mance of staff in relation to communication, identification, and management of psychosocial and spiritual problems;

  • the negative attitudes of professionals that often demean and discourage integration of these aspects into total care because of the stigmatization of nonphysical “psychological” domains (an equally important barrier is the negative attitudes of patients and families who sometimes feel embarrassed or angered by a consultation by a mental health person, especially a psychiatrist);

  • the absence of training of professional staff in the recognition, diagnosis, and management of distress and the absence of an algorithm to trigger referral to supportive services;

  • the need for mental health professionals and pastoral counselors to be part of, or be an immediately available resource to, the end-of-life care team to address the psychosocial, spiritual, and religious issues; and

  • the absence of reimbursement for these supportive services given to the poor.

  1. The panel should outline standards for psychosocial care and obtain endorsement from professional organizations involved in end-of-life care. These should be promulgated in a manner similar to that used with pain management:

    • Distress should be assessed at every visit on a 0–10 scale, verbally or with paper and pencil, identifying the level and source of the distress; using the algorithm of scoring 5 or above, patients should be referred to the proper supportive service that can be accessed in a seamless delivery system from the patients’ perspective.

    • Educational standards must include training of the primary end-of-life care team in the recognition of distress and its management.

    • Educational standards must teach mental health professionals how to modify their concepts to include end-of-life care (psychologists, psychiatrists, psychiatric social workers, and nurses) and clergy who are qualified as pastoral counselors).

    • Pastoral counseling should be included in psychosocial services, since this should not be fragmented and distanced from other aspects of care during end of life.

    • Patients and families must be educated to understand that the psychosocial and spiritual domains are an integral part of their end-of-life care and should not be viewed as disconnected and unrelated.

    • Governmental and managed care organizations must be made aware of the inequity in reimbursement for the nonphysical aspects of end-of-life care which impacts negatively on ensuring quality of care to reduce suffering and distress.

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