Integrative Assessment Tool - Upaya Zen Center

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An Integrative Assessment Tool
By Corinna Chung, Buddhist Chaplain
Author’s Note: I have removed all footnotes in this file, please refer to my paper entitled
‘Paradigm Shifts in Chaplaincy & An Introduction to Spiritual Assessment” which is posted in its entirety
and contains the reference list.
“Follow Me, and I will make you become fishers of men” (John 21:17)
Assessment must be done in a way that ‘casts the net’ as wide as possible. “The
Integrative Assessment Tool” was created by the author as a sensitive method aimed at
identifying spiritual distress and coping skills of as many patients as possible, independent of
their faith or lack thereof. Although patients in the United States will predominantly be Christian,
the word “God” does not appear explicitly. Instead, a more inclusive language is used in order to
encompass both vertical (concerned with relationship to God and concern in earthly activities
affecting an afterlife) and horizontal belief systems (concerned with social relationships and a
concern with the effects of activities in the community). In this way the tool is not overtly
religious but does not exclude religion either.
The set of questions offers a framework eliciting thoughts, memories and experiences
that give coherence to a person’s life, and help locate their source of strength or distress (be it
intrapersonal, interpersonal or transpersonal). It is the author’s hope that patients will be
encouraged to name anything that lends support at this vulnerable time and to have their needs
(identified in a previously mentioned study) met: to feel free to express true feelings without
being judged, to speak about important relationships, to discuss unresolved issues, to have time
to prepare for death. The other research cited in the discussion under the heading ‘Secular
Chaplaincy’ demonstrates that patients’ questions mainly pertained to general existential issues;
only 8% were overtly religious in nature. This is reflected in the author’s ‘The Integrative

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Assessment Tool’. At the same time ‘The Integrative Assessment Tool’ covers what Stoll
describes as the four essential areas for spiritual assessment:
1. Concept of God/transcendence
2. Source of hope and strength
3. Religious practices
4. Relationship between spirituality and health
On one hand, the set of questions in ‘The Integrative Assessment Tool’ help the chaplain
to effectively collect objective data, such as faith denomination and the impact of the patient’s
faith on medical care. On the other hand, and in contrast to most existing tools known to the
author, ‘The Integrative Assessment Tool’ focuses on deeper, more subjective data. The different
sets of questions provides a framework for the chaplain and the patient to explore the two basic
categories of spiritual assessment 44 :
1. Functional information, the ‘How’ of spiritual life, because most people can relate
to these common human quests, even if the patient has found no answers:
(cognitive) search for meaning/ purpose;
(experiential) feeling hope/joy/peace/comfort;
(relational) relationship between health and beliefs/practices; relationship to
family/ friends/ community; coping skills.
2. Substantive information, the ‘What’ of spiritual life:
past spiritual/religious background and present spiritual/religious affiliation;
beliefs about self/others/ transcendence;

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present personal practices, rituals, faith community;
the level of involvement/support they provide. 44
The ‘Integrative Assessment Tool‘ also contains a section for palliative care patients to
facilitate end-of-life planning, once a patient has reached the level of acceptance that allows
addressing these issues directly. The set of questions aid the chaplain and patient to explore
subjects such as end of life reaction, terminal event arrangements, afterlife beliefs and
reconciliation with self/others/Spiritual Source.
Instruction to the Chaplain on how to use ‘The Integrative Assessment Tool’:
• Chaplains can use ‘The Integrative Assessment Tool‘ as a guide to support them
in conducting semi-structured interviews. Not all questions have to be asked; they
represent available options for the chaplain to invite reflections, memories and
stories, slowly mapping this individual’s resources and the barriers to using them.
• The author assumes the religious denomination has already been determined
during the screening protocol. This information, together with answers about faith
community and who the patient would like to contact to talk with about religious
or other matters, will come up naturally as the chaplain poses the questions that
explore resources and how the patient finds meaning.
• Besides establishing rapport and trust in whatever way is appropriate, chaplains
need to determine how best to preface the questions themselves. For example, by
beginning with “If you are comfortable talking about this topic, would you please
share some of your beliefs about…”.

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• With minor modifications (not included here) ‘The Integrative Assessment Tool‘
can be used for assessing family, friends or medical staff. It is of course crucial to
follow up, explain, reassure and counsel the patient’s loved ones.
• While with the patient, it is recommended to keep note-writing to a minimum in
order to give as much undivided attention as possible to the patient. Even if notes
have to be made, the chaplain aspires to provide an atmosphere of communion
rather than that of an interview.
Listen to where resources stem from / who or what gives meaning; listen to what might be
source of distress; listen to clues for effective interventions:
1. intrapersonal / self: recognition of positive traits, healthy self-esteem in spite of physical
disabilities, being in touch with oneself, quiet time, ability to relax, ability to tolerate stress,
ability to endure loss/vulnerability/uncertainty/ambiguity, accepts and embraces the impossibility
to find meaning, completion of tasks, finished business, feels involved in decision-making, has
some degree of control, positive outlook, gratitude, forgiveness.
2. interpersonal / relational: love, sense of belonging, closeness, closure with others,
significant other, family, friends, pets, social networks, fellowship – spiritual, cultural,
professional or other.
3. transpersonal / religious / contemplative: God, deities, ultimate reality, sense of the sacred,
set of values, connectedness with or feeling looked after by Higher Power, surrender into God’s
hands, sacred scriptures, sacraments, spiritual community, clergy, faith, worship, hymns, prayer,
guided imagery, meditation, spiritual/religious practices, rituals.

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4. environmental / creative / therapeutic: experience nature, music, literature, poetry, beauty,
creating collage or other art projects, journal-keeping, life review.
THE QUESTIONS:
(a) Securing and Strengthening Resources
(past – coping skills)
How has your attitude to life, spirituality or religion sustained you
during difficult times in the past?
What in your life has brought you joy or peace?
(present - resources)
What could nurture your inner strength or your spirit while you are here?
How does your faith, relationships or other resources you have, help you during this illness?
What can I do to make you feel more comfortable?
(future – retaining hope / goal setting)
What inspires you with hope?
What kind of goals do you look forward to? (consider short, medium and long-term goals)
(b) Opening to a higher perspective/Finding meaning
(past)
Looking back over your life, what moments, people or experiences stand out as important?

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What did you consider the most meaningful things in life?
(present)
What really matters to you now?
What helps you make sense of being here?
How has your relationship changed to important things in your life?
Where does your sense of what to do, or how to look at things come from?
(future)
What is important for you to happen in the next few days or weeks?
What would help you find peace of mind?
What do you wish for?
(c) Impact on Medical Care and Decision Making 46
How do your beliefs influence the way you think about your health?
How do your beliefs influence how you look at your disease?
How do your beliefs impact your decisions about your treatment and medical care?
What would you like your caregivers to know and pay special attention to?
(d) Special Considerations
TV on/off, curtains open/closed, lights bright/soft, temperature higher/lower, frequency of
visitors more/less, display of religious or cultural symbols, personal photo frames, flowers, wall

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decoration, special blanket and other personal items, CD player, DVD player, writing or art
supply, room with a view of sky/mountains if desired and possible.
(e) Cultural / Interfaith Considerations
Interfaith and cultural considerations become particularly important toward end of life and
require awareness of the chaplain’s own ethnocentricity. Although it is unrealistic to expect a
chaplain to be fully competent at intercultural communication skills and to know the customs,
taboos, etc. of all cultures, an effort in behavioral flexibility and interfaith education has to be
made to avoid major missteps. It might be helpful to solicit the patient/their loved ones as
teachers regarding faith/cultural practices by saying, for example, “I am not very familiar with
your culture / faith, could you help me understand…”.
(f) End of life Planning
Terminal event planning is intended for patients with grave illnesses. It can only be undertaken if
the patient / family is not overwhelmed by the fear of dying and has reached a sufficient level of
acceptance of dying.
Care:
How do your beliefs impact your hospital care, treatment or medical procedures?
What aspects of your religion or spirituality might impact how you would like
– or would not like to be cared for?
Do you have an advanced directive to let caregivers know what treatments you wish them to
withhold?

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What would you like your caregivers to know and pay special attention to?
Regrets / Forgiveness / Closure:
What do you feel you have lost in the course of this illness?
Is there any kind of “unfinished business” you would feel comfortable sharing with me?
If you had your life to live over – what would you like to be the same
and what would you like to have done differently?
In terms of your relationships (or whatever issue causes distress) – what would you like to be the
same and what would you like to have done differently?
Whose visit would mean a lot to you now?
Are there people you would like me to contact for you now, even if you have not seen them in a
long time? (For example, to say that you forgive them, or to ask for their forgiveness 69 )
Are there people who you would like to call and come visit
(so that you can say ‘good-bye’ and ‘I love you’ 69 )?
How can I support you in finding a sense of closure as you approach the end of your life?
Even if your body should not get cured, what would help you now to find peace of mind?
Life review
What would you say were ‘the milestones’ in your life?
Would you be interested in drawing or writing a timeline of your life (or spiritual history)
including remarkable encounters and important events?

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Some say “wisdom is what floats to the top like cream after a rich life” – What kind of wisdom
or legacy would you like to share or leave behind for others?
Would you like to tell me about X as a person?
Preparation:
Where would you like to die?
What does death mean to you?
What does it mean to you that this is happening?
Actual death:
What is important about how others will care for your body before and after you die?
What is important about how others conduct themselves at time of your death?
What specific instructions do you have about the care of your body after you die?
Funeral arrangements:
Where and how would you like to be buried or cremated?
What kind of ritual or funeral service would you choose?
Is there someone special you would like to officiate?
Is there something special you would like to be said at your funeral?
After death / Afterlife:
How do you want to be remembered?
What do you believe happens after death?

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If your health should decline, how does your faith - or other resources -
prepare you for what is ahead?
Palliative Care Chaplaincy
The historical relationship between spiritual and palliative care goes back to the Middle
Ages when monasteries offered hospitium, a safe resting place for weary, and sometimes dying,
travelers. The ancient monks’ mission was to save souls. Although today’s standards of spiritual
care reflect the changes the role of chaplain has undergone over the centuries, the mission of
palliative care – of which spiritual care is an important component - remain the same: to make
dying easier.
The medical profession still treats its role as an art as much as a science, relying on
philosophical principles like the rule of double effect, attributed to the 13 th century
Roman Catholic philosopher Thomas Aquinas. Even if there is a foreseeable bad
outcome, like death, it is acceptable if it is unintended and outweighed by an intentional
good outcome – the relief of unyielding suffering before death.
To avoid misunderstanding, it has to be said that most comfort measures do not hasten
death in any way. Because of the comfort palliative care can provide, patients’ requests for
euthanasia diminish. Spirituality is a dimension of palliative care, and spiritual well-being, too,
stands in inverse relationship with desire for hastened death, suicidal ideation and hopelessness.
Research has already been cited that demonstrates religion and spirituality to be a crucial coping
skill protecting the patient against end-of-life despair, and that spiritual care greatly comforts

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terminal patients. Even though, as discussed previously, some people’s interpretation of doctrine
can also cause spiritual pain to arise.
One provision of the House health care bill passed in November 2009 recognizes that
palliative care may include treatment “furnished for the purpose of alleviating pain or
discomfort, even if the use may increase the risk of death.” Constant vigilance concerning abuse
is appropriate, for example to monitor whether terminal sedation is administered because of
pressure from family, economic reasons or simply out of convenience. In their recommendations,
the Institute for Healthcare Improvements (IHI) lists “learn how to provide care that is death
accepting” as optimum practice. Ars moriendi, ‘the art of dying’ (a term originating in the
Middle Ages) in modern times could refer to palliative care efforts to restore death to its sacred
or significant place, in contrast to it being a technological or management issue. Florence
Nightingale reintroduced the notion of holistic care in the 19 th century.
The Sisters of Charity, the same Order that established St. Vincent in New Mexico in
1865, opened the first hospices in Ireland and France. Dame Cicely Saunders was a key figure
from the 1940’s onward and pioneered the hospice movement in England. In the USA Elizabeth
Kubler-Ross captured the interest of a large lay audience with her research on the stages of
dying. Between 1986 and 1996 the Elizabeth Kubler-Ross Institute in El Rito was part of the
Northern New Mexico College. For linguistic reasons, the French Canadians chose to name their
hospice service in Montreal ‘palliative’ care when it was established in 1974 (palliative from
Latin palliare, to cloak or cover; care that palliates, i.e. alleviates or relieves suffering).
The author’s ‘Integrative Assessment Tool’ contains an ‘end-of-life planning’ section. It
takes into consideration the particular concerns of palliative care patients and helps the chaplain

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to address them in a sensitive manner. Palliative care chaplains explore the patient’s/their loved
one’s beliefs about death and afterlife, how these affect medical decisions, such as organ
donation and blood transfusion. They may have to lend their support to discuss an advanced
medical directive, including DNR (Do Not Resuscitate order), and the patient’s preferred site of
death.
Besides assuring the collection of essential information, the ‘Integrative Assessment
Tool’ could also point out areas a chaplain avoids consciously or unconsciously, because of
his/her own unease with the subject. This can occur due of a lack of self-knowledge, for
example, if chaplains have not explored their own hopes and fears about what a ‘good death’ or
‘bad death’ might mean for them; attitude and issues concerning mortality, loss of control, etc.
Self-knowledge is an essential prerequisite for a chaplain to use assessment tools in general and
in palliative care in particular.
Many examples of empirical research studies have already been cited in this document
showing that patients, especially those in palliative care, feel spirituality is one of the most
important contributors to their quality of life and strongly desire it to be included in their care.
Further research affirms that questions of a spiritual nature - Who am I? Is there a meaning to
life? - arise around the teenage years and stay prevalent into the early 20s. They are mostly put
aside when time and energy is dedicated to building a career and founding a family. However,
these concerns resurface and become a vital focus again when a life threatening illness is
diagnosed or a person approaches the end of their life. This renewed urge to reconnect to one’s
spiritual ‘roots’ and to explore these profound questions has to be satisfied by chaplains being
integral part of all interdisciplinary palliative care teams.

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The chaplain’s presence could be of pivotal importance for people who experience the
crisis as an opportunity for spiritual healing, growth or transformation. Both the spiritual and
psychosocial dimensions of dying are within the scope of a chaplain. Most patient benefit from
support in dealing with end of life reactions, including: anger, feeling like a burden, the change
and loss of virtually everything familiar and dear, self-image, social station etc., issues of
forgiveness and reconciliation with oneself, an estranged friend / family member / Spiritual
Source. All these are prominent needs and exploring them might well be a prerequisite for being
at peace and dying in peace.
Early referral is a major factor in successful intervention. It takes time to establishing
rapport and trust. One of the most important things a chaplain can convey is that he/she is not in
a hurry, that this meeting is the most important and precious thing to do at this moment. As
discussed under the heading ‘Dangers of Interpretation’, a person’s interpretation of religious
doctrine can also be the cause of spiritual struggle. Exploring spiritual pain is not done quickly.
Dame Cicely Saunders concept of ‘total pain’ emphasizes that the patient’s mood, morale and
the meaning pain has for the patient all modulates the experience of pain. Spiritual interventions
such as gathering of loved ones the patient wishes to take leave of; finding closure through
reconciliation; a life review, spiritual genogram and other creative tools for the reframing or
renovation of experience all take time and must not be rushed. Yet, decline is often rapid, as in
advanced cancer, and energy and clarity of mind are quickly lost; functioning becomes slower
and spiritual work might become difficult to master.
Most Americans would prefer to die at home, but an analysis of Medicare recipients
shows that up to 85% die in hospitals or nursing homes. In hospital settings medical staff is often
pressured by understaffing, limited budget and management demands. If not trained in end-of -

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life care, a professional attitude to medical care could mean one that is based on facts, but does
not necessarily consider the emotional impact of giving bad news for example. The conventional
curative model places emphasis on technology, quantity of life, curing at any cost. Patients, even
when close to death, might still be intubated, ventilated and monitored by machines. The
palliative model and holistic medicine integrate spiritual care and promote a person-centered
approach. This means services are people oriented, centering the patients’ experience more in
terms of human relationships and quality of life, rather than only medical and physiological
issues. With holistic care it is possible for a dying patient to feel comfortable and experience
healing, even if the illness cannot be cured.
As previously mentioned studies have demonstrated, prevalent needs of palliative care
patients include: to have time to think, to resolve ‘unfinished business’ and to prepare for death.
There does not seem any reason to delay referrals other than misconceptions about the role and
function of palliative care of which spiritual care is a very important component. In recent public
debates over the House health care bill, which allows doctors to be reimbursed for discussions
with patients about what treatments they would want or decline, some Republicans charged that
‘death panels would decide who deserves to live or die’. Another misunderstanding is that not
prolonging life artificially equals euthanasia. In fact, providing high quality palliative care,
including pain management and spiritual care, results in patients feeling more comfort and the
wish for a hastened death diminishes.
Considering that the average stay of people in hospice unfortunately still only averages
one week, it is imperative to continue educating medical staff about why early referrals. A
chaplain recognizes when the moment it is not right and will not impose his/her visit, and it is
always hoped that patients will graduate from hospice. It also impacts the patient’s family and

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friends because bereavement support needs to start prior to the death of the patient. Family can
also benefit by trained chaplain assisting them to make difficult decisions by being coached in
the 4 bases of ethical decision-making: autonomy, non-maleficence, beneficence and justice. An
optimal practice for Christus St. Vincent would be a as a matter of course to include a chaplain’s
visit to all palliative care patients on a daily basis, and to continue offering education on the
benefits of both palliative and spiritual care.