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Tuesday
Oct252016

New WHO Guidance on Planning & Implementing Palliative Care: What Should Chaplains Know?

As many know, in May 2014, the World Health Organization (WHO) adopted an extensive new document (WHA 67.19) on palliative care that among other landmarks included spiritual care for the first time. Now, as is customary for WHO, they have issued a guidance document for those in the 192 member countries of the WHO to help them roll out palliative care in their countries. (Planning and implementing palliative care services: a guide for programme managers. (http:// www.who.int)

This is a hugely important document for all palliative care providers including spiritual care providers. It reaffirms WHO's stand that palliative care is not just a "nice to have" in health care but a human right. This means that all countries should provide it.

   "Ensuring the accessibility of palliative care is not just an ethical obligation of health systems;         it is also an obligation under international human rights law. The right to palliative care and pain     relief is recognized under the human right to health." (p.6)

For the chaplain reader in North American, it is necessary to understand something about the international context for palliative care in order to understand a lot of why the guide is written the way it is. Readers will notice a significant emphasis on the availability and use of pain relievers- especially opioids. While opioids are maybe too plentiful in the US, they are often very hard to get in many countries because of severe legal restrictions. At the same time in many countries where treatment for diseases like cancer are hard or impossible to obtain, pain relief is all that can be done. As the guide comments on page 6,  "Unfortunately, countries have paid far more attention to their obligation to prevent abuse than to their obligation to ensure access for medical purposes."

For anyone who is at home with the complexities of US health systems, the extensive step-by-step advice on how to set up palliative care in a variety of settings may seem simplistic.  However, in many countries, these models that we often are so used to are rare or unknown.

Finally, chaplain readers will notice that the word, "chaplain" is largely missing. In fact, it is only used once, incongruously, in the list of recommended staff for pediatric palliative staff. The point to remember is that, in most of the world, "chaplain" is far less known than even in North America and Europe. The term does not even have an equivalent in many languages. More importantly, providing trained chaplains is not a model that probably most countries in the WHO can aspire to. Maybe the major challenge for spiritual care providers is how to provide what we would call "specialist" spiritual care as part of palliative care in these contexts.

That all said, the guide makes very clear that spiritual care is to be a part of the palliative care that is required. "Spiritual" is used over thirty times. On page 12, the guide states" Spiritual distress and existential concerns should be treated with the same level of intensity and priority as psychosocial and physical distress or pain. Support may involve a spiritual carer." Spiritual care is not a second-class citizen.

  "Spiritual care should be provided to patients (page 9) families (page 13) and 'professionals             providing care (including self'" (page 10)

    "Palliative care services should, therefore, at a minimum: .... assess and reassess patients for        physical, emotional, social and spiritual distress and   (re)assess family members for emotional,      social, orspiritual distress; ..address spiritual, psychological and social needs;" (page 9)

    "Spiritual "understanding" is described as one of the core tasks of the palliative team (page 60       and discussion of "spiritual suffering" is part of the sample curriculum for training all staff."             (page 87)

Thus the mandate to include spiritual care is quite emphatic and all encompassing. What is beyond the scope of this guide and seems to be the challenge for us in professional chaplaincy to come up with answers to are issues like:

            If professional chaplains are largely not an option, who are these "spiritual    carers" on the team going     to be?

            Where are they going to come from?

            How are they going to be trained?

            How is this training going to be delivered often over vast distances?

Answering these questions presents a colossal challenge but also a colossal opportunity to impact spiritual care around the world.  The WHO has set the bar but much is left to be done.

We in chaplaincy and spiritual care are seriously indebted to a large number of those listed in the acknowledgments who have long championed the inclusion of spiritual care in palliative care and who have yet again carried this inclusion forward.  Those best known to the US audience would include Kathy Foley, Diane Meier and Christina Puchalski but I personally know a number of others in the group who undoubtedly supported this inclusion as well. 

 

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