Standards › Standard 10 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HSP-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.5
At a glance
- Every patient is asked about spiritual, cultural and psychological needs at admission and at each review.
- The patient is connected to the chaplain or religious leader they choose.
- Cultural practices about care and the body are recorded and respected.
- The answer and the action are recorded on HSP-FRM-004.
- Stop and get help straight away if: a patient asks for a chaplain or religious leader and is not connected, or a stated cultural need is ignored with no reason recorded.
1. Purpose
To address the spiritual, cultural and emotional needs that matter at the end of life (10.5).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Patients at the end of life have spiritual, cultural and emotional needs that can be as important as the physical ones. Asking about them, and acting on the answer, respects the whole person.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead palliative clinician | Asks and acts on the answers | Clinician |
| Chaplain or religious leader | Provides the support the patient chooses | Chaplain |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Ask.
- Ask about spiritual, cultural and psychological needs at admission and each review.
Key point: Asked every time.
Step 2. Connect.
- Connect the patient to the chosen chaplain or religious leader the same day.
Key point: The patient’s choice.
Step 3. Record.
- Record the need, the action and any reason an action was not possible.
Key point: Recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Patients asked about needs at admission | 100% | Monthly | Lead palliative clinician | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HSP-FRM-004 | Spiritual, cultural and psychological needs record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Palliative Care guidance and the WHO Package of Essential Noncommunicable Disease interventions (2020). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)