Asking for Spiritual Care or a Chaplain During Cancer

Chaplaincy is a clinical service with its own training and its own place in federal rules. It is not a religious visit that happens to occur in a hospital. Knowing the difference changes how you ask, and how fast you get it.

The Department of Veterans Affairs publishes its hiring standard, and it is a fair picture of the field. A VA chaplain must "hold a Master of Divinity degree or degree of equal qualification and religious education." They must have "completed at least four units of Clinical Pastoral Education in a program accredited by the Association for Clinical Pastoral Education or the Institute for Clinical Pastoral Training." Clinical Pastoral Education, or CPE, is supervised training done in a hospital. They must also show "an ecclesiastical endorsement dated within 12 months of applying." That means their own faith body vouches for them.

Four units of CPE is close to a full year of supervised hospital work. That training is why a chaplain can sit with someone who is dying, or furious at God, or an atheist, without needing the talk to go anywhere in particular. NCI notes that hospital chaplains "are trained to work with a wide range of issues." You do not have to share their faith. You do not have to have one.

NCI defines religion as "a specific set of beliefs and practices, usually within an organized group." It defines spirituality as "an individual's sense of peace, purpose, and connection to others, and beliefs about the meaning of life."

That difference matters at the desk. "I want a priest for confession" and "I cannot find any point to this" are not the same ask. Both get you a chaplain.

NCI's summary for clinicians describes acute spiritual distress as coming "from the belief that cancer reflects punishment by God." It may also "accompany a preoccupation with the question 'Why me?'" NCI adds that "a cancer patient may also suffer a loss of faith."

It is common. In one study cited by NCI, 61% of 57 inpatients with advanced cancer reported spiritual distress.

The numbers in NCI's summary are blunt. In a survey of hospital inpatients, 77% "reported that physicians should take patients' spiritual needs into consideration," and 37% "wanted physicians to address religious beliefs more frequently." In a separate survey of cancer outpatients in New York City, a slight majority thought it appropriate for a doctor to ask about their beliefs and spiritual needs, but "only 1% reported that this had occurred."

Among patients with unmet spiritual needs, 47% said those needs were not met by a religious community. And 72% said they were not supported by the medical system. NCI adds that patients with unmet spiritual needs "gave lower ratings to quality of care."

Read that as permission. If nobody has asked you, that is the pattern. It is not a sign that your need is odd.

Structured tools exist. Knowing them takes the surprise out.

FICA covers four areas: Faith, Importance or Influence, Community, and Address. It opens with "What is your faith?" and "How important is it?"

SPIRIT covers six areas. They are spiritual belief system, personal spirituality, integration with a spiritual community, ritualized practices and restrictions, implications for medical care, and terminal events planning.

Those last three are the practical ones. Ritualized practices and restrictions covers fasting, food rules, prayer times, modesty during exams, and who may wash or touch the body. Implications for medical care covers blood products, feeding decisions, and sedation. Terminal events planning covers what must happen at the end and in what order. Say all of this early, not during a crisis at 2 a.m.

Medicare-certified hospices run under 42 CFR part 418. Two parts are worth quoting.

The hospice interdisciplinary group "must include, but is not limited to" a doctor, a registered nurse, "a social worker, marriage and family therapist, or a mental health counselor," and "a pastoral or other counselor." A chaplain is a required member of the team. It is not an extra.

On the service itself, the hospice must do four things:

• "Provide an assessment of the patient's and family's spiritual needs."
• "Provide spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service, and in a manner consistent with patient and family beliefs and desires."
• "Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs."
• "Advise the patient and family of this service."

Look at the second one. It is bound to your beliefs, and only if you accept it. Declining is written into the rule.

Look at the third one. If your own imam, rabbi, priest, or elder cannot get to you, the hospice must make reasonable efforts to help.

NCI says it plainly. Chaplains "are generally available in large medical centers but may not be reliably available in smaller hospitals," and are "rarely available in outpatient settings where most cancer care is now delivered."

Most cancer treatment is outpatient. So the chaplain may be one building away and never offered while you sit in an infusion chair. Ask anyway, and ask these:

• Does this center have a chaplain, and can I be seen on an infusion day?
• Can I be seen by phone or video between visits?
• Is my request in the chart, so I do not repeat it every time?
• Can you help my own clergy get in during an admission?
• Who covers nights and weekends when the office is closed?

• You believe your cancer is a punishment, and it is changing whether you take treatment.
• You have lost a faith you leaned on, and you cannot sleep or eat.
• A rite or sacrament has a time limit and death may be close.
• Your family is split over stopping or continuing treatment.
• A treatment conflicts with a religious rule and nobody has raised it.
• You are alone with the question of what your life meant.

If you are thinking about suicide or self-harm, call or text 988 now. A chaplain is not a substitute for that call, and a good one will make it with you.

• Spirituality in Cancer Care (PDQ), Health Professional Version — National Cancer Institute
• Spirituality in Cancer Care (PDQ), Patient Version — National Cancer Institute
• 42 CFR 418.56, Interdisciplinary Group, Care Planning, Coordination of Services — eCFR
• 42 CFR 418.64, Core Services — eCFR
• Chaplain Career Opportunities — US Department of Veterans Affairs