grass and flowers need it.
him because we shall see him as he
May our faith and witness be as fresh
really is.
1 John 3: 1-2
and fruitful as the world washed by the
rain we see outside our window. It is
A reading from the book of
not always easy for us to keep our
Lamentations
faith and witness fresh, for life now is
It is good to wait in silence for the Lord
not as good as we wish it to be. Help
God to save. This is what I shall tell
us to keep the little things that bother
my heart, and so recover hope: The
us, little. Help us to give thanks for
favours of the Lord are not all past,
the people in our lives who love us
His kindnesses are not exhausted;
and try to make things easier and
every morning they are renewed,
brighter. Help us, too, Lord, to see
great is his faithfulness. “My portion is
people around us who seem sad or
the Lord,” says my soul, “and so I will
discouraged and give us a helpful
hope in him.” The Lord is good to
word for them for Jesus’ sake. Thank
those who trust him to the soul that
you, God, for the many signs we see
searches for him. It is good to wait in
3: 21-26
silence for the Lord to save.
524
Loving God, ______ knows what it is
For One Growing Old
to be growing old. Everything is a
Even to your old age and grey hairs I
bigger effort than it used to be.
am he, I am he who will sustain you.
She/he would rather be at home, living
I have made you and I will carry you;
her/his everyday life, free to come and
I will sustain you and I will rescue you.
Isaiah 46: 4
go. But we thank you for placing
_____ here where daily help is
For the Dying
available. You are here beside
Who shall separate us from the love of
her/him in the love of others, in the
Christ? Shall trouble or hardship or
care of nurses, in the thoughtfulness
persecution or famine or nakedness or
of the staff, and in the wisdom of
danger or sword? As it is written: “For
those who have helped her/him make
your sake we face death all day long;
decisions. May she/he see your hand
we are considered as sheep to be
in all things, thus making it easy to
slaughtered.” No, in all these things
trust the future to you. Amen.
we are more than conquerors through
him who loved us. For I am convinced
Anticipating Surgery
that neither death nor life, neither
You will keep in perfect peace all who
angels nor demons, neither the
trust in you, whose thoughts are fixed
present nor the future, nor any
on you! Trust in the Lord always, for
powers, neither height nor depth, nor
the Lord God is the eternal Rock. And
anything else in all creation, will be
we know that God causes everything
able to separate us from the love of
to work together for the good of those
God that is in Christ Jesus our Lord.
who love God and are called
Romans 8: 35-38
according to his purpose for them.
Isaiah 26: 3-4; Romans 8:28
525
The Lord’s Prayer
Our Father, who are in heaven,
Blessings
Hallowed by thy name.
May God bless this day with the
Thy kingdom come, Thy will be done
assurance of his presence,
On Earth as it is in heaven.
the power of his healing in its many
Give us this day our daily bread,
and varied forms and the knowledge
And forgive us our trespasses,
of his deep and abiding love for us.
As we forgive those who trespass
Amen.
against us.
Lead us not into temptation,
May God bless us with peace to calm
But deliver us from evil,
our fears, strength to support our
(For thine is the kingdom,
weakness, faith to drive away our
And the power and the glory,
despair, love to fill our loneliness and
forever and ever,)
Amen.
hope to conquer doubt. Amen.
Psalm 121
I lift up my eyes to the hillsWhere does my help come from?
My help comes from the Lord, The
God has promised always to go with
Maker of heaven and earth.
you, never to leave you or forsake
He will not let your foot slip- He who
you-
watches over you will not slumber;
God goes before you to lead you.
indeed, He who watches over Israel
beside you to accompany you,
will neither slumber nor sleep. The
behind you to support you,
Lord watches over you- the Lord is
beneath you to uphold you,
your shade at your right hand; the sun
above you to bless you,
will not harm you by day, nor the
within you to inspire you,
moon by night. The Lord will keep you
and so you go in peace.
from all harm- he will watch over your
life; the Lord will watch over your
coming and going both now and
forevermore.
526
Gracious Father,
to savour the sweetness of the Lord,
Send your purifying grace into our
to behold his temple. O Lord, hear my
minds and hearts that we may live in
voice when I call; have mercy and
your light and walk in your way. Weak
answer. It is your face, O Lord, that I
as we are, we know that you are ever
seek; hide not your face. I am sure I
ready to help us if we will but believe
shall see the Lord’s goodness in the
and come to you earnestly seeking.
land of the living. Hope in him, hold
Help us, we pray. Amen.
firm and take heart. Hope in the Lord!
-Dr. Ott McKennitt
Psalm 27: 1, 4, 7-9, 13-14
The Lord is compassionate and
Merciful God,
gracious,
You who are without age, look upon
slow to anger and abounding in love.
your servant ______ with love. Help
As far as the east is from the west,
______ to accept the changes of life
so far has he removed our
that come with an abundance of
transgressions from us.
years. Give her/him the courage to
Psalm 103: 8, 11
live this day in harmony with you. As
bodily strength wanes, grant ______
Create in me a pure heart, O God,
increasing faith.
and renew a steadfast spirit within me.
As eyesight dims, enable her/him to
Psalm 51: 10
see your presence. As hearing fails,
let her/him attend to your Word. As
days grow long, give _____ patience
to wait upon you.
A reading from Psalm 27
The Lord is my light and my salvationwhom shall I fear? The Lord is the
stronghold of my life- of whom shall I
be afraid? There is one thing I sake of
the Lord, for this I long, to live in the
house of the Lord all the days of my
life,
527
Forgiveness
For strength
Forgive us our sins as we forgive
Even youths grow tired and weary and
those who sin against us.” How many
young men stumble and fall; but those
times have we prayed these words,
who hope in the Lord will renew their
Lord? Yet we remember only too well
strength. They will soar on wings like
the old hurts and injustices done to us,
eagles; they will run and not grow
the harsh words and cold shoulders
weary, they will walk and not be faint.
Isaiah 46: 4
we have experienced. By your Spirit
free us from the hold of past
grievances. Grant us a fresh
Thank you God, That today ______
awareness of your great grace shown
experiences your healing power. The
to us in Jesus who came to make all
journey through illness is not over, but
things new. Amen.
healing has begun. We are grateful
that past days are but memories. We
ask for faith to live today trusting in
Do Not Fear
Do not fear what may happen
your Spirit. We place the hope of
tomorrow. The same loving Father
tomorrow in your hands. Amen.
who cares for you today will care for
you tomorrow and every day. Either
Loving God, You who give comfort to
he will shield you from suffering or he
the weary and frightened, give ______
will give you unfailing strength to bear
peace and courage as the time of
it. Be at peace, then, and put aside all
surgery approaches. Reassure
anxious thoughts and imaginings.
him/her of your presence. Creator
God, you who designed ______’s very
St. Francis de Sales
Let nothing disturb you, nothing
being, may your Spirit fill the medical
affright you. All things are passing;
staff with your wisdom and
God never changes. Patient
knowledge. Merciful God, provide
endurance attains to all things.
your strength where ______’s own is
Whoever possesses God is wanting in
insufficient. Call ______ to surrender
nothing; God alone suffices.
himself/herself into your care this day.
St. Teresa
Amen
528
God of compassion,
In our human weakness we claim your
Upon Death O Lord,
strength. We pray that through the
Receive the spirit of ______, your
skills of the doctors and nurses, your
child. Free him/her from the pain and
healing gifts may be granted to
struggle of this life. Give ______’s
______. May she/he respond to your
family and friend’s faith and strength
healing
to release him/her into your loving
will and return with thankfulness to the
care. May the saints and angels
community that praises you. Amen
welcome him/her into the life that has
no end.
For the Recovery
Patti Normile
God will wipe away every tear from
their eyes, and there shall be no more
– death or mourning, crying or pain,
Lord Jesus,
You know what pain is like
(for)
You know the torture of the scourge
The sting of thorns
the old order has passed away.
Revelation 21: 4
The agony of the nails.
You know what _____ is going
Lord,
through just now.
Help ______ in her/his pain.
Even now in the face of death we put
Help her/him to remember that she/he
our confidence in you, for what we are
will never be tried
is not what we shall be when your love
above what she/he is able to bear,
in Christ has set us free and made us
and that you are with her/him,
whole. This world is not what it will be
even in this valley of the deep, dark
when you have made your glory
shadow.
known, wiped all tears from your
people’s eyes and brought death to an
-adapted from William Barclay
In “Prayers for Help and Healing”.
end.
Thanks be to God.
529
This sacred journey—
Never Found the Time for Prayer
a caregiver’s promise
I knelt to pray but not for long,
I will hold your hand
I had too much to do.
I will dry your tears
I had to hurry and get to work
I will stay with you
For bills, would soon be due.
Until your fears subside.
So I knelt and said a hurried prayer,
Never will you be alone against the
And jumped up off my knees.
night.
My Christian duty was now done
Gently I will walk this sacred journey
My soul could rest at ease………
with you.
All day long I had no time
Let us share our stories,
To spread a word of cheer
Our still unfinished dreams.
No time to speak of Christ to friends,
Let us bring each other
They’d laugh at me I’d fear.
The comfort that we need.
No time, no time, too much to do,
Through all your pain and anguish
That was my constant cry,
I will be with you.
No time to give to souls in need
To bear with you your burdens,
But at last the time, the time to die.
To ease your troubled heart.
I went before the Lord,
I came, I stood with downcast eyes.
At times we’ll pray together,
For in his hands God held a book;
At times we’ll laugh and sing.
It was the book of life.
I’ll sit with you in silence,
God looked into his book and said
I’ll listen when you speak.
“Your name I cannot find
And your faithfulness!
I once was going to write it down…
But never found the time.”
To You I will sing, O Holy One of
**
Israel. My lips rejoice when I sing to
You, and my soul, which You have
redeemed.
530
Happy moments, praise God.
Difficult moments, seek God.
Quiet moments, worship God.
Painful moments, trust God.
Every moment, thank God.
Cancer is limited…
It cannot cripple love,
It cannot shatter hope.
It cannot corrode faith.
It cannot eat away peace.
It cannot shut out memories.
It cannot invade the soul.
It cannot reduce eternal life.
It cannot quench the spirit.
It cannot lessen the power
of the Resurrection.
Psalm 71
531
Prayer for the Aged
You are my trust from my youth.
You have upheld me from birth.
You took me out of my mother’s womb.
My praise shall be of You.
Do not cast me off in the time of old age;
Do not forsake me when my strength fails.
Do not be far from me:
O my God, help me!
O God, You have taught me from my youth;
I declare Your wondrous works.
Now when I am old and gray headed,
O God, do not forsake me until I declare You to this generation.
Oh God, who is like you?
You, who have shown me severe troubles,
Shall revive me again.
You shall comfort me on every side.
I will praise You –
A Celtic Blessing
May the Christ who walks on wounded feet walk with you on the road.
May the Christ who serves with wounded hands stretch out your hands to serve.
May the Christ who loves with a wounded heart open your hearts to love.
May you see the face of Christ in everyone you meet, and may everyone you meet
see the face of Christ in you
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A Celtic Prayer
You’ve blessed me with friends and laughter and fun
With rain that’s as soft as the light from the sun.
You’ve blessed me with stars to brighten each night.
You’ve given me help to know wrong from right.
You’ve given so much, please Lord give me too;
A heart that is always grateful to you.
A Volunteer’s Prayer
“I thank Thee, Lord as a volunteer
For the chance to serve another year.
And to give of myself in some small way,
To those not blessed as I each day.
My thanks for health and mind and soul,
To aid me ever toward my goal.
For eyes to see the good in all,
A hand to extend before a fall.
For legs to go where the need is great,
Learning to love--forgetting to hate.
For ears to hear and heart to care,
When someone’s cross is hard to bear.
A smile to show my affection true,
With energy aplenty — the task to do.
And all I ask, dear Lord, if I may,
Is to serve you better day by day.”
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Lord’s Prayer for Children
God of the skies
You are so Awesome!
Let everything in the world
happen the way you want it to!
Give us everything we need
To be healthy
And forgive us for our sins
And we will forgive others
Don't let us be tempted
Keep us from doing bad
All the world is yours
And you are strong and mighty!
Forever!
Prayer of St Francis of Assisis 1200 AD
Lord, make me an instrument of your peace.
Where there is hatred, let me sow love.
Where there is injury, pardon.
Where there is doubt, faith.
Where there is despair, hope.
Where there is darkness, light.
Where there is sadness, joy.
O Divine Master,
Grant that I may not so much seek to be consoled,
as to console; To be understood, as to understand;
To be loved, as to love.
For it is in giving that we receive.
It is in pardoning that we are pardoned,
And it is in dying that we are born to Eternal Life.
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Self-Care for Volunteers
Some strategies for caring for your well-being.
1.
Know yourself. Know what feeds you and depletes you. Know what your ”normal”
(i-e
2.
healthy) state is, and recognize then some extra care may be needed.
Know your own grief process, how you grieve, and what losses you may be
dealing with no. Remember that issues you thought you had dealt with (losses you
have grieved) may creep to the surface again in the context of difficult visits.
Grieving is an on-going process.
3.
Be conscious of your emotional health, and watch for changes. Take the time
to ask yourself, and to seek an answer to, what is going on beneath the surface. It
may be something at home or something in your work that resonates with a
personal issue.
4.
Take time when it is needed, especially before and after a visit. Be still. Breathe
deeply. Take not of your emotional state, and leave behind what is not needed for
your next task. Make a note of thoughts or emotions with which you will need to
spend some time, if you cannot do so now. Journal. Talk to someone who
understands. Pray. Sing. Cry.
5.
Make time for people or activities that are important to you. Indulge your need
for closeness with those you love. Encourage yourself to be creative in writing, art,
crafts, music, dance or movement, designing, cooking, or whatever else works. Do
it for you, and don’t expect others will understand or appreciate your creativity. Don’t
be concerned with ‘failures’, because there are none. There are only learning
experiences.
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6.
Don’t forget that you are part of a team. You are not alone in this process, and
need to avail yourself of support, advice or time out when necessary. Your pastor or
trained/experienced lay person need to be at the top of your list, but it can also
include the chaplain (if visits are in a facility), a counselor, even your doctor or
friends. Be careful, however of privacy issues-share only of your own reaction
whenever possible.
7.
Respect you own boundaries. Expect others to respect your boundaries. You
cannot take on the problems or the dying or grieving process for your clients, or
their families. Sometimes you may want to, and sometimes they may want you to.
Share only what you are comfortable sharing, and what you thin will be helpful.
Love Laugh Live !
**
The Senility Prayer !!
God, grant me the senility to forget the
people I never liked anyway,
The good fortune to run into the
ones I do like,
And the eyesight to tell the difference!!
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First Aid for Stress
Use breathing or relaxation techniques to reduce anxiety and help yourself feel
more in control of the situation. .
Reduce caffeine, sugar and salt intake. If you are a smoker, try to reduce the
amount of cigarettes you smoke. All of these add to your stress, they are called
'internal stressors' and cause a stress response within the body.
Talk your problems out with a trusted friend, co-worker or professional. Talking
out worries, concerns and fears relieves the strain and puts things into perspective.
Problem-solving: Sort out what the problem is, then look for workable solutions.
Then develop an action-oriented plan. Get help if you need it from co-workers or
friends.
Perfectionism is a disease. When you find yourself striving for perfectionism, sit
back and check if your expectations of yourself are realistic. Relax and move
toward working for a feeling of satisfaction and fulfillment rather than perfectionism.
Give yourself permission to make mistakes.
Take stock of your own power. Recognize your strengths and weaknesses. Play
up your strengths and admit that you may need help from others in certain areas
when you do not have the training or expertise. Be aware that you have all the
resources within you to deal with stress; that you do not have to be a victim and can
develop the ability to interpret stress events in a positive way.
Find some way to release your emotions, especially anger and frustration. Talk it
out, exercise, hit a pillow or punching bag, find a place to yell if you need to.
Suppressed feelings can cause added stress and can lead to anxiety and physical
symptoms of distress. Let go in the privacy of your home. Once pent-up feelings are
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released you will feel better and they will not cloud your perception of other events
in your life. Be good to yourself and let your friends know what is going on with you.
Time out: find a place to get away from the situation for a few minutes. Walk
around the block, visit another office or visualize a peaceful scene in your mind to
activate the relaxation response in your body/mind.
If you worry about things, STOP! Worry is a condition which can cause us to
slip out of balance and cause distress. Take it easy and let go of any worrying
thoughts. Remember, worry is useless, and causes anxiety.
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Care for the Caregiver
1. Be gentle with yourself. Remind yourself that you are an enabler-- not a
magician.
2. We cannot change anybody else. We can only change how we relate to
them.
3. Find a hermit spot--use it daily.
4. Give support, encouragement and praise to peers and management. Learn
to accept it in return.
5. Remember that in the light of all the pain we see, we are bound to feel
helpless at times. Admit it without shame. Caring and being there are
sometimes more important than doing.
6. Change your routine often and your tasks when you can.
7. Learn to recognize the difference between complaining that relieves and
complaining that reinforces negative stress.
8. On the way home focus on a good thing that occurred during
9. Be a resource to yourself.
10. If you never say NO what is your YES worth?
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the day.
For the Pastoral Care Volunteer
A class of Pastoral Care participants shares…..
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For finding Peace,
Living on Lakefront
Music
My prayer time at sunrise (sunrise with Jesus)
Exercise (ride a bike and Pray)
My morning prayer time and also a song for the day to praise the Lord.
Watching the sunrise over the river (mountains) and giving thanks for a new day.
Talking to God,
Walking
Nature
Yoga
Exercise
Reading
Gardening
Water – sound
Candlelight
For finding Acceptance
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Face lights up when they see you.
Positive verbal response.
Sharing personal thoughts.
“Will you come again?”
Relaxed
Positive body language
Invite you to sit down.
Asking for prayer.
Turning off the T.V. or radio.
Hand-holding
Crying
Thanking you.
May extend their hand towards you.
Ask you to pray with them.
Invite you back again.
They smile when you come in.
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Being told by family that we have done a good job .
Greeted with warm friendly smile and words.
 Given a hearty thanks when you give a patient water or something
For Finding Contentment:
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Happy to see you, meant a lot that you are here.
Just happy to get through that first prayer on the spot.
If we felt we have done what we went in to do.
If our expectations were not too high, then we could be content easier.
Satisfaction when visiting someone who is lonely and has very few visitors.
My Symptoms of Stress:
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Shoulder pressure
Stomach pressure
Chest pressure
Blood pressure when waiting
Headaches – migraines
Impatience
Jaw clench
Flush
Shallow breathing – can’t think
Back pain
Fatigue
Increase in pain in different parts of body, shoulders, stomach,
Mountains out of mole hill
Tense when asked to role play or stand up and make presentation
I feel very vulnerable if I get ill as I’m very independent.
Anxiety when watching situations teenagers are going through.
Stress of over work and peoples impatience
Doing too much because I can’t say no
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My Feelings of Guilt:
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If we didn’t spend as much time as we thought was necessary.
Not able to respond to some comments especially elderly people who
question why they are still alive – what purpose are they serving.
If we were to say something that upset them.
Not meeting their expectations.
Missed a visit (person dies before you got there)
Family obligations not being met at home.
Putting off a visit (avoidance – voice saying you should have been there)
I’m not prepared spiritually.
Unworthiness
Felt guilty someone not there when really needed (on call)
Not being able to pray out loud.
Feeling guilty by not accomplishing what you set out to do (for a day.)
When I was rejected
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1st visit to Palliative Care Person – husband would not let me in.
Body language – turning away from person.
Comments – Example: I suppose you have to be moving in.
People do not want me to come in with my therapy dog wheb they are not
feeling up to it. You do not feel welcome.
Fear of talking about their illness.
No response
“I’m tired”
“Not up to a visit”
“Can you come back later?” (or never).
Not turning off the TV or radio
Not listening
Fidgety
Starting to read a book or do a puzzle.
Negative body language
The person does not make any eye contact
Rejected by a family member.
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Common Sense Commandments of Humour
1. It is important to take your job seriously...and yourself lightly. There is a big
difference between being “serious” and being “solemn”.
2. Laughter is the shortest distance between two people. (Victor Borge)
3. There is a direct relationship between the funny line and the bottom line.
4. You can't help getting older....but you can help getting old. (George Burns)
5. When humour goes, there goes civilization. (Erma Bombeck)
6. Humour is our greatest national resource which must be preserved at all costs.
(James Thurber)
7. Love may make the world go 'round, but laughter keeps us from getting dizzy.
(Donald Zochert)
8. Humour is a proof of faith. (Charles M. Shultz)
9. You grow up the day you have your first real laugh....at yourself. (Ethel
Barrymore)
10. Misery loves company....but laughter loves it even more!
Ye shall go forth and multiply mirth and give birth to creativity.
Serenity Prayer
God grant me the serenity to
Accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
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10 Steps to Happiness
WORK like you don’t need the money
PLAY like a five year old child
LOVE like you’ve never been hurt
DANCE like nobody’s watching
SMILE like you know a big secret
GIVE like God is inside you
HOPE like your life is beginning
DREAM like everything is possible
LIVE like there’s a million tomorrows
PRAY like you’re grateful for life
**********
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When the Chaplain needs a Chaplain…
As some of you may already know my father who is 84 has been hospitalized
a couple of times over the past few months and both times it was for life-threatening
reasons and the hospital stays were long. My mother, who is a little older than my
father (85) has congestive heart failure and has leaned on my father to help care for
her as her illness progresses. They still live in their own home and my father still
drives…until recently. They now rely heavily upon my brother and I to provide care
and support for them so they can continue to have their independence and this
presents unique challenges for us as it does for anyone in similar situations.
Hospital chaplains are the people that patients and families turn to in their
time of spiritual distress, and often we are the ones that others have the
uncomfortable conversations with; conversations about fears of debilitating illness,
the freedom of choices that have been taken away, and ultimately questions of life
and death. I am comfortable with these subjects and do not shy away from them,
but recently with my father’s illness, I find myself needing a chaplain as I wrestle
with the prospects of the future for my parents in their declining years.
Being a caregiver with a lot of education and experience does not insulate
any of us from needing the care of others. In my daily work I meet patients who
remind me of my parents and in many ways I believe this familiarity allows me to
provide even better care for them. But it is hard at the same time, because in the
hospital where my father is, there is no spiritual care chaplain to help us navigate
the difficult road of declining health.
So…when a chaplain needs a chaplain it’s like when a nurse or a doctor
needs a nurse or a doctor! We are caregivers - trained to give the best care to
others and there will be times in our lives when we will need to let go of the reigns of
control and allow others to give us their best care. Pretending we are strong when
we are weak is foolish pride. I know the right things to say and do, but I am grateful
to have a team of caring professionals around me who understand that I have
emotional needs during these days of uncertainty. There are days when I feel the
stress of this season more than others, and on those days I am thankful to be
surrounded by friends and colleagues who understand that sometimes a chaplain
needs a chaplain.
Rev. Brenda Haggett, MTS, BGH Chaplain
February 2014
Brockville General Hospital Pastoral Care Education
545
Care for the Caregivers
A well-beloved nurse died recently on the same floor where she had worked
for many years. Staff members were recently upset during a murder trial because
one of their colleagues had been killed. The staff was in crisis when they heard
alarming news that one of their own had lost a child to suicide. Add to this, the
normal incident of grieving for one’s patient who has died.
In providing a good spiritual care program for patients in hospital, we often
overlook the needs of staff. Nurses need an opportunity to grieve and to express
feelings and concerns. I recently learned that a nearby long term care home had
more than eighty residents die last year. With all of this going on, nurses are
expected to get up out of bed the next day, come to work with cheerful attitudes and
be productive.
Spiritual Care services have to provide care for the staff as well as the
patients. If the workers are well-cared for, then it stands to reason that they in turn
can provide better care. We have been called to do staff de-briefings, last-minute
prayer services, memorial services and even funerals.
reflection, meditation, prayer and expression.
A de-brief is a time for
The team gathers strength in
knowing that they are united in their concerns or losses. It helps validate the stress
level among the staff.
Another thing, of which we should all be aware, is that nurses bring their own family
concerns with them. They may be experiencing difficulties, health problems in their
families and personal grief and loss. Even for a professional, it is hard to separate
this personal weight when arriving at work to care for others. Let us remember to
view the caregiver as a whole person, in the same way we do the patient.
Janet Stark
Brockville General Hospital Pastoral Care Education
546
Stress Management Tips

Recognize that you are stressed

Become aware of feelings of being overwhelmed; note situations that trigger
reactions of stress

Determine alternative actions to deal with stress in a constructive way.

Plan a daily relaxation program and DO IT

Allow for quiet times during the day to reduce tension

Learn ways to become more assertive (this will help overcome feelings of
powerlessness in relationships with others)

Learn to say NO

Delegate and/or combine tasks

Take a course in biofeedback, yoga, meditation, or some other advanced relaxation
technique

Learn from past mistakes; ask for help

Share feelings with other people

Listen to other people's concerns

Find ways to deal with problems constructively

Accept what cannot be changed as there are limitations in every situation

Work on being Positive!
Brockville General Hospital Pastoral Care Education
547
Good day / Bad day
Good Day – I’ve Mail
oo
Bad Day- No Mail
When I am lonely I like to ___________________________________________
________________________________________________________________
When I feel depressed, I can get out of it by _____________________________
________________________________________________________________
When I am feeling good, I like to ______________________________________
________________________________________________________________
Some things I enjoy doing with my family _______________________________
________________________________________________________________
A bad day to me is when ____________________________________________
________________________________________________________________
Things to do when I have a bad day ___________________________________
________________________________________________________________
Whom to talk with when I have a bad day _______________________________
________________________________________________________________
Things to do when I have a good day __________________________________
________________________________________________________________
Whom to talk with when I have a good day ______________________________
________________________________________________________________
Things to avoid when I have a bad day _________________________________
________________________________________________________________
Things to avoid when I have a good day ________________________________
________________________________________________________________
Brockville General Hospital Pastoral Care Education
548
Ministry of Labour
Protecting Jobs for Caregivers
This has passed effective June 10 2013
On March 5, 2013, the Ontario government introduced new legislation which, if passed, would
create three new job-protected leaves.
The new Ontario government has introduced legislation that provides unpaid job-protected
leave for employees while they care for sick or injured loved ones or cope with the illness or
loss of a child.
Family Caregiver Leave:
The Employment Standards Amendment Act (Leaves to Help Families), 2013 applies to all
employees covered by the Employment Standards Act, 2000, whether full-time, part-time,
permanent, or term contract. The new leave provides job-protected leave for caregivers to
care for:
Their spouse; ; Their parent, step-parent, or foster parent
Their child, step-child, or foster child of the employee
Their grandparent, step-grandparent, grandchild, or step-grandchild
The spouse of their child; Their brother or sister
Their relative who is dependent on them for care or assistance
Family Caregiver Leave - up to 8 weeks of unpaid leave for employees to provide care and
support to a family member with a serious medical condition.
NEW: Critically Ill Child Care Leave – up to 37 weeks of unpaid leave to provide care to a
critically ill child.
Crime-Related Child Death and Disappearance Leave - up to 52 weeks of unpaid leave for
parents of a missing child and up to 104 weeks of unpaid leave for parents of a child that has
died as a result of a crime.
If passed, the leaves would allow parents and other family caregivers to provide care and
support for loved ones without fear of losing their jobs. These leaves are in addition to the
current Family Medical Leave, which is available when a family member has a serious medical
condition with a significant risk of death occurring within 26 weeks. A doctor’s note would be
required for the Family Caregiver Leave and the Critically Ill Child Care Leave. Complementing
the new federal Helping Families in Need Act, employees covered by the Critically Ill Child Care
Leave and the Crime-Related Child Death and Disappearance Leave would be eligible to apply
for federal Employment Insurance benefits.
Brockville General Hospital Pastoral Care Education
549
Brockville General Hospital Pastoral Care Education
550
The Art of Possibility!
Don’t make assumptions!
Give everyone an “A”
Be a contribution
Lead from any chair
Be responsible for your own actions
Empower others
Don’t take yourself so seriously!
Accept the way things are
Don’t use winner/loser thinking
Look for shining eyes!
Don’t attempt to change others, only change yourself
Don’t get on the downward spiral
Look for the possibilities!
Give way to passion
Have the best _________ ever!
Have a vision, enroll every voice!
Become part of “we”; share empowerment
By Rosamund and Benjamin Zander
2002, Harvard Business School Press,
Boston Massachusetts
Brockville General Hospital Pastoral Care Education
551
Sharing the Caring
Mary Slingerland, Palliative Care Volunteer
Southlake Regional Health Centre
Here is another story about Away in a Manger, it is a true story told by a hospice
volunteer: “Every year a few evenings before Christmas, Hospice Volunteers
gather with staff to sing carols in the palliative care units. On one of our caroling
evenings, I had arrived early in order to visit a friend in another part of the hospital.
Later, as I waited at the elevator to go the palliative care unit, Muriel, another
volunteer joined me. Muriel had also been to visit a friend and she was feeling quiet
saddened because her friend was now unconscious. Muriel hadn’t been able to get
any response either by touching or speaking her friend’s name. After our singing on
the unit, Muriel asked a few of us to go with her to her friend’s room “just to sing one
carol”. Three of us joined her and gathered around her bed. Again, Muriel could
evoke no response from her friend. We decided that Away in a Manger would be a
suitable choice and softly, we began to sing. Then something happened that still
brings a certain moistness to my eye and a lump to my throat. To our utter
amazement, Muriel’s unconscious friend joined us, singing along through all
three verses! We held each other’s hands and wept. At the end of the carol, Muriel
took her friend’s hand and spoke her name. There was no answer. That response
brought Muriel some comfort and she believed that we had also brought her friend
some comfort. Muriel’s friend died the following day.
Proof again that God is very much present to walk with us even through death, to
eternal life.
**
~the last sense to go is ‘hearing’~
Brockville General Hospital Pastoral Care Education
552
Oscar the Cat
I love the story about how the cat was an important part of the health team.
Perhaps you have read about Oscar, as he has been made famous in the news.
Dr. David Dosa who also worked on Oscar’s team, wrote about him in the New
England Journal of Medicine July 26, 2007, and validated this story. (paraphrased)
Oscar lives in a nursing home in Rhode Island where many of the residents
have dementia. He has an uncanny ability to detect when a resident is nearing
death. No one knows exactly how or why, but Oscar can sense when a resident is
nearing the last hours of life. He pads down the hall to their room, climbs up on the
bed and curls up near the dying person! He has been successful in predicting
approaching death in many cases.
The health team pays attention to Oscar’s
actions, and when they see him spending extra time with a resident, they take
notice. They call the family to let them know their loved one is passing away.
They feel Oscar provides comfort and solace, and that companionship is very
much appreciated. The local hospice has given him his own wall plaque, so that he
knows he is a valuable part of the health team. It reads, “For his compassionate
hospice care, this plaque is awarded to Oscar the Cat.”
One time a mother and her child were visiting an elderly woman who was
bedridden. Oscar came in the room and climbed up next to the lady. “Why is Oscar
here?” the little boy asked. His mom answered, “He’s here to help Grandma get to
heaven.”
Brockville General Hospital Pastoral Care Education
553
Alone!
By Lea Hamblett
I know I’m sick and must be here,
But these people I don’t know.
They care for me, and keep me fed,
Oh help, I’m so alone.
The days drag by, I still feel ill,
I really want to go home.
This room is nice, but it’s not mine,
Oh help, I’m so alone.
Today a light shone in my room,
Someone else I did not know.
They said they were just visiting,
Now, I’m not so alone.
They said the worked with Spiritual Care,
Would I like them to go?
“Oh no”, I said, “Please stay with me”,
Now, I‘m rarely alone.
I’m feeling somewhat better now,
And can leave my bed and go
To sing and pray with friends I’ve made.
Now I’m not alone.
Thank you, to the staff and every single Volunteer and the Spiritual Care
Department for their dedication to caring for the whole person.
Brockville General Hospital Pastoral Care Education
554
Trust in Providence
Call to presence:

The God who provides us with life lives within us.

God of all goodness be here with us,

As we pray, let us rest in God.
Philippians 4: 6-7
Joy is a true sign of God’s presence and blessings. It comes with our trust in Gold’s
providence. God is here. God is with us. So, as Saint Paul told the Philippians,
“Never worry about anything: but tell God all your desires of every kind in prayer
and petition shot through with gratitude, and the peace of God which is beyond our
understanding will guard your hearts.”
Instead of worrying, in a moment of silence tell God some of your desires and ask
for more trust in God’s providence.
{Pause}
God, you are listening to what we want. May we be open to what you want for us –
joy and peace.
Brockville General Hospital Pastoral Care Education
555
Prayer for Life
Spirit of life,
Infinite weaver of the fabric of our lives,
take up from each of us our raveled threads:
the golden threads of our hope and our best intentions,
the deep midnight blue of our disappointment and despair,
the warm yellow strands of our affections,
and the hot reds of our passions,
the dull gray of our regrets and the flowing silver of
remembrance.
Take up all these, we pray,
our fears and yearnings,
Join the threads of our lives
with the threads of generations gone before
and generations yet to come.
Make of all these a tapestry
both fine and rough,
both humble and noble.
Lets us glimpse in your grand and mysterious design
your urging us toward Life, more Life,
and yet again, more Life.
and we heed your call.
Reverend Kathy Reis
Interim Assistant Minister
Unitarian Universalist Church of Marblehead
Marblehead, Massachusetts
Brockville General Hospital Pastoral Care Education
556
Come as you are
By Paul Gurr
Come as you are, that’s how I want you,
Come as you are, feel quite at home;
Close to my heart, loved and forgiven,
Come as you are; why stand alone?
No need to fear, love sets no limits,
No need to fear, love never ends,
Don’t run away, shamed and disheartened,
Rest in my love; trust me again.
I come to call sinners, not just the virtuous,
I came to bring peace, not to condemn,
Each time you fail to live by my promise
Why do you think I’d love you the less?
Come as you are, that’s how I love you;
Come as you are, trust me again;
Nothing can change the love that I bear you,
All will be well, just come as you are.
The best prayer is to rest in the goodness of God, knowing that, that goodness can
reach right down to our lowest depths of need.
Julian of Norwich
Brockville General Hospital Pastoral Care Education
557
Pebble of Thought
In this wonderful world we live in…….
We have taller buildings, but shorter tempers; wider freeways, but narrower
viewpoints.
We spend more, but have less; we buy more and enjoy it less. We have bigger
homes and smaller families; more conveniences, but less time.
We have more degrees, but less sense; more knowledge, but less judgment; more
experts but more problems; more medicine, but less wellness.
We spend too recklessly, laugh too little, drive too fast, get angry too quickly, stay
up too late, get up too tired, read too seldom, watch TV too often and give thanks in
prayer far too infrequently.
We’ve learned to make a living, but not a life. We’ve added years to our life, but not
life to our years. We have been all the way to moon and back, but have trouble
crossing the street to meet our neighbour.
We’ve done larger things, but not better things – we’ve cleaned up the air, but
polluted the soul, we’ve split the atom, but have barely dented our prejudices.
We write more and plan more but learn less. We learned to rush, but not to wait; we
have higher incomes, but lower morals; more food but less appeasement: more
acquaintances but fewer friends.
We make more effort, but endure less success. We build more computers to hold
more information and to produce more copies than ever, but end up with less
communication.
We’ve become long on quantity, but short on quality. These are the times of “fast
food” and slow digestion; tall men and short character; steep profits and shallow
relationships.
We have more leisure and less fun; more kinds of food but less nutrition. These are
the days of two incomes and fancier houses, but more broken homes. There is
much in the showroom and nothing in stock. So where are you in this picture…think
about it.
Embrace your faith, family, friends and cherish your life dearly. It’s only one you’ve
got. It has been said that your life is a gift from God…how you live your life is
your gift back to Him.
Brockville General Hospital Pastoral Care Education
558
Do You Remember The Call?
Do you remember the call?
When did you hear your name out loud?
Can you remember the word that you heard
when the story began in you?
Do you remember the call?
The call into full red rose of day?
Can you remember the vision, the dream,
and the courage to love for life?
Listen, remember, catch glimpses of Summer,
and a blossomed gentleness, radiant with light,
and you were dancing, full and given to life,
In the name of Love.
Do you remember the call?
and youth letting go, golden to brace,
trusting the journey and all it would be,
born of love and fidelity?
Listen, remember, catch glimpses of Autumn,
of all that’s surrendered in wisdom and hope,
for it is given for the “yet-to-become”’
In the name of Love.
Do you remember the call?
Sung in the silent depths of you?
Know that its power is deep in your heart,
as a fire, a song, a dream.
Listen, remember, catch glimpses of Winter,
touch new life in hiding and set it ablaze,
and let it grow, into fullness of life,
In the name of Love.
Brockville General Hospital Pastoral Care Education
559
Mother Teresa’s Poem
People are often unreasonable, illogical and self-centered;
Forgive them anyway.
If you are kind, people may accuse you of selfish, ulterior motives:
Be kind anyway.
If you are successful, you will win some false friends and some true enemies:
Succeed anyway.
If you are honest and frank, people may cheat you:
Be honest and frank anyway.
What you spend years building, someone could destroy overnight:
Build anyway.
If you find serenity and happiness, they may be jealous:
Be happy anyway.
The good you do today, people will forget tomorrow;
Do good anyway.
Give the world the best you have, and it may never be enough;
Give the world the best you’ve got anyway.
You see, in the final analysis, it is between you and God,
It was never between you and then anyway!
Mother Teresa
Missionaries of Charity
Aug. 27/1910 – Sept. 5, 1997
Aug. 27/ 1910 – Sept. 5 1997
Brockville General Hospital Pastoral Care Education
560
Tears
The fruit of faith is love, and the fruit of love is service.
Tears, and the ability to shed them, are a gift, truly a gift. To be able to express
self, the emotions, as it were, so fully, so completely, is not a frustration, is not an
irritation, but rather is a celebration.
Weep not only I sorrow, but weep with joy. It is the water of the soul. That gift has
been earned, and is the reward for the struggle – not on this plane, at this time, but
in other times. For there has been much suffering, yet there has been love and
growth.
So fight them not, but rather celebrate the joy of them, the truth they represent, and
the purity of them.
Do not cast your eyes behind, but look only ahead. Be thankful for what is given
unto you, and know that it is right and true.
Love who you are; celebrate what you are – for you are magnificent. You are
imperfect; yet you are perfect in your imperfection, and the Creator loves you as you
are.
David L. Silver
Brockville General Hospital Pastoral Care Education
561
What a Wonderful Way to Explain It!
A sick man turned to his doctor, as he was preparing to leave the examination room
and said,
“Doctor, I am afraid to die. Tell me what lies on the other side.”
Very quietly, the doctor said, “I don’t know.”
“You don’t know? You, a Christian man and a doctor, do not know what is on the
other side?”
The doctor was holding the handle of the door: on the other side came a sound of
scratching and whining, and as he opened the door, a dog sprang into the room and
leaped on him with an eager show of gladness.
Turning to the patient, the doctor said, “Did you notice my dog?”
He’s never been in this room before. He didn’t know what was inside. He knew
nothing except that his master was here, and when the door opened, he sprang in
without fear.
I know little of what is on the other side of death, but I do know one thing…..
I know my Master is there and that is enough.”
Brockville General Hospital Pastoral Care Education
562
My Patient
As I sit with my patient in the dead of night
Her breathing illuminated by one dim light
I see her lie there so still with her hand in mine
While her life runs out with the sands of time.
I look down at her face and see pain fear and strife
And know that I will remember her the rest of my life.
I think to myself as the minutes tick by
Who will wait with me when it’s my time to die?
Will it be someone who loves me, whose memories I share
Or will it be a stranger like me who is paid to care?
Perhaps no one will be with me on my last night or day
No one to give comfort as I slip away.
Hours later I look at the window and see it is dawn,
Then when I look back at my patient I see she has gone.
He suffering has gone too and there in its place
A look of peace and contentment has come to her face.
I say goodbye to my patient as they take her away
Then run to the window to greet the new day.
Someone waits for me at the hospital gate
Someone I care for, I don’t want to be late
I can no longer help her, and so I must leave
Life is for living, I have no time to grieve
Barbara Crompton Reeder ’58
Brockville General Hospital Pastoral Care Education
563
SPECIAL ANGELS
We have Special Angels in our midst
Too many of us are unaware
They are very dedicated people
They spread the word of God—They Care!!!
They come from many walks of life
Different faiths, cultures, gender and race
Clergy, lay ministers, volunteers, women and men
All messengers for God—Whatever the case!!!
They do their work with passion and zeal
Always there to hold a hand and pray
Bringing hope to people who believe
Trusting their God to lead the way!!!
These Special Angels fall under Spiritual Care
They quietly do God’s work on earth
Helping those who have a cross to bear
By prayer, love, hope and mirth!!!
We cannot do without you
You’re truly an inspiration to all
Doing God’s work is a privilege
It isn’t everyone who gets that special call!!!
It is indeed an honour
For me as a humble volunteer
To work with Special Angels
On this spiritual journey God steers!!!
May God bless you always
In this service when you so willingly give
We all work for the same Boss
In this earthly life we live!!!
Maureen LeClair
Brockville General Hospital Pastoral Care Education
564
June 1 2010
The Eight Beatitudes of Leadership
Blessed – is the leader who has not sought the high places, but who has been
drafted into service because of ability and willingness to service.
Blessed – is the leader who knows where he/she is going, why and how to
get there.
Blessed – is the leader who knows how to lead without being dictatorial, true
leaders are humble.
Blessed – is the leader who seeks for the good of the most concerned and not for
the personal gratification of his/her own ideas.
Blessed – is the leader who develops leaders while leading.
Blessed – is the leader who marches with the group and interprets correctly the
signs on the pathway that lead to success.
Blessed – is the leader whose head is in the clouds, but whose feet are on the
ground.
Blessed – is the leader who considers leadership an opportunity for service.
Brockville General Hospital Pastoral Care Education
565
Leadership for Champions
Personal

You have 1500+ thoughts per day. Make most of them positive

Be aware of your “automatic pilot”. Does it need correction?

Focus less on yourself and more on the world around you

Learn to listen to your own body language

Authenticity is about being transparent

If you try to change someone, it means you don’t really like them

Make a chart of personal characteristics:

Strengths / Weaknesses / Challenges / Opportunities

Identify external (shared) pleasures and internal (personal) pleasures

The image in the mirror does not always reflect the feelings inside the body

“Pay it forward”. Do something nice for three people and ask each of them to
do it for three others

Your self-value should not be tied to what you do

Be a ‘being’ not a ‘doing’

Everyone else’s happiness does not depend on me; it depends on
themselves

Keep an “encouragement” file of notes and comments sent to you

When you have good self-esteem, you can easily give power away

I am continually evolving: a work in progress

You are responsible only for your own behaviour

The theory of reciprocity is that you get what you give
Lifestyle & Home

The destination of passionate living is ‘quality of life

Work/home balance is created—it is not left up to chance

Do not call it work/life balance! Call it work/life integration!

These two spheres can be mutually supporting: eg: working from home, flex
hours
Brockville General Hospital Pastoral Care Education
566

I don’t mind the distance if I am enjoying the journey

It doesn’t have to be “all or nothing”. It can be a little bit now and a little bit
later.
Lifelong Learning

Be a lifelong learner!

Colour outside the lines, increase creativity

Push the boundaries of your ‘comfort zone’. The ‘stretch zone’ is also called
the ‘courage zone’

Ask meaningful questions

Trust your instincts

Be vision-driven and solution-oriented

If you believe that you are the expert, and behave like you are the expert,
then you will be perceived as an expert
Vision & Dreams

It takes 28 consecutive days of practice to make a habit

Dream of the “best case” scenario…. In a perfect world, I….

‘anticipation’ is good for you—it is called HOPE

Proactive resilience means you can anticipate change

What song lyrics speak to you? What do you dream about?

Begin with the end in mind

Make a list of 50 of your goals: domains are: family, travel, home, finances, work,
church, health, social, volunteering, hobbies etc.

List the desired outcome, the cost of each goal (time, money, resources) and then
prioritize. Review this plan monthly

There are no coincidences in life; each event has a purpose

Dare to Dream (Imagination)

To Be a sponge (Inspiration) = Innovation

Break the rules (Ideation)
Brockville General Hospital Pastoral Care Education
567
Difficulties & Obstacles

The first step is the hardest. Sometimes we need a push

There are no mistakes, only lessons

Try surrendering control

Step back and do not give in to the ‘knee-jerk’ reaction

Fix your brakes and not your accelerator

Negatives will always be there, but there is no need to constantly describe them to
other people!

FEAR is False Evidence Appearing Real

Break overwhelming projects into small do-able pieces

With a difficult choice, ask “What’s the worst thing that could happen to me?”

Say “Why Not?” instead of “Why?”

Dump the “should”. Either do it or dump it.

To avoid an argument, acknowledge hearing the other person before changing the
subject
Wisdom

Intuition is a natural and accessible tool—trust intuition, be aware of your own
intuition. Quiet the brain chatter. Intuition leads to wisdom

“Gratitude” is short for ‘great attitude’

We don’t always act on what we know

Life is unfolding the way it should

Don’t live for the future, live for today

Take delight in small ordinary things

Keep your parachute ready

When someone speaks to you from the head, respond with the head

When someone speaks to you from the heart, respond with the heart

When someone speaks to you from the wallet, respond with the wallet

You always have two choices: take it or leave it. You can stay where you are, or
choose to change

Build reserves of: time, energy, money & love
Compiled by Janet Stark
Brockville General Hospital Pastoral Care Education
568
The Long View
By Monseñor Oscar Romero
It helps, now and then, to step back and take the long view.
The kingdom is not only beyond our efforts,
it is beyond our vision.
We accomplish in our lifetime only a tiny fraction
of the magnificent enterprise that is God’s work.
Nothing we do is complete,
which is another way of saying that
the kingdom always lies beyond us.
No statement says all that could be said.
No prayer fully expresses our faith.
No confession brings perfection.
No pastoral visit brings wholeness.
No program accomplishes the church’s mission.
No set of goals and objectives includes everything.
That is what we are about:
We plant seeds that one day will grow.
We water seeds already planted, knowing that they hold future promise.
We lay foundations that will need further development.
We provide yeast that produces effects beyond our capabilities.
We cannot do everything and
there is a sense of liberation in realizing that.
This enables us to do something, and to do it very well.
It may be incomplete,
but it is a beginning, a step along the way,
an opportunity for God’s grace to enter and do the rest.
We may never see the end results,
but that is the difference between the master builder and the worker.
We are workers, not master builders,
ministers, not messiahs.
We are prophets of a future not our own.
Brockville General Hospital Pastoral Care Education
569
Brockville General Hospital Pastoral Care Education
570