Catholic Health World - May 1, 2021

Ethics as wise advice 2 Executive changes 7 PERIODICAL RATE PUBLICATION

MAY 1, 2021 VOLUME 37, NUMBER 7

Ethics frame how Catholic systems make care decisions for unrepresented patients

By LISA EISENHAUER

In her early days as a medical ethicist just over 15 years ago, Leslie Kuhnel remembers getting one or two requests per year for consultations regarding patients who lacked decision-making capacity and had no known surrogate to speak on their behalf about their care.

These days, Kuhnel says, there are two or three ongoing consultations underway at any given time regarding what Kuhnel are known as unrepresented or unbefriended patients receiving care in the hospitals she serves across CHI Health, where she is vice president of ethics and theology. CHI Health is CommonSpirit Health’s regional system operating in Nebraska and Southwest Iowa.

There is apparently no tracking done

nationwide for unrepresented patients.

But ethics professionals say facilitating the creation or approval of care plans for incapacitated patients with no identified surrogates or advance medical directives makes up a large and growing portion of their workload.

Establishing a care plan for an incapacitated patient who doesn’t have a designated surrogate can pose ethical challenges for health care providers.

Disconnected from family Nick Kockler is vice president for system ethics services at Providence St. Joseph Health. He says about 20% of the clinical ethical consult requests Kockler at Providence’s Center for Health Care Ethics in Portland, Oregon, in the first quarter of 2021 involved unrepresented patients. He adds that experts forecast that this patient population will increase across the nation because of the Continued on 4

Hugs, hand-holding: Long-term care opens up to more intimate visits

By JULIE MINDA

Patricia Addarith Magaña Lozano, director of nursing schools for CHRISTUS MUGUERZA-UDEM, is among the several dozen people who have taken part in the system’s leadership development program for women.

In CHRISTUS MUGUERZA leadership program, women gain skills, confidence to advance Course is increasing gender diversity in management ranks

While most residents of Benedictine Living Community | Garrison, North Dakota, had been troubled by the visitation lockdowns that were necessary to prevent viral spread during the pandemic, a particular resident had an especially difficult time with the isolation.

Scott Foss, the eldercare facility’s executive director, says, “When open visitation returned, she was able to actually see her family, including her Tennessee family, in-person on her birthday! You could sense her smile from a mile away and her laugher that we haven’t heard for so long returned. It was like sweet music!”

With vaccination rates very high among residents of eldercare facilities nationwide and with COVID infection rates low in numerous communities, public health agency guidelines are allowing facility doors to open wider to visitors and, for the vaccinated, the protective plexiglass barriers no longer need separate them from visitors.

“The joy and life that have been injected back into our residents is such a blessing!” says Foss. “Families are so grateful they get to see their loved ones again; there are many tears of joy!”

A long year The Centers for Medicare and Medicaid Services issued a memorandum in March 2020 recommending that, to prevent viral spread, long-term care facilities restrict all visitors and nonessential staff from entrance, with few exceptions.

Long-term care facilities across the U.S. adapted to the initial lockdown on visitation by connecting residents with their loved ones via videoconferencing, phone calls and window visits. They erected plexiglass and other nonporous barriers when protocols allowed for indoor visitation without contact.

Ethel Hauf, 93, is eager to resume playing for chapel services at Benedictine Living Community | Garrison in North Dakota. She’s played piano all her life.

Continued on 8

Continued on 3

Indigenous people have fared far worse in pandemic than Caucasians Ministry providers support efforts to reduce COVID’s impact on American Indians

By JULIE MINDA

About five years ago, executives at the CHRISTUS MUGUERZA system in Mexico saw that women were underrepresented in the leadership ranks of the system and its facilities and that when management opportunities did open up, very few women applied.

To better understand that reticence, the system conducted focus groups among female employees. The most respondents — about 50% — said they did not seek out promotions because of self-doubt about their skills. They did not feel entitled to claim a place in a management cadre dominated by men let alone aspire to executive leadership.

Melodies Now, in many facilities, protocols are allowing for vaccinated residents to hug

By JULIE MINDA

St. Vincent Healthcare staff place flags in the front lawn of the Billings, Montana, hospital to commemorate the lives of patients who died from COVID-19 while hospitalized at the facility.

American Indians have suffered far worse health outcomes and experienced much higher mortality rates from COVID than Caucasians.

The Indian Health Service and tribal governments have led the work to mitigate the impacts of the coronavirus upon American Indians, including with an effort to vaccinate against COVID. Ministry facilities have helped to address the needs of American Indians amid the pandemic.

Leroy “J.R.” LaPlante, director of the American Indian LaPlante Health Initiative, says “the most Continued on 6

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CATHOLIC HEALTH WORLD May 1, 2021

Bioethicists have duty to provide guidance, archbishop says

By LISA EISENHAUER

The role of the Catholic bioethicist does not end at sharing theories and reviewing options on ethical conundrums, in the view of Archbishop Anthony Fisher of Sydney.

Archbishop Fisher, who has published extensively on bioethics, moral theology, history, law and spirituality, said Catholic health care ethicists have a duty to use their knowledge of the church’s teachings and medical ethics to Archbishop Fisher offer specific guidance to patients, families, professionals and institutions.

“Bioethicists must assist in good health care decision-making and in sound education of professional or institutional consciences, rather than confusing everyone or making them unconfident about the way forward or unconcerned about the ethical implications of their choices,” Archbishop Fisher said.

He shared his thoughts during a discussion titled “The Vocation of the Healthcare Ethicist” that closed out the 2021 CHA Theology and Ethics Colloquium on March 10. The one-day event was held virtually.

‘Wise advisers’ Archbishop Fisher reviewed the Hippocratic, Jewish and Christian traditions that he said have provided the foundation for the medical profession and shaped modern health care ethics. He pointed out that those traditions are reflected in the most recent version of the “New Charter for Health Care Workers” drafted by the Pontifical Council for Pastoral Assistance to Health Care Workers.

The responsibilities the charter gives to health care ethicists and hospital ethics committees include covering for deficits in experience and sensitivity, articulating what values and principles are at stake, assisting in resolving conflicts or doubt, and enabling more reasonable clinical decision-making.

“Ethicists are wise advisers, teachers and mentors who help form the con-

In concluding his discussion, he noted: “In turbulent times like these, as several CHA ethicists have pointed out, ethicists are critical to preserving the identity and integrity of Catholic health care, in assisting people in dealing with ethically complex matters, in challenging some individual behavior and organizational culture, and in engaging in the ongoing formation of leaders and staff.”

sciences of health practitioners and managers, always challenging them to do more and better,” the archbishop said.

To be effective, he said, bioethicists need appropriate education or apprenticeship as well as conviction about the importance of their service, willingness to immerse themselves in the practice, and readiness to be public advocates for moral decisions.

“If the idea of a medical or nursing profession itself is an ethical notion, then the profession of bioethicist, at least in part, is to support his or her medical colleagues in being faithful to their profession,” Archbishop Fisher said. “When patients, relatives, colleagues, insurers or others press the health care worker to act contrary to sound ethics and professional conscience, the ethics advisers can both support them in their resolve and advance education and discussion with those promoting a contrary agenda.”

Spiritual role The archbishop sees a spiritual dimension to the role of Catholic bioethicists similar to that of others called to religious life. For the ethicists, he said, their vocation requires them to serve a sort of missionary role in health care institutions, making clear the ethical course that aligns with Catholic teachings.

“Even in the face of such intractable issues as abortion, euthanasia, sterilization, sex change, or vaccine hesitancy, bioethicists can share with people a broader historical, cultural and spiritual vision, and invite them into a conversation that is at once candid about basic norms yet respectful of those who think differently,” Archbishop Fisher said.

Global palliative care In her presentation, Dr. MarieCharlotte Bouësseau, adviser on integrated health services for the World Health Organization, discussed that organization’s push for a global commitment to palliative care. She said WHO estimates that 56.8 million people Bouësseau around the world would benefit from palliative care aimed at preventing and relieving suffering from lifethreatening illness but only 12% of that need is met.

The agency is working with partners across the globe to address hurdles to palliative care that include poor access to medication, lack of trained professionals and insufficient national and community support. Palliative care “has to be carefully adapted to the cultural social setting, to the health system and obviously the resources available,” Bouësseau said.

She shared a success story from a hospice in Kampala, Uganda, where the staff found a way to manufacture oral morphine to alleviate the misery of some patients. “This is actually changing the lives of hundreds of people in a simple way, in a very cheap way,” she said. “I think it’s the kind of innovation that can come from very vulnerable settings to try to improve the quality of life and serve the dignity of the people.”

leisenhauer@chausa.org

Wilson

Is trust enough?

In another session, Yolonda Wilson, an associate professor in health care ethics at Saint Louis University, explored whether trust on its own

Upcoming Events from The Catholic Health Association

What Counts as Community Benefit?

Diversity & Disparities Networking Zoom Call

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We Are Called – Confronting Racism to Achieve Health Equity Conversation Series II

Webinar: Advanced Issues in Sponsorship – Session Three: Sponsor and Mission Leadership Relationship

Webinar IV: The Elderly – Our Future: Connecting for Greater Understanding and Action for Elders

Co-sponsored by CHA and Vizient May 4 | Noon – 1:15 p.m. ET

May 5 | Noon ET

May 12 | 2 - 3:30 p.m. ET

May 24 | 1 – 2 p.m. ET

May 26 | Noon – 12:30 p.m. ET

May 26 | Noon – 1 p.m. ET

Webinar: Advanced Issues in

is an adequate measure of how well care providers are serving patients.

“In questioning whether trust is enough, I’m acknowledging that trust can and does serve an important function,” Wilson said. “In general, trust fosters social cooperation while the absence of trust inhibits it.”

However, she said she wonders if more concrete measures — such as how vaccines get distributed — might be better gauges of quality and access to care for minority communities.

“Part of fostering trust is for institutions to show themselves to be trustworthy and it’s worth thinking about what steps should be taken in order to achieve this,” she said.

Wilson said she sees it as part of the role of bioethicists to facilitate trust between communities and health care institutions.

To do that, she said, requires intention and collaboration.

Poet, essayist and funeral director Thomas Lynch wove a commentary on his life as a man of letters with insights on loss, tragedy and the role of ritual in the grieving cycle. He drew on personal losses and his career in the Lynch Michigan mortuary business founded by his father. He said he thinks that one lesson from the COVID19 pandemic has been in reinforcing how essential funeral rites and practices are to assist mourners through their grief.

“I think as Catholic health care workers you should be alert to a generation hobbled and damaged by a pandemic that removed the normal offices of community mourning and public grief from the world, and we’ll have to be playing catch up in the best way we can,” Lynch said to those attending the colloquium.

Sponsorship – Session Four: Recruitment and Selection of Sponsors June 9 | 2 - 3:30 p.m. ET

2021 Virtual Assembly June 14 – 15

Webinar: Advanced Issues in Sponsorship – Session Five: Initial and Ongoing Formation of Sponsors July 14 | 2 - 3:30 p.m. ET

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May 1, 2021 CATHOLIC HEALTH WORLD

Eldercare opens up

stretch of in-person visits she normally has with her mother during her annual trip to her hometown. When she sees her mother this summer, she plans to sit outdoors and reminisce with her as the two love to do.

From page 1

their visitors and to visit with them without a barrier separating them, provided they use masks, otherwise maintain social distancing and wash their hands before and after the visit. Groups of residents are again gathering. Here too, social distancing and masking are still required. Protocols vary by state and locality, and even by facility, with some sites choosing a more conservative approach to visitation and group gatherings.

The first thing 93-year-old Ethel Hauf did when she was able to leave her room at the Benedictine Garrison facility was to head straight for the keyboard in the chapel. She’s been playing piano all her life and loves religious music, but had to stop while sequestered in her room during the pandemic. It felt really good to be making music again, says Hauf, who is known as the life of the party in the skilled nursing facility.

Foss says that Hauf telegraphed her happiness with every note. “Staff and residents listened to her beautiful music, and she brought many to tears of joy. Everyone connected to her in that moment and could see what it meant for her to play in the chapel again.”

Barriers down “I think everybody is very optimistic about what is going on,” says David Becker, vice president for post-acute care for Covenant Health of Tewksbury, Massachusetts, which has 12 long-term care facilities, mainly in the northeastern U.S. “Everybody has been just ready to be with their families.

They have been looking forward to this for a year.”

Marissa Varney is director of nursing and assistant administrator at Covenant’s St. Mary’s d’Youville Pavilion in Lewiston, Maine. She says that facility had been locked down to visitors for the past year and had not seen a single COVID case during that time. She says staff and residents had worked so hard to achieve that zeroinfection rate that they were very nervous before visitation resumed, but that hesitancy gave way to elation. In line with regulatory guidelines, the facility brought back indoor visitation in March, complete with

Normalcy Kara Trosen, a therapeutic recreation director at Saint Mary Home in West Hartford, Connecticut, says that during one of the first in-person visits at her facility, a usually composed man practically sprinted to his waiting mom for their first hug in a year.

Trosen Another family was overjoyed to celebrate their loved one’s 103rd birthday with her in-person. “It sends a shiver down my spine to witness these moments,” says Trosen.

Residents of Saint Mary Home in West Hartford, Connecticut, bop balloons around a corridor. Loosened restrictions allow for residents to gather for such activities.

Dorothy Ahmann plays window tic tac toe with Benedictine Living Community | Garrison employee Desiree Klinker and Klinker’s son Archer. Ahmann is a resident of the North Dakota facility.

hugs and hand-holding.

“Residents are very excited. When you tell them they have a visitor coming, you can see the spark in their eyes now, when they know it will be an in-person visit,” Varney says. Staff get emotional too as they witness the long-awaited reunions.

Laurette Chamberlain and her daughters Doris Chamberlain and Doreen Caron were among the many who had struggled over the past year with the lockdown.

Laurette Chamberlain has dementia, and she had some trouble understanding the dynamics of the visits separated by windows or plexiglass dividers. And Caron found it difficult to endure the year with no physical contact with her mother.

When visitation without barriers opened in late March for the vaccinated, Caron embraced her mom for the first time in over a year. Her mother wept.

Doris Chamberlain lives in Florida — last summer she had to miss the long

Sigh of relief Like Saint Mary Home, the Sanctuary at Holy Cross in South Bend, Indiana, is part of Trinity Health Senior Communities, which operates Trinity Health’s 33 eldercare facilities in six states. Holy Cross Executive Director Jack Mueller says this period of gradual reopening has felt like a spring reawakening. He mentions the daughter Mueller who had come to see her mother three times a day before the pandemic and is beyond grateful to get back to that schedule. He says one gentleman now waits eagerly at the door each day for his wife’s visit. “The staff has been ecstatic, because we’d seen what isolation has done to our residents, and that has been terrible.”

Now, in addition to hosting in-person visits, residents can leave the facility, dine with their loved ones and return without having to quarantine. Mueller says residents talk excitedly about the meals they enjoyed during their excursions.

The resumption of in-person, barrierfree visits “has been a huge change for longterm care, and we are thrilled,” Mueller says. “We’ve been really privileged to watch residents come back out of their shells and come back into themselves.” jminda@chausa.org

Some eldercare residents hesitant to resume activities, socialize with others W

hile most long-term care residents had been eager for a resumption of group activities and have embraced the chance to socialize again, some elders have been so significantly impacted by the amount of time they’ve spent isolated in their rooms as part of contagion prevention protocols, they have been slow to reengage.

“They feel comfortable in their rooms watching TV. There is a sense of disconnect and also a little bit of depression,” said Fr. Matthew Perumpil, mission integration director of the St. Camillus eldercare campus in Wauwatosa, Wisconsin.

He said visitors who have returned to the facility after a year away comment on the emotional and physical toll the isolation has taken on residents.

Lonely, anxious, depressed Fr. Myles Sheehan, SJ, is a physician who directs the Pellegrino Center for Clinical Bioethics at Georgetown University Medical Center. In his presentation at a recent CHA webinar Fr. Sheehan on the plight of longterm care patients during the pandemic, he said that lockdowns were necessary to help prevent infection among those most likely to die from COVID-19. However, the

3

lockdowns were “a very bad thing in the way that they impacted those individuals with loneliness, anxiety, depression and just boredom and the pain from deprivation of normal contact and activities.”

Fr. Sheehan said for nursing home residents with mild cognitive disorders, the lack of stimulation and routine that happened during the pandemic lockdowns may have caused decline. He said, “Lacking the markers that would help to reorient a person, (they could) become more confused and … have their cognitive problems worsen quite a bit.” The added burden of depression also may have worsened conditions.

“I just can’t imagine what it’s like for somebody in their 80s or 90s to be shut in a room, not able to see their kids or their grandkids,” Fr. Sheehan said. “They have to have their meals in the room. Not to have any of the activities that they might’ve looked forward to — it’s almost like being in prison.”

He said he believes many long-term care residents were traumatized. “It was day after day of real fear for one’s life. Worrying about how you would get through the day without having some of the supports you were used to as well as that trauma of being ripped away from your loved ones — multiple events that cause great stress and cumulative trauma on our older residents.”

Webinar co-presenter Dr. Leonardo Palombi, director of the department of biomedicine and prevention, and professor

of hygiene, epidemiology and public health at University Tor Vergata in Rome, said there is a link between loneliness and isolation and worsening of diseases, including cardiovascular conditions.

Out of hibernation Scott Foss, executive director of Benedictine Living Community | Garrison, North Dakota, said such impacts were evident throughout the lockdown, including when it came to residents experiencing depression connected with the isolation. He says while staff had spent extra time in residents’ rooms to engage them and had connected them with loved ones via technology during the lockdowns, “That only goes so far.

Human interaction and getting out and about really is meaningful for our residents and truly gives them a sense of purpose.”

Foss said as that facility began reopening earlier this year, “Initially it was very different for our residents and staff. The residents literally were very wary of coming out of their rooms especially on the first couple of days. It really almost seemed like they had been in hibernation and had to get reacclimated to all of their surroundings.

“We had several residents that had lost some weight and were a little depressed. But that quickly began to change after they were able to get out of their room more, socialize and even eat in the dining room on a rotation with social distancing.”

Kaysee Amado, a therapeutic recreation

director at Saint Mary Home in West Hartford, Connecticut, said she’s seen some residents so used to worrying about socializing that they are nervous to join newly restarted group activities. She said she and fellow Amado recreation therapists like to experiment with different activities and approaches to see what will draw out the few holdouts who used to do group activities but have not rejoined them.

Kathleen Kelleher is director of mission and spiritual care for Youville House in Cambridge and Youville Place in Lexington, both Covenant Health eldercare sites in Massachusetts. She said that when both facilities’ chapels reopened with limited capacity, not all available chairs were filled initially. She attributed that to cognitive and physical decline, and residents having become accustomed to viewing chapel services from their apartments. They are slowly coming back to the chapel.

Kelleher said staff have been coaxing people out to receive spiritual and sacramental nourishment. “We’re trying to help them feel safe and comfortable” so they can embrace the new level of freedom.

— JULIE MINDA

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CATHOLIC HEALTH WORLD May 1, 2021

Unrepresented patients From page 1

10 million baby boomers who live alone and the 20% who are childless.

Patrick McCruden, chief mission integration officer at St. Louis-based SSM Health, says unrepresented patients are seen at the system’s hospitals quite often. “I think as our society has become more McCruden mobile and people are more distant from one another, it’s easy for a person to get disconnected from family,” he says.

Kuhnel says a patient’s attending physician is responsible for determining that the patient does not have decision-making capacity. That physician then turns to relatives or designated surrogates to speak for the patient.

When a patient is incapacitated long term or permanently and no surrogate can be found, states have various mechanisms to appoint a guardian to make the patient’s health care decisions.

Kuhnel says that in the region CHI Health serves there is a significant shortage of public guardianship resources, which exacerbates the problems associated with decision-making for patients who can’t make medical decisions for themselves.

And David Ozar, a philosophy professor emeritus at Loyola University in Chicago who studies and writes about issues related to unrepresented patients, says the process of getting a court-appointed public guardian can be cumbersome and sometimes only adds to the complexity of decision-making.

“In the real world, many hospitals don’t go to court for a guardian in these situations because it’s expensive, it takes weeks or months, and you often end up with somebody who knows no more about the situation than you,” Ozar says.

The need to respond quickly and ethically to treatment decisions for unrepresented patients until a search turns up a surrogate, a court or agency appoints a guardian or the patient regains capacity has prompted Catholic health care systems to set up review processes for ethical decision-making.

Establishing a process At CHI Health, Kuhnel pulls together a multidisciplinary review committee once an unrepresented patient is identified. The

The complexities that health care workers face in caring for unrepresented patients include following legal processes for surrogates that vary by jurisdiction and determin­ing what is in the best interest of a person about whose life values care providers know nothing.

committee’s systematic review process is designed to ensure that such patients get appropriate and compassionate care and that responsibility for formulating a care plan doesn’t fall solely on whoever happens to be the patient’s attending physician. (See related story, page 5.)

“What we try to do is automatically prompt the start of that process so that we can look at the issues and questions raised by this type of decision-making situation and do that in a holistic interprofessional way that both supports the unrepresented patients and supports their care teams,” Kuhnel says.

Even with an explicit process in place, Kuhnel says the challenge of reviewing the care of an unrepresented patient can be daunting.

“Some of the most difficult case consultations are those centered around unrepresented patient cases because there is not always agreement about the various options, and the most important voice — the patient’s voice — is the hardest to hear,” Kuhnel says. “The gravity of what we are considering for patients when they are not able to clearly tell us what they would want is very heavy sometimes, especially when it involves significantly life-altering decisions.”

Patient-centered response Kockler says there are myriad ethical concerns that figure into any situation involving unrepresented patients. One is that, as decisions are being made, the focus of the care team must not shift from the humanity of the patient to other matters, such as the procedure under consideration.

“There’s often a temptation or a moral

hazard in getting caught up in the particular mechanics of a decision or treatment plan and losing sight of the person at the center of it all,” he says.

Other issues are how long a search should go on to find a surrogate to make medical decisions for the patient before care teams start making them and how to ensure that biases don’t creep into decisions that providers end up making on patients’ behalf.

Kockler says those ethical considerations are weighed whenever unrepresented patients are identified across the Providence St. Joseph Health system, which spans seven states and includes 51 hospitals and more than 1,000 clinics. However, the process for deciding on care plans for unrepresented patients varies and depends on circumstances.

At Providence St. Joseph Health’s larger hospitals, medical decisions for unrepresented patients with complex comorbidities generally undergo a review by representatives from across multiple disciplines.

At rural critical access hospitals, the treating physician’s care plan gets a less expansive review involving a physician who is not on the patient’s care team.

Whatever the process, Kockler says ethical considerations are not overlooked. “An ethics consultant is usually brought in in some form or fashion to support and facilitate sound decision-making,” he says.

‘Best interest principle’ McCruden says SSM Health’s process for making care decisions for unrepresented patients in its four-state service area is shaped by the patient’s health situation. He points out that the care considerations for a

person with a terminal illness who is nearing death are different than, say, those for someone who has been in a crash and has sustained injuries that he or she will survive but without ever regaining the capacity to make care decisions. “You can’t have a process that applies to every type of patient because they’re not a homogenous population,” McCruden says.

In any case involving an unrepresented patient, he says, SSM Health care providers follow “the best interest principle.” “For the most part, their best interest is you’re going to take care of their medical needs, you’re going to err on the side of life,” he says.

But in some cases, that goal to preserve life might not be in the patient’s best interest, such as when keeping someone alive requires artificial life-support measures.

To assist clinicians in making medical decisions for those who can’t make their own and have no known representative, SSM Health social workers and case managers who are on the care teams offer their expertise and bioethicists and ethics committees are brought in as needed for consults, McCruden says.

“One of our first values that we talk about is compassion, so we want to make sure that we’re compassionately responding to all of our patients’ needs and certainly that would include the unrepresented patients,” he says.

Wider advocacy Even though he is confident that SSM Health, as well as most medical providers, strive to provide the best and most ethical treatment for unrepresented patients, McCruden says that responsibility shouldn’t be left solely up to the medical community. He sees it as incumbent upon health systems and providers to push for government policies and laws that bring clarity and consistency to how decisions are made across systems and across the care continuum.

An example he points to is the Uniform Health Care Decisions Act that some states have passed. The comprehensive act covers a multitude of decision-making issues, including setting up rules for appointing medical surrogates and simplifying the process for advance health care directives.

“I think it is important for us in our advocacy effort and as physicians and clinicians and health systems to advocate for the passage of these types of laws so that we can help our patients and protect them,” McCruden says. leisenhauer@chausa.org

Ethicist leads effort to set up consistent review process for unrepresented patients D

avid Ozar is a founder of the Unrepresented Patients Project for Illinois, an initiative aimed at bringing clarity and consistency to how care providers decide on treatment for patients with no one to speak for them.

Ozar is a philosophy professor emeritus at Loyola University in Ozar Chicago and a longtime member and consulting ethicist for the Institutional Ethics Committee of NorthShore University Health System in Evanston, Illinois, which provided the resources for initiating this project. He taught medical ethics for years and continues to study and write about issues related to unrepresented patients.

Ozar bemoans the lack of a systematic and ethics-based approach to how providers make care decisions for this population. “It just seems to me to be a shame that almost nobody seems to be thinking about this seriously,” he says.

In his research, Ozar says he has turned up various examples across the nation of efforts by hospitals or health systems to establish a systemic process for making

care decisions for unrepresented patients.

None have been put into wide use, that he is aware of. Meanwhile, laws covering care for these patients vary from state to state and the mechanisms they set up can be slow and cumbersome.

As he explained in an article he wrote in July 2019 in the AMA Journal of Ethics: “In most states, with only a few exceptions, there is only one legally authorized decisionmaker for such patients: a guardian ad litem is appointed by a judge to make medical decisions. In most jurisdictions, however, this solution usually takes longer to implement than a treatment decision can be put on hold. It is also expensive, and often guardians have heavy caseloads and know little about the patient.”

Ozar identifies three major ethical concerns about how important medical decisions are made for unrepresented patients.

The first is that existing legal mechanisms vary by jurisdiction, generally are slow to kick in and often provide poor representation for patients.

The second concern is that unrepresented patients are cared for by hospitalists or attending physicians who rotate and who might have differing views about what constitutes proper goals or care plans. The

third is about the complexities of determining what is in the best interest of a person about whose life values care providers know nothing.

The Unrepresented Patients Project for Illinois proposes that the medical decisions for these patients and goals of care plans be determined in consultation with committees of at least three people with differing perspectives, such as a physician, a social worker and an ethics committee member, who aren’t on the patient’s care team.

The supporters of the project hope to

find a health system or hospital that will pilot their proposal and show that it’s workable and effective. Their ultimate goal is to get the process adopted statewide, even if that requires legislative action.

Ozar had recruited about 100 people affiliated with hospital systems across the state to work with him on the project before the COVID-19 pandemic drew their attention away. He has plans to regroup and resume the effort soon.

— LISA EISENHAUER

Who is an ‘unrepresented patient’?

T

he Unrepresented Patients Project for Illinois, a statewide initiative aimed at ensuring that ethical decisions are made on behalf of incapacitated patients, defines an unrepresented patient as someone who: Is facing an important medical decision.

Is not capable of making an autonomous decision about this matter at the relevant time and is unlikely to recover this capacity before the decision needs to be made.

Has no advance directive.

Lacks an identifiable substitute decision-maker or legally authorized representative.

In addition, there must be no evidence from the patient’s past or from other parties that would support a reasonably conclusive judgment about what the patient would likely choose in the present situation if that person were capable.

May 1, 2021 CATHOLIC HEALTH WORLD

CHI Health sets systematic review process for voiceless patients

By LISA EISENHAUER

At CHI Health hospitals, the Unrepresented Patient Ethics Review Process is activated as soon as a care team member (usually a social worker or care manager) identifies a patient as unrepresented. It runs concurrent with ongoing efforts to find a surrogate spokesperson for the patient or have a public guardian appointed by a court, a process that can take months.

Leslie Kuhnel, the system’s vice president of ethics and theology, researched suggestions made by bioethicists and legal experts before collaborating with the chief medical officer at CHI Health Creighton University Medical Center – Bergan Mercy in Omaha, Nebraska, and other colleagues to pilot the process in 2013. The process has since been adopted at all CHI Health hospitals. The system is part of CommonSpirit Health.

When an unrepresented patient is identified, Kuhnel convenes an interdisciplinary committee. The committee’s members

generally include an ethics consultant and a team from the hospital caring for the patient made up of the chief medical officer, chief nursing executive, attending physician, chaplain, legal counsel, risk management representative and medical social worker or care manager. Palliative care specialists, translators and others with special expertise are sometimes asked to join the committee, depending on the situation.

The committee reviews the proposed treatment plan, evaluates the identified risks and benefits of the options and provides recommendations. When possible, the committee considers as much information as is known about the patient, including conversations from past hospital visits and information from individuals who may have some insight into the patient’s values and beliefs, such as case managers at a homeless shelter. It bases its evaluations and recommendations on a long list of questions that include: What decisions, if any, does the patient

have the capacity to make at this time?

What are the potential sources of conflict of interest and bias within the review team and how can they be mitigated?

How is this decision aligned with/ informed by the Ethical and Religious Directives for Catholic Health Care Services?

What if the patient would disagree with this plan even after careful review?

The committee meets in person or by videoconference and makes recommendations as needed until a surrogate is identified, the patient regains the capacity to make his or her own choices or the patient’s circumstances are otherwise resolved.

“In a way, the attending physician has this unrepresented case review committee to work with in a similar way they might if they were having the conversation with the patient’s surrogate or family member,” Kuhnel says. “The review committee is there to wrap around the attending physician and care team as much as the patient in terms of support in this type of unique decision-making circumstance.”

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6

CATHOLIC HEALTH WORLD May 1, 2021

Native American patients adapt spiritual practices to COVID realities

By JULIE MINDA

Staff at ministry facilities that serve relatively large populations of Native Americans say that they have been aiming during the pandemic, as in usual times, to accommodate spiritual and cultural practices and preferences of their Native American patients.

The spiritual practices of Native Americans can vary greatly by tribe and by individual.

Karen Brannon is spiritual care manager for Brannon SCL Health’s St. Vincent Healthcare in Billings, Montana. She says Native American patients often ask to have a spiritual leader or healer present in their hospital room to pray and perform sacred ceremonies. But visitation restrictions for hospitalized COVID patients generally prohibit such in-person visits from outside clergy or spiritual care practitioners.

The hospital’s spiritual care team talks with patients and their family members and tribal spiritual care providers to determine how religious rituals and sacraments that are meaningful to individual patients can be adapted to be compliant with COVID infection protocols.

Gordon Jackson, St. Vincent’s health disparities program coordinator, notes that for many Native American patients, technology workarounds — such as videoconference sessions — do not carry the same spiritual weight or meaning as in-person ceremonies. In those situations, the hospital has arranged window visits between patients and spiritual healers.

Leroy “J.R.” LaPlante directs the American Indian Health Initiative of Sioux Falls, South Dakota’s Avera Health. He says many Native Americans in Avera’s service areas are part of Lakota, Dakota, and Nakota Sioux tribes. Many practice a ritual commonly called “smudging,” and termed Waziliya by these tribes, to clear a space of negative events and thoughts or to

Indigenous people and COVID-19 From page 1

important thing Avera (Health) has done is to listen” to American Indians and then to respond. LaPlante is Sioux Falls, South Dakota-based Avera’s primary liaison with regional governments of the 17 tribes within Avera’s Great Plains service area, many of which are Sioux tribes.

Elevated risk Centers for Disease Control and Prevention studies show that “persisting racial inequity and historical trauma have contributed to disparities in health and socioeconomic factors” between indigenous populations and white populations. “American Indians and Alaska Native people have suffered a disproportionate burden of COVID-19 illness during the pandemic,” Dr. Robert Redfield, who was then director of the CDC, said in an August press release.

A Kaiser Family Foundation report published in February said American Indians were among the elders of color who were nearly twice as likely to die of COVID-19 than older white adults. From Jan. 1, 2020, to Nov. 21, COVID-19 cases among American Indian Medicare beneficiaries were 1.7 times higher than among white beneficiaries. Hospitalization rates for American Indian beneficiaries were at least double the rate among white beneficiaries, the report said.

Shephard

Deep roots Doug Shephard is interim regional director of mission integration for

welcome positive spiritual energy.

The ritual normally includes spoken prayers and the burning of sacred medicines such as sage, cedar, sweet grass and tobacco or a combination of those plants.

The materials are rolled into a ball and put in a fireproof container and lit to create a smoke and fragrance. LaPlante says the concept is similar to the incense used by Catholics. He says the rising of the smoke and the fragrance are reminders that prayers are rising to the creator.

Small gatherings of relatives and the sick person usually participate in the Waziliya ritual. A ceremonial leader does not have to be present. LaPlante says chaplain services departments at Avera hospitals can supply the organic ingredients and a properly ventilated room to clear the fragrant smoke.

Some facilities have designed rooms specifically for this purpose.

LaPlante says because infection prevention protocols during COVID made it difficult to hold Waziliya rituals, many Native American families have relied on another common spiritual practice to provide spiritual intervention for their loved ones in the hospital.

Under the practice, a ceremonial leader wraps tobacco or other plant material in colored broadcloth and ties the bundle and blesses it in a sweat lodge ritual called an inipi ceremony. Relatives of a sick person will place the blessed bundle near their loved one, often on the hospital bed where it remains until the patient takes it home. The sacred bundle is returned to the ceremonial leader and often put in a sacred place.

Extended family St. Vincent’s Brannon notes that many Native American people define family quite broadly. Family for American Indians often includes multiple extended family members who maintain a presence throughout a hospital stay, as compared to Caucasian families who tend to have more of an inner circle of immediate family visiting and perhaps not remaining present for the entirety

SCL Health’s Montana region. He says that during the pandemic the state has been “confronted with the realities of health care disparities in ways that we never imagined.”

While Native Americans make up just 7% of Montana’s population, they account for 18% of the state’s coronavirus cases and 35% of its COVID deaths. This is according to data from an August epidemiological study from the Montana Department of Public Health and Human Services.

Gordon Jackson is health disparities program coordinator and Kathleen Usuriello is infection prevention specialist at SCL Health’s St. Vincent Healthcare in Billings. Jackson says that Native Americans’ susceptibility to the virus, espeJackson cially early on, was related in part to systemic racism and related social determinants of health.

For instance, the high poverty rates among Native Americans is linked to poorer health access Usuriello and outcomes. Usuriello says that as compared with whites, many Native Americans have higher rates of chronic diseases, including diabetes, chronic obstructive pulmonary disease and kidney disease. Those comorbidities put them at higher risk of COVID complications.

Avera’s LaPlante adds that many American Indians live in very remote areas, which makes it difficult for them to get health information and to access health services.

Also, due to poverty, many American Indians live in crowded, multifamily, multigenerational homes, so it is challenging for them to socially distance, isolate or quaran-

with loved ones when in-person visitation is barred, a greater proportion of Native Americans than Caucasians lack access to online connections. Jackson adds internet access is often limited on remote rural reservations. Many Native families cannot afford to purchase computers, smartphones or the internet subscriptions that are required for those devices.

William Big Day, of a Montana Crow tribe, performs a ceremonial ritual during a service at St. Vincent Healthcare in Billings, Montana. The February service involved hospital leadership, Crow and Northern Cheyenne tribal members and Bishop Michael Warfel of the Diocese of Great Falls and Billings. Service participants honored those who have died of COVID, prayed for survivors and recognized staff’s commitment to care.

of the patient’s stay.

With COVID restrictions barring such extended visitation and visitation by large groups, spiritual care team members and clinicians have tried to find ways to connect Native American patients by phone, televisits or window visits to all the family they wish to see, just as the team does for all patients.

LaPlante says the communitarian aspect of Native American life has presented some challenges for Avera amid the pandemic especially when it comes to end-of-life care consults for those patients who are unable to have in-person visitors. It is usual for Native Americans to involve their extended family in important medical decisions. Spiritual care teams and others have been grappling with how to incorporate everyone who seeks to be involved in such decisions when they cannot meet in-person to talk due to COVID restrictions.

St. Vincent’s Jackson notes that while videoconferencing technology has come to play an important role in uniting patients

tine, LaPlante says. The August CDC release said lack of access to running water may be an issue for Native Americans, more so than for whites. Water is vital to infection prevention hygiene practices.

LaPlante and Jackson say that tribes were reeling last summer and early fall from fast viral spread and high death rates.

They say most of the tribes in the communities their health systems serve rallied to implement protocols that were much more stringent than state mandates. For instance, many tribal governments mandated mask wearing, social distancing, lockdowns and curfews. Some closed off their communities to outside visitors.

LaPlante, Jackson and Usuriello say the mitigation efforts have helped decrease those tribes’ infection and death rates.

Vaccine acceptance Since the pandemic’s onset, Jackson and LaPlante have been part of coalitions involving tribal leadership, Indian Health Service representatives and public health departments in the states where their health systems operate. These coalitions’ members exchange information on COVID infection and mortality rates, mitigation efforts, screening and testing activity and, now, vaccination work.

Jackson says in surveys upwards of 70% of indigenous Americans have expressed great openness to vaccination.

In both the Avera and SCL service areas, most of the COVID education, screening, testing, treatment and vaccination for American Indians has been provided on reservations by Indian Health Service facilities in conjunction with tribal leadership.

Avera and SCL sites have supported that work. Avera has an extensive telehealth network and its telehealth specialists have consulted with those providing care on reserva-

Open minds While cultural awareness and diversity education at Avera and St. Vincent’s teach about heritage and the traditions of indigenous tribes, the education also underscores the importance of dispelling stereotypes, recognizing members of tribes as individuals worthy of respect, and adhering to their personal preferences and care goals.

LaPlante and Jackson say they regularly educate colleagues about Native American culture, spirituality and practices. LaPlante notes that he spends extra time doing so with chaplains, so they can know how to communicate with Native American patients about their spiritual preferences.

LaPlante recalls a relatively recent situation in which a Lakota patient was in an Avera hospital, unconscious. Her husband had brought in a spiritual article, blessed in an inipi ceremony, and had left it on her bed, in line with the couple’s spiritual practices. When the woman was discharged, the couple found that a nurse had put the ceremonial article into the patient’s luggage while the patient was unconscious.

“The nurse didn’t realize that this was a mistake,” and so it was an education process to help the nurse to understand the practice and the appropriate way to handle such articles, LaPlante says.

He adds that cultural competence education is an ongoing process that includes everyone gaining a better understanding of both the differences and similarities between themselves and the patients they serve. jminda@chausa.org

tions, says LaPlante.

Indian Health Service has its own stream of vaccine supply, which is separate from state supplies. LaPlante says early in the vaccine distribution cycle when the limited supply was being distributed to seniors and other high-risk people, he advised many American Indians who normally may not access their health care from Indian Health Service sites to go there for shots. SCL and Avera hospitals and ambulatory care sites provide COVID testing and treatment for indigenous patients who don’t receive care from Indian Health Service facilities.

Foundation of trust Usuriello and Jackson say that SCL has deepened its relationship with local providers in the Indian Health Service during the pandemic. Usuriello says she and colleagues are in frequent contact with public health nurses who now are a vital link to Indian Health Service nurses in tribal communities.

LaPlante says Avera’s regular communication with tribal groups and the Indian Health Service during the pandemic is built upon relationships strengthened by its American Indian Health Initiative. That initiative was established in 2015 at the urging of tribes. Avera has worked with tribes on developing school-based mental health counseling, telehealth and dialysis care, as part of that effort.

LaPlante, who was born and raised on a Cheyenne River Sioux Indian Reservation in north-central South Dakota, says trust building is central to the ongoing effort to address seemingly intractable health and social service challenges plaguing Native American communities. “There are no easy answers,” he says. jminda@chausa.org

May 1, 2021 CATHOLIC HEALTH WORLD

7

KEEPING UP

Boatwright

Dardeau

PRESIDENTS/CEOS Damond W. Boatwright will succeed Mary Starmann-Harrison as president and chief executive of Hospital Sisters Health System of Springfield, Illinois. StarmannHarrison will retire in July having headed the system for a decade. Boatwright, who was regional president of SSM Health Wisconsin, will join HSHS in June.

Nicholas Lymberopoulos to chief executive of Providence Cedars-Sinai Tarzana Medical Center of Tarzana, California. He was chief operating officer of the medical center.

Lugli

Boudreaux

Steve Loveless is departing as president of SCL Health Montana and St. Vincent Healthcare of Billings, effective April 30. He plans to become an executive coach. He joined SCL Health in 2012. Michael Skehan, chief operating officer for SCL Health Montana, will be interim president until SCL Health fills the position.

ADMINISTRATIVE CHANGES PeaceHealth of Vancouver, Washington, and one of its facilities have made these changes: Dr. Doug Koekkoek to chief physician executive of PeaceHealth and Jack

Rawls

Guidry

Estrada to chief administrative officer for PeaceHealth Peace Island Medical Center in Friday Harbor, Washington.

Sean Dardeau to chief operating officer of Mercy Health – Cincinnati.

Rick Lugli to vice president and deputy general counsel of Covenant Health of Tewksbury, Massachusetts.

CHRISTUS Ochsner Health Southwestern Louisiana of Lake Charles, Louisiana, has made these changes: David Boudreaux to administrator of CHRISTUS Ochsner Lake Area Hospital and Jane Rawls to chief nursing officer of the regional system.

Love thy neighbor, get vaccinated, CHA and other Catholic organizations urge CHA has joined a coalition of more than 30 Catholic organizations urging Americans to get vaccinated as an act of charity and solidarity with others that will help prevent the spread of COVID-19 and build immunity against the virus.

The coalition’s members plan to use their social media platforms to share facts and correct disinformation about the vaccines. The campaign also will highlight the moral responsibility of doing good works for one another and encourage adoption of the Vatican’s COVID-19 resource kit for church leaders, which provides content for the preparation of homilies and tailored messages that can be used for parish websites, bulletins and other media.

“As COVID-19 vaccines become more widely available, we encourage everyone to seek the facts about how the vaccine works and understand that other measures, such as wearing a mask in pubSr. Mary lic, will still be necessary,” said Sr. Mary Haddad, RSM, CHA president and chief executive officer. “Our health care workers have been heroically caring for COVID-19 patients and urgently need everyone to do their part to ensure we can finally overcome the virus.”

Participating organizations, which also include Catholic Charities USA, Catholic

Relief Services and the Association of Catholic Colleges and Universities, have committed to: Share information about the importance and moral responsibility of individuals to get vaccinated against COVID-19.

Provide human, spiritual, and pastoral support for those struggling to understand, affirm, and act on Catholic social teaching, including the teachings of Pope Francis and the U.S. Catholic bishops.

Advocate for the equitable distribution of vaccine in the U.S. and globally.

The coalition is posting information and resources on issues related to COVID-19 vaccines at catholiccares.com.

Gaudet

López

Pierce

Smallwood

Facilities within Franciscan Missionaries of Our Lady Health System have made these changes: Kevin Guidry to administrator of Assumption Community Hospital in Napoleonville, Louisiana; Dr. Craig Greene has been elected chief of staff and Wendy Gaudet to vice president of operations of Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana.

Ascension Michigan region of Warren, Michigan, has made these changes: Shanna Johnson to chief operating officer of Ascension St. John Hospital in Detroit and Ascension River District Hospital in East China; and Cecilia Rutherford to vice president of nursing for Ascension Providence Rochester Hospital in Rochester.

Trinity Health facilities have made these changes: Dr. José J. López to chief medical officer of Holy Cross Health in Fort Lauderdale, Florida; Stonish Pierce to chief operating officer of Holy Cross Health; and Alisa Smallwood to chief development officer of Holy Cross Health of Silver Spring, Maryland.

NOW ACCEPTING NOMINATIONS

21

Mission Doctors Association is now accepting nominations for the 2021 Catholic Doctor of the Year Award!

Past recipients include Sr. Deirdre Byrne, MD (2019) and Dr. Tom Catena (2018).

The award recipient will be honored following the annual Archdiocese of Los Angeles Annual Mass Celebrating Catholic Healthcare Professionals.

This is an opportunity for patients, colleagues, friends, and family members to recognize an outstanding Catholic doctor.

MISSION DOCTORS ASSOCIATION www.MissionDoctors.org _________________________________________

For more than 60 years, MDA has trained, sent, and supported Catholic doctors and their families to serve people of all faiths in some of the most under-served areas of the world.

8

CATHOLIC HEALTH WORLD May 1, 2021

Women's leadership program

Female representation in CHRISTUS MUGUERZA leadership According to information provided by CHRISTUS MUGUERZA, the percentage of women in top leadership positions increased between 2018 and 2020:

From page 1

The system, which has 11 hospitals, responded by establishing a leadership development program for women with management potential, that includes skillbuilding workshops, networking and other activities geared to improve their professional and personal skills.

Horacio Garza Ghio, chief executive of Monterrey, Mexico-based CHRISTUS MUGUERZA, says, “We are helping them to go deep inside themselves to explore what they are feeling.

We said, we need to help them to bring into their own consciousness the feelings that are working against them and look at how Garza Ghio to address those feelings and acquire new skills, knowledge and tools.”

He says the program called Mujeres Líderes CHRISTUS, which began in 2018, is producing a pipeline of female job candidates who are prepared to pursue opportunities to advance in their careers and then take on management challenges.

Mujeres Líderes translates to “Women Leaders.”

Chief executive and vice president Director* Manager System director

2018 2020 20% 36%

TOTAL

42% 49%

13% 28% 52% 57% 0% 25%

*Includes hospital administrator, medical director, Adelaida Lafon Foundation administrator and director of nursing schools.

Consultant Almendra Ramírez de Wisdeen, standing, leads a session of the CHRISTUS MUGUERZA women’s leadership program. The June 2019 session was at the health system’s corporate office.

Accelerating change According to a June 2020 analysis by the nonprofit consultant Catalyst, while the gender gap has essentially closed in terms of attendance in primary, secondary and post-secondary education in Mexico, Alicia López Romo women are not experiencing corresponding gains in levels of participation in the en’s careers by making women more aware workplace. Catalyst says it researches work of their thinking and how internalizing environments and employees’ experi- those hidebound beliefs about a woman’s ences to understand role can hinder prowomen’s barriers “We are helping them to go fessional growth. and measure their career success. It deep inside themselves to Pursuing a vision tracks women’s repManagers at the resentation in cor- explore what they are feeling. system headquarporate leadership ters or facilities We said, we need to help and determines the nominate women root causes of gen- them to bring into their own with management der gaps. potential for particiconsciousness the feelings pation in the proThe 2020 analysis says 75% of female gram. Women aged that are working against college graduates in 30 to 60 have particMexico do not have ipated. Between 10 them and look at how to a paid job in the forand 13 women take address those feelings and part in the program mal economy. The same report says acquire new skills, knowledge at a time. Graduates women hold just receive a diploma 37% of entry level from CHRISTUS and tools.” positions at Mexican MUGUERZA. — Horacio Garza Ghio companies and 10% Most program of executive compresenters are femittee positions. Women are paid on aver- male executives from CHRISTUS age 18% less than men doing comparable MUGUERZA or other Mexican companies. work.

Participants also receive mentoring from Garza Ghio believes the employment their managers and one-on-one job coachgap is rooted in large part in informal cul- ing from an outside consultant. Program tural beliefs that men should be the pri- participants build connections with the mary breadwinner and women should other women in their class as well as with the focus on the home and children. This female executives who are guest lecturers. ethos has influenced hiring and promoParticipants learn communication tion practices in Mexican companies, he skills, strategic thinking, change mansays. Garza Ghio says younger generations agement and career planning. They are appear to be more open to women pursu- encouraged to talk with one another and ing careers. with their mentors and coaches about Alicia Estela López Romo is an epide- their self-perception, beliefs and attitudes, miology system manager at CHRISTUS professional experiences, goals and vision.

MUGUERZA who completed the lead- They also receive advice on how to nurture ership training cur- themselves, such as through relaxation riculum. She says techniques. cultural attitudes in The program started with in-person Mexico have been slow sessions in Monterrey, with some of to change. The prevail- the participants traveling in from their ing attitude is “that if facility locations around the country. you’re married or have CHRISTUS MUGUERZA switched much of a family, you can’t do the program to an online format amid the work activities.” pandemic.

López Romo Garza Ghio says the So far, 35 women have graduated from CHRISTUS MUGUERZA leadership devel- the program. Garza Ghio says CHRISTUS opment program is “speeding up the pro- MUGUERZA is exploring ways to expand cess” of promoting and advancing wom- the reach of the program.

Diverse perspectives Garza Ghio says because of a concerted effort to promote qualified women to management roles, female representation among system management has increased (see box).

He says CHRISTUS MUGUERZA is benefitting from the perspectives that women bring, particularly since women generally are the health care decision-makers in families.

Luz del Carmen Muñoz Hernández is a CHRISTUS MUGUERZA integration and innovation manager who graduated from the diploma program in December. She says women generally tend to excel in crisis management and are adaptable to change — valuable attributes Muñoz Hernández given the uncertainty and ambiguity involved in leading health care organizations now.

Elvira Carvajal Sánchez

Better together In interviews conducted by email with responses translated from Spanish to English, participants spoke about the impact of the leadership training on their career goals.

Since graduating from the course in 2019, Elvira Carvajal Sánchez has advanced from operations manager to hospital administrator for CHRISTUS MUGUERZA Hospital San Nicolás, the top position at that facility. She says taking part in the leadership program “strengthened my push to determine how to keep moving forward, making decisions that keep me active professionally, but ensuring the desired emotional balance.”

Maria Patricia Acosta Mariño, who was in the first group of participants, says the women she met in her cohort stay in touch and support one another in their careers.

She is the system’s manager of biomedical engineering.

Maria Teresa Arana Cavazos, a strategic project manager at the system, says she has formed personal and professional bonds with Acosta Mariño Acosta Mariño and others in that first class of leadership trainees. She says the time she shared with the women enabled them to establish relationships that remain important today. Arana Cavazos has advanced from human resources manager at the hospital level to strategic project manager at the system.

Introspection Claudia Krowicki says her participation in the course last year — she graduated in December — taught her to analyze her feelings, get to know herself better, and see herself in a new way.

“It helps you grow by expanding your vision, observing and watching yourself from new Krowicki points of view.” She is the digital transformation manager with the CHRISTUS MUGUERZA corporate office.

Patricia Addarith Magaña Lozano, director of nursing schools for CHRISTUS MUGUERZA-UDEM, says she graduated from the program in 2018 with a better understanding of the value she brings to the nursing school team and the company.

“This encouraged me to continue advancing my self-confidence, in truly believing in everything I do.”

Sandra Ceniceros Guillén, who leads at CHRISTUS MUGUERZA Hospital Conchita, says the self-reflection component of the training enabled her to recognize that “we all have our inner fears that often don’t help — (they) just paralyze us.”

Sandra García Ortíz is a nursing manager at CHRISTUS MUGUERZA Hospital Reynosa. She says the Ceniceros Guillén close relationships she built with her program peers dispelled some of her self-doubts. “I had the perception that they were better than me and that perhaps that place (in leadership) did not belong to me, and when I heard their vulnerable side, I realized that we all came with the same fear and uncertainty.

Discovering our humanity, we opened ourselves to receive from each other the teachings and learnings of life.”

Sandra Gómez Hernandez, nursing services manager at CHRISTUS MUGUERZA Hospital Alta Especialidad, says the curriculum taught her “to value myself, dedicate time to myself, know me, love me, take care of me and be well.” jminda@chausa.org