•Describe the impetus that led to the investigation and the methods of the overall project.•Describe the key components and language of the three core categories regarding spiritual health at EOL.•Identify strategies to educate palliative care teams and professional chaplains as to the importance of EOL assessments that are constructed based on the direct experience of patients and their families. Hospital chaplains are integral to interdisciplinary palliative care teams, yet little is known regarding the role they play in end-of-life (EOL) decision-making and care of seriously ill patients and their family members. Fill important knowledge gaps by investigating and documenting the impact that hospital chaplains have on EOL decision-making and care of seriously ill patients and their family members, with a focus on the experiences of African Americans. The site of this study was a 511-bed community-based full-service hospital where 70% of all patients that receive a palliative care consultation are African American. We conducted 24 in-depth interviews of approximately 60-90 minutes with 12 patients, 8 family members, and 2 patient-family dyads. Data collection methods included in-depth interviews and ethnographic observations. Using a subset of data from 14 African American participants (6 patients and 8 family members), we performed a thematic analysis using constant comparative methods consistent with a grounded theory approach. Findings showed that although chaplains rarely initiated EOL discussions, they nevertheless played a crucial role when seriously ill, predominately lower income African American patients and their families considered EOL decisions. We identified three categories of EOL decision-making among participants that reflect varied levels of chaplain involvement: 1) chaplain-supported decision-making; 2) chaplain-centered decision-making; and 3) religion-centered decision-making. We report these findings in the form of three illustrative case studies. Chaplains' primary role in EOL decision-making was to relieve spiritual distress, ease guilt, and provide comfort. One participant described this support as “something that only the chaplain could offer.”