Title of Course: Challenges in Aging: Managing Loss, Complaining, and Spirituality CE Credit: 3 Hours (0.3 CEUs) Learning Level: Intermediate Author: Donald R. Koepke, MDiv Abstract: Aging brings with it questions of meaning elicited by loss. This course explores three areas common to geriatric patients: complaining as a window to a patient’s needs, loss as an opportunity to explore issues of meaning, and spirituality in aging. This “suite” of three topics provides a thoughtful and caring perspective that encompasses the biological, social, and psychological aspects of aging and loss in long‐term care. Multiple case illustrations and suggested techniques contribute to a “how‐to” learning experience that will increase the insight and effectiveness of caregivers. Learning Objectives: 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Define caregiving from a perspective of managing physical or cognitive loss Analyze patient or client limitations from a cultural and spiritual standpoint Identify approaches for coping with and integrating loss List steps a caregiver may use to assist an individual in managing loss Name methods of discerning the meaning behind a complaint Describe five spiritual insights that can ground a complaining person List methods of spiritual caregiving for complaining persons Describe the issues related to spirituality and aging in the long‐term‐care setting Differentiate between spirituality and religion List ways to provide spiritual care without a chaplain Posttest: You can access the posttest for this course 24/7 from your personal account on our website. We recommend printing the posttest for use while reading the course materials and then submitting online when ready. 1. Login to your account @ www.pdresources.org 2. Go to My Courses 3. Attend course 4. Click view/print/take test link to open test 5. Click print test link in top right corner to print *Please Note: You will no longer be able to download this course pdf once you pass the online posttest. If you would like to save this document, please do so prior to taking your test online. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 1 of 37 Challengges in Aging: M
Managin
ng Loss, Compllaining &
& Spirittuality
I. M
Managing Lo
oss Loss—
—it is nothingg new. We exxperience it th
hroughout ou
ur lifetim
me. Many of us have child
dhood memorries of a friend’s moviing away. Thee picture of m
my friend Ben in the back seat of hiss family’s car,, waving good
d‐bye to me, knowing we woulld never see o
one another aagain, remain
ns burned into
o my m
memory. Most of us can re
emember the loss of a firstt love, a big footballl game, a job
b, or the loss o
of loved oness in death
h. As we grow older,, the losses se
eem bigger, m
more pervasivve, and h
harder to han
ndle. That is p
probably becaause losses later in lifee are sometim
mes permane
ent. When wee were youngeer, we often were able to replace what we had
d lost. A friend
d moves awayy, and we gaiin a new frien
nd. A job is losst, and we over is lost, and we find a new lover. Ass we grow old
der, howeverr, the losses b
become more persistent, get aa new job. A lo
chron
nic, and devastating. It see
ems that whaat we lose can
n no longer bee replaced: our energy, mo
obility, memo
ory, and abilitty to care for ourselves. Care
egiving Is Maanaging Losss Careggiving can be described ass the task of m
managing losss. As caregiveers we meet p
patients at thee point in theeir lives when they are experiencing many lossses. We seekk to be the legs for the onee who cannott walk, the arrms for the on
ne who cannot reach, the strength for the one who has become weak, and th
he eyes for th
he one who caannot see. Th
hat is the physical side of caaregiving, the side we see, the tasks thaat we perform
m. It wears uss out at the en
nd of a long d
day and saps our p
physical energgy. But there is another element in the equation, an
nother aspectt of caregivingg to consider—
—that of the spiritt. Now,, I am not using the word “spirit” as a ““church‐word,” although iff you do happ
pen to be partt of a faith grroup, the word
d carries addittional meanin
ng that is consistent with w
what I mean. The spiritual side of careggiving is the p
part of us thatt eitheer embraces tthe task or be
ecomes discou
uraged. It hass more to do with attitudee than with th
he amount of physical energgy one has. TTo get tired in the body is o
one thing, butt to be “bonee‐tired” is ano
other. To be ““pooped out” and in need of a b
break is one tthing; to feel so tired that it threatens tto overwhelm
m the desire to
o care for som
meone is another. The Myth of Beiing Perfect aand the Reality of Loss
A cou
uple of years ago I was in cchaplaincy traaining at UCLA Medical Ceenter when I w
was assigned to make a prresentation on th
he spiritualityy of suffering. One Saturdaay morning I traveled to Fu
uller Seminaryy in Pasadenaa to do some research in their library. Not b
being a stude
ent, I checked in at the fron
nt counter, w
where a deligh
htful gentleman from Nigeeria met me. When I told him m
my name and that I was wo
orking as a ch
haplain at UCLA Medical Center, the maan quipped, ““What a wond
derful ministrry. Americanss don’t suffer very well.” A
Americans don
n’t suffer veryy well or hand
dle loss very w
well. We do not liike to conced
de defeat. Ratther, “Go West, young man,” or “Onwaard and upward” is our batttle cry. o my wife and
d I were expeccting our firstt child. That w
was before the days of eassily knowing the gender of A “feew” years ago
your unborn child
d. I was a pasttor at the time, and many people asked
d me, “What d
do you want, a boy or a girl?” My respo
onse was similar to that off many persons, “I don’t caare what gender, just as lo
ong as he or sshe is perfect.” © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 2 of 37 Americans h
have a love afffair with perffection. We lu
ust after a 30
00 game in bowling. Wee marvel wheen a baseball pitcher throw
ws “a perfect game.” We expect life tto be perfect. We expect to
o have the “A
American Dream” with 2.5
5 children; a h
house with a white picket fence—an idyyllic life that includes spouse, children, job, and success. Even our religio
on challenges us to be perfect and to follow God’s laws, to o
offer perfect ssacrifices thatt are pure and unblem
mished. We likke to put our best foot forw
ward, dress n
nicely for church, and even die at h
home surroun
nded by friends and familyy. When d. When we ggo to the docttor we expectt illness strikees, we expectt to be healed
that he will prescribe a p
pill or perform
m a proceduree that will restore us to good health. Television aand radio advertisements b
bombard us w
with the samee them
me, “Have a heeadache? Takke this pill.” ““Upset stomach? Take thiss remedy.” “Sagging eyelids or flabby th
highs? A little cosm
metic surgery is a quick wayy to health an
nd happiness.” And we havve all seen th
he ads that suggest that lifee is great, as long as you have yyour health. But w
what happenss when we do
on’t have our health, we caan’t remember what we h
had for breakffast, pain resttricts our abilitty to move, an
nd “bad thinggs happen to good people,,” bad things that will neveer really go aw
way? Many aask, “Why me? What did I do
o to deserve tthis?” If they are a part of the faith trad
dition, they m
may wonder, ““Why has God
d deserted ove me anym
more?” Person
ns who are no
o longer able to walk, thinkk, or hear aree called “disab
bled,” less me? Doesn’t He lo
than able, and thu
us, of less worth. We wantt—no, we exp
pect—life to b
be perfect; an
nd when it isn
n’t we becom
me angry, frustrated, or even despairing. A Sp
piritual Persp
pective on LLoss nsidered that maybe the so
o‐called perfeect life is not tthe human liffe; that just m
maybe the losss we Havee we ever con
experience and seeek to managge is not an ab
berration but is, instead, a normal part of life and an
n essential eleement in perso
onal growth? An example comes out off my faith trad
dition. My faaith tradition, as well as th
hat of Judaism
m, holds a porrtion of Scriptture in comm
mon. The first book of these Sacred Scrip
ptures is the b
book of Genessis that describes in what I believe are poetic and im
maginative terrms, the essence of what it meeans to be human. In the second chapteer of Genesis life is ideal. TThe man and woman weree connected. TThey could eat w
well. They eveen named the
e animals, sho
owing power,, influence, an
nd dominion. But more thaan that, they were conn
nected to each
h other. Gene
esis 2:25 statees: “And the m
man and the woman weree both naked and unasham
med.” Nakeed—open, recceptive, intim
mate, without masks or gam
mes. Naked and unashameed—no guilt, no impulse to
o hide, no sham
me. Doesn’t th
hat sound ide
eal? But what made it ideal? Our aanswer is found in the thirrd chapter. In the interchange with the tempter the woman is askked, “Did God
d say that you
u should not eat of anything in the garden?” ““No,” the woman said, “w
we can eat anyything in the ggarden excep
pt for the treee that is in the midsst of the garden; neither sh
hall we touch
h it, lest we die.” “You shall not die,” thee serpent ressponded, “Instead you will b
be like God, kknowing good
d and evil.” “A
And so,” the n
narrator conttinues, “since the tree wass in the midst of the garden and
d it looked goo
od for food and was a deliight to the eyyes...she ate, aand the man ate.” Notee that the treee of the know
wledge of good and evil waas in the midsst of the gardeen. It was righ
ht there in the middle wherre the man an
nd woman wo
ould pass it aggain and agaiin. Also the trree looked great. It could aalso make a p
person wise. (How
w great is thatt?) What mad
de Genesis, ch
hapter two, so idyllic was n
not that the m
man and wom
man received everything they wanted. It was that they h
had accepted
d a “no” in theeir life. They aaccepted thatt they could n
not do everything. They embrraced the fact that they were not God. What made tthe man and woman perfeect was embrracing their lim
mitations, accep
pting that theey didn’t have
e all the answ
wers, and thatt there were tthings that haappened to th
hem that werre beyond their knowing and
d thus beyond
d their contro
ol. © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 3 of 37 Isn’t that what loss, particularly a loss that doesn’t go away, teaches us? Isn’t that what we resist hearing? The losses that we experience confront us with a “no” in life that we cannot ignore or deny. When we were younger we could just skirt around the “no’s” and emphasize what we could do. I cannot play the piano. I love music and would like to play the piano, but instead I sing and listen to music. This satisfies my desire and need to create music, but someday I will reach a time when I will no longer be able to sing. Some‐
day, if I live long enough, I will lose my wife whom I dearly love; I will lose my job to retirement; I will perhaps even lose my memory, since dementia runs in my family. But all is not lost. To be human is not to be perfect. In fact, I have never been, nor ever will be, perfect. To be human is to be growing, changing, and becoming. I am more than my ability to sing or remember or be productive. I am human. Loss teaches me that truth by experience, even if I don’t want to hear it. I can close my ears to the message and choose to be in denial. I can become a grumpy old man and rail at my limitations. I can seek to ignore the fact that “I can’t,” by not acting my age and seeking to act younger. But I can never escape the fact that I am not, and never have been in control of my life, that I am not perfect. “A more realistic goal than perfection,” writes Ernst Kurtz in his book, The Spirituality of Imperfection, “is to refuse to lose heart when things are going badly and also refuse to become complacent when things are going well.” (Kurtz, 1992) Nancy Eiesland, in her work entitled The Disabled God, notes that physical health is contingent and often short‐lived. ”Nonetheless, the experience of loss, the reality of disability, is an ever‐present possibility for all people. A greater than 50 percent chance exists that an individual that is currently able‐bodied will be physically disabled, either temporarily or permanently” (Eiesland, 1994). Limitations in life are never easy and should never be minimized or patronized. It hurts to be in pain. It’s frustrating not to be able. It’s maddening to be dependent. And, as caregivers, sometimes it is not pleasant to be someone else’s legs, or arms, or memory. There’s Gold in Them Thar Hills! As the Gold Rush prospectors used to say, “There’s gold in them thar hills.” Embracing the loss opens us to a different way of life that offers different gifts—gifts that we would not have except for the losses we experience. Embracing the loss, facing and learning from what ails us is never easy, but it is affirming our bodies for what they are in a simple, honest way that is palpable, not tragic. It affirms life as it is, not as we want it to be or as society expects it to be. To use the words of Nancy Eiesland, embracing our loss allows us to “see clearly the complexity and the mixed blessing of life and bodies without living in despair.” (Eiesland, 1994) Embracing loss is never easy, but neither is the despair that comes from railing at what cannot be changed. For real suffering—bone‐bending, spiritual suffering—is clinging to what was, rather than receiving what is and what is to be. Like a trapeze artist, one has to surrender what has been, letting go of the bar to which you are clinging, before you are able to grasp the bar that is coming and move forward, rather than going back and forth over the same territory repeatedly. In her book, Kitchen Table Wisdom, Rachael Naomi Remen writes, “I was thirty‐five years old before I understood that there is no ending without a beginning. That beginnings and endings are always right up against each other. Nothing ever ends without something else beginning, or begins without something else ending. Perhaps it would be easier if we had a word for it. Something like, ‘endbegin’ or ‘beginend’...I was thirty‐five years old and I had never trusted life before. I had never allowed any empty spaces. Like my family, I had believed that empty spaces remained empty. Life had to been about hanging on to what you had. Anything I had ever let go of had claw marks on it. Yet, at [thirty, sixty, ninety] this empty space had become different. It held all the excitement and anticipation of a wrapped [birthday] present” (Remen, 1996). © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 4 of 37 Whereas our culture suggests that all loss is bad and should be avoided at all costs, spirituality proclaims that loss is a part of the unfolding of life; that though painful, can bring growth. Whereas our culture implies that all loss should be eschewed, and when it can’t be, its presence is to be grieved, spirituality points to an embracing of loss, learning and expanding through loss. Loss is not to be sought. People don’t need to seek it; it unfailingly enters everyone’s life at some point. We can lament its coming and seek to cling to what has been, or we can grieve the loss of what has been, even as we look to the new thing that is entering our life because of the loss. Or to use Rachael Naomi Remen’s thought: As we experience an end, we can look for the beginning that always accompanies it if one is willing to release what was and embrace that which is becoming. Moving Towards an Enhanced Expectation of Healing Embracing the loss by believing that there is life in the midst of limitations, that there is indeed gold in these seemingly barren hills of loss and beginnings in the midst of endings, is a matter of expanding our understanding of what it means to be healed. Usually when a person seeks healing from an illness or even a loss they seek a cure, a restoration of life to the way it was. Healing to many is only a return to being able to walk or see, a return of strength, vitality, and vigor of youth. To be sure, that kind of healing happens, sometimes by medical means, sometimes by an encounter with divine things. Sometimes people are indeed cured, restored, or healed, and what was lost is returned. But I contend that there is an additional definition of healing that does not include a cure. Sometimes we must learn to cope. Now, by coping I do not mean that we resign ourselves to what is because we cannot change it. Coping is not something we do because we have no other choice. Truly coping means taking the loss and incorporating it into our life, not necessarily making our life better, but definitely different. To cope with loss is to “grab it by the tail” and hang on to it until it releases the blessing that it has to share. In her book, Counting on Kindness, Wendy Lustbader writes of a woman stricken with multiple sclerosis who refused to move her bedroom from the second floor of her home to the first. Each day she would walk up the stairs with great pain and effort, but it was important for her not to give in to the disease. Each day, however, it seemed harder to climb those stairs than the last, until one day she just had to stop and sit and rest right there in the middle of the staircase. How she hated herself for being so weak, powerless, and limited! As she sat on the stair, she cried and cried. When she finished crying, she just sat back to regain her composure. She looked around, and suddenly she was overwhelmed, for as the light of the sun poured into that narrow stairwell, she saw the most amazing displays as shadow and window combined to create a symphony of shape and color. “It was one of the most beautiful things that I had ever experienced,” the woman later wrote. “And to think that I had lived in that house for years and had never experienced it before. Normally, I just used the stairs for walking, but my MS forced me to sit and look and see. It was just beautiful, and without my MS I would never have seen it.” Nancy Mairs, also living with MS, is a woman who recognizes and comes to terms with the difficulty that loss brings. She lives life not as a martyr, not in anger or frustration, but with the resolve of someone who realizes that life is filled with blessings and curses and that it is sometimes hard to differentiate between the two. “At the same time,” she writes, “if a cure was found, would I take it? In a minute. I may be a cripple, but I am only occasionally a loony and never a saint. I’d take a cure; I just don’t need one. A friend who also has MS startled me by asking, ‘Do you ever say to yourself, “Why me, Lord?”’ ‘No, Michael,’ I replied, ‘I don’t, because whenever I try, the only response I can think of is, “Why not?” If I could make a cosmic deal, whom would I put in my place? I might as well do the job myself, now that I am getting the hang of it” (Eiesland, 1994). There is gold in the hills of loss. Limits and loss, while being challenging, can also be affirming, even helping us to grow. Healing comes not just with cure but also with coping. But sometimes both cure and coping are far off. That’s when care comes to the fore. For when the loss is great and seemingly final (There is no cure.); when we feel frustrated and angry (It’s called “mourning the loss.”), there can be healing in care. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 5 of 37 Remeember when we were you
ung and we feell down and sscraped our kknee? We ran
n with tears ro
olling down o
our cheeks to that person whom
m we could co
ount on for co
omfort. And tthat person, tthat caregiverr, said to us, ““Let me kiss itt and make itt feel b
better.” Now,, did that kisss have medicinal qualities tthat brought cure? Hardlyy! Did that kiss bring us a d
different persp
pective? Perh
haps, because
e the kiss told
d us that the p
pain was onlyy temporary, tthat it would go away. Butt the deepestt cure came from ju
ust being reco
ognized, affirm
med as beingg important and valued, baathed in a sim
mple love exprressed in a gentlle kiss. Instan
ntly the pain ssubsided and we felt betteer. We had beeen affirmed, received, and
d loved. The loss became bearaable, becausee we did not h
have to experrience it alone. w perspectivee, a spiritual p
perspective that looks beyyond limitatio
ons and loss aand shares a h
hope in possib
bilities, is the A new
gift that a caregiveer can give to
o a person exp
periencing evven the ultimaate loss—deaath. A number of years ago
o I heard Dr. Elizab
beth Kubler‐R
Ross tell the sstory of a child in a cancer unit who kep
pt ringing his call light at night. The firstt time the child rang, the nurse went into
o the room, zipped down the opening to
o the o
oxygen tent, aand heard her young patieent ask, “Whaat is going to happ
pen when the tent catchess on fire?” “Th
he tent is not going to catcch on firre” the nursee replied. “It iss quite imposssible, so roll o
over and go tto sleep
p.” The nurse barely return
ned to the nursing station when the child’s call light went on again.. For a second
d time the nurse went into
o the room, zipped down the oxyygen tent, and listened to her young chargge ask, “Whatt is going to h
happen when the tent catcches on fire?”” The n
nurse, who w
was having a d
difficult night, said with a liittle more forceefulness and aauthority, “Yo
our tent is not going to cattch on fire. Theree are many saafety switche
es that make iit impossible. Roll over and
d go to
o sleep.” By th
he time the nurse had retu
urned to the n
nursing statio
on, she rrealized what it was that th
he child was rreally asking. The child was not aasking logical,, rational, me
edical questions but ratherr a question o
of the h
heart, of the sspirit. So this wise nurse ju
ust stood besiide the call lightss for a moment and, sure e
enough, her little patient’ss light went o
on for th
he third time.. Going into the room, thee nurse zipped
d open the oxygen tent. “What’s going to happen when
n the tent cattches on fire??” the liittle voice askked. The nursse smiled, gavve the child a big hug, and said, “I’ll be there.” And the ch
hild rolled oveer and went to sleep. Somee people wou
uld call this exxchange just ggood nursing psychology, or being attentive to the n
needs of the p
patient. It is that, but it is more. It is providing the care tthat is healingg, the care that says, “I’ll b
be here for yo
ou,” when theere is nothingg moree that can be said. It is offe
ering a new reelationship, aa new beginniing, even as tthe old is slipp
ping away. It is touching the sspirit, the esseence, and the
e heart. It is b
being a caring human beingg to another human beingg. It is embraccing the fact that healing is nott always cure;; it can also b
be coping; it ccan also be reeceiving care.
Finding the Gold
d in Loss This new perspecttive on loss does not comee through discussion. Ultim
mately, it can only be expeerienced. A caaregiver cannot give a persson a new sen
nse of life thaat overcomess the despair o
of loss. Each p
person needss to find it. A caregiver can’tt even point to a new perspective. New
w life and fresh
h perspectivees are discoveered, not giveen. The kkey to facing loss is in the belief that there will be a beginning aftter every ending. The key is believing that there is light at the end off the tunnel, e
even if everytthing at the m
moment seem
ms black. The key is lookingg for the new
w thing, expecting and waiting for it, evven if the waiting seems fu
utile and the llooking emptty. This stancee on life is mo
ore than pullin
ng oneself up
p by the bootsstraps or whisstling in the d
dark. Embracing the darkness and loss b
by feeling it, living it, and beingg it without d
despair or fear means belieeving that theere is gold in tthose hills. It is embracingg the fact thatt we are not perfeect and life isn
n’t always fair, but that wee are not alon
ne. © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 6 of 37 Margaret is a resident in a skilled‐care center where I once worked. She has end‐stage macular degeneration, hypertension, and arthritic knees that put her in a wheel chair. Yet Margaret does not look back, but forward. She can’t see, but she places herself near the front door and listens to other residents, the staff, and even guests of other residents who come through the door. If you want to know what’s going on in the facility, talk to Margaret. Tess is a resident in an assisted‐living facility. At ninety‐eight years old, her body has worn out; she has advanced macular degeneration, a poor heart, and aching bones. But her mind is sharp, and she never misses a chance to exercise that mind, even if it is by complaining to the staff or participating in “spell and define,” a game in which she is devastatingly good. As a former professional woman in an era before the women’s liberation movement, she had a mind of her own. She never looked back but always sought new ways of thinking and believing. Wendy Lustbader writes of a man named George Estabon, “It wasn’t till my stroke,” George notes, “that anyone ever saw me cry. Even when Ethel died, I didn’t shed a tear—after fifty‐two years of marriage. Well, I never did let it out, not while I had her, anyway. I just couldn’t do it. But five years ago, my stroke did it. The part of my brain that controls emotions got damaged and there I was, half paralyzed, blubbering like a baby. I think I must have cried seventy years worth of tears all at once. As terrible as it was, the relief was tremendous. My daughter says I’m acting like the father she always wanted. Can you believe it? I’m emotional. If there’s a spirit world, I know Ethel’s impressed” (What’s Worth Knowing, 2001). Healing may come through cure, a restoration of what has been, but healing also comes through coping, as we incorporate the loss into our lives and grow from it. Healing also comes through care, as we are connected with people beyond our own perceptions and allow ourselves to receive their concern. Thus the caregiver is the cheerleader, not the curer. The caregiver is the encourager, not the one who makes everything all right. The caregiver listens and brings compassion, love, concern, and support to patients, residents, or loved ones in their quest for healing and wholeness. Sometimes this encouragement comes by believing for a person who has lost faith. Often it is by not fearing the loss ourselves that we encourage others not to fear. This encouragement comes through as being human together, walking with each other as one limited human being with another. It was Viktor Frankl, the noted Viennese psychiatrist and holocaust survivor who noted, “Despair equals suffering [loss] without meaning.” It is to be the bearers of meaning, the believers in meaning, the directors to meaning, which is at the heart of senior adult healthcare today.” Five Steps for Managing Loss 1. Listen to the loss. The most important offering a caregiver can give is a listening ear. This means affirming another person’s feelings, anger, frustration, and loss, allowing her to vent, rage, be depressed, wonder why, and ask all those important questions that really have no answer. 2. Assist in giving voice to the loss. Listening is more than receiving information; it must be active, seeking to help the person give voice to the feelings that are the aftermath of loss. It is here that hurt, terror, and rage are expressed. The sharing of feelings must not stop at just venting, but become a sharing of the deeper loss of the soul that always exists when one has experienced any loss. 3. Enter into the loss. Listening and assisting must not be done at arm’s length. Caregivers have to enter into the pain, feeling the loss and experiencing what the other person is experiencing in order to strip the loss of its power completely. Caregivers must enter the world of others, rather than requiring them to come into their world. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 7 of 37 4. Explore the possibilities of loss. Just saying, “You still have the ability to see,” when the person is lamenting the loss of hearing, is not helpful. Each person must discover the new meaning. The caregiver’s task is to believe that there is gold in the hills of loss, and to keep vigilant as it is uncovered, grain by grain and nugget by nugget. Caregivers or professionals cannot impose what they perceive to be the blessing of loss upon another. 5. Celebrate discoveries along the way. At first, gold seldom reveals itself as big nuggets. Until the “mother lode” is found, traces sometimes no bigger than a grain of sand tantalize, even as they guide to deeper riches. Such it is with the blessings of loss. At first they are almost imperceptible, which is why they are so often missed, and people remain stuck in their past losses. But gradually one grain becomes two, two become ten, ten become a stone, a stone becomes a rock, and the rock becomes the “mother lode.” LeBron McBride describes this process using different words. He suggests that there are three phases of managing trauma and thus loss: (1) the responding and releasing phase; (2) the reflecting and reconciling phase; and (3) the resurrecting and rebuilding phase. The responding and releasing phase is a time of “holding,” as the person is confronted with the many feelings of grief that come with loss. This time of holding must be non‐judgmental and tolerant. McBride quotes E. P. Estes when he poignantly writes, “A wound is not disinfected once and then forgotten, but it is tended to and washed several times while it heals.” (McBride, 1998) Just because healing begins, the caregiver does not shrink from the intensity of emotions that are present. In the reflecting and reconciling phase the person whose pain is affirmed begins to explore its meaning and depth, even its pain. This is the time of struggle between meaning and meaninglessness. This is a time of grieving for what was, and what is yet to be is yearned for. Reflecting and reconciling is the phase of growing and becoming. The final phase, according to McBride, is called “resurrecting and rebuilding.” This is a time of revelation and unfolding. This is a time of expanded vision where the loss is incorporated into life, or one’s sense of being loved and accepted is strengthened. There is a movement towards wholeness, well‐being, even peace. Life has meaning and purpose again. Depression has succeeded in teaching the person to keep his life full of people. Lack of eyesight gives way to a depth of listening. An inability to walk has resulted in taking time to observe and learn from what is at hand, rather than always seeking something more. Becoming bedridden has challenged one to become open to love, and thus become more loving in return. Gold has thus been found in the barren hills of loss. Nine Maxims of Loss The following is entitled “Nine Maxims of Loss,” by Carl Siegel III. Read it and think about each of the maxims. If you are uncomfortable with the word “God,” you may substitute “Life,” “Jehovah,” “Higher Power,” or whatever you can relate to. I believe that the maxims address deep beliefs regarding loss within our culture. Print out the page by selecting all the text with your mouse, then click on File–Print–Print Selection. As you read, mark the maxims as follows: • Put an exclamation point next to perspectives new to you. • Underline items you wish to remember. • Put a question mark next to ideas you wonder about or challenge. • Put an “X” beside perspectives with which you disagree. Ask a family member or coworker to read the maxims as well, marking them as above. Discuss your lists together. It will provide some stimulating lunch‐break conversation. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 8 of 37 Remember that loss is a part of living. Endings are as important as beginnings, but they need not end in despair. The mining of the blessing, even if it is a disguised blessing, completes the cycle and offers at least a different life, if not a better one. It is the privilege of healthcare workers and caregivers to share in the agony of the search and the joy of discovery. Nine Maxims of Loss Many see God as punishing or see loss as God’s will, but that is not the case. Here are some thoughts regarding suffering and loss: 1. Loss is not God’s desire for us but occurs in the process of life. 2. Loss is not given in order to teach us something, but through it we learn. 3. Loss is not given to punish us, but it is sometimes the consequence of poor judgment. 4. Loss is not given to teach others something, but through it they may learn. 5. Loss does not occur because our faith is weak, but through it our faith may be strengthened. 6. God does not depend on human loss to achieve His purposes, but through it His purposes are sometimes achieved. 7. Loss is not always to be avoided at all costs but is often embraced with remarkable results. 8. Loss can either destroy us or add meaning to our life. 9. The will of God has more to do with how we respond to life than with how life deals with us. Learning Activity Complete the following self‐reflection activity. This activity should take you at least fifteen minutes to complete. 1. How has your view of loss changed as the result of completing this session? 2. Picture one person for whom you provide care. Provide a brief description: 3. Answer the following questions about that person: a. What losses remain incomplete in that person’s life? b. What should be your clinical goal, cure, coping, or care? c. Describe what the achievement of that clinical goal might look like. d. Describe your role in meeting that goal. 4. How does this perspective on loss affect the experience of loss in your own life? © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 9 of 37 II. Complaining “If I were a rich man, da da da da didee dum…” So the fiddler in the famous stage play and movie, “Fiddler on the Roof,” sings a song of complaint. “Would it foil some vast eternal plan, if I were a wealthy man?” It is a delightful song, almost playful; but nonetheless, it is a song of complaint. Why has life turned out the way it has? What difference would it have made if I had “zigged” instead of “zagged” in my life? Life would be so much better if … Complaining. No one likes to deal with it; no one likes to hear it. And yet in many hospitals and long‐term care communities there is a constant flow of complaints: ⋅ “The food is too cold.” ⋅ “The food is too hot.” ⋅ “Who opened the door and let in the cold?” ⋅ “It’s too stuffy in here. Why doesn’t someone open a window?” ⋅ “I haven’t had any breakfast.” ⋅ “The housekeeper is too noisy.” ⋅ “The maintenance man doesn’t respond to my needs.” ⋅ “I ring my call bell and no one answers.” All complaints are a form of communication. They say something is wrong, someone is suffering, and someone has needs. A complaint can be an expression of grief, even despair, and thus forms a pathway to the person, since it reveals the experience of loss or pain. Complaints are a pathway to the person, because something of what a person values is revealed though those plaintive, sometimes hostile words. This truth can be seen as we look at some other words commonly used for complaint. There is “wail,” a cry that is long and loud, because of grief or bitter pain. There is lament, to mourn aloud, weep, grieve, or express sorrow. Complaining is a cry of the soul. It is a way of saying “ouch.” It is an expression of fear, vulnerability, and doubt. Diagnosing the Complaint Physiological Causes One of the most basic skills of the caregiver is the ability to diagnose a complaint. Such a diagnosis is not as easy as it sounds, because complaining can come from many sources and can be expressive of something that is unknown even to the complainer. The first step is to rule out some of the most common physiological reasons for complaining. Number one on the list is depression, one of the most under‐diagnosed and under‐treated challenges of older adults. The banner ad at the National Institute of Mental Health depression site reads: “Older adults, before you say, ‘I’m fine,’ ask yourself if you feel empty, worthless, very tired. Depression is not a normal part of aging. Talk to your doctor.” Four times in my life I have had a clinical depression, and I can testify that it is no fun. Depression is often experienced as a sadness, gloom, low spirits, despair, dejection, or melancholy. Depression is often accompanied by fatigue, headaches, vague body aches, anorexia, and sleeplessness. When a person is depressed, thinking becomes clouded, fears become overwhelming, and joys and blessings become minimized. Depressed people do not always withdraw; sometimes they become grouchy as they experience a pain that cannot be identified, like an itch that they cannot scratch. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 10 of 37 Effecctive managem
ment of comp
plaining begin
ns with rulingg out depression. These are some comm
mon physiological reasons for depression: • Polypharm
macy • Thyroid co
onditions, Lupus, rheumattoid arthritis, diabetes • Hormonal imbalances • Cancer • Metaboliccally debilitatting treatmen
nt regimes succh as radiatio
on or chemoth
herapy • Drugs succh as anti‐hyp
pertensives, analgesics, antti‐Parkinson’ss, and cardiovvascular • Urinary trract infectionss with electro
olyte imbalance Polyp
pharmacy reffers to a mediication regime that includees multiple prescription ass well as over‐the‐ccounter supplements and m
medications. The metabollic changes assocciated with agging cause many of these medications tto interact differently and beco
ome more or lless potent. P
Persons with tthyroid condiitions often p
present confllicting emotio
onal concernss as well, one of which is d
depression. So
ome medicinees, such as those for hypertension
n and coronarry disease, can have depreession as a sid
de effecct. These, of ccourse, must b
be ruled out aas a cause forr the depresssion, because if the d
depression is caused by me
edication, few
w other intervventions will work. Accuraate diagn
nosis of the co
ondition, not the symptom
m, can lead to
o a much high
her quality of life for th
he resident. Theree was a resident in a comm
munity wheree I worked wh
ho began to sshow more an
nd more signss of depressio
on—distaste for previously enjo
oyable activitties, loss of ap
ppetite, and ssleep disturbaance. At the interdisciplinaary meeting itt was omplete physsical examination. The fam
mily was enlistted to investigate any factors that suggeested that she receive a co
migh
ht be contribu
uting to her de
ecline. The reesident’s docttor was contaacted by Nurssing prior to the appointment, sharing the cconcerns of th
he committee
e. The doctor found that sh
he was takingg five differen
nt drugs, some of which sh
he had been receiiving for twen
nty years. Afte
er discontinuing two and aadjusting the prescription on the otherr two, she bou
unced back to
o her o
old self in threee weeks. She
e was not dep
pressed, just over‐medicatted. In on
ne retirementt community I had the privvilege of chairring the interd
disciplinary group that revviewed the ph
hysical, emottional, and sp
piritual status of residents.. It became a protocol wheen a resident had a significcant change o
of behavior, be it aggression or withdrawal,, the first queestions asked were, “Whatt medicationss are being prrescribed? Ho
ow long has itt been
n since the ressident has had an evaluation by a physiician or a psychologist?” The ttreatment teaam should keep in mind th
he classic sym
mptoms of dep
pression: • A persisteent sad or anxxious mood • Apathy • Verbalizattions about death or self‐h
harm • Poor conccentration • Weight lo
oss or gain • Anhedoniia, the inabilitty to experien
nce joy • Expressions of hopelesssness, helpleessness, or wo
orthlessness
• Anxiety • Irritabilityy and complaiining • Sleep distturbance, inso
omnia or hypersomnia (too much or too little sleep)) • Tearfulness • Change in
n ADL status: neglecting grrooming and b
bathing, paying little atten
ntion to appearance • Recurringg aches and paains that do n
not respond tto treatment (a classic cry for help from
m the body) © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 11 of 37 The importance of correctly identifying and referring residents with depression cannot be overstressed. Aside from obvious quality of life issues, the primary risk in a depressed resident is suicide. Complaining that takes the form of severe loss of interest in life, verbalizations of self‐harm, and extreme pessimism (“There’s no use in living anymore.”) should be taken seriously. Elderly men are six times more at risk for suicide than the national average, especially after age 85, according to the National Institute of Mental Health. NIMH reports in Older Adults: Depression and Suicide Facts: “Many older adults who commit suicide have visited a primary care physician very close to the time of the suicide: 20 percent on the same day, 40 percent within one week, and 70 percent within one month of the suicide.” Healthcare pro‐
fessionals are often the failsafe prior to a suicide attempt. With 9.5 percent of the US population affected by depressive disorders in a given year, your patient or even a family member visiting the patient may be affected. There are excellent depression resources for residents, families, and healthcare professionals on the Internet at http://www.nimh.nih.gov/healthinformation/depressionmenu.cfm Psychological and Situational Causes There are also psychological and situational causes of depression: loss of memory, independence, and intellectual func‐
tion, loss of family and social supports as one moves to strange surroundings or attends too many funerals of friends and loved ones, loss of vision hearing, or the ability to walk steadily. Many older adults are experiencing several of these losses at the same time. Dementia and Stroke Also to be considered is that dreaded thief of memory and personhood—dementia. Depression can be a logical result of continually feeling as if you just came into a theatre in the middle of a movie, not knowing what has happened or what is going to happen. After a stroke, patients may not be able to walk, talk, swallow without choking, or make others understand them. No wonder they complain just to express their frustration and fear. They feel frightened at the downhill slide in their quality of life and so complain about the dirty carpet. They feel cranky after another restless night’s sleep and so complain that a TV is too loud. We must not forget that hostility and combativeness can be a form of complaint. This is especially true for persons who are aphasic or diagnosed with dementia and thus unable to communicate effectively. They might feel threatened at what is happening to them and have no other way to express their anger than to strike out in complaint. In many communities, complaining becomes a way of life. Complaining is seen as the only effective method to get the staff’s attention. Patients wail, lament, and complain, and unless we, their caregivers, understand their wailing and interpret it, the complaint will remain unresolved and the sorrow unrelieved. Yes, complaining is the pathway to the person, but it is also a window to the spirit of a person. When complaining we express hurt or fear, something that is of importance to our personhood, and the complaining will not go away until someone finally hears and responds. Complaining can be a healthy sign. What is the difference between a complainer and a feisty person? Strength of will often manifests itself in complaints. The difference is in the eye of the beholder. There was a resident at my facility whom the nurses disliked dealing with because she complained all the time. She was a former nurse and founder of the home health program in her state. She was nearly one hundred years old and blind, due to advanced macular degeneration. She was a brilliant person with a quick wit and deep‐thinking mind. I saw her complaining as an expression of her person, her soul, her indomitable will. Her complaints were her defiance at the hand that life had dealt her, her courage in standing up to her limitations. She was not going to ‘go quietly into that good night.’ Perhaps I saw her that way due to my emotional and physical distance. I did not have to deal with her several times a day, assisting her when she so clearly resented needing assistance. To the nurses she was a complainer and the object of complaints by staff around the lunch table. For me her complaining was a testimony to the fire of the person that I admired. To our CNAs she was an obstacle in getting their job done, a thorn in the flesh. They almost drew straws to see who was to be her caregiver for the day. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 12 of 37 Whaat Is the Goaal? This eexperience leeads us to an important qu
uestion: Whatt do we reallyy want from o
our residents?? Compliancee? Quiet? A willin
ngness to let ggo and just do
o what they aare told? Or d
do we want th
hem to be theemselves, to have the dign
nity of being peop
ple, expressing themselvess for who theyy really are? TTheoretically,, we all want residents to b
be themselvees, but are wee willin
ng to allow th
hem to do thiss even when it is through ccomplaining?? Complainingg is, after all, an indirect orr direct assau
ult on our perrception of co
ompetency. Iff the food is ccold, it must b
be someone’ss fault—the kkitchen or thee delivery staff.. Perhaps we are to blame
e for not bringging it to the resident’s roo
om before it ccooled. A com
mplaint impliees fault, and we do not like to be less than ccompetent. TThe need to be liked by ourr residents is a positive forrce that drivees good care.
We w
want to be seen as capable
e and helpful.. It is the reasson many of u
us entered heealthcare in th
he first place.. I grew
w up with a m
mother whose
e most imporrtant value waas compliance on the partt of the intimaate people in her life. Her drivee for complian
nce was enforrced by dominance, silencce, and withdrrawal. My bro
other fought her. I remem
mber vividly the p
pitched battlees between th
hem as my brother went th
hrough his teeen years. Wh
hen he was eighteen, he w
went off to college, never to rreturn exceptt for brief visits. I, on the o
other hand, co
omplied. I waanted, with evvery bone in m
my body, to win m
my mother’s approval. As I m
mentioned ab
bove, I have h
had at least fo
our clinical deepressions in my life. TThis last one aand the accom
mpanying theerapy has beeen the most fruitfful. For the firrst time I have gotten in to
ouch with myy anger at my moth
her. I rememb
ber the day fo
ollowing one of my session
ns I was drivin
ng to workk, mulling oveer what had o
occurred the p
previous day. Suddenly I feelt this aalmost overw
whelming need
d to drive to tthe airport, b
buy a ticket, flly to the ccity where myy parents are buried, rent aa car, drive first to a hardw
ware storee and buy a laarge knife and
d then drive to the cemeteery where I would desecrate my motther’s grave. The rage continued for some time. It w
was fortu
unate that thee freeway was crowded, so
o I could not h
hurt myself o
or anyo
one else in myy car. I began to plan how I was going to
o do it. I had the credit carrds in my poccket. The road
ds were familliar since child
dhood. I even
n thought of aa nice motel cclose to the cemetery. I haad the power to buy anyth
hing I would need
d, including a warm coat. Itt would have been so easyy to drive to the airport, geet on a plane,, and chop up
p my moth
her’s grave. I did not do it, not because I felt my anger was evil, b
but because th
he residents iin my retirem
ment comm
munity were looking forwaard to my com
ming that dayy for a speciall event. Ragee is the result of compliancce and of not being listened to. As careggivers we forgget our own eexperience th
hat any time anyo
one demands compliance b
by saying, “Yo
ou gotta,” we will sooner o
or later, in som
me form or another, respo
ond with, “Likee —— I will.” A
As caregiverss, people who
o truly desire to be of serviice and help, we really do not want com
mpliance, only cooperation. We do not w
want blind obedience; we w
want a partneership. Coopeeration and a partnership require a relationship between persons where the neeeds of each aare honored aand respected. Often
n caregivers eexpect patien
nts to conform
m to their ratiional beliefs aabout things. “I can’t get yyou any food now, it is onlyy thirtyy minutes unttil supper tim
me.” “I have beeen in here fo
our times in tthe last hour aand you still w
want more.” We look at our ssituation thro
ough our eyess when we sho
ould look at w
what we do frrom the persp
pective of thee resident. So
ometimes a comp
plaint is not rational. Some
etimes patien
nts just need tto complain b
because they are angry. So
ometimes theey need to comp
plain becausee it is better than punchingg someone ou
ut. Sometimees complaining is the only w
way they can give voice to
o their loss of auton
nomy and feaar of dependeence. Some paatients have jjust been com
mplainers all ttheir lives. Maaybe they have dementia an
nd thus canno
ot put a fingerr on their real pain, so theey complain about anything at hand. Complaining can b
be a healthy aactivity, someetimes more ‘fun’ for resid
dents than bin
ngo games, b
because at leaast staff are havin
ng to deal witth them and n
not just enterrtain them. Co
omplaining caan be a normal thing, something to actually encour‐‐
age. Complaining can be a path
hway to the p
person and a glimpse into the spirit as tthat person gives us a peek into the soul, the hurt, neeeds, panic, an
nd what ails th
hem. © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 13
3 of 37 Managing a Complaint How do we manage a complaint? First of all, we must see some form of complaining as normal. Human beings cannot live together in intense relationships with each other without hurt and complaints. In fact, caregivers should be happy when someone is complaining rather than fighting. (Remember my grave story.) In addition, complaining can be an expression of independence, which might be inconvenient for the caregiver even as it is healthy for the care receiver. The drive for independence, the need for something more, the anger at whatever is oppressing us, is a good thing. Secondly, caregivers are on risky ground when they see avoidance and withdrawal as being good (“At least she is quiet.”), for such behaviors can be a form of complaint, too. Do not give thanks for the quiet, compliant patients without first knowing if they are feeling powerless to express what they really wish to say. Thirdly, and most importantly, caregivers need to recognize the complaint and enable the person to give voice to it. Not recognizing complaints can result in loss of independence, loss of dignity, elder abuse, and even poor pain management. Again, rule out the physiological before settling on the psychological. Some simple suggestions that were given me by a nursing colleague: For pain try pain medication. How many elderly persons have chronic arthritis that makes every ADL painful? How many persons who are older have grown up before all of the over‐the‐counter pain remedies and thus just “tough out” the pain, because they always have? How many persons are over‐medicated and thus feeling out‐of‐sorts and more than a little grumpy? If the person is not on pain medication, get a physician consult. If pain medication works—great. If not, the medication can be discontinued. A trial of pain medication usually does not hurt and might relieve a cause for complaint. For depression try an anti‐depressant. A geriatric specialist will know which dosage is best for gender and age—an important consideration in your residents, who do not metabolize antidepressants the same as someone forty years old. If it works—great. If not, no harm is done; discontinue its use. Encourage the resident to become more involved in activities. Pay more attention to the resident. Try “tag teaming” the resident for a couple of days. Tag teaming is arranging for multiple contacts by staff, volunteers, and family members, thus insuring a continual flow of relationships. Giving people the attention they need can break the cycle and lead to peace not only for staff, but for the resident as well. Anxiety and its cousin, panic, can be a horrible experience, especially for a person who already feels vulnerable. In fact, that very vulnerability can become a trigger for a feeling of loss and foreboding that can become overwhelming. As with depression, there are some wonderful medications for anxiety and to give one a trial run could prove fruitful. This is not “better living through chemistry.” It is only allowing the wonderful strides in psychotropic drugs to become our allies in caregiving. Insomnia. All caregivers have encountered the resident who gets up in the middle of the night all the time, pushing call bells, interrupting the sleep of neighbors. Lack of sleep can cause irritability; just ask any new parent. There are some effective over‐the‐counter medications, but check with the doctor first. What about a simple Tylenol that might soothe some unperceived discomfort or just quiet the body a little? One resident in a SNF where I worked could not go to sleep unless she had some ice on which to suck prior to bedtime. Some people swear by old‐fashioned warm milk and cookies. Sometimes people, like my granddaughter, complain just because they are tired. Finding a way to insure a restful night can be helpful to these tired complainers. Internal Causes. All of the management strategies above deal with external, physiological reasons for complaint. Internal causes can be more difficult to treat. There can be psychological hurts and fears that bring on complaints in later life. Research tells us that we cannot go back ninety years to find out what is hurting the patient. There is just too much history to unearth. Too much time has evolved. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 14 of 37 Patteerns of behavvior and feelin
ngs born in on
ne’s early yeaars have beco
ome imbedded in cement b
by hundreds, if not thousands, of repetitions. In sittuations such
h as these, all we can do is ride the com
mplaint. Perhaaps you have seen those electtric bulls that twist and turrn, seeking to
o throw the rid
der to the gro
ound. Sometimes managin
ng a person’s complaint can ffeel as turbuleent as riding o
one of those bulls must bee. It takes work to stay witth the bull as forces try to throw us off. The o
only differencce is that the forces seekin
ng to stop us ffrom riding th
he complaint come from w
within us, not from the bull. “You shouldn’t feeel that way,” we either sayy or think or ffeel (which is just as ineffeective). Ridingg the complaint does not denyy, explain, or rredirect feelin
ngs, but insteead honors the feelings, em
mbraces the p
perspective, aand sees wheere it takes uss. I have often felt a need to deall immediatelyy with the com
mplaint so I can go and do
o something that I deem m
more impo
ortant. Often I am afraid to
o ride the com
mplaint becau
use I believe tthat I do not h
have the timee to go whereever it takes me. TThe result is tthat the comp
plaint only retturns, over an
nd over again
n, until it is em
mbraced and dealt with. ngs or put a liid on them, aand do not cover a behavio
or with an Do not deny feelin
anti‐psychotic dru
ug. Yes, it is crrucial to deal with any psyychological orr physiological reassons why a pe
erson is comp
plaining; but d
drugs should not be a meth
hod of managgement, only an attempt in
n caregiving. In a recent neewsletter publiished by The Park Ridge Ce
enter, a thinkk tank regardiing ethics, one author asked
d, “Should the Buddha havve been on Prrozac?” The aauthor went o
on to recou
unt the life off the Buddha,, how he left the prospero
ous family bussiness, strugggled with thee meaning of life, and retu
urned with inssights that haave guided almo
ost half the wo
orld. What if,, in the midst of his struggle, the Buddh
ha was given
n Prozac? Perrhaps the drugg would havee healed over his struggles and he woulld have return
ned to the fam
mily businesss and becomee a corporate executive insteead of a religio
ous leader. Pe
eople have a right to comp
plain becausee, in their eyes—
—and percep
ption is everytthing—they h
have been wrronged, hurt, threaatened, or defeated. Whatt they need iss not salve bu
ut a listening eear and someeone who is w
willing to liste
en to the com
mplaint. The Spirituality of Complain
ning Help in riding the complaint caan come from
m a surprising source: spirittuality. Spiritu
uality is seldo
om seen as haaving practicaal use, particularly in
n dealing with
h complainers. Why call th
he chaplain? SShe will just p
pray, hold han
nds, or talk. W
What we need
d is acttion. The persson’s complaiint needs to b
be received, d
dealt with, an
nd acted upon
n. Yet there are times wheen the action required is to listeen. There are times when w
what is demaanded is open
nness; what iss needed is th
he spirit. Within the Judeo‐‐Christian Scriptures the heart is the seat of the persson, the sum total of all th
hat one is, hass been, and will b
be. The mind is the seat off the intellect—analytical, logical, seeking understan
nding. The bow
wels (yes, thee bowels) aree the p
place of emottion. Do we no
ot speak of our stomach’s turning as w
we witness tragic events or having a feeling in the pitt of ou
ur stomach? B
But the heart takes in the eentire person
n, all perspecttives and events, and makes sense of itt all. Some suggeest that spirittuality is one’’s attitude tow
wards events, how one ap
pproaches and
d interprets eevents. Spiritu
uality is that and m
more. Thomaas Moore, in h
his book, Cariing for the Soul, suggests tthat spiritualitty has more tto do with thaat which is “beyond our capaacity to devise
e and to control” (Moore, p. xviii). Spirittuality is morre comfortablle with imagin
nation than proof, with intuition than with concrete acttions. One’s spirituality is tthe sum of alll that one is, iintellect, mem
mory, feeling,, and b
body. It is thee expression o
of the soul, th
he heart, the core, the cen
nter of a perso
on. Spiritualitty is the totaliity of one’s life and thus is wh
hat makes a p
person tick insstead of tock.. Whatt, in the patieent’s perceptiion of self and
d the world iss causing him
m to cry out in pain, in complaint, ratherr than embrrace what is w
with hope and
d confidence? What attitu
udes, directions, and focuss cause one person to com
mplain and another to smile aand embrace even the mo
ost difficult of circumstancees? © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 15
5 of 37 The Hebrew Bible is filled with complaining. “Why have you brought us into the wilderness to die?” the people cried after their miraculous release from Egypt. “I, only I, am left!” laments the prophet Elisha, who was frustrated with God. In the Psalms, complaining is honed to a fine edge. In fact, the authors of many of the Psalms could be called “professional” complainers who have taken the art of complaining to new heights. The authors, as people of faith, had no qualms in complaining to God. In fact, they recorded their complaints for all to hear and see. Perhaps we can learn something about complaining from these professionals. One does not have to be religious to be helped by this perspective. If you are not Jewish or Christian, read the following as an expression of a human experience that has touched a common chord in the hearts of millions over the centuries. Walter Bruggeman, in the forward to Ann Weems’ wonderful book, Psalms of Lament, describes six characteristics of Biblical lament. The classic model begins with the naming of God in intimate address: “My God, God of my ancestors.” The complaint is not addressed to a stranger but to someone who is known, has helped in the past, is trusted, and is believed to be listening. Many residents cry out, “Nurse, Nurse,” which sounds impersonal until one realizes what the word “nurse” stands for: someone caring, compassionate, who can and will help, who listens and cares for some of my most basic needs and bodily functions. The Biblical lament moves immediately to complaint. It is specific, unabashedly to the point. There is no hyperbole or metaphor, just an expression of being wronged, used, or ignored. Overstatement is intrinsic to pain. When we hurt, physically, psychologically, or spiritually, we want attention and we want it NOW. So we complain to the person whom we feel can help. The complaint then focuses on petition. Again, the petition of lament is specific. “Turn O God. Listen, Creator of All.” The petition is insistent, even demanding, for it believes that if God were mobilized then all would be well. If God would only do what God normally does, life would be great. God’s power is not in doubt, only His attentiveness. Such might end most complaints. But remember, the psalmists were the masters of complaint, so they do not stop with merely saying their piece and sharing their needs. The laments in the psalms continue to give God a reason for listening and responding. In the Hebrew Scriptures the psalmist often knows God to be silent, absent, indifferent, or uncaring. God must be “recruited” into the trouble. Usually these are not noble theological concepts, but instead appeal to God’s virtue, to repentance, to God’s honor, even to His vanity. My need is not reason enough for God to act. God needs to act out of God’s own self‐interest. It might not sound pretty or even pious, but it is honest. Hurting people usually are very honest with their needs. If you are a person whom they trust, they might express their needs over and over again. Phase Five is probably the most frightening. Phase Five is vengeance. The psalmist usually asks God to destroy the enemies, to bring them chaos, fear, and suffering, similar to the suffering that the psalmist is experiencing. In a healthcare setting the caregiver might hear, “I hate my children for putting me here.” “I wish everyone would just go away and leave me at home.” “This place doesn’t really care about people at all.” It is here, in the words of vengeance, that the real feeling behind the complaint is revealed. Here is the pathos, fear, hurt, the feeling of being abandoned, betrayed, and ignored. Here is the true source of the complaint, a source that is often beyond reason, a source experienced deep in the soul. Few people want to go to this fifth phase. It is too frightening, embarrassing, and shameful. But if the vengeance is received, not rationalized, judged, or condemned, if the heart and soul of the person is received, accepted, even loved, then perhaps the miraculous happens. For, oddly enough, when the need, hurt, demands, and venom are fully voiced, something unexpected happens. The mood of the psalm changes. Anger, protest, and fear seem to be spent and there is left a positive resolution. At the end of most of the psalms of lament the writer is thankful at being heard and dealt with bountifully. Why the turn happens is not clear. What is clear is that most of the laments in the psalms end with thanksgiving, praise, and blessing. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 16 of 37 This is the very point I am trying to make. Is it possible that the reason why some residents complain all the time is not that they are seeking attention but that they are seeking to be heard? They know that, in the grand scheme of things, the staff person is not able to fix what they are really complaining about. They even resent the fact that they are in a position of having to complain so that someone might pay attention to them. Maybe the reason why some residents complain all the time is that they are not complaining enough. At least they are not complaining deeply enough, honestly enough. Maybe instead of being short‐circuited and thwarted in their complaining they need to be empowered and encouraged to complain more strongly, more fully. In her book, What’s Worth Knowing, Wendy Lustbader writes of an 88‐year‐old woman, Sadie Farber, who has been stricken with tiny fractures throughout her spine and legs due to bone loss, a condition that is quite painful. Sadie notes, “I never wanted to be like this. I growl at everyone who tries to help me. It’s awful. The nicer someone is to me, the nastier I am. There isn’t a bone in my body that doesn’t bother me night and day. I wish someone would say, ‘Hey, I don’t blame you. I’d be irritable, too.’ That would take a load off my shoulders. I can’t even unscrew a bottle of ketchup myself. I have to grit my teeth and say, ‘please’ and ‘thank you.’ I just don’t qualify to be Saint Sadie” (p. 156). Learning Activity: Riding the Complaint Here is an activity for you to think about. You may download and print the charts by placing your mouse on the top left of the text, not the top left of your browser. Scroll down until all the text is selected, or blue. Next go to the File menu, and pull down to Print. (Do not click on the Printer icon.) Choose Print Selection, then hit OK. Note the names of the columns: “What Is Said” and “What Is Meant.” Of course, there are differences between these two columns. The art of dealing with a person who is complaining is in looking for that difference. Make notes of phrases you have heard complainers say and what you think they might mean in terms of their real need. Note the comment between phases three and four. Often a caregiver’s desire to seek a quick fix or to put the person off cuts off the process of complaining too early. Note the changes that come in the later phases. Most importantly, note that things get worse before they get better, but it is in the expression of the “worst” that healing and resolution come. Riding the Complaint: An Illustration Phase What Is Said What Is Meant 1 ‐ Call to a familiar “You are the helper. You have the power “Nurse! Nurse!” person to do something I can’t.” 2 ‐ Complaint “I want to go home.” “I am feeling lonely and frightened.” 3 ‐ Petition* “Take me home now.” “You can relieve my pain.” “To act and relieve my pain will make you feel good; it fulfills your goals; and it is what you “Don’t ignore me or treat me as a non‐
4 ‐ Bargaining are paid to do.” (Challenge of the caregiver: person. I am still human.” “Someday you might be in this wheelchair.”) “I am mad at my children for putting me here. I “I am finally in touch with what is really am furious at my husband for leaving me. I the issue and what is really bothering 5 ‐ Vengeance wish my roommate would just die so I could me.” get a good night’s sleep.” “I have been heard, respected, accepted, and “Thank you, thank you for touching me at 6 ‐ Resolution loved.” the core.” *Note: This is where most complaining is thwarted and short‐circuited. The next page contains a worksheet that you will be using in the next part of this course. Please print three copies of it, following the earlier instructions. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 17 of 37 Write the name of a different person who has a complaint at the top of each copy. Write out complaining interchanges on the chart. Try to be as specific as possible in listing what is said. Continue with the second column, “What Is Meant.” Use your imagination and intuition. If at first you do not know what they mean, seek to find out. Ask the patient. If the person receiving care cannot answer due to confusion or whatever, confer with other staff or contact family members. Talk with your “significant other.” Discuss it with your dog if it will help! Continue to raise the basic question: Since complaining is a mode of communication, what is the person saying? What is the meaning behind the words or actions? Riding the Complaint: Worksheet Spiritual Phase What Is Said What Is Meant Care Provision Foundation 1 ‐ Call to a familiar person 2 ‐ Complaint 3 ‐ Petition 4 ‐ Bargaining 5 ‐ Vengeance 6 ‐ Resolution Wendy Lustbader again quotes Sophie Noble: “For a long time after I lost my sight, I was going to doctors, looking for them to make things better for me. I felt cheated. Why did this happen to me? I can’t even read the directions on the back of a frozen meal. Just recently, something in me clicked. I woke up one morning and said to myself, ‘I want to live, so this is it.’ I have certain medical problems, and they’re not going to get any better. It’s time to start living again—a different life, but at least it’s life. Now I wake up in the morning and I’m not complaining. My son writes the directions with a thick marker on the back of my frozen meals” (What’s Worth Knowing, p. 170). Sometimes the heart of the complaint is not merely physical or emotional, but spiritual. It takes spiritual tools to hear and respond healthfully. Spiritual Insights That Help Care for the Complainer Unlike other disciplines, the tools used in spiritual care are difficult to quantify. Often these tools seem abstract and subjective rather than concrete and objective because, as noted above, they deal more with the heart than with the mind or even the emotions. What are some of the spiritual tools that can be used in clinical practice with persons who are complaining? Below are spiritual beliefs that are fundamental to life and thus are often missing in the lives of persons who complain. Take a moment to picture in your mind a person who is receiving care from you who often complains. Be as detailed as possible in your imaging. What does the person look, feel, and sound like? Once you have the picture in mind, consider the following spiritual insights, which persons who are depressed or in despair will not affirm themselves: “I am human and thus I am of worth and don’t have to take this anymore.” © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 18 of 37 Somee will becomee compliant aand quiet and others, grouchy. They deaal with extrem
mes. They livee in complain
nt, either quiett or loud. But this first spirritual insight is positive, real, true, and eeven healthy. It lies at the core of peop
ple whom I woulld call “feisty”” and thus can be something to encourage, not extin
nguish. This in
nsight, expresssed in a million ways from “It’s too cold
d in here,” to “No one com
mes to visit mee,” expressess a sense of personhood, aa fire within th
he soul that will n
not be quench
hed by whate
ever life is deaaling out. Som
metimes an in
ncrease in com
mplaining is d
driven by a feear that the fire iss going out an
nd is thus a caall for help so
o that one’s p
personhood iss not lost. “Life,, even with itss ups and dow
wns, is basica
ally good.” Undeerneath manyy complaints is the belief tthat “life has d
done me dirt,” plunging th
he person eith
her into desp
pair or anger.
Theree is a sense o
of powerlessness that makes any experiience of vulneerability a slap in the face rather than aan oppo
ortunity to heeal and grow. mbrace the futture with joy and receive tthe present w
with thanksgivving.” “I em
Often
n a person wh
ho complainss feels as thou
ugh there is n
no future; that their best years have co
ome and gone, and the on
nly thing left is to wait for tthe Grim Reap
per. A person who has an o
open future, w
who anticipattes what is yeet to be with a feeling of ggratitude does not complain about the “small stuff” but is propelled into a fu
uture that see
es experiencees of disappointment and frustration as bein
ng a molehill, not a mounttain. Persons who embracee the futurre, even if thaat future prom
mises to be veery different ffrom the pastt or the preseent, have an o
optimism thaat manages th
he fear that iss often expresssed in comp
plaining. “There is a mysterry to human ssuffering.” It is n
natural to want to avoid su
uffering, but w
when sufferin
ng happens, aas it always seeems to do, itt should not b
be looked upon
n as somethin
ng strange and
d alien but raather as an op
pportunity to grow and chaange, the birtth pangs of a new future. A perrson should n
not seek suffe
ering nor be ssurprised by itt and thus complain at thee discomfort, fear, disappo
ointment, and
d doub
bt. better than th
he alternative.” “Life isn’t always ffair, but it’s b
A perrson who is complaining m
might well sayy, “Life isn’t faair,” but they will not follo
ow the statem
ment with, “bu
ut it’s better than the alternative.” People w
with a healthyy spirituality ssee fairness aas a childhood
d need because, at the tim
me, they felt so po
owerless. Now turn again to
o your worksh
heet. Under ““Spiritual Foundations” note the foundaation that seeems to be misssing in the lives of the patien
nts you have cchosen. I havee listed five fo
oundations. YYou might havve some otheers. You might find yoursself choosing more than one. Resist sayying, “All of th
he above,” which will makke the exercise too easy. The goal is to thinkk spiritually in
nstead of med
dically, psycho
ologically, or socially. Thosse disciplines are essentiall to providingg quality care,, but sso is spirituality. Careggiving a perso
on who comp
plains is not easy, but for the most part,, the difficultyy is not a mattter of time. It is a matter of wiill, the willingness of the caaregiver to lo
ook deeper an
nd to enter th
he patient’s w
world. Sometimes it is a maatter of spirit. Strattegies for Sp
piritual Care
e of People W
Who Complaain with a difficultt person, the person who is always com
mplaining? Ussing some of tthe principless noted How do we deal w
abovve, here are so
ome concrete
e ways of tending to the sp
pirit of such aa person. © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 19
9 of 37 Listen with compassion. Listen for the spiritual issues that form a foundation for the complaint. Listen to what patients mean, not always what they say. Thomas Moore put it this way: “The basic intention in any caring, physical or psychological, is to alleviate suffering. But in relation to the symptom itself, observance means first of all listening and looking carefully at what is being revealed in the suffering. An intent to heal can get in the way of seeing. By doing less, more is achieved.” (Care of the Soul, p. 10). When dealing with the spirit of a person, the ultimate cure comes from love, not logic. In her book, My Grandfather’s Blessing, Rachel Remen writes, “Perhaps the most important thing we bring to another person is the silence in us, the sort of silence that is a place of refuge, of rest, of acceptance of someone as they are.” She then goes on to describe an incident in the childhood of a highly skilled AIDS doctor. When the woman was very small her kitten died. This being her first experience with death, the little girl was crushed. Her parents had encouraged her not to be sad, but she was not comforted. In her anguish she went to her grandmother, a person who had not told her not to be sad as the others did. Instead, her grandmother simply held her and reminded her of the time when her grandfather had died. She too had prayed to God to give him back, but it also didn’t happen. The little girl didn’t know why but the story caused her to turn into the warmth of her grandmother’s shoulder and sobbed. When the little girl was able to look up, she saw that her grandmother was crying as well. Rachel Remen writes, “Although her grandmother could not answer her question, a great loneliness was gone and she felt able to go on.” (Remen, p. 164) Sometimes listening with compassion rather than detachment is all that is needed. Don’t try to solve all the problems. A complaint is a cry for action, but do not get sucked in by the initial experience of fury. Some complaints are not fixable. In fact, many persons in our care know that what they are complaining about and hoping for is impossible to achieve in this setting. Sometimes they are not seeking solutions, even though they are demanding them. Often they are only seeking connection with someone, a hug, a word of recognition, an expression of solidarity, an affirmation that “Yes, aging is not for sissies.” Sometimes what is needed is simply to stand in the presence of the mystery of life, a mystery that the older person has probably encountered many times. Americans cringe at mystery. We like to know, find out, and manage, but often that is not possible. Change our attitudes as caregivers. We do not need people to stop complaining as much as we need to change our way of thinking about complaining. We need to see the person behind the complaint, take advantage of the opportunity being presented to us, and see complaining as not necessarily bad, but as a part of the frustration of the person and the way he is dealing with and expressing hurt. Listen for what the person is hoping for and wanting as a result of the complaint. Do not take statements at face value. Go deeper; use your intuitive skills. Listen not just to words but to attitudes, fears, disappointments, worries, joys, and dreams. Listen to what the person is feeling, not what she is saying. Risk entering into the complaint. Do not just observe from a comfortable emotional distance. Feel what people are feeling; walk in their shoes. Do not judge what you experience. Merely accept people even as you accept their complaints. Remember the patient—not the complaint—is the person. Do not try to solve the problem immediately; instead, touch the person. What is often behind a complaint is a need for relationship. Give the person relationship. There was a resident in a long‐term care community who was always complaining about something until, after a unit meeting on the subject, staff began literally to touch the person each time they passed. A nurse might be going to a supply closet; a housekeeper might be securing clean linen; an activity director might be going to visit another resident in the room; but each time they touched and greeted the person. The complaining did not stop completely, but the resident changed from being a complainer to being just a feisty old woman. One of the advantages of caregiving in a community setting is that a caregiver can have multiple contacts during the day, each of which might be brief, but collectively are very powerful in their healing qualities. It is a matter of patience and a willingness to enter into the world of another. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 20 of 37 Do not be afraid of the “R” word. Religion has become scary for many in the health professions. We do not want to pressure someone into believing something or to offend anyone. We do not want to raise issues that are beyond our expertise. And yet, as we deal with older adults, particularly complaining older adults, we confront spiritual issues. (Remember “spiritual foundations” above.) When one explores issues of meaning and purpose, religion will often become a topic of conversation. As long as the care receiver drives the conversation about religion, we are on strong ethical footing as we seek to serve the person where they are and not where we feel more comfortable. Often conversation with a person who is complaining will evoke greater anger, specifically at God or whatever word the patient uses. Immediately begin using their words rather than your own. If they call the Divine “Jehovah,” then use the name “Jehovah.” If they use “Higher Power,” use “Higher Power.” Secondly, if the person expresses anger at God, do not act shocked or negative. Instead recognize that God searches the heart and not the hands and that the Creator of all things can take the heat. In fact, God might find the honesty refreshing. If you don’t happen to be of the same faith as the patient, listen and learn. Ask, “Why do you feel that way?” Affirm feelings: “If I saw things the way you do, I would be mad, too. It isn’t fair.” Now turn your attention once again to your “Riding the Complaint” worksheet. The fourth column is labeled “Care Provision.” In this column note the spiritual care strategies that might be helpful in each situation described. Which ones seem to be the most helpful in evoking the spiritual foundation that is suggested? Avoid the tendency (translation: cop out) to say “All of the above.” Which strategy is best for this situation? Is another strategy better for a different person? Do you change strategies in midstream? What additional strategies can you devise? Good spiritual care is an art form that touches the depth of a person, evoking within them the strengths and directions for life that are already present. Conclusion People do not complain to make caregivers miserable. People complain because they are miserable. Sometimes that misery is hidden behind feelings of guilt or attitudes of the past that cause people to minimize their value and worth. Sometimes that misery is understood, but often it is unknown, particularly to the patients themselves. Perhaps the following poem sums up something of what has been said in this course. You Heard Me ‐ By Donald Koepke You heard me… I was screaming to drown out the pain and you heard my fear I was angry and hostile and you saw my need I was obstinent and uncooperative and you saw the child, crying within You heard me… Even though you have lots to do, not only on my behalf, but also in the service of others You heard me… Though your life is filled with personal needs and worries and pains, you took the time to listen to mine You heard me… When I was at my worst When I was not loving...or caring...or compassionate...or pleasant You heard me… Even though I was self‐centered (and probably still am) Even though I was engrossed in my problems, my pains, my worries And not caring about yours © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 21 of 37 You heard me… Cutting through the barbs of words and the walls of silence You saw my anger and were not repelled You saw my fear and did not laugh You saw my need and responded with an ear and also a tear You heard me… Even though you could not change anything Even though you have nothing new to say Even though I will continue complaining tomorrow You heard me… And my heart sang III. Spirituality Over the years an increased secularization of society has caused healthcare administrators and staff to be wary at best when dealing with religious expression in the long‐term care setting. Even so, spirituality has become a word that is increasingly common in the healthcare setting. This presentation will explore “tending to the spirit” of residents, clients, or patients in a non‐sectarian, inclusive manner. The Context Religion and long‐term care seem to be at odds these days. Due to a number of factors, budgeting being only one of them, long‐term care communities have been cutting back on chaplaincy services and have become cool toward any religious expression on their campuses. This was not always the case. In fact, long‐term care had its roots in the faith communities of America as Lutherans, Catholics, Methodists, Presbyterians, and a myriad of others sought to fill a need that they saw within their congregations and communities. One of the first founders of long‐term care in the United States was a man by the name of Passavant who established hospitals and homes for the infirm throughout the East and Midwest. Many long‐term care employees work in organizations that have faith‐based roots. There was a time in the not‐so‐distant past when being involved with the elderly required the presence of clergy, not only for hands‐on care, but in the boardroom as well. But in recent years there has been a decline of interest in the involvement of religion in long‐term care. It is beyond the parameters of this course to provide an exhaustive list, but it important that we consider at least a number of these factors. Over recent years there has been a tendency among long‐term care facilities to leave their faith‐based roots, because their organization is no longer controlled by their historic faith communities. At the same time, there is a desire to market their facility beyond their original faith group. Walnut Manor Retirement Community in Anaheim, California, is a prime example. Established in the 1930s by a consortium of local Lutheran Church Missouri Synod congregations, the facility was basically a place for Missouri Synod Lutherans. Then, because of financial stress in the 1950s, the facility was purchased by a pan‐Lutheran multi‐campus organization. But a facility cannot live by Lutherans alone. At present, only twenty‐eight percent of the residents have any connection to the Lutheran Church. What is more, Walnut Manor’s parent corporation merged with two other not‐for‐profit corporations to form a non‐faith‐based corporation. The result was a blurring of religious drive and focus. In recent years this story has been repeated hundreds of times across America. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 22 of 37 Another factor in the decline of interest in religion and spirituality in long‐term care facilities is the recent history of religion in America. In the 1950s America was caught up in what I call the “Denomination Wars.” Every denomination, every church was in competition with others, each claiming greater purity, moral focus, or theological correctness. “I am the only true church,” was the call, and it was expressed in a sectarian isolationism that is just now breaking down. The 1960s saw the rise of “flower children," fueled by an anti‐authoritarian drive. “If it feels good, do it,” was the motto as the shackles of a prescribed rightness and absolute truth were shattered. In the late 1960s and into the 1970s we find contact with Eastern philosophies that challenged our assumptions of being a Christian nation. Soldiers returning from Vietnam brought an interest in Asian religions, particularly Buddhism and Hinduism. Suddenly, Americans came to realize that there was something more than incense‐burning going on in those groups led by people with unusual‐sounding names. These factors of recent history have given rise to several concurrent forces in the American religious experience. Phyllis Tickle, religion editor of Publishers Weekly and author of the book, Rediscovering the Sacred: Spirituality in America, suggests that the rise in the number of books and CDs in the bookstores and music shops devoted to religion in general and New Age in particular, is an indication of a growing interest in spirituality, if not religion. In fact, she goes so far as to suggest that America, with our increasing religious diversity, is in the process of redefining religion. An example of this is found in an episode of the television sitcom, “Dharma and Greg.” Dharma was asked to “cleanse the aura” of a friend lying in a hospital bed and got into an argument as to whether her actions were actually cleansing the patient or pushing the uncleanness deeper into the person. This kind of behavior is relatively new to mainstream America. At the same time, we see the rise of secularism that is often disturbing to religious people on campuses. Secularism can be defined as the absence of the spiritual in day‐
to‐day life. Secularism is often caused by the multi‐religious context in which we find ourselves. Christmas has become something of a minefield in long‐term care communities. Do we have a Christmas tree or a menorah? What if Ramadan comes in the middle of December? What about Kwanzaa, a new quasi‐religious ethnic celebration practiced by many of our employees and residents? A resident in a California comprehensive‐care residential community complained to the state regarding prayers being said at meals. The result was that the state banned all prayers, moments of silence, and even piano music before meals and enforced the ban with a fine of one hundred dollars per occurrence. It is no wonder that administrators and other staff have begun to soft‐pedal religion on campus. These people are responsible for the well‐being of the most frail and vulnerable in our society. At the same time, they are confronted with an ever‐oppressive regulatory government that is ready to criticize and even fine their every move. Thus, when challenged with a “hot potato” like religion, a subject on which everyone has an opinion and no one has a consensus, it is hardly surprising that administrators throw up their hands and say, “Enough is enough.” The Dilemma For many of our residents, if not most, religion is an essential part of life. The World War II generation that comprises the bulk of long‐term care residents at the present time is a generation that often defines itself by religion. They grew up filling out forms that list religion as an identifier: Jewish, Catholic, Jehovah’s Witness, or Muslim; few left this space blank. Even those who do not attend religious services still describe themselves as being religious, as being believers. At the same time, Americans are beginning to sense the limitations of technology and biomedics. We are beginning to sense that there is more to being human than a body made hard by hours spent in a gym. In fact, the experience of aging with its confrontation of human frailty can be our best teacher. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 23 of 37 Thomas Moore, author of The Care of the Soul, once noted, “Aging is one of the ways the soul nudges itself into attention to the spirit.” In the second half of life, as our bodies begin to slow down, we are reminded of our mortality and are compelled to consider the larger realities of life. “Aging,” he continues, “forces us to decide what is important in life.” Jane Thibault, writing for the periodical, Aging and Spirituality, suggests that the process of growing older is a natural monastery where a person surrenders attachments to things long held dear, moves into a place of communal living, adopts a simpler, quieter lifestyle, and contemplates the meaning of his life. In an article in The Journal of Long‐Term Care Administration (Winter 1996‐97), Kenneth Lewis writes, “From my experience, I remain convinced religion can help residents adjust to nursing home life as well as provide a source of strength, purpose and comfort during their stay...In nearly 23 years of working with institutionalized elderly, I cannot recall a significant instance when a resident has voiced a total disinterest in religious issues.” And so we find ourselves on the horns of a dilemma. On one hand, there is the wide range of religious expressions and experience, and on the other, a cautious, if not hostile, regulatory environment. Yet our residents have religious needs that cry for attention. Is it possible to express one’s religion without being sectarian and exclusive? The answer is and always has been, “Yes.” Defining Spirituality Not everyone has a religion, but everyone has spirituality. Every person has both a formal belief and a functional belief. One’s formal belief is expressed in creeds, sacred writings, and worship and is usually something akin to the beliefs of the faith group into which one has been born or which one has adopted. Functional belief, on the other hand, has to do with what one personally believes and acts upon. Functional belief is of the heart, sometimes the emotions. Formal belief is of the head—it is logical, cognitive, and organized. One’s functional belief is more personal and may not be identical with one’s formal belief. Thus a person can be Catholic and still practice birth control. A Lutheran can believe that Jesus died for his sins, but still be overwhelmed by guilt over past sins. People usually argue religion using their formal beliefs. When listeners hear attempts to convince and defend, they tend to tune out. But when a person shares a functional belief, something different usually happens: People listen, understand, and learn. “I can only speak of what I know,” says the Rev. Pati Mary Andrews. “That’s the only way to share my faith. What I know, what I have experienced.” Religion is the expression of formal belief. Spirituality is the expression of functional belief. Religion is the sum total of what one believes, should believe, or perhaps would like to believe. Spirituality or functional belief is what one actually does believe. This insight is the reason institutions have problems when they seek to deal with formal beliefs (i.e., religion) instead of functional beliefs (i.e., spirituality). In formal belief there are winners and losers. In functional belief there are only believers, each seeking to understand life’s great mysteries. Unfortunately, for some people the spiritual cannot be precisely defined. Seeking to analyze, understand, or even closely define the spiritual is the realm of religion. Simply experiencing the spiritual is spirituality. One’s spirituality is all of one’s life. As Kathleen Fischer notes in her book Winter Grace, “Spirituality means not just one compartment of life, but the deepest dimension of all of life. The spiritual is the ultimate ground of all our questions, hopes, fears and loves.” (Fischer, 1998) Religious tradition teaches that spirituality, one’s soul, is midway between understanding and unconsciousness and that its mode of expression is neither mind (logic, reason) nor body, but imagination. Spirituality is concerned more with listening than managing, controlling, or even curing. While medicine sees the limitations of older life as problems to be solved, spirituality sees the same experience as providing gifts to be received and from which we can learn. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 24 of 37 Yes, not everyonee has a religion, but everyo
one has spirituality—a wayy of experienccing and findiing meaning iin life. “Spirrituality,” notes James Fow
wler in his boo
ok, Stages of Life, “is the w
way in which aa person understands and lives life in view of her or his ultimate meaaning, beliefss and values.”” If spiritualityy can be liken
ned to wine, then religious expression d becomes thee vehicle for tthe wine, being both shareed and may be a goblet that gives the wine shape aand form and
receiived. “Soul (sp
pirituality),” w
writes Thomaas Moore, “is the font of w
who we are, and yet is far b
beyond our caapacity to devisse and to control. We can cultivate, ten
nd, enjoy and participate in
n the things o
of the soul, bu
ut we can’t ou
utwit it, or manaage it or shap
pe it to the de
esigns of a willlful ego” (Mo
oore, 1994).
mething that is both within and beyond
d, something as real as thee nose on you
ur face but yeet intangible The sspiritual is som
and m
mysterious ass a puff of win
nd or the exp
perience of lovve. The spiritual is experieenced when w
we sense something beyo
ond what we ccan know or u
understand cognitively. It is more than what we can
n see, touch, ttaste, feel, orr prove. The spirittual takes in tthe whole, the total, the G
Gestalt, if you will. At its mo
ost basic leveel, spirituality is the embraacing of the vulneerable self within. When o
one is vulnerable, one is pliable and opeen to change. When one iss vulnerable, embracing humaanity with all its gifts and llimitations, one is ready to
o receive from
m beyond oneeself and williing to learn.
All off the great religious traditiions of the wo
orld have succh a life‐stancce as the goal of their faith
h. Buddhism sspeaks of detacching yoursellf from all attaachments thaat, from its peerspective, is the root causse and sourcee of human su
uffering and pain.. Islam teachees that follow
wing the will o
of Allah who iss supreme ovver all, a follow
wing that, am
mong other th
hings, is expreessed in five d
daily prayer ttimes where tthe worshiper prostrates h
himself beforee the Divine. New Age philosophies speak of centeringg the self and
d focusing thee self within. C
Christianity saays to “deny yourself, takee up your cross, and follow
w.” The doorway to the sp
piritual and a connection w
with that whicch is beyond is found through an embraacing of our humaanity. It is an undeniable ffact of our humanity that tthe elderly, esspecially the ffrail elderly, live with everry moment off their lives. Appllying Spiritu
uality to Agin
ng Whatt do these inssights regardiing spirituality have to sayy regarding the golden years of old age?? The golden years are nott goldeen because w
we have the time and resou
urces to engaage in a secon
nd adolescencce. What makkes them gold
den is that wee have the time and
d the opportu
unity to discovver the essen
ntial truth of life and to gro
ow from desp
pair to integritty, which 0). We discovver that while all of the trin
nkets that wee have gathered throughou
ut our life can
n leadss to wisdom (Erikson, 1950
be fu
un, they are not life‐giving or life‐fulfillin
ng. We find m
meaning in lifee by really fin
nding meaningg in limitation
n (Frankl, 1959
9). Whatt makes the ggolden years ggolden is thatt we discoverr that relation
nships are moree important than achievem
ment; loving, more vital than getting; “b
being,” moree important than “doing;” and that the journey inwaard is of deep
per value than our ability to
o manage and
d control. Meaning and purpose becom
me rooted in who we are and n
not our abilityy to see, remeember, walk, and hear. A rresident in an asssisted living ffacility recenttly said to mee, “My old agee has given m
me time to read,, to think, to p
pray.” Charles Fahey, Dirrector of the Third Age Center at Fordh
ham Universitty and past presiident of AAHSSA writes, “Th
he elderly ressident challen
nges us in more ways than our psycholo
ogical responsse to geriatricc dependencee. She (or he) calls into w of the spiritu
uality of the h
human being. The book off Leviticus in question our view
the B
Bible calls for a year of “Jubilee”—a perriod during which memberrs of a comm
munity set things right in aall relationshiips. It is a greaat boon to reecall that for m
many elderly,, including nursing home residents, the Thirrd Age is a tim
me for ‘setting things rightt’ spiritually, aa time for cultivation of th
he interior lifee and, for a perso
on such as myyself, a time ffor prayer. True, a strength
hened spiritu
uality will not eliminate poverty or sickn
ness, but it makees coping with these visitations of old aage much easier.” © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 25
5 of 37 When we relate to
o others thro
ough our form
mal belief, ourr theology, do
octrine, dogm
ma, or traditio
on, we get into
o trouble. Relattionships become fraught with complications, differences, and deefensiveness.. When peoplle approach eeach other insteead from a plaace of practice or functional belief, our spirituality—
—that which iss beyond know
wing, beyond
d undeerstanding—w
we touch the soul and are strengthened
d by each oth
her even when there are disagreementss. The problem with spirritual care in llong‐term carre settings is tthat some ten
nd to focus on the religiou
us instead of tthe spiritual.
Theyy concentrate on what peo
ople know and
d understand
d instead of th
he experiencee of the “beyo
ond” in life, on external belieef and practicee instead of internal experrience. How
w One Long‐TTerm Care O
Organization
n Provides Sp
piritual Care
e he development of the spiritual withou
ut being sectaarian, divisive, or exclusivee? One modell How can a facility encourage th
is California Lutheeran Homes and Communiity Services in
n Southern Caalifornia. Thro
ough their eigghteen‐memb
ber interdisciplinary eethics committtee, they havve composed a teaching sttatement on sspiritual form
mation and paastoral care.
A cop
py of their teaaching statem
ment follows. After printing, take a few moments to read the entire statementt. In the marggin place the ffollowing: A
on point by th
hose statemen
nts that you ffind helpful and/or excitingg • An explanatio
• A question ma
A
ark by those sstatements o
of which you aare not sure
• An asterisk by
A
y those sentences that you
u wish to sharre with someo
one else • A sad face by A
ments that you
u do not agreee with, noting in the marggin what you do believe those statem
Califo
ornia Lutheraan Homes Teaching Statem
ment on Spiritual Formatiion and Pasto
oral Care Policcy Statement a Lutheran Ho
omes and Com
mmunity Serviices, motivateed by a love ffor Jesus Chrisst and ground
ded in Judeo‐
California
Christian values of com
mpassion, incllusiveness, an
nd empowerm
ment to grow,, extends a ministry of pastoral care and spiritual formation
n to all residents, regardlesss of religiouss affiliation an
nd belief. Not eeveryone has a religion, bu
ut everyone h
has spirituality. Some, becaause of ch
hoice or chancce, have foun
nd themselvess estranged frrom “organized religiion.” But people have spirituality, a meeans of making meaning an
nd sensee out of their world and th
heir life. Spirittuality is the w
way in which one undeerstands and lives life in vie
ew of one’s u
ultimate mean
ning, beliefs, and valuees. Spiritualityy is the unifying and integrrative aspect of a person’ss life, giving vibrancy to the identity, establishing a fundamenttal basis for a perso
on’s relationsship with othe
ers and with ssociety. Spirittuality may orr may not be expressed in religio
ous language (James Fowleer, pp. 85, 94
4). One’s spirituality needs to be aattended to in
n order for it to form and deveelop. This proccess of “atten
nding” may bee demonstratted through traditional religiou
us practices, or it may be eexpressed in fforms that arre outside traditional religiious practicess. Our spirittuality is nurtured and shaped within uss through inteeractions with other perso
ons and their experiences with the spirittual things in life. These interactions miight be through personal cconversationss, books, the arts, group exxpressions and eexperiences, worship, prayyer, and the sstudy of Sacreed Scriptures. Spirituality is personal exxperience. Ho
owever, all perso
ons need to b
be informed aand nurtured by the experience of otheers who provide insights an
nd understan
nding that otherwise might h
have been ign
nored or misssed altogether. This interacction of perso
ons and their spiritual environment is the p
process of spiritual formation. Spiritual formation occcurs as one rreflects on lifee and the meaning of life. One place wherre this reflection can take place is throu
ugh religious expression. © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 26
6 of 37 If spirituality may be likened to wine, then religious expression may be a goblet that gives the wine shape and becomes the vehicle for the wine to be both shared and received. Personal spiritual growth, an encounter with the transcendent in life, is the goal of religious expression. While spirituality is essentially an experience of the present moment, religion connects the individual with the past, the tradition, and the experience of the ages. While spirituality focuses on what is and what is to come, religion reminds us of what has been and what has worked in the past. Spirituality is fluid, open, always moving, while religion is ritual, grounding, and foundation building. Whether or not a person’s spirituality is expressed and fashioned through religion, all persons have a deep need for the spiritual in life. This is particularly true for the elderly and those suffering from terminal or chronic illnesses. The works of Carl Jung, Erik Erikson, Victor Frankl, James Fowler, Paul Tillich, and many others point to a deeply spiritual root of human existence. More recent thinking and writing regarding aging is moving past the traditional biomedical approach with elderly persons. As one is confronted with the loss of spouses, siblings, and friends, limited by chronic illness and debilitating experiences, and confronted, perhaps for the first time, with one’s own humanity and essential vulnerability, questions are raised that might be medical, psychological, or sociological, but are essentially spiritual. What is the meaning of life? What is my value since I feel I can no longer “produce?” It was the philosopher Descartes who said, “I think, therefore I am,” but what happens when I can no longer think? Is there any meaning in my suffering? Is there something beyond what I can see, touch, taste, and feel? These are essentially spiritual questions that can “de‐spirit” a person. When persons become “de‐spirited”, out‐of‐touch with the spiritual, the intangible, in life, effects can be seen in their sense of personal dignity, as well as their physical, emotional, and social well‐being. Thus, California Lutheran Homes and Community Services seeks to assist persons to seek, find, and grow in meaning‐
making through pastoral care and spiritual formation. We are responsive to the religious needs of persons, linking them to their traditions that give guidance for their living, as well as assisting persons to grow as spiritual beings. While affirming and encouraging the spirituality of its residents and the practice of all religious expressions, California Lutheran Homes and Community Services remains essentially Judeo‐Christian in orientation, with its emphasis on unconditional love and a desire to walk with persons as they seek meaning through spirituality and religious life. Statement of Values and Purposes Regarding Spiritual Formation on CLH/CS Campuses Aging is a life‐long process. From birth we are aging, growing, changing, seeking, finding, and seeking again. For life experiences teach, encourage, and guide us. Age, a dynamic teacher of the spiritual life, cannot be resisted or ignored as it guides persons toward the deeper issues of life and the meaning of existence. The following is a statement of values and purposes regarding spiritual formation at CLH/CS and is meant to be a guide to CLH/CS campuses in their encouragement of spiritual formation in elders. 1. Spiritual formation happens when a person is affirmed as essentially a spiritual being with an innate need to be in relationship with the transcendent beyond what can be seen, touched, tasted, felt, or proven. 2. Spiritual formation happens when a person is seen as a unique individual and thus of ultimate worth, striving for wholeness in physical, mental, social, emotional, and spiritual strengths and needs. 3. Spiritual formation happens when life is expressed as a journey of choice between growth and despair lived out in community with others as one learns from the pains as well as the joys, the tragedies as well as the triumphs of life. 4. Spiritual formation happens when life is viewed as having value and meaning from active and independent living through disability and illness, even in pain and suffering, even through the moment of death. 5. Spiritual formation happens at every age, but it becomes essential for the elderly, the chronically ill, and the dying, who cannot mask the finiteness of life and living. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 27 of 37 6. Spiritual formation happens when persons are a part of a community that is open to personal and corporate search for meaning. 7. Spiritual formation happens when the staffs that care for the elderly, the chronically ill, and the dying are encouraged to discover and express their own spirituality, thus becoming a part of the searching community. 8. Spiritual formation happens when corporate personnel affirm and encourage spiritual growth throughout the corporation. 9. Spiritual formation happens within a community that both supports and challenges one’s personal faith. 10. Spiritual formation happens when residents are served by clinically trained chaplains who understand their role as companions on residents’ spiritual journeys and thus are committed to providing for the spiritual and religious needs of all persons in the community they serve. Spirituality and Religion on CLH/CS Campuses Aging evokes spiritual questions. Spiritual questions require religious observances that support and encourage the inner spiritual journey towards meaning taken by all residents. The goal of religious expression is not indoctrination, but rather the stimulation and growth of the residents’ personal encounter with the transcendent in their lives. Therefore, California Lutheran Homes and Community Services provides for the religious observance of all residents of all religious faiths. Our campuses do not foster “sectarian expectations,” but rather provide for spiritual growth and formation as the resident defines such spiritual growth. Every effort is made to provide the means for the spiritual growth of each resident within the bounds of his health concerns, regulations, time constraints, and a concern for the larger resident community. The chaplain may recruit volunteer religious leaders from off‐campus in order to provide for the “spe‐
cialized” religious needs that might otherwise go unmet. The chaplain shall promote the celebration of festivals appropriate for the religious traditions found on the campus (i.e., Christmas, Easter, Yom Kippur, Passover, Buddha’s Birthday, Chinese New Year, and Ramadan). Where appropriate, all residents will be invited to participate with residents from that tradition, thus promoting understanding and a sense of community among all who are seeking a deeper experience with the divine. Comments on the Teaching Statement Note the phrase from the policy statement, “… grounded in Judeo‐Christian values of compassion, inclusiveness, and empowerment to grow.” This statement suggests that to be Christian is to be caring and empowering. We are not called by God to be Christians serving Christians, but Christians serving. If you or your facility has a faith‐based background, use that heritage to support and guide your actions, but do not be a slave to it. If you do not come from a faith‐based background you might ask yourself why you seek to provide spiritual formation and pastoral care. Your answer might be, “To follow the Torah of God,” ”To honor our mother and father,” or “Because it is the nature of aging to become more spiritual.” Motivations are important. I would hope that those motivations are inclusive rather than exclusive in nature, seeking to be of service rather than seeking to expand membership in some organization. The policy statement continues, “…extends a ministry of pastoral care and spiritual formation.” Note the last two words. Most pastoral ministries emphasize merely pastoral care that can deteriorate into simple handholding. Handholding is not bad, just limiting. Spiritual care is to help every resident, patient, or client develop the spiritual side of her person. To provide spiritual formation as well as pastoral care is to expect and encourage growth and change. It is to view persons as being always in the state of becoming, no matter what their age or physical abilities. Finally, the policy statement concludes, “…to all residents regardless of religious affiliation and belief.” Actually, it is important to provide spiritual care for all persons regardless of their belief or non‐belief. Remember, not everyone has a religion, but everyone has spirituality. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 28 of 37 The ten life‐affirming values and purposes seek to reveal the context in which the statement is written. The first value, that persons are essentially spiritual in nature, is at the heart of spiritual care. One does not need to bring the spiritual to anyone. A spiritual caregiver’s task is merely to point to what is already there and help residents, clients, or patients embrace that which is. The second value is also basic, noting that each person has worth and trying to do the best he can with what he has. There is no room for judgment by spiritual caregivers—only encouragement to grow, and eyes that can see the forest rather than the trees. Spiritual formation is a matter of choice. No one can force spiritual formation on another person. But when this path is chosen, self and others support the spiritual journey of aging as they experience the ups and downs of life and living. Obviously, each person has worth and life has meaning, even though life includes suffering, pain, and even death. These experiences do not have to defeat life, but instead can deepen one’s life experience. It is not just a question of whether the glass is half empty or half full. It can be a question of whether one is even thirsty and needing water, even if the glass is only ten percent full! Asking questions can lead one deeper into life. Spiritual formation happens at any age, but it is more dramatic and even essential for the elderly and chronically ill who are struggling with issues of self‐worth, value, and meaning. Spirituality invites a person to embrace the future and experience the joys of the present instead of lamenting over the past. Community is crucial to spiritual formation. Without it, a person struggles alone in isolation. Without community, a person’s vision is limited to her own prejudices and perspectives, and there is no one to give support during times of trial or to share with in times of joy. Although spiritual care is personal, it is not private. Because spiritual care is based upon relationships, it is fostered when staff members throughout the facility are concerned with spirituality, both that of the resident, client, or patient and their own. Spiritual care is based upon a willingness to become vulnerable and open to change and new experiences and ideas. Thus the eighth and ninth values speak about the need for community. Spiritual formation happens best when it is guided by a clinically trained person who is comfortable with facilitating discussions of spirituality. While having such a person on staff might not be financially possible in many facilities, it should be a goal. Finally, the expression of diversity in religious matters should be assured, not suppressed. Spiritual counseling should be easily accessible, and all should have a place to express their faith. Everyone at one time or another is presented with the opportunity to respond to the spiritual needs of the patient. The person designated to do this full‐time is the chaplain. The information that follows is from California Lutheran Homes Chaplaincy Statement. You are welcome to use this in your own facilities as a basis for a chaplain position. Read with an eye to understanding the difference between someone who intermittently responds to the spiritual needs of the patient, and the chaplain who is responsible for the task full‐time. Vision Statement and Statement of Goals and Purposes for Chaplaincy Vision Statement The chaplains of California Lutheran Homes and Community Services extend a ministry of pastoral care and spiritual formation to all residents, regardless of religious affiliation and belief (or non‐belief). We are grounded in the Judeo‐
Christian values of compassion, inclusiveness, and empowerment to grow. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 29 of 37 State
ement of Valu
ues and Purp
poses 1. Persons are e
P
ssentially spirritual beings w
with an innatte need to be in a relationsship with the transcenden
nt beyond w
what one can see, touch, taste, intuit, o
or prove. 2. EEach person iss a unique cre
eation of God
d, striving for wholeness in
n his or her ph
hysical, mental, social, emotional, and s
spiritual stren
ngths and nee
eds. between grow
wth and desp
pair, lived out in communitty with other journeyers ass one learns 3. LLife is a journeey of choice b
f
from the pain
s as well as th
he joys, the tragedies as w
well as the triu
umphs of life. 4. LLife has value and meaningg, from activee and indepen
ndent living, tthrough disab
bility and illneess, even in pain and s
suffering and through the moment of death. 5. C
Chaplains are companions on life’s jourrney. We seekk to “care for the soul” by listening morre that speaking, e
encouraging r
residents to e
embrace theirr imagination, and involvin
ng them in experiences thaat touch the h
heart within.
B
By using tradi
tional strateggies such as w
worship, Biblee study, prayeer groups, visiitation, as weell as other creeative meanss o
of ministry, w
we seek to empower resideents to cultivaate and particcipate in the tthings of the soul through reflection, imagination, aand meaning making. 6. A
As chaplains w
we are advocaates for strucctures and relationships on
n our campuss that lead to reflection and meaning m
making. We accept and embrace th
he cultural an
nd religious diiversity of ressidents and sttaff and seek to minister w
with them 7. W
b
based on thos
se diversities.. Not everyon
ne has a religion, but everyyone has spiriituality. Purpose and Role
e of the Chaplain As a companion o
on life’s journe
ey, the chaplaain is the spirritual directorr of the resideents and staff on each campus. His prim
mary purpose is to assist an
nd encouragee residents and staff in their own spirituaal developmen
nt as they deffine that deveelopment. Th
he chaplain is not there to givve answers, sso much as to
o encourage aand accompan
ny residents aand staff on their spirittual journeys.. However, since each chaplain brings h
his own uniqu
ue gifts, insigh
hts, and educcation into thee spiritual life
e of the comm
munity, he is eencouraged to interact creeatively with each resident or staff mem
mber while not imposing h
his own viewss upon them. The cchaplain shalll be a resourcce to the stafff on the subjeect of spirituaality and religion. In this role, the chaplain will provide tthe nursing and social servvice staff with
h sensitivity training and information on the religious exxpressions of all residents,, particularly tthose surroun
nding death and d
dying. The cchaplain shalll interact with
h other staff aand campus aadministration advocating for resident experiences tthat promotee the V
Vision Statement and State
ement of Valu
ues and Purpo
oses of Chapllaincy. In this role, the chaaplain will advvocate for thee free religious exprression of all residents. Th
his vision stateement shall b
be reviewed b
by appropriate corporate sstaff, campus admiinistrators, an
nd chaplains n
no less than eevery three yeears in order to keep it freesh and current to the pressent needs off the residents. CLH//CS shall provide a current corporate job description
n for the chap
plain that shalll provide thee basis for thee chaplain’s job d
description on
n each campu
us. This corpo
orate job desccription shall b
be reviewed by appropriatte corporate staff, campuss admiinistrators, an
nd chaplains n
no less than eevery three yeears so that tthis policy migght remain fresh and curreent to the preseent needs of tthe residentss © 2004 Pro
ofessional Develo
opment Resourcces & Care2Learn | www.pdreso
ources.org | 30‐14 Challenges in
n Aging | Page 30
0 of 37 Essential Duties and Responsibilities of the Chaplain (Other duties may be assigned) • Lead regular worship services. • Prepare and deliver sermons and other talks. • Visit residents in their apartments and elsewhere on campus to provide advice, counsel, and to listen to personal concerns. Comfort residents and family members during times of crisis. • Create and maintain spiritual assessments, care plans, and documentation of ministry for nursing and assisted living residents. Maintain records of resident participation in programs and pastoral visitations. • Make visits to residents who are hospitalized. • Participate in weekly care‐conferences. • Conduct Bible study, prayer groups, and other spiritually supportive programs. • Occasionally provide pastoral care to facility staff. • Write articles for publication if appropriate; and engage in interfaith, community, civic, educational, and LCMS/ELCA programs. • Assist chaplains of other campuses when needed. Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education and Experience Graduate from an accredited college or university and theological school with three to four units of clinical pastoral education. Previous experience working with older persons in a residential and clinical setting is strongly preferred. Language Skills Needed abilities include the ability to read, analyze, and interpret the most complex documents; to respond effectively to the most sensitive inquiries or complaints; to write speeches and articles using original or innovative techniques or style; to make effective and persuasive speeches and presentations on controversial or complex topics to public a group. Reasoning Ability The pastor should have the ability to apply principles of logical thinking to a wide range of intellectual and practical problems and the capacity to deal with a variety of abstract and concrete variables. Certificates, Licenses, Registrations Ecclesiastical endorsement for specialized ministry required. Certification by a national chaplaincy organization or association preferred. Other Skills and Abilities The chaplain must be comfortable with religious diversity and able to provide pastoral care to residents of all beliefs (or non‐belief). The chaplain must be able to fulfill the Vision Statement and Statement of Goals and Purposes for Chaplaincy. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 31 of 37 Physical Demands The physical demands described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is required to talk to and listen to residents, families, and staff. The employee frequently is required to sit with residents and family members during counseling. The employee must regularly lift and/or move up to ten pounds and occasionally lift and/or move up to twenty‐five pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Work Environment The work environment characteristics described here are representative of that which an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually moderate. Basic Facility Needs Where possible, space will be provided for the religious expression of residents on a twenty‐four‐hour basis. Symbols meaningful to each religious expression will be utilized as much as reasonably possible. Each campus is encouraged to have at least one small space for quiet reflection, meditation, and prayer. Role of CLH/CS Staff in Pastoral Care and Spiritual Formation Evangelizing, the intentional effort to promote one’s personal sectarian expectations and views, is prohibited by California Lutheran Homes and Community Services. The spirituality and religious expression of each resident or staff member must not only be respected and honored, but also affirmed and encouraged. Most religious or spiritual needs are to be referred to the chaplain. However, other staff members, by their presence and relationship with a specific resident, are sometimes in a unique position to encourage and influence that resident’s spiritual life. Therefore, in a spirit of being companions on life’s journey, staff members are allowed to share their personal faith‐stories as appropriate if requested by the resident. Personal stories and views are to be shared from one journeyer to another, without the staff member’s trying to convince the resident of the validity of his or her views. Prayer is essential for spiritual development. Staff members are encouraged to pray with residents in a way that supports the resident, while not fostering sectarian expectations. Supportive prayer includes praying for peace, the presence of God, forgiveness, for family members, for personal health, even for death. Inappropriate prayer includes unsolicited prayer, and praying in the name of God other than the God as defined by the resident. Questions regarding this policy should be directed to the chaplain. Guidelines for Visiting Clergy of All Faith Groups Clergy from all religious expressions are encouraged to visit members of their synagogue, church, temple, ward, or mosque who are residents on campus. However, no evangelizing is to be done. All studies of religious literature, prayer groups, or religious celebrations must be conducted in the resident’s room. No religious activity or distribution of religious materials may be offered outside a resident’s room without the expressed, written approval of both the chaplain and the administrator of the facility. Every effort will be made to contact local spiritual leaders when there is a change in status of a member of their synagogue, church, temple, ward, or mosque. The chapel or other appropriate space will be made available to off‐
campus religious leaders in order to conduct funerals and other services required by a resident’s religious expression. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 32 of 37 After reading the information about the role of a full‐time chaplain, think about your current paradigm of chaplaincy. How does the job description compare with your understanding of the task of spiritual caregiver? While you might not have a professional chaplain on staff, most of the same duties need to be performed by someone else, either staff or volunteer. Go through the job description and note in the margins those items that could be done by staff, and which could be done by volunteers from outside your facility. Recruiting Local Clergy to Help Perhaps a word about visiting clergy would be helpful at this point. Executive directors and other staff often feel very capable of dealing with everyone except a clergy person. Suddenly they feel vulnerable and disempowered. Considering the Vision Statement and Statement of Goals and Purposes for Chaplaincy as noted previously, the following are questions to ask a visiting clergy person: • How do you feel about ministering in a multi‐religious situation? (Be sure to enumerate the diversity on campus.) • What experience have you had in dealing with end‐of‐life issues? • What have you read regarding the aging experience? (This question will reveal the person’s interest in aging issues.) Remember, you are looking for a person of compassion as well as knowledge and insight. Treat local clergy as staff persons, especially when it comes to responsibilities. You have to set the tone. Consider designating a parking space for visiting clergy. Even if it is not as convenient as it might be, the message that it sends speaks volumes. Think multi‐religion. Review the religious preferences of your residents and ensure that all have the opportunity to be served by someone. Providing Spiritual Care When There Is No Chaplain Let’s get even more practical. Ideally facilities should hire a full‐time, clinically trained chaplain. This is the only way to get consistent spiritual care. But not all pastors are prepared to work in a multi‐disciplinary, multi‐religious setting such as a long‐term care facility. Most of them have spent their entire lives ministering to like‐minded people and seeking to encourage everyone else to join their church. Clinical training, through a means such as clinical pastoral education, expands a pastor’s view of life and diffuses his understanding of life, both of which are essential to effective ministry to older persons in a long‐term care setting. So although it is ideal if your facility could hire a qualified person, certified by the Association of Professional Chaplains and/or the National Association of Catholic Chaplains, it takes time to develop what might be a new position for your facility. As you plan and develop a chaplaincy position over the next five years, what do you do in the meantime? How can a facility tend to the spirit without having a full‐time chaplain? Learning Activity: “Forty‐Two Ways to Provide Spiritual Care Without a Chaplain" •
•
•
Put parentheses around five things you are already doing. You might be doing more spiritual care than you realize. Perhaps that care just needs to be recognized and focused so that it becomes more effective. Cross out five strategies that you would like to do, but feel would be impossible to do within your facility at this time. Perhaps you do not have the staff or even the volunteers to lead such a group. It may be the cost would be prohibitive, or the turnover in your facility is too great. Underline five items that you feel could be implemented and could be offered by other staff persons in your facility. Write the names of those persons in the margins. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 33 of 37 •
•
Circle five things that you feel could be done by yourself as a part of your service with residents, clients, or patients. Make a note to yourself regarding materials that you might have to gather and when such services could be provided. Finally, since “Forty‐Two Ways to Provide Spiritual Care Without a Chaplain” is always going to be a work in progress, scan the list one more time and add to the list two additional ways of providing spiritual care. Forty‐Two Ways to Provide Spiritual Care Without a Chaplain 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Use volunteer groups from local churches to provide worship experiences. Have volunteers provide one‐to‐one room visits. Ask volunteer clergy from the community to provide regular Bible study. Hold a community gathering to sing hymns. Display paintings from a local senior center. Arrange mini‐concerts from a local school of music. Designate a religious heritage day when residents share their personal heritage. Celebrate religious holidays of all residents in the facility for all to share. Foster a life review that evokes reflection and meaning and is more than reminiscence. Encourage finger‐painting or abstract collage, expressions of abstractions such as forgiveness, death, and life beyond death. Facilitate meditation prayer groups. Encourage resident‐led devotions. Publish a booklet of resident experiences, entitled, “I Met God When….” Promote the development of ethical wills. Hold a “celebration of aging” festival, using local speakers. Schedule a Tai‐Chi class. Devise a ceremony for celebrating the life of a resident who has died. Develop a ritual for welcoming residents to their new home. Provide prayer cards appropriate for differing religious traditions for the meal tables. Give staff the freedom to talk about religion and faith without proselytizing. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 34 of 37 21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
Establish a dedicated space for worship and/or prayer. Ensure that residents are not only asked but are provided the means of attending religious experiences held on campus. Make a person’s spirituality a part of the intake assessment. Have at least one TV in the facility tuned to religious programming when appropriate. Mail a letter to local faith groups inviting them to partner with the facility. Take residents for a walk in the park. Provide a variety of devotional literature often available free through faith groups. Show videotaped presentations of stories with a meaning. Don’t forget to discuss their meaning afterwards. Have a library of audio and videotapes of sermons from local faith groups for residents to view. Hold a workshop for residents and families on end‐of‐life choices, including advance directives. Sponsor a grief support group. Hold an agenda‐less “caring and sharing group” for resident discussion, led by a person oriented toward discovering the meaning in life events. Ask a local synagogue to sponsor a Passover Seder. Allow local faith group choirs to hold their dress rehearsals at your facility. Hold a religious expression festival, and invite local clergy from differing faith groups to participate. Secure from residents the names of the clergy of their faith groups, and invite them to extend their ministry to your facility. Provide in‐service training for staff on spirituality, and make spiritual care one of the expectations of their work. Ask residents to write an article entitled “This I Believe” for your facility newsletter. Host a Chinese New Year celebration. Develop a policy on spiritual formation and pastoral care that gives guidelines for participation of clergy and faith groups from the community. Arrange a concert using local talent from high schools, elementary schools, churches, or individuals. Identify and use existing staff that has been trained within their own faith traditions to provide spiritual care and development. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 35 of 37 Conclusion Spirituality and aging might seem like a new frontier because its value and worth in providing excellent senior‐care services has been denied for years. It might even look like a new frontier, because it is being expressed in different terms and strange‐sounding emphases. But it really isn’t new. In fact, it is as old as age itself, for aging is a spiritual journey. It sometimes requires the gifts and the support of physicians, social workers, nurses, CNAs, housekeepers, dietary staff, maintenance personnel, computer gurus, administrators, executive directors, and business office staff. But all of them, including the campus spiritual director, are but cheerleaders or observers of what is really going on within the persons of residents, patients, or clients—the spiritual challenge, growth, and pushing of the edges of belief. Challenging the values of a lifetime as a person not only confronts the reality of death, limitation, and humanity, but also takes the many pieces of one’s personal life and puts them together into a portrait of meaning. If this course has elicited questions, concerns or suggestions, e‐mail me at [email protected] for information or coaching. I would be glad to point you in the right direction to find the information you need. Internet Links of Interest Center for Spirituality and Aging: http://www.spiritualityandaging.org American Association of Homes and Services for the Aging: http://www.aahsa.org/ American Society on Aging’s Forum on Religion, Spirituality and Aging: http://www.asaging.org/forsa National Council on the Aging’s National Interfaith Coalition on Aging: http://www.ncoa.org Judaism and Spirituality: http://www.sacredseasons.org Buddhism: http://www.urbandharma.org Author Bio Donald R. Koepke, MDiv, is currently Director of the CLH Center for Spirituality and Aging established and funded by California Lutheran Homes, Anaheim, California. Rev. Koepke earned his Master of Divinity from Lutheran School of Technology at Chicago in 1967 and completed his residency in clinical pastoral care at the UCLA Medical Center in 1995. He also earned his certificate at the Geriatric Pastoral Care Institute at the Center for Aging, Religion and Spirituality in Minneapolis, Minnesota. Rev. Koepke is a member of the American Society on Aging, Forum on Spirituality and Religion, ASA, serving on its governing council; the National Council on the Aging, National Interfaith Coalition on Aging, serving as secretary to its delegate council; and a board‐certified member of the Association of Professional Chaplains. Since 1995 he has been endorsed by the Evangelical Lutheran Church in America for specialized ministry and has conducted numerous professional workshops for service providers, caregivers, families, and older adults specializing in spirituality and aging. He is a board member of the Council on Aging of Orange County and the South Bay Retirement Residence in Compton, California. He is also an Advisory Council member, Department of Gerontology, at the University of La Verne, California. His book, Ministering to Older Adults: The Building Blocks is published through Haworth Press; http://www.haworthpress.com © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 36 of 37 References and Suggested Reading Albom, Mitch. Tuesdays with Morrie. New York: Doubleday, 1997. Au, Wilke. The Enduring Heart: Spirituality for the Long Haul. New York: Paulist Press, 2000. Bell, V., and Troxel, D. The Best Friends Approach to Alzheimer’s Care. Baltimore: Health Professions Press, 1997. Birren, James, and Cochran, Kathryn. Telling the Stories of Life Through Guided Autobiography Group booklet of resident experiences. Baltimore: The Johns Hopkins Press, 2001. Cohen, Gene 2005 The Mature Mind: The Positive Power of the Aging Brain Cambridge, MA: Basic Books 223 pp. ISBN 13‐978‐0‐465‐01203‐9 Cole, Thomas. The Journey of Life, A Cultural History of Aging in America. New York: University of Cambridge, 1993. Eiesland, Nancy. The Disabled God Nashville: Abingdon Press, 1994. Erikson, Erik H. Childhood and Youth. New York: Norton, 1950. Fischer, Kathleen. Winter Grace. Nashville: Upper Room Press, 1998. Fowler, James. Stages of Faith: The Psychology of Human Development and the Quest for Meaning. San Francisco: Harper and Row, 1995. Frankl, Viktor. Man’s Search for Meaning. New York: Simon & Schuster New York: Washington Square Press,1959. Jung, Carl. Modern Man in Search of a Soul. New York: Harcourt, Brace, and World, 1955. Kahle, Peter A. and Robbins, John M. (2004) The Power of Spirituality in Therapy: Integrating Spiritual and Religious Beliefs in Mental Health Practice New York, Haworth Press ISBN 0‐7890‐2114‐5 Kimble, Melvin (ed.) (2000) Viktor Frankl’s Contribution to Spirituality and Aging Haworth Press. Koenig, Harold G., McCullough, Michael E., Larson, David B. Handbook of Religion and Health 2001New York: Oxford University Press 712 pp. IBSN 0‐19‐511866‐9 Koepke, Donald R. (2005) Ministering to Older Adults: The Building Blocks Binghamton, NY: The Haworth Pastoral Press, 209pp IBSN 0‐7890‐3049‐7 Kriseman, Nancy The Caring Spirit Approach to Eldercare 2005 Baltimore: Health Professions Press IBSN 1‐932529‐06‐3 Kurtz, Ernst, and Ketcham, Katherine. The Spirituality of Imperfection. New York: Bantam Trade Paperback, 1992. Lustbader, Wendy. Counting on Kindness. New York: The Free Press, 1991. Lustbader, Wendy (2001) What’s Worth Knowing. New York, Penguin Putnam, Inc. McBride, J. LeBron. Spiritual Crisis; Surviving Trauma to the Soul. Binghamton, New York: Haworth Press , 1998. Miller, James and Cutshall, Susan (2001) The Art of Being a Healing Presence Willowgreen Publishing, Fort Wayne, Indiana ISBN 1‐885933‐32‐0 Miller, James (1995) Autumn Wisdom: Finding Meaning in Life’s Later Years (Second Edition) Fort Wayne, IN: Willowgreen Press 79 pp. IBSN 1‐885933‐37‐1 Moody, Harry, and Carroll, David. The Five Stages of the Soul. New York, Anchor Books, 1997. Moore, Thomas. Care of the Soul: A Guide for Cultivating Depth and Sacredness in Everyday Life. New York: HarperPerennial Library, 1994. Remen, Rachel Naomi, M.D. (1996) Kitchen Table Wisdom New York, Riverhead Books. Remen, Rachel Naomi, M.D. My Grandfather’s Blessing—Stories of Strength, Refuge and Belonging New York, Riverhead Books Richards, Marty. Caregiving, Church and Family Together. Louisville: Geneva Press, 1999. Schachter‐Shalomi, Zalman From Age‐ing to Sage‐ing 1995 New York: Warner Books, Inc. IBSN 0‐446‐67177‐0 Thibault, Jane Marie. A Deepening Love Affair, The Gift of God in Later Life. Nashville: Upper Room Press, 1993. Thomas, William (2004) What are Old People For? Acton MA: VanderWyk and Burnham. 370 pp. IBSN 1‐889242‐20‐9 Tickle, Phyllis. Re‐Discovering the Sacred: Spirituality in America. New York: Crossroad Publishing Company, 1995. Wimberly, Anne Streaty. Honoring African American Elders. San Francisco: Jossey‐Bass, Inc. Publishers, 1997. © 2004 Professional Development Resources & Care2Learn | www.pdresources.org | 30‐14 Challenges in Aging | Page 37 of 37