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Sample Policies





These sample policies may be used as a resource for chaplaincy departments in developing relevant policies.




Religious/ Spiritual Preference of Patients and Family Members

A protocol for Religious/Spiritual Preference of Patients and Family Members was developed by the APCTM Commission on Quality in Pastoral Services in 2001 in a collaborative effort with the Society for Social Work Leadership in Health Care. This protocol sought to address how patient dignity can be affirmed by health care institutions and how access to professional chaplaincy care can be assured. Below you will find both the template as designed by the commission, which can be adapted to any institutional setting, and a policy adapted for use at St. Luke's Episcopal Health System.






Policy Template for Religious / Spiritual Preferences
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Category: Patient Rights and Organizational Ethics

Policy Subject: Religious/Spiritual Preferences of Patients and Family Members

Reference Guide: JCAHO Standard R1.1.3.5

Purpose

To ensure that respect is extended to all patients and family members in relation to their preferences of religious rituals or spiritual activities.

General Discussion

It is the responsibility of this hospital to demonstrate respect for a patient's desire for chaplaincy care and other religious/spiritual services, and to provide necessary access. Hospital staff confer dignity to the patient and family by addressing religious and/or spiritual needs throughout the hospital stay. In certain situations, specific rituals or activities may be requested by a patient or his/her legal guardian that must be addressed in certain specific, timely ways. This policy provides general guidelines to help safeguard the patient/family dignity by respecting their cultural, psychosocial and spiritual values. Responding to such requests and safeguards is the responsibility of all staff.


Policy

Requests for specific religious/spiritual services by a patient or his/her legal guardian (when the patient cannot communicate his/her own wishes directly) should be honored, where possible and appropriate. Examples of requests may include the following:

  • administration of holy communion/Eucharist
  • baptism of an infant or adult near death
  • hearing a patient's confession
  • anointing with oil/sacrament of the sick
  • prayer of commendation and blessing at the time of death or following a death
  • prayer before a surgical procedure
  • specific foods or foods prepared in a specific way
  • to be visited by a hospital chaplain
  • respect for religious objects
  • native American sage and pipe ceremony
  • to be visited by a patient and/or family's own faith practitioner

Procedural Guidelines and Safeguards for Honoring a Religious/Spiritual Preference Request.

a. Determining a bonafide request. In most adult situations where competent patients can communicate for themselves, they must make their request for a religious procedure directly, and in a clearly understood fashion. This is especially true in situations where baptism is requested, due to its irrevocable nature and the responsibilities attached to it by many faith traditions. When the patient cannot communicate for himself/herself, by virtue of age, medical condition or level of competency, then a parent, spouse or other, with clear authority to decide matters on behalf of the patient, may initiate the request. When there is ambiguity, as to the exact nature of the request or the authority to make it, do not hesitate to consult with a hospital chaplain, social worker or the unit-nursing supervisor.


b. Routine requests. Whenever a request is made to a hospital staff-person, the request shall be charted in the patient's medical record and the chaplain on duty shall be notified of the request. It shall be the responsibility of the chaplain to assure appropriate follow-up of the religious request and to chart the outcome.


c. Religious requests of an emergent nature. When death of the patient appears imminent, religious procedures such as baptism, reception of Holy Communion, special prayers and/or anointing may be a very meaningful spiritual and therapeutic action, not to mention time-sensitive. In other situations where death has just occurred the same may be true. Prayers following the death of a loved one or special blessings said for a stillborn child may greatly assist in coping with grief. In any of these situations, do not hesitate to request consultation from the chaplain, social worker, nursing supervisor, family, or with the family's permission their pastor, priest or rabbi. Finally, when making a necessary referral, the assessment, intervention and planned outcome shall be recorded in the patient's medical record by hospital staff.


d. In all situations where there is absence of a clear consent, no religious ritual or activity should be administered based on presumptions, such as appearance or surname.




Sample Hospital Policy for Spiritual/Religious Preferences
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Provided by St. Luke's Episcopal Health System, Houston, TX
For additional information, contact Chaplain Rod Pierce at rpierce@sleh.org.

Subject: Pastoral Care & Other Spiritual Services

This policy/procedure rescinds all other policies/procedures and memoranda related to this subject issued prior to April 2001. St. Luke's Episcopal Health System and pertinent St. Luke's subsidiaries such as the hospital are included and referred to collectively in this policy as St. Luke's Purpose.

To outline St. Luke's policy to ensure that the patient, family and significant other's cultural, psychosocial and spiritual values are treated with dignity and respect. Also that, to the extent possible, pastoral counseling to these individuals in relation to their preferences of religious rituals or spiritual activities is made available.

Statement of Policy

All personnel and the medical staff, regardless of their own religious convictions, are expected to respect the convictions and desire for chaplaincy care and other religious/spiritual services requested by any patient, family member or significant other.

Procedures

Request for Specific Religious/Spiritual Services

a. The patient may make requests for specific religious/spiritual services or, when the patient can not communicate his/her own wishes directly, his/her legal guardian.

b. Examples of requests may include, but are not limited to:
  • administration of Holy Communion/Eucharist
  • baptism of an infant or adult near death
  • hearing a patient's confession
  • anointing with oil/sacrament of the sick
  • prayer of commendation and blessing at the time of death or following a death
  • prayer before a surgical procedure
  • specific foods or foods prepared in a specific way
  • to be visited by a hospital chaplain
  • respect for religious objects
  • native American sage and pipe ceremony
  • to be visited by a patient and/or family's own faith practitioner

Guidelines and Safeguards

Determining a bonafide request
  • In adult situations, the competent patient will communicate the request in a clearly understood fashion.
  • In situations where the patient cannot communicate for himself/herself, by virtue of age, medical condition or level of competency, then a parent, spouse or other with clear authority to decide matters on behalf of the patient may initiate the request.
  • When there is ambiguity, either about the request or the authority to make the request, the hospital chaplain on duty, social worker, or the unit-nursing supervisor should be contacted to make the determination.
  • In all situations where there is absence of a clear consent, no religious ritual or activity should be administered based on presumptions, such as appearance or surname.

Routine requests
  • Whenever a request is made to a hospital staff-person, the request shall be charted in the patient's medical record and the unit chaplain, or the chaplain on duty shall be notified.
  • It shall be the responsibility of the chaplain to assure appropriate follow-up of the religious request and to chart the outcome.

Emergent Requests

  • When death appears imminent, or in situations where a death has just occurred, do not hesitate to contact the unit chaplain, chaplain on duty, social worker or unit nursing supervisor for consultation.
  • Certain religious procedures such as baptism, reception of Holy Communion, special prayers and/or anointing may be a very meaningful spiritual and therapeutic action, not to mention time-sensitive.
  • In other situations where death has just occurred the same may be true. Prayers following the death of a loved one or special blessings said for a stillborn child may greatly assist in coping with grief.
  • It shall be the responsibility of all staff to assure that emergent requests are referred in a timely manner, and the course of action recorded in the patient's medical record.