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How to Pass Surveys with Hospice Patients Who Decline Spiritual Counselors


The Medicare Conditions of Participation (CoPs) for hospice care require hospice organizations to assess patients and their families’ spiritual needs and provide spiritual counseling if the patient chooses to accept these services.

The State Operations Manual (SOM) Interpretive Guidelines instruct surveyors to determine through an interview, clinical record review and home visits how hospice organizations address the spiritual needs and concerns of patients and their families.

Why Would a Patient Decline Spiritual Care?

While the involvement of spiritual counselors (also known as chaplains) in the care of patients is an easily identifiable way to show that spiritual care is being addressed, patients and families often decline this care.

Dr. Saul Ebema, D. Min., founder and president of Hospice Chaplaincy, a hospice chaplain resource site that offers an accredited hospice chaplain certification program, states that there are many variables as to why a chaplain may be declined, including:

  • Their clergy visits regularly
  • They are not religious or spiritual
  • They are religious or spiritual but very private and do not want a lot of visitors
  • They want to focus on family only

Suppose a hospice interdisciplinary group (IDG) member identifies that a patient or their family member has a need for spiritual counseling and the patient or family has declined this service. In that case, the IDG member can educate the family on how the chaplain can help meet their needs.

The chaplain does have the option to make a joint visit with another IDG member. However, hospices should keep in mind that it is also considered spiritual care to honor the wishes to decline this service.

“Every hospice chaplain would love to visit every patient [cared for by the IDG team] because we value personal connections,” said Dr. Ebema. “But medical ethics respects autonomy. So spiritual care in this sense may mean honoring their wishes.”

Documenting Refusal of Spiritual Care to Meet Compliance

When a patient and their family decline the services of the hospice spiritual counselor, it is essential to document the reason for the declination, a task made easier with a hospice software that allows for point-of-care documentation.

In the Axxess Hospice Hospice Item Set (HIS) question on the Spiritual/Existential Assessment, there is an option to document a lack of concern in this area, as well as a request for contact with local clergy.

There is also an option to document spiritual distress and a request for spiritual counselor support.

When a patient or their family declines spiritual counseling, the admitting nurse can document this discussion in the Spiritual/Existential section of the RN Initial/Comprehensive Assessment or the RN Comprehensive Assessment. However, additional documentation will ensure the organization has the highest compliance to withstand any surveyor scrutiny.

The Spiritual Counselor’s Role After Refusal

Dr. Ebema suggests that the hospice chaplain document on at least the first IDG Summary for the patient, using a statement such as: “Meeting the patient’s spiritual needs by honoring their wishes of declining chaplain services, but the chaplain will continue to remain available as needed for spiritual support.”

Also, hospice organizations can discuss with surveyors that the SOM states that meeting needs in accordance with the patient’s and family’s wishes and desires also includes respecting the refusal of this service.

Recognizing that respecting patient autonomy is spiritual care is important in documentation to ensure compliance with the spiritual care provisions in the CoPs. This follows the widely recognized hospice maxim of meeting the patient and family where they are and allowing them to guide their personal end-of-life journey.

Axxess Hospice, a HIPAA-compliant hospice software, provides HIS assessment questions built in, along with an intuitive IDG Center that supports the needs of the IDG and their patients.

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