Atlas›Domain XV · Nature, philosophy, social & rites of passage›Guide 115
Guide XV-115

Hospice spiritual care

Cicely Saunders1967London
A 41 · L 44 · M 1520 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: hospice and healthcare chaplaincy as NHS England's NHS Chaplaincy: guidelines for NHS managers on pastoral, spiritual and religious care (August 2023) sets it out (these guidelines say hospice chaplains are expected to follow them). Alongside it: the FICA Spiritual History Tool as the George Washington University Institute for Spirituality and Health (GWish) publishes it; Cicely Saunders' concept of "total pain" as the Cicely Saunders Institute (King's College London) describes it; dignity therapy in the outline given by Hall, Chochinov and colleagues' 2009 trial protocol; and Meaning-Centered Psychotherapy (MCP) as Memorial Sloan Kettering (MSK) describes its training programme. The UK Board of Healthcare Chaplaincy (UKBHC) publishes Standards for Spiritual Care Services (2020) and Spiritual Care Competences for Healthcare Chaplains (2020) [source: UKBHC, Standards & Competencies]; they are named here, not summarised. US chaplaincy certification standards (Association of Professional Chaplains, Board of Chaplaincy Certification) are named but their detailed content is [uncertain: not verified].

Hospice spiritual care is not a psychotherapy. It is a service: "pastoral, spiritual and/or religious care and support" offered to patients, families, carers and staff of all religions and beliefs, including none, delivered mainly by chaplains as members of the multidisciplinary team (MDT) [source: NHS England 2023]. Its roots lie in the modern hospice movement that Dame Cicely Saunders founded with St Christopher's Hospice, London (opened 1967). Her idea of "total pain" holds that suffering goes beyond the body to include psychological, social, spiritual and practical struggles [source: Cicely Saunders Institute]. Change, in this tradition's own account, happens through being listened to and accompanied: an "empathetic and reflexive" presence that hears the person's own story and respects what matters to them, access to the rites and communities that carry meaning for them, and the chance to find or affirm meaning, dignity and connection near the end of life [source: NHS England 2023; Cicely Saunders Institute; MSK MCP brochure]. These are the tradition's own claims, attributed, not established mechanisms.

What the psychotherapist does with it: (a) works alongside the hospice chaplain as a fellow MDT member, referring both ways; (b) takes a spiritual history and includes spiritual and existential distress in the formulation; (c) where trained, delivers structured existential interventions used in palliative care (dignity therapy, MCP); (d) supports a client's own religious, cultural or secular practices around dying and mourning, including disrupted rites; (e) assesses and treats grief in the bereaved, including prolonged grief disorder; (f) supports staff. Cross-refer IX 069 (palliative care and hospice), VI 128 (grief counselling), II 127 (prolonged grief treatment), XV 112 (mourning rites) and XV 113 (ancestor rites) [synthesis].

2. Framework

The sources describe a service pathway rather than a phased therapy. The stages below follow the NHS England 2023 guidelines; the therapist-side goals and moving criteria are [synthesis].

Stage 1. Introduction and referral. Chaplaincy can be introduced at admission, when booking surgery, or after bad news is given; patients, families, carers and staff can self-refer; clinical staff should be trained to introduce the service and refer, and consent should be noted in the referral record [source: NHS England 2023]. Therapist goal: make sure the client knows the service exists and that it is for people of every belief or none. Move on when the client has agreed (or declined) and the referral and consent are recorded.

Stage 2. Spiritual history and assessment. The NHS guidelines do not set out an assessment process [source: NHS England 2023]. GWish recommends taking a FICA spiritual history early in the relationship and repeating it at follow-up where appropriate, especially in acute, chronic and end-of-life illness [source: GWish FICA]. Therapist goal: know what gives the client meaning, purpose and hope, how belief bears on care decisions, who their community is, and what they want done. Move on when spiritual needs and preferences are in the care plan.

Stage 3. Ongoing care within the MDT. Chaplains are part of the MDT for the dying person's individual care plan; people may be supported to practise their religion or belief, observe festivals and, where feasible, hold ceremonies in the care setting; some may want a chaplain of their own religion, belief or gender [source: NHS England 2023]. Structured existential interventions sit here: dignity therapy is brief and can be done at the bedside [source: Hall et al. 2009]; MCP is a manualised 7 or 8 session intervention, individual or group [source: MSK MCP brochure]. Move on as the person's condition changes; existential work is paced to energy and prognosis [synthesis].

Stage 4. Dying and death. Staff must learn the person's cultural or religious requirements, including respectful treatment of the body after death; chaplains perform or facilitate rituals for death with appropriate authorisation, and services should allow these to be led by someone who shares the person's faith or belief [source: NHS England 2023].

Stage 5. After death: funeral, memorial and bereavement. Chaplains support families before bereavement and often play a significant role in bereavement care; they help with funeral plans, with funerals the organisation arranges when no family can, and with memorial services [source: NHS England 2023]. The psychotherapist's grief assessment, including prolonged grief disorder, belongs here [synthesis].

Session counts: none are given for chaplaincy itself. MCP: 7 or 8 sessions [source: MSK MCP brochure]. Dignity therapy: brief, a recorded interview followed by return of an edited document [source: Hall et al. 2009]; the exact number of meetings is [uncertain: not verified].

3. Guiding principles

  • For all beliefs and none. "All religions and beliefs" includes non-religious beliefs and the absence of belief [source: NHS England 2023]. Practical meaning: never assume a religious frame; offer the same care to the atheist, the devout and the unsure.
  • The person's own story leads. An "empathetic and reflexive" approach that listens to each person's unique story [source: NHS England 2023]. Practical meaning: ask, do not tell; follow the client's language for God, fate, nature or nothing.
  • Choice, values and preferences. Chaplaincy is tied to personalised care [source: NHS England 2023]. Practical meaning: the client decides whether spiritual care happens, who gives it and what it includes.
  • Rites led by someone who shares the faith. Rituals need appropriate authorisation and should be led by someone of the person's own tradition where wanted [source: NHS England 2023]. Practical meaning: the therapist does not perform religious rites; connect the client with an authorised person.
  • Total pain. Suffering is physical, psychological, social, spiritual and practical [source: Cicely Saunders Institute]. Practical meaning: formulate distress across all five; refer physical symptoms to the palliative team and never treat them as "only spiritual".
  • Every person matters to the end. Saunders' guiding idea that people should be helped to live until they die and to die peacefully [source: Cicely Saunders Institute]. Practical meaning: keep the focus on the living person, not only on the dying.
  • Teamwork and confidentiality together. Spiritual care data come under information governance; chaplains keep clear, accurate records and need confidential space [source: NHS England 2023]. Practical meaning: agree with the client what goes in shared notes before writing it.
  • Competence and scope. Chaplains are expected to follow the UKBHC Code, receive supervision and do ongoing CPD; the UKBHC register is accredited by the Professional Standards Authority [source: NHS England 2023]. Practical meaning: a psychotherapist does not become a chaplain by asking spiritual questions; refer for religious, sacramental or ritual needs, and get training before delivering dignity therapy or MCP [synthesis].
  • Copyright and fidelity. The FICA tool is copyrighted; no excerpts, translations or adaptations without written permission [source: GWish FICA]. MCP is manualised [source: MSK MCP brochure]. Practical meaning: use the official versions and trainings; do not improvise "versions".
  • No proselytising, no dismissing. [synthesis] Practical meaning: concepts such as afterlife, karma, ancestors or the efficacy of last rites are described as the client's tradition holds them, neither affirmed as fact nor challenged.
  • Dual roles. A therapist who is also an ordained or authorised chaplain, celebrant or faith leader must keep roles distinct; see APA Ethics Code Standard 3.05 (multiple relationships) [source: APA Ethics Code]. Practical meaning: say which role you are in, and do not move from therapy into religious ministry with the same client without explicit discussion and documentation [synthesis].
  • Pacing to the body. [synthesis] Practical meaning: fatigue, delirium, pain and medication effects set the length and timing of conversations; short is often right; never advise on medicines (route to the prescriber).
  • Staff are also cared for. Chaplaincy supports staff wellbeing, including Schwartz Rounds and support after major incidents or staff deaths [source: NHS England 2023]. Practical meaning: the therapist's own and colleagues' grief is part of the work.

4. Intervention inventory

The sources describe chaplaincy activities, one assessment tool and two structured interventions; they do not supply a full therapist-side inventory. The items below combine what the sources describe with therapist procedures marked [synthesis]. Example language is illustrative throughout.

4.1 Introducing spiritual care and recording consent

  • Purpose and when: at first contact, at admission, or after bad news, so the client knows spiritual and pastoral support exists for all beliefs and none [source: NHS England 2023].
  • Steps: (1) Say briefly that the hospice offers pastoral, spiritual and religious support, including non-religious support. (2) Ask whether the client would like it now, later or not at all. (3) Ask whether they want someone of a particular religion, belief or gender [source: NHS England 2023]. (4) Record consent, or refusal, in the referral record [source: NHS England 2023]. (5) Leave the door open; offer again when circumstances change [synthesis].
  • Example language (illustrative): "Some people here find it helps to talk about meaning, faith or what matters most to them; others don't. The chaplaincy team supports people of any belief or none. Would that be useful, now or later?"
  • Watch for: a polite "no" covering past hurt from religion; family members answering for the client; assumptions from a name or appearance. Working: the client makes an informed choice and the record reflects it.

4.2 Spiritual history with the FICA tool

  • Purpose and when: early in the relationship and at follow-up when appropriate, especially in serious or end-of-life illness, to learn what gives meaning, purpose and hope and how belief bears on care [source: GWish FICA].
  • Steps: (1) Use the official GWish version (free download; copyrighted, no adaptations without permission) [source: GWish FICA]. (2) Work through its four domains in conversation, not as a checklist: Faith, belief, meaning; Importance and influence; Community; Address or action in care [source: GWish FICA]. (3) For clients without religion, keep the meaning domain broad (family, nature, work, art, values) [synthesis]. (4) Close the A domain by agreeing what, if anything, should change in care: a chaplain visit, a ritual, a conversation with family, or nothing. (5) Document with consent.
  • Example language (illustrative): "What helps you get through hard times? Is there a faith, a set of beliefs, or something else that gives your life meaning?" … "How much does that shape the choices you are making about your care?"
  • Watch for: imposing a religious frame; turning the history into a test of faith. Working: you can state in one sentence what sustains the client and what they want from the team.

4.3 Total-pain formulation

  • Purpose and when: when distress is not explained by one domain, or symptom control is not relieving suffering. Based on Saunders' view that suffering spans physical, psychological, social, spiritual and practical struggles [source: Cicely Saunders Institute].
  • Steps [synthesis]: (1) Map the client's distress under the five headings with them. (2) Note links (pain worse when alone at night; fear of being a burden feeding hopelessness). (3) Allocate actions: physical to the palliative medical and nursing team, practical (money, care of dependants, wills) to social work, spiritual to the chaplain and therapist, psychological to the therapist. (4) Bring the map to the MDT with consent. (5) Review as the illness changes.
  • Example language (illustrative): "Let's look at everything that is hurting right now: your body, your worries, your family and money, and the bigger questions. Which of these weighs most today?"
  • Watch for: psychologising unrelieved physical pain; any medication question (route to the prescriber, never advise). Working: the team acts across domains and the client feels understood as a whole person.

4.4 Recognising spiritual distress and deciding who responds

  • Purpose and when: when the client voices guilt, fear of judgement, anger at God, loss of faith, meaninglessness or worry about rites not being performed [synthesis].
  • Steps [synthesis]: (1) Reflect what you hear without arguing theology. (2) Ask what the client's tradition holds about it and whether they want to speak with someone from that tradition. (3) Refer for doctrinal, sacramental, confessional or ritual needs to the chaplain or a local faith leader (chaplains hold information about local faith leaders for this) [source: NHS England 2023]. (4) Keep the psychological work: shame, fear, guilt and conflict. (5) Where the problem centres on faith or tradition, the DSM-5-TR "Religious or Spiritual Problem" may be recorded as Z65.8 (ICD-10-CM Z65.8, "Other specified problems related to psychosocial circumstances", lists religious or spiritual problem under Includes) [source: ICD-10-CM Z65.8 (Unbound Medicine)]; DSM-5-TR wording [uncertain: not verified].
  • Example language (illustrative): "It sounds as if part of what frightens you is what comes after. Would it help to talk that through with someone from your own faith, as well as with me?"
  • Watch for: spiritual language masking depression, delirium or psychosis; religious guilt used against the client by others. Working: distress is named, the right person is involved, the client feels less alone with it.

4.5 Cultural Formulation Interview with the spirituality module

  • Purpose and when: when culture, religion or moral tradition shapes how the client understands illness, dying or care decisions [synthesis].
  • Steps: (1) Use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions, in the official version, without reproducing items [uncertain: not verified]. (2) Ask about the client's own explanations, sources of support and preferred helpers. (3) Hold cultural humility: the client teaches you the tradition as they live it. (4) Feed findings into the care plan (diet, modesty, prayer times, body care after death).
  • Example language (illustrative): "People from different backgrounds understand illness and death in different ways. How do you and your family understand what is happening?"
  • Watch for: treating a whole community as uniform; intergenerational or interfaith disagreement inside the family. Working: care plans reflect the client's actual practice.

4.6 Referral to and collaboration with the hospice chaplain or faith leader

  • Purpose and when: when the client wants religious care, ritual, sacraments, prayer, or a chaplain of their own belief or gender [source: NHS England 2023].
  • Steps: (1) Confirm the client's wish and consent; record it [source: NHS England 2023]. (2) Share only what the client agrees to. (3) Clarify roles with the chaplain: who addresses ritual and doctrine, who addresses psychological symptoms [synthesis]. (4) Discuss in the MDT, where chaplains sit [source: NHS England 2023]. (5) Accept referrals back when the chaplain sees depression, anxiety, trauma, suicidality or complicated family conflict [synthesis].
  • Example language (illustrative): "Would you like me to ask the chaplain, or someone from your own community, to visit? What would you like me to tell them, and what should stay between us?"
  • Watch for: the client feeling handed off; duplicated or conflicting messages. Working: one shared plan, and the client knows who does what.

4.7 Making room for religious practice, festivals and rites in the care setting

  • Purpose and when: so the client can practise their religion or belief, observe festivals and, where feasible, hold ceremonies (including rites for birth, marriage or death) [source: NHS England 2023].
  • Steps: (1) Ask what practices matter now (prayer, scripture, music, food rules, washing, objects, visits). (2) Liaise with the chaplain and ward or hospice staff on space, timing and privacy [synthesis]. (3) Rites with religious authority are performed or facilitated by authorised persons, ideally of the client's own tradition [source: NHS England 2023]. (4) Do not lead, script or quote liturgy yourself [synthesis]. (5) Afterwards, invite reflection if the client wants it.
  • Example language (illustrative): "Is there anything you would usually do at this time of year, or at a time like this, that we could help make possible here?"
  • Watch for: practices conflicting with infection control or safety (work with the team rather than refusing outright) [synthesis]. Working: the client reports feeling more like themselves.

4.8 Non-religious pastoral support

  • Purpose and when: for clients with no religion, who are owed equal support [source: NHS England 2023].
  • Steps [synthesis]: (1) Offer the same time and attention as for religious clients. (2) Explore values, relationships, achievements, regrets, nature, humour, music. (3) Offer non-religious chaplains or pastoral carers where the hospice has them. (4) Support secular goodbyes and memorial wishes (cross-refer secular celebrants in this domain).
  • Example language (illustrative): "You've said religion isn't part of your life. What has mattered most to you, and what do you want people to remember?"
  • Watch for: filling silence with religious comfort the client did not ask for. Working: the client engages in meaning conversations on their own terms.

4.9 Dignity therapy (where trained)

  • Purpose and when: a brief intervention, possible at the bedside, for people near the end of life, aimed at sense of dignity; developed by Harvey Max Chochinov and colleagues [source: Hall et al. 2009]. Its basis in Chochinov's empirical model of dignity is [uncertain: not verified].
  • Steps (outline only, per the published protocol): (1) The client takes part in a recorded interview about their life and what they want known or passed on. (2) The recording is transcribed. (3) The transcript is edited into a document. (4) The document is returned to the client, who can bequeath it to people they choose [source: Hall et al. 2009]. The official question framework, how it is shared in advance, the editing rules, the read-back step and the number of meetings are [uncertain: not verified]; use Chochinov's published materials and training, not an improvised version.
  • Example language (illustrative): "This is a chance to record, in your own words, the things you most want your family to know or keep. I'll record it, we'll turn it into a written document, and you'll decide who gets it."
  • Watch for: fatigue and cognitive impairment; prognosis too short to complete the document (prioritise speed); painful or harmful content about named family members (discuss with the client before including) [synthesis]; family pressure to participate. Working: the client approves the document and wants to share it.

4.10 Meaning-Centered Psychotherapy (where trained)

  • Purpose and when: for patients with cancer, especially those experiencing loss of meaning around illness; a manualised 7 or 8 session intervention, individual or group, developed at MSK and inspired primarily by Viktor Frankl's work; it aims to help patients create, reconnect with, experience and sustain meaning [source: MSK MCP brochure]. A version for cancer caregivers has its own therapist manual and workbook (Oxford University Press) [uncertain: details not verified].
  • Steps: (1) Train first: MSK runs a two-day live virtual intensive with pre-training videos and a year of follow-up, for psychosocial providers in cancer, medical and palliative care [source: MSK MCP brochure]. (2) Follow the manual session by session; sessions combine didactic teaching, experiential exercises, open-ended discussion and interpretive comments to promote emotional expression and a meaning-focused perspective [source: MSK MCP brochure]. (3) The session-by-session themes (for example Frankl's sources of meaning) are in the treatment manual; their exact content and order here are [uncertain: not verified]. (4) In hospice, check that the client's expected course allows the full sequence; if not, consider dignity therapy or flexible meaning work [synthesis].
  • Example language (illustrative): "Over the next sessions we'll look at where meaning has come from in your life, and where it can still come from now, even with everything that has changed."
  • Watch for: deterioration between sessions; group members dying during a group programme (plan for this in advance) [synthesis]. Working: the client describes reconnecting with what makes life meaningful.

4.11 Legacy and life-review conversations outside a formal protocol

  • Purpose and when: when a client wants to leave something for others but is not suited to, or cannot access, dignity therapy or MCP [synthesis].
  • Steps [synthesis]: (1) Ask what the client would want passed on and to whom. (2) Offer the client's chosen form: letters, voice notes, a recipe book, photographs with captions, a list of wishes. (3) Help with wording only as asked; the client is the author. (4) Agree who keeps it and when it is given. (5) Do not present this as dignity therapy.
  • Example language (illustrative): "If you could leave one thing in words for each of your grandchildren, what would it be?"
  • Watch for: guilt at not finishing; legacy items written under family pressure. Working: the client finishes something that feels like theirs.

4.12 Supporting families before death and anticipatory grief

  • Purpose and when: chaplains support families before bereavement [source: NHS England 2023]; the therapist helps relatives and carers with anticipatory grief, conflict and decisions [synthesis].
  • Steps [synthesis]: (1) Ask the patient's consent before talking with family about them. (2) Meet relatives with or without the patient, as agreed. (3) Name anticipatory grief as common and not a betrayal. (4) Surface differing religious or cultural expectations among relatives and help them talk. (5) Encourage saying what needs saying while there is time, without forcing reconciliation.
  • Example language (illustrative): "Many families start grieving before a death. Feeling that already doesn't mean you have given up on your mother."
  • Watch for: relatives in conflict over rites or beliefs; carers' exhaustion; a carer with their own mental-health or suicide risk. Working: the family can talk about what is coming.

4.13 Planning for death rites, body care and the funeral

  • Purpose and when: so the person's cultural or religious requirements, including respectful treatment of the body after death, are known in advance; chaplains help with funeral plans and with funerals the organisation arranges where no family can, taking the deceased's known religion or belief into account [source: NHS England 2023].
  • Steps: (1) Ask what the client wants around the time of death (who is present, prayers, music, silence, objects) [synthesis]. (2) Ask about requirements for the body and timing of burial or cremation, as the client's tradition holds them; check with the chaplain or faith leader [source: NHS England 2023]. (3) Record wishes in the care plan with consent. (4) Explore conflicts between the client's wishes and family expectations [synthesis]. (5) For clients with no family, flag early so wishes are known [source: NHS England 2023].
  • Example language (illustrative): "Some people find it a relief to say what they want for their funeral. Others would rather not. Would you like to talk about it, or leave it for now?"
  • Watch for: distress at the topic (stop and return later); legal or practical constraints on a requested rite (route to the chaplain and team). Working: wishes are recorded and the client feels more settled.

4.14 Disrupted or unfinished rites

  • Purpose and when: when rites could not happen as the client or family wished: pandemic restrictions on visiting and funerals, migration and distance from home or homeland, repatriation of the body, estrangement from a faith community, sudden death in hospital [synthesis].
  • Steps [synthesis]: (1) Ask what should have happened and what did. (2) Allow grief, anger and guilt about the gap. (3) Explore what the tradition itself permits later (a delayed memorial, a prayer on an anniversary, a visit to a grave) and consult the chaplain or faith leader. (4) Where clinicians co-design a therapeutic ritual, attribute the method and keep the client as author of the ritual. (5) Review whether the rite has been felt as complete.
  • Example language (illustrative): "You weren't able to be there, and the funeral couldn't happen the way your family would have done it at home. What feels unfinished?"
  • Watch for: shame about breaking religious obligations under constraint; the therapist inventing ritual content for a tradition. Working: the client reports some sense of completion. Cross-refer XV 112 mourning rites.

4.15 Bereavement follow-up and grief assessment

  • Purpose and when: chaplains often play a significant role in bereavement care and organise memorial services [source: NHS England 2023]; the therapist assesses the bereaved for usual grief versus prolonged grief disorder, depression, PTSD and suicide risk [synthesis].
  • Steps: (1) Ask about the death, the relationship, support, the rites that did or did not happen, and current functioning [synthesis]. (2) Prolonged grief disorder: DSM-5-TR places it in the trauma- and stressor-related disorders chapter; its core features are intense yearning or longing for the deceased and preoccupation with thoughts or memories of them (in children and adolescents, preoccupation may centre on the circumstances of the death) [source: APA DSM-5-TR fact sheet]; the reaction must exceed culturally normative expectations [source: Psychiatric News]. DSM-5-TR requires that the death occurred at least 12 months earlier for adults and at least 6 months earlier for children and adolescents [source: APA news release on prolonged grief disorder]; the ICD-11 threshold (at least 6 months) and the full accessory-symptom lists are [uncertain: not verified]; check the manuals. (3) Use a validated measure in its official version where trained; do not reproduce items [synthesis]. (4) Usual grief needs support, not treatment; refer suspected prolonged grief disorder for targeted treatment (cross-refer II 127) and grief counselling (VI 128).
  • Example language (illustrative): "How have things been since your husband died? What has helped, and what has been hardest?"
  • Watch for: pathologising grief that fits the client's own culture; missing depression or suicidal thinking. Working: the bereaved person is matched to the right level of support.

4.16 Children's grief in hospice families

  • Purpose and when: when a parent, sibling, grandparent or other close person is dying or has died [synthesis].
  • Steps [synthesis]: (1) Support parents and carers to tell children honestly in language suited to their age, avoiding euphemisms that confuse. (2) Ask what the family's beliefs say about death and help them explain these in the child's terms. (3) Offer children choices about visiting, saying goodbye and taking part in rites, with an adult beside them. (4) Watch for preoccupation with how the death happened (one of the DSM-5-TR features in children and adolescents [source: APA DSM-5-TR fact sheet]). (5) Refer to specialist child bereavement services; follow safeguarding procedures; never name the child in shared materials.
  • Example language (illustrative, to a parent): "Children often cope better when they're told the truth simply. Would it help to plan together what you'll say?"
  • Watch for: children excluded from rites against their wishes; adult tasks placed on a child. Working: the child asks questions and is included.

4.17 Desire to die, suicide risk and suicide bereavement

  • Purpose and when: when a patient expresses a wish to die or hasten death, or a relative is bereaved by suicide [synthesis].
  • Steps [synthesis]: (1) Ask directly and calmly; explore meaning (a wish for symptoms to end, fear of burden, a request for information about legal assisted dying where it exists, or active suicidal intent). (2) Assess current risk following your service's standard risk-assessment practice, and alert the palliative team; distress, pain and depression are treatable and must be reviewed by the medical team. (3) Discuss lethal-means safety in terms of storage and removal only (for example, with the nursing team for medicines kept at home), never method details. (4) For questions about legal assisted dying, follow local law and your organisation's policy; do not advise, and route to the responsible clinicians. (5) For those bereaved by suicide, follow safe-messaging principles: no method or location details, avoid framing suicide as a solution, emphasise help and recovery. (6) Give crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland).
  • Example language (illustrative): "When you say you'd like it all to be over, can you tell me more about what you mean? Are you having thoughts of ending your life?"
  • Watch for: dismissing suicidal thinking as "understandable" in the terminally ill; carers at elevated risk after the death. Working: the person is safer, symptoms are reviewed, and the bereaved are connected to support.

4.18 Staff support after deaths

  • Purpose and when: chaplaincy supports staff wellbeing, including meditation sessions and Schwartz Rounds, and support after major incidents or unexpected staff deaths [source: NHS England 2023].
  • Steps: (1) Offer or join reflective spaces the hospice already runs (e.g. Schwartz Rounds) [source: NHS England 2023]. (2) After a distressing death, offer a brief, voluntary debrief focused on support, not mandatory processing [synthesis]. (3) Signpost occupational health or employee support for staff with persistent distress [synthesis].
  • Example language (illustrative): "That was a hard death for the team. Would anyone like some time together to talk about it?"
  • Watch for: pressure to attend; one person's distress overshadowing others. Working: staff say they feel supported and able to continue.

4.19 Supervision and self-care for the therapist

  • Purpose and when: ongoing. Chaplains should receive supervision, preferably not from their line manager, and continuing professional development [source: NHS England 2023]; the same applies to therapists in hospice settings [synthesis].
  • Steps [synthesis]: (1) Arrange regular clinical supervision with someone experienced in end-of-life work. (2) Track your own losses and beliefs and how they colour sessions. (3) Seek spiritual or religious consultation (with a chaplain) when a client's tradition is unfamiliar. (4) Take time between deaths where possible.
  • Example language (illustrative, in supervision): "I noticed I avoided talking about her faith because it reminded me of my own father's death."
  • Watch for: numbness, over-involvement, rescuing. Working: you can stay present without being overwhelmed.

4.20 Delivering spiritual care as a dual-trained practitioner

  • Purpose and when: when the therapist is also an ordained minister, authorised faith representative or chaplain.
  • Steps: (1) Check the hospice's requirements: chaplains usually need leadership experience in their own faith or belief, spiritual and pastoral care experience, and often a degree or professional qualification; all are expected to follow the UKBHC Code, safeguarding and Disclosure and Barring rules [source: NHS England 2023]. (2) Keep roles explicit and documented, with reference to APA Ethics Code Standard 3.05 [source: APA Ethics Code]. (3) Check that your professional indemnity insurance covers each role [synthesis]. (4) Offer the client another chaplain or therapist if roles blur.
  • Example language (illustrative): "In this room I'm here as your therapist. If you'd like prayer or a blessing, I can ask another chaplain to come, or, if you prefer me, we can agree that clearly as a separate visit."
  • Watch for: clients feeling unable to refuse religious input from their therapist. Working: the client can say what they want from each role.

5. Handling problems

The sources address service organisation, not clinical difficulties; nearly all guidance below is [synthesis] unless a source is given.

  • Client declines all spiritual talk. Respect it; spiritual care is offered, not imposed, and covers people of no belief [source: NHS England 2023]. Keep meaning-related themes available in ordinary language (family, legacy, what matters) and offer again later. [synthesis]
  • Stuck in hopelessness or meaninglessness. Check first for treatable depression, delirium or uncontrolled symptoms with the palliative team; then consider structured meaning work (MCP if time allows, dignity therapy if time is short) [source: MSK MCP brochure; Hall et al. 2009], or brief legacy work (4.11). [synthesis]
  • Overwhelm or exhaustion. Shorten sessions, use the bedside, stop when the client tires, and return later; dignity therapy is designed to be brief [source: Hall et al. 2009]. Do not push life review on someone who wants rest. [synthesis]
  • Cognitive decline or delirium. Pause structured interventions; rely on presence, familiar music, prayers or objects the family identifies; involve family and chaplain. Resume only if capacity returns. [synthesis]
  • Non-completion (death before the work ends). Plan for it from the start: prioritise what matters most, agree in advance what happens to unfinished recordings or documents, and support the family with what exists. [synthesis]
  • Rupture over religion. If the client feels judged for their faith, or for lack of it, acknowledge, apologise and re-ask what they want; offer a different chaplain or therapist, including one of their own belief or gender [source: NHS England 2023 on chaplain preference]. [synthesis]
  • Family disputes about rites, beliefs or the body. Clarify the patient's own wishes while they can state them and record them [source: NHS England 2023 on care plans]; hold a family meeting with the chaplain or faith leader; avoid taking theological sides. [synthesis]
  • Religious guilt, fear of punishment or anger at God. Validate, explore the client's tradition's own resources for forgiveness or reconciliation with a chaplain or faith leader of their choosing; treat the psychological component (shame, trauma) yourself. Record Z65.8 only where the problem is the focus of care [source: Unbound Medicine ICD-10-CM Z65.8]. [synthesis]
  • Religious community harm or estrangement. Some clients have been hurt by a faith community; do not refer them back to it automatically; offer non-religious pastoral care or a chaplain from another background. [synthesis]
  • Suicidal thinking or a wish to hasten death. Treat as a clinical priority (4.17): direct questions, standard risk assessment, medical review, lethal-means storage and removal only, local law and policy on assisted dying, crisis resources 988 (US) and Samaritans 116 123 (UK and Ireland). [synthesis]
  • Medication questions. Never advise on starting, stopping or changing medicines, including sedation or pain relief; route to the prescriber and palliative team. [synthesis]
  • Prolonged or complicated grief after the death. Distinguish culturally normative grief from prolonged grief disorder [source: Psychiatric News; APA DSM-5-TR fact sheet]; refer for targeted treatment (II 127) or grief counselling (VI 128). [synthesis]
  • Confidentiality across the team. Spiritual information falls under information governance; agree with the client what is recorded and shared [source: NHS England 2023]. [synthesis]
  • Requests for rites the hospice cannot provide. Work with the chaplain, who should hold contacts for local faith leaders [source: NHS England 2023]; for traditions with restricted or initiatory rites, connect the client with the people who hold authority, and never attempt the rite yourself. [synthesis]
  • Therapist's own beliefs pulling in. Notice urges to reassure with your own beliefs or to challenge the client's; take this to supervision [source: NHS England 2023 on supervision]. [synthesis]
  • Using copyrighted tools. Use official FICA, dignity therapy and MCP materials and trainings; do not translate or adapt FICA without written permission [source: GWish FICA]. [synthesis]

Sources

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