December 12, 2012
Cedars-Sinai’s chaplaincy program puts spirituality on the medical charts
Usually, the frantic words, “Someone get the rabbi!” uttered in a hospital room mean only one thing. So Debbie Marcus burst into tears when Rabbi Jason Weiner was summoned to her grandfather’s room at Cedars-Sinai Medical Center in July 2008.
Weiner, then interim Jewish chaplain at Cedars-Sinai, quickly assessed the situation: Albert Rubens, 97, had been brought in with a massive heart attack. Although he was still lucid, it was clear he was not going to make it.
But even with that devastating news, the rabbi detected that Debbie’s tears were about something more. And he was right. Albert, known to his family as Pop-Pop, had been eager to see Debbie, then 39, get married, but she and her then-fiancé, Marty Marcus, had not set a date for the wedding.
So someone floated an idea: Get married. Right now.
Pop-Pop liked it and so did the couple. Weiner agreed to officiate and scrambled to get the ritual items they would need. Within two hours, Debbie and Marty were holding Pop-Pop’s hands under a tallit — the family prayer shawl — which family members raised over the bed as a wedding canopy using poles Weiner had procured. Weiner recited the wedding blessings, and Marty gave Debbie a ring, which he had just bought from her aunt (tradition requires he own the ring used in the ceremony). Marty sealed the deal by stomping on a Styrofoam cup.
Pop-Pop died just hours after cries of “mazel tov” filled his room.
“It made me feel good that he got to see us married, that he was at peace and that he knew I was going to be taken care of. That’s what he was really concerned with,” Debbie said.
For Weiner, now senior rabbi and manager of spiritual care at Cedars, this story dramatically illustrates what hospital chaplains are called upon to do: to step into a family’s life at a critical moment, when the deepest questions and family relationships and unfinished business are all intensely focused.
“These are moments that are very sacred, but you might not recognize the sacredness of the moment because of the bells and everything going off. And if you stop and have someone help you do a life review or make meaning out of it, you realize the profundity of what is happening here,” Weiner said, standing outside a patient’s room last summer, one of several conversations over a few months that this reporter spent talking to and shadowing chaplains, doctors and patients at Cedars.
Recognizing that refuat hanefesh, healing the spirit, is as integral to its mission as refuat haguf, healing the body, over just the last two years, Cedars has nearly quadrupled its staff of chaplains, from three clergy members to 11, five of them Jewish. In the month of August 2011, its Jewish, Catholic, non-Catholic Christian and interfaith chaplains visited fewer than 400 patients. One year later, that monthly number had risen to more than 1,000.
Cedars’ investment reflects a national trend. In the last five years, medical institutions have caught on to the advantages of offering spiritual care. Now hospitals not only hire more chaplains but also require professional training and certification in the field. Chaplains have been upping professional standards for at least the last 25 years, replacing volunteer rabbis, nuns and other clergy with chaplains certified only after 1,600 hours of supervised field work and achieving an advanced degree in their religion. Spiritual care has even become a factor in accrediting health care organizations.
A 2011 study published in the Journal of General Internal Medicine found that patients who feel their spiritual and religious needs are being met say they are more satisfied with their overall hospital experience.
In 2010, following a six-month assessment involving 20 departments, Cedars, which has 923 beds and an overall budget of $2 billion, began to include its newly enlarged staff of chaplains on daily rounds visiting patients, alongside doctors, nurses, social workers and ethicists. Chaplains now document a patient’s progress on the same chart as the doctors. In November, Cedars opened its own clinical pastoral education program, which will train up to six chaplains a year.
“When Cedars was founded 110 years ago, it was a place where people went to die. It was called the Mount Sinai Home for Incurables,” said Jonathan Schreiber, director of community engagement at Cedars. “Today, the majority of people who come to our hospital live and go on and thrive, and this is a moment where they are at perhaps a challenge in their life, and to be there at their side and help them through that moment is remarkably precious and important work.”
A few months after Debbie and Marty Marcus’ hospital-room wedding, Weiner officiated at a more formal ceremony in a Malibu vineyard, and two years later, he named their now almost-2-year-old twins, Ilan and Alea — in memory of Pop-Pop, Albert.
Cedars-Sinai Medical Center head chaplain Rabbi Jason Weiner talks with patient Michele Rauch. Photo courtesy of Cedars-Sinai Medical Center
‘I’m here with you’
One day last summer, Weiner stopped outside a room on the fifth floor of the south tower, sanitized his hands with Purell, pulled on some latex gloves, then tapped gently on Michele Rauch’s door. She invited him in, and he slid a chair up to her bedside.
There were no flowers or balloons in the room, though Rauch had already been in the hospital for more than a week. Rauch, 51, was hospitalized for an autoimmune disorder and serious gastrointestinal issues — her 11th admission this year — but at the moment Weiner visited, she hadn’t told her father, a stroke victim, or her mother, who has respiratory problems, where she was.
“When I had brain surgery last year, I didn’t know whether I should talk to my mom about it. She was recovering from surgery, and we were worried about her,” said Rauch, a nurse. “I wasn’t able to lean on her or other people in my family for help, because the focus was on my mom, and now the focus is on my dad, and it always seems the focus isn’t on me.”
With warmth and gentle humor, Weiner guided the conversation with questions. In their 15 minutes together, Rauch talked about her daughter, showed Weiner a needlepoint she just finished — the stitching calms her, she said — and told him about some letters her great-grandfather wrote from Treblinka. She talked about wanting to learn more about Judaism and about the stress of needing to hold herself, and everyone else, together.
Before Weiner left, he offered a personal prayer for Rauch, asking God to relieve her suffering, to recognize the support she gives to so many others and to allow her to accomplish all that she wants. His prayer reflected exactly what Rauch told him, and as he asked her to offer her own prayer, tears welled in her eyes.
Weiner often quotes Rabbi Levi Meier, his predecessor, who served as chaplain at Cedars for almost 30 years, until his death in 2008.
“Rabbi Meier always said that even when a cure is impossible, healing is still possible,” Weiner said. “People start thinking about things and talking about things they never thought about at home, but they are forced to when they’re in a hospital. It’s like every day is Yom Kippur in the hospital.”
Meier, who was the first Jewish chaplain at Cedars, created a vast infrastructure of ritual support — kosher food, Shabbat-friendly elevators and entrances, mezuzahs on every door, opportunities to light candles, live and televised religious services for Christians and Jews, and inspirational classes for patients, caregivers and doctors of all faiths.
But more than that, Schreiber said, Meier made the intersection of spirituality and psychology central to healing at Cedars.
A visit with a hospital chaplain can be different from any other visit with clergy, doctors or loved ones, though a chaplain may have been a stranger to the patient just moments before. Chaplains are trained to focus on active listening, on trying to discern what is most important to a patient and to reflect that back to the patient. Many chaplains say they don’t talk much at all during visits — the words, “Hi, I’m a chaplain,” are often enough to open the floodgates.
“One of the things that I find to be most rewarding is the opportunity I have to help people reframe the way they think about something when they’re really upset,” said Laura Young, a Jewish chaplain embedded in Cedars’ critical care units. “I don’t give them the answer. I let them figure out what gives meaning to their lives so they can figure out their own direction.”
Young trained for four years at the Academy for Jewish Religion, California, the only program in the country where students earn a certificate of Jewish chaplaincy by simultaneously completing a master’s degree in Jewish studies and, in partnership with Methodist Hospital of Southern California, four units of clinical pastoral education.
The Rev. Lester Avestruz has been a priest for 40 years and trained to be a chaplain about 20 years ago. He has been the lead Catholic chaplain at Cedars for the last six years. He said that he has learned that directing his own peaceful energy into a violent or traumatic situation can help soothe a family. He remembers one situation where he was asked to minister to a family that was hysterical after a 21-year-old died violently.
“I couldn’t answer the question of, ‘Why is this happening to my son?’ I had no answer for that. But I tried to harness this peace energy and just direct it, and it worked,” Avestruz said.
George Baghdassarian, a minister trained in the Armenian Apostolic Church, works from 4 p.m. to midnight as the emergency room chaplain. He said he has learned the value of presence.
“I don’t think it’s appropriate to walk into a crazy situation and think you can say something that fixes it,” he said. “All you can say is, ‘This is a really crazy situation, but I’m here with you, with your screaming and your crying, and you’re not alone. And if you need to have it out with God, go ahead, but I want you to know I’m here.’ ”
Chaplains encounter family dynamics at their most stressful, times when “life gets cracked open,” said Peggy Kelley, Cedars’ lead Christian chaplain for just over a year. Embedded in the pediatrics department, she often deals with guilt — parents who believe God is punishing their own past behavior.
But she also sits with children, raw and honest, who inspire her daily. Kids close to death often talk about seeing angels, and they envision heaven. She remembers one cancer patient who said he had a special question for her:
“Do you think there are french fries in heaven?”
Kelley asked the boy what he thought.
“Yes,” he told her. “And ketchup, too.”
Ministering to all
Of course, what heaven or God or spirit means varies for each patient. While Cedars is, at its core, a Jewish hospital — founded by the Jewish community in 1902 and continuing its mission based on Jewish values — it is also a nonsectarian medical center that ministers to a diverse population and employs staff of all races, denominations and many nationalities. About 26 percent of patients are Jewish, 29 percent are non-Catholic Christians, 20 percent are Catholic and 5 percent are other — Muslims, Buddhists or Jehovah’s Witnesses, for instance. A full 20 percent are either unaffiliated, or decline or are unable to state.
Angelina Orduno, 58 and a documentary film researcher, considers herself spiritual but not religious; she was raised by a Catholic mother and an atheist father. Diagnosed with a form of leukemia, she was in the hospital last summer for a risky stem-cell transplant.
Lining every inch of the walls in her room were photos of friends and family, as well as several brooms — symbolic, for her, of her process of sweeping the cancer out, rather than destroying it, along with her tissues.
One picture showed Orduno fit and tan with silky waist-length hair, a contrast to her now-sallow cheeks and the baseball cap she wore to cover her bald head.
Orduno had visited several times with interfaith chaplain Christina Shu, a graduate of the Harvard Divinity School and a candidate for ordination with the Unitarian Universalist Association. Shu makes rounds with the palliative care unit, which is focused on alleviating severe symptoms and increasing patient comfort.
“Most people who come in and want to help just end up irritating me, but Christina has this calm and peace about her, and she brings it to me, and I take it in,” Orduno said. “It’s been really helpful, particularly in the beginning when they thought this was the end for me.”
A few weeks before Orduno’s transplant, Shu talked with her about how to cope during her two weeks at home before the procedure. Shu recommended some meditations, and Orduno talked about spending time with friends, about noticing each leaf on each tree.
“I want you to give me a prayer about not freaking out about the transplant, about staying in the moment,” Orduno requested.
“Holy One, gracious God, spirit of life,” Shu began, taking Orduno’s hands, bruised from IV lines, “we ask for your blessing for Angie. We pray you will surround her with your love and comfort. We ask that with every breath that she takes she will feel herself grounded in this present moment, that she feel open to the peace and the gratitude and the joy that is present in each day. … We ask that wherever she goes she feels that sense of peace and calm in her body, and in her mind, and in her spirit, and that she knows that whatever comes she has the strength to accept it and be present with it. Amen.”
Patients generally are matched with chaplains of their own faith, however given that having someone available at any moment is crucial with this kind of work, all the chaplains are trained and expected to minister to patients of all faiths, and to those with no faith at all.
Shu said some patients have asked her to visit, but only on condition that she not mention God.
“One of the most important things about training chaplains is we learn how not to impose our own beliefs on someone else, but to work with what their beliefs are,” said the Rev. Pamela Lazor, a Presbyterian chaplain at Cedars.
Lazor trained and then worked at UCLA’s Clinical Pastoral Education program before coming to Cedars. She said she learned there the importance of working to understand what a patient’s perception of God and spirituality is, and meeting them there.
Rabbi Pearl Barlev, a chaplain at UCLA’s Ronald Reagan Medical Center, remembers being on call when a baby was not going to make it through the night and the parents wanted him baptized.
“A rabbi performing a baptism is not genuine for the family or the rabbi,” Barlev said.
Instead, she relied on the script and accouterments the chaplaincy office has for baptisms, and she gathered the family, doctors and nurses, handing out parts to the Christians who were there.
Often, chaplains help hospital staff understand cultural and religious sensibilities. Barlev remembers a case of an Orthodox man admitted to UCLA’s psychiatric unit whose doctors initially banned his tefillin, fearful the patient might harm himself with the long leather straps that wrap around the head and arm during morning prayers. Barlev explained to the doctors that disrupting this important ritual would distress the patient, and she sat with him while he prayed each morning.
Barlev is one of four staff chaplains at the Ronald Reagan UCLA Medical Center campus in Westwood, and UCLA’s Santa Monica campus has two staff chaplains. The university’s widely respected Clinical Pastoral Education program provides an additional five to seven chaplains working in the hospitals.
The 250-bed St. John’s Health Center in Santa Monica employs three full-time chaplains, as well as a part-time priest and a visiting rabbi.
But while many hospitals across the country are investing in chaplaincy departments, insurance companies and government health programs like Medicare don’t reimburse facilities for the cost, leaving such care somewhat vulnerable.
“Funding becomes an issue. Because it’s not reimbursable, there has to be some rationale for a health care facility to justify such a position,” said Cecile Asekoff of the National Association of Jewish Chaplains.
‘An amazing gift’
At Cedars, chaplaincy is slowly working its way even deeper into the fabric of the hospital.
At an early morning meeting with his team of three physicians and chaplain Shu, Dr. Parag Bharadwaj, director of palliative care services, pointed out patients and families who are in spiritual distress, inviting Shu to some family consultations that day. He also asked Shu to look in on the nurses and doctors dealing with a young patient who was about to undergo a bone marrow transplant. He has a fragmented family structure and a difficult personality, Bharadwaj said.
“The staff has been trying to support him, and initially he was very receptive, but as he got closer to his bone marrow transplant, he started pushing people away,” Bharadwaj said. “For the staff it’s very difficult to gauge — one day he’s receptive, and the next day he doesn’t want you there and pushes you away. It affects the staff — sometimes they take it personally.”
The staff for palliative care patients — some of the most severe cases in the hospital — often turn to Shu for support.
Given that their main concern is patients’ holistic well-being, the palliative care team is, by nature, predisposed to having chaplains involved. Bharadwaj and his team make regular referrals to chaplains. In most other of the hospital’s units, the majority of referrals come not from doctors, but from nurses and social workers.
Doctors, however, are becoming increasingly enthusiastic about the impact spiritual care can have. Dr. Claude Killu, staff physician and director of the Medical Intensive Care Unit (MICU), called his rounds with the chaplain an integral part of his care plans.
“Does the patient live longer or better? If that is the question, the answer to that obviously is no. But does it improve the outcome in terms of comfort? Yes. Satisfaction on behalf of the family? Yes. Satisfaction on behalf of the nurses and treating medical team? Yes. Absolutely, yes.”
Several times a week, Killu traverses the MICU on the seventh floor of the Saperstein Critical Care Tower with a group of fellows and nurses, an ethicist, social workers, and Young, the Jewish chaplain.
As the group does the rounds, blips and beeps in the background seem incessant, coming from cell phones and the array of monitors that tower over a central nurses’ station. The team stops outside each room and identifies nonmedical issues that might affect a patient’s outcome.
Young makes notes of which patients and families might need spiritual care and will make time to see them the same day. But she also knows that once the family leaves the hospital, she may never see them again or even know what happens to them.
It’s just one more challenge of the job: While chaplains sometimes get phone calls or see patients who return for check-ups, they often don’t get closure.
“We work with people in intense situations, and we might never see them again. And we also see many of the really difficult cases and are called more to death than to celebrations of recovery,” Lazor said.
“On the other hand, to me it is so absolutely breathtaking that a complete stranger can walk into a room, and someone going through an incredible crisis will just open up about the deepest parts of their life, and I think some of that may be because they won’t see me again. That is an amazing gift.”