Health Progress - Spring 2025

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

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SPRING 2025

Faith & Medicine

CHA PRAYER LIBRARY Discover our extensive library filled with prayers relevant to timely liturgical and health care themes Reflecting on Pilgrimage Pilgrimage is traditionally a journey to a holy place — a place where saints have walked and where God has met people and blessed them.

O holy St. Joseph, who died in the arms of the Son of God and in the presence of his holy Mother, I beseech you at my last hour, to stand by me that I may repent of my sins, and breathe my last breath in an act of perfect love and confidence in my Savior.

May I repeat his blessed Name, exalted above every name, and proclaim joyfully “Lord, into your hands, I commend my spirit.”

Amen.

PRAYER TO ST. JOSEPH FOR A HAPPY DEATH

2 © 2016 The Catholic Health Association of the United States

Prayer to Prepare

God of the burning bu

show us your way .

People through the ages have journeyed with God on pilgrimage to perform a penance, ask for healing, pray for places where there is war or national disaster, and pray for family and friends.

God of the stormy sea from chaos … give us faith .

God of the small, still blows where it choose

fill us with light .

Pilgrimage is an opportunity to travel lightly, to walk free of daily routines, to meet people, to make friends, to enjoy and celebrate God’s creation. Too, in the traveling, the conversations and the silences, pilgrimage opens the space for us to reflect on the journey of our lives and on our journey homewards to God.

God of manna and liv

satisfy our deepes

God of the elements, o outward journeys …

set our feet on yo

Loving God, bless us w May the angels and sa May we live this day a and peace.

Amen.

[Adapted from: This is the Meditations from the Iona

“On this Twenty-fifth World Day of the Sick, I once more offer my prayerful support and encouragement to physicians, nurses, volunteers and all those consecrated men and women committed to serving the sick and those in need. I also embrace the ecclesial and civil institutions working to this end, and the families who take loving care of their sick. I pray that all may be ever joyous signs of the presence of God’s love …”

POPE FRANCIS

CHAUSA.ORG/PRAYERS Prayers for patients and families, church observances, Catholic health care workers, liturgy, daily meetings, social justice and much more.

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FEATURE

FAITH & MEDICINE

48 NORMOTHERMIC REGIONAL PERFUSION AND THE DETERMINATION OF DEATH Brian M. Kane, PhD

DEPARTMENTS 2 EDITOR’S NOTE BETSY TAYLOR 51 MISSION Moving Beyond ‘No Margin, No Mission’ in Catholic Health Care — Understanding the Means to the Mission DENNIS GONZALES, PhD, and BECKET GREMMELS, PhD 54 FORMATION Why Good Is Better Than Best DARREN M. HENSON, PhD, STL 57 ETHICS Calling Balls and Strikes: Clinical Ethics Consultants as Umpires FR. PETER FONSECA, MA, MS, MDiv 60 COMMUNITY BENEFIT Navigating Financial Assistance at Mercy: Compassionate Care for Patients STERLING COKER, MBA, EHRC, CRCR, and GARRETT KATES 64 AGING Preserving Catholic Health Care’s Footprint in Post-Acute Services TRISH GATHERS, CPA

Illustrations by Roy Scott 4 A THEOLOGICAL RESPONSE TO THE ISOLATION OF MEDICAL DISPLACEMENT Caterina Baffa, MTS 10 WHAT SINGING FOR BLOOD TAUGHT ME Abraham M. Nussbaum, MD, MTS

66 SOCIAL JUSTICE Catholic Churches and Hospitals as Sanctuaries and Places of Refuge BRIAN M. KANE, PhD

17 THE IMPORTANCE OF NEUROCRITICAL CARE: SAVING LIVES AND ENHANCING RECOVERY IN CENTRAL TEXAS Shahed Toossi, MD, FNCS, and Meredith Wells, MBA, BSN, RN

69 THINKING GLOBALLY From Parachutes to Paradigm Shifts: My Global Health Journey BRUCE COMPTON

22 RECLAIMING THE SPIRITUAL DIMENSION OF HEALTH AND HEALING: A SEASONED CHAPLAIN’S PERSPECTIVE Rev. Michele J. Guest Lowery, MDiv, BCC

21 FINDING GOD IN DAILY LIFE 72 PRAYER SERVICE

28 SUPPORTING PATIENTS AND THEIR LOVED ONES COPING WITH SERIOUS OR TERMINAL ILLNESS Kelly Bilodeau 34 TIMELESS APPROACH, LATEST INNOVATIONS COMBINE IN PERSONALIZED MEDICINE Gautum Agarwal, MD 38 THE UNIQUE NEEDS OF VOWED RELIGIOUS ELDERS IN LONG-TERM CARE Kelly O’Shea Carney, PhD, ABPP 44 RELIGIOUS COMMUNITIES SEEK PATHS TO LONG-TERM CARE FOR AGING MEMBERS David Lewellen

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IN YOUR NEXT ISSUE

PILGRIMS OF HOPE

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EDITOR’S NOTE

F

ocused on Faith & Medicine, this issue of Health Progress takes a closer look at how faith, reason and science work together as part of patient care in Catholic health environments and celebrates some of the groundbreaking therapies and treatments provided in these settings.

We certainly know spirituality is important to many patients.

CHA has been paying close attention to research that shows spirituality can play a significant role in medical decisions, that unaddressed spiritual needs are associated with poorer patient BETSY quality of life, and that wellness TAYLOR includes a spiritual dimension.

Both the Journal of the American Medical Association (JAMA) and Health Affairs have explored these issues in recent years, and CHA continues to educate about them.1 If you work in Catholic health care day in and day out, Health Progress aims to advance your knowledge of topics that may already be familiar to you or provide a fresh take on them, with authors from both Catholic and secular care systems. This exploration includes physicians writing about how they are transformed by their calling to care, and experienced chaplains and other care providers discussing what they’ve learned from their own work with patients that may provide some new learnings for those engaged in pastoral and end-of-life care.

This Faith & Medicine issue also nods to the current moment in U.S. health care. As we publish quarterly, I certainly encourage readers to visit our website for the latest articles and developments and to explore the fine work being done by our advocacy colleagues. That’s not simply a plug for www.chausa.org, but a reminder for readers that is where CHA’s latest and updated content lives.

The opening article of this issue, by Caterina Baffa, explores social forms of displacement, noting that it’s something immigrants and migrants may experience, and then more broadly focuses on medical displacement — how people with illness or chronic conditions may feel separate from themselves and their communities. It suggests a

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theological response to these realities to promote wholeness and connection.

CHA’s Senior Director of Ethics Brian Kane provides a historical perspective of how the concept of sanctuary has roots in the Gospel teachings of compassion and mercy. “The historical development of Catholic churches and hospitals as sanctuaries and places of refuge reflects the enduring Christian commitment to mercy, justice and care for the marginalized,” he writes. He reminds us of the Catholic Church’s vital role of protector and provider for society’s most vulnerable members.

For the Faith & Medicine issue, we also wanted to provide an update on care approaches for aging vowed religious with two articles, one that includes a framework for healthy aging for all people, and continues with a discussion of psychosocial needs special to aging religious. The companion article takes a snapshot of some of the approaches to care for aging religious. So many Health Progress readers are vowed religious or work and live alongside them. We hope these articles provide thought for how we can both celebrate their ongoing ministries and help readers to think about how these efforts can be supported.

It is also a time when we are reminded again of Pope Francis’ repeated call for Catholicism to be a field hospital, about the need for closeness and proximity with those we serve and the need to heal wounds. The hope is that this issue gives you some inspiration to meet needs starting from, as he advocates, the ground up.

NOTE 1. Valerie Schremp Hahn, “Researchers Analyze Hundreds of Articles on Spirituality’s Role in Health Care,” Catholic Health World, August 2024, https://www. chausa.org/publications/catholic-health-world/archive/ article/august-2024/researchers-analyze-hundreds-ofarticles-on-spiritualitys-role-in-health-care.

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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON

EDITORIAL ADVISORY COUNCIL Trevor Bonat, MA, MS, chief mission integration officer, Ascension Saint Agnes, Baltimore Sr. Rosemary Donley, SC, PhD, APRN-BC, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Redeemer Health, Meadowbrook, Pennsylvania

EDITOR BETSY TAYLOR btaylor@chausa.org

Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana

MANAGING EDITOR CHARLOTTE KELLEY ckelley@chausa.org

Gabriela Robles, MBA, MAHCM, president, St. Joseph Fund, Providence St. Joseph Health, Irvine, California

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ARTICLES AND BACK ISSUES Health Progress articles are available in their entirety in PDF format on the internet at www.chausa.org. Photocopies may be ordered through Copyright Clearance Center, Inc., 222 Rosewood Dr., Danvers, MA 01923. For back issues of the magazine, please contact the CHA Service Center at servicecenter@chausa.org or 800-230-7823.

REPRODUCTION No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission from CHA. For information, please contact copyright@chausa.org.

Jennifer Stanley, MD, physician formation leader and regional medical director, Ascension St. Vincent, North Vernon, Indiana Rachelle Reyes Wenger, MPA, system vice president, public policy and advocacy engagement, CommonSpirit Health, Los Angeles Nathan Ziegler, PhD, system vice president, diversity, leadership and performance excellence, CommonSpirit Health, Chicago

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA; Kathy Curran, JD; Clay O’Dell, PhD; Paulo G. Pontemayor, MPH; Lucas Swanepoel, JD COMMUNITY BENEFIT: Nancy Lim, RN, MPH

OPINIONS expressed by authors published in Health Progress do not necessarily reflect those of CHA. CHA assumes no responsibility for opinions or statements expressed by contributors to Health Progress.

CONTINUUM OF CARE AND AGING SERVICES: Indu Spugnardi

2024 AWARDS FOR 2023 COVERAGE Catholic Press Awards: Magazine of the Year — Professional and Special Interest Magazine, First Place; Best Special Section, First Place; Best Special Issue, First Place; Best Coverage — Political Issues, First Place; Best Essay, First and Second Place; Best Feature Article, Third Place; Best Reporting on Social Justice Issues — Dignity and Rights of the Workers, Second Place; Best Reporting on Social Justice Issues — Life and Dignity of the Human Person, First Place; Best Reporting on Social Justice Issues — Option for the Poor and the Vulnerable, Third Place; Best Reporting on Social Justice Issues — Rights and Responsibilities, Third Place; Best Writing — In-Depth, Honorable Mention.

ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD

American Society of Business Publication Editors Awards: All Content — Enterprise News Story, Regional Gold Award; All Content — Government Coverage, Regional Silver Award; All Content — Editor’s Letter, Regional Silver Award.

Produced in USA. Health Progress ISSN 0882-1577. Spring 2025 (Vol. 106, No. 2).

Copyright © by The Catholic Health Association of the United States. Published quarterly by The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797. Periodicals postage paid at St. Louis, MO, and additional mailing offices. Subscription prices per year: CHA members, free; nonmembers, $29 (domestic and foreign); single copies, $10.

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FINANCE: Loren Chandler, CPA, MBA, FACHE GLOBAL HEALTH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Diarmuid Rooney, MSPsych, MTS, DSocAdmin LEGAL, GOVERNANCE AND COMPLIANCE: Catherine A. Hurley, JD MINISTRY FORMATION: Darren Henson, PhD, STL MISSION INTEGRATION: Dennis Gonzales, PhD; Jill Fisk, MATM PRAYERS: Karla Keppel, MA; Lori Ashmore-Ruppel THEOLOGY AND SPONSORSHIP: Sr. Teresa Maya, PhD, CCVI

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FAITH & MEDICINE

A Theological Response to the Isolation of Medical Displacement CATERINA BAFFA, MTS Contributor to Health Progress

I

llness, impairment and pain are displacing experiences, separating a person from their sense of self and their community. This separation can occur in many forms. In my own life, my impairment, a permanent brachial plexus injury from birth, can come up in jarring ways.

Although I adjust to limited arm strength and motion in my everyday life, this limitation often goes unnoticed by people around me until it suddenly becomes apparent. For example, once in high school, I fell into a mess of tears when I could not practice infant CPR in my health class because I could not hold the practice doll at the correct angle. In moments like this, I did not just feel exposed, I felt physically apart and isolated. On a personal level, I felt that my body had abandoned me, so that I was displaced not only from others but from my own corporeality. How could I feel at home in a body that betrayed me in simple tasks?

This liminal experience of being present in my body, yet set apart by it, resonated closely with other moments of feeling displaced, even if not physically. As the daughter of immigrants, I would sometimes slip up when I was young and say words incorrectly — repeating what I heard at home, with a different inflection or accent — or mention foods with funny names, only to be met with the confused faces of my friends.

These experiences also drew me out of myself so that I no longer existed among my friends, joking as peers, but now seemed to look at them from far away — a distant place marked by other customs and language. The best analogy to describe

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these experiences would be that of physical distance: when my physical or cultural differences came into full view for myself and others, I was transported far from myself and the people around me by these differences and no longer felt in the same orbit as them.

As I grew older and developed an interest in bioethics, these experiences of alienation seemed less like unrelated, sporadic events, but representative of modes of displacement. I caught glimpses of an experience of being displaced from myself and from my community in ways that were not unique to me. In fact, these experiences mark the lives of most people who experience illness and seek medical care. Thinking about these experiences in terms of displacement can be ethically useful for considering how we can best care for people experiencing displacement due to illness and treatment.

BEING ‘PRESENT’ TO THE SICK

It is likely already familiar to think of social forms of displacement. Immigrants and migrants experience a kind of locational displacement when forcibly or voluntarily moving from their original country to another. It is also common to face cultural-linguistic displacement when one is tied

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This disconnect in the experience of people who suffer and those who care for them strains the empathetic capacity of both, particularly in the case of long-term suffering. We can understand that another person is in pain but cannot truly feel and understand it ourselves in the same visceral way that the suffering person does. to a culture and/or language that differs from the social context one currently inhabits. While immigrants likely endure both of these modes of displacement, it is possible to be culturally displaced without physical relocation, as is often the case for the descendants of immigrants. I suggest also thinking of medical displacement as an experience in which a patient’s illness and treatment displace them from their own self-understanding and surrounding communities.

Two theologians can help us to think of illness and health care as displacing forces: Stanley Hauerwas and Ada María Isasi-Díaz. Hauerwas has an insightful gaze on the alienation that comes with suffering and illness. To him, it is impossible to fully communicate the lived experience of one’s suffering because it is always unique to the individual. He explains that “it is impossible for us to experience one another’s pain” and to fully understand one another’s suffering more broadly. This disconnect in the experience of people who suffer and those who care for them strains the empathetic capacity of both, particularly in the case of long-term suffering.1 We can understand that another person is in pain but cannot truly feel and understand it ourselves in the same visceral way that the suffering person does.

This separation from others not only drives a wedge between patients and those caring for them but also alienates patients from themselves by threatening their sense of self and their understanding of their place in the world. In short, suffering breaks down one’s modes of understanding and connection within oneself and one’s community. That is, suffering is an experience of displacement.

For this reason, Hauerwas sees the purpose of health care as being a bridge between the suffering patient and the rest of the human community.2 This bridge-building challenges the way

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that impairment and disease isolate and alienate by reconstituting the ill and healthy as one community. But this work of bridging and binding people together is not simple — rather, it requires the practice and development of a certain kind of ethical character. Hauerwas describes health care as shaping the sick and their caregivers “to remember, learn and pass on the skills of learning to live with a body.”3 In particular, health care professionals bridge the gap between the ailing and the healthy through skills that connect them with the sick by being present to them. Hence, ethically, these professionals strive to develop the capacity to steadfastly accompany those who are ill and suffering, regardless of the expected outcomes of care or the possibility of a definitive cure.

Even still, it is nearly impossible to foster this practice of accompaniment alone, especially in the face of the magnitude of people’s suffering and our inability to simply eliminate suffering.

This ability to accompany others in their struggles must be based on communal knowledge and practices. Even being truly present to suffering patients requires a community that is present to one another, supporting and shaping those working in health care.4

CONNECTING THROUGH NARRATIVES

However, Hauerwas’ ethics of presence also challenge us to ask questions about what this practice of accompaniment practically looks like for different people. This questioning is even more pertinent for people who are facing multiple layers of displacement, not only from illness and treatment, but cultural, linguistic and locational displacements. How can we think about binding people together and fostering a sense of belonging in cases of those who are isolated by a matrix of displacing forces? Isasi-Díaz provides helpful insight on these issues through what she calls

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FAITH & MEDICINE

mujerista theology. She draws from theology and ethnographic work to understand and articulate the wisdom of Latina women to inform Christian ethics.

Isasi-Díaz describes Latinas in the United States as “displaced” to capture not only some Latinas’ physical displacement from their original location to the U.S., but also their experience of existing in an in-between space of cultures, practices and communities. Hence, displacement describes how different places and experiences “inhabit” women as they go about their lives, shaping their consciousness and decisions in particular ways.5 This approach reveals a new dimension of displacement: it is not only about alienation from one’s surroundings but also about the hidden interpersonal connections people always carry within themselves. The experiences of locational, cultural and linguistic displacement that Isasi-Díaz notices in Latina women’s lives often isolate people from one another. However, by paying attention to these displacements, one can also uncover how human beings are necessarily dependent on and responsible for one another, even across distances and cultural barriers. While Hauerwas articulates how displacing experiences divide us, Isasi-Díaz helps us to understand that even these experiences show how humans are interconnected and interdependent. Moreover, both theologians call for us to make strong efforts to overcome the alienation of displacement.

Like Hauerwas, Isasi-Díaz turns to narrative approaches as key ethical tools to connect people and overcome displacement. The mujerista perspective focuses on how sharing personal stories can be a subversive practice for displaced and marginalized people because it reasserts personal dignity and challenges dominant narratives that often undermine the value and wisdom of people experiencing displacement.6 This sharing contributes to Isasi-Díaz’s vision of justice and liberation operating within the realm of everyday life.7 While Isasi-Díaz focuses on cultural displacement, her insights about displacement also provide wisdom for how to approach experiences of displacement in health care. When engaging with patients already alienated from their own bodies and communities, listening to their stories is essential to connect with them and reintegrate them within their social context and relation-

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ships. Isasi-Díaz’s understanding of displacement reminds us that seeing patients as whole persons and addressing their displacements requires us to remain attuned to the many ways in which injustice operates at the everyday level. Thus, facing the reality of displacement in health care involves promoting care that seeks flourishing in ways appropriate to a patient’s personal narrative and relationships and strives toward a greater justice within their own everyday experiences.

Drawing on the insight of Hauerwas and IsasiDíaz also helps us to recognize how patients can experience multiple displacements. Many people facing illness and treatment are already burdened with locational, cultural and linguistic displacements. These forms of displacement are intertwined and compounded in complex ways. For example, for undocumented migrants, the threat of deportation has been shown to negatively affect their health,8 and in one case, the raids of antiimmigration agencies correlated with lower birth weights for Latina mothers who are both American-born and immigrants.9

SOCIAL, CULTURAL ATTUNEMENT FOR BETTER CARE

By caring for suffering patients, the character of health care professionals should be shaped by practicing accompaniment in ways that are informed by the awareness of the multiple types of displacement that many patients endure. Moreover, health care practices should avoid displacing and alienating patients who are already experiencing multilayered forms of displacement.

Health care settings generate their own internal cultures and operate based on specialized knowledge. These characteristics are often unfamiliar and intimidate patients of all backgrounds.

Part of the work of health care professionals, then, is to extend hospitality to patients entering the health care landscape and to consider the experiences they carry with them into this new space. Overall, Hauerwas’ call to build bridges that foster presence and connection and IsasiDíaz’s call to doggedly seek justice and wholeness within everyday life stand as demanding ethical challenges for modern health care.

In my own experience as a patient, what helped me most to flourish and be healthy was care attuned to the culture and values I inherited from my immigrant parents, while recognizing the social impacts of my impairment. Simply put,

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when I and those around me, especially health care professionals, recognized and addressed the ways my experiences made me other and displaced me from myself and my community, I experienced care that fostered a sense of wholeness, connection and belonging.

CATERINA BAFFA is a doctoral student in Boston College’s theology department. Her research is focused on theological ethics and bioethics.

She began work on the topics in this article for her master’s thesis as a Theology, Medicine and Culture Fellow at Duke Divinity School in Durham, North Carolina.

NOTES 1. Stanley Hauerwas, Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped, and

the Church (University of Notre Dame Press, 1986), 76.

2. Hauerwas, Suffering Presence, 26, 78.

3. Hauerwas, Suffering Presence, 48.

4. Hauerwas, Suffering Presence, 81.

5. Ada María Isasi-Díaz, La Lucha Continues: Mujerista Theology (Orbis Books, 2004), 142-147.

6. Isasi-Díaz, La Lucha Continues, 56-58.

7. Isasi-Díaz, La Lucha Continues, 94.

8. Olga Khazan, “The Toxic Health Effects of Deportation Threat,” The Atlantic, January 27, 2017, https:// www.theatlantic.com/health/archive/2017/01/ the-toxic-health-effects-of-deportation-threat/514718/.

9. Nicole L. Novak, Arline T. Geronimus, and Aresha M. Martinez-Cardoso, “Change in Birth Outcomes Among Infants Born to Latina Mothers After a Major Immigration Raid,” International Journal of Epidemiology 46, no.

3 (June 2017): 839–849, https://doi.org/10.1093/ije/ dyw346.

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Navigating the complex ethical realities of health care can be a challenge.

WE’RE HERE TO HELP.

Access a variety of resources to help understand and apply the Ethical and Religious Directives.

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What Singing for Blood Taught Me ABRAHAM M. NUSSBAUM, MD, MTS Chief Education Officer and Designated Institutional Official at Denver Health

“I

can’t get ‘the stick.’ She won’t let me near her.”

The third phlebotomist of the day walked out of Renee’s room with an unused needle.

Unless this patient’s blood could be drawn to test it, I would have to discontinue clozapine, the only medication that reduced Renee’s commanding voices to tolerable whispers. When she took clozapine, she could live with her brother. When she went off it, she walked alone on the streets. To continue prescribing, I would need to be the one who drew near her, but like a vampire.

I asked the phlebotomist for the needle and the medical student with me to turn on her smartphone. We were going to sing to draw blood from Renee.

SINGING TO UNDERSTAND

The formal strategies for medical care and training are verbal and procedural. Attending physicians like me assess how patients are doing and how much trainees know by asking questions: “How is your medicine treating you? How frequently does clozapine induce agranulocytosis?”

Then we verify by asking patients and trainees alike to perform procedures of various sorts: “Can we sample your blood? Will you examine the patient to assess for adverse effects?”

The informal strategies develop your senses to see how a person sticks herself in the world.

Medical professionals seek understanding of a person by sensing their mood, memory and even their ability to carry a tune. You learn more about depression by how your own mood darkens when listening to a depressed person. You learn dementia by the smell of an older woman no longer able to bathe. You learn mania by the sound of a young

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man sing-shouting his favorite lyrics.

In the psychiatric wards where I meet people as patients, some songs crescendo into agitation.

When the agitation is sustained into acting out, a nurse often messages me for medications to chemically calm a patient. Sometimes, I prescribe.

Sometimes, I return with a music therapist who can calm the patient by playing along.

I work with Maria Schimpf, a music therapist who can match the pitch of her voice and the rhythm of her guitar to the sound of an agitated young person. A song or two in, she often guides them to a more stable rhythm. Her songs often work as well as any of my medications, but they are guaranteed to make the encounter more humane, even for vampires like me.

Schimpf was off on the day Renee was declining blood draws. (I am using a pseudonym for this patient to respect her privacy.) I cannot carry a tune, but medical training teaches you to do what needs to be done. I borrowed one of Schimpf ’s tricks, asking Renee what song we could sing together. She picked the Chi-Lites’ “Oh Girl.” The med student queued it up on her phone.

I didn’t know the song, but I knew the anatomy.

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Goal

Task

Why Desired health outcome

Bond

What Health-seeking activities

How Emotional relationship

Therapeutic alliance

Adapted from Psychologist Edward S. Bordin’s Therapeutic Alliance

I placed the tourniquet as the song started. The smooth harmonies told about trouble when alone.

Renee’s face settled. She sang along. Her arm relaxed to the sound of familiar voices. I cleaned her elbow, sang along to the lyrics in the video, and then threaded the needle into her vein. We had the blood.

BUILDING ‘DIAMOND’ BONDS

Psychiatrists like me learn to sit with someone, even sing with them, to build a relationship that allows us to help a patient achieve health outcomes she could never achieve alone. Through experience, we learn to build alliances with patients through the three components of the therapeutic alliance (see graphic above).

The first is a goal, a health outcome, that a patient and a clinician work toward together.

The goal is the why of a clinical relationship, and I check in on our progress toward it every time I see a patient. The second is a task, a healthseeking activity, that a patient pursues as a step toward her goal. Each task is the what of a clinical relationship, the activities that we do together and apart, like an exercise regimen or a cognitivebehavioral workbook. The third is a bond that a clinician develops with a patient. The bond is the how of the clinical relationship, the way we relate together. A bond can be challenging, supportive or even a sing-along.1 I tell patients and trainees it’s like high school chemistry. A pile of coal and a shining diamond are both made of carbon; what distinguishes them are the bonds between the molecules of carbon.

If you want to make coal with a patient, studies show that you avoid eye contact, stand over a patient, cross your arms and ask a series of closeended questions. I call it being a psychiatric robot when I ask a patient something like, in one great rush of words, “Are you experiencing a headache, chest pain, shortness of breath, nausea, thoughts of suicide, depressed mood or an adverse med-

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ication effect?” If you want to make a diamond, sit with a patient, let her tell her story, reassure her, respect her opinions, examine her gently and ask more follow-up questions.2 If you form a good alliance, patients across many mental and medical illnesses experience approximately 10% better health outcomes, when controlling for all other factors, while clinicians experience greater joy in their work.3 I removed the tourniquet and needle, but held on to Renee’s arm as she sang on.

THE TRANSFORMATIVE EXPERIENCE OF BECOMING A PHYSICIAN

After we drew Renee’s blood, the medical student shared that she’d neither heard of the Chi-Lites nor learned to draw blood. She asked how I knew.

I told her I first heard the Chi-Lites while volunteering with the Sinsinawa Dominicans at a respite center for medically ill and injured homeless people in the west of Chicago. We lived in a Dominican priory, where our days began and ended chanting hymns, but we spent the middle of our days on the streets, collecting and driving homeless people to and from hospitals. Many of the people I collected tuned the homeless center’s van to the station playing “dusties,” a genre of smooth soul songs from the 1960s and ’70s. The Chi-Lites were in heavy rotation. The experience of learning dusties with patients and hymns with the friars led me to medical school. I wanted to learn how to sing along with patients.

When I began training a quarter century ago, medical students were taught to read their own X-rays, place their own lines and draw blood from their own patients. Medical students learned most procedures while taking overnight call with whatever clinical team they were assigned. This could involve every second night in transplant, every third night in trauma and every fourth night in the medicine wards. If you worked hard through the nights, the team allowed you to “get” a procedure.

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of becoming a vampire: marrying, birthing a child and training as a physician.4 Vampires, spouses, parents and physicians: All are transformed in the night. It is at night that vampires bleed others, while spouses talk as they drift off to sleep, only to wake up to soothe crying children. Becoming a physician overnight variously involves each act: bleeding patients, helping them sleep, tending to crying children, and, along the way, mending those you can.

Being a physician changes how you stick yourself in the world. I told the med student that while volunteering with the Dominicans and discerning my future, I read a book by the Catholic physician turned novelist Walker Percy. Toward the end of the novel The Moviegoer, the protagonist, Binx Bolling, decides to go to medical school and explains it by saying, “There is only one thing I can do: listen to people, see how they stick themselves into the world, hand them along a ways in their dark journeys and be handed along, and for good and selfish reasons.”5 The quote has stayed with me. A physician sometimes cures, even fixes, but all our patients eventually diminish and die.

Most of what we can do is listen to people, see them, acknowledge their journey, and travel a little way with them, for good and selfish reasons.

Being a physician is often like being a vampire.

A physician engages in acts that are assaultive outside the physician-patient relationship: dissecting bodA physician sometimes cures, even fixes, ies, performing intimate examinations, and prescribbut all our patients eventually diminish ing mind- and body-altering and die. Most of what we can do is listen medications. Society grants us the right to perform those to people, see them, acknowledge their acts to improve the health journey, and travel a little way with them, of the sick. In return, it asks physicians to be different in for good and selfish reasons. the world.

I admitted to the med stuhow until after the experience. It’s a catch. You dent that I rushed the process, going through all know you will be a different person on the other of Paul’s transformative experiences in a single side, but you cannot know how different. year. During my clinical year, my classmate and There is no way out but through.

I married, welcomed our first child and selected You may think the decision can be made ratio- our future specialties. We both underwent triple nally by gathering information, weighing options vampire training. and selecting the one that best fits you. Paul says We both chose a career in medical education that works for many choices, but not when you are so we can help the next generation navigate their choosing to be transformed. own transformative experiences. My wife runs a Paul includes additional examples of experi- family medicine residency at a local Catholic hosences as transformative as the metaphorical one pital. I don’t work in a Catholic system, but I still Seeking experience, I learned to draw blood and run tests. I learned to ask penetrating questions and expect intimate answers. I learned that I could listen well and save a life. I learned to deliver evidence-based care while sleepdeprived. The experiences exhausted and energized me, unmade and made me. I began medical training wanting to be a surgeon, but ended up as a psychiatrist.

Medical students often describe the serial immersions of the clinical year as finding their place in medicine. I told the med student that for me, it was more like vampire training. I shared with her that a decade after residency, I read the philosopher L.A. Paul’s Transformative Experience. The book opens: “Imagine that you have the chance to become a vampire. With one swift, painless bite, you’ll be permanently transformed into an elegant and fabulous creature of the night. As a member of the undead, your life will be completely different. … if you pass up this opportunity, you’ll never have another chance. … To make a choice like this, you’d want to make the best decision you could.”

Paul writes that when facing a choice to become a vampire, you are facing an intense, overwhelming and life-changing choice, one that is irreversible. You choose an experience that you know will fundamentally change you, but you cannot know

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try to teach the kinds of songs I learned with the Dominicans. At Denver Health, my team oversees the experiences of the 1,200 resident physicians and 2,000 students in 34 professions who train annually at our hospital. At the University of Colorado School of Medicine, I teach medical students the basic sciences underlying psychiatry.

I tell each trainee I meet they are going through a transformative experience. When they smell a festering wound, they will not turn away. When they see a person suffering, they will sit with them. They are becoming the kind of people who respond to the needs of the ill. They have chosen their transformative experience, and now they must live it out. Just like vampires.

CHANGING EXPECTATIONS

But a medical student may now graduate without ever learning to draw blood.

The transformative experience has changed dramatically in the 15 years since I finished training. Women now make up most applicants and entrants to medical school. Twenty-nine allopathic and 17 osteopathic schools have opened since 2010, many of which are experimenting with curricula.6 Seeking an understanding of how these changes are altering medical training and practice, I spent the past five years following a group of medical students. I watched them in clinics, operating rooms and emergency departments. I sat in as they learned in small and large groups.

I learned what works and what does not with today’s learners, then published a book about their experiences and the future of medicine.7 I saw that medical students no longer routinely learn to draw blood, many hardly take call, many think it daft that my wife and I welcomed a child during training, and some resist the idea that medical education should change you, for good and selfish reasons.

Some practicing physicians tell reporters that the changes in future physicians’ expectations amount to a generational gap between the physicians of today and those of tomorrow, which threatens the future of the profession. 8 After hours at medical education conferences, colleagues trade stories of emergency medicine residents who ask to never work nights and weekends; psychiatry residents who decline to see suicidal patients because it triggers their own trauma; family medicine residents who describe medical

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education as a human rights violation; and other instances of young physicians seemingly prioritizing their well-being over a patient’s. The New England Journal of Medicine has published a series of essays by a leading physician about the growing generational differences between physicians, which directly ask if physicians and trainees now expect such different things from medicine that we are no longer pursuing the same calling.9-11 I still have hope for our calling because when I ask most medical students and residents, they still want to learn how to sing with patients.

Which brings me back to my patient, Renee.

We sang on to the song’s final verses, which discussed helpless people and useless tears.

Singing with her, I thought about all the conversations in the last few years about what’s gone wrong in medicine. Is it burnout? Compassion fatigue? Moral injury?12-14 I appreciate the attention to the challenges physicians and other clinicians face, but find these conversations discouraging.

Attending another CME event or conference keynote about burnout feels like nothing more than an opportunity to cry my own useless tears.

After all, physicians like me are far from helpless people. I find it unhelpful to describe an experience I chose — even one that challenged me before it transformed me — as traumatic. I find it disobliging to account for an experience that taught me useful skills as injurious. I find it rude to describe residency as a human rights violation when the people I meet as patients are experiencing profound illnesses and injustices.

Yet, there are days when doctoring seems too much. Patients say our care is too costly, too complex and too difficult to access. I agree, and admit that I am tired of the documentation chores, the administrative interferences and the bureaucratic hoops. I feel less than human after some clinical days, even as I am engaging in one of the most human tasks: caring for another person.

Renee squeezed my hand. The song was over.

The doctoring goes on.

LEARNING TO SING

I learned from watching today’s students that there are better ways to engage all generations of physicians.

First, I don’t believe it’s truly helpful to treat health care providers as heroes. During the COVID-19 pandemic, it became fashionable to praise health care workers as heroes. When we

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We need to train clinicians for a lifetime of caring for others, without risking their own lives. We don’t need to save one day; we need to serve a community for a generation or more. That’s not hero work; it’s the day-to-day work on the other side of a transformation, the marriage after the wedding, the parenting after the birthing. left hospitals, we were serenaded with cheers and whistles. Someone graffitied the side of our hospital with painted letters spelling out “HEROES.” It felt good for a week or two, but as the pandemic wore on and its recovery never arrived, we were tired of being called heroes.

Eventually, the hospital’s maintenance team blasted the letters off, one at a time. As they washed away, I thought about how heroes risk life and limb while performing extraordinary feats, all to save the day. We need to train clinicians for a lifetime of caring for others, without risking their own lives. We don’t need to save one day; we need to serve a community for a generation or more. That’s not hero work; it’s the day-to-day work on the other side of a transformation, the marriage after the wedding, the parenting after the birthing.

Second, teach us from two textbooks. For the past century, physicians like me have been trained in the textbook of the body. Our first patient was a cadaver. Our task was to memorize the bones, vessels, muscles and organs of the body and then select one distinct area of it that we specialized in for the rest of our careers. It worked for a time, but today our patients are dying from chronic diseases. Our gains in life expectancy are reversing.

We need physicians who know the communities in which they live and serve. It starts with recruiting medical students with more life experience before medical school, whether because they know illness personally, served in the military, worked a previous job, learned to speak multiple languages, immigrated from another country, studied disciplines beyond the basic sciences, come from an underrepresented background, parented a child or some other experience that prepares them to be transformed. During training, it means integrated care models, longitudinal training, home visits, more teaching health centers, rural training programs and other experiences

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that transform medical students.

Third, engage us in therapeutic alliances.

Instead of asking us to rate our burnout, ask physicians and other clinicians about our own therapeutic alliance with our patients and our organization. Dozens of validated rating scales exist for assessing the therapeutic alliance and can be easily adapted for clinicians.15 Many industries have adapted such measures. (When you push a smiley button to rate your service, it’s built on therapeutic alliance measures.) I don’t think physicians are suffering from burnout, compassion fatigue or moral injury so much as we are suffering from loss of alliance, agency and purpose. What we need is for medicine to be a kind of magic again, the magic of learning to sing along with other people.16 We can rebuild upon the insights from positive psychology so that when we ask people what’s going well and what can be better, we engage their alliance, agency and purpose.

Finally, be more human. Many of the things I memorized in medical school are no longer necessary in the world of artificial intelligence (AI).

Soon, many of the things I do, like hours of documentation, may also be replaced by AI. If a psychiatric robot can do those portions of my work, I am grateful. What will remain is being human: the parenting, the partnering and the doctoring.

Today’s medical students and tomorrow’s physicians don’t have to learn to draw blood, but they do have to learn to sing with patients like Renee.

DR. ABRAHAM M. NUSSBAUM is chief education officer and designated institutional official at Denver Health. At the University of Colorado School of Medicine, he is a professor of psychiatry and an assistant dean of graduate medical education. He has authored six books, most recently Progress Notes: One Year in The Future of Medicine, which follows seven medical students during their clinical training.

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NOTES 1. Edward S. Bordin, “The Generalizability of the Psychoanalytic Concept of the Working Alliance,” Psychotherapy: Theory, Research and Practice 16, no. 3 (1979): 252-60, https://doi.org/10.1037/h0085885.

2. Rafael Zambelli Pinto et al., “Patient-Centred Communication Is Associated with Positive Therapeutic Alliance: A Systematic Review,” Journal of Physiotherapy 58, no. 2 (June 2012): 77-87, https://doi.org/10.1016/ S1836-9553(12)70087-5.

3. Dr. Warren A. Kinghorn and Dr. Abraham M. Nussbaum, Prescribing Together: A Relational Guide to Psychopharmacology (American Psychiatric Association Publishing, 2021).

4. L. A. Paul, Transformative Experience, 1st Edition (Oxford University Press, 2014).

5. Walker Percy, The Moviegoer (Alfred A. Knopf, 1961).

6. “U.S. Medical School Enrollment Surpasses Expansion Goal: Averting Physician Shortage Now Depends on More Slots for Residency Training,” AAMC, July 25, 2019, https://www.aamc.org/news/press-releases/usmedical-school-enrollment-surpasses-expansion-goal.

7. Dr. Abraham M. Nussbaum, Progress Notes: One Year in the Future of Medicine (Johns Hopkins University Press, 2024).

8. Te-Ping Chen, “Young Doctors Want Work-Life Balance. Older Doctors Say That’s Not the Job,” The Wall Street Journal, November 3, 2024, https://www.wsj. com/lifestyle/careers/young-doctors-want-work-lifebalance-older-doctors-say-thats-not-the-job-6cb37d48.

9. Dr. Lisa Rosenbaum, “Being Well While Doing Well — Distinguishing Necessary from Unnecessary Discomfort

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in Training,” The New England Journal of Medicine 390, no. 6 (January 17, 2024): 568-72, https://doi.org/ 10.1056/NEJMms2308228.

10. Dr. Lisa Rosenbaum, “Beyond Moral Injury — Can We Reclaim Agency, Belief, and Joy in Medicine?,” The New England Journal of Medicine 390, no. 10 (January 24, 2024): 951-55, https://doi.org/10.1056/ NEJMms2311042.

11. Dr. Lisa Rosenbaum, “On Calling — From Privileged Professionals to Cogs of Capitalism?,” The New England Journal of Medicine 390, no. 5 (February 1, 2024): 471-75, https://doi.org/10.1056/NEJMms2308226.

12. Dr. Helena Winston and Dr. Bruce Fage, “Resilience, Resistance: A Commentary on the Historical Origins of Resilience and Wellness Initiatives,” Psychiatric Services 70, no. 8 (August 1, 2019): 737-39, https://doi.org/10.1176/appi.ps.201800477.

13. Dr. Kinghorn and Dr. Nussbaum, Prescribing Together: A Relational Guide to Psychopharmacology.

14. Fiona Cocker and Nerida Joss, “Compassion Fatigue Among Healthcare, Emergency and Community Service Workers: A Systematic Review,” International Journal of Environmental Research and Public Health 13, no. 6 (June 22, 2016): https://doi.org/10.3390/ ijerph13060618.

15. Dr. Kinghorn and Dr. Nussbaum, Prescribing Together: A Relational Guide to Psychopharmacology.

16. Abraham M. Nussbaum, “The Worthless Remains of a Physician’s Calling: Max Weber, William Osler, and the Last Virtue of Physicians,” Theoretical Medicine and Bioethics 39, no. 6 (2018): 419-429, https://doi.org/10.1007/s11017-018-9470-z.

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The Importance of Neurocritical Care

Saving Lives and Enhancing Recovery in Central Texas SHAHED TOOSSI, MD, FNCS Medical Director of Neurocritical Care Unit at Dell Seton Medical Center at The University of Texas MEREDITH WELLS, MBA, BSN, RN Vice President of Neuroscience Service Line, Ascension Texas

“I

t happened so quickly. One moment she was perfectly fine, then the next, she stopped talking normally and slumped over,” said Cindy’s husband. “Will she ever be able to walk again? Will she be able to hold her children again?”

Neurointensivist Dr. Shahed Toossi explained to Cindy’s family that she had suffered an acute subarachnoid hemorrhage from a ruptured aneurysm in her brain. The aneurysm was repaired by an endovascular surgeon, providing the initial treatment to ensure there wasn’t ongoing bleeding.

As Cindy’s family looked relieved, Toossi continued to explain that the patient wasn’t fully out of the woods yet. The coming days and weeks would be spent in a dedicated neurocritical care unit where she would be getting specialized care from a multidisciplinary team with expertise in caring for patients suffering from neurologic emergencies.

Toossi explained that the woman would be receiving frequent neurologic assessments that may prompt rapid interventions to ensure she wouldn’t develop further neurological complications. Furthermore, Toossi warned that it may be a long road ahead, as recovery from neurologic emergencies often takes many weeks to months and would likely entail intensive rehabilitation. (Cindy is a pseudonym out of respect

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for her privacy.)

In the not-too-distant past, suffering from an acute neurological emergency such as a highgrade subarachnoid hemorrhage was often associated with severe disability or even death. With the rise of advances in emergency neurocritical care, this is no longer necessarily the case.

Neurocritical care is a specialized field of medicine focused on the management of severe, life-threatening illnesses that affect the central and peripheral nervous system. Some examples of disorders treated by neurocritical care experts include acute intracerebral hemorrhage, acute ischemic stroke, seizures, neuromuscular emergencies, traumatic brain injury and swelling in the brain. The goal of neurocritical care is to not only stabilize and treat the emergency, but to prevent secondary neurologic injury to improve both immediate and long-term outcomes.

PROVIDING MULTIDISCIPLINARY CARE IN ONE SPACE

The first of its kind in Central Texas,1 the neurocritical care unit at Dell Seton Medical Center

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at The University of Texas, which expanded last sponsive. Neurocritical care nurses, who have year, provides advanced, multidisciplinary and specialized education and training in caring for compassionate care for patients with neurologic patients with acute brain injuries, checked on her emergencies. The unit is part of Ascension Texas, frequently and alerted the medical team to the which covers a 21-county primary service area in most subtle changes in Cindy’s clinical condition.

These updates led to the rapid identification Austin and Waco and operates 11 adult acute care of neurologic decline from several pathologies. facilities and two pediatric acute care facilities.

According to many studies, one of which These included cerebral vasospasm, which is appeared in Neurocritical Care, patients who when blood vessels in the brain narrow abnorreceive specialized neurocritical care have bet- mally and can occur following a subarachnoid ter outcomes, including improved survival rates hemorrhage. This narrowing of blood vessels can and reduced disability. 2 They are less likely to Neurocritical care units integrate physical, need long-term care, have shorter hospital stays and occupational and speech therapy into are more likely to return patient care plans, even during the acute to their normal daily activities. phase of illness. This early intervention The presence of a neucan make the difference between a patient rocritical care unit in a community is crucial for regaining their independence or facing longseveral reasons: First, rapid access term disability. to s p e c i a l i ze d c a re improves survival rates and outcomes. When patients experience condi- lead to ongoing, secondary brain injury. Cindy tions like strokes, brain hemorrhages or traumatic received medications and further procedures to brain injuries, every minute counts. A neurocriti- treat these complications. She eventually woke up cal care team is trained to quickly assess, diag- from her coma, engaged in physical therapy and nose and treat these life-threatening conditions, ultimately returned home.

For patients like Cindy, a crucial aspect of neupreventing further brain damage.

Second, these units are equipped with state- rocritical care is early rehabilitation. Patients of-the-art technology, such as intracranial pres- who suffer from severe neurological conditions sure monitoring, continuous electroencephalo- often face long recovery journeys, and beginning gram (EEG) monitoring and advanced imaging, rehabilitation as early as possible significantly all of which are critical in diagnosing and manag- improves functional outcomes. Neurocritical care units integrate physical, occupational and speech ing neurological emergencies effectively.

Additionally, neurocritical care units use a therapy into patient care plans, even during the team-based approach that enhances patient care. acute phase of illness. This early intervention can These teams include neurointensivists, neurolo- make the difference between a patient regaining gists, neurosurgeons, critical care nurses, respira- their independence or facing long-term disability.

Beyond patient care, neurocritical care units tory therapists and rehabilitation specialists who work together to create individualized care plans. serve as centers for medical research and educaThis collaborative approach not only enhances tion. They contribute to advancements in neupatient outcomes but also provides crucial sup- rological treatments, ensuring that communities port to families navigating the uncertainties of benefit from the latest innovations in stroke care, brain injury management and neuromonitoring neurological illness. techniques. These units also train future generaOver the coming weeks, Toossi watched Cin- tions of neurologists, nurses and allied health care dy’s family at her bedside daily, holding her hand professionals, strengthening the overall health and speaking to her while she remained unre- care infrastructure.

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EXPERT CARE WHEN SECONDS MATTER

ONLINE RESOURCE

Health Progress Diversity and Health Equity Discussion Guide Health Progress’ Diversity and Health Equity Discussion Guide supports learning and dialogue to move toward a greater understanding of patients, care providers and ways to work together for improved diversity, equity and inclusion in Catholic health care settings.

GUIDE INCLUDES Introduction on how to use the materials.

Health Progress articles for reflection, discussion and as a call to action.

Opening and closing prayer from CHA’s resources.

Toossi received an update from Cindy’s family recently. She was walking and laughing with her two young children, holding one of them up with her left arm. Her beautiful smile, although subtly different now given the mild facial weakness that only a trained neurologist may be able to detect, was the only outwardly visible sign of the incredible road to recovery that she undertook.

Cindy’s outcome may have been different if she didn’t have access to a dedicated neurocritical care unit and comprehensive stroke center, but fortunately, she did. And it made all the difference in the ultimate answer to her husband’s initial questions: “Will she ever be able to walk again? Will she be able to hold her children again?” For Cindy, the answer to both those questions was a resounding “yes.”

By ensuring that neurocritical care units are available within communities, we provide patients with the best possible chance of recovery and a return to normal life. These units are not just a luxury for large metropolitan hospitals — they are a necessity for every community, ensuring that when seconds matter, expert care is available to save lives and improve long-term outcomes.

The impact of neurocritical care extends far beyond hospital walls, touching families, workplaces and entire communities. It is an investment

in the health, resilience and well-being of society as a whole.

DR. SHAHED TOOSSI is the medical director of the Neurocritical Care Unit at Dell Seton Medical Center at The University of Texas. She is also a clinical associate professor in the departments of neurology and neurosurgery at The University of Texas at Austin. MEREDITH WELLS is vice president of the Neuroscience Service Line for Ascension Texas and national administrative director of the Neuroscience Service Line for Ascension.

NOTES 1. Caroline McConnico, “UT’s Dell Medical Center Expands Neurocritical Care Unit,” The Daily Texan, August 4, 2024, https://thedailytexan.com/2024/08/04/ uts-dell-medical-center-expandsneurocritical-care-unit/.

2. Owen Samuels et al., “Impact of a Dedicated Neurocritical Care Team in Treating Patients with Aneurysmal Subarachnoid Hemorrhage,” Neurocritical Care 14, no. 3 (June 2011): https:// doi.org/10.1007/s12028-011-9505-z; Dr. Katharina Maria Busl, Dr. Thomas Bleck, and Dr. Panayiotis Varelas, “Neurocritical Care Outcomes, Research, and Technology: A Review,” JAMA Neurology 76, no. 5 (May 2019): https://doi.org/10.1001/ jamaneurol.2018.4407.

DOWNLOAD THE GUIDE AT

CHAUSA.ORG/EQUITYGUIDE

OR SCAN THE QR CODE BELOW.

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“

Heal me, Lord, that I may be healed; save me, that I may be saved, for you are my praise.

(JEREMIAH 17:14)

Finding God in Daily Life

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Reclaiming the Spiritual Dimension of Health and Healing A Seasoned Chaplain’s Perspective REV. MICHELE J. GUEST LOWERY, MDiv, BCC Contributor to Health Progress

H

olistic health care is a buzzword these days, written into the mission, vision and values of health care systems throughout the country. There’s a good reason for this: more and more research points to the positive impact of treating the whole person on patient outcomes, patient and family satisfaction, and staff morale.

Paradoxically, health care is increasingly specialized and productivity-driven, with little time for practitioners to truly know their patients.

Interdisciplinary teams often function in a silo manner rather than working together to understand how each aspect of a person’s life impacts their illness trajectory and healing pathways. Perhaps the least understood aspect of human life is its spiritual dimension.

WHAT IS THE SPIRITUAL DIMENSION OF LIFE?

I respond to a nursing referral for spiritual assessment. As I enter the patient’s room, she sees my badge identifying me as a chaplain. Before I can introduce myself, she calls out: “I don’t need what you’re pedaling. I am not religious.” Taking the risk of slightly irreverent humor, I immediately respond: “Well, this is your lucky day. I’m not a religious chaplain.” My comment lands well, and I hear her chuckling: “All right, come in. You have three minutes to deliver your elevator speech.”

I stand bedside and ask her these questions: “As you lie here, are you wondering what really matters

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in your life?” She nods her head affirmatively. I continue: “Do you find yourself considering the nature and state of your relationships with yourself, others and however you understand a higher power?” She nods affirmatively again. I notice her eyes welling up with tears. I ask, “Are surprising questions and concerns rising up unbeckoned?” At this point, she says, “Please pull up a chair, I need to talk about these things.” I then listen to key elements of her life story.

Spirituality is that aspect of human life concerned with meaning, purpose and connection. It finds expression in our ultimate values, key relationships and core beliefs. Our values reflect what matters most to us. Our key relationships are primary sources of comfort, strength and love. Our core beliefs collectively form the lens through which we see, interpret and experience life events.

When healthy, the spiritual dimension of life helps us to ground ourselves in hope, engage with coping resources, and find meaning and purpose in life’s many circumstances, including illness and,

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ultimately, death. When unhealthy, it amplifies stress, lessens peace, creates or increases anxiety, and may even contribute to illness.

Spirituality and religion are often confused or conflated. Spirituality is a dimension of all human life. However, not all expressions of spirituality or means of nurturing it are religious in nature. Religion is an organized system of beliefs and practices that provide a framework for understanding the Sacred and our responsibilities to all of creation. Every religion embraces specific values, beliefs and practices to inform and guide followers’ behaviors and relationships. As such, all religions are expressions of spirituality. However, the converse is not true, as not everyone practices a religion. All expressions of both religion and spirituality can be barriers or conduits to wellness.

The crisis of illness or injury inevitably impacts

WHY SPIRITUAL CARE IS IMPORTANT IN HEALTH CARE

I’m hired by a health care system to develop a chaplaincy presence at an outpatient practice. At the time, outpatient chaplaincy is in its infancy, and the clinic is unsure of my role, as am I. Space is at a premium and so I’m asked to “sit in the waiting room and talk to people.” At first, I feel awkward; however, in time, people come to the clinic just to talk with me. As trust develops, I hear information that provides context to their health issues and, with permission, bring it to the attention of their practitioner.

I summarize each visit with a presenting issue and underlying spiritual dynamic. One particular case catches the eye of the medical director. The patient, well-known to the clinic for her chronic gastrointestinal issues, is referred to me as a “Hail Mary pass.” She has had numerous tests to rule out life-threatening diseases and was ultimately diagnosed with Spirituality and religion are often irritable bowel syndrome. The confused or conflated. Spirituality is a patient continued to come to clinic in distress; medical staff dimension of all human life. However, not felt they had exhausted care options, and a social worker all expressions of spirituality or means had also been working with the of nurturing it are religious in nature. patient.

As I talk with her, I notice something intriguing. She identifies several core the spiritual dimension of our lives: What matters most becomes clearer. Are we values and then describes a significant lifestyle living in sync with our values, or neglecting who choice that is in direct conflict with these values. I and what are important to us? This may elicit feel- gently point this out to her, which takes her by surings of guilt, regret and/or prompt us to make prise. As we discuss the situation in greater detail, she realizes she has an important decision to make: changes in our priorities, choices and behaviors.

The health of our key connections becomes either she changes her behaviors to align with her front and center. Do we have the support we values, or she reassesses her values and sheds those need? Do we experience more community or iso- that no longer “fit” with her life. She spends several lation in life? What internal resources have we weeks in prayerful reflection, makes her choice and developed through self-care and spiritual prac- comes to terms with what this will require of her.

Within a matter of months, her gastrointestinal tice? The quality of our relationships with self, others and a higher power figures prominently in distress is gone! Afterward, the medical director asks me to present a monthly case study to medical our ability to be resilient.

Our ultimate beliefs show up in the ques- staff and highlight the impact of a spiritual issue on tions we raise and in how we interpret and thus a patient’s presenting health concern. experience our illness. Do we wonder what we’ve While spiritual issues don’t usually play such done to deserve this illness? Do we blame others or God? Or do we see this experience as part and a dramatic role in a person’s medical condition, parcel of life, asking not why but what next? Like a there are many reasons why identifying and computer operating system, our core beliefs may addressing them is important for health and healnot be consciously apparent to us but are always at ing. Health crises can shake us to the core, both work in the background, strongly influencing our challenging our entire belief system and uncovering any cracks or gaps in our spiritual foundaperspectives and understandings.

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tions. Illness or injury can cause spiritual distress, described as “a state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world or a superior being.”1 Reasons for integrating spiritual care into a patient’s overall treatment include the following: Spiritual distress may cause us to feel helpless and hopeless, especially if we believe it’s God’s will that we are sick. This may directly impact our willingness to engage in treatment. Further complications can arise if we feel God has caused the illness or accident, leading to emotional turmoil and isolation from the very resources we may need for recovery.

The experience of physical pain can be enhanced by spiritual distress. This directly impacts one’s quality of life. In 2018, the Joint Commission dedicated two issues of its periodical, The Source, to spiritual distress. Its findings included: “Unmet spiritual needs have been associated with greater emotional distress, more pain and poorer quality of life.”2 I’m called to see a patient being monitored hourly for pain management. I listen attentively as she shares her life context, spiritual journey and concerns. As she shares her burdens and I respond in ways that help her navigate them while honoring her faith, I see subtle changes in how she holds her body and in her facial expressions. When her nurse comes in and asks her pain level on a scale of 1 to 10, she answers, “About a 4.” The nurse is surprised, reminding the patient that just an hour earlier her pain level was a solid 10. She looks up, giggles and says: “Well, the chaplain is almost as good as a pain pill.”

Additional reasons for integrating spiritual care into a patient’s overall treatment include: When faced with life-threatening, unexpected or chronic illness, we inevitably confront underlying spiritual beliefs. This kind of spiritual distress often presents as an existential crisis, and patients may need skilled help to get unstuck from tunnel vision or find different frameworks for understanding and making peace with their circumstances.

Life-altering health events disrupt many aspects of life: finances, relationships, work, our sense of self and the spiritual need to find meaning and purpose in life. How now shall we live?

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It is critical that we find new ways to contribute meaningfully in life.

Illness or injury often brings us face-to-face with our mortality. I find that patients frequently want to talk about death and dying when confronted with serious illness or as they approach surgery.

In addition to issues or concerns, many of us also have spiritual resources to draw from, which can help us face whatever may come with courage and hope. Identifying internal and external spiritual resources can contribute to resilience.

Integrating spiritual and cultural values and practices into a patient’s treatment plan can improve communication and collaboration with the treatment team and encourage active participation in the healing process.

STEPS TOWARD INTEGRATING SPIRITUAL CARE INTO TREATMENT

I am in Arizona sitting in a circle with members of a clan of the Navajo Nation, reflecting on the past year. The grandfather, whom I’ve been supporting as a hospice chaplain, is approaching the end of his life. I am approaching the close of my time here.

I am struck in this moment by the beauty of barrenness, the stark desert in sharp contrast with the brilliant sunset hues. Life on the reservation isn’t easy, and yet this is a people known for the phrase and fuller prayer “In Beauty May I Walk.” The prayer is about balance and harmony in life. It is rooted in the understanding that, like strands intertwined in the blankets they weave, all aspects of life are interconnected. A spiritual perspective is woven into their understanding of illness and wellness, with the basic theme of bringing all dimensions of life into balance.

As I’ve reflected on what I experienced among the Diné (Navajo people), I see parallels in Eastern medicine and wonder how our Western practice of medicine has become so compartmentalized, with spirituality, at best, a stepcousin and, at worst, an afterthought fraught with stereotypical understandings. Here are a few thoughts on practical steps toward a fuller integration of spiritual perspectives and care into medical treatment.

Appropriate provision of spiritual care:

While all members of a health care team can contribute to spiritual care by honoring what matters most to their patients, professional, board-certified chaplains have the education, training, skill

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Life-altering health events disrupt many aspects of life: finances, relationships, work, our sense of self and the spiritual need to find meaning and purpose in life. How now shall we live? It is critical that we find new ways to contribute meaningfully in life. sets and competency standards to provide clinically informed spiritual care to people of any or no religion. They are medically and religiously “bilingual,” allowing them to serve as a bridge between both worlds.

The intense interpersonal components of Clinical Pastoral Education, the cornerstone of chaplaincy training, promote professional boundaries so that chaplains “First, do no harm.” Board-certified chaplains should be the backbone of a health care organization’s delivery of spiritual care.

Many health care systems, however, continue to use volunteers as primary spiritual care providers, which is problematic on many levels.

While there is a role for volunteers within the spiritual care team, including community clergy, this should not include direct patient care, except for sacramental ministry. Volunteers are not members of the health care team, rarely understand the intricacies of HIPAA privacy rules, lack adequate training and may directly or indirectly engage in proselytizing. Chaplains refrain from imposing their own values and beliefs on those they serve.

Patients are vulnerable persons and “captive audiences” who may be harmed by well-meaning volunteers who impose their own beliefs, provide uninformed counsel and offer insensitive or offensive prayers. Investing in professional chaplains is foundational for integrating spiritual perspectives and care into medical treatment.

The importance of education: Professional chaplains bear the primary responsibility for educating staff on spiritual issues, resources and their role on treatment teams. While a growing number of medical and nursing schools offer coursework on spirituality, many do not, leaving medical staff with their private understandings, including biases. Chaplains must create opportunities for informal and formal education.

Informally, there is no substitute for consistent rounding. Chaplains should check in with a

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patient’s nurse before and after visits. They should meet and greet administrators, department heads, nursing managers, social workers and unit coordinators, with regular check-ins. Furthermore, they should introduce themselves to hospitalists and seek them out when they have shareable information pertinent to a patient’s context. Intentional visibility creates opportunities. Always.

Chaplains can also create formal educational opportunities through audacious advocacy. They can offer to do presentations at staff meetings, lunch-and-learns and case conferences for staff development. They can work with education staff to embed a standard module on the spiritual dimension of health into the organization’s annual mandatory education program. They can identify key referral resources (providers, nurses, social workers, palliative care) and modify a core presentation to each discipline’s role, always identifying ways in which their service can assist them in patient care. If their organization is connected to a nursing or medical school, they can offer to teach a class. Appropriate education increases patient care referrals. Always.

Demonstrate value: Hiring professional chaplains and educating medical staff serve little purpose if chaplains fail to demonstrate the value their role brings to patient care. They can do this through multiple ways: Documentation or charting is a primary way to communicate patient care interactions. Many spiritual care departments rely on checklists with “kitchen sink” drop-down menus in electronic medical records, which communicate little and are rarely read. Instead, chaplains can learn and use the same charting format as other members of the treatment team and become skilled at concisely and incisively capturing the visit.

Effective chaplain consults often take time, which can be problematic in environments where productivity is measured by the number of visits.

Instead, chaplains can identify and use key patient

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outcome indicators to measure productivity.

Chaplains can capture and collect vignettes of consults that offer teaching opportunities and can also illustrate patient outcomes. They can excel at the use of narrative and engage patients to share foundational stories.

Chaplains can find ways for their work to be noticed by medical staff and leverage this to present at ethics meetings and case conferences. For example, I was invited to present at monthly provider case conferences by simply identifying presenting issues and underlying spiritual dynamics in my documentation.

The practice of obtaining referrals by asking patients if they wish to see a chaplain is ineffective. It doesn’t identify patients who may be at risk for spiritual distress. Additionally, it presents a barrier for those with negative views of the word “chaplain.” I highly recommend the spiritual struggle protocol screening developed by George Fitchett and James Risk.3 It is an effective and simple algorithm to be administered by nonchaplain health care staff and can be modified as needed.

Consistent and persistent demonstration of spiritual care’s value promotes its fuller integra-

tion into treatment. Always.

Holistic care means treatment of the whole person, including the spiritual dimension of life.

Spiritual care is good medicine. Healing has a rippling effect on each dimension of life. May we who are called to health care ministry in its various capacities commit to the work of reclaiming the spiritual dimension of health and healing.

REV. MICHELE J. GUEST LOWERY is an ordained minister in the United Church of Christ and a board-certified chaplain with the Association of Professional Chaplains.

NOTES 1. NANDA International, Nursing Diagnoses: Definitions and Classifications 2015 — 2017, 10th Edition (WileyBlackwell, 2014).

2. “Hospital Chaplains Contribute to Patient Satisfaction and Well-Being,” The Source 16, no. 1 (January 2018): https://store.jcrinc.com/assets/1/14/ ts_16_2018_01.pdf.

3. George Fitchett and James Risk, “Screening for Spiritual Struggle,” Journal of Pastoral Care & Counseling 63, no. 1-2 (Spring/Summer 2009): 1-12.

QUESTIONS FOR DISCUSSION Author Rev. Michele J. Guest Lowery provides examples from her own experience to illustrate ways that chaplains can practically care for patients and increase integration of spiritual care in health environments.

1. As she discusses how chaplains speak with patients about what they value, it may be beneficial to consider your own core values. What are they? How did they come to be your core values? How do they shape you and how you interact with colleagues and patients?

2. As you read about the techniques Rev. Lowery uses with patients and as part of the care team, is there new language or an approach you might draw from in your own work?

3. What in your health care setting is successful when it comes to the integration of spiritual care in your workplace? What could be modified or improved?

4. How does your ministry demonstrate that it recognizes, appreciates and invests in the vital role of certified chaplains in caring for patients, families and staff? What can you do to encourage and support this?

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Supporting Patients and Their Loved Ones Coping With Serious or Terminal Illness KELLY BILODEAU Contributor to Health Progress

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haka Brittain’s mother used to bring her along on her visits to terminally ill people in her community. “My mom was somewhat of a death doula, if you would,” she said. “I remember even as a young girl going to people’s houses, and they were dying. She’d come in and sit with them and stay with them until they had ‘gone to glory.’”

Now a palliative nurse practitioner and assis- tionships with everyone around them,” said Sheri tant professor of nursing at the University of Bartlett Browne, spiritual care manager at AscenNorth Florida, Brittain believes these early expe- sion Saint Thomas in Nashville. “And the other is riences prepared her to work with seriously ill the fear of the unknown.” or dying patients. “Death was never scary. My mother “I wish that we had more honest, never really explained it, but she never shielded me from transparent conversations as a nation it,” she said. around the end of life and what it really Brittain’s ease around death is not the norm in looks like.”

America, where human mortality remains a taboo topic.

— ASHLEY NEVILLE Americans would prefer to discuss any other third-rail subject over dying, For health care providers, chaplains, hospice including money, politics or religion, according and palliative care specialists, helping families in to one survey by Ethos, a life insurance company.1 these circumstances requires tools to break down This reticence can make navigating a seri- cultural and interpersonal barriers. But some also ous illness even more challenging, contributing say a broader shift is needed.

“I wish that we had more honest, transparent to family conflict, reluctance to seek resources such as hospice or palliative care, and hampering conversations as a nation around the end of life and what it really looks like,” said Ashley Neville, communication.

“One of the biggest challenges with serious a supervisor of holistic care at PeaceHealth Whatillness is the impact that it has on people’s rela- com Hospice in Bellingham, Washington.

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A PROGNOSIS OF SILENCE

an anoxic brain injury. She had 10 children, the Sick patients sometimes don’t know they’re dying, youngest was 19, and she never named a surrobecause their doctor can’t get the words out, Brit- gate,” Brittain said. In this case, the family dynamtain said. For some doctors, the idea that the ics made it virtually impossible to gain a needed patient has exhausted treatment options and is consensus.

Conflicts often center on how far to go with moving toward end-of-life care sometimes feels like a personal failure. “I’ve had providers tell me medical interventions. “A common issue is, for that they can’t do it because the patient will feel example, someone saying, ‘I want my mom to do everything. I want her to live forever. I want her like they’re giving up on them,” she said.

It’s not only doctors that have difficulty con- to go through every possible treatment,’” Browne veying the truth. Patients sometimes try to shield said. Mom might disagree but feel guilty if she family members from a harsh reality and vice opts to forgo taxing treatments that aren’t likely to versa. “People always try to protect the people that they “Chaplains, in their role, are often the love, understandably. But bridge builders. We’re focused on the the less that everybody can be silenced in that, the betrelationships, building rapport with ter,” Browne said. Hiding the patient’s prognosis doesn’t family, with a patient, and trying to spare anyone from its course listen for opportunities to bring people and can make it harder to manage. together.”

When asked, patients appear to prefer the truth. A — SHERI BARTLETT BROWNE recent AARP survey found that 88% of those polled said their doctor should provide a realistic, not a hope- extend her life. People’s views on treatment may ful, view of their condition.2 They also want to be driven by their relationship with the patient, have the ability to plan. Some 92% of Americans cultural factors or religious views. The question say it’s important to discuss their wishes for end- becomes whose voice will prevail and whether of-life care, and 95% are willing, however, only the chosen path aligns with the patient’s wishes.

“Chaplains, in their role, are often the bridge 32% have had the conversation, according to the Institute for Healthcare Improvement’s Conver- builders. We’re focused on the relationships, building rapport with family, with a patient, and sation Project.3 People working with patients and families are trying to listen for opportunities to bring people together,” Browne said. “As you mirror back what often left to fill the gaps.

“By not telling the truth, you silence con- people are reflecting or how they are processing flicts that are already there in the family sys- what is going on, you can look for opportunities tem,” Browne said. “And if you can start to tell the to be a mediator, to de-escalate conflict, and to let truth about this and face it together, then perhaps everybody feel that they are heard.”

Many patients and families facing end-of-life there’s other things that you will be able to face.” care are waiting and hoping for a miracle, Brittain said. Patients and families often don’t realize what NAVIGATING FAMILY DYNAMICS Communication is also a challenge when navigat- medical interventions involve or the toll they take ing care decisions for a patient. “You can end up on patients. “I think this is where it gets really with many family and friends with a lot of opin- tricky because, as providers, we want to respect ions about what this person should do. And that faith and that belief in miracles, but there’s also creates a lot of stress and a lot of conflict,” Browne that desire for us to get them to understand the medical piece,” she said. said.

A 2024 study looked at how public health is The most difficult situations arise when the patient’s wishes aren’t clear, and they aren’t able portrayed on television versus in reality by lookto speak for themselves. “I had a patient with ing at two popular shows, House and Grey’s Anat-

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omy.4 They found that these shows often misrepresented specific interventions, such as cardiopulmonary resuscitation. “CPR is not what you see on TV,” Brittain said. “When we do it, we break ribs, we puncture lungs and we bust sternums.”

And CPR is successful only 21% of the time when carried out in a hospital by trained professionals, according to the American Red Cross.5 Explaining the realities of treatments and interventions can help families make more informed decisions. “At the end of the day, if they say that they still want all the interventions, at least I know that they know exactly what they’re signing up for,” Brittain said.

Some people will still opt to exhaust every option. Brittain said cultural factors may play a role. Many of her Black families are unwilling to stop medical treatments, holding out for a miracle. Some evidence supports Brittain’s anecdotal experience. A survey in 2016 found that Black and Hispanic Americans were more likely to prioritize living as long as possible.6 For example, while living as long as possible ranks below other considerations across racial and ethnic groups, Blacks (45%) and Hispanics (28%) are more likely than whites (18%) to say this is “extremely important” to them, according to one poll. Blacks and Hispanics were more likely than whites to say the health care system in the U.S. places too little emphasis on extending life as long as possible, according to KFF, a health policy organization.7 For Black Americans, who have historically endured suffering and oppression, views about persisting through adversity may drive these decisions, Brittain said. “It’s almost like that same mentality still is ingrained in the culture of Black Americans. Suffering is not a bad thing. It’s what you have to endure. Life is hard, you suffer, but you have faith, and things will turn around,” she said.

Decisions like these may also be fueled by distrust of the medical system. Brittain, who is Black, said many families are often relieved to see her walk in, a face that looks like their own, which engenders trust. “I think there is a need for some reassurance that, yes, all these physicians have told me that I am going to die, but I need to be sure that they’re just not trying to avoid treating me,” she said.

Family decisions to persist with likely ineffective treatments can be difficult for health care providers who have already seen the path ahead for

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many patients. To help understand why patients take this challenging road, Brittain explored religious views and theories, such as vitalism, which views life as more than biology and often prompts people to try and maintain it at all costs.

“I don’t think a lot of my colleagues really know how to approach it, because we see a lot of suffering, and we naturally are empaths. We don’t want people to suffer. But this person, this family, doesn’t see it as suffering like we do,” Brittain said.

In the end, allowing families to experience the process in their own way can build trust, she said.

MEASURES TO HELP FAMILIES

Whatever path the patient chooses, there are other measures that health care professionals can take to make the process easier.

A crucial step is helping patients assign decision-makers and to communicate their wishes. This includes choosing a health care proxy or proxies who can make decisions based on the patient’s wishes. Planning should also include other aspects of end-of-life care as well.

“We never have enough people who have done their own end-of-life care planning. Many have not signed an advance directive, or don’t have a living will, and often that makes things very complicated,” Ascension’s Browne said.

While many people say they worry about how their illness and death will affect loved ones and pets, they rarely act. “While over six in 10 (63%) older adults say they have had an end-of-life conversation with a loved one, far fewer have made end-of-life preparations, like preparing a last will and testament (36%) or a living will (33%). Moreover, less than half of the adults ages 45 and older who have not made these or similar preparations, say it is very likely they will,” according to an AARP study.8 Health care providers can also encourage families to seek resources, such as palliative or hospice care for a seriously ill family member. Palliative care provides support for people with a serious but not imminently terminal illness, and can include curative treatments. For people in the early stages of a serious illness, it can help with symptom management, give them a better understanding of their medical condition and its progression, document their preferences for end-of-life care, and reduce the amount of time they’ll need to spend in the hospital.9 Hospice care offers needed support to families who are often

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“Anybody who’s experiencing a serious illness is scared.

They’re not sure. They receive a lot of information from their medical team. They get information and advice from people all around them. And there’s just so much uncertainty.”

— SHERI BARTLETT BROWNE

struggling to meet the needs of a family member who is likely to die within six months, said Dr. Shelley Rice, medical director at PeaceHealth Whatcom Hospice. Most people don’t reach out for services until too late in the process.

“I would encourage families to think about hospice much earlier and not to think of it as throwing in the towel, but to think of it as gaining resources,” she said. People are sometimes reluctant to make this shift due to fears that going onto hospice will shorten their life, she said, which isn’t true. The goal of hospice is to help people live as well as possible with good symptom management for the time that they’re granted.

Planning can also help people carry out their end-of-life wishes, when feasible.

“As other research has shown, most Americans (71%) say that given the choice, they would prefer to die at home, with few saying they would choose a hospital (9%), hospice (7%) or nursing home (1%),” according to KFF.10 “That planning ahead part is a lot of what our team does for folks, which is helping to have those conversations. And they’re hard, because I think a lot of people really do think that ‘Oh, my insurance is going to cover that cost to be in a skilled nursing facility,’ and it usually doesn’t,” PeaceHealth’s Neville said.

Beyond planning and logistics, what patients need is support, both emotional and spiritual.

“Anybody who’s experiencing a serious illness is scared,” Browne said. “They’re not sure. They receive a lot of information from their medical team. They get information and advice from people all around them. And there’s just so much uncertainty.” They often need to tell their story over and over again, she said. “Listening is active, you’re responding. An important aspect would be to ask open-ended questions. Instead of saying, ‘Oh, that must be really hard for you,’ it’s better to say, ‘Wow, you know, that sounds kind of scary,’ or, ‘That sounds frustrating. Could you tell me more

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CHA RESOURCES CHA offers resources to educate and raise awareness about the significance of hospice and palliative care, their distinctions and their essential role in the mission of Catholic health care. https://www.chausa.org/palliative/resources

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It’s also important to meet patients where they are. “Sometimes the difficulty is that what we, as caregivers, define as a good death doesn’t necessarily match up with what our patients feel,” Rice said. The same is true of family expectations. The goal is to remain focused on giving the patient what they need.

Having that support can help patients and families explore aspects of the life transition that are truly important. “It can open everything up, to provide space to have those hard conversations, important conversations, and for all of the folks involved in that family to think about what really is meaningful,” Neville said. This offers the closure and connection people crave at the end of life.

PeaceHealth has helped patients not only bridge gaps with family members, but realize dreams, such as returning to their alma mater on a virtual reality trip, or real-life stadium seats to see the Seattle Seahawks play. “Those things, I think,

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fill everybody’s cup, the days when you really can make a dream come true. That may not be the dayto-day work, but gosh, they’re really kind of sparkly moments for everybody,” Rice said.

Death can be a mirror for life. “I think when we feel like we’ve had a full and meaningful life, it’s easier to be prepared for a peaceful and natural death,” Rice said. “I think so many of these conversations are about how we want to live, as well as knowing that death is coming.”

Working with families living through these moments is hard. “But it’s also so beautiful and vulnerable and raw, and that’s why I love this work, because it’s just humanity in its most real form,” Neville said.

KELLY BILODEAU is a freelance writer who specializes in health care and the pharmaceutical industry. She is the former executive editor of Harvard Women’s Health Watch. Her work has also appeared in The Washington Post, Boston magazine and numerous health care publications.

NOTES 1. “With End-of-Life Preparedness, Actions Speak Louder than Words, Ethos Survey Finds,” PR Newswire, July 13, 2022, https://www.prnewswire.com/news-releases/ with-end-of-life-preparedness-actions-speak-louderthan-words-ethos-survey-finds-301585801.html.

2. “Views on End of Life,” AARP, 2024, https://www. aarp.org/content/dam/aarp/research/topics/

aging-experience/demographics/end-of-life-views. doi.10.26419-2fres.00782.002.pdf.

3. “About Us,” The Conversation Project, https:// theconversationproject.org/about/.

4. Daniela Zago et al., “TV Medical Dramas: Assessing the Portrayal of Public Health in Primetime,” Frontiers in Public Health 12 (July 24, 2024): https:// doi.org/10.3389/fpubh.2024.1432528.

5. “CPR Facts and Statistics,” American Red Cross, October 2, 2024, https://www.redcross.org/ take-a-class/resources/articles/cpr-facts-and-statistics.

6. Liz Hamel, Bryan Wu, and Mollyann Brodie, “Views and Experiences with End-of-Life Medical Care in the U.S.,” KFF, April 27, 2017, https://www.kff.org/report-section/ views-and-experiences-with-end-of-life-medical-carein-the-us-findings/.

7. Hamel, Wu, and Brodie, “Views and Experiences with End-of-Life Medical Care in the U.S.” 8. Cheryl L. Lampkin, “Thoughts on End of Life: For Most, Concerns Do Not Equate to Action,” AARP, March 18, 2024, https://www.aarp.org/ pri/topics/aging-experience/demographics/ death-dying-end-of-life/.

9. A related study on early palliative care for cancer patients: Dan Monnery and Joanne Droney, “Early Palliative Care and Its Impact on End of Life Care,” Current Opinion in Supportive and Palliative Care 18, no. 4 (December 2024): https://doi.org/10.1097/ SPC.0000000000000729.

10. Hamel, Wu, and Brodie, “Views and Experiences with End-of-Life Medical Care in the U.S.”

QUESTIONS FOR DISCUSSION Navigating a serious or life-threatening illness is challenging for patients and their family members, friends and care providers.

1. What does your health care system do to encourage patients to make care plans for themselves?

How do you educate them about what these may include, and who and when to share them with?

2. Does your health care environment support educational and awareness campaigns to help people understand the distinctions between palliative care and hospice? Are these tied to calendar dates, like National Healthcare Decisions Day on April 16, or are they year-round efforts?

3. Family dynamics come into play when a relative experiences a serious or terminal illness. How do you keep focused on the patient and their wants and needs? How often do you communicate with them to see if those wants and needs are changing?

4. What practices, programs and processes does your ministry have in place to provide spiritual and emotional support for patients and their families as they cope with an end-of-life situation?

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Timeless Approach, Latest Innovations Combine in Personalized Medicine GAUTUM AGARWAL, MD Director of Precision Medicine, Mercy

O

ne in a million describes a young woman I cared for with a rare form of kidney cancer. Unfortunately, despite all efforts, including clinical trials, she passed away from her disease. Patients like her propel me and our Mercy ministry to find solutions to enable early and accurate detection of disease, to maximize treatment response and minimize side effects.

This is the field of precision medicine, which is the latest iteration of what doctors have been trying to do since the beginning of modern medicine. It is through God’s grace that the human genome was first sequenced in the early 2000s. At that time, the cost was in the billions, and it took more than a decade to do.1 The same process now takes less than a week and costs less than $1,000.2 The ability to decode the building blocks of the human body allows for insight into the causes of disease. Artificial intelligence (AI), using multimodal data acquired from imaging, pathology and numerous data points within the medical record, helps predict the risk of disease in patients and develops more accurate treatment plans.

At Mercy, we have invested heavily over the last two decades in preparing to use genomics and AI on every patient within our ministry.3 From rural Arkansas to city centers like St. Louis, every patient has access to this life-changing care.

It is my hope that as our precision medicine program progresses, patients like the one men-

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tioned earlier will have different outcomes. My hope is for early detection of patients’ diseases and treatment tailored specifically for them to lessen their suffering.

MOVING BEYOND ‘ONE-SIZE-FITS-ALL’ CARE

Throughout my 10 years of practicing medicine, I have had the privilege of walking alongside my patients and their families, helping them navigate the delicate balance between triumph and sorrow.

From a young age, I was fascinated by how things worked. That curiosity, paired with a deep desire to serve others, naturally led me to a career in medicine. Every day, I’m given the opportunity to not only understand the complexities of the human body but also to make a difference in the lives of those who seek care. It’s this combination of curiosity, service and faith that drives me.

Medicine is an emotional roller coaster, a journey filled with breathtaking victories and heartbreaking setbacks. Yet, at its core, it is a deeply human endeavor, one that calls on us to alleviate

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suffering, improve lives and nurture the hope that our patients and their families place in our hands.

Whether it’s extending a person’s life or helping them reach a cherished milestone, we enter a profound relationship with those we serve, dedicating ourselves to making their goals possible.

For me, this deep connection is where faith and medicine intersect. Working within Catholic health care, I have found this union of faith and medicine to be especially meaningful. Mercy’s mission, rooted in the Catholic tradition, reminds us that medicine is more than a profession. It is a ministry of healing that seeks to uphold the sanctity of life in all its forms, no matter where someone is on their life’s journey.

And yet, as the world of medicine evolves, so too must our methods. Precision medicine leverages the latest advancements in technology — AI and genomics — to augment the practice of medicine. It enables us to move beyond the “one-sizefits-all” model of care and gives us the tools to offer more personalized and effective treatments.

me that medicine, at its best, extends life while enhancing its quality.

This is just one example of what is possible when we embrace innovation. Precision medicine is about more than treating disease after it occurs — it is also about preventing disease and extending one’s good health. The ability to use cell-free DNA, or cfDNA, from urine, blood, saliva and other fluids to potentially diagnose disease in its earliest stages — or even before disease truly takes hold — represents a major leap forward.4 If these tests become part of regular screenings, cancers could be caught and treated before any symptoms are even noticed.

INNOVATION TO COMPLEMENT THE HUMAN TOUCH

AI is transforming our ability to diagnose and treat disease. AI-powered tools are helping us see patterns in radiology and pathology that would otherwise go unnoticed by the human eye. Our recent rollout of Aidoc’s aiOS platform, which enables a comprehensive additional review of most diagnostic imaging, can Medicine is an emotional roller coaster, a flag possible incidental findings outside of the scope of journey filled with breathtaking victories an ordered test.5 These technologies can predict disease and heartbreaking setbacks. Yet, at its outcomes, expedite results, core, it is a deeply human endeavor, one suggest treatment responses and ultimately reduce the that calls on us to alleviate suffering, burden on our clinical colleagues. They empower us improve lives and nurture the hope that to make more informed deciour patients and their families place in sions faster and with greater accuracy. In this way, AI our hands. becomes not a replacement With precision medicine, we can identify the right for the human touch, but a complement to it, augtreatment for the right patient at the right time, menting our ability to care for our patients in the while minimizing harm and improving outcomes. most effective way possible.

Already, we are seeing lives changed forMercy also is among those leading the charge ever through some of our first uses of genomic in precision medicine. Through our pioneering technology. Take the case of an older gentle- work with an extensive longitudinal database of man who was diagnosed with Stage 4 incurable patient information as part of a multiyear collabobladder cancer. After surgery and three failed ration with Mayo Clinic, we are making insights rounds of chemotherapy, this patient’s future and predictions that have a direct impact on appeared bleak. But when we ran next-gener- patient care. The work of our data science team ation sequencing on his tumor, we found a tar- is truly groundbreaking. By leveraging this vast geted mutation. He was then started on a newly amount of data, we can tailor treatments more approved targeted therapy for that specific precisely, reduce side effects and improve the mutation, and now, nearly one year later, he is chances of success for our patients. cancer-free and still living each day with a The Chen Chemotherapy Model is one examrenewed appreciation for life. His story reminds ple of the impact data can have on patient care.6

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Photo courtesy of Mercy

Mercy held its first precision medicine summit about the future of personalized health care in September 2024 in the St. Louis region. Pictured, left to right, are June Cha, PhD, MPH, policy director at FasterCures — Milken Institute Health; Gautum Agarwal, MD, the director of Mercy precision medicine; and Gaurav Singal, MD, physician at Brigham and Women’s Hospital and Harvard Medical School faculty, who is a health care data and technology advisor.

Using a daily, smart-texting model, patients receiving chemotherapy can help care teams identify early on if they are experiencing problems that could result in hospitalization, and if so, to try and address them before that point. We’ve seen 26% reduced readmissions after chemotherapy and 42% fewer chemo-related emergency room visits.

Through the partnerships we’ve developed with industry leaders — both large and small — we are bringing solutions to the problems our patients and providers face daily. Nearly 1,000 physicians across Mercy are using ambient generative AI to clinically document summaries of patient conversations in exam rooms. Patients say they appreciate the more personalized conversation, enabling more time for patient-physician interaction by reducing physicians’ time on the computer, and it enables us to see more patients

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each year.

This is the work that Mercy was founded to do. Our mission is not simply to provide medical care but to bring life-changing medicine to all our patients. Faith and medicine, together, call us to lead with compassion, to innovate with purpose and to ensure that everyone — regardless of their location, background or means — has access to the best care available. As we stand at the forefront of a new era of health care, we can shape a future in which precision medicine is not a privilege but a standard of care. By leading the way, we can ensure that this revolution in medicine is equitable and just, reaching even the most underserved among us.

PROGRESS AND FAITH AS GUIDES

As we embrace these advances in medicine, we must remain grounded in the values that have

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guided us for centuries. I often think of part of a quote from Thomas Jefferson, inscribed on the southeast wall of the Jefferson Memorial in Washington, D.C.: “I am not an advocate for frequent changes in laws and constitutions, but laws and institutions must go hand in hand with the progress of the human mind. As that becomes more developed, more enlightened, as new discoveries are made, new truths discovered and manners and opinions change, with the change of circumstances, institutions must advance also to keep pace with the times.”

Jefferson’s words remind us that progress is necessary — not just in science and medicine but in the institutions that guide our practice. Our health care system must evolve, just as our medical knowledge evolves. But as we move forward, we must always remember why we entered this field in the first place: to heal, serve and honor the sanctity of life. Faith and medicine together give us the strength to pursue innovation while keeping compassion at the center of all we do.

I believe the key to providing the best care lies in understanding the whole person. Knowing a patient’s medical history is crucial, but so is learning about their family, profession and passions.

When I take the time to learn about what makes each person unique, I can treat them with greater empathy and precision. I can tailor treatments to fit their lifestyle, making care more effective and personalized.

Medicine is not just about science — it’s about people. By seeing patients as individuals rather than just cases, we can use the advancements being made every day with precision medicine to provide care that addresses not only the illness but the person behind it. In my practice, this philosophy is the foundation of every interaction, and I

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believe it leads to better outcomes for my patients and greater fulfillment in my role as a physician.

Together, with faith as our guide and precision medicine as our tool, we can create a future where health care is more effective, more equitable and more compassionate than ever before.

DR. GAUTUM AGARWAL is a urologic oncologist and the director of precision medicine for Mercy in St. Louis.

NOTES 1. “Fact Sheet: Human Genome Project,” National Human Genome Research Institute, June 13, 2024, https://www. genome.gov/about-genomics/educational-resources/ fact-sheets/human-genome-project.

2. “Sequencing the Human Genome,” J. Craig Venter Institute, https://www.jcvi.org/research/ sequencing-human-genome.

3. “Microsoft and Mercy Collaborate to Empower Clinicians to Transform Patient Care With Generative AI,” Mercy, September 27, 2023, https://www.mercy.net/ newsroom/2023-09-27/microsoft-and-mercycollaborate-to-empower-clinicians-to-transfo/; “Mayo Clinic, Mercy Collaborate to Globally Transform Patient Care,” Mercy, July 26, 2022, https://www.mercy.net/ newsroom/2022-07-26/mayo-clinic--mercycollaborate-to-globally-transform-patient-car/.

4. “Cell-Free DNA Testing,” National Human Genome Research Institute, https://www.genome.gov/ genetics-glossary/Cell-Free-DNA-Testing.

5. “Mercy Harnesses AI to Revolutionize Imaging Services and Improve Patient Outcomes,” Mercy, January 28, 2025, https://www.mercy.net/newsroom/2025-01-29/mercy-harnesses-ai-to-revolutionizeimaging-services-and-improve/.

6. “Mercy Launches AI-Driven Texting Program to Prevent Chemo-Related Hospitalizations,” Mercy, November 14, 2023, https://www.mercy.net/ newsroom/2023-11-14/mercy-launches-ai-driventexting-program-to-prevent-chemo-relate/.

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The Unique Needs of Vowed Religious Elders in Long-Term Care KELLY O’SHEA CARNEY, PhD, ABPP Geropsychologist and Contributor to Health Progress

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rowing old is not for the faint of heart, nor is caring for frail elders. This is particularly true when one is caring for retired sisters, priests and brothers who have lived lives vowed to God and service. Their unique perspectives on life, the sacrifices and adventures experienced during their ministries, and the challenges of living a vowed religious life deserve special efforts to ensure a high quality of life and enjoyment in their later years.

Dr. Bill Thomas, a thought leader in the care of frail elders, has said that the three plagues of long-term care settings are loneliness, helplessness and boredom. Ideally, caregivers in these settings strive to ensure that their residents’ needs are met and encourage connection, autonomy and purpose, thereby eliminating the potential conditions that diminish well-being.

In licensed settings staffed by trained professionals, policies, processes and operational norms are in place to reduce the likelihood of loneliness, helplessness and boredom. However, ideal conditions are not always met. And in the varied and often unlicensed settings where aging religious are cared for, these safeguards may not be observed. Moreover, because retired religious present with unique histories and needs, the impact of unaddressed loneliness, helplessness and boredom can be particularly harmful.

MEETING UNIQUE NEEDS

Let’s consider examples of retired religious receiving long-term care services in different care settings and the extraordinary life experi-

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ences each has enjoyed. It’s essential to remember that older vowed religious share commonalities but also have varied experiences as individuals.

The examples below are composites inspired by experiences with aging religious men and women encountered by the author in a variety of retirement care settings: Sr. Michael is a retired teacher and principal who worked in schools in low-income neighborhoods where safety was a concern. At 92, she lives in a nursing home that provides services under contract to her order.

Fr. Murphy, an 88-year-old resident of a diocesan retirement home, was a World War II paratrooper and served as a beloved but bombastic pastor in small rural parishes throughout his diocese.

Sr. Mary Louise is 97 years old and lives in a retirement villa where she is cared for by informal caregivers employed by her order. She served as a missionary in Africa and South America, setting up health care services in remote areas. Living abroad, her closest relationships are with the sisters she served alongside in the missions.

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Br. Gregory is a member of an order that maintains its own long-term care setting staffed by an interdisciplinary team of professional caregivers. It is attached to their congregation home.

He is 102 years old and is a retired professor of theology who taught at a small Catholic university.

Religious communities determine the care settings for their members based on the number of individuals to be served, the financial resources of the community and the individuals, and the capacity of the younger community members to participate in the care of older members. Some religious communities choose to operate their own care settings. These settings may be full-scale care settings staffed by professionals, or informal settings supported by younger members of the religious community. Other religious communities establish partnerships with long-term care providers and aging services in the larger community. The choice of care setting determines whether the aging members live in professionally run care settings or more informal settings where care is provided by caregivers who may have limited training. Regardless of the setting, each of these retired

While their life paths were quite different, each of these individuals dedicated themselves to God in a life of service according to their vows and the charism of their congregation. Like many people, their health and function have declined with advancing age, and now each of them requires care, assistance and support to manage day to day and to thrive in this new stage of life.

The specific religious community that a vowed religious person is a part of determines the way in which that person is cared for and supported as they need more When vowed religious are cared for in a assistance. Religious communities assume the role long-term care setting managed apart from of family in the care of dependent elders, offering the religious community, it is imperative help with decision-makthat those providers understand the ing, accompanying the person in their aging prospecial needs of this population. cess and offering hands-on assistance when needed.

Historically, these needs were met organically religious have unique care needs resulting from and informally by younger members of the com- their clinical diagnoses and specific functional munity. But as the average age of vowed religious decline.

But unlike their lay counterparts receiving increases, many communities are struggling to long-term care and support, retired religious also meet these needs.

Typically, each religious community creates have unique needs resulting from their experisystems of care guided by the leadership team ences of faith, service and a vowed life in a reliand/or identifies informal and formal resources gious community. Even settings with the structo ensure that each of their members has the emo- ture, expertise and resources to identify and tional and functional support they need as they address the psychosocial-spiritual needs of their age. However, many communities are also expe- residents may not be familiar with the unique riencing challenges in meeting these needs effec- needs of retired religious. Yet, in every setting, it tively. Fewer younger members, shrinking com- is imperative that care partners recognize the spemunity size and growing numbers of older mem- cial needs of vowed religious elders to promote bers all challenge the capacity of communities to well-being, life satisfaction and thriving despite support their dependent elders. To address these age-related challenges.

The International Council on Active Aging challenges, many religious communities must partner with external resources. When vowed provides a framework for understanding the interreligious are cared for in a long-term care setting related domains of healthy aging, and this framemanaged apart from the religious community, it work serves as a guide to meeting the needs of is imperative that those providers understand elders within long-term care settings.1 The areas the special needs of this population. Therefore, of wellness identified by the council include intelwhere those individuals will be cared for becomes lectual or cognitive stimulation, physical movean important decision for religious communities. ment and activity, active spiritual pursuits and

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FAITH & MEDICINE

The challenge in caring for Sr. Michael is to engage and leverage her retained skills as an educator, team leader and community builder so she feels she is contributing to the world. Sr. Michael may not find meaning in playing bingo or doing crafts at the nursing home. She may even see these activities as childish. But participating in planning meetings for the youth volunteer program at the nursing home or planning a fundraiser for a local children’s charity may be engaging and purposeful Understanding the specific spiritual to her. practices and supports that are desired Without this kind of meaningful outlet, Sr. Michael is and needed by vowed religious is an likely to experience boredom and despair which will, important part of ensuring well-being as in turn, impede her physical these individuals age. health and function. Therefore, it is incumbent upon her potential as health and function decline. But for caregivers in the nursing home to first recognize frail vowed religious individuals, attention to Sr. Michael’s unique skills, acknowledge her spespecific wellness domains is critically impor- cial need to be of service to others, and then meet tant to well-being and quality of life. Specifically, this need with creativity. the domains of purpose or vocation, spirituality, social connection and intellectual engagement SPIRITUAL SUPPORT are essential to the well-being and quality of life When caring for retired religious, it is obvious of retired religious. that spiritual support is an important aspect Recognition that retired priests, sisters and of care. However, the focus and nature of spiribrothers have lived lives of service must provide tual practices among retired religious may vary the foundation for care planning and daily activ- greatly, and their spiritual care needs are likely to ity in long-term care. Moreover, caregivers should exceed traditional pastoral care support in longrecognize that many retired religious have lived term care. expansive lives marked by adventure, resourceUnderstanding the specific spiritual pracfulness and significant responsibility and author- tices and supports that are desired and needed ity. Informed by these insights, caregivers can be by vowed religious is an important part of ensurintentional in offering meaningful opportunities ing well-being as these individuals age. For those for activity and engagement that draw upon pre- who are members of more traditional orders, their served skill sets and invite service to others. lives of faith may center around participation in the rhythm of the Church calendar and participation in the Eucharist. In some congregations, indiFULFILLING ACTIVITY Sr. Michael is an example of a servant leader who vidual spiritual practices and prayer may be more enjoyed taking charge as a school principal. Serv- familiar and comfortable. Others may have relied ing in marginalized communities, she learned to more upon the prayer practices of their congrebe tough and assertive, while also tending to the gation, such as praying the Liturgy of the Hours needs of the children in her care. In the skilled together.

During Fr. Murphy’s 55 years as a priest, he care facility where she lives, staff may experience her as demanding and difficult because of offered Mass for his small congregations every her high expectations and authoritative manner. day, and he served as a spiritual guide to his Misperceiving her tough exterior, staff may not parishioners. In retirement, he longs for the daily realize that Sr. Michael is a bright, resourceful and celebration of the Eucharist. But he requires assisresilient woman, and even as her health and cog- tance to get to the chapel or say Mass at a private nition decline, she wants to be of service to others. altar. While there is a chaplain who serves the support, meaningful social connection and community, purposeful tasks and activities to support a sense of vocation or contributing to others, outlets for healthy emotional expression, and a physical environment that is pleasant, homelike and supports function.

To support the well-being of any elder, caregivers must strive to provide intentional engagement, purpose and support to foster their full

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retirement home, Fr. Murphy is uncomfortable receiving spiritual guidance from a younger person. Although he lives in a diocesan retirement home, his spiritual well-being is suffering because he is not able to engage in the spiritual practices of faith sharing and worship that have sustained him throughout his life.

To enhance his spiritual well-being, Fr. Murphy’s caregivers should explore ways to support him in leading or participating in Mass each day, meeting with friendly visitors to whom he might offer spiritual support, and/or offering a faithsharing group for the older priests who live in the home. These approaches, while different from traditional pastoral care practices in a long-term care setting, would be better suited to his spiritual needs.

SOCIAL CONNECTION AND CLOSE TIES

Each of us has a need for social connection, but the manner and extent we like to socialize varies for everyone. In long-term care, socialization often occurs through the activity programs offered in group settings and is typically augmented by the presence of family and friends who visit and provide support. For many retired religious, however, family connections may not be as available, potentially because of years spent away from relatives while serving in ministry or living within their religious community. Moreover, as discussed earlier, the religious community the individual is part of may be facing some capacity challenges, thereby limiting the extent to which younger members of the order can be present and actively involved in offering emotional support and socialization.

Sr. Mary Louise is an example of someone who has limited social support. She has outlived many of her contemporaries in her extended family, and because she lived abroad for most of her adult life, she is not connected to the younger members of her family. Her closest relationships have been with those she served alongside in ministry, but many of those sisters have passed away. Moreover, while her religious community has historically served as her family, the number of members in her congregation is declining, and there are fewer sisters to provide social support to the aging sisters.

Sr. Mary Louise is an example of a vowed religious person who needs extra support to meet her social-emotional needs. While she may enjoy

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attending group activities, these are unlikely to provide the closeness and functional support that family or friends might. Creating mechanisms by which she can connect with others in her order or providing her with the support of a lay volunteer affiliated with the Church will help her feel connected and supported in her final years.

INTELLECTUAL STIMULATION

By virtue of their training and education, most retired religious are bright, intellectually curious and value lifelong learning. In fact, for retired religious currently living in long-term care, many sought out religious life because it was an avenue to education and meaningful vocations, in addition to a means of living out their faith. Moreover, research has shown that aging religious tend to retain health and function and live longer than their lay counterparts, thereby reaching advanced ages before changes in function and cognition occur.2 Nonetheless, eventually, advancing age catches up with us all, and illness, functional loss and cognitive decline can occur. Yet, current research on brain health also tells us that cognitive stimulation, even in the context of cognitive decline, is critical to maintaining function at its highest level.3 At 102, Br. Gregory is living with early-stage dementia. Because he is well-educated and a lifelong learner, he benefits from a high level of cognitive reserve, which allows him to compensate for some of his cognitive losses due to dementia.

To help him preserve his retained abilities, it is important that Br. Gregory engages in meaningful cognitive stimulation through new and challenging activities.

Unfortunately, in long-term care settings, activities are often designed to appeal to the broadest group of participants, and this may not meet Br. Gregory’s intellectual needs. Rather than inviting him to engage in word games or sing-alongs, he may be better served by watching TED talks on YouTube, reviewing familiar theological texts or offering miniseminars on theology to his fellow residents. This kind of individualized, stimulating activity is more likely to meet the needs of a man who has dedicated his life to God and learning. But these kinds of activities also require creative care planning and coordination of resources to ensure that Br. Gregory’s intellectual needs are met.

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INTENTIONAL COMMUNITY

PAU S E . B R E AT H E . H E A L .

Retired religious are as diverse and unique as any other group of older adults. However, they do share common life experiences that center on service, spirituality, community and the life of the mind. While traditional long-term care settings strive to meet these needs for all their residents, they often do so in ways designed to meet the needs of the greatest number of people, relying upon the expertise of recreation professionals, chaplains and counselors.

But not all professionals may be familiar with the exceptional circumstances of a vowed religious person. Moreover, many retired religious are cared for in settings that have minimal resources and expertise to address needs beyond daily care. As a result, too many aging religious find themselves without purpose, community, spiritual structure and support, and/or appropriate intellectual stimulation.

Our retired religious have given their lives in service to God and others. In their later years, as health, function and cognition decline, we owe it to them to recognize the special needs that arise from their selfless and expansive lives in ministry and religious community. Drawing upon the best practices in caring for older adults and incorporating the most effective structures and processes

of long-term care settings is a start in ensuring their needs are met.

But more than that, meeting the psychosocial and spiritual needs of retired religious demands that we first recognize the unique aspects of caring for these individuals and then bring intentionality, sensitivity and creativity into creating the opportunities and experiences designed to address the individual needs of each retired religious person we care for.

KELLY O’SHEA CARNEY is a board-certified geropsychologist and spiritual director.

She has decades of leadership in long-term care and serving older adults, including aging religious.

NOTES 1. “Active Aging and Wellness,” International Council on Active Aging, https://www.icaa.cc/activeagingand wellness/wellness.htm.

2. David A. Snowdon, “Aging and Alzheimer’s Disease: Lessons From the Nun Study,” The Gerontologist 37, no. 2 (April 1997): https://doi.org/10.1093/geront/37.2.150.

3. Dr. Gill Livingston et al., “Dementia Prevention, Intervention, and Care: 2024 Report of the Lancet Standing Commission,” The Lancet 404, no. 10452 (August 2024): 572-628.

I Find Rest For just this moment, bring your attention to your breath.

INHALE deeply and settle yourself into your body.

EXHALE the stress and tension you feel.

On your next inhale, pray, I Find Rest.

And as you exhale, In Your Shelter.

I Find Rest, In Your Shelter KEEP BREATHING this prayer for a few moments.

(Repeat the prayer several times) CONCLUDE, REMEMBERING:

Even now, God is with you, as near to you as your breath. Continue giving yourself the gift to pause, breathe and heal, knowing you are not alone.

Whoever dwells in the shelter of the Most High will rest in the shadow of the Almighty. PSALM 91:1 © Catholic Health Association of the United States

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Religious Communities Seek Paths to Long-Term Care for Aging Members DAVID LEWELLEN Contributor to Health Progress

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n 2004, the Sisters of the Presentation of the Blessed Virgin Mary decided that they could not offer on-premises skilled care to their aging members. “We made the decision with our heads, and we’re living it now with our hearts,” said Senior President Sr. Mary Catherine Redmond, PBVM.

The congregation has been drawing on its financial portfolio to pay its bills since 2017. Sr. Redmond hopes the money will last another 10 to 15 years, but she says of those investments, “It could go tomorrow.”

When the sisters can no longer safely stay in the congregation of 69 women, with a median age of 81, they go to one of two long-term care facilities — a Catholic one about 45 minutes from their motherhouse in New Windsor, New York, or, if no spot is available there, a secular one close by. Sr. Redmond has also worked with two other congregations to explore and negotiate together for other retirement facilities.

The Catholic facility offers daily Mass and has more sisters in residence, offering a greater sense of community — but the nearby facility makes it easier for sisters from the motherhouse to stop by to offer the Eucharist and a visit.

Hundreds of congregations across the country face variations on this dilemma, as fewer workingage sisters try to support more who need skilled care or assisted living. The problem has been growing more acute for decades, and even as religious communities discern the best choice from imperfect options, no perfect formula for success has been found.

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LONG-TERM PLANS ‘IN THE MIND OF GOD’

A 2023 study by the Center for Applied Research in the Apostolate reported that as of 2021, there were approximately 36,000 vowed women religious in the United States — a 51% decrease from 20 years earlier.1 Most congregations, seeing the coming demographic crunch, began serious retirement planning no later than the 1980s, according to Sr. Thu Do, LHC, PhD, the co-author of the report.

“Compound interest pays off if you start 30 or 40 years ahead of time,” she said. Also, for many decades most congregations have enrolled their members in the Social Security program.

Fr. Thomas Gaunt, SJ, PhD, the other co-author, said that congregations have used every possible living arrangement, depending on individual circumstances. Some have their own retirement home, some have an arrangement with a public retirement home, and some keep their oldest members in the same facility with their sisters in ministry, bringing in a nurse on a regular basis.

But a separate report in 2023 by the National Religious Retirement Office found that out of 476 responding congregations, only about 6% were adequately funded — including approximately 7% of the 119 men’s communities and 5% of the 357 women’s communities.2 Fr. Gaunt estimates

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that in the coming decades, between 10% and 30% of all communities, particularly the small orders, will no longer be autonomous.

Communities’ resources for raising money vary widely. Fr. Gaunt said that orders that focused on education may often have generous donors: “For Sister Mary who taught me in third grade, they’ll send money every month.” Orders that focused on health care or social services may not have formed those same personal ties. But communities that ran hospitals are often able to make arrangements to reserve spots in nursing care or assisted living for their aging sisters — and they may also find themselves with a large sum of money if and when they sell facilities.

There are lots of creative ways for congregations to collaborate — sometimes, they will merge outright if they have an affinity in ministry or spirituality, or a smaller group will “come to completion.” Another arrangement is for the members of one order to move into the facility of another.

The Sisters of Sts. Cyril and Methodius, a small congregation in eastern Pennsylvania, have welcomed other orders into their assisted living facility since 2007, beginning with 14 Dominican sisters. “It was an incredible success,” said Sr. Barbara Sable, the congregation’s general superior.

“We had our own sense of community when we wanted it, but we blended in many ways.”

Since then, there have been several arrivals and departures, but currently, the site is home to sisters from five congregations. Each community has a private gathering room, but many activities, meals and liturgies are shared in the larger common space. Almost every table in the dining room has sisters from different orders sitting together.

More than once in the past 17 years, a group of sisters has departed because their congregation found another living space for them. “They’re sorry to move away from their friends,” Sr. Sable said, “but they understand the value of being with their own community. We take vows, and obedience is one of them.”

The Sisters of Sts. Cyril and Methodius currently have 49 members, Sr. Sable said, with a median age of 80. Their long-term plan “is in the mind of God, and has not been shown to us yet,” she said. “We think about the three sisters who were our founders in 1909, and they also didn’t know what would come next.”

Fr. Gaunt said that a particularly challenging

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situation is when a contemplative order can no longer care for an elderly or infirm member in their cloistered location. “It can be very traumatic if you went into the monastery at age 20 and now, you’re 87 and the superior says, ‘We can’t take care of you, so you need to move to assisted living or nursing care.’”

A move to a new place is often a chance to consider the difference between mission and ministry. Vowed religious will always have a mission to serve God, but the form of ministry may change over a career. And when a career is no longer possible, “your ministry is praying for the Church and for society,” Fr. Gaunt said. “It isn’t just a throwaway line. In the infirmary or in nursing care, they’ll say, ‘Here is what we should be praying for.’”

“When someone goes to a nursing home, they are missioned to the nursing home,” said Sr. Redmond of the Sisters of the Presentation. That mission might be prayer, visiting other residents or tasks such as ordering socks for homeless people online — but the sisters still have a purpose.

FINANCIAL STRAINS AHEAD

Looking at the numbers, Fr. Gaunt sees an inflection point happening now or soon. As the large number of post-World War II novices die, the average age of American religious will come down due to the lower numbers who joined in later years.

And more international sisters (such as Sr. Do) are coming to the United States to do ministry under their home orders.

“When the community needs to put money aside, but they have 80 retired sisters and 20 active, that’s a real crisis,” Fr. Gaunt said. “Many communities do not have a single sister with a real income. And if a sister who was earning $300,000 as the president of a hospital steps down, that’s a huge hit.”

Individual dioceses cover retirements for diocesan priests separately, and National Religious Retirement Office (NRRO) Director John Knutsen said that many dioceses do separate collections to raise funds for that purpose. Congregations of brothers and priests are fewer than those of women religious, but they face the same issues.

The NRRO serves as one systematic source of help, distributing almost $28 million to about 300 congregations in 2023, according to a formula that weighs each group’s census data, assets, cost of care and other factors. Since its founding in 1988,

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the organization has distributed more than $970 tions a wellness coordinator, whose job included million in direct aid and other assistance.3 “For the researching better deals on prescriptions and next 10 years or so, the need is going to be very making sure that sisters were receiving benefits great, simply because of the average age of con- from Medicare or Medicaid. Góral-Makowski gregations,” said Knutsen. “If it does fall off, it will said that aging sisters were more apt to open up about their difficulties to the wellness coordinamainly be because the numbers are dropping.”

Preparation for the financial strain runs the tor. To their superiors, the impulse was to say, gamut, he said, but “like anyone else, the earlier “I’m fine.”

In New Windsor, Christine Rodriguez has you get started, the better off you’ll be.” The 6% or so of congregations with adequate funding had taken on that role, serving as government ben“strong planning, getting advice on the right topic efits coordinator for the Sisters of the Presentafrom the right people,” or a strong development tion. She advocates for the community, makes sure everyone gets the benefits they are entitled office of their own, he said.

The NRRO funds direct costs of long-term to and works to create a social environment. “I tell care for aging religious, but another agency, Sup- them, ‘Whatever service you’re asking for, I will port Our Aging Religious (SOAR!), has a mission try to get it for you’ — with very few questions to enable specific capital projects for congrega- and no judgment at all,” she said. She asks sisters tions, such as an elevator or a van. The NRRO if they are satisfied with their doctors and medicaappeal is routed directly through parishes; SOAR! tion and arranges transportation off the campus.

As another wellness service, Rodriguez began looks for grants from foundations and individuals.

Sr. Kathleen Lunsmann, IHM, the president of offering bingo to the residents some time ago.

SOAR!, said that very few congregations of Catho- But she is quick to forestall any retirement home lic sisters in the United States are fully funded for stereotypes. “It’s much bigger than just bingo,” she said. “You can see cognitive issues and also retirement, and most are underfunded.

SOAR! awards about $3 million per year relationships.” and most applications are granted, but the needs are SOAR! awards about $3 million per year increasing. Selling a mothand most applications are granted, but erhouse or other real estate will often help a particular the needs are increasing. congregation, “but that’s hard, too,” she said. “Women religious in their 80s have never been involved in The transition to a nursing home, whether discussions about selling real estate.” secular or Catholic, can be difficult for anyone.

Sr. Lunsmann said that every year, SOAR! Sr. Imelda Maurer, CDP, founded the nonprofit In gets grant applications from several first-time Service to Our Own to advocate for the needs of applicants. older sisters. “With our culture, the temptation is to say, ‘We’re older, we’re fewer, and ain’t it sad,’” she said. “I think we need to say, ‘But what is our SERVING AS WITNESS TO THE GIFT OF AGING In addition to money, SOAR! has offered support mission to do now?’”

Sr. Maurer thinks sisters can lead the way in to congregations through Pathways to Wellness, a pilot program that aims to reduce the cost of breaking down ageism and to “witness to the gift health care for religious congregations and alle- of aging. I think that is our prophetic call today.”

Another related purpose comes from Sr. Tere viate stress upon their leaders. Elizabeth GóralMakowski, SOAR!’s director of development, said Maya, CCVI, CHA’s senior director for theology that the program offered quarterly webinars and and sponsorship. She notes that many women conference calls among superiors, where they religious are energized about the years of service “could talk to each other and realize they were ahead of them, and that the United States should not alone. They could share some strategies and look beyond its borders to consider how vowed women serve, whether domestically or abroad. thoughts and get a sense of community.”

The program also assigned some congrega- One aspect of congregational life is to prepare

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younger sisters to accompany their elders in aging. Ongoing research about aging religious, such as the Nun Study, a longitudinal study by the School Sisters of Notre Dame,4 can hold lessons for the aging population as a whole.

The shift in prophetic calls is nothing new in the long term. “It’s been going on for 2,000 years,” Sr. Do said.

“Communities sprout up, they exist for a few years or a few centuries, and they disappear.”

“This is not the end,” Sr. Maya said.

“Something else is going to happen.”

DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin.

NOTES 1. Thu T. Do, LHC, and Thomas Gaunt, SJ, “Women’s Religious Institutes Successfully Planning and Funding Members’ Elderly Care,” Center for Applied Research in the Apostolate, June 2023, https://static1. squarespace.com/static/629c7d00b33f845 b6435b6ab/t/64baa32d9f664238023 f4aa5/1689953077434/specialrepsum 2023.pdf.

2. “National Religious Retirement Office: 2023 Annual Report Supplement,” National Religious Retirement Office, 2023, https://retiredreligious.org/wp-content/ uploads/2024/09/rfr24_2023_ supplement.pdf.

3. “National Religious Retirement Office: 2022 Annual Report Supplement,” National Religious Retirement Office, 2022, https://retiredreligious.org/wp-content/ uploads/2023/08/rfr23_2022_ supplement.pdf.

4. “Nun Study: Alzheimer’s Study Demonstrates SSND Commitment to Educating in Broadest Sense,” School Sisters of Notre Dame, https://ssnd.org/ministries/ nun_study/.

GET IT DELIVERED Health Progress and Catholic Health World CONTACT THE SERVICE CENTER AT SERVICECENTER@CHAUSA.ORG

Issues are complimentary for those who work for CHA members in the United States.

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Normothermic Regional Perfusion and the Determination of Death BRIAN M. KANE, PhD Senior Director of Ethics, Catholic Health Association

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ecently, some organ procurement organizations (OPOs), agencies responsible for organ retrieval and transplantation in the United States, have initiated a procedure that challenges Catholic ethics on organ donation. It is called normothermic regional perfusion (NRP).1 This procedure provides artificial circulation of blood to diminish the deterioration of organs for transplant. This is not a topic that occurs in ordinary conversation.

However, it is a topic that should be understood by those who work in Catholic health care to make informed decisions about organ transplants that occur in its facilities.

To place this procedure in context, it is helpful to first review existing policies and laws about organ donation and the determination of death.

When organ donation was first successful in 1954, with the transplantation of a kidney from one brother to another in Boston, the success of the procedure was unexpected, and it raised several ethical issues. Many questioned the ethics of removing a healthy organ from one person and implanting it in another to replace a diseased organ. In Catholic moral theology, the procedure seemed to violate the understanding that it was immoral to remove a healthy organ from a person.

Shortly after this transplant, Pope Pius XII weighed in on the conversation and said that in the instance of a transplant for a paired organ, such an act of donation was charitable and not selfish. So, it was moral under Catholic teaching.2 In the following years, the success of organ transplantation led to further conversations of moral clarification. Once organ transplantation

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became clinically successful, other ethical issues arose. Most accepted that organ donations were moral, so long as the donation was not the cause of the death of the donor. So, deathbed donations that benefited one person but that hastened or resulted in the death of another were not allowed.

Next, the discussion shifted to whether some people who were now bedridden and sustained on respirators and other equipment, with little hope of recovery to ordinary existence, could be considered organ donors. Harvard Medical School and, later, the Uniform Law Commission took on the challenge.

Both asked, “When is a person dead?” Traditionally, for most of human history, the answer to this question has been that we are dead by cardiopulmonary criteria. In short, we are dead when our heart and lungs cease to function. The lack of circulation and respiration are established through ordinary observation and simple tests.

In 1968, the Ad Hoc Committee of Harvard

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Medical School to Examine the Definition of Brain Death discussed the issue and argued that we could also be declared dead by neurological criteria, when the entire brain ceases to function.

This is known as whole brain death.

It is important to say that there was a choice here as to a definition of brain death. An alternative proposed definition, which is still being debated more than 50 years later, is whether damage to the “thinking” parts of the brain is sufficient to declare death.

The Harvard Committee did not think that the alternative definition was sufficient. Later, when the Uniform Law Commission, which suggests common language to states for drafting legislation, proposed a legal definition of brain death, it used the Harvard criteria. I think that this was and is the correct definition.

So, assuming that cardio-pulmonary criteria are usually used to determine death, how would NRP challenge that? In short, NRP recognizes cardio-pulmonary criteria at the start of the procedure to harvest organs and then ignores them during the procedure to ensure more viable organs for transplant.

ETHICAL AND LEGAL CHALLENGES

When physicians have a high degree of certainty, because of underlying clinical criteria, that a person already meets the criteria for a neurological determination of death, or that once life support is discontinued, cardio-pulmonary death will occur, the process for assessing the patient for organ donation can occur. The patient may have already given consent before they were incapacitated through an advance directive, or the patient’s health care proxy may also have the legal authority to consent for the patient. Then an assessment is done by the OPO to determine if there are viable organs for transplant. If so, the donor is brought to the surgical suite, and the procedure of discontinuing life support is performed. After the required time period when there is no heart or lung activity, the patient is declared dead. Then, the transplant team begins the process of retrieving the viable organs.

The challenge for the transplant team is that once cardio-pulmonary activity has ceased, the organs to be harvested will begin deteriorating.

The transplant team’s goal is to harvest as many viable organs as they can with the best chance for transplantation in possible recipients.

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For those OPOs that accept normothermic regional perfusion, after the patient is declared dead, NRP is then initiated before any organs are removed. The carotid arteries to the brain are clamped to prevent blood flow to the brain and to concentrate circulation in the thorax and abdomen. Then, lines are placed, which are connected to a machine that oxygenates the blood, so that the organs to be transplanted are perfused.3 There are two types of NRP. In donors where the heart, as well as other abdominal organs, are planned to be recovered, thoracoabdominal normothermic regional perfusion (TA-NRP) is performed, while in donors with only abdominal organ recovery, abdominal-normothermic regional perfusion (A-NRP) is performed. They differ in the placement of where the lines go. In TA-NRP, they are placed in the aorta and right atrium of the heart, while in A-NRP they are placed in the femoral artery and vein.4 From the perspective of the OPOs, this practically results in more viable organs. Since the patient has been declared dead by cardio-pulmonary criteria, they assert that the patient remains dead. In their view, by clamping the carotid arteries, the perfused blood is now directed only to the organs that will be retrieved, which increases the likelihood of successful transplantation. The brain does not receive the blood and the oxygen the blood carries is now directed to the other organs.

But, in clamping the carotid arteries, there is a problem with the determination of death, from a Catholic, and even, perhaps, from a legal perspective. First, death was initially determined by cardio-pulmonary criteria, but by clamping the carotid arteries and then restoring circulation and restarting the heart, they are no longer met.

There is now a functioning heart, which invalidates the initial determination of death. Of course, the person is no longer breathing, so that part of the definition of death is still met. In NRP, the oxygenation of the blood is done by a machine.

With the carotid arteries occluded, there is now a direct action taken which will cause brain death. Without circulation, the criteria for whole brain death are met. But, the action by which that happens is not the result of the natural process of death. Instead, it is a result of a deliberate decision to occlude the carotid arteries. To be clear, there is not a second determination of death by neurological criteria, since the OPOs think that the first determination of death is sufficient.

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EXAMINING A SOLUTION

So, NRP scrambles the two definitions of death.

While cardio-pulmonary criteria start the process and are met, the procedure then invalidates those accepted criteria by restarting the heart, which is still in the body. It resumes its natural function of perfusing organs with blood. Then, by occluding the carotid arteries, brain death results, but not by the natural process of death.

The OPOs intention of perfusing the organs to increase the viability of the organs to be harvested is a practical answer to a problem that does limit organ transplantation. The problem is that the solution of restarting the donor’s heart in order to initiate NRP violates the agreed ethical and legal definitions of declaring death by cardio-pulmonary criteria.

There is a solution to this problem, but, for now, it is expensive. Perhaps, if it is adopted, the expense can be reduced. If a patient were declared dead by cardio-pulmonary criteria, and their organs were viable, then they can be ethically removed for transplant. The solution is to perfuse those organs outside of the donor’s body.

Once the organs are removed, we have a very different ethical context. Now, the organs are not considered to be co-existent with the personhood of the donor. They are separate, and their viability for transplant becomes the concern. The technology is present, but it is expensive because it is infrequent.

Perfusing an organ outside of a direct transplant can add $65,000 to the cost.5 So, I understand the motivation of the OPO’s approach, which

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seeks to minimize the expense. But I will argue that it also comes at a moral cost. NRP is not ethical for Catholic health care because it confuses the accepted criteria for death and then uses that confusion to make ethically challenging choices about organ donation.

BRIAN M. KANE is senior director, ethics, for the Catholic Health Association, St. Louis.

NOTES 1. “Introduction to NRP and Perfusion in DCD: What Do These Concepts Mean?,” The Alliance, July 2022, https://www.organdonationalliance.org/insight/ introduction-to-nrp-and-perfusion-in-dcd-what-dothese-concepts-mean/.

2. Pius XII to the Italian Union for The Blind, “Comment on Corneal Transplants,” Acta Apostolicae Sedis, May 14, 1956.

3. The technical term for the machine is a venoarterial extracorporeal membrane oxygenation unit, which is usually shortened to the term VA-ECMO. 4. Emad Alamouti-Fard et al., “Normothermic Regional Perfusion Is an Emerging Cost-Effective Alternative in Donation After Circulatory Death (DCD) in Heart Transplantation,” Cureus: Journal of Medical Science 14, no. 6 (June 29, 2022): https://doi.org/10.7759/ cureus.26437. I disagree with the ethics of NRP in this article, but they have a very detailed clinical explanation of the procedure.

5. Ted Alcorn, “The Organ Is Still Working. But It’s Not in a Body Anymore.,” The New York Times, April 2, 2024, https://www.nytimes.com/2024/04/02/health/ organ-transplants-perfusion.html.

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MISSION

MOVING BEYOND ‘NO MARGIN, NO MISSION’ IN CATHOLIC HEALTH CARE

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recently had the opportunity to present and participate in the CHA-hosted Sponsorship Institute in Albuquerque, New Mexico. This is a gathering that takes place every other year and is attended by CEOs, chief mission officers and sponsors from across the ministry. In one particularly engaging session, Sr. Tere Maya, CCVI, CHA’s senior director for theology and sponsorship, used clips from the movie Cabrini to generate discussion about the future of Catholic health care. She also explored the vital role of sponsors in ensuring our Catholic identity as a ministry of the Church and the sustainability, growth and transformation of the ministry in reading the signs of the times.

While there are many profound moments in the film, one that I found especially powerful is Mother Cabrini’s consistent response to those who doubted DENNIS her aspirations: “Begin the misGONZALES sion, and the means will come.”

This immediately caused me to reflect on the constant tension that we have faced

between margin and mission, or between our faith-based ministry and heritage and the harsh realities of the health care business in the United States. One could argue that the challenges today are greater than they have ever been, and, therefore, revisiting this conversation is very timely.

My colleague, Becket Gremmels, system VP of Theology and Ethics at CommonSpirit Health, offers his perspective on this issue.

UNDERSTANDING THE MEANS TO THE MISSION BECKET GREMMELS, PhD

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he saying “no margin, no mission” is used in Catholic health care to convey the idea that if a ministry is not financially viable, it will cease to exist, rendering it unable to live out its mission into the future. As catchphrases go, it quickly conveys the importance of having a sustainable financial margin. Given the substantial financial difficulties that many Catholic health systems (and nonprofit health care in general) have faced during recent years, it is no surprise that the phrase is heard regularly. While well-intentioned, this mantra contains several misunderstandings of our mission and how the partnership of faith and medicine is lived out on the operational side

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of Catholic health care.

DUTY AS GOD’S STEWARDS

First, “no margin, no mission” relies on a dichotomy between finance and mission. It assumes that the two are different things, separate and distinct.

The phrase contains an inherent presumption that “being financially viable” is not the same as “living out our mission.” This relies on an overly narrow conception of mission. Good stewardship of resources is a core part of our Catholic identity and our mission. This includes financial resources just as much as any other resources, like our people, the environment or our time.

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For example, if we do not focus on caring for employees and creating opportunities for them to grow, we undermine the long-term sustainability of the ministry. If we do not use our resources well, are inefficient or permit waste to persist, we are not using creation in the way God intended.

We have been entrusted with these assets to serve God’s people. St. Paul speaks about the financial realities of ministry to the Corinthians (1 Corinthians 9:4-12); even the founder of modern accounting systems, Friar Luca Bartolomeo de Pacioli, was a Franciscan monk.1 If we lack financial sustainability, then we miss opportunities to be of service and fail in our moral duty as God’s stewards.

Moreover, a budget is a moral document. Budgets reveal priorities, given the size and scope of allocation to various departments and projects.

To a certain extent, the more valued an area is, the higher its allocation, and the reverse is also true.

quality as those in the community.5 If a ministry of the Church cannot meet basic standards — and a group from another faith, a secular group or the government can — then why are we doing it? We should cede that ministry to those who can best serve God’s people. Quality includes financial health. A financially unstable organization cannot be described as being of sufficient quality.

EXPANDING THE VIEW OF FINANCIAL SUSTAINABILITY

Third, “no margin, no mission” takes a narrow view of financial sustainability, which is far more robust than “making margin.” Certainly, an organization cannot be financially viable without a margin, but existing to make money is very different than existing to make some money to reinvest it in the tools, resources and people needed to carry out the ministry.6 Intention is an essential component of any ethical analysis, and assessing operational actions is no exception.

While margin helps the ministry flourish, it does not deCertainly, an organization cannot be fine the broader purpose. In a larger organization, it is likely financially viable without a margin, but that some areas or departments existing to make money is very different do not bring in any revenue or provide cost savings and are inthan existing to make some money to stead supported by those that reinvest it in the tools, resources and do. Financial sustainability allows an organization not only to people needed to carry out the ministry. provide these services but also to reinvest in and update areas We must all place value on some things more than that do produce revenue. Moreover, a finance deothers, but this is inherently an ethical choice. partment’s responsibilities include much more Thus, financial sustainability is just as much a part than making money, such as capital planning, fiof our mission as anything else. Catholic health nancial analysis or payor analytics. The phrase care connects faith and the practice of finance just “no margin, no mission” risks reducing this entire field down to “making margin,” which does a as it connects faith and the practice of medicine. disservice to finance and the concept of financial sustainability itself.

SUSTAINABILITY AND QUALITY Second, financial sustainability is a key aspect in canon law of being a ministry of the Church.2 As a INTENTIONAL FOCUS AND REFLECTION work of the Church, each ministry must “possess Fourth, the phrase “no margin, no mission” could the means which are foreseen to be efficient to be seen as prioritizing finance over mission which achieve their designated purpose.”3 Those carry- can send the wrong message that our focus is ining out this work are entrusted with their function come first and caring for people second. People to fulfill the public good.4 This implies a certain who use this phrase likely do not mean to convey stewardship and responsibility to maintain the this, but it is often what is understood by those organization, which requires financial sustain- who hear it. They may very well respond by asking, “If we focus so much on margin that we lose ability.

Moreover, canon law states that a ministry sight of our mission, then why do we even need should be of sufficient quality, or at least as high the money?”7 Clear communication on this point

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is critical when developing the leaders who will guide the ministry into the future to avoid organizational drift and loss of identity.

For example, a colleague recently recounted to me how a CEO affirmed this with new leaders in an executive formation session. He emphasized that they must be balanced in their approach to living the mission and managing financial needs.

All leaders have different strengths, but they must keep the reason why we exist front and center in their work to ensure a sustainable ministry. This was a new concept for some leaders in that session who came from secular organizations. However, it reinforced their new reality of leading a ministry that requires intentional focus and reflection.

EVER EVOLVING AND ADAPTING

Given these limitations of the “no margin, no mission” mantra, Catholic health care is better served by turning to other language that depicts an authentic understanding of the relationship between finance and mission. The best option, in my opinion, is “financial sustainability.” This reflects the mutually supportive relationship between mission and financial margin.

If this does not resonate, some alternative phrases can include: “called to be stewards,” “continuing our heritage,” “cultivating our future,” “maintaining our mission” or “stewardship sustains.” Using these or similar terms can fulfill the good intentions behind “no margin, no mission” without reducing our ministry and the field of finance to the goal of generating income.

Ultimately, we should move away from phrases that oversimplify systemic challenges toward language that complicates the narrative with a nuanced approach.

As leaders in Catholic health care, we are called to join faith and medicine in finance meetings, strategy planning and other operational aspects of our work. This may require us to think differently and change how we talk about our work, but a ministry that has lasted for centuries must constantly adapt and reinvent itself to survive. To do so, we must portray an accurate picture of the deeper relationship between financial sustain-

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ability and Catholic identity in our words as well as in our actions.

Some questions you may want to consider and discuss: How do you think about the relationship between mission and finance in your work? Are they separate or mutually supportive?

What is your first reaction to the idea that financial sustainability is a core part of living out our mission? How might this change your approach to budget planning?

What language do you think best reflects the idea of financial sustainability? How does this language support our Catholic identity?

How do you define stewardship in your ministry? How can you help your colleagues and coworkers develop an expanded understanding of stewardship beyond financial sustainability?

BECKET GREMMELS is system vice president of theology and ethics at CommonSpirit Health.

NOTES 1. Lawrence Murphy Smith, “Examining Intersecting Lives: Luca Pacioli, Father of Accounting, and His Friend, Leonardo da Vinci,” Accounting History 27, no. 3 (April 2022): https://doi.org/10.1177/ 10323732221084988.

2. Code of Canon Law, c. 1284, 1, in The Code of Canon Law: Latin-English Edition (Washington, DC: Canon Law Society of America, 1983); Fr. Francis Morrisey, “Canon Law—What Does Canon Law Say About the Quality of Sponsored Works?,” Health Progress 88, no. 2 (March/ April 2007): 10-11.

3. Code of Canon Law, c. 114, 3.

4. Code of Canon Law, c. 116, 1.

5. Code of Canon Law, c. 806, 2.

6. Pablo Bravo Vial, “Boundless Collaboration: A Philosophy for Sustainable and Stabilizing Housing Investment Strategy,” Health Progress 100, no. 5 (September/October 2019): 23-26.

7. This rejoinder is discussed in more detail in the following: Dr. Thomas Beckman, “No Money, No Mission: Addressing Tensions Between Clinical Productivity and the Culture of Medicine,” Mayo Clinic Proceedings 94, no. 8 (August 2019): 1401-1403.

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FORMATION

WHY GOOD IS BETTER THAN BEST

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s spring shoots out green stems and colorful blossoms, the Church’s Easter Vigil syncs up with the reality around us, as heard in the opening reading from the first chapter of Genesis. God created one thing, then another and then more things, and at the end of each day, “God saw that it was good.” (Genesis 1:10) The sacred story speaks of God gazing upon creation as good, and the sixth and final instance God looks upon all creation and finds it very good. (Genesis 1:4-31) This repeated refrain of goodness stands in juxtaposition, if not a radical critique of a societal fixation on “the best.” Publications and social media boast the best tech gadgets, the best summer vacation spots, the best physicians and more. This conDARREN M. stant parade of “the best” forms the ego to only desire what othHENSON ers have identified as top-notch.

Good seems so hackneyed in these contexts, even dismissed, as the ego drives the mind’s awareness to a narrow focus. We overlook that best comes at the end of the line of good and better.

BEST PRACTICES

cal intervention becomes a best practice because it has become accepted as superior or preferred over alternative actions. Naturally, when a patient enters a surgical prep bay, they trust the surgical team to follow only the best proven clinical techniques. These practices save lives and lead to higher quality and safety outcomes.

Aspiring to the best is quite normal. Yet a disproportionate disappointment can unfold when a best-case scenario eludes us. Even if the outcome is good, yet not the best-case scenario, a person may feel they missed out or were harmed. Social jargon tries to make light of it with the phrase “the fear of missing out.” Psychologists back this up.

A handful of terms relate to a psychological phenomenon where people experience losses more heavily than equivalent gains or experiences of goodness. One such term is loss aversion.2 In other words, when the best lies beyond our reach, loss aversion and its perceptions may obfuscate the good. Take, for example, a story I heard

The best of consumer goods and social gathering spots are a close cousin to “best practices.” Over the past three decades, the “best practice” label soared in health and human services, public policy and Aspiring to the best is quite normal. Yet higher education, among a disproportionate disappointment can other disciplines. One early usage of the phrase emerged unfold when a best-case scenario eludes in a book by an American mechanical engineer, Fredus. Even if the outcome is good, yet not erick Taylor, in the wake of the best-case scenario, a person may feel the Industrial Revolution.

Taylor believed there could they missed out or were harmed. be “one best way” to perform every worker’s action.

Therein lies the connection between today’s lingo one afternoon in which a reporter described a of “best practices” with benchmarks.1 painful stall in labor negotiations among striking The idea is that a workflow, policy or medi- workers as one side sought to “get the best deal

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possible.” The holdouts wagered that better options would come to them even when good options had been presented by the opposing side.

Popular leadership publications and academic journals have applied scrutiny and skepticism to the prolific use of “best practices” for more than a decade. Critics point out that they work only if they fit one’s intended use and situation.3 Managers who espouse them too closely tend to shut down fresh ideas from their team. Best practices tend to reinforce so-called norms, which may not apply universally across populations, such as to the disability community, rural populations, diverse groups or other marginalized communities.

One writer suggests shifting to “next practices” as an alternative.4 Similarly, I choose phrases such as “leading practices” or the wordier, “an example to consider is … .” These prompt reflection, and they respect prudential judgment and leadership freedom.

These linguistic gymnastics are an initial (yet minuscule) indicator of larger practices. They reflect an awareness and appreciation of a broader goodness that permeates diverse circumstances, conditions and individuality. The words reverence that what is best is rare and only comes forth from first identifying what is good.

Looking for the good can be a counterpoint practice to the bombardment of the best that saturates our society. The problem is that our egoic mind becomes so fixated on someone else’s best practice, capitalizing on the fear of missing out, that we suppress creativity. Also, like my younger self sitting on Lee’s couch, we may fail to see and celebrate the good that is already present. Perhaps the task is not to duplicate some other best practice but to recognize, foster and advance the existing good.

I realized that I was saturated in seeing many things askew. I didn’t see all the good around me.

Lee started me on a formation journey toward the good.

FORMATION FOR THE GOOD

Ministry formation programs typically commence with reflection on a leader’s vocation.

That process entails claiming one’s gifts and talents. These are outward signs of one’s own goodness. It is as if God looked upon them when God dreamed the individual into being and said, “How good you are!”

Dictionary definitions of “good,” when used as a noun, refer to “something conforming to the moral order of the universe.” This explains why in the Genesis story, God’s creative acts were described as good, which was an ordering of the TREASURING THE GOOD I learned to savor what is good during sessions universe. More commonly, this is why humans on a couch across a cozy room from a wise man, praise their dog or pet for being “a good girl.” It I’ll refer to as Lee. Lee patiently sat with me as is because the pet displays actions that conform my spiritual companion, receiving my rants and to an order. More importantly, when it is said that tending to the grief I experienced in the twists of someone is a good person or has displayed goodmy journey and vocation. Once I paused from my ness, it is because the individual has fostered their grumbling, Lee looked at me with that sage, worn own character in such a way that they demonstrate a moral uprightness.

The ongoing formation expePerhaps the task is not to duplicate rience includes content, reflecsome other best practice but to tion and dialogue on the Catholic moral tradition. Formation recognize, foster and advance the involves a process of equipping leaders to guide with integrity in existing good. ways consistent with this Cathosmile and soft eyes beholding me through the lic worldview and ethical lens. It is a process of deep wrinkles of his face, and just said, “Darren, further forming leaders who come to the ministry look for the good.” He had to help me a bit. Like with their own inherent goodness and supporta skilled analyst, he gently pointed to the things ing them with additional skills, habits and ways of my upset ego blinded me from recognizing. Lee being so that part of their character as a Catholic gently reminded me of the many good things I had health ministry leader entails integrating into the shared in recent sessions. “Look for the good” then moral vision and Reign of God. These all serve to became a mantra and enduring spiritual practice. foster great good.

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When we seek the good in our role as leaders in the healing ministry, we support the bountifulness of the ministry and the flourishing of the patients and people served by our ministry.

A second definition in The Merriam-Webster Dictionary says “good” refers to the “advancement of prosperity or well-being,” such as the good of the community. This definition resonates with CHA’s vision of strengthening the common good. In other words, ministry formation cultivates leaders who enable the healing ministry in service to human goodness.

A final insight is when “good” is used as an adjective, it means bountiful or fertile. Striving for what is good is to participate in the Creator’s life and activity. It is a co-creative act. It is our efforts to be bountiful in our work and to share our God-given gifts. When we seek the good in our role as leaders in the healing ministry, we support the bountifulness of the ministry and the flourishing of the patients and people served by our ministry.

Ministry formation creates a space where participants discover God’s goodness working through them. God desires us to experience our own goodness and the goodness of the world around us. Indeed, our world remains broken, and though imperfections outnumber occasions of achieving “the best,” God’s grace draws us forward into goodness.

Looking for the good opens a new horizon where God’s energy of love calls us forth. Our awareness of such goodness often comes in bitesized experiences, and seldom with pinnacle experiences of “the best.” The lens of “the best” shackles the mind to default to diminishing one’s self, harboring low esteem or worse, engaging shame.

For example, when laypersons were first called into roles of mission leadership, they often doubted, saying, “I don’t know that I can do this. I’m not as good as sister.” The perception that sister was seen as the best stymied many of our predecessors, at least initially, in their journey.

A similar sentiment echoes among those called into sponsorship. The responsibility entrusted to leading a ministry of the Church, with origins

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in Jesus’ own ministry and with proper canonical grounding, can cause lay individuals to doubt whether they are best suited for the role. Real discernment, of course, is necessary to test this or any call to ministry. The Second Vatican Council and the more recent Synod on Synodality affirm the inherent goodness of the role of the laity in the life and mission of the Church. Whether called to sponsorship, mission leadership or an executive role, others often see in us a goodness that we might dismiss.

Lee lovingly initiated my vision for the good.

With practice, any of us can see the goodness all around us, in ourselves and in others, and share it abundantly. The best, after all, does not exist without lots of other goodness and betterness behind it. Good is enough, and what is good leads to flourishing.

DARREN M. HENSON, PhD, STL, is senior director of ministry formation at the Catholic Health Association, St. Louis.

NOTES 1. Frederick Taylor, The Principles of Scientific Management (Harper & Brothers, 1911); Gretchen RumohrVoskuil, “Best Practice: Past, Present, and Personal,” Language Arts Journal of Michigan 25, no. 2 (2010): 26-28.

2. The concept of loss aversion was first introduced and studied by Daniel Kahneman and Amon Tversky in 1979: Daniel Kahneman and Amon Tversky, “Prospect Theory: An Analysis of Decision Under Risk,” Econometrica 47, no. 2 (March 1979): 263-291.

3. Liz Ryan, “The Truth About Best Practices,” Forbes, November 3, 2014, https://www.forbes.com/ sites/lizryan/2014/11/03/the-truth-about-bestpractices/.

4. Nirit Cohen, “Best Practices Are Yesterday’s News—Welcome To Next Practices,” Forbes, December 12, 2024, https://www.forbes.com/sites/ niritcohen/2024/12/12/best-practices-are-yesterdaysnews-welcome-to-next-practices/.

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ETHICS

CALLING BALLS AND STRIKES: CLINICAL ETHICS CONSULTANTS AS UMPIRES FR. PETER FONSECA, MA, MS, MDiv

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linical ethics consultations, which first emerged in the 1970s and ’80s, have rapidly developed to the point that it is nearly impossible to imagine hospitals without ethics committees or clinical ethics consultants (CECs). While CECs have quickly become established in hospital wards, there are still important ongoing conversations about the role of this health care profession and debates about how best to use their services.

Over the past decade, organizations like CHA and the American Society for Bioethics and Humanities (ASBH) have developed various competencies and certifications for clinical ethicists, which have proven beneficial for the training and support of CECs.1 Yet, as useful as these competencies and certifications are for those seeking to do ethics consultations, CECs still need to find a way to succinctly introduce their role to patients and health care providers.

DISCERNING GOD’S WILL

As a priest who spent several years in pastoral ministry and is now pursuing a PhD in health care ethics, I frequently contemplate the relationship between spiritual care and the hospital’s CECs. Many of my previous parishioners sought pastoral care for spiritual accompaniment during their illness, as well as for assistance in recognizing and following God’s will in the circumstances of that illness.

This art of discernment, however, presupposes a clear understanding of the available treatment possibilities, which is the role of the medical team, and a clear understanding of which of these possibilities are ethically appropriate, the responsibility of the CEC. Only after a patient or their surrogate decision-maker understands what is ethically appropriate can they properly discern the best course of treatment in their unique circumstance.

While most patients understand the role of a chaplain, very few patients, families and sometimes even members of the hospital team under-

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stand the role of CECs. If hospitals are going to become places of true discernment, we need to find a way to explain what exactly this field of health care ethics is. Through trial and error, I have found several different elevator pitches that, for better or worse, seem to assuage the curiosity of those who have not heard of health care ethics.

But as spring dawns and baseball returns, I can’t help but wonder if perhaps drawing a comparison between umpires and CECs may be a helpful analogy for introducing the role and responsibility of CECs. Umpires have a precarious relationship with the game of baseball. They are both part of the game and, at the same time, not part of it. They are part of the game because, without an objective eye to call balls and strikes, the game would descend into chaos. At the same time, as arbitrators of the game, they must stand outside the game and ensure it is played according to the rules.

Similar to how umpires are beholden to these rules, CECs are beholden to the way that God formed humankind and the kinds of actions that lead to a person’s flourishing. They are responsible for having an intimate knowledge of the principles and theories of bioethics so that they can inform patients and the medical team if their proposed treatment is in the zone or outside.

Just as it is not the umpire’s job to make tactical decisions about where the ball should be thrown, it is not the CEC’s responsibility to determine what type of care should be given. Doctors and the medical team have the expertise and

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knowledge to inform the patient of the best strategy to approach their condition; however, it is up to the patient to determine what care they believe is most appropriate for them in their unique circumstance.

For as much as umpires may be despised from time to time, they are still a necessary part of the game. Sure, there are many pitches, like a fastball down the middle, that everyone in the stadium knows is a strike, but there are also those borderline pitches that require the objective eye of the umpire to judge if it qualifies as a strike or not.

Similarly, CECs help patients and the medical team understand what is ethically permissible and assist in the discernment process related to the patient’s care. For example, a clinical ethics consultation is probably not needed to help the family of an 85-year-old diagnosed with Stage 4 lung cancer discern that artificial nutrition and hydration (ANH) will not be used when he stops eating while he is dying on hospice care. A CEC, however, can be extremely beneficial for a family to decide if this same type of treatment is appropriate for a 65-year-old with advanced dementia who refuses to eat because he does not feel hungry and, due to his confusion, continues to remove the tube used to provide him with nutrition.

In the case of the 85-year-old cancer patient,

to withdraw that care, is ethically justified or not.

Being a good umpire requires comprehensive knowledge of the rules of the game, but it also requires a certain demeanor that is professional, impartial and exudes confidence while remaining calm under pressure. A good umpire not only calls balls and strikes but forms relationships with players and coaches to ensure that, even in contentious times, the game moves smoothly.

Likewise, CECs need to have not only an intimate knowledge of the principles of bioethics but also interpersonal skills to navigate difficult and stressful circumstances, often among parties who are seeking to understand and perhaps disagree with each other.

CREATING A SPACE TO PAUSE, REFLECT AND ASSESS

For all the benefits of using this analogy between an umpire and a CEC, it falls short at some point.

Perhaps the biggest weakness in this analogy is that umpires deliver decisions or verdicts, while CECs offer recommendations. While umpires choose sides in a disagreement, a good CEC mediates disagreements and helps all sides come to a consensus about the best path forward.

CECs bring ethical expertise to create a space where all parties involved can pause, reflect and assess if the proposed treatment is ethically appropriate. For example, rather Just as it is not the umpire’s job to make than coming in and issuing a judgment “from on high” about tactical decisions about where the ball whether the 65-year-old with advanced dementia can have should be thrown, it is not the CEC’s the ANH removed, a good CEC responsibility to determine what type of takes the time to meet with the surrogate decision-maker to care should be given. understand the wishes of the patient, explain the ethical and the doctor’s explanation of how the body reacts moral implications of the desired choice, and, during the dying process is usually enough for the where necessary, encourage conversation surpatient or his surrogate decision-maker to com- rounding areas of confusion that ultimately leads fortably decide to withhold ANH. However, in the to the surrogate decision-maker making a more case of the patient with advanced dementia, the informed decision. family may find the assistance of the CEC helpPatients have the often-challenging responsiful for understanding ethical obligations to feed bility of deciding on the best possible treatment those who cannot feed themselves, important available for their illness. This art of discernment ethical distinctions like killing and letting die, and requires a space where patients or their decisioneven the Catholic Church’s position on the use of makers can pause, reflect and assess their unique ANH. In this case, the CEC can help the patient’s circumstances before discerning the best path surrogate understand the parameters of ethical forward. care, which will assist them in determining if their When discerning what care is most approdesired choice, either to continue with ANH or priate, patients can benefit from the assistance

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of the medical team to discover what is medically possible, CECs to distinguish which treatment options are ethically appropriate, and chaplains to recognize God’s will in their unique circumstances. While not all medical decisions require the skills of a CEC, in more complicated cases, they facilitate conversations that help the patient objectively determine if their desired course of treatment is ethical.

Like an umpire, who ensures the game of baseball is played according to the rules, a CEC brings ethical expertise to assist the patient in making medical decisions that lead to the flourishing of the patient and the practice of medicine.

FR. PETER FONSECA is director of Continuing Formation for Priests in the Archdiocese of St. Louis. He also serves as a mission fellow for the Catholic Health Association, St. Louis.

NOTE 1. Qualifications and Competencies for Ethicists (Catholic Health Association, 2018), https://www.chausa.org/store/ products/product?id=3804; American Society for Bioethics and Humanities, Core Competencies for Health Care Ethics Consultations, 2nd Edition (American Society for Bioethics and Humanities, 2010).

WE WILL EMPOWER BOLD CHANGE TO ELEVATE HUMAN FLOURISHING

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COMMUNITY BENEFIT

NAVIGATING FINANCIAL ASSISTANCE AT MERCY:

COMPASSIONATE CARE FOR PATIENTS STERLING COKER, MBA, EHRC, CRCR, and GARRETT KATES

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t Mercy, we are committed to delivering compassionate, high-quality care and understand that financial barriers should not prevent anyone from receiving the care they need. Accessing health care can be overwhelming, particularly for individuals and families facing economic difficulties. As part of our mission to bring the healing ministry of Jesus to life, we offer financial assistance programs to try to ensure equitable access to medical services for all.

While it’s important that our mission is reflected in our financial policies, it is even more important that related practices demonstrate our mission in action to patients. With a commitment to living our mission through financial care, we have implemented ways to better link patients to financial programs, and the health care system has received recognition in recent years for this work.

Such measures are important to health. For example, our Patient Services team, who process assistance applications, has heard from people that financial assistance gives them peace of mind and willingness not to delay treatment due to financial concerns, but to receive care to treat their conditions. By helping patients manage medical costs, we ensure they are not denied care due to their financial circumstances, promoting a culture of dignity and respect for those who choose Mercy.

RECOGNITION FOR ETHICAL BILLING PRACTICES

Mercy’s commitment to financial fairness has not gone unnoticed. In 2022, we were recognized by the Leapfrog Group and Money magazine for our ethical billing practices,1 preventing medical errors and providing clear communication to patients. This recognition highlights our dedication to transparency and patient-centered care, values that extend to every aspect of our financial assistance program.

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CHANGES TO THE SYSTEM

Traditionally, a patient or their loved ones could fill out forms seeking financial assistance. To try and ease this process, we’ve pared that back substantially. We now ask for the minimal information necessary for the determination of assistance, understanding that all patients may not have the vast amount of documentation we once required.

Another important step at Mercy involves preand post-care screenings to identify patients with financial need, and to try and separate this process from their medical appointments, when possible.

COMPREHENSIVE APPLICATION PROCESS

Mercy’s financial assistance process offers multiple ways for patients to apply: Presumptive screening: Mercy uses advanced data tools to proactively screen patients both during the scheduling conversation and after their service, prior to issuing a billing invoice. If these tools show that a patient falls below or meets 200% of the federal poverty guidelines, they may be automatically approved for financial assistance without needing to submit a formal application.

Traditional application: Patients can also apply by submitting written forms, which are available online or at any of our health care facilities.

Verbal application: Applications can be submitted verbally during registration or through

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customer service to accommodate patients who may find it difficult to complete written forms.

UNDERSTANDING ELIGIBILITY

HOW FINANCIAL SCREENINGS WORK

Income guidelines:

Through the prescreening process, when a patient in need arrives at a medical office or hospital, the person checking them in for their appointment may see an electronic flag on the account that indicates if a patient has been determined eligible for presumptive financial assistance. They greet the patient and ask them to have a seat, but there’s no financial conversation or request for payment.

This practice is about honoring the dignity of the patient and not having that uncomfortable conversation with them about services that they cannot afford to pay. For other individuals who show as not being eligible for presumptive financial assistance, the person at the front desk will be prompted on screen to collect routine co-pays or coinsurance amounts.

Before we place anyone with a collection agency, we do a post-service presumptive screening to identify patients whose financial circumstances have changed in the 90 to 100 days since the service occurred. We screen the patient encounter again through our automated presumptive eligibility process before it’s placed with a collection agency so that we have that opportunity to catch those individuals in the process as well. Mercy also has payment plan programs available.

CONNECTING PATIENTS TO MEDICAID

Financial care also includes working with patients to improve access to care by connecting them with Medicaid and other programs. We have financial specialists who screen emergency room patients for Medicaid eligibility, our financial assistance process and additional financial programs. They can guide that patient toward the appropriate aid or assistance track. Community health workers also do Medicaid screenings and financial assistance screenings to assist patients.

BILLING AND COLLECTION

With Mercy vendors and collection agencies, we require their leadership to take part in a condensed orientation to our organization, which includes formation. We want every Mercy patient to feel like they’re talking to someone with the organization when communicating with related vendors and agencies.

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Mercy’s financial assistance is primarily based on income relative to the Federal Poverty Guidelines (FPG). For example, full assistance is available for individuals and families earning up to and including 200% of the FPG, while those with incomes between 201% and 300% of the FPG may qualify for partial assistance.

This tiered system ensures that financial help is available to those who need it most.

Medically necessary care: Financial assistance is available for services deemed medically necessary. While essential health care services are covered, nonmedical services such as dental and vision care, unless specified, may not be included.

Insurance status: Patients are encouraged to explore all available insurance options before applying for financial assistance. Mercy provides insurance eligibility screenings to help patients determine whether they qualify for Medicaid or other insurance programs.

We do not practice extraordinary collection actions at Mercy. A key component of any new acquisition is to quickly assess if any of these actions are happening so we can retrain staff to align with our practices. Failing to do so would be inconsistent with our mission and would be a reputational risk.

CULTURE OF ACCOUNTABILITY

We have a culture of accountability, and it starts at the top. Mercy’s board, chief financial officer and other leadership are actively involved in the oversight of financial assistance policies. This culture of accountability is key to maintaining a patientcentered revenue cycle, where the focus is always on providing compassionate care. Mercy’s leadership challenges us as an organization to constantly strive to identify improvements and avoid complacency in our processes. Our CFO asks us to make our revenue cycle different and to make it a patient attractor. We consider preserving patient

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This commitment and shift to actively embed mission into our patient-centered financial care has been an ongoing process. It is not likely to be accomplished in a single set of policy changes; it requires cultural and policy changes. dignity as the cornerstone of our assistance program. We also find ways to leverage automation to allow patients to spend less time on financial considerations related to their care.

This commitment and shift to actively embed mission into our patient-centered financial care has been an ongoing process. It is not likely to be accomplished in a single set of policy changes; it requires cultural and policy changes.

A phenomenal resource for those looking to enhance their financial assistance program is to consider their entire approach to patient billing through the widely available Healthcare Financial Management Association Patient Financial Communications Best Practices.2 This is an excellent tool for assessing present practices against industry-leading practices and then developing a road map to make necessary and desired changes.

PRE-BAD DEBT SCREENING AND ACCOUNTABILITY

Mercy also conducts pre-bad debt screening to ensure that patients are eligible for financial assistance before any outstanding debt is sent to collections. This proactive approach preserves patient dignity and ensures that the process is respectful at every stage. This approach paid tremendous dividends, resulting in a significant drop in the amount of debt being placed to an agency. It also reduced the amount of time invested in service recovery efforts.

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PATIENT-CENTERED SUPPORT

Mercy’s customer service teams are available to guide patients through applications, answer questions and help set up payment plans for any remaining balances. This support prevents patients from facing collection actions whenever possible, ensuring a compassionate, patient-first experience.

OUTREACH AND COMMUNICATION

We actively communicate the availability of financial assistance through various methods, including patient statements, brochures, signage and online resources. This comprehensive outreach ensures that all patients are aware of their options and how to access the support they need.

CONCLUSION

At Mercy, financial assistance is a key component of our mission to provide compassionate and accessible health care. Through transparent eligibility guidelines, multiple application methods and a commitment to ethical billing practices, we ensure that patients are not left without care due to financial barriers. Our patient-centered approach extends beyond clinical care, fostering a culture of dignity, fairness and respect that aligns with our mission to serve and heal.

STERLING COKER serves as the chief revenue cycle officer for Mercy in St. Louis. GARRETT KATES is the executive director of patient services for Mercy in Springfield, Missouri.

NOTES 1. “Methodology: Best Hospitals and Surgery Centers for Billing Ethics,” Money, November 9, 2022, https:// money.com/methodology-best-hospitals-billing-ethics/; “Leapfrog Ratings: Mercy Hospital St. Louis,” The Leapfrog Group, https://ratings.leapfroggroup.org/facility/ details/26-0020/mercy-hospital-st-louis-st-louis-mo.

2. “Patient Financial Communications Adopter Recognition Program,” Healthcare Financial Management Association, October 8, 2024, https://www.hfma.org/revenue-cycle/ patient-financial-communications/19961/.

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Our ministry is an enduring sign of health care rooted in the belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind and spirit. This vibrant video series shines a spotlight on the contributions of CHA member ministries in promoting human dignity and the common good.

CHAUSA.ORG/CATHOLICHEALTH

AGING

PRESERVING CATHOLIC HEALTH CARE’S FOOTPRINT IN POST-ACUTE SERVICES TRISH GATHERS, CPA

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n reflecting on my life and the profound impact that Catholic health care and the dedicated work of Catholic sisters have had on my journey, I find it fitting to introduce Carith Ministries, an organization born last year from a rich tapestry of experiences rooted in compassion, care and community service.

The inspiration for Carith Ministries emerged from a powerful conversation I had in 2008 with Sr. Mary Caritas of the Sisters of Providence. Her words resonated deeply: “Finance person, you need to preserve the footprint of the Catholic post-acute ministry.” By addressing me as “finance person,” not only was she referring to my role in finance at the time, but she was also trying to tell me that financial stewardship needed to be embraced to maintain and preserve the Catholic identity.

This moment crystallized my understanding of the responsibility that comes with managing the resources of Catholic institutions. It became clear that finance and stewardship were not just about numbers; they were about safeguarding the mission and values of the Church.

A FOCUS ON MISSION SUSTAINABILITY

So what is Carith Ministries, and why was it formed? Quite simply, the Carmelite Sisters for the Aged and Infirm identified a pressing trend and decided to boldly respond with a solution: to offer a Catholic-sponsored ministry focused on supporting Catholic post-acute care, senior services and other related ministries to ensure a vibrant future for the Catholic Church. Our mission is not just to preserve but to carry forward these ministries that align with our values and Catholic social teaching.

As one of the few congregational-sponsored post-acute entities seeking to preserve the Catholic footprint, we provide Catholic-sponsored ex-

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pertise for real estate management, construction, marketing, business development, operations, revenue management, finance and strategic banking. Carith Ministries assists congregations and other Catholic ministries in their discernment process regarding strategic options and keeps our costs for overhead and services within 4% to help preserve ministry assets. By aligning with experts in these fields, we ensure that these ministries can make informed decisions that benefit their communities.

Originating from the Fitzgerald Institute for Real Estate at Notre Dame University, Carith Ministries provides options for Catholic sponsors of post-acute ministries. It focuses on affordable housing and the preservation of church properties. Therefore, we are not just looking to manage or own skilled nursing facilities, but to work with other ministries who are looking to find cost-effective solutions to serve middle- to lowincome community members with various needs (for example, the infirm, seniors, etc.) through affordable housing. This effort helps maintain the Catholic Church’s presence and honors the legacy of those who dedicated their lives to service.

Currently, Carith Ministries serves areas in New York, Florida, Iowa, Ohio, Kentucky, Pennsylvania, Wisconsin, Illinois and even internationally in Ireland, with plans to expand into Michigan, Maine and Rhode Island. The mission emphasizes delivering exceptional care to more than 3,000 residents, supported by a workforce

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of more than 3,500 employees and 120 sisters actively serving in these communities.

We are committed to ensuring that aged religious and vulnerable populations receive the care they deserve within the fiscal constraints allotted to the service line. If for-profit organizations can find ways to survive, so can we. It requires leveraging our strengths, preserving our balance sheets, maintaining our real estate, and aligning with market needs.

This is a financial stewardship decision. That’s what was so brilliant in Sr. Caritas’ statement to me — she emphasized the role of financial stewardship, not just clinical leadership or executive oversight. Preserving what we have while acknowledging and accepting constraints is crucial.

We are focused on mission sustainability, especially in post-acute care. It is not only possible but imperative.

FINDING PURPOSE

As a young child growing up in western Pennsylvania, I vividly recall the warmth and kindness of the nurses during my visit to a Mercy hospital in Johnstown, Pennsylvania, when I broke my arm.

The comforting presence of the crosses adorning the walls reminded me of the love and safety I felt in church. This early experience of compassionate care laid the groundwork for my understanding of the vital role that Catholic health care plays in the lives of individuals and families.

Years later, I found myself back at that same hospital as my grandmother battled cancer. It was a time when patients often stayed at hospitals for extended periods, and the atmosphere was one of unwavering support and empathy. On the day my grandmother passed, I sat in the lobby, playing with my Barbie doll, when a Mercy sister approached me. She invited me to the snack shop for a hamburger and a milkshake, and during our conversation, she imparted wisdom about love, loss and the importance of being there for my mother.

That moment and the kindness of the sister left an indelible mark on my heart, exemplifying the unique spirit of Catholic health care.

Years later, as an adult starting my professional career in accounting for a major secular retirement community, I felt a void — a lack of purpose that I later found in Catholic health care. A pivotal moment came during a meeting when I was asked about hitting the glass ceiling. That ques-

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tion prompted me to seek opportunities within Catholic health care, where I discovered a culture that valued diversity and embraced the contributions of women.

My experiences in Catholic health care were transformative. I had the privilege of working alongside remarkable leaders who taught me the importance of trust, delegation and mentorship.

Sr. Julie Casey, IHM, a dear friend and mentor, guided me in understanding the challenges faced by religious sisters as they transitioned their ministries. It was through these relationships and insights that I recognized the urgent need to preserve the legacy of Catholic health care.

PRESERVING THE CATHOLIC IDENTITY

Looking ahead, Carith Ministries aspires to expand our reach into affordable housing and educational programs for individuals with disabilities.

In a time when many Catholic ministries are at risk of being sold or diminished, Carith Ministries stands firm in its mission to safeguard and nurture these vital services. We recognize the rich history and teachings of Jesus that have guided Catholic health care for generations and seek to honor that legacy through our actions.

As we move forward, we are dedicated to building a sustainable model that preserves the values of Catholic health care while addressing the evolving needs of our communities. Our commitment to education, training and responsible financial management will ensure that we remain a viable presence in the lives of those we serve.

Carith Ministries embodies the spirit of compassion, resilience and faith that has been central to my life and the lives of many others. We are here to ensure that the legacy of Catholic sisters, priests and brothers who built this ministry continues to shine brightly for generations to come.

Together, we can navigate the challenges ahead, preserving the footprint of the Catholic Church and offering hope to those in need. Let us be a testament to the power of collaboration, creativity and unwavering commitment to our shared mission of service.

To learn more about Carith Ministries, visit https://www.carithministries.org.

TRISH GATHERS is president and chief executive officer for The Carmelite System in Germantown, New York.

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SOCIAL JUSTICE

CATHOLIC CHURCHES AND HOSPITALS AS SANCTUARIES AND PLACES OF REFUGE

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hroughout history, Catholic churches and hospitals have functioned not only as centers for religious worship and care but also as sanctuaries and places of refuge for those in need. Rooted in the teachings of Christ, the Church has long been seen as a protector and provider for society’s most vulnerable members. From the early Christian era to the modern day, both churches and hospitals have been spaces where people seek physical, emotional and spiritual solace.

Yet, recent political decisions in the United States to violate the Church’s exercise of sanctuary in the name of immigration enforcement are troubling because they ignore the valuable tradition of sanctuary and its role in furthering the common good. Sanctuary has often been BRIAN a friction point between governKANE ment leaders and the Church.

However, historically, many government leaders, while pushing against sanctuary, have not violated its boundaries because to do so would place government into a sacred space. That is not true today. Looking back at the historical origins of sanctuary, we find its implications in today’s current environment.

EARLY CHRISTIAN BEGINNINGS

In the early centuries of Christianity, the concept of sanctuary was rooted in the Gospel teachings of compassion and mercy. Jesus’ life and ministry, as recorded in the New Testament, emphasized care for the marginalized — healing the sick, sheltering the homeless and offering comfort to those in distress. These principles would come to shape the Church’s role in society, laying the foundation for its involvement in providing sanctuary and protection. As one author has noted, “The Church’s ministry of healing is essentially related to its ministry of proclaiming the Word of God … .”1 Sanctuary emerged as both a recognition of holiness and the actions that resulted from that.

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In the early Christian period, there was no distinct separation between places of worship and sites of sanctuary. Churches were often seen as havens for those fleeing persecution. This practice can be traced back to the time of the Roman Empire, particularly in the post-Constantinian period, when Christianity began to gain imperial favor.2 After the Edict of Milan in 313 A.D. legalized Christianity, Christians could openly practice their faith but still faced sporadic persecution from local authorities. As a result, churches became places where individuals, especially clergy and persecuted Christians, could find refuge from political or military authorities. There was an acknowledgment that the power of the Church was different from that of political authority.3 The notion of sanctuary was formalized under later Roman law, notably during the reign of Emperor Theodosius I from 379-395 A.D., who not only encouraged the construction of churches but also provided legal protection for those seeking asylum within them. During this time, churches became places where individuals could flee from both secular justice and threats of violence. In the centuries that followed, this tradition evolved, especially during times of war or political upheaval, when churches became havens from the violence of invading forces or feuding local warlords.

THE EMERGENCE OF HOSPITALS

Alongside the Church’s role as a sanctuary, medieval Europe saw the rise of hospitals, which were also rooted in Christian charity and mercy. The word “hospital” itself derives from the Latin hos-

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pitale, meaning a place of care or refuge, and from hospes, meaning guest or stranger. Early Christian hospitals were often established by monasteries and religious orders to care for the sick, the poor and travelers.

The establishment of these early hospitals was inspired by the Christian mandate to care for the “least among us,” as outlined in Christ’s teachings.

The first hospitals were not hospitals in the modern sense but rather places where the sick could be cared for by religious communities. These institutions were often attached to monasteries, and the labor of caring for others was considered an act of charity, where monks and sisters would offer healing through both physical care and spiritual counsel. The hospital’s function as a sanctuary extended beyond its role in health care, as it was a place where people could seek rest and protection from both disease and social marginalization.

One of the most influential early hospital systems was that established by the Benedictine order. Monasteries under the Benedictines often had infirmaries to care for monks who fell ill, but these spaces also served local populations. Hospitals like those founded in the Holy Land during the Crusades, particularly by the Knights Hospitaller, served dual roles as places of medical care and military refuge. As these religious orders expanded across Europe, their hospitals became places of both sanctuary and healing, where the wounded and ill from all walks of life could find refuge.

CHURCHES AS SANCTUARIES IN THE MIDDLE AGES

While hospitals developed as centers of care, churches continued to serve as vital sanctuaries throughout the Middle Ages. During this period, the concept of sanctuary expanded to include not only religious asylum but also protection from criminal justice systems. The right of sanctuary was formalized in many parts of medieval Europe, granting individuals accused of crimes the opportunity to seek refuge in a church to avoid immediate punishment.

The practice of sanctuary was especially important during times of social and political turmoil.

The medieval church, with its vast land holdings and influential position in society, wielded significant power and autonomy. Church leaders could offer protection to individuals, and the boundaries of the church or cathedral often marked a space where secular authorities had no jurisdiction.

This was a significant development, as it gave indi-

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viduals a degree of security from what could often be brutal legal and social systems.

However, this protection was not always guaranteed. One notable example of the failure of the Church’s sanctuary role took place at Canterbury Cathedral in England. Thomas Beckett, at the time, the Catholic Archbishop of Canterbury, quarreled with King Henry II in the 12th century. The Archbishop of Canterbury had the power to offer protection to fugitives and those who sought asylum from the crown’s justice. The Church’s role as a mediator between the law and the individual was crucial during this period, as it allowed individuals to seek refuge within church walls without the immediate threat of execution or other punishments. So, Beckett fled to the cathedral for protection. The soldiers that Henry II sent to kill him ignored the tradition of sanctuary and murdered him at the altar.

Furthermore, the sanctuary provided by churches was not unconditional. It was often limited by certain rules and time frames, and individuals had to demonstrate remorse or a willingness to stand trial for their crimes. Despite these limitations, the Church’s sanctuary system represented a form of justice that balanced the power of secular authorities with a Christian understanding of mercy and rehabilitation.

CHANGING ROLES AND CHALLENGES

As the Renaissance and Enlightenment periods brought about shifts in political and social thinking, the role of the Church as both a sanctuary and provider of health care evolved. The rise of nation-states and centralized monarchies reduced the power of local churches to offer sanctuary from secular justice, and the increasingly secular nature of the state meant that the legal right to sanctuary gradually waned, but was not lost. The Church’s role in offering refuge remained in some regions, and in others, religious institutions continued to operate as places of sanctuary for those fleeing oppression.

Similarly, hospitals continued to play an important role in providing care for the poor and sick, but the rise of scientific medicine and the development of public health systems led to a gradual separation between church-run hospitals and the secular medical establishments that began to emerge.

Hospitals operated by religious orders continued to provide care for marginalized populations. And secular governments began to take on a more active role in health care provision, especially

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in Europe after World War II, when health care provided by the state became the norm.4

CATHOLIC CHURCHES AND HOSPITALS AS REFUGES TODAY

By the 19th and 20th centuries, Catholic hospitals had fully integrated into modern health care systems, and while the sanctuary role of churches and hospitals diminished but did not disappear in the secularized West, it persisted in many parts of the world. In many developing nations, Catholic hospitals remain among the few providers of quality medical care, particularly in rural areas. Even in the West, however, the right to sanctuary continued to be respected by most governments.5 The Church’s role in providing care to the poor, the sick and refugees is still evident, with institutions like the Vatican, through Caritas Internationalis, and Catholic health care and Catholic Charities in the United States continuing to provide both emergency assistance and long-term health care solutions worldwide.

Despite the challenges posed by secularization, the principles that undergird the role of churches and hospitals as sanctuaries and refuges remain integral to Catholic social teaching. Pope Francis, for example, has emphasized the importance of the Church as a refuge for migrants and the oppressed, advocating for policies that ensure safe spaces for those in need of protection. In late 2024, for example, he made the offer of refuge at the Vatican to Aung San Suu Kyi, the former leader of Myanmar and Nobel Peace Prize winner.6

CONTINUING COMPASSION’S TIMELESS LEGACY

The historical development of Catholic churches and hospitals as sanctuaries and places of refuge reflects the enduring Christian commitment to mercy, justice and care for the marginalized. Catholic Churches, and by extension, the locations where Catholic ministries operate, such as health care facilities, are sacred spaces that should be honored as such. From the early Christian period through the Middle Ages, churches and hospitals offered sanctuary both from physical dangers and from the injustices of secular systems.

While the role of the Church as a political and legal sanctuary diminished somewhat with the rise of nation-states, the Church’s dedication to serving those in need continues today. Catholic hospitals remain essential to providing care for those who cannot access medical services else-

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where, and churches continue to be places of refuge for those suffering, reflecting the timeless legacy of compassion that has defined Catholic social teaching for centuries. Even when secular political authorities do not recognize this work and its corresponding respect for sacred spaces to promote the human good, that does not mean that we should accept that view of the world.7 BRIAN M. KANE, PhD, is senior director, ethics, for the Catholic Health Association, St. Louis.

NOTES 1. Dennis Krouse, “Health and Healing in Traditional Catholic Expression,” in Liturgical Foundations of Social Policy in the Catholic and Jewish Traditions, ed. Daniel F. Polish and Eugene J. Fisher (University of Notre Dame Press, 1983), 63.

2. Tertullian, Apology, 37.

3. The scope of this essay doesn’t go into the details of this event, but the standoff in the 11th century between Pope Gregory VII and Henry IV, the Holy Roman Emperor, can give some sense of the two powers.

4. The earliest state-supported health system was established in Germany in 1883 by Otto von Bismarck, under the concept of social insurance. In the aftermath of World War II, other nations, like the U.K., adopted similar programs. There, it is known as the Beveridge model, and it is slightly different, but its goals are the same: to provide a level of health care that will keep all citizens healthy. They discourage profit as the driving force for health care.

5. The challenge between the influence of the Church versus the state is important in contemporary international politics. The suppression of the Church occurs within political systems that are threatened by its message. Modern-day examples include China and El Salvador.

6. Salvatore Cernuzio, “Pope: Free Aung San Suu Kyi; Vatican Ready to Welcome Her,” Vatican News, September 24, 2024, https://www.vaticannews.va/en/pope/ news/2024-09/pope-free-aung-san-suu-kyi.html.

7. The recent statement by Bishop Mark J. Seitz, chairman of the U.S. Conference of Catholic Bishops’ Committee on Migration, Sr. Mary Haddad, RSM, president and CEO of CHA, and Kerry Alys Robinson, president and CEO of Catholic Charities USA, demonstrates this determination: “Human Dignity is Not Dependent on a Person’s Citizenship or Immigration Status,” United States Conference of Catholic Bishops Office of Public Affairs, January 23, 2025, https://www.usccb.org/news/2025/ human-dignity-not-dependent-persons-citizenshipor-immigration-status.

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T H I N K I N G G L O B A L LY

FROM PARACHUTES TO PARADIGM SHIFTS: MY GLOBAL HEALTH JOURNEY

I

f I were to write a book about my global health journey, it would likely be called From Parachutes to Paradigm Shifts. I jumped with one of those “parachutes” when I took my first mission trip 28 years ago. I have been untangling myself from the aftereffects of that mess for more than two decades. After living in Haiti and seeing the complexities that these “parachute missions” created when they didn’t have the appropriate perspective, I decided that if I wasn’t part of the solution, I would be part of the problem. You may be confused, so let me explain.

In 1996, my life took an unexpected turn. I transitioned from the fast-paced world of stock brokering to a role in the mission office of the Diocese of Springfield, Illinois. This shift was more than just a career change; it was a profound transformaBRUCE tion in how I viewed the world COMPTON and my place in it.

Within months of joining the mission office, I embarked on what I would now call a “parachute mission trip” to Haiti. This term refers to short-term missions in which volunteers, often with little understanding of the local context, drop in to provide aid. At the time, I was filled with enthusiasm and a desire to make a difference.

Over the next four years, I led 13 such health missions to Haiti, each time believing we were making a significant impact.

However, in late 2000, I made a more permanent move to Haiti to become the administration and finance director for a clinic and public health outreach organization funded by the United States Agency for International Development (USAID).

Living and working there for two years opened my eyes to the unintended consequences of these parachute missions. I began to see the distractions, damage and disconnection they brought to the ongoing operations of local health services.

In light of the current global health environment, it is now more important than ever to en-

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sure that we participate in and support partnerships that follow the principles highlighted in this column. A preferential option for those who are poor and vulnerable has always been at the heart of the Catholic health ministry. Catholic social teaching calls us to advance human dignity and the common good. It reminds us that we are one human family and that loving our neighbor has global dimensions. Our founders and sponsors have walked alongside people all over the world as missionaries and have supported them through their donations to international aid organizations.

WELL-INTENTIONED, BUT MISGUIDED EFFORTS

One of the most glaring issues I witnessed firsthand from parachute missions was the lack of understanding of the local culture and beliefs. Many volunteers, myself included, arrived with preconceived notions and little effort to truly understand the community we were trying to help. This cultural disconnect often led to well-intentioned but misguided efforts that did not align with the community’s needs or values.

Language barriers further compounded these issues. Communication is crucial in any health care setting, and the inability to speak the local language creates significant obstacles. Misunderstandings were common, and the effectiveness of our interventions was often compromised.

Egos and a savior mentality also played a role.

Many volunteers, again including myself at times,

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arrived with a sense of superiority, believing we had all the answers. This attitude not only alienated the local staff but also undermined their expertise and efforts. The local health workers, who toiled day in and day out, were often overshadowed by the temporary presence of foreign volunteers.

Perhaps the most damaging aspect was the lack of respect for the local staff. These dedicated individuals worked tirelessly 365 days a year, even when we “paratroopers” were not there. Yet, their contributions were frequently overlooked, and their knowledge was undervalued. This lack of recognition and support created a rift between the local staff and the American volunteers, further hindering the effectiveness of our missions.

SHIFTING FROM SUPERFICIAL INTERVENTIONS TO SUSTAINABLE PARTNERSHIPS

Since returning to the U.S. after living in Haiti, my career has revolved around addressing many of the difficulties that I witnessed from these wellintentioned but often misguided parachute missions brought to the health workforce, the patients

and ultimately, the health system. I have dedicated myself to doing all in my capacity to ensure that others who engage in this work do so with a better understanding of these realities. It has been a long and challenging journey, but one that I believe is necessary for creating sustainable and meaningful change.

CHA, the Global Health Advisory Council and many others have helped to lay the groundwork for a paradigm shift in global health. CHA played an integral role in the development and launch of a study produced by the Uganda National Academy of Sciences (UNAS) called “Enacting an Ethic of Care and Responsibility in Global Health Partnerships.”1 We have also recently released the 10th-anniversary edition of CHA’s Guiding Principles for Conducting Global Health Activities.2 We believe that the paradigm shift is in motion that will allow for a future without the need or desire for parachute missions because those who wish to be of assistance enact the principles outlined in the UNAS consensus report.

For this shift to play out, Catholic health care and others must continue to learn and engage in

Findings from “Enacting an Ethic of Care and Responsibility in Global Health Partnerships”

Conclusions

Recommendations

1. Global health funding is inherently complex due to diverse partners, priorities and power imbalances.

1. Promote transparency about financial incentives and constraints and address funder dependence.

2. Harmonization efforts in global health can inadvertently perpetuate inequities and hinder systemic change.

2. Embrace contextual understanding and flexibility, and foster collaboration and shared ownership.

3. Capacity-building should move beyond a deficit-based approach, recognizing existing strengths and self-determination.

3. Shift from capacity-building to capacity strengthening, and prioritize local ownership and knowledge exchange.

4. The pursuit of equity in global health necessitates acknowledging the interconnectedness of humanity.

4. Cultivate mutual understanding, trustworthiness and shared decision-making.

5. Effective communication, humility and adaptability can enable truly transformative partnerships.

6. Humility — acknowledging limits, embracing uncertainty and adapting to change — holds the key to equitable global health partnerships.

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5. Establish clear communication channels, cultivate a culture of openness and humility, prioritize emotional intelligence and empathy, and embrace power-sharing.

6. Practice active self-reflection and vulnerability, cultivate a learning and growth mindset, and embrace decolonial perspectives and practices.

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Scan to read “Enacting an Ethic of Care and Responsibility in Global Health Partnerships.”

global health partnerships following the guidance from these important documents to ensure that we are part of the solution and not part of the problem. This involves moving away from short-term, superficial interventions to long-term, sustainable partnerships.

It requires a deep understanding of the local context, respect for the local staff and true collaboration. It means recognizing that we do not have all the answers, and that true change comes from recognizing the agency of those from local communities and supporting their efforts to strengthen their capacity.

My journey from parachutes to paradigm shifts has been one of learning and growth. It has taught me the importance of humility, respect and collaboration. As we move forward, let us continue to build on these lessons and create a more just and equitable world for all.

BRUCE COMPTON is senior director, global health, for the Catholic Health Association, St. Louis.

Scan to read CHA’s Guiding Principles for Conducting Global Health Activities.

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from The Catholic Health Association

Theology and Ethics Colloquium (invitation only) April 8 – 10

What Counts and Accounting for Community Benefit April 22 | 1 – 2:30 p.m. ET

Global Health Networking Call

May 7 | 1 – 2:30 p.m. ET

Diversity & Disparities Networking Call June 25 | 2 – 3 p.m. ET

NOTES 1. “Enacting an Ethic of Care and Responsibility in Global Health Partnerships,” Uganda National Academy of Sciences, 2024, https://unas.org.ug/wp-content/ uploads/2023/04/Global-HealthPartnerships-27-October-CC-NoPri_241027_104757.pdf. For more coverage of this report, see the Jan. 2025 coverage in Catholic Health World, https://www.chausa. org/publications/catholic-health-world/ archive/article/january-2025/report-onglobal-health-partnerships-a-huge-wintoward-working-together-for-change.

2. “Guiding Principles for Conducting Global Health Activities,” Catholic Health Association, https://www.chausa.org/docs/defaultsource/international-outreach/cha_guiding principles_2022-update_lr_single.pdf.

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Upcoming Events

United Against Human Trafficking Networking Call July 22 | 1 – 2 p.m. ET

Faith Community Nurses Networking Call July 30 | 1 – 2 p.m. ET

Global Health Networking Call

Aug. 6 | 1 – 2:30 p.m. ET

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P R AY E R

SERVICE

Witnessing God’s Healing Hand in Sacred Moments JOY KAPLAN, DMin, BCC, EXECUTIVE DIRECTOR OF MISSION, MERCY WASHINGTON

INTRODUCTION Faith and medicine are very similar — even though most people would feel that they are at odds. “Faith is the realization of what is hoped for and evidence of things not seen.”

(Hebrews 11:1) We do not get to see the intricate workings of the medicine we take within our bloodstream. We do not each pay attention to a surgeon’s mysterious handiwork. Nor do those of us who work with a physical therapist fully understand how doing one stretching exercise makes us feel better. We just see the results of all this science.

So much is the same with faith. We don’t see with our own eyes God’s Spirit at work in us. We don’t fully understand how a “coincidence” happened. We don’t pay attention to the intricate details of how a prayer was answered. We just see the results of the Trinity in the world.

Many people have asked me, as a person of faith, “How do I continue to work in health care, a scientific field?”

For me, the answer has been simple: I bear witness firsthand to the healing power of Jesus through the ministry of Catholic health care. Sometimes, it is through miracles. Other times, it’s a doctor’s treatment plan. Now and again, it’s the hard work of the patient to follow their therapy goals.

Nonetheless, it’s humanity joining together with the Godhead to bring

our faith into reality in the world — it’s bringing the Kingdom of Heaven to earth.

Where do I feel out of control and need to receive God’s healing for my own thoughts, feelings and worries?

Even Pope Francis has reiterated in his new memoir, Hope, that he has a “desire for the Catholic Church to be seen as a field hospital, not a fortress.” The ideas of faith and medicine are intricately linked and are a welcome place for all to enter and find “rest for the weary.”

(Jeremiah 31:25)

How can I contribute to the “field hospital” that Pope Francis is calling us to provide for our community members?

The world wounds us, and we are in need of healing, through our faith in God and the power He grants through medicine. Through this, we can come to a place of solace and rest, and find the peace our souls desperately need.

As spring comes forth from the ground and we see the beauty of creation all around us, take time to reflect on how God is doing a new thing in your life, in your work and in the world. It is when we stop and see the sacred moments of the work of God all around us that we can follow the advice of the 17th-century monk Brother Lawrence, and “practice the presence of God.” PAUSE AND REFLECT As we look to find God’s presence in our work and daily lives, ponder these questions:

CLOSING PRAYER Good and Gracious God: Every day we see Your handiwork through the miracles we perform in Catholic health care. Thank You for the revelations You have provided us through the power of medicine. We’re grateful for the brilliant clinicians who develop healing pathways.

We continue to marvel at the new discoveries through research. We see Your omnipresence in the steady hand of the surgeon being led by the Holy Spirit.

As we follow in Jesus’ footsteps, we are proud to join in Your work of healing our community members’ spiritual, physical, emotional and psychological needs. Help us to be faithful in living out Your incarnational principles of being “Your hands and feet.”

We give You all the glory. Amen.

How do I see God at work around me in Catholic health care?

Where do I put my faith into action at work?

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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Earn your advanced degree in

Healthcare Ethics Duquesne University offers an exciting graduate program in Healthcare Ethics to engage today’s complex issues.

Courses are taught face-to-face on campus or through online learning for busy professionals.

MA in Healthcare Ethics (Tuition award of 25%) This program requires 30 credits (10 courses). These credits may roll over into the Doctoral Degree that requires another 18 credits (6 courses) plus the dissertation.

The curriculum provides expertise in clinical ethics, organizational ethics, public health ethics and research ethics, with clinical rotations in ethics consultation.

Doctoral students research pivotal topics in healthcare ethics and are mentored toward academic publishing and conference presentation.

Doctor of Philosophy (PhD) and Doctor of Healthcare Ethics (DHCE) These research (PhD) and professional (DHCE) degrees prepare students for leadership roles in academia and clinical ethics.

MA Entrance – 12 courses BA Entrance – 16 courses Graduate Certificate in Healthcare Ethics This flexible program requires 15 credits (5 courses). All courses may be taken from a distance. The credits may roll over into the MA or Doctoral Degree (PhD or DHCE).

Questions? 412.396.4504 or chce@duq.edu

duq.edu/globalhealthethics

Slow and Simple

CONTEMPLATIONS FOR THE LENT AND EASTER SEASON This 14-week series offers reflective images, audio meditations, prayers and discussion questions designed for personal or team use.

Order your printed or digital cards at:

CHAUSA.ORG/LENT