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PROFESSIONAL DEVELOPMENT AND RESOURCE SERIESSpiritual Care in HospiceFoundation ofThe historical roots of the hospice movement are deeplyimbedded in the soil of spiritually motivated service. InEurope, care for the dying sprang from religious faith and wascharacterized by a sense of divine calling. When hospice tookroot in the United States, volunteers and professionalscontinued to hold their work as a sacred trust. In the yearsthat followed, hospice workers were challenged to be inclusiveand to remove cultural barriers to access to hospice care. Forspiritual care this meant practicing unconditional regard forall beliefs, values and ways of giving meaning. The spiritualcare practitioner affirmed and facilitated the authenticspiritual traditions of diverse cultures regardless of theirdifferences from any dominant traditions.The journey of dying provokes a heightened awareness ofa persons mortality, personal relationships andcompelling spiritual issues. Dying is a profound rite ofpassage, sometimes mysterious and often filled withchanges, suffering, distress and refining realizations for allinvolved. Concerned hospice professionals, volunteers andfamily caregivers are sojourners with patients in the searchfor meaning, comfort, strength and hope. Practiced withreverence and compassion, in relationships of trust andmutuality, hospice care remains always essentially sacredand spiritual in nature.Hospice brings to the end-of-life journey a holistic philosophyand practice intended to help patients and familiesaccomplish with dignity the outcomes of self-determined lifeclosure, safe and comfortable dying and effective grieving.Hospice attends to the spiritual dimensions of the end-of-lifejourney in facilitating these outcomes. Specifically, thesedimensions involve the universal longing for meaning in lifethat manifests in ones interests, relationships, values,beliefs, traditions and rituals. Spiritual care in hospicesupports the exercise of each persons unique spirituality,with the hope that meaning and love may be found in thepresence of suffering and death.Guidelines for Spiritual Care in Hospice Copyright 2009. National Hospice and Palliative Care Organization. All Rights Reserved.Table of ContentsIntroduction 1Principles of Spiritual Care 3Palliative Care 4Interdisciplinary Team Spiritual Care 5The Care of the Spiritual Counselor 6Availability and Scope of Practice 7Spiritual Care Assessment and Plan of Care 9Team Collaboration 11Volunteers 12Documentation 13Confidentiality 15Diversity and Access to Care 16Advocacy 17Ethics 18Religious and Spiritual Community Relations 19Bereavement 20Policies 21Qualifications 22Competencies 23Compensation 25Supervision 26Productivity 27Performance Improvement 29Research and Education 30National and State Organization Affiliation 31Additional Resources 31Acknowledgements 32I N T R O D U C T I O Nhis marks the Second Edition of the Guidelines the first having been published in2002. With all the changes facing hospice in 2008, it was felt that it was time torevisit this document so that it can continue to inform the field. It has benefitedfrom the insights, thoughts and prayers of innumerable people. In some ways theseGuidelines arise out of everyone who has taken an interest in the Spiritual CaregiverSection of the National Council of Hospice and Palliative Professionals. There hasbeen much listening and much concentration and consolidation of what washeard. We hope that what results in the document is an inspiration to thecontinuing improvement of spiritual care in hospice.It is also important to acknowledge the direct impact regulations, such as the newConditions of Participation, have on the re-visioning of this document. They have, ina sense, offered our discipline a compelling challenge. The Centers for Medicare andMedicaid Services (CMS) has made it clear that spiritual care and the spiritual needs ofpatients and families are core elements to the provision of the Hospice Medicare Benefit.At the same time they have proposed a wide interpretive field as to the form andpractice of that care. This means that hospice programs have a broad range of optionsregarding how they facilitate the spiritual care requirements of the new Conditions ofParticipation. Our hope is that this document can serve as what we might consider the“Gold Standard” level of practice for the discipline of spiritual care.Guidelines for Spiritual Care in HospiceNHPCO PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES1T Copyright 2009. National Hospice and Palliative Care Organization. All Rights Reserved.2Here are some of the important points about the plan, structure and content of the Guidelines:_ These Guidelines are not regulations or standards, but they are built upon the NHPCO Standardsof Practice for Hospice Programs (/quality), as well as the revised Conditions ofParticipation, 42 CFR Part 418 Medicare and Medicaid Programs: Hospice Conditions of Participation;Final Rule, June 5, 2008, mandated by the Centers for Medicare and Medicaid Services (CMS).Where appropriate, these regulations are listed alongside each Guideline._ The Guidelines are based on principles, which reflect the philosophical perspective of spiritualcare in hospice and account for both the structure and content of the Guidelines._ The Guidelines are divided into two parts. Some are addressed to the interdisciplinary teamin general, including the spiritual caregiver. Other guidelines are specifically addressed to thespiritual caregiver._ For clarity, the terms “chaplain” and “hospice chaplain” were employed throughout the FirstEdition of the guidelines to reference the professional spiritual caregiver working in hospice andpalliative care programs without reference to specific faith tradition or denomination. For theSecond Edition we would like to note that the revised Conditions of Participation for 2008 utilizethe terms “pastoral,” “spiritual” and “other” to define the practice of spiritual care in hospice,as well as the provider of that care. The term “chaplain” is not present.In this revised edition the terms “spiritual” and “spiritual counselor” are used throughout. This termis inclusive of the other terms, such as “pastoral,” “clergy,” as well as “chaplain.” This conventionreflects the language and changes in the Conditions of Participation, as well as other recent changesin sources such as the Joint Commission.Hospice spiritual counselors are challenged, both individually and collectively, to live up to the decidedlyspiritual nature of hospice. That is, each of us comes from and practices within our own faith-tradition.Yet in hospices, the “spiritual” is diverse. Each spiritual counselor practices one faith, yet we serve manywhose practices differ. Participation in this tension is essential to spiritual care in hospice.It is essential for us to remember what it means for us to leave this place in a state of wholeness. To be seenand witnessed for all that we were and still are, even within our death. Our spiritual life is part of the commonhuman experience and so is elemental to the work of hospice. We are a partner in this discovery, and so westrive to bring to this important transition the best we can bring. These Guidelines fashion an aspiration topreserve the hospice value of caring holistically for another for the whole is greater than the parts.PRINCI P L E S OF S P IRITUAL CARE_ At the heart of spirituality is the universal human capacity for transcendence, that is, theawareness that we humans, individually and collectively, participate in a spiritual realitygreater than ourselves._ As for the relationship between spirituality and religion: The relationship is of the whole to thepart; religion is spiritual but not all spirituality is religious. They are not synonymous terms. Spirituality,the larger reality, may be expressed explicitly or tacitly in traditional religio-cultural terms,in non-traditional religious terms and/or in humanistic terms. Thus spiritual care considerationsare appropriate even when patients and families identify little or no interest in religion._ As for the spiritual care relationships on the hospice interdisciplinary team: Spiritual care attendsto fundamental issues of existentially transcendent awareness, relatedness, meaning, purpose andwholeness. The spiritual perspective may come, as it often does, from any person on the team.However, the spiritual care professional brings a particular focus to the spiritual care of the team.This focus is informed by knowledge of the role of religion in human development. Spiritualformation in the early developmental years of the vast majority of patients and families was informedby religion. Positively or negatively, religion will always be a reality to be reckoned with in any settingsuch as hospice where spirituality is taken seriously in the care and treatment of patients and families.In other words, it is the hospice spiritual counselor who brings to the team expertise regarding spiritualityand the impact of religion, its meanings, rituals and symbols upon individuals, families andcommunities. This unique expertise is essential in addressing the sensitive and subtle significanceinvolved, often covertly, as the spiritual becomes manifestly present at the end of life._ As for the relationship between psychosocial and religious aspects of care: the language ofthe social sciences and that of spiritual and religious experience carry different meanings.They are on a continuum, yet are distinct and require separate but integrated assessments.Neither clinical practice is subsumed under the heading of the other. Indeed, both physicaland religious lenses are necessary to bring into complete focus hospice care._ In hospice, spiritual care accepts, affirms and respects authentically expressed diverse beliefsystems and spiritual practices. This principle applies to both the hospice staff involved andthe “primary unit of care,” the patient and family._ In hospice, the needs and goals of the patient and family are central to the planning andprovision of spiritual care.Guidelines for Spiritual Care in HospiceNHPCO PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES3 Copyright 2009. National Hospice and Palliative Care Organization. All Rights Reserved.4PAL L IATIVE CAREAs the presence of palliative care programs continues to flourish, it seems prudent to speak to the role of spiritualcare within this growing practice. This is especially true given the reality that many palliative programs havebegun to utilize spiritual counselors as core members of those teams. The very nature of palliative care is to beable to address the impact of illness and death on all aspects of a persons comfort and quality of life. So, whatwe speak to in the confines of this document could easily apply tothe palliative care practice.Although palliative care teams are not guided by the sameMedicare Conditions of Participations as hospice programs, theyare still prone to regulatory standards of care and quality initiatives.Palliative care programs should use the National ConsensusProjects Clinical Practice Guidelines for Quality Palliative Care as aresource. A copy of the guidelines can be downloaded or purchased from the NHPCOMarketplace. Palliative care programs around the country are acknowledgingthe vital role spiritual care plays as teams explore the profound questions that arise as one facesserious illness. The voice of spiritual care adds balance to the team of physician, nurse and social worker, so thatdynamic care can be achieved.Often the practice of the spiritual counselor within palliative care is one of collaboration and true interdisciplinaryteam work. This serves as an excellent model as to how the various disciplines can work cohesively to share anunderstanding of the work as well as how to develop a common language of practice that each member can utilize.INTERDI SCI P L INARY TEAM S P IRITUAL CAREBecause spirituality affects and is affected by the totality ofhuman experience, effective spiritual care in hospice is ashared responsibility and concerns all of the variousdisciplines. In respect to the breadth and diversity ofhuman experience, hospice care celebrates the diversity ofpeople and disciplines that bring it to be.Guidelines:_ Provision of spiritual care requires working relationshipsof collaboration and mutual respect betweenspiritual counselor and those in other disciplines.Within the shared, spiritual, responsibility ofhospice care, these relationships foster the spiritualcounselors affirmation of other team members contributionsto spiritual care, and team membersreceptivity to training and guidance from thespiritual counselor in spiritual care._ Trained hospice team members may initiate assessments and interventions based on thepatients and familys stated spiritual issues and affirmed by the interdisciplinary team. Theteam members quality of presence as a provider of discipline-specific care is foundationalto effective spiritual care.Guidelines for Spiritual Care in HospiceNHPCO PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES5 Copyright 2009. National Hospice and Palliative Care Organization. All Rights Reserved.6THE CARE OF THE S P IRITUAL COUNS E LORThe hospice spiritual counselor is an integral member of the hospice team. Hospice spiritual counselors areencouraged to be thoroughly educated and specifically trained in the practice of clinical spiritual care. While allmembers of the hospice team touch the spiritual lives of patients, the spiritual counselor is that team memberwhose professional expertise is spiritual care. The spiritual counselors distinct education, training, skills, certificationand sense of calling characterize the spiritual care professional. When patients and families require professionalspiritual counsel and care, the team turns to its spiritual counselor(s).Guidelines:_ The spiritual counselor leads the creation of a spiritual plan of care based upon an assessment ofpatient/family needs with input from the interdisciplinary team._ The spiritual counselor provides guidance to the team regarding spiritual assessment, observation andexpressed needs of the patient and family._ Spiritual counselors conduct the new hire orientation and ongoing in-services for staff of all disciplinesregarding interdisciplinary spiritual care assessment, intervention, documentation and the role of thespiritual counselor in the team._ The spiritual counselor consults with team members when community clergy are directly involved withthe patient and family._ The spiritual counselor consults with, and serves as a resource to, community clergy directly involved withthe patient and family.AVAI LABI L ITY AND SCOP E OF PRACTICEThe 2008 Hospice Conditions of Participation include spiritualcounseling as a core element to the interdisciplinary team.Spiritual care has been designated clearly in these updatedregulations and adds clarity to the description for spiritualcounseling that first appeared in the 1983 hospice Conditionsof Participation. Of particular interest is the fact that the“spiritual needs” of patients and families has been highlightedas a key element to be tracked by the hospice program. This isa significant step in acknowledging the role of spirituality andthe position it plays in end-of-life experiences.As stated earlier, the language around this requirement issomewhat vague and so by result is the scope of practice. Thisdocument maps out what we see as the basic points regardingavailability and scope of practice that aids in “filling in” thesegaps where the language is unclear. Please refer to the resource document below for furtherexploration of this issue.The spiritual counselor is an integral part of the interdisciplinary hospice team. Standards requirethat hospice patients and families are made aware of the spiritual counselors availability and areable to access this resource at any appropriate time during their care. CMS has also indicated thatthere is to be coordination from the team regarding outside clergy and to facilitate visits per patientand family requests.We encourage spiritual counselors to serve as a spiritual care manager for all patients and familymembers. In cooperation with the interdisciplinary team, spiritual counselors can determine theneeds of patients and families on a continuing basis as well as maintain a collaborative network ofoutside faith community support.Guidelines for Spiritual Care in HospiceNHPCO PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES7 Copyright 2009. National Hospice and Palliative Care Organization. All Rights Reserved.8Resources:_ NHPCO document: Medicare Hospice CoPs by Discipline Spiritual CareGuidelines:_ The services of a qualified spiritual counselor are accessible to patients and families as needed andrequested on a 24-hour, seven day a week basis._ Spiritual counselors honor the distinctions between spiritual care in congregational ministry and ministryin a specialized setting._ The spiritual counselor refers individuals in need of long term, in-depth counseling to credentialedcounseling professionals._ The spiritual counselor, as spiritual care case manager, is responsible for coordinating the spiritual andreligious care of all patients and families receiving hospice care.Conditions of Participation:418.56 Interdisciplinary group, care planning, and coordin