Center to Advance Palliative Care

Here is the spiritual assessment I mentioned above. I will also send copies directly to your e-mail (for those who requested) which is easier to read, print, etc. Since we use a computer charting system, I have this assessment on-line and then I just delete the parts that don't apply to that particular assessment. I am interested in creating an updated version of this, now that I have been using this form for a year. Comments and suggestions are welcome.

Palliative Care Spiritual Assessment

Current Support System
Faith Group:
Name of Community:
Name of Spiritual Leader:
Family:
Friends:
Others:

Particular cultural or religious practices to be observed:
________________________________________________

Sources of Spiritual Pain:
Guilt__ Denial of Reality__
Meaninglessness__
Need for Reconciliation__
Fear of Death__ Isolation__
Powerlessness__ Grief__
Anticipatory Grief__ Anger__ Other__

Sources of Spiritual Comfort:

Acceptance of Reality__ Afterlife Beliefs__
Spiritual Practices__
Music__ Hope__ Forgiveness/Reconciliation__
Life Review__ Nature__
Sense of strength or empowerment__
Other__


Narrative Description of pt’s sources of spiritual pain and/or comfort: (if needed)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
____________________________________

What are patient’s and/or family’s hopes/needs/concerns in regard to the above?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______

Interventions/Plan of Care for Spiritual Support:
______________________________________________________________
______________________________________________________________
____________________
________________________________________________