Ethical and Cultural Considerations During the Final Days

Comprehensive 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 Directives

Case 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 Education

Case 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.