NASW Standards of Social Work Practice in Palliative and End of Life Care

DRAFT 9/16/03

Gary Bailey, MSW
NASW President (2003-2004)

Palliative and End of Life Care Expert Steering Committee (2002)

• Susan Blacker, BSW, MSW, RSW, Volunteer Leader
• Iraida V. Carrion, MSW, LCSW
• Yvette Colon, MSW, ACSW, BCD
• Pamela M. Jackson, MS
• Stuart Kaufer, MSW, CSW, ACSW
• Patricia O'Donnell, DSW, LICSW, CCM
• Mary Raymer, MSW, ACSW
• Sherri Roff, CSW, PhD Candidate
• Elizabeth Smart, MA
• Sharon Hines Smith, PhD, QCSW, MSW
• Mila Ruiz Tecala, ACSW, DCSW, LICSW, LCSW-C, LCSW
• Kathy Walsh-Burke, DSW

NASW Staff:

• Elizabeth J. Clark, PhD, ACSW, MPH
  Executive Director
• Toby Weismiller, ACSW
  Director, Professional Development & Advocacy
• Tracy Whitaker, ACSW
• Karyn Walsh, ACSW, LCSW

Contents

• Introduction
• Definitions
• Background
• Guiding Principles
• Standards for Professional Practice
• Standards for Professional Preparation and Development
• References
• Resources
• Acknowledgement

NASW Standards of Social Work Practice in Palliative and End of Life Care

Introduction

All social workers, regardless of practice settings, will inevitably work with clients facing acute or long-term situations involving life-limiting illness, dying, death, grief, and bereavement. Using their expertise in working with populations from varying cultures, ages, socioeconomic status, and nontraditional families, social workers help families across the life span in coping with trauma, suicide, and death and must be prepared to assess such crises and intervene appropriately. 

In relation to the number of agencies, institutions, and other sites of practice, social work is the most broadly based profession that encounters individuals and families affected by end of life issues. Social work practice settings include health and mental health agencies, hospitals, hospices, home care, nursing homes, day care and senior centers schools, courts, child welfare and family service agencies, correctional systems, agencies serving immigrants and refugees, substance abuse programs, and employee assistance programs.

Social workers are challenged to provide expertise and skill in palliative and end of life care. At the same time, they have the opportunity to influence a range of professionals, consumers, and laypersons regarding care of the dying and the bereaved. The need for social workers trained and skilled in working with palliative and end of life care situations has increased because of advancements in medical technology combined with rising rates of chronic illness.

End of life care is a growing area of practice, and social workers may feel unprepared to deal with the complex issues it encompasses (Raymer 1999, Christ and Sormanti, 1999). These standards are designed to enhance social workers’ awareness of the skills, knowledge, values, methods, and sensitivities needed to work effectively with clients, families, health care providers, and the community when working in end of life situations.

Definitions

1. End of Life Care

End of life care refers to the approach to dying and death in the life of an individual. Whether sudden or expected, the end of an individual's life has a great impact on that individual and his or her family system.

Ends of life decisions encompass a broad range of medical and psychosocial determinations that each individual must make before the end of his or her life. Individuals may address such decisions through advance planning, or in emergencies, when careful consideration is not possible, they may leave the difficult decisions to be made, in anguish, by family members and friends who are ill prepared to decide what their loved ones might have wanted. Such decisions may include where one plans to spend the final months before death and the degree of self-sufficiency one wishes at that time. The use of personal, family, and societal resources to attain these decisions may change, depending on the course of a particular illness, and are among some of the most important decisions individuals and family members may face.

End of life decision making is a health care matter. End of life care crosses ethical, religious, cultural, and emotional areas. The complexity of issues covers the allocation of individual, family, and societal resources. It concerns individuals' deepest and most dearly held fears, values, and beliefs. End of life care remains delicate and often controversial. 

There is increasing agreement that coming to terms with end of life issues, making informed decisions, ensuring that loved ones are untroubled by these decisions, and that society honors them, are vital life tasks for everyone. It is with just such a constellation of responsibilities that social work's values and skills can make a significant contribution (Kaplan, 1995).

2. Palliative Care

Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and comprehensive assessment, and treatment of pain and other physical, psychosocial, and spiritual problems. Palliative care:

• Provides relief from pain and other distressing symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten or postpone death
• Integrates the psychological and spiritual aspects of patient care
• Offers a support system to help patients live as actively as possible until death
• Offers a support system to help the family cope during the patient’s illness and in their own bereavement
• Uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated
• Enhances quality of life and may also positively influence the course of illness
• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications (World Health Organization, 2003)

3. Hospice and Palliative Care

Considered the model for quality, compassionate care for people facing a life-limiting illness or injury, hospice and palliative care involve a team-oriented approach to expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient's needs and wishes. Support is provided to the patient's loved ones as well. At the center of hospice and palliative care is the belief that each of us has the right to die free of pain, with dignity, and that our families should receive the necessary support to allow us to do so.

Hospice focuses on caring, not curing and, in most cases, care is provided in the patient's home. Hospice care also is provided in freestanding hospice centers, hospitals, and nursing homes, and other long-term care facilities. Hospice services are available to patients of any age, religion, race, or illness. Hospice care is covered under Medicare, Medicaid, most private insurance plans, HMOs, and other managed care organizations.

Palliative care extends the principles of hospice care to a broader population that could benefit from receiving this type of care earlier in their illness or disease process. No specific therapy is excluded from consideration. An individual’s needs must be continually assessed, and treatment options should be explored and evaluated in the context of the individual’s values and symptoms. Palliative care, ideally, would segue into hospice care as the illness progresses (National Hospice and Palliative Care Organization, 2003).

4. Bereavement

Bereavement has been defined by several experts as the objective situation of a person who has experienced the loss of a significant person or other attachment figure.

5. Grief

Grief is a reaction to loss. Grief is an individual experience for each person who has sustained a loss. Certain losses affect entire group systems such as families, communities, cultures, and countries. Grief affects persons from every standpoint including the physical, emotional, behavioral, cognitive, and spiritual. 

NASW endorses the Last Acts Precepts for Palliative Care. (The precepts can be obtained from http://www.lastacts.org)

Background

During the past decade, consumer advocacy groups, health professional organizations, and government agencies have paid increased attention to the quality and accessibility of care at the end of life. The result has been that professions involved in care delivery more closely scrutinize their own ability to train members of their respective disciplines, and to contribute to the building of a knowledge base for excellence in care of the dying. Social work is no exception.

A 2002 Social Work Leadership Summit on End of Life and Palliative Care addressed the need for a formalized collaborative effort in the social work profession that focuses on palliative and end of life care. During this meeting, participants designed an agenda for the profession to improve care for the dying and their families, and to elevate social work’s role and contributions in this arena (Project on Death in America, 2002).

Building on this foundation, the National Association of Social Workers (NASW) has developed Standards for Social Workers in Palliative and End of Life Care as a useful practice tool for social workers. The standards reflect core elements of social work functions in palliative and end of life care and professional social work practice, and are targeted toward the social worker practicing in various settings dealing with these issues. For many practicing social workers in palliative and end of life care, these standards will reinforce current practices. For others, they will provide an objective to achieve and guidelines to assist in practice.

Guiding Principles

Social workers have unique and in-depth knowledge of, and expertise in working with, ethnic, cultural, and economic diversity; family and support networks; multidimensional symptom management; bereavement; interventions with trauma and disaster relief; interdisciplinary practice; interventions across the life cycle; and systems interventions that address the fragmentation, gaps, and insufficiency in health care. These are critical areas for implementing change in palliative and end of life care.

Social workers also have expertise in analyzing, influencing, and implementing policy change and development at local, state, and federal levels that can be used to make important improvements in the care of the dying. Social work research in the care of the dying is also developing and addressing many previously overlooked areas of end of life care, such as issues concerning ethnic, cultural, and economic diversity, substance abuse, incarceration, interventions at different life cycle stages, problem-solving interventions, and intervention in community contexts.

Social workers are concerned with enhancing quality of life and promoting well-being for individuals, families (defined broadly), and caregivers. When confronting issues related to palliative and end of life care, social workers have a multidimensional role as clinicians, educators, researchers, advocates, and community leaders.

The scope of social work in palliative and end of life care extends across many practice settings and populations, and requires intervention at the individual, family, group, community, and organizational levels. These standards consider practice within palliative and end of life care and relevant to death-specific loss situations and their aftermath.

STANDARDS

Standards for Professional Practice

Standard 1. Ethics and Values

The values, ethics, and standards of both the profession and contemporary bioethics shall guide social workers practicing in palliative and end of life care. The NASW Code of Ethics (NASW, 1999) is one of several essential guides to ethical decision-making and practice.  

Interpretation:

Social workers who practice in palliative and end of life care must be prepared to do so, as the area of practice is challenged with ethical dilemmas, value conflicts, and questions related to religion and the meaning of life. Specialized training beyond the master’s degree is required to be an effective practitioner.

The minimal knowledge base needed for work in this practice area includes an understanding of the following basic ethical principles:

• Justice: the duty to treat all fairly, distributing the risks and benefits equally
• Beneficence: the duty to do good, both for the individual and for all
• Nonmaleficence: the duty to cause no harm, both for individuals and for all
• Understanding/tolerance: the duty to understand and to accept other viewpoints, if   reason dictates that doing so is warranted
• Publicity: the duty to take actions based on ethical standards that must be known and    recognized by all that are involved
• Respect for the person: the duty to honor others, their rights, and their       responsibilities; showing respect for others implies that we do not treat them as a mere means to our end.
• Universality: the duty to take actions that hold for everyone, regardless of time, place, or people involved
• Veracity: the duty to tell the truth
• Autonomy: the duty to maximize the individual's right to make his or her own      decisions
• Confidentiality: the duty to respect privacy of information and action
• Equality: the duty to view all people as moral equals
•   Finality: the duty to take action that may override the demands of law, religion, and
• social customs

In addition, the social worker working in palliative and end of life care will be expected to be familiar with the bioethical considerations common in palliative and end of life care. Some examples include the right to refuse treatment; assisted suicide; proxy decision making; and withdrawal of treatment, including termination of ventilator support and withdrawal of fluids and nutrition. Particular consideration should be given to special populations, such as people with mental illness, people with mental retardation, individuals whose competency is questioned, children, and other groups who may lack decisional capacity.

Standard 2. Knowledge

Social workers in palliative and end of life care shall demonstrate a working knowledge of the theoretical and biopsychosocial factors essential to effectively practice with clients and professionals.

Interpretation:

The social worker possesses knowledge about navigating the medical and social systems that frequently present barriers to the client. Social workers have expertise in communication, both within families and between the client/family and the health care or interdisciplinary team. Drawing on knowledge of family systems and interpersonal dynamics, the social worker is able to examine the family’s experience in a unique way, to conduct a comprehensive assessment, and to guide the team in their interactions. Social work’s view includes an appreciation of the socioeconomic, cultural, and spiritual dimensions of the family’s life. As experts at helping individuals and families maximize coping in crisis¾and at addressing the psychosocial domains of symptoms and suffering, as well as the experience of grief and loss¾social workers are able to provide intensive counseling for those confronted by life-limiting illnesses and the complex problems imposed by illness.

Essential areas of knowledge and understanding about palliative and end of life care include:

• The multifaceted roles that social workers may use in palliative and end of life care
• The physical and psychological stages of the dying process
• The physical and psychological manifestations of pain
• The range of psychosocial interventions that can alleviate discomfort
• The biopsychosocial needs of clients and their family members
• The impact of ethnic, religious, and cultural differences on the dying and death experience
• The range of settings for palliative and end of life care, including home care and hospice settings
• The available community resources and how to gain access to them
• The impact of financial resources on family decision-making at the end of life
•   The development, use, support and revision of advance directives throughout the progression of the illness
•   The accreditation and regulatory standards governing settings providing palliative and end of life care
•   The needs faced by members of special populations and their families, such as children; those with physical, developmental, mental, or emotional disabilities; and those in institutionalized, nonmedical setting

Standard 3. Assessment

Social workers shall assess clients and include comprehensive information to develop interventions and treatment planning.

Interpretation:

Assessment is the foundation of practice. Social workers plan interventions with their clients based on assessments, and must be prepared to constantly re-assess and revise treatment plans in response to newly identified needs and altered goals of care. Comprehensive and culturally competent social work assessment in the content of palliative and end of life care includes considering relevant biopsychosocial factors and the needs of the individual client and the family (as defined by the client). 

Areas for consideration in the comprehensive assessment include:

• ·   Relevant past and current health situation (including the impact of problems such as pain, depression, anxiety, delirium, decreased mobility)
• ·   Family structure and roles
• ·   Patterns/style of communication and decision making in the family
• ·   Stage in the life cycle, relevant developmental issues
• ·   Spirituality/faith
• ·   Cultural values and beliefs
• ·   Social supports, including support systems, informal and formal caregivers involved, resources available, and barriers to access
• ·   Past experience with illness, disability, death, and loss
• ·   Coping style, history, and crisis management skills
• ·   Unique needs and issues relevant to special populations such as refugees/immigrants, children, individuals with severe and persistent mental illness and homeless people
• ·   Communicating the client's psychosocial needs to the interdisciplinary team

Standard 4. Intervention/Treatment Planning

Social workers shall incorporate assessments in developing and implementing intervention plans that enhance the clients' abilities and decisions in palliative and end of life care. Social workers shall be skilled in grief theory and practice.

Interpretation:

Social workers in all practice areas use various theoretical perspectives and skills in delivering interventions and developing treatment plans.Social workers use their initial assessments and team input in developing plans of care and offering interventions. Social workers must be able to adapt techniques to work effectively with individuals from different age groups, ethnicities, cultures, religions, socioeconomic and educational backgrounds, lifestyles, and differing states of mental health and disability and in diverse nonmedical care settings.

Essential skills for effective palliative and end of life care include:

• Ability to recognize signs and symptoms of impending death and prepare family members accordingly
• Competence in facilitating communication among clients, family members, and members of the care team
• Competence in determining appropriate interventions based on the assessment
• Competence in advocating for clients, family members, and caregivers for needed services, including pain management
• Competence in navigating a complex network of resources and making appropriate linkages for clients and family members
• Competence in supporting families, including anticipatory mourning, grief, bereavement and follow-up services

Interventions commonly provided in palliative and end of life care include:

• Individual counseling and psychotherapy
• Family counseling
• Family-team conferencing
• Symptom management
• Support groups, bereavement groups
• Case management and discharge planning
• Decision making and the implications of various treatment alternatives
• Resource counseling (including caregiving resources; alternate level of care options such as long term care or hospice care; financial and legal needs; advance directives; and permanency planning for dependants)
• Client advocacy/navigation of systems

Standard 5. Attitude/Self-Awareness 

Social workers in palliative and end of life care shall demonstrate an attitude of compassion and sensitivity to clients, which respects the client's right to self-determination and dignity. Social workers shall be aware of their own concepts and feelings regarding palliative and end of life care and how their personal self may influence their practice.

Interpretation:

To practice effectively, social workers in palliative and end of life care must demonstrate empathy and sensitivity in responding to the pain and distress of others. Specific social work attitudes and responses that encompass compassion and sensitivity in caring for clients shall include, but not necessarily be limited to, the following:

• Courage on a daily basis, to be able to confront human suffering
• Consistent individualization of client/client system needs as the primary care unit
• Facilitative interactions with clients/client systems 
• Ability to communicate and work collaboratively as an interdisciplinary team member to achieve care goals
• Willingness to advocate for holding the focus in palliative and end of life care on client/client system choices, preferences, values, and beliefs
• Awareness of compassion fatigue and the ethical responsibility to mitigate this condition
• Confidence and competence to enhance professional identity and the importance of social work roles in palliative and end of life care

Standard 6. Empowerment and Advocacy

The social worker shall advocate for the needs, decisions, and rights of clients in palliative and end of life care. The social worker shall engage in social and political action that seeks to ensure that people have equal access to resources to meet their biopsychosocial needs in palliative and end of life care.

Interpretation:

Social workers shall engage in social and political action that seeks to ensure that all populations with whom they work have equal access to the resources, services, and opportunities they require to meet their biopsychosocial needs in palliative and end of life care. In advocacy efforts, social work provides unique and essential skills and perspectives such as a rich understanding of the person-in-environment, communication skills, expertise in group process and systems, a social justice commitment, strong values and ethics background, and a broad psychosocial and spiritual knowledge base. Crucial components of effective empowerment and advocacy include identifying and defining needs from the client’s perspective, including cultural and spiritual beliefs, and communicating the concerns and needs of the client to decision-makers and providers of care. Advocacy and empowerment come into practice at both the micro and macro level. 

Practice examples include linking clients with resources, identifying and supporting family of choice, assisting individuals and families negotiate their goals of care, navigating through systems of care, pain and symptom management, quality-of-life issues, team conferencing, consulting, and caregiver support. Broader examples of advocacy include advocacy with special populations, institutions, and communities, as well as the health care policy arenas. It is essential to identify barriers to effective palliative and end of life care at the macro level by addressing issues of financial inequities, lack of culturally competent services and other access issues, and to address those barriers so that individuals experience the highest quality of life possible to the end of life.

Standard 7. Documentation

Social workers shall document all practice with clients in either the client record or in the medical chart. These may be written or electronic records.

Interpretation:

Ongoing documentation of social work service should reflect the assessment, issues addressed, treatment offered, and plan of care, and must assure continuity of care between all settings (for example, hospital to hospice). 

The transfer of medical records must be conducted in compliance with current federal and state law with an emphasis on confidentiality/privacy of medical information. Compliance with agency policy, particularly regarding the transfer of electronic records, is essential.

Standard 8. Interdisciplinary Teamwork

Social workers should be part of an interdisciplinary effort for the comprehensive delivery of palliative and end of life services. Social workers shall strive to collaborate with team members and advocate for clients’ needs with objectivity and respect.

Interpretation:

Interdisciplinary teamwork is an essential component in palliative and end of life care. Social workers are integral team members. Social workers should advocate for the views and needs of individuals and families in palliative and end of life care within the team, and should encourage and assist clients in communicating with team members. Often, clients, families, and team members rely on the expertise of the social worker in problem solving concerns, conflicts, and needs in palliative and end of life care. 

The team role of the social worker is to identify resources and assist clients and families in gaining access to these resources. The social work role calls for a collaborative nature with an ability to empower and advocate for clients and families when necessary. The psychosocial expertise of the social worker affords ability to deliver support and counseling services as part of the interdisciplinary team. 

Standard 9. Cultural Competence

Social workers shall have, and shall continue to develop, specialized knowledge and understanding about history, traditions, values, and family systems as they relate to palliative and end of life care within different groups. Social workers shall be knowledgeable about and act in accordance with the NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001).

Interpretation:

Social workers use special knowledge of how individuals and families are influenced in palliative and end of life care by their ethnicity, culture, values, religious and health beliefs, and economic situations. Many cultures maintain their own values and traditions in the areas of palliative and end of life care. 

Culture influences individuals' and families' experience in palliative and end of life care. Social workers should consider culture in practice settings involving palliative and end of life care. Because each cultural group has its own views about palliative and end of life practices, social workers shall understand how these views affect individuals’ response to dying, death, illness, loss, and pain.

Social workers who understand how culture affects the end of life experience of an individual and family will be able to assist clients manage the psychosocial impact of pain, dying and death. Therefore, social workers should be familiar with the practices and beliefs of the cultural groups with whom they practice to deliver culturally sensitive services in palliative and end of life care.

Standards for Professional Preparation and Development

Standard 10. Continuing Education

Social workers in palliative and end of life care shall assume personal responsibility for their continued professional development in accordance with the NASW Standards for Continuing Professional Education (NASW, 2002) and state requirements.

Interpretation:

Social workers must continue to grow in their knowledge of theories and practices in palliative and end of life care to effectively work with individuals and families. Palliative and end of life care is a rapidly expanding and changing field, which crosses all practice settings. Social workers must be clinically competent and up-to-date with the most effective practice skills and the broadest possible knowledge base to work with clients at the vulnerable time at the end of life.

Numerous opportunities in professional development are available through NASW and other professional organizations, institutions, coalitions, and service agencies at local, state, and national levels. Social workers should participate in and contribute to professional conferences and training activities on a regular and consistent basis to provide the highest possible level of care. Social workers should also assist in identifying palliative and end of life professional development needs by participating in research and encouraging NASW and other organizations and institutions to provide appropriate education for the field. 

Standard 11. Supervision, Leadership, and Training

Social workers with expertise in palliative and end of life care should lead educational, supervisory, administrative, and research efforts with individuals, groups, and organizations.

Interpretation:

Social workers shall provide their expertise in the areas of palliative and end of life care with individuals, groups, and organizations. Social workers shall offer training and mentoring opportunities to beginning social workers or those transitioning into palliative and end of life care. When able, skilled social workers shall work in conjunction with schools of social work to enhance and encourage interest in the specialization of palliative and end of life practice. 

Social workers shall offer supervision to practicing social workers, interns, and students to provide a guiding expertise to clinicians in this area. Social workers who provide supervision in the field of palliative and end of life care should have the necessary knowledge base, experience, and competence in this practice area.

Social workers shall contribute to research initiatives in palliative and end of life care, not only to demonstrate the efficacy of the social work profession and social work interventions, but also to advance the recognition among other professions of the essential need to address psychosocial needs of individuals and their families in palliative and end of life care.

References

 

Christ, G., & Sormanti, M. (1999). Advancing social work practice in end-of- life care. Social Work in Health Care, 30 (2), 81- 99.

 

Csikai, E.L. & Raymer, M. (1999). The Social Work End of Life Care Education Project: An assessment of educational needs. Insights. Retrieved October 6, 2003, from http://www.nhpco.org/files/public/InsightsIssue2_2003Social_Worker_pp8-9.pdf

 

Field, M. J., & Behrman, R. E. (Eds.). (2002). When children die: Improving palliative and end of life care for children and their families. Washington, DC: National Academy of Sciences, Institute of Medicine, Committee on Palliative and End of Life Care for Children.

 

Field, M. J., & Cassel, C. K. (Eds.). (1997). Approaching death: Improving care at the end of life. Washington, DC: National Academy of Sciences, Institute of Medicine.

 

Kaplan, K. O. (1995). End of Life decisions. In R. L. Edwards (Ed.-in-Chief), Encyclopedia of social work (19th ed., Vol. 1, pp. 856–868). Washington, DC: NASW Press.

 

National Association of Social Workers. (1999). NASW code of ethics. Washington, DC: Author.

 

National Association of Social Workers. (2002). NASW standards for continuing professional education. Washington, DC: Author. 

 

National Association of Social Workers. (2001). NASW standards for cultural competence in social work practice. Washington, DC: Author.

 

National Hospice and Palliative Care Organization. (2001). Competency-based education for social workers. Arlington, VA: Author.

 

National Hospice and Palliative Care Organization. (2003). Hospice and palliative care. Retrieved September 3, 2003, from http://www.nhpco.org/i4a/pages/index.cfm?pageid=3281

 

Project on Death in America. (2002). Social Work Summit on End of Life and Palliative Care. (Press release). Retrieved October 6, 2003, from http://www.swlda.org/Summit.htm

 

Taylor-Brown, S., Blacker, S., Walsh-Burke, K., Altilio, T., & Christ, G. (2001). Care at the end of life (Best Practice Series: Innovative Practice in Social Work). Philadelphia: Society of Social Work Leadership in Health Care.

 

World Health Organization. (2003). WHO definition of palliative care. Retrieved September 23, 2003, from http://www.who.int/cancer/palliative/definition/en/

Resources

NASW has developed several policy statements, which are published in Social Work Speaks: National Association of Social Workers Policy Statements (2003-2006), related to palliative and end of life care. These statements are listed below:

• Client Self-Determination in End of Life Decisions
• Health Care
• Hospice Care
• Long-Term Care
• Managed Care

Acknowledgements

NASW would like to acknowledge the work of the following individuals for their contributions to the "Social Work Scope of Practice and Competencies Essential to Palliative Care, End of Life Care and Grief Work" (as yet unpublished) as part of the National Social Work Leadership Summit on Palliative and End of Life Care in conjunction with the Last Acts Provider Education Committee, the Duke Institute on Care at the End of Life, and the Soros Foundation's Project on Death in America. The authors are Lisa P. Gwyther, Terry Altilio, Susan Blacker, Grace Christ, Ellen Csikai, Nancy Hooyman, Betty Kramer, Julie M. Linton, Mary Raymer, and Judy Howe. 

The work of the aforementioned authors provided the foundation of the NASW Standards of Practice for Social Workers in Palliative and End of Life Care.

NASW would also like to thank and acknowledge Project on Death in America for the grant to fund the development of practice standards for social workers in palliative and end of life care.