As part of the admission process for a hospice patient, the admission team will ask the patient about their spiritual orientation and/or religion. Because there is so much information and education to convey at the admission, the discussion of a patient’s spiritually may only be minimally discussed. It is important for the hospice team to be aware of a patient’s spiritual orientation because it can affect their choices regarding treatment decisions, for example their willingness to accept signing a do-not-attempt-resuscitation (DNR) form.

Patients who define themselves as atheists, agnostic or a non-believer are often definitive in their refusal of spiritual care and we should respect the patient’s beliefs (or non-belief as the case may be.) For these patients and families, I believe it is the social worker’s responsibility to advocate for the patient and ensure the team respects the patient’s preference to decline spiritual care or conversation.

Other patients decline a visit from the hospice chaplain because of preconceived notions about the hospice chaplain or the support they provide. To provide the best care possible to the patient and family, the social worker needs to feel comfortable and competent to delve further into the discussion of patient spirituality and their reason for refusing the chaplain.

(Please note: Some hospices use the title “chaplain,” others may have a more generalized title such as “Spiritual Care Coordinator.”  For simplicity in this article, I’ll continue to use the title hospice chaplain.)

Common reasons a chaplain is declined

1. The patient has an existing long-term relationship with their church, mosque, synagogue or other group. They often believe their spiritual leader knows them and will be a supportive presence during their end-of-life journey.

2. The patient is concerned the hospice chaplain has a spiritual orientation different from their own and will proselytize a conflicting belief system.

3. The patient believes chaplains are supposed to be called in only at the very end. Inviting the chaplain in to their lives may represent “giving up.”

4. A well-meaning family member may speak on behalf of the patient, which may or may not represent the patient’s own view.

5. The patient or family is overwhelmed by the number of new people in their home, and initially refuses all non-medical services.

Tips for spiritual assessment by the social worker

1. Re-assess spiritual needs with the patient if their refusal was due to their own church involvement. Sometimes patients expect they will receive more support than they do. Check in occasionally with patients and families regarding their church support. I started doing this after I had a family member tell me they were not receiving the support believed they would have. They had refused chaplain originally but then requested a visit.

2. Inform patients with a strong spiritual/religious orientation that the hospice chaplain is not meant to replace their church support but complement it.

3. Assess potential compatibility of hospice chaplain and patient. Most hospice chaplains should be flexible and let the patient lead the discussion. Assure the patient the chaplain is there to help the patient process their own beliefs and won’t be pushing a spiritual agenda.  (Note: only say this if you know that your chaplain doesn’t proselytize!)

4. Differentiate between the spiritual beliefs of the patient and the family member. It is not uncommon for family members to have a different belief system than their loved ones. Frequently, adult children are less religious than their parents. Ensure the family member is truly speaking for the patient if they refuse chaplain rather than making the decision based on their own personal beliefs.

5. Offer support to the family. Sometimes a patient will be less spiritual than their family members. The hospice model promotes supporting the entire patient/family system. If the patient refuses chaplain but you sense the family would like to hear from the chaplain, let them know that the hospice chaplain is there for them as well.

6. Don’t forget the atheist, agnostic or non-believer. Without the chaplain, it is up to the social worker to provide the emotional support. Atheists may present as logical and task-oriented, but there can still be deep underlying emotions surrounding the dying process. Some may have prior traumatic experiences which have led them to avoid religious or spiritual support. It is important to create a safe place for them to feel comfortable with sharing.

7. Keep our own spiritual views in check. Patients feel more comfortable sharing their spiritual orientation if they don’t feel they are contradicting us.

8. Listen! Perhaps stating the obvious here, but some of my best insights into the patient have come from undirected open conversations. Assessment questions have their purpose, but remember to allow for free-flow thought too.

Lizzy Miles is a social worker who blogs at Pallimed.