The chaplain’s next assessment is, “At what point do I insert myself into the frantic activity surrounding the care of the newly received trauma patient?” As the trauma surgeons and nurses focus intently on their examination, maintaining vital signs and airways, the chaplain seeks out the prehospital rescue and transport team. Very often the emergency medical services (EMS) crew can provide a tentative name, address, date of birth, social security number, and, possibly, other essential information that might help the
chaplain to locate family members. When they have no information, the chaplain and security personnel examine the patient’s personal effects searching for information about the patient’s identity. We have found that this task gives chaplains an automatic connection to the patient and his/her family. The chaplain quickly becomes familiar with the situation and gaining this familiarity is a critical element in the intake process. It is important to be accurate when notifying next of kin. When the patient cannot speak, this process becomes more difficult but no less important. The chaplain receives vital information from the family that might be critical to the urgent care and treatment of the patient. Our trauma medical staff recognized, early on, the value of this information and rapidly came to appreciate the input from the trauma chaplain.

The task of locating next of kin can be taxing, tricky and demands patience and a willingness to follow sometimes obscure leads. Obviously, the conscious patient can give the name and telephone contact information for the person to be notified. Often the patient is unconscious or in a life-threatening situation and the chaplain must rely on other sources or techniques to identify and locate next of kin. Each case is very different. In one instance our records showed that we made 55 phone calls trying to locate the father of a trauma victim and finally, after a few days found him at a resort in another state.

The Internet provides a number of resources that are useful in efforts to contact family members. An address from a driver’s license or other identification permits location of the next-door neighbor. The neighbors can often help locate a family member. For example, several years ago we received a patient who was involved in an accident. She lived on the east coast of Florida. Unfortunately the patient lived alone. We contacted the neighbor who let us know that the patient was en route to her son’s wedding on the west coast of Florida. The neighbor also provided the name of the church where the wedding was to take place. These facts enabled the chaplain to contact the patient’s family ensuring their timely arrival at the hospital. In addition, we have found that police agencies around the country are incredibly helpful. When asked they will send an officer to a person’s home or to an address in order to facilitate the search.

Once the chaplain positively identifies the patient he or she places telephone calls to the patient’s next of kin. The chaplain must resolve some important questions before the call is made. “How shall I introduce myself?” Introducing oneself as the chaplain can frighten family members. Many perceive the hospital chaplain to be like the military chaplain who brings news of death. The family reaction, “My loved one has died because the chaplain is calling” is most often inaccurate. This perception demands yet another self-assessment from the chaplain. How am I being heard? Am I being too abrupt? Do they hear the concern in my voice? What happens to people when I introduce myself to them as a chaplain? Does it make them want to shy away and avoid contact with me? Does it help them to immediately share intimate concerns because they see me as a caring representative of a loving God? Does it raise fear immediately? These and many other more subtle questions are raised by the call from the chaplain.

Chaplains in trauma centers identify themselves as the chaplain at some point during the initial phone call. Reassuring families that the chaplain is responsible for contacting all families during a traumatic situation eases some of the fear accompanying the news that a loved one has been injured. When fear is eased, family members are able to realize that the chaplain’s call is a normal part of the hospital protocol. It also helps the loved one to relax enough to hear the content of what the chaplain has to communicate.

A third and critical assessment during the initial call to the patient’s family is “how much should be divulged?” As a general rule chaplains do not give out medical information. An attempt is made to summarize the patient’s condition in one word. The chaplain is able to add more detail when the patient is stable and survival is assured. In cases of death we let family members know the patient is critical and urge them to come to the hospital as quickly and safely as possible. The chaplain’s initial assessment evaluates the frame of mind and the coping resources of the family. Every effort is made to avoid giving a message of patient death by telephone. An exception is made when family members live at a distance. In those cases we ask the trauma surgeon to speak with the family on the phone. In that conversation the surgeon provides information about the medical circumstances as well as how the trauma occurred. Some surgeons are very good at giving this information over the phone or in person. Others have less comfort in delivering bad news or dealing with the emotions of grieving people. In the latter case, the surgeon is usually relieved to inform the patient of the death and leave the rest to the chaplain. It certainly underlines the importance of having a well-integrated chaplaincy staff capable of assuming this function at critical moments.

When family members arrive at the hospital they are ushered into a consultation room. The optimal combination of quiet, privacy, and proximity to the patient care area is sought. Physical structure barriers are frequently cited as causes for failure of communication between grieving
families and caregivers.⁴ The chaplain meets the family in the consultation area. This can be a difficult moment for the chaplain. He or she has information that the family wants and yet the chaplain knows it would be professionally inappropriate to share the information at the time of the initial interview. At this time, the chaplain tries to work with the anxiety of the family and assure them that a surgeon will speak with them as soon as possible. As the chaplain sits with the family he/she builds on their initial telephone assessment of the family and possible dynamics present in the family.

The chaplain delivers the assessment of the family to the surgeon before the first contact between surgeon and family. The chaplain then introduces and connects the surgeon to the family. The surgeon is able to enter the interview more completely informed as a result of the chaplain’s assessment. The chaplain often provides critical information about the family or family dynamics that shape the approach to this critical early encounter. As the surgeon talks with the family, the chaplain continues to assess whether and how much the family understands from the information that has been given. Occasionally, when the chaplain believes the family has missed information, he/she may simply raise the question in a new way. At other times the chaplain will assist the surgeon to hear and understand the question or concerns of the family. In these ways the chaplain helps ensure clear communication. A number of factors, including the family’s anxiety for the well-being of their loved one and the surgeon’s primary concern for the medical condition of the patient, can combine to lead to poor communication.⁵

As the surgeon leaves the consultation room the family members face a world turned upside down. Their various reactions to news can range from the extreme expression of rage to numbness. The chaplain responds to the family at the point of their emotion. All along the way, the chaplain assesses how to build on the family strengths or to address family weaknesses.

This, perhaps, is the most crucial moment for the family and for the chaplain. The chaplain helps family members recognize the reality of their loss when the message conveyed involves the death of a loved one. The chaplain seeks to help the family build on coping skills they have used in the past when faced with traumatic circumstances. When the family is clearly unfamiliar with loss and grief, the chaplain models a way of dealing honestly with feelings. How effectively people move through the grief process is often determined by how effectively and how soon they are able to implement critical coping skills. Experiencing and processing the grief is vital to the newly bereaved family member(s).

The chaplain must know the normal grief process well. People naturally tend to move away from grief rather than toward it. In contrast, the chaplain seeks to move toward the grief. This requires one to be comfortable with and value the expression of deep feelings. Dealing with the feelings of others requires familiarity and facility with the difficult experiences in one’s own life. This is a major part of the clinical training and development that certified chaplains receive.

We view the role of the chaplain as “coming alongside” the family. This, in turn, enables them to have a sense that someone understands the pain and anxiety they are experiencing with this terrible news they have just received. The chaplain also has a sense that he/she is fulfilling a vital mission by carrying the other person’s burden for a little while. The capacity to listen, to respond empathetically, and to be present to the other person’s grief and pain is the essence of the art of pastoral care. This is also a primary focus of the clinical training that student chaplains receive. It is not easy to respond in these ways nor even possible for some. Some student chaplains take to it like a duck to water; others avoid approaching grief like the plague.

The trauma ministry of chaplains may begin in the ER, but it continues in the intensive care units (ICUs), waiting rooms, and in the other patient care units of the trauma center. It is not only imperative but also a condition of their work at Toronto General Hospital (TGH) that chaplains honor the faith traditions and struggles that are unique to each patient and family. Chaplains provide opportunities for patients, families, and staff members, including physicians, to talk about the interplay between one’s life experiences, faith, and the universal search for meaning. In the emergency resuscitation area, that journey can become confusing and uncertain. Once the patient has moved to other patient care areas of the hospital the reality begins to set in. For the patient it involves the realization that this tragic incident affects the way he or she will live the rest of their life. For families it means living without their loved one or reshaping their life to care for their loved one.

Although trauma patients enter a very complex medical setting, the movement of patients generally follows a pattern. The pattern begins with an initial physical examination and assessment by the trauma team followed by imaging studies and one or more surgical procedures. The largest exception to this pattern would be patients who die or whose physical examination requires them to undergo immediate surgery. The pastoral care of families continues after a patient dies as well as when the patient moves to the ICU.

Caregivers often find it difficult to be truthful with patients and families when we expect the difficult news we might impart will provoke emotion-filled responses. When we encounter a family filled with fear we often attempt to soften the news they are receiving. We do this because we do not want to hurt them or add to the hurt they are already experiencing. At the same time, we sometimes avoid the people we perceive to be angry. Dealing with someone’s anger often reminds us just how powerless we are. The chaplain needs to counter the normal response of people to grief and tragedy. By moving toward people in painful situations of grief and trauma, the chaplain expresses care and concern.

Surgeons sometimes find it difficult to deal directly with family members. This is particularly true when the feeling exists that their job is to rescue people from situations in which they suddenly, and often through no fault of their own, find themselves. The surgeon may feel he/she has failed. Physicians also need to acknowledge the limits of medicine and medical care and be realistic with their own expectations. In these instances it is important for the surgeon to seek support for himself/herself. No less than nurses and other members of the medical staff, and perhaps precisely because the medical staff look so much to the surgeons for direction, they can benefit from a chaplain who can also extend compassion and empathy to them. Gentleness with oneself is a lesson everyone benefits from.

Learning how to talk to people about tragedy, anticipated poor outcomes, and even death requires a person to be honest and communicate sensitively with another human being. It is a tremendous shift for the surgeon or nurse to move from the intensity of attempting to resuscitate a patient to the different, sometimes more stressful intensity of dealing with a family’s anxiety or grief. The required sensitivity comes from one’s development as a person and acquaintance with one’s own grief. We teach our students to journey alongside the patient or family. This requires them to deal with their anxiety or grief and be responsive in the midst of anxiety producing situations.

Talking to people honestly means respecting their ability to deal with whatever they are facing. The more people are respected, the more they can grow through a situation. In the not so distant past, physicians often prescribed medicine for grieving family members. The desire was to ease the suffering of families, and perhaps also to ease the suffering of the medical team. It is not easy to watch people grieve. Fortunately this has changed in recent years. Seeing others grieve can create feelings of failure in medical professionals although it need not be so. Understanding that grief is a natural and necessary process can help alleviate those feelings. At the same time, seeing others grieve often reminds us of our mortality. When this happens the impact of someone else’s tragedy surprises us. The artistry, and it is art, of pastoral care and medicine lies in helping people address the feelings present around traumatic and tragic situations. This is the first step toward wholeness and healing. As chaplains work with families they model a way of dealing directly with people at the point of their pain. This, in turn, helps physicians and staff members observe the value of dealing openly with people, valuing their feelings, and in this way validating their response to a tragic event.