





































With the elderly population growing, there is a great need to improve the 
quality of end-of-life care. Traditionally, the healthcare industry has focused 
on the pathology-oriented medical model when assisting terminally ill 
patients. This focus can lead to patients feeling depressed, anxious, and 
hopeless about the dying process. By incorporating spirituality into the dying 
process, the hospice movement diverged from this medical model, but the role 
of social workers is often divided between these two very different paradigms. 
This paper discusses spiritual practice theories that hospice social workers 
can use to benefit the well-being of terminally ill patients while working 
within the current health care system. 

Samantha Chipetz

The Hospice Movement: Spirituality 
Within the United States’ Health 
Care System

The history of the American hospice movement reveals the importance 
of spirituality in end-of-life care. In the early hospice movement 

beginning in the fourth century, care for the dying was almost solely driven 
by religious communities that promoted spiritual well-being during a 
patient’s last phases of life. What differentiates the hospice movement today 
from these earlier efforts is the implementation of modern medicine (Garces-
Foley, 2003). Within this new medical context, a question arises for social 
workers: How can we effectively work within the current medical model, 
which places value on curing, deficits, and pathology, and still attend to the 
patient’s social, emotional, and spiritual comfort in an increasingly secular 
society? This paper will seek to answer this question by exploring current 
theories and practices social workers can employ to promote the well-being 
of patients with terminal illness by focusing on spirituality in hospice care. 

Choosing Hospice Care

Today more than 3,200 hospices have been established in the U.S. 
(“Brief History of Hospice Movement,” n.d.). Types of hospice care vary 
from independent, to nonprofit, and for-profit. The National Association for 

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Home Care and Hospice (NAHC) noted that in 2000, one in four terminally 
ill individuals in the U.S. received hospice care (NAHC, 2002). The majority 
of patients receiving hospice care are elderly, with more than 79% age 65 or 
older and only 3.9% of hospice patients under the age of 45 (NAHC).

 Race and social class play a significant role in identifying patients 
most likely to use hospice services. NAHC (2005) asserted that although 
utilization of hospice services has increased among all racial and economic 
groups over the past decade, white, middle-class patients are still more 
likely to use hospice assistance than other groups. Blacker (2004) suggested 
that many vulnerable populations, including refugees, immigrants, those 
with severe physical and mental disabilities, and people of color, continue 
to be underserved during end-of-life situations. Barriers to hospice care may 
include a lack of knowledge concerning end-of-life options and the limited 
number of hospice services available in some local communities. In addition, 
different views on death and dying shaped by philosophical, spiritual, and 
social beliefs often lead to lower rates of hospice use by different cultural 
groups. For example, Sullivan (2001) asserted that many Latinos would not 
choose to be cared for in nursing homes or hospices due to their strong 
cultural emphasis on familial responsibility, privacy, and modesty. 

With the growth of hospice care since the 1970s, an increasing number 
of Americans are choosing hospice as an option for themselves and their 
loved ones. Cicely Saunders, a social worker and founder of the first 
modern hospice in 1974, and Dr. Elisabeth Kubler-Ross, who wrote the 
groundbreaking book, On Death and Dying, both brought the topic of dying 
to public attention. They did so during a time when the medical community 
viewed terminal illness as something to be controlled rather than a condition 
that required relief. Saunders and Kubler-Ross illustrated how the medical 
community all too often ignored and abandoned the emotional needs of a 
dying patient, once it became apparent that the patient could not be cured 
(Raymer & Reese, 2004). 

According to Tyrer and Exley (2005), the most common reasons patients 
choose hospice care over hospital facilities are the support and care available 
to families, the patient’s wishes to die at home, and the inability of medical 
interventions to cure the patient. NAHC (2005) also suggested that hospice 
policies that allow patients to stay with family in the comfort of their own 
home and policies that encourage family members to take an active role in the 
treatment of their loved one lead patients to prefer hospice care over hospital 
or nursing facilities. In addition, when compared to trained nursing and 

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hospital services, hospice is a more cost-effective option for eligible patients 
with a life expectancy of 6 months or less to live (NAHC). Hospice services 
are covered by both the Medicare Hospice Benefit under Medicare Part A, 
and the Medicaid Hospice Benefit. In addition, most private insurers will 
cover portions of hospice services. Since the majority of hospice recipients 
are 65 years of age or older, they qualify for entitlement services under 
the Medicare Hospice Benefit, resulting in almost no out-of-pocket costs to 
the patient (“Caring Connections,” n.d.). Due to its increased accessibility 
and cost-effectiveness, hospice use rose 20% from 1992 to 2000 (NAHC). 
Today, as a greater number of elderly patients seem to be choosing hospice 
as the baby boom generation continues to age, a focus on end-of-life care by 
the healthcare system is imperative (Nakashima & Canda, 2005).

Social Work Practice in Hospice Care

Social workers involved with hospice are part of a team of physicians, 
nurses, counselors, home health aides, clergy, therapists, and trained 
volunteers (NAHC, 2005). Together they offer support and emphasize a 
holistic framework that places attention on palliative as opposed to curative 
care. The hospice team relies on the skills and knowledge specific to each 
discipline in an effort to organize a unique and supportive plan beneficial to 
each patient and family (NAHC). Blacker (2004) noted that social workers 
have a unique role on the hospice team, which is to assist patients and families 
managing complicated psychological, medical, social, legal, and ethical 
decisions associated with end-of-life issues. Also, social workers serve as 
patient advocates on the hospice team by assisting the patient in navigating 
through complex medical and social systems. When developing a model 
for hospice care, Saunders conceptualized professionals working as a team 
comprised of many fields of study, since Saunders herself assumed the roles 
of social worker, physician, and nurse. The current model for hospice care, 
similar to social work practice, suggests that collaboration is essential for 
boosting the physical, mental, and social conditions of the patient (Parker-
Oliver, Bronstein, & Kurzejeski, 2005). 

Although social workers hold a distinct place within the interdisciplinary 
hospice team, Batten (1997) suggested that the social worker’s role in 
a hospice setting is often variable and unclear (NAHC, 2005). While 
providing patients’ psychosocial and spiritual care is an essential and 
standard aspect of hospice service, social workers do not exclusively 

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perform these tasks, but share the responsibilities with nurses, clergy, and 
volunteers. As Reese (2001) explained, “although hospice philosophy holds 
that all members of the team address spirituality, sometimes spirituality is 
considered the chaplain’s domain. Social workers may do the initial spiritual 
assessment, but not intervention with spiritual issues” (p. 149). Therefore 
competition may arise between social workers and chaplains regarding 
their core responsibilities. In addition, turf issues may also surface between 
social workers and nurses concerning the task of completing psychosocial 
assessments. Often, social workers in hospice settings perceive that nurses 
are assuming this duty, which is specifically assigned to social workers, 
creating high levels of frustration and conflict within the interdisciplinary 
team (Parker-Oliver et al., 2005). Although the role of the social worker is 
not clearly defined within many hospice settings, social workers’ diverse 
knowledge of intervention strategies can decrease conflict and motivate 
change within the hospice team (Parker-Oliver et al.). By working to assess 
and respond to the needs of the interdisciplinary team, social workers can 
improve the cooperation, communication, and success of the hospice team 
and enhance hospice service to patients and their families.  

Spirituality in End-of-Life Care

Nakashima and Canda (2005) argued that while the hospice movement 
has played an important role in improving terminal care by providing a 
holistic approach, the leading philosophy of patient care is still embedded in 
a pathology-oriented medical framework. This medical approach can lead 
patients to feel depressed, anxious, and hopeless about the dying process. 
The current medical model does not address a patient’s spiritual concerns, 
such as questions about the origin and purpose of life and the meaning of 
suffering (Reese, 2001). While the hospice setting incorporates different 
religious and spiritual elements to address spiritual issues, social work as 
a profession has historically fought traditional religious paradigms that 
often blame individuals for their problems. As a result, social workers have 
successfully shifted the profession’s attention to the person-in-environment 
context (Bullis, 1996). Therefore, social work in hospice may differ from 
the current orientation of many in the social work profession. Hospice work 
requires social workers to attend to the spiritual dimension of a person, 
which is vital in understanding how patients define their environment during 
their final days (Garces-Foley, 2003). Nakashima and Canda maintained that 

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spiritual practices offered by social workers in a hospice setting can provide 
profound support for patients to heal, grow, and feel more comfortable in 
the last stages of life.

Transpersonal Social Work
Reese (2001) argued that focusing on spirituality when working with 

the terminally ill can act as a source of strength for patients. Reese claimed 
that, when faced with death, all adult patients can achieve a stage of spiritual 
growth. This stage, called transegoic, occurs when “ordinary life is infused 
with a sense of the sacred. Heightened empathy, compassion, and moral 
standards naturally arise as the individual experiences a profound connection 
with others” (p. 137). Although the transegoic level of consciousness is not 
an automatic development during the last stage of life, Reese contended that 
a smooth shift into the transegoic stage can support a comfortable death by 
reducing death anxiety and increasing social support. She pointed to the 
need for hospice social workers to incorporate transpersonal theory as a 
foundation for practice technique to assist dying patients and their relatives 
make the transition to the transegoic stage (Reese). 

Application of these transpersonal techniques may help patients take full 
advantage of the time that remains and to live in as much peace as possible 
during their last phase of life. An example of one transpersonal technique 
is teaching meditation practice as a way to support spiritual growth and 
relieve stress. Specific meditation techniques include “paying attention” 
and “intentional breathing” (Reese, 2001, p. 152). Paying attention supports 
awareness by encouraging patients to take pleasure in a shower or appreciate 
each moment with a loved one. Intentional breathing is a technique that helps 
patients to diminish stress by repeating a mantra while concentrating on 
their breathing. Other transpersonal techniques used to help transegoic stage 
development are movement mediation, group chanting, dream interpretation, 
music and art therapy, acupuncture, and keeping a journal (Reese). 

Focusing on a Patient’s Resiliency
Nakashima and Canda (2005) conducted a qualitative study that 

examined the opinions of older adults who had positive experiences during 
their last stages of life. From their findings, the researchers concluded that 
in order to promote the psychosocial and spiritual well-being of terminally 
ill patients, social workers need to create intervention plans to help patients 
identify their internal and external resources that have helped them cope 

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with adversity in the past. Through this process, patients will re-live past 
experiences of resiliency, which can lead to a more positive and peaceful 
death. 

Examples of a patient’s internal and external resources might include 
spiritual attitudes, unique skills, talents, and relationships with others that 
can be shared with the social worker through narrating events of past 
resiliency. By storytelling past positive experiences, patients can create 
meaningful narratives of living and dying. Findings from Nakashima 
and Canda’s (2005) study also indicated that strong spiritual or religious 
relationships in the community strengthen the ability for individuals to cope 
during stressful situations. A strong connection to the church, involvement 
in prayer, or attending spiritual rituals all promote spiritual practices and 
beliefs and strengthen the ability of individuals to thrive and benefit in 
adverse circumstances (Nakashima & Canda).  

Buddhist Approach to End-of-Life Care
While social workers need to focus on a patient’s resiliency and spiritual 

strengths to promote the well-being of terminally ill patients, Garces-Foley 
(2003) argued that it is also important to create a nonsectarian spiritual 
language, along with nonsectarian social work practices, to aid in a patient’s 
positive end-of-life experiences. Garces-Foley pointed out that over the 
past 20 years, Buddhism and hospice have created a mutually valuable 
relationship based on the attraction to nonsectarian language of spirituality, 
the craving for realistic techniques of coping with death, and the potential 
capacity of Buddhism to meet this need.

During the 1980s, the American hospice movement was searching for 
a spiritual language that was not associated with a particular religious 
denomination and that would be appropriate for clients of different ethnic, 
religious, or cultural backgrounds (Garces-Foley, 2003). In addition, hospice 
was becoming a mainstream option for terminally ill patients. Around this 
same time, Buddhism was expanding in popular culture through advocates 
of Buddhist practice who used books, Buddhist centers, conferences, and 
trainings to raise public awareness of Buddhist philosophies. Through this 
increased social consciousness, leaders of the hospice movement became 
aware of Buddhist wisdom towards death and dying and discovered that 
Buddhism offered an appropriate nonreligious language to use within 
hospice practice (Garces-Foley).

Within Buddhist philosophy, there are many teachings and applicable 

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practices that speak specifically to end-of-life issues. As a result, many 
religious and non-religious people who are searching for supportive 
practices during the dying process turn to Buddhism as a guide to dying and 
post-death rituals. Buddhist teachings present meditation practices for both 
the patient, whose objective is to begin to let go of life, and the caregiver, 
whose objective is to develop compassion. For either patient or caregiver, 
these practices permit the increase of a sense of power in times when people 
often feel powerless. In contrast to the view of medical institutions, which 
view death as a failure, Buddhist practices present a means to a successful 
and positive death, which can be accomplished through discipline during 
meditation practices (Garces-Foley, 2003). 

Patients who are receiving hospice services may be attracted to 
Buddhist teachings on death and dying, but are not necessarily converting 
to Buddhism. Instead, religious and nonreligious hospice providers and 
patients are borrowing Buddhist practices to enhance their own religious 
ideals and practices. Garces-Foley (2003) called this type of melding of 
religious practices “religious mixing or combination” (p. 342). Through this 
process of religious selection, people can maintain their personal religious 
backgrounds while selecting aspects of Buddhism that seem appealing 
and applicable in their daily spiritual practices. With the establishment 
of Buddhism within the modern hospice movement, social workers have 
access to a unique spiritual language and applicable meditation practices 
that support positive spiritual end-of-life experiences for patients of diverse 
religious backgrounds. 

The Future of Spirituality in Hospice Care

In addition to learning spiritual techniques and approaches, there is also 
a need for hospice social workers to be trained in spiritual assessment and 
intervention. Wesley, Tunney, and Duncan (2004) suggested that even though 
the Joint Commission on Accreditation of Healthcare Organizations includes 
spiritual assessment in it principles, it does not offer precise guidelines for 
social workers. Furthermore, the social work profession needs to define 
what constitutes standards of spiritual care, as little social work research 
exists concerning spirituality and terminal illness (Wesley et al.). 

In addition, Reese (2001) suggested that there are inconsistencies among 
social workers to define, identify, and address spiritual issues. She proposed 
that social work education needs to focus attention on the various spiritual 

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beliefs about dying that exist within our society. Social workers also need 
to come to a consensus and create suitable documentation of spiritual 
interventions that can effectively monitor and evaluate the effectiveness 
of various approaches. Lastly, Reese noted that it is important for social 
work education to address the social worker’s personal beliefs about death 
and spirituality, which may influence their willingness to address spiritual 
matters with clients. 

Conclusion

Social workers’ use of spirituality in a hospice setting can greatly  
enhance and promote a patient’s well-being during their last stages of life. 
As a result of the work of Saunders and Kubler-Ross, the topic of dying has 
been brought to public attention (“Brief History of Hospice Movement,” 
n.d.). There is now a critical need for social workers to move away from 
the current pathology-oriented medical model (Nakashima & Canda, 2005). 
Hospice social workers need to incorporate spirituality to support patients’ 
ability to emotionally heal, grow, and feel more comfortable in their last stages 
of life. Transpersonal social work, focusing on the resiliency of terminally 
ill patients, and incorporating a Buddhist approach to death practices are all 
types of spiritual practice theories that social workers can use to benefit the 
well-being of people with terminal illness. Spirituality training for social 
workers employed at hospice settings, as well as addressing spirituality and 
hospice in graduate social work programs, are also necessary to support the 
hospice movement’s use of spirituality in end-of-life care. Even with all of 
the existing theories and lessons for social workers to understand and apply 
when working with dying patients, Reese (2001) put it simply when she 
said, “in the end, the people who are dying will teach us these lessons more 
often than we will teach them” (p. 158). 

References

Batten, D. (1997). Conceptualizing spiritual care in three diverse hospices: A  
 phenomenological study. Ann Arbor, Michigan: UMI.
Brief History of Hospice Movement. (n.d.). Retrieved October 8, 2005, from  
 http://www.hom.org/movement.asp
Blacker, S. (2004). Palliative care and social work. In J. Berzoff & P.  
 Silverman (Eds.), Living with dying (pp. 409-423). New York: Columbia  

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Bullis, R. (1996). Spirituality in social work practice. Washington, DC:  
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Caring Connections. (n.d.). Retrieved February 13, 2006, from http://www. 
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Raymer, M., & Reese, D. (2004). The history of social work in hospice. In  
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Sullivan, M. (2001). Lost in translation: How Latinos view end-of-life care.  
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Tyrer, F., & Exley, C. (2005). Receiving care at home at end of life:  
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Samantha Chipetz is a first year master’s student at CUSSW. 
She is currently an intern at a public elementary school in Bronx, 
NY. She is a graduate of the University of Vermont with a bachelor’s 
degree in Sociology and a double minor in Religion and Environmental 
Studies. Her email address is sc2517@columbia.edu.

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