Palliative Care Social Work Standards of Practice – Review of Select International Protocols

Outline of the PCSW standards of practice reviewed

1. NASW standards of palliative and end-of-life care’ (2004), United States of America.^[5]

   The ‘NASW standards of palliative and end of life care for social workers’ (2004) has its origins in the deliberations of the 2002 social work leadership summit on end of life and PC that focused on the enhanced and formalised role of social workers in the domain. It is a 36-page document divided into five major sub-sections on (i) definition of key terms, (ii) background of the document, (iii) guiding principles, (iv) standards for PCSW practice and (v) standards for professional preparation and development. The eleven standards of professional practices of social workers are ‘(a) ethics and values, (b) knowledge, (c) assessment, (d) intervention/treatment planning, (e) attitude/self-awareness, (f) empowerment and advocacy, (g) documentation, (h) interdisciplinary teamwork, (i) cultural competence, (j) continuing education and (k) supervision, leadership and training’.

2. ‘The palliative and end-of-life care social work standards’ (2020), ‘palliative care social work Australia Inc’.^[14]

   ‘The Palliative and End of Life Care Social Work Standards’ (2020) published by the ‘Palliative Care Social Work Australia Inc.’, Australia, were created to promote harmless, top-notch, competent palliative and end-of-life care and bereavement services^[20] by linking practice-based competencies with published evidence on the role of PCSW. These standards were an outcome of the increased realisation to have exclusive frameworks for PCSW that emerged in 2012 and the subsequent consultation in 2018 regarding the same. The standards spread over 47 pages are divided into three major subsections on (i) framework of the standards, (ii) overview of PC and (iii) PCSW standards. The eight components of practice are ‘(a) values and ethics, (b) professionalism, (c) culturally responsive and inclusive practice, (d) knowledge for practice, (e) applying knowledge to practice, (f) communication and interpersonal skills, (g) information recording and sharing and (h) professional development and supervision’ each having multiple relevant standards.

3. ‘The British Association of Social Work Position Statement on Social Work Support to People who are Dying’ (2016) and the ‘Role of social workers in palliative, end of life and bereavement care’ (2018) document by ‘Association of Palliative Care Social Workers in collaboration with the former College of Social Work and Making Waves Lived Experience Network/OPEN FUTURES Research, with support from the British Association of Social Workers and Hospice, United Kingdom’^[18]

   The 46-page document entitled ‘the role of social workers in palliative, end of life and bereavement care’ presented by the ‘Association of Palliative Care Social Workers’ is an offshoot of the 2010 Social Care Framework^[21] and the 2012 roadmap for PCSWers^[22] that sought to concretise the PCSW practice and hone the requisite social work competencies. Further, the UK document is in sync with the 2014 Core Competencies for PCSW in Europe identified by the European Association for PC’s Task Force.^[18] It contains sub-sections on (i) the context of PC, (ii) Rationale, (iii) Concept of PCSW, (iv) Vision for excellence in PCSW and (v) the role of PCSWers. It endorses the ‘British Association of Social Workers’ position statement on social work support to people who are dying’ (2016) by spelling out four mandatory clauses namely, ‘(a) Social workers should fully adhere to their code of ethics and provide sensitive, consistent, evidence-based social work support to all concerned when a person is dying. (b) Social workers should ensure they are well-prepared and able to undertake a safeguarding role, if required, in relation to a person who is dying. (c) The law and agency practice should uphold the human rights to life and freedom from inhuman and degrading treatment (Articles 3 and 5, Universal Declaration of Human Rights). No dying person should be encouraged to take their own life by any individual or any societal, (a) legal or institutional influences and (d) social and health policies which maximise support to those who are dying and minimise external pressures should be adopted, this should include access to free social care’.

Comparative analysis of the PCSW standards of practice reviewed

The comparison of the American, Australian and British PCSW standards of practice in terms of identifying attributes, purpose, standards of practice, role of PCSW is presented in Table 1. To facilitate understanding, verbatim excerpts from the relevant base documents are presented.

As shown in Table 1, it is inferred that while the Australian and British standards of practice for PCSWers have been put forth by respective associations of PCSWers, the American document is presented by the relevant association of Social Workers. Furthermore, it is clear that the Australian standards of practice for PCSW is more recent. On perusal and also based on word count, the Australian and British documents were found to be more detailed.

In terms of the purpose of the document, the American standards of PCSW practice are very focused and are directed towards the PCSWers. Its two-fold goals are to increase the awareness and the sensitivities of PCSWers. The Australian standards of PCSWers practice focus on social work practice per se and seek to promote ‘effective, professional and accountable’ PCSW. The four-fold objectives of the British standards of PCSWers practice focus on social workers, people in need of PC, fellow professionals and employers. Thus, in terms of purpose, the British standards of practice is more holistic address stockholders. The NASW document spells out 11 standards of practice as against the eight components of practice having a total of 39 standards identified by the Australian document, and the 10 standards of practice identified by the British document.

The definitions of PC in the three documents are closely in sync with the universal definition of PC given by the World Health Organization (WHO)^[1] and emphasise on ‘improving quality of life of the patients and their families affected by life-limiting illness by preventing and relieving suffering, pain and other problems’. The British document goes one step further and touches upon enhancing ‘remaining life opportunities’. This presents a more positive outlook on the subject matter by focusing beyond dying or death or grief or bereavement; it presents opportunities for making the most of what remains.

The American standards of practice present the role of the social worker in terms of practice with the individuals, families, caregivers, PC team members, participation in policy formulation and engagement in research. In the Australian standards of practice, the role of the social worker in PC is focused on individuals, families, caregivers and the community at large. In the British standards of practice, the role of the social worker in PC has been traced during, at the close of and immediately after PC, and also towards promoting health. Thus, the comprehensiveness of the three documents is richly varied.

The three standards of practice are discussed below based on the ethics, coordination, assessment and intervention, resource allocation, education competencies for PCSWs.^[23]

1. Ethics: PC is fertile ground for numerous ethical dilemmas. All three standards adopt a non-negotiable stand regarding ethics. This reiterates the importance of ethics and ethical conduct as a standard of practice for PCSW.

2. Coordination: Coordination as a pre-requisite competency of PCSW can be understood at three levels. At the lowest level, coordination is necessitated with the individual and the family during the course of the assessment, family meetings, intervention planning and implementation, follow-up, caregiver support and so on. At the intermediary level, coordination of care as a member of the multi-disciplinary team and coordination with fellow professionals across organisations is required. At the macro level, coordination is entailed while working on issues necessitating advocacy, resource mobilisation and inter-organisational/inter-regional linkages. Coordination as a precept is enshrined in the standard of practice ‘Interdisciplinary practice’ in the NASW standards, ‘Applying knowledge to practice’ component in the Australian standards and ‘Contexts and Leadership’ in the British standards.

3. Assessment and intervention: Assessment in PCSW is of prime importance for effective interventions. Assessment in PCSW is dynamic and multifaceted. It is dynamic as it has to constantly consider the evolving preferences of the client and the family, bio-psychosocial conditions, resource opportunities or limitations and client’s spiritual, cultural and social beliefs. It is multifaceted as it must be aligned with the individual and the family and also with developments in the PC ecosystem per se. While the NASW standards call for ‘comprehensive and culturally competent SW assessment’, the Australian standards emphasise on ‘comprehensive and holistic options’.

4. Resource allocation: Committing resources to the client and the family in terms of material, legal, financial and informational support, either directly or through referral services, is an integral aspect of the PCSW process. This calls for liaising with the organisation, community agencies while keeping the client’s well-being in mind. Advocacy is vital to direct the course of matters such as community participation, policy formulation, resource allocation and legislative amendments. This has been addressed by the ‘Intervention/Treatment Planning’, ‘Empowerment and Advocacy’ standards of the NASW document, ‘Applying knowledge to practice’ standard of the Australian document and the ‘Intervention and Skills’ standard of the British document.

5. Education: Education is a critical resource that operates at multiple levels. It encompasses facilitating knowledge and awareness among the client and the family, clarifying matters pertaining to PCSW in the multi-disciplinary team context, upholding the ideals of the profession in the society where divergent points of view are possible, contributing to the professional formation of all budding PCSWs and investing in the continuing education of self. This has been expressed in the ‘Continuing Education’, ‘Supervision, Leadership and Training’ standards of the NASW document and ‘Professional Development and Supervision’ standard of the Australian document.

Suggestions

1. As PCSW is in the nascent stage in India, the academia, in consultation with the stakeholders, could provide the leadership in documenting the body of knowledge concerning PCSW and in making it available to aspirants and novices. The preparation of a model curriculum of PCSW in the Indian context could be a step in this direction. PCSW as a specialisation of a post-graduate degree of social work could be rolled out and alternatively, it can be extended as a continuing education programme.

2. Standards of practice for PCSW should be an integral topic of study in the model curriculum of PCSW.

3. Existing bodies/networks associated with PCSW could initiate discussions on the formulation of a standard of practice for PCSW in the Indian context.

4. Research in PCSW practice could be done to map the stakeholders’ perspectives on the must have or widely practised standards of practice.

Implications for further research and social work practice

Globally, despite the increasing demand for PC services, much of it remains unmet.^[2] The Indian experience in rendering PC services offers valuable lessons to developing countries.^[24] This will apply to the social work protocols developed in the Indian context as well. These documents on standards of practice published by the various associations of social work not only reflect their official standpoints but also serve to guide social workers tenured and upcoming in their practice. It also serves as a guide to fellow members of the multi-disciplinary PC team in terms of what to expect and otherwise. For academic institutions, they serve as a resource material for teaching and directing academic discussions. The results of the thematic analysis of these standards of practice have helped to understand and appreciate the similarities and unique aspects of the same. It has been widely acknowledged that there is inadequate PC content in the professional formation of social workers.^[25-30] In such a backdrop, documents such as standards of practice are vital to provide insights for practice. As PCSW in India is yet to mature in terms of practice, training and research,^[15] the time is opportune to shape it with these cognitive exercises and thereby accentuate the professionalisation of PCSW practice in the Indian context.