Palliative care models are increasingly deepening the integration of a more diverse range of spiritual support, but reimbursement obstacles are stymieing innovative progress.

This is according to Sarah Byrne-Martelli, palliative care researcher at the Center for Aging & Serious Illness at Massachusetts General Hospital. She previously served as senior chaplain for the hospital’s division of palliative care and geriatric medicine. Byrne-Martelli is also assistant professor of spiritual care at St. Vladimir’s Orthodox Theological Seminary.

Palliative Care News recently sat down with Byrne-Martelli to discuss the most significant challenges and greatest opportunities shaping palliative spiritual care for today’s seriously ill patient populations.

What is important to understand about spiritual care delivery in the palliative care space?

Chaplains are able to develop a certain kind of relationship with patients that is deeply reflective of their life.

In palliative care we use this concept of total pain and we talk about social, spiritual, emotional and physical pain. That spiritual care is an important component of palliative care, but the truth is that the staffing of spiritual palliative care across the country is uneven. Some regions may have board certification in advanced practice chaplaincy, teaching, research and leadership, while other palliative care teams may not even have a dedicated chaplain or rely on local clergy members.

The palliative care team is not complete if they are missing the chaplain, and it’s largely because these positions are underfunded. But the argument about reimbursement can’t be the only reason. Part of it is just palliative care being a relatively newer specialty that’s growing, changing and learning.

A palliative care chaplain is supposed to not only provide spiritual care for patients and their families, but also do things like leading goals-of-care conversations, educating communities about care options and teaching medical students about spiritual support. But there are not a lot of places where chaplains can learn the advanced palliative care skills, very few programs specifically include it.

A fundamental aspect of palliative care is having interprofessional services that overlap in certain ways. A clinician or social worker can help with spiritual screening and then refer to a chaplain colleague. This model of screening is for all aspects of total pain and includes different perspectives and interpretations. Similarly, a social worker or chaplain might screen for physical pain and then refer to a clinician. If a clinician hasn’t had the chance to work with a skilled board certified chaplain, they may not realize the breadth of our skill set is and how we can help patients navigate decision-making processes, especially related to spiritual and religious beliefs.

What would you describe as the most significant trends shaping spiritual palliative care delivery?

There is this sort of a chicken-and-egg situation happening when we’re talking about goals of care in palliative populations. Chaplains can engage patients and their families in nuanced discussions that explore their faith, values and goals while aligning with the palliative care team. 

But if chaplains are not officially integrated into the team, they cannot hone those skills and the team won’t know how to engage with us. Also, will remain stuck in the old mindset that chaplains just “hold hands and pray.” We know how to help both the team and the patients. Until systems are set up to guarantee that integration, chaplaincy will remain on the sidelines.

What are the biggest challenges facing today’s spiritual palliative care providers? How are providers working to address these issues?

What we want the world to know is that chaplaincy training has its own set of very standardized and advanced practice competencies in hospice and palliative care. People sometimes have uneven experiences with spiritual care providers because the hiring standards for this staff are uneven. One goal is to continue to develop programs that teach more palliative care skills on the chaplain side of things.

Palliative care teams need to recognize and prioritize that chaplains have standard credentialing. Often, their salaries are way lower than everyone else on the palliative care team, even though all board-certified chaplains have a master’s degree and clinical training. That’s a profound disparity in the way that chaplains are compensated.

Chaplains often care for the most acutely sick patients and their caseloads are very heavy and much larger than other palliative care team members’, which can contribute to burnout. Chaplains spend half of their time trying to figure out where to go because they have so many patients, and they’re just triaging constantly.

Improving spiritual screening assessments to address someone’s pain, connectivity and moods could really help better utilize chaplain teams to provide robust team support.

What are some of the common issues preventing greater access and improved quality of spiritual palliative care services?

Some of the subtle barriers are just that religion and spirituality can be touchy subjects for many people. Spiritual care is something that patients and staff can have strong feelings about. The key thing is to recognize that spirituality is a part of palliative care, and we need to shift our models toward having a team that includes chaplaincy.

Chaplains are trained to protect freedom of religion, respect all faiths and speak to anyone no matter what their belief system may be. It’s so hard sometimes to communicate that, because the non-chaplain staff may not have that sense of the breadth and depth of their knowledge and skills. The way they portray us to other people really matters in outcomes.

Having chaplains more present at the time of a new patient consultation, for example, would make spiritual care become more normalized.

What might be some of the lesser-known issues that spiritual palliative care providers need to better understand?

Religious beliefs are prevalent in a lot of patients and among certain demographic groups compared to others. It’s knowing that religiosity and spirituality are very prevalent in a lot of the communities we serve. We always need to respect beliefs and try to at least understand them while screening periodically for spiritual distress. But most of the time that spiritual distress screening is not done by chaplains.

Joint patient visits with chaplains and working as a team with others eventually lead to more efficient care because we’re addressing primary concerns, which can be spiritual. Just as patients’ physical needs change, so do their spiritual concerns.

Providers’ own perceptions of the role of their religion affects their comfort level engaging in spirituality with patients and families. It has a lot to do with building trust and really understanding how to work together with chaplains to form the best connection for patients and families.

Having chaplains involved earlier on recognizes that spiritual language and how it relates to [whether] people tend to seek more aggressive interventions at the end of life. Chaplains can translate that language for the medical team to understand. The chaplain can talk to the patient, the family and the palliative team to really offer insight on ways to help alleviate suffering and make decisions more manageable.

What are some of the key elements to consider when it comes to building and sustaining person-centered models of spiritual palliative care?

Appropriately hiring and staffing chaplains is a key factor. There is not a career ladder within chaplaincy or a lot of leadership opportunities within palliative chaplaincy care. They also don’t receive significant raises or recognition for advanced degrees or doctorates. It’s hard, you have to be completely intrinsically motivated.

Offering chaplains the same educational, teaching and research opportunities as other team members can help the field to grow and share insights, gifts and skills with one another. That can contribute to resilience and feeling like they have a voice and their skills are valued. It’s bringing chaplains more into the fold of research studies and grant projects.

Chaplains often benefit from mentorship, research and education opportunities in palliative care. It’s really important to include social work and chaplaincy in these opportunities to grow. That really challenges teams to learn quality improvement. You need a champion that advocates for spiritual care. Then we can take the lead and develop more advanced palliative care skills and have more leadership on these teams.