This document discusses spiritual assessment in palliative care according to clinical guidelines. It begins by noting that while spirituality cannot be measured, it must still be assessed according to standards. The document then outlines the preferred practice of developing a plan based on a structured spiritual assessment and integrating it into the overall palliative care plan. It provides details on screening for spiritual distress, using a proven assessment instrument called FICA, and documenting the assessment. The assessment addresses faith, importance of spirituality, community, and plans for spiritual care. The assessment is then integrated into the holistic palliative care plan developed by an interdisciplinary team.

1. Meeting Consensus Guidelines
for Palliative Chaplaincy –
Spiritual Assessment
Spirituality cannot be measured. That is why you can buy dozens
of books on “spiritual assessment in health care” and read
hundreds of articles on assessment. One meta-study intended to
”identify psychometrically sound measures of outcomes in end-of-
life care” screened 261 instruments and tested the best 91.[i]
Yet spirituality must be assessed. The current clinical guidelines[ii]
from the National Consensus Project on Quality Palliative Care set
forth this standard for spiritual assessment.
PREFERRED PRACTICE 20
Develop and document a plan based on assessment of religious, spiritual,
and existential concerns using a structured instrument and integrate the
information obtained from the assessment into the palliative care plan.
Develop a Plan
Reading the patient comes first. I notice and notate both facts and impressions. Generally, you
have to know where someone is in order to relate well with them. Specifically, palliative care
operates largely in emotion.
Screen for Spiritual Distress
Throughout the interview, I am screening for spiritual distress. The most empirically proven
approach comes from the National Comprehensive Cancer Network. Over 10 years, vetting by
many chaplains has recognized three kinds of spiritual distress:[iii] isolation, hopelessness, and
ritual need. I find this definition both clinically and theologically accurate.
Isolation. One might think that life-threatening disease would produce above all fear of death.
Cicely Saunders stated that what people in the end of life fear most is isolation. Next come pain
and death. Anything scarier than pain and death must be severe.

2. Hopelessness. The Gate of Hell in Dante’s Inferno commands “Abandon hope, all ye who enter
here.” It comes - by its theological synonym despair - when I am so far down I believe not even
God can help me. To be hopeless is to be already in Hell.
Ritual Need. A well-known formal example is a Roman Catholic who may believe that
receiving the Sacrament of the Sick will ensure dying in a state of grace. A less-recognized
informal example is an Evangelical who believes that a dying loved one must say the Sinner’s
Prayer - accepting Jesus as personal Lord and Savior – to ensure going to Heaven. The formal
and informal needs may be equally intense.
Assess with a Proven Instrument.
Many good ones are available. I adopt one despite its acronym, FICA - which sounds like a tax,
credit report or spy court - because it comes from the National Consensus people who defined
“spirituality” and crafted the preferred practices. My FICA flow often works like this.
Faith, Beliefs and Meaning. Hear Heritage.
Everyone has childhood memories, and most folks find it easy and pleasant to relate early
memories of church or other religious experience. This both opens intimacy and reveals
something important. I now echo the question to find emotional memory.[iv] This can prove
important later because people dying may revert to their roots.[v]
Importance and Involvement. Assess Now.
Childhood memories lead naturally to present condition. People, their story begun, often enjoy
telling how they got to where they are now. Any existential concerns may arise here. The story
itself may take shape as a spiritual pilgrimage to a known holy place or as wandering in the
desert without any destination yet known.
Community. Seek Support.
I then inquire about community. Patients find it easy to name their church and pastor (or
equivalent). Do they know you are in the hospital? If not, would you like them notified?[vi]
The community may be informal, or offer no way to engage.[vii]
Address/Action in Care. Plan Care.
The Electronic Medical Record System in use, EPIC, lists six spiritual interventions.[viii] They
usually integrate easily with the medical and social portions of the plan of care.
Document the Spiritual Assessment.
I created a “SmartPhrase” in our electronic medical record system (EPIC) to document each
spiritual assessment:
Palliative Medicine Team Note
Spiritual Assessment:

3. Screen for spiritual distress
Hear heritage of and changes from childhood faith (cognitive and emotional)
Identify faith and religious community/leader (if any)
Assess spiritual condition
Provide spiritual portion of IDT care plan
Frederick Poorbaugh, M.Div., BCCC, BCPC, CACPF, CPF
Board Certified Clinical Fellow in Hospice and Palliative Care
The clinical note may include detail to help other clinicians understand the Patient:
Palliative Medicine Team Note
Patient lies unconscious on vent, eyes open but not seeming to focus. The daughter is present. She says
her mother is very religious. In the room are two bottles of Holy Water from Lebanon, two rosaries, and
two small Greek Orthodox icons. Patient enjoys having Coptic priest pray with her. Chaplain introduces
the Thou Verses, which the daughter says she will keep and read aloud. Daughter says patient is making
her way back from a stroke several months ago, and may be taken off vent tomorrow.
Daughter feels hopeful, she assists with Spiritual Assessment:
Screen for spiritual distress –
No signs of Isolation or Despair, may feel need for Ritual
Hear heritage of childhood faith (cognitive and emotional)
Patient is lifelong Roman Catholic from Lebanon, happy in childhood faith
Identify faith and religious community/leader (if any) –
Worships now with daughter and family in a Greek Orthodox Church Led by a Priest
Assess spiritual condition
Not possible, but seems attentive to Thou Verses[ix
Provide spiritual portion of IDT care plan.
Encourage visitation and support from home church.
Help family begin to prepare for possible disappointed hopes
Chaplain senses that both medical and emotional dimensions may be volatile, but are stable for now.
Integrate the spiritual assessment into the palliative care plan
The Palliative Care Medicine Team on which I serve operates under the Department of
Medicine. It includes five palliative care specialists (MD, DO, NP, LCSW, and MDiv) who
collaborate in framing the holistic palliative care plan. Four of us are Board Certified in
Palliative Care. The medical, social and spiritual components usually mesh well. In
implementing the care plan, we often ask other team members to address issues within their
scope of practice, as such issues arise.
We are learning. The more we learn, the more we realize how much remains unknown.[x]
Questions:
1. What have you found helpful in treating isolation or hopelessness?
2. What ritual needs have you encountered? What has satisfied them?
3. What distinctives are you finding in palliative chaplaincy?
Footnotes

4. [i] Richard Mularski et. Al., “A Systematic Review of Measures of End-of-Life Care and Its Outcomes” in Health Serv
Res. 2007 Oct; 42(5): 1848–1870.
[ii] National Consensus Project for Quality Palliative Care, “Clinical Practice Guidelines for Quality Palliative Care
3rd
edition 2013,” cited at http://www.nationalconsensusproject.org/Guidelines Assessment is the first of four
“Preferred Practices” that apply to spiritual care. The others are: 21-serve everyone, 22-have chaplain certified in
palliative care, and 23-build partnerships in the community. The full text is at the URL cited.
[iii] Identified in the National Comprehensive Cancer Network Compendium and Guidelines, updated January 6,
2012. These Guidelines have been vetted and revised for over 10 years, so provide solid evidence-based
standards. http://www.nccn.org/about/news/ebulletin/ebulletindetail.aspx?ebulletinid=154
[iv] Stern, Theodore A., MD and Sekeres, Michael A. MD, MS, Facing Cancer: A Complete Guide for People with
Cancer, their Families, and their Caregivers, McGraw-Hill, 2004
Ned Cassem (a Professor of Psychiatry at Harvard Medical School and a Jesuit priest)…has advocated asking about
the details of cognitive childhood memories (e.g., service attendance, daily prayer, home rituals, holidays, and
community activities). Then, inquiries about the emotional memories with which these events are associated (e.g.,
joy, expectation, tedium, guilt, dread, warmth, isolation, mystery, anger, resentment, confusion and disbelief)
should follow. (270)
[v] An extreme, but not rare, example is the soldier dying on the battlefield who cries out for his mother.
[vi] The Chaplain supplements the pastor, priest, rabbi or whomever the patient trusts for long-term spiritual care.
[vii] One person named the spiritual fellowship of an esoteric group who could be notified by “aural emanations.”
[viii] Supportive Pastoral Conversation, Theological Discussion, Prayer, Scripture, Ritual, Contact Outside Resource.
[ix] To minister to an unconscious patient, whom we always assume can hear, the chaplain or – better – a family
member may read aloud verses from the Psalms that directly address God and may help frame the thoughts and
feelings of the Patient. I use a collection I call the Thou Verses which address God directly as “Thou.” For example:
Mine eyes are ever toward the Lord;
Turn Thee unto me, and have mercy upon me; for I am desolate and afflicted.
O keep my soul, and deliver me: for I put my trust in Thee…I wait on Thee.
Thy lovingkindness is ever before mine eyes.
Taken from the King James Version as possibly most familiar to older patients, the Thou Verses note that The
Psalms are respected as great poetry, and revered by Jews, Christians and Muslims as Scripture.
[x] This article has two open borders. What’s distinctive about Palliative Chaplaincy? How do you treat Spiritual
Distress? The answers to those questions belong to the vast area of my ignorance, but I’m working on them.
Frederick Poorbaugh, M.Div., earned the A.B. in Philosophy of Law from Stanford University
and the M.Div. from Yale University. Clinical training followed: four units of CPE and six years
in the Analytical Psychology of C.G. Jung. He then spent 10 years pastoring a dirt-poor rural
church, where God made him into something useful. In chaplaincy, he was among the first
board certified palliative chaplains, becoming a Clinical Fellow in Hospice and Palliative Care
in 2012 through the College of Pastoral Supervision and Psychotherapy (CPSP).
He presently holds a dual appointment in the Chaplaincy Service and the Department of
Medicine with Sentara CarePlex Hospital in Virginia, where he does advance care planning
and serves on the Palliative Care Medicine IDT.