Background:  Spirituality refers to the way individuals seek and express meaning, purpose, and connectedness with the sacred or significant (1). Patients and families dealing with serious illness often experience spiritual distress or desire spiritual support. Chaplains’ roles are often misunderstood as being religious faith leaders for patients, but a more accurate description would be that of spiritual care specialists who identify and support patients with spiritual distress or unmet spiritual needs (1,2). This Fast Fact addresses the scope of clinical chaplaincy practice within an inter-disciplinary team (IDT).

Why is Spirituality a Key Component to Quality Care?  Studies have shown that many patients want their clinicians to ask them about spirituality, as many utilize spirituality to cope with health threats to their mortality (1,3). Inattention to spiritual distress by clinicians has been associated with higher end-of-life costs, including more ICU deaths and less hospice utilization (4).  By addressing spiritual needs, chaplains provide a safe forum for patients and families to acknowledge their sources of spiritual distress, as well as identify ways to improve their spiritual health. A qualitative study identified the following common spiritual needs and sources of spiritual distress in patients nearing the end-of-life (5):

Spiritual Needs

• To finish business: such as forgiveness, reconciliation, or to review their lives for meaning.
• To have involvement and control: in their care plan, medical decisions, hospital or home environment.
• To maintain a positive outlook: by utilizing spiritual strengths and personal resources to keep an open mind and live in the present.

Sources of Spiritual Distress

• Fear: of death, the afterlife, separation from loved ones, pain and suffering, and not leaving a legacy.
• Losses or grief:  such as a loss of independence, mobility, life, control.
• Other negative emotions: despair, anger, frustration, helplessness

Who are Chaplains?  Board Certified Chaplains (BCC) complete graduate-level theological training and at least 1600 hours of supervised clinical training called “clinical pastoral education.”   Subsequently, they appear before a national committee for approval, and participate in continuing education to maintain certification.  No matter what their own faith tradition may be, BCCs are interfaith, meaning they are trained to assist patients and families of any faith as well as those of no faith or those unsure of their faith. 

How Can Unmet Spiritual Needs Be Identified?  As spiritual care generalists, nurses, social workers, physicians, and other IDT clinicians have the responsibility to screen for spiritual distress and spiritual needs as part of the consultation or history and physical process (see Fast Facts #19 and 274) (7). This includes listening for phrases which may indicate a need for spiritual support such as: “Why is this happening to me?”, “What God would allow this?”, “I still have things to do in my life!” or “I’ve lost touch with my faith leader since I’ve been in the hospital.” Alternatively, when pain or other physical symptoms are refractory, clinicians should consider whether spiritual or existential distress may be present.  Clinicians should refer to a chaplain if unmet spiritual needs and/or spiritual distress are suspected.

What Do Chaplains Do?  Chaplains serve as the spiritual care specialists on an IDT. They perform an independent assessment of the patient and family’s spiritual needs, as well as cultural and religious factors which may be influencing medical decision-making.  They utilize their training to design an individualized spiritual care plan. Interventions may include reflective listening, prayer, empathetic support, contacting the faith community, performing a life review, and assisting patients in integrating their spiritual beliefs with their new medical reality (6).​

How Can Chaplains be Effectively Utilized?  There is no “one-size-fits-all” approach to utilizing chaplaincy.  Ideally, a hospice or palliative care program would have a chaplain integrated into their IDT, but many must rely upon unit-based chaplains.  Examples of potential approaches include:

• Routinely informing patients and families of the availability of chaplains.
• Involving chaplains in the discussion of patients during IDT meetings.  Chaplains add a spiritual lens which helps IDTs with identifying patients with spiritual or existential sources of suffering.
• Incorporating chaplains into usual IDT care practices by performing bedside rounds with the chaplain. By doing so, the IDT can address spiritual issues in real time and demonstrate spiritual care priorities to patients and families. Chaplains can also role-model and educate best spiritual care practices to IDT members or trainees.
• Involving chaplains when cultural or religious beliefs are cited as reasons for disagreement with medical recommendations, as chaplains may be able to function as cultural/religious translators. 
• Including chaplains in goals-of-care discussions.  Often, non-medical factors influence patient or surrogate decision-making.  Chaplains listen for spiritual or religious coping influences during goals-of-care meetings and offer a unique, real-time perspective.

References

1. Puchalski C, Ferrell B, Virani R, et al. Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference. Journal of Palliative Care. 2009;12(10):885-904
2. Handzo G, Koenig H. Spiritual Care: Whose Job Is It Anyway? Southern Medical Journal. 2004;97(12):1242-1244.
3. Otis-Green S, Ferrell B, Borneman T, Puchalski C, Uman G, Garcia A. Integrating Spiritual Care within Palliative Care: An Overview of Nine Demonstration Projects. Journal of Palliative Medicine. 2012; 15(2):154-162
4. Baloboni T, Balboni M, Paulk ME, et al. Support of cancer patient’s spiritual needs and associations with medical care costs at the end of life. Cancer. 2011;117(23):5383-5391.
5. Edwards A, Pang N, Shiu V, Chan C. The understanding of spirituality and the potential role of spiritual care in the end-of-life and palliative care: a meta-study of qualitative research. Palliative Medicine. 2010; 24(8):753-770.
6. Jeuland J, Fitchett G, Schulman-Green D, Kapo J. Chaplains working in palliative care: who they are and what they do.J Palliat Med. 2017 May;20(5):502-508
7. Balboni TA, Fitchett G, Handzo G, Johnson KS, Koenig H, Pargament K, Puchalski C, Sinclair S, Taylor EJ, Steinhauser KE. State of the science of spirituality and palliative care research PART II: screening, assessment, and anterventions.J Pain Symptom Manage. 2017 Jul 19.

Conflicts of Interest:  None

Author Affiliations:  Medical College of Wisconsin

Version History:  Originally edited by Sean Marks MD; first electronically published in December 2017.