Very comprehensive of the social worker role in serious illness and palliative care. Thank you for bringing together well respected social workers to complete this effort. I worked in pediatric palliative care for 22 years as a social worker and bereavement coordinator.

Nancy Carst, MSW, LISW-S, CT, APHSW-C

Hello,
My colleagues and I would like to sincerely thank the NASW Task Force for preparing and drafting this amazing document on NASW Standards for Practice in Serious Illness: Palliative and Hospice Social Work.

Working firsthand with physicians to improve their access to palliative care, we recognize that having such practice standards in place is crucial. After sharing the document with fellow social workers and colleagues at my placement, we collectively want to suggest a few enhancements to refine the wording.

We recommend including “advanced practice providers, chaplains, and other essential team members” on page 6, lines 95–96, with the intention that “advanced practice providers” refers to nurse practitioners (NPs) and physician assistants (PAs).

Our second recommendation is to eliminate the word “competence” on page 15, line 173. Instead, we suggest shifting to “Cultural Humility and Accountability” (or “Cultural Sensitivity and Accountability”). The term “cultural competence” emphasizes knowledge and skills about different cultures, implying a level of mastery that can be achieved. However, the alternative wording encourages continuous learning and curiosity rather than suggesting a point at which learning is complete. This change would also better align with language used later in the document, specifically on page 35, line 625.

We also wanted to bring to your attention that the NASW Standards and Indicators for Cultural Competence (2015) may warrant updating due to these same language considerations.

Additionally, on page 17, line 215, we suggest adding “advanced practice providers” to the core palliative care team.

Another recommendation is for page 22, under the heading “Ethical Responsibilities to Colleagues”. This section was incredibly in-depth and critical to include, as our responsibilities to colleagues are often overlooked. We recommend adding specific language about the need to keep colleagues updated regarding new information shared by the patient/caregiver(s) and to collaborate and communicate frequently as the patient’s care evolves.

Lastly, we deeply appreciated and honored the section on “Interprofessional Teams” on page 33, which highlights the importance of recognizing biased and potentially harmful language and modeling reframed language for the team and/or caregivers.

Thank you for considering our comments and recommendations for this document. We hope they are helpful!
Have a great day!

Best,
Hana Kisswani, BSW Student Representative,

The only addition I might consider is screening for financial exploitation and elder abuse. I didn’t see this explicitly mentioned, but I wonder if there’s a correlation between elder abuse, financial exploitation, and marginalized populations. I bring this up as a potential area for further exploration. I hope this suggestion is helpful in some way—overall, I think the document is fantastic!
Warm regards,
Amanda Jones, LCSW-S (Texas)

Limited Practice Examples

The NASW Standards document establishes a strong theoretical framework for palliative and hospice social work, but it would be far more effective with the addition of real-world examples. While the document thoroughly outlines guiding principles and ethical standards, much of it remains theoretical. Without concrete applications, social workers may find it challenging to translate these standards into their daily practice.

Currently, the document presents fundamental frameworks and ethical considerations, yet it does not illustrate how these principles apply in practice. Standard 3 on cultural and linguistic competence emphasizes the importance of cultural awareness in end-of-life care, but it lacks practical examples of how social workers might approach these situations. Without context, practitioners may struggle to implement these principles effectively, especially in culturally diverse settings.

The Value of Practical Examples

Adding real-world case examples would enhance the document's usefulness by:

1. Bridging Theory and Practice – Showing how abstract concepts translate into real-world decision-making.
2. Providing Actionable Guidance – Giving practitioners clear models for applying standards in different contexts.
3. Demonstrating Complex Problem-Solving – Showcasing how multiple ethical considerations intersect in real-life scenarios.
4. Supporting Different Learning Styles – Offering concrete examples for those who learn best through experiential or visual methods.

Suggestions for Improvement:

1. Adding brief illustrative case studies showing how specific standards apply in real-world situations, for example:
• Handling an ethical dilemma where a patient's advance directive conflicts with their family's cultural beliefs.

2. Including examples that break down the thought process behind ethical and professional decision-making, for instance:
• A case where a social worker must balance a patient's autonomy with family expectations in end-of-life care.

3. Having scenarios that illustrate how multiple NASW standards work together in real cases, for example:
• A palliative care social worker balancing cultural competency, ethical considerations, and advocacy in an end-of-life scenario.

4. Providing practical applications tailored to different care environments, for instance:
• Hospital-based palliative care – Addressing family conflicts over treatment options.
• Home hospice – Helping caregivers manage a loved one's end-of-life needs at home.
• Rural settings – Working with patients who have limited access to healthcare.
• Urban settings – Navigating diverse linguistic and cultural needs.

Respectfully,
Pedro Hernandez, MS, MSW, PhD (Mississippi)

This comprehensive document is well written. I believe it covers the primary issues that Social Workers in this area of our field are faced with daily. Thank you to all who contributed.
Grace L. Davis, LCSW-S
Texas

I work in medical aid in dying (MAiD) and I see you have a part about helping the client with decisions related to MAiD, but I don't see any advocacy about that here. I work in a county where the nearest medical provider who can write a prescription for MAiD is over 3 hours away, even though MAiD is legal in my state. Social workers can talk to medical providers and the public (I spoke at the Lion's Club, for example) to help them understand that patients should have access to all legally available options at EOL, including MAiD. Many religious organizations are actively trying to deny patients this information. In WA State, there is a law that providers must share what is legally available to patients, but this is not always enforced and some states don't have a law like this, so that's another advocacy role. (It's similar to our stance on abortions--SWs assist people with legally available reproductive options even when a religious or other organization tries to limit patient access.)

Thank you for the excellent work of the taskforce on the NASW STANDARDS FOR PRACTICE IN SERIOUS ILLNESS: PALLIATIVE AND HOSPICE SOCIAL WORK updates. The updated information on cultural competence and cultural humility is important to the work of hospice and palliative care social works and an excellent addition to the standards.

As a recently retired hospice and bereavement social worker with 20 years of experience in the field, I ask how we recognize and support the application of clinical social work for hospice social workers who come to the job with LCSWs, or for LSWs who undergo clinical supervision as part of their practice experience in ways that honor the holistic underpinnings of the hospice and palliative models of care as distinct from the traditional western biomedical focus, but also honors the experience and expertise of hospice social workers in the eyes of state licensing boards. While individual states have different credentialing requirements that are beyond the scope of this task forces work, I am requesting that you consider how the standards can begin to address this difficult topic.

I am one of many social workers who obtained their clinical licensure through clinical supervision in the hospice setting. Current changes to state licensing practices have made obtaining clinical licensure as a hospice social worker more difficult, with indication that the word “psychotherapy” needs to be in the job description. With a recognition that psychotherapy may not be part of the scope of practice of all hospice social workers, we risk losing qualified, dedicated social workers from the hospice and palliative care setting if they are unable to obtain clinical licensure after years of clinical supervision. Under clinical supervision, LSW’s are qualitied and can provide clinical levels of support, including psychotherapy in both hospice and bereavement. The American Psychiatric Association¹ and the American Psychological Association² indicate that psychotherapy may address emotional distress or emotional changes related to grief, medical illness, or the death of a loved one.

Palliative care Licensed Clinical Social Workers are now able to bill Medicare for psychotherapy services provided to patients with co-occurring behavioral health diagnosis or emergent issues. In the hospice setting, an LCSW or LSW under clinical supervision is qualified to provide psychotherapeutic support for end-of-life issues. Anxiety, sadness, and depression can be part of the existential experience of palliative care and hospice patients. End-of life decisions, crisis intervention, coping with changes in the family system, redefining hope, and undertaking life-review can all be clinical psychotherapeutic interventions provided by qualified social workers.

With respect for maintaining a holistic approach to hospice and palliative care social work that keeps us distinct from private practice guidelines, we run the risk of losing qualified professionals if they are unable to obtain clinical licensure within the hospice and palliative care setting. As we advocate for a holistic approach to total pain, we need to recognize that qualified hospice social workers provide psychotherapeutic support to seriously and terminally ill patients and families, as well as bereaved family members.

I request in addition to the excellent work already done by the taskforce to consider if wording to support the clinical work that can and does occur in the hospice and palliative care settings be included in the updated standards. I suggest areas where wording to support the clinical and at times, psychotherapeutic work being provided could be included are in NCP Domains, 4, 5, and 7, under grief and bereavement support on page 17, under professional growth on pages 33 and 34, documentation/demonstration of skills on pages 39 and 40, or supervision on page 47.

As hospice and palliative care social workers continue to work at the top of their licensure, considerations for discussing the psychotherapeutic work that takes place in the hospice, bereavement, and palliative care settings from qualified staff in the updated standards could be a step in supporting hospice and palliative care social workers with obtaining clinical licensure in an increasingly difficult licensure landscape.

Thank you for your excellent work and consideration for the suggestions in this comment.
Sincerely,
Joan A. Ordille, DSW, LCSW
New Jersey

¹American Psychiatric Association (2023). What is Psychotherapy? at https://www.psychiatry.org/patients-families/psychotherapy
²American Psychological Association (2023). Understanding psychotherapy and how it works Learn how to choose a psychologist, how therapy works, how long it lasts, and what should and shouldn’t happen during psychotherapy at https://www.apa.org/topics/psychotherapy/understanding