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Clinical Focus Long-Term Care Guiding Hands
Clinical Focus Long-Term Care Guiding Hands
| Guiding Hands |
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| Written by MAUREEN HOWARD, BSN, M.Ed., CCM, CHPN |
| Monday, 01 December 2008 07:00 |
Ethical and Cultural Considerations During the Final DaysComprehensive case management continuously addresses the complexities of illness and the promotion of optimum outcomes in disease.As a result of this focus,case managers often deal with either potential or real end-of-life issues among their individual patients and families.Knowledge of and respect for both ethical and cultural dimensions in this regard will enhance case management interventions and outcomes.Education and Benefits of Advance DirectivesCase management is required to focus upon the consumer needs of clients (payer or provider) while also meeting the consumer needs of program participants.When addressing this dilemma,case managers should communicate to all consumers that studies have demonstrated both psychosocial and financial benefits to both patients and families when an advance directive has been adequately documented and communicated.Education regarding both the benefits of advance directives and the procedures for completion and communication of advance directives should begin during the intake assessment phase of case management and should span the management of every case.Education should not be limited to the individual patient.It also should be focused upon all caregivers and family members.The need is not only universal,but family education increases the likelihood that patient preferences,or autonomy,will be assured at end of life. Continuous Reassessment and EducationCase managers should include an ongoing assessment of the patient’s advance-directive status on a regular basis.Open-ended questioning should be used within the assessment in order to determine any ambiguities or issues concerning end-of-life planning.In situations where the patient has not completed an advance directive, the case manager should identify and address barriers for completion.While lack of knowledge is one barrier to advance-directive completion,the major issue is often cultural.Often patients and families will raise cultural or religious objections to discussions on advance directives because such conversations are viewed as precursors to death.Care managers can often avoid such objections by first asking if there is any familial or personal opposition to questions about planning for end of life.If there is,the case manager can indicate that the topic will be avoided but that questions and discussions will occur regarding preparations for medical emergencies. Within these assessment and education conver-ations for medical emergency preparedness, case managers can facilitate verbal communication of treatment wishes by engaging patients and families in conversations concerning how they would address situations where the patient might be unable to speak for himself. Care managers should encourage patients and families to discuss religious,philosophical and cultural thoughts concerning treatment (or non- treatment) with both their families and their health providers so that concerns and wishes are addressed appropriately.In addition,while the family or caregiver may be culturally opposed to end-of-life conversations with a care manager or health care provider,they are often open to gen- eral family education concerning life-prolonging or natural death treatment options.The ideal time for such discussions is within nonacute assessment and education interfaces so that the patient and family have the time and energy to examine all aspects of treatment decisions prior to a medical emergency. AdvocacyAdvance-directive assessment questions should include reassessment of the patient’s and family’s understanding of their rights to use an advance directive,any questions or concerns regarding advance directives,and inquiries regarding whether an advance directive has been documented and communicated to both providers and the health care proxy.This assess- ment should occur regularly even if an advance directive is completed.As an advocate for the patient,the care manager needs to promote beneficence and autonomy by ensuring that any changes to the patient’s wishes are adequately reflected and communicated through changes in the advance directive.The care manager must continuously reinforce among patients and families the need to communicate wishes to all providers in every care setting,especially during care transitions. Conflict ResolutionCase managers are often called upon to assist in addressing common end-of-life conflicts. Many of these involve continuation or discontinuation of treatment,as well as issues related to adequate symptom management.The role of the case manager includes facilitating communication among providers and family and acting as an advocate for both patient and family.Care managers should encourage provider and family team meetings,educate patients and family members concerning their rights with respect to health care decision-making,and educate about end-of-life resources such as hospice and organizations,clergy,facility ethics commit- tees,and the patient’s own advance directive. More important,the case manager must engage patients and family members in conversations about goals and concerns.Early interactions can reduce conflicts and crises at the terminal stage of an illness. Cultural and Ethical Self-ExaminationFinally, case managers need to examine their own views on end-of-life decision-making and care.Ethically,case managers are required to respect and support the free will of patients, even if their decisions are not what we would choose for ourselves.When encountering ethical or cultural dilemmas,case managers should refer to professional or personal resources,such as ethics committees,religious counselors,corporate legal counsel,or legal and ethical topical literature.Case managers have a professional responsibility to improve upon the quality of services they provide by increasing their own competence regarding advance directives,end-of-life care options,and the cultural and ethical dilemmas within end-of-life care decisions.In order to promote quality end-of-life care,case managers need to identify their own end-of-life wishes, beliefs and concerns,and they need to promote this practice among their peers and family members,in addition to their patients. |