Center to Advance Palliative Care

Here is an assessment I use:

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PALLIATIVE CARE SPIRITUAL ASSESSMENT
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- CHAPLAIN VISIT REQUESTED BY:
Palliative Care Consultation Team requested
Spiritual Care Consult,
Primary Care Team requested Spiritual Care Consult,
Admission to Palliative Care,
Other:

- REASON FOR CHAPLAIN VISIT:
Patient terminally ill,
Patient with non-terminal intractable symptoms,
patient with diagnosis pending,
Other:

- PATIENT'S DEMEANOR:
PATIENT is receptive to chaplain visit,
receptive but too fatigued for interview at this time,
polite but unreceptive,
unreceptive,

Comment:

-
PATIENT'S RELIGIOUS/SPIRITUAL BACKGROUND:

Adventist,
Assembly of God,
Baptist,
Brethren,
Buddhist,
Catholic,
Christian Scientist,
Church of Christ,
Church of God,
Disciples of Christ,
Eastern Orthodox,
Episcopalian,
Evangelical Covenant,
Friends,
Islam,
Jehovah's Witness,
Jewish,
Latter-Day Saints,
Lutheran,
Methodist,
Native American,
Nazarene,
Pentecostal,
Presbyterian,
Protestant,
No Denomination,
Reformed,
Salvation Army,
United Church of Christ,
Unitarian Universalist,
Unknown/no preferences,
Other:


- SPIRITUAL PRACTICES:

Prayer,
Meditation,
Home ritual,
Community worship,
Fasting,
Music,
Bible Study,
Communion,

Comments:

a) How does the practice help the patient?

Peace giving,
Calming,
Comforting,
Sense of God's presence for them,
Reduces tension,
Helps patient focus on strength in God/Higher Power,
Helps patient feel secure in facing their death,
Helps patient to cope with separation from family,
Patient finds no help from beliefs,

Comments:

b) Patient's Perception of God/Higher Power:

positive,
negative,
neutral,
judgmental,
punitive,
merciful,
compassionate,
faithful,
wrathful,
supportive,
source of strength,
other:

- FREQUENCY OF PRACTICE:

daily,
once a week,
once a month,
occasionally,
only in a crisis,
special occasions,
major holidays

- SPIRITUAL ASSESSMENT:

a. Are you affiliated with a religious community?
Yes
No
b. Is your religious community aware of your hospitalization?
Yes
No
c. Would you like us to contact him/her?
Yes
No
If yes, name of person:

- PATIENT'S SPIRITUAL HISTORY AND CONDITION AT PRESENT TIME:

a) The patient's feelings about their present situation including
Spiritual Injury:

shock,
denial,
anger,
bargaining,
depression,
acceptance,
spiritual suffering,
fear of dying,
fear of being dead,
fear of what will happen after death,
fear of abandoning loved ones,
fear of being abandoned,
fear of uncontrolled pain,
fear of loss of independence,
fear of loss of functioning,
grief and bereavement,
loss of self,
loss of important relationships,
loss of meaning,
withdrawal from previous roles and activities,
suicidal ideation,
forgiveness,
sharing,
reconciliation,
integration of dying
experience with pt's belief system,
guilt and remorse,

Comments:

b) Effects of illness on their God relationship:

unchanged,
improved
relationship,
raised question about relationship,
surfaced anger towards God,
unexamined,

Comments:

c) Effects of illness on spiritual practice:

increased need for practice,
provides comfort,
allays fears and anxiety,
consolation,
decreased desire for practice,
ceased practice in light of present crisis,
no impact,
no change,

Comments:

- PASTORAL ASSESSMENT OF SPIRITUAL NEEDS OF PATIENT

ASSESSMENT/IMPRESSION OF THE IMMEDIATE RELIGIOUS/SPIRITUAL NEEDS OF THE
PATIENT: