Support Care Cancer (2013) 21:1061–1069
DOI 10.1007/s00520-012-1626-1
ORIGINAL ARTICLE
Spirituality in palliative home care: a framework
for the clinician
Mieke Vermandere & Jan De Lepeleire &
Wouter Van Mechelen & Franca Warmenhoven &
Bregje Thoonsen & Bert Aertgeerts
Received: 14 May 2012 / Accepted: 2 October 2012 / Published online: 13 October 2012
# Springer-Verlag Berlin Heidelberg 2012
Abstract
Purpose Spiritual care at the end of life remains poorly
understood despite its promotion by the World Health Or-
ganisation. The purpose of this paper was to develop a
consensus-based framework of the main elements of spiri-
tual care in palliative home care.
Methods Expert meeting using the nominal group tech-
nique, followed by a two-stage web-based Delphi process,
was used. Experts from three stakeholder groups (physi-
cians, professional spiritual care givers and researchers)
representing two countries (Belgium and the Netherlands)
participated in this study.
Results Fourteen elements of spiritual care were retained:
(1) being sensitive to patient’s fear of the dying process; (2)
Electronic supplementary material The online version of this article
(doi:10.1007/s00520-012-1626-1) contains supplementary material,
which is available to authorized users.
M. Vermandere (*) : J. D. Lepeleire : W. Van Mechelen :
B. Aertgeerts
Department of General Practice,
Kapucijnenvoer 33 blok j bus 7001,
3000 Leuven, Belgium
e-mail: mieke.vermandere@med.kuleuven.be
J. D. Lepeleire
e-mail: Jan.DeLepeleire@med.kuleuven.be
W. Van Mechelen
e-mail: Wouter.VanMechelen@med.kuleuven.be
B. Aertgeerts
e-mail: Bert.Aertgeerts@med.kuleuven.be
F. Warmenhoven : B. Thoonsen
Radboud University Nijmegen,
P.O. Box 9101, 6500 HB( Nijmegen, the Netherlands
F. Warmenhoven
e-mail: F.Warmenhoven@anes.umcn.nl
B. Thoonsen
e-mail: B.Thoonsen@anes.umcn.nl
listening to the patient’s expectations and wishes about the
end of life; (3) giving attention to patient’s wishes about the
design of the farewell; (4) offering rituals if the patient
experiences them as meaningful; (5) listening to the stories,
dreams and passions of the patient; (6) helping the patient
find strength in inner resources; (7) connecting with the
patient in truth, openness and honesty; (8) supporting com-
munication and quality of relationships; (9) making sure the
patient feels comfortable and safe; (10) seeing spirituality as
an interwoven, though specific dimension; (11) caring for
your own spirituality; (12) knowing and accepting your
vulnerability; (13) being able to learn from your patient;
and (14) having an interdisciplinary team that is there when
needed.
Conclusions The experts agreed to the 14 main elements of
spiritual care in palliative home care. There were no differ-
ences in this regard between the stakeholder groups. This
study provides a first step towards the development of an
interdisciplinary spiritual care model in palliative home care.
Keywords Spirituality . Palliative care . Primary health
care . Interdisciplinary health team . Delphi technique
Introduction
Most individuals with advanced progressive disease pre-
fer to receive end-of-life care at home and die there, if
adequate support is available to minimise their suffering
and the burden on family care givers [1–3]. A partner-
ship between general practitioners (GPs) and interdisci-
plinary palliative care experts is needed to effectively
manage multiple disease symptoms, which are often
clustered together [4]. Whilst managing complex symp-
toms, the teams must also be skilled in responding to
emotional and spiritual distress [4].
1062 Support Care Cancer (2013) 21:1061–1069

Before the publication of the definition of spirituality by the palliative home care team agree to act on the basis of the same
European Association of Palliative Care (EAPC) [5], the field interpretation of spiritual care. In this article, we have attemp-
of spirituality in research has long been hampered by a lack of ted to arrive at a consensus-based description of spiritual care
conceptual clarity about the nature of spirituality itself [6]. We within the context of palliative home care.
do not discuss the interpretation of spirituality in this paper
because we used the definition of the EAPC, published in the
European Journal of Palliative Care [5]: “spirituality is the Methods
dynamic dimension of human life that relates to the way
persons (individuals and community) experience, express Nominal group technique
and/or seek meaning, purpose and transcendence, and the
way they connect to the moment, to self, to others, to nature, Attempting to define ‘spiritual care’ is a conceptually com-
to the significant and/or the sacred (…) [5]. plex and intricate undertaking, and there are no examples in
Meanwhile, spiritual care at the end of life remains poor- the research literature that we can turn to for authoritative
ly understood despite its promotion by the World Health guidance (Fig. 1). Therefore, we have used a qualitative
Organisation and the recent publication of an American
consensus document [7, 8]. It is unclear how this type of
care is actually delivered [9, 10]. Elements of spiritual care
Hummel et al. [11] found that nearly two thirds of the in palliative care
articles that contained ‘spiritual care’ in the title had been
published in nursing journals, and nearly 10 % had been
published in medical journals. This study reveals that spir-
itual care is more widely discussed in nursing than in any 35 experts Nominal Group Technique
other health care profession. Nursing studies define spiritual
care as referring patients to others (i.e. to spiritual care
providers), facilitating religious rituals and practices, and N = 149
being present to patients [12]. elements
Edwards et al. performed a qualitative evidence synthesis
about the understanding of spirituality and the potential role
of spiritual care in end-of-life and palliative care [13]. This
review of 11 patient articles and eight health care provider Authors Summary of highest ranked elements
articles stresses the relational quality of spiritual care in
palliative care. This is often realised in the manner in which
physical care is given, with a focus on presence, journeying N = 30
together, listening, connecting, creating openings, and en-
gaging in reciprocal sharing and common nurturing elements
[14–32]. Furthermore, it involves assisting patients to find
meaning, hope and strength [25, 27, 29–32].
Daaleman et al. [26] published an exploratory study of Delphi round 1; exclusion of elements with
31 experts
spiritual care at the end of life in which they interviewed 12 equimedian 7; addition of 1 new element
clinicians and other health care workers who had been chosen
as spiritual care givers by dying patients and their family N = 21
members. A total of 38 patients and 65 family caregivers
identified 237 spiritual care givers; 95 (41 %) of these were elements
family or friends, 38 (17 %) were clergy, and 66 (29 %) were
clinicians and other health care workers. The analysis of the
Delphi round 2; exclusion of elements with
interviews resulted in the identification of three major themes 25 experts
equimedian 7
that were reported as core elements of spiritual care: being
present, opening eyes and co-creating [26].
The literature illustrates the lack of consensus about spiri- N = 14
tual care within the context of palliative care. Depending on the elements
perspective from which spiritual care is highlighted within this
context, its definition and content can differ. However, it is of
the greatest importance that all members of an interdisciplinary Fig. 1 Flowchart of methods
Support Care Cancer (2013) 21:1061–1069
research method, i.e. the nominal group technique (NGT),
which enables researchers to gather information from rele-
vant experts [33, 34]. We have followed the methodology
described in Stolper et al. [35]. NGT facilitates creative
problem solving by means of judgmental decision making
in situations where routine answers are inadequate [36–38].
NGT involves four phases: generating ideas, recording
them, evaluation and a group decision phase. These four
phases will be described in detail below.
Selection of experts
We purposively sampled well-known opinion leaders and
experts on spiritual care and palliative care in the Nether-
lands and Belgium. The inclusion criteria were familiarity
with or awareness of spiritual care and practical or research
experience in palliative care. All authors had to agree that
the invited persons were ‘experts’ in the field. We
approached 67 experts by e-mail from different professional
groups representing both academic and community pallia-
tive care practice. Thirty-five of the experts were willing to
participate: 13 Belgian experts and 22 from the Netherlands.
They received an invitation to a meeting in a conference
centre in Belgium, including information about the purpose
of the meeting and the procedure. Three stakeholder groups
were represented: 17 physicians (49 %; 12 GPs with special
interest in palliative care, 2 geriatricians, 2 palliative care
physicians and 1 oncologist); 9 professional spiritual care
givers (26 %; hospital chaplains both from catholic and
humanistic denomination); and 9 researchers (26 %; in
psychology, religion, palliative care and ethics research).
There were 20 men (57 %) and 15 women (43 %). There
was no financial or other compensation. One researcher and
one professional spiritual care giver are also psychologists.
Due to organisational and practical reasons (e.g. the ideal
number of participants in a NGT is not larger than 12), not
all professional groups working in palliative home care (e.g.
nurses, physiotherapists, social workers, volunteers, etc.),
neither patients, are represented in our expert sample. We
chose physicians and professional spiritual care givers be-
cause they are mostly the ones who take responsibility for
the spiritual care plan. We also approached researchers in
spiritual and palliative care because they are used to think-
ing on a ‘meta-level’ and they could give us some interest-
ing insights based on their research experiences.
NGT sessions
The experts were divided into four groups. The stakeholder
groups were not equally distributed between countries, but
there was a balanced distribution between the four NGT
groups as to the three stakeholder groups, the Belgian and
the Dutch professionals, and the men and the women, resulting
1063
in two groups of eight, one group of nine and one group of ten
experts. Two NGT sessions (involving groups 1 and 2) were
chaired by experienced and independent moderators, each
assisted by one of our authors (FW, JDL) using flip charts.
The other two NGT sessions (groups 3 and 4) were each
chaired by one of our other authors (BA, WVM), also using
flip charts. They were each also assisted by one of our other
authors (BT). The authors did not intervene in the discussion.
The scenario for all the NGT sessions was developed in ad-
vance to ensure that all phases of NGT would be completed.
In the first phase, ‘generating ideas’, the moderator
explained the procedure and asked the participants to write
down for themselves in silence what they considered to be ‘the
main elements of spiritual care within the context of palliative
home care’. We explained the home care context as a non-
institutional context, but did not further specify the context in
terms of symptom burden, cancer or non-cancer patients, etc.
Stimulated by the written information (purpose of the meet-
ing, methodology of NGT and research question) they had
received from beforehand, some of the experts had already
formed specific ideas in their mind. The same procedure was
repeated, with the participants being asked to write down what
they considered to be ‘the relevant outcome measures of
spiritual care within the context of palliative home care’ (this
second issue will be presented in another paper).
In the second phase, ‘recording’, the members of the
group were engaged in a round-robin feedback session to
record each proposed ‘element of spiritual care’ concisely.
These elements of spiritual care in palliative home care were
noted and numbered on flip charts (50, 32, 36 and 31
elements, respectively, for groups 1–4).
In the third phase, ‘evaluation’, each element recorded was
clarified and evaluated by means of a group discussion in
which those present weighed the arguments for and against
the proposed elements of spiritual care in palliative home care.
The purpose of the fourth and final phase, ‘prioritisation’,
was to aggregate the judgments of individual members in order
to determine the relative importance of the elements of spiritual
care in palliative home care. In this phase, the experts voted
individually to prioritise the elements, and their votes were
used to arrive at a group decision on the most relevant elements
of spiritual care. Each member selected five elements and
wrote the numbers down, starting with the most important
element and ending with the least important one. The numbers
of the votes were noted on a flip chart and an overall prioritised
list was drawn up. Some elements received no votes and stayed
at the bottom of this list. Afterwards, a brief discussion was
held to evaluate the procedure and the outcome.
Analysis of NGT sessions
Once all the NGT sessions were completed, we compared all
the proposed elements of spiritual care in palliative home
1064
care and categorised them. The results of the four groups
were not entirely comparable since each group had pro-
duced a number of unique ideas. Therefore, a ranking of
all the elements across the four groups was impossible. Four
of the authors (MV, WVM, BA, JDL) analysed the results
independently. Following a group discussion, the highest
ranked elements of the four groups were categorised and
summarised.
Delphi consensus process
Using the NGT results of the four groups, a Delphi process
was performed to check the agreement of the experts with
the summary of elements of spiritual care. For this Delphi
process, we invited the same 35 experts that participated in
the NGT (17 physicians, 9 professional spiritual caregivers
and 9 researchers) to minimise the risk of misunderstanding
the elements yielded with the NGT. Indeed, during the
Delphi consensus process, there was an option for changing
the formulation of the elements. Therefore, we needed the
same experts to explain to the other experts—if needed—the
elements of spiritual care they produced themselves during
the NGT. We followed the methodology described in Elwyn
et al. [39] for the Delphi process. The process comprised the
following steps.
Describing elements of spiritual care in palliative home
care
We summarised and categorised the highest ranked elements
of the four nominal groups. We subjected this list of ele-
ments to iterative consultation about comprehensiveness
and subsequent editing by the ‘Palliative Care’ Steering
Committee of our department (KU Leuven). This committee
consists of ten palliative care experts from different disci-
plines (a palliative care physician, a radiotherapist, a psy-
chologist, an ethicist, two GPs, a nurse, a theologian, a
geriatric and a professional spiritual care giver). We estab-
lished a final set of 30 elements of spiritual care in palliative
care, categorised in ten domains.
Establishing participant stakeholder groups
We considered the same three stakeholder groups as in the
NGT to be relevant: physicians, professional spiritual care
givers and researchers. We decided that the elements of
spiritual care in palliative care would represent views among
stakeholder groups equally on the basis of the view that
those elements should reflect a balance, if possible, between
positions taken by physicians, professional spiritual care
givers and researchers at large concerning the attribution
of priorities and choices. We based the statistical analysis
on this intent. The physician group was overrepresented, but
Support Care Cancer (2013) 21:1061–1069
we weighted the group ratings to ensure equal contribution
(see “Analysis of ratings”).
Rating elements of spiritual care in palliative home care
We invited the experts by e-mail to complete a two-stage rating
process and gave them access to a password-protected web site
[40]. For each element of spiritual care in palliative home care,
we asked the participants to rate the relevance of the element
on a scale ranging from 10not important to 90very important.
The raters could also choose to add free text comments. We
sent two e-mail reminders in each round. At the second round,
we presented the raters with the (anonymous) written com-
ments for each of the elements of the first round.
Analysis of ratings
To account for unequal stakeholder groups, the equimedian
was calculated. Disagreement was obtained using the defi-
nition of Elwyn et al. [39], with disagreement in the event
that 30 % or more of the ratings are in the lower third and
30 % or more of the ratings are in the upper third. As an
additional indicator of disagreement, we calculated the stan-
dard deviation per item and the range (maximum value−
minimum value). Larger values of both measures indicate
more spread and, therefore, less agreement.
The Kruskal–Wallis test was used to analyse the differ-
ence between the three stakeholder groups on each of the
items. To correct for multiple testing, we applied the false
discovery rate, where a significance level of 5 % was
assumed.
Finally, we performed a sensitivity analysis by obtaining
the equimedians when one stakeholder group was omitted.
All analyses were performed using SAS software, version
9.2, of the SAS System for Windows.
Results
Nominal group technique
The four groups produced 149 elements of spiritual care in
palliative home care (Appendix in Electronic supplementary
material). There was considerable overlap in the ten highest
ranked elements of each group (Table 1). We distinguished
30 main elements, which were related to ten domains.
Delphi consensus process
Table 2 describes the participants in the first and second
rounds. Of those invited, 31 participants (86.1 %) provided
ratings at the first round; 25 of 31 (80.6 %) participants
completed both rating rounds.
Support Care Cancer (2013) 21:1061–1069 1065

Table 1 Nominal groups’ elements of spiritual care in palliative home care: highest ranked elements

Scores No. of No. of scores/ Overall

scores no. of experts score

Group 1 items
Patient being comfortable 5+5+5 3 0.375 15
Giving meaning 5+4+3 3 0.375 12
Being sensitive to patient’s inner resources 5+1+3 3 0.375 9
Fear of dying and fear of the hereafter 5+4 2 0.25 9
Connecting with the patient in truth, openness and honesty 4+3 2 0.25 7
Hope 5+2 2 0.25 7
Interdisciplinary team that is there when needed 4+2 2 0.25 6
Rituals 3+2 2 0.25 5
Convictions and philosophy of the patient 3+2 2 0.25 5
Giving attention to head, heart and soul 5 1 0.125 5
Group 2 items
Do I know the story of my patient? Is it finished? (dreams, passion) 3+5+3 3 .33 11
Making an inventory of needs 5+5 2 .22 10
Making contact 5+3+2 3 .33 10
Facilitating (not pushing) rituals (whether or not religious) 3+3+1+3 4 .44 10
Multidisciplinary meetings (GP, nurse, etc.) 4+4+2 3 .33 10
Tuning in to the patient 5+4 2 .22 9
Giving space for what lives inside the patient, allowing emotions 4+5 2 .22 9
Do I know the values of my patient? 3+1+5 3 .33 9
Assessment of spiritual peace/anxiety of the patient 4+1+4 3 .33 9
Giving attention to wishes and expectations about end of life 3+1+4 3 .33 8
Group 3 items
The care giver as a healer, with his own spirituality 4+4+4+4+5 5 .5 21
Attention for all elements of care for this palliative patient 2+1+5+4+5 5 .5 17
Creating a safe environment where something can flow (physical, 5+5+4 3 .3 14
emotional and social care)
Preserving connectedness (in all layers of being) 3+4+3 3 .3 10
Inner resources 5+2+3 3 .3 10
Finding and accepting a new place in life 1+3+5 3 .3 9
‘Wounded healer’: knowing and accepting your vulnerability 4+2+3 3 .3 9
Patient as a teacher 5+3+1 3 .3 9
Really making contact 5+3 2 .2 8
Creating space for rituals 3+2+2+1 4 .4 8
Group 4 items
Giving shape to the final goodbye 1+3+1+5+4+1 6 .75 15
Feeling at home, being yourself, feeling secure 5+5 2 .25 10
Giving support to the inner resources of the patient 3+2+5 3 .375 10
Presence of spiritual care givers in the home care team 3+4+3 3 .375 10
Attitude and skills of the care giver to stimulate the patient to reflect 5+4 2 .25 9
about spiritual issues; posing good questions
Attention for the ‘now’ (the present) 5+2 2 .25 7
Attention for communication and quality of relationships 4+2 2 .25 6
Supporting the spirituality of the nearest ones 2+2+2 3 .375 6
Attention for end-of-life (decisions) 2+4 2 .25 6
Interwoven and specific dimension 5 1 .125 5
Create preconditions (space, time) to realise what patients find valuable 5 1 .125 5
Attention for giving meaning 3+1+1 3 .375 5
1066
Table 2 Delhi consensus pro-
cess participants’ characteristics
by stakeholder group and
country
Stakeholders
Physicians
Professional spiritual care givers
Researchers
Country
Belgium
the Netherlands
The free text comments of the first Delphi round promp-
ted the addition of one new element of spiritual care in
palliative care for the second round: ‘giving attention to
the presence of volunteers’. After the second Delphi round,
however, we had to exclude this element again. The domain
‘finding meaning in life’ was also excluded after the second
round.
Equimedian ratings after the second round were very
homogeneous: none of the 19 resulting elements were given
an overall equimedian rating of 9, 14 elements had a rating
of 8, and 5 had a rating of 7. We decided to include the
elements with an equimedian of 8 and to exclude those with
an equimedian of 7 in order to differentiate between more
and less relevant items.
All individual p values are above .05, so we do not have
evidence of the differences between the stakeholder groups
after correction for multiple testing. The exclusion of any
one set of stakeholder results did not change the overall
inclusion or exclusion of elements.
This study resulted in the establishment of nine domains
of spiritual care within the context of palliative home care:
(1) end-of-life expectations and wishes, (2) rituals, (3)
stories, (4) inner resources, (5) making contact, (6) creating
a safe environment, (7) integration in biopsychosocial care,
(8) care for the care giver and (9) interdisciplinary team
(Table 3).
Discussion
Principal findings
The NGT and Delphi consensus process resulted in nine
domains with 14 core elements of spiritual care within the
context of palliative home care (Table 3). It is remarkable
that there are no differences between the three stakeholder
groups: physicians, professional spiritual care givers and
researchers. There seems to be agreement between experts
about the content of spiritual care within the context of
Support Care Cancer (2013) 21:1061–1069
No. of participants Round 1 Round 2
invited
Number Response Number Response
rate (%) rate (%)
17 16 94.1 13 81.3
9 7 77.8 6 85.7
9 8 88.9 6 75
13 11 84.6 8 72.7
22 20 90.9 17 85
palliative home care despite the lack of consensus in the
literature.
During the consensus process, the discussions in the
expert meetings were focused mainly on the choice of
words. The physicians often used a different ‘spiritual lan-
guage’ than did the professional spiritual care givers or
researchers. The possibility to write free text comments in
the Delphi process was often used to clarify the meaning of
a word or a sentence for the other stakeholder groups.
Our results indicate that spiritual care in palliative home
care is perceived as a shared responsibility of the interdis-
ciplinary team. Having a well-functioning interdisciplinary
team available in palliative home care, including the pres-
ence of a professional spiritual care giver, is a desire
expressed by nearly all experts. Though spirituality is per-
ceived as an interwoven dimension in biopsychosocial pal-
liative care, it seems important to preserve its individuality.
Besides care for the palliative patient, care for the care
giver is another very important element of spiritual care. The
three stakeholder groups agreed that caring for your own
spirituality, knowing and accepting your vulnerability, and
being able to learn from your patient are necessary charac-
teristics for the survival of the professional care giver in
palliative home care.
Results in context
To our knowledge, this is the first study in Europe in which
physicians, professional spiritual care givers and researchers
have worked together to reach consensus about the core
elements of spiritual care in palliative home care. It bears a
lot of similarities to the recent American consensus docu-
ment about spiritual care in palliative care [8]. The nine
domains of spiritual care in palliative care we identified in
our study can be recognised in the American document,
although they are not always literally the same.
Despite the similarities, there is one remarkable difference
between our results and the American document. It is striking
how the word ‘referral’ is not mentioned once in our final
Support Care Cancer (2013) 21:1061–1069 1067

Table 3 Domains and elements

of spiritual care in palliative Domains and elements of spiritual care in palliative home care Equimedian rating
home care after two rating
rounds 1 End-of-life expectations and wishes
1.1 Being sensitive to patient’s fear of the dying process 8
1.2 Listening to the patient’s expectations and wishes about his/her end of life 8
1.3 Giving attention to patient’s wishes about the design of the farewell 8
2 Rituals
2.1 To offer rituals if the patient experiences them as meaningful 8
3 Stories
3.1 Listening to the stories, dreams and passions of the patient 8
4 Inner resources
4.1 Helping the patient to find strength in his/her inner resources 8
5 Making contact
5.1 Connecting with the patient in truth, openness and honesty 8
5.2 Supporting communication and quality of relationships 8
6 Creating a safe environment
6.1 Making sure the patient feels comfortable and safe 8
7 Integration in biopsychosocial care
7.1 Seeing spirituality as an interwoven, though specific dimension 8
8 Care for the care giver
8.1 Caring for your own spirituality 8
8.2 Knowing and accepting your vulnerability 8
8.3 Being able to learn from your patient (‘patient as a teacher’) 8
9 Interdisciplinary team
9.1 Having an interdisciplinary team that’s there when needed 8

results, whilst the first recommendation for a spiritual treat-
ment plan, as formulated by Puchalski et al. [8], is the referral
to chaplains, spiritual directors, pastoral counsellors and other
spiritual care providers for spiritual counselling. Throughout
the American document, referral by clinicians to professional
spiritual care givers seems very important. This could be due
to the common availability of professional spiritual care givers
in the USA, in contrast with the shortage of this professional
group in Belgium and the Netherlands.
Strengths and weaknesses
The representation of 35 experts on spiritual and palliative
care from three different stakeholder groups (physicians,
professional spiritual care givers and researchers) from two
different countries (Belgium and the Netherlands) has cre-
ated a unique opportunity to reach consensus about the
content of spiritual care in palliative home care. However,
we realise that physicians and spiritual care experts are not
the only professional groups who provide spiritual support
for patients and carers in this area. The collaboration of
researchers from two countries with the same language but
a different medical and home care system resulted in inter-
esting discussions about priorities. These priorities, howev-
er, may be different in other countries, with other
professional groups or with experts from different denomi-
nations than those present in this study. Therefore, we must
be careful in terms of the representativeness of our findings.
We followed a well-established methodology and de-
scribed our methods carefully. However, due to the limited
variation in equimedian ratings after the second Delphi
round, we decided to exclude the elements with an equime-
dian of 7. This may have caused the loss of valuable
insights, but it was necessary to further differentiate between
the more and less relevant elements of spiritual care.
Implications
Thanks to the results of this consensus procedure, the con-
tours of spiritual care in palliative home care have become
more delineated. Both physicians and professional spiritual
care givers expressed the need for a well-functioning inter-
disciplinary team. This study provides a first step towards
the development of an interdisciplinary spiritual care model
in palliative home care. Further research is needed to oper-
ationalize it in daily practice and to investigate whether
these elements of spiritual care in home care could be
generalized for hospitalized patients. Another area for fur-
ther work may concern the perceptions of patients and
informal carers about spiritual care.
1068
Conclusion
Being sensitive to patient’s fear of the dying process; listen-
ing to the patient’s expectations and wishes about the end of
life; giving attention to patient’s wishes about the design of
the farewell; offering rituals if the patient experiences them
as meaningful; listening to the stories, dreams and passions
of the patient; helping the patient find strength in inner
resources; connecting with the patient in truth, openness
and honesty; supporting communication and quality of rela-
tionships; making sure the patient feels comfortable and
safe; seeing spirituality as an interwoven, though specific
dimension; caring for your own spirituality; knowing and
accepting your vulnerability; being able to learn from your
patient; and having an interdisciplinary team that is there
when needed are the 14 core elements of spiritual care in
palliative home care, according to the 35 experts who par-
ticipated in this consensus process. There are no differences
between the three stakeholder groups: physicians, profes-
sional spiritual care givers and researchers. Further research
is needed to develop, implement and evaluate an interdisci-
plinary spiritual care model in palliative home care.
Acknowledgments This work was supported by the Constant Van de
Wiel Fund in General Practice, KU Leuven. The authors thank Agnes
van Swaay and Karel van Spaendonck for moderating the nominal
groups. We also thank the experts who participated in this study (in
alphabetical order): Anne Beyen, Harmke Boon, Johan Coppens,
Katrien Cornette, Marc Cosyns, Marianne Dees, Wim Dekkers, Luc
Deliens, Marc Desmet, Yvonne Engels, Marie-José Gijsberts, Roel
Hekking, Koen Herwijers, Marina Kuyper, Carlo Leget, Jo Lisaerde,
Betty Morel, Mick Raeven, Hans Schilderman, Willemjan Slort,
Richard Starmans, Karin Steenbakkers, Joep van de Geer, Bart Van
Den Eynden, Hanneke van Laarhoven, Jacqueline van Meurs, Pieter
Vandecasteele, Paul Vanden Berghe, Claude Vandevoorde, Carel Veld-
hoven, Etje Verhagen, Anja Visser, Kris Vissers, Marijke Wulp, and
Filip Zutterman.
Conflict of interest statement The authors declare that there is no
conflict of interest. They have full control of all primary data and agree
to allow the journal to review their data if requested.
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