It is a bit funny to me that I have written so little about the role of the hospice chaplain, since that is how I first entered the world of hospice. I guess my lack of writing on the subject is about in line with the lack of attention that many hospices give to this position. Although Medicare does require all hospices to have a chaplain, what, exactly, this person is supposed to do and how often he/she should do it is very much up in the air.
Obviously I have a bias since I am talking about my chosen field here, but I believe that most hospices short change the chaplain position greatly. In all reality, I think that the industry as a whole may very well ignore this position a bit too much. Proof? The generally accepted industry staffing standards claim that a full time social worker should have a case load of 30 patients while a chaplain can handle 50. Why can a chaplain handle almost twice as many patients as a social worker? The argument I usually hear is that some patients don’t want visits from the chaplain at all. True. There are also those who have little use for the Social Worker, but want weekly spiritual support. I have also never seen a hospice social worker officiate a funeral service, while an effective chaplain can easily do two a month.
I have two theories here. First, I think chaplains are under used because many hospice administrators are uncomfortable with the separation of church and state issues that come with spending Medicare money on chaplains. A huge percentage of chaplains are Christians. Sure, they are willing to do their best providing spiritual care to anyone no matter what their beliefs, but in the end they specialize in helping Christians deal with all of the issues that arise when death is coming. Is it right for Medicare to pay for this? If your chaplain converts a Jew or Muslim patient to Christianity can you get in trouble? Will one religious community demonstrate outside your office if you hire someone that believes differently then they do? Do you really want the PR nightmare that comes with any of these scenarios? I think many hospice administrators are scared so they water down their chaplain program to the point that it can do little harm or good.
My second theory, which won’t surprise anyone, is that hospice administrators see this as an area where they can save some money. As I said earlier, we are required to provide spiritual care, but what that means is very open to interpretation. There are hospices that only offer chaplain services to people who do not have a church affiliation. If you have a church, then you don’t need spiritual care. At least that’s the theory. Working from that theory, here in the Bible Belt a chaplain could cover over a hundred patients. I would guess that 80% of the people on our service have a church affiliation. That doesn’t mean that they have gone to that church in 40 years, but they are members there. It sure doesn’t mean that the church is actively caring for them! Nonetheless, if they have a church, why should I pay to offer them spiritual care? (That is a rhetorical question, please don’t e-mail me to answer that question.)
When you add those two theories together, you have all the reason in the world to expect very little in the way of spiritual care from your hospice. If spiritual care is important to you, and you are not getting what you need from your church, then you may want to evaluate the hospices in your area to see how they deal with the chaplain position. The number of patients the chaplain serves is the best indicator to use, but while you are looking you might as well find out the religious background of the chaplain.
Please understand that I think hospices should pay great attention to spiritual care. It is a very important part of the team concept, and one that most hospices should make better use of. I’m only trying to prepare you for what you are likely to find when you sign up with the local hospice.