“What do you talk about in there?" Hospice palliative social work

Hospice palliative social work areas of competency.

As I wrap up my master’s degree in social work, with a focus on hospice palliative care, it’s helpful to look back on my time and try to understand what it is that I have learned to do.

Residential Hospice

In my first placement at Bethell Hospice, I tracked the activities of the resident social worker and came up with a conceptualization of how social work can fit into a residential hospice model.

An estimate by Linda Hochstetler, MSW, RSW is that 25% of time is spent on work that could be considered non-specific individual and family counselling around issue impacting the family, case management etc. 20% is specialized medical social work activities such as supporting residents and families as they make informed medical decisions, and fully 50% is more specialized hospice palliative social work knowledge.

A breakdown of some of the main activities of hospice palliative social work in a residential hospice setting, along with the perceived benefits according to residents, family members, and other staff.

More importantly, I began to see the value we bring to hospices — to residents, their families, to hospice staff and to the organization as a whole. When I broke out the specialized activities social work was doing in the hospice, I found some activities one might expect, and some that might surprise you. I also asked around about the perceived benefits of social work in the hospice, from staff and from families who completed quality assurance surveys.

In an interdisciplinary team comprised of palliative physicians, nurses, registered practical nurses, a spiritual care coordinator, and personal support workers, the social workers came to be seen as natural leaders in psychosocial support. All disciplines on the team enjoyed the work of supporting residents and families emotionally as well as physically. Social workers were called upon primarily to provide support to those with more in-depth, complicated issues that were impacting their stay in hospice, or their family functioning. Social workers were a sounding board for other staff when they experienced challenges supporting residents or family members. And they took a leadership role in speaking to families about their hospice experiences through quality assurance, as well as imparting best practices to all staff about providing psychosocial support, through regular lunch and learns and individual meetings.

Theories for effective psychosocial support at end-of-life.

Community Hospice

My second placement was in a community visiting hospice. I saw that more time was spent on case management than in residential hospice, as we tended to connect with families earlier in their end-of-life journey. Families needed more support with advance care planning, accessing compassionate leave and other benefits, and with system navigation. While a part of the local palliative care teams staffed by a similar mix of disciplines, much of the work was carried out as an individual practitioner, unless clients were experiencing extremely complicated issues.

Theory

Social workers have the reputation of being good talkers, but for non-social workers, it might be a surprise to learn about all the theoretical background we bring to our conversations.

In both residential and community roles, I had to translate classroom theory into the real world of hospice palliative social work. Here’s quick flyover of the theories I concentrated on to help address the psychosocial spiritual needs of clients and families.

Dignity Therapy: Chochinov’s techniques help me to grasp clients’ personhood and priorities, which allows us to both preserve dignity and support peoples’ hopes for how they might be remembered.

I now use motivational Interviewing to address resistance, ambivalence, and encourage resident autonomy, and to help move individuals through the process of seeing and accepting the stages of dying.

Narrative Therapy: Lorraine Hedtke’s work on re/membering lives and shaping meaning around lives, families and around end-of-life events was essential during residents’ last week and days as clients became quieter and we encouraged more storytelling among family members.

Logotherapy: Victor Frankl’s existential approach enhances clients’ sense of meaning, peace, and purpose in the life lived.

From Contemplative Care we used elements of mindfulness, relationship, the power of integrating the spiritual aspects, verbal and nonverbal communication, and ideas for understanding our roles as caregivers.

Finally, from Dr. Ira Byock, we can help residents and families work through the “Four Conversations” about gratitude, forgiveness, love and saying goodbye. This work provides a release valve for feelings that can be hard to verbalize, and gives people something to “do” in the hospice together during the long hours.