The NCCN practice guidelines, developed by social workers and a multidisciplinary panel, determined that the services given by social workers fall into two domains: psychosocial services and concrete services such as transportation. They constitute the first algorithm-based treatment guidelines for delivery of social work services in cancer. These guidelines require only minor revision to apply to end-of-life care. The role of social workers varies enormously across institutions; in some, they provide all of psychosocial services as they address all the psychosocial needs of both patients and families during palliative treatment (see Table 7-2).

Long an integral part of hospice care, interest is growing in how we can better incorporate the spiritual and religious domains in palliative care in all settings (Post et al., 2000). When life ebbs, beliefs and philosophy take on new meaning so that the clinician should be sensitive to the need to explore these areas with a patient and, if the patient expresses concerns about spiritual or religious matters, to refer him or her to a pastoral counselor (Puchalski and Romer, 2000). The NCCN practice guidelines for management of distress include pastoral counseling as part of psychosocial services to encourage the integration of pastoral services into total support services (Holland, 1999). The common problems referred to pastoral counselors, and for which they counsel, are grief, concerns about death or afterlife, conflicted belief systems, loss of faith, concerns about the meaning or purpose of life, relationship to God, isolation from religious community, guilt, hopelessness, conflicts between religious beliefs and recommended treatment, and ritual needs (Speck, 1998). Clergy who have been trained in pastoral counseling should be available to assist in end-of-life care. Problems such as guilt, hopelessness, and grief may require mental health or social work evaluation, prompting the need for close collaboration among all staff taking care of patients in a palliative setting (see Table 7-2).

TRAINING OF TEAM The team giving end-of-life care must be trained in how to recognize, diagnose, and treat distress and in using an algorithm for referrals to mental health, special social work services, or pastoral counseling. A brief curriculum is needed that can be given to staff easily, similar to the curricula in palliative care.