Academic journal article Care Management Journals

Care Management Role in End-of-Life Discussions

Academic journal article Care Management Journals

Care Management Role in End-of-Life Discussions

Article excerpt

How do we prepare our patients for decisions that will need to be made for end-of-life care? End-of-life care discussions should occur early on in the patient's disease process and often requires a great deal of coordination between multiple caregivers. There are also ethical, cultural, social, and spiritual considerations during this very important time in the disease process. Research suggests that we are not doing an adequate job of addressing end-of-life care with our patients and that a great deal of money and resources are being spent in the last days of life when there may be no clinical indication to do so. Registered nurse case managers have a unique knowledge base to serve in the role of coordinating care and leading the multidisciplinary care team in an effort to use resources responsibly while providing patients and families with options for end-of-life care.

Keywords: case management; hospice; palliative care; care coordination

Hospital case managers today wear many hats. Case management is relied upon to ensure that patients are receiving quality of care, to maintain compliance, to maximize reimbursement, and to minimize financial risk to the patient and to the hospital. All of this is done through care coordination. In the past, care coordination has been focused on episodes of acute illness and traditionally occurs while a patient is in the hospital. However, as the health care environment changes, so does the focus of care coordination. As clinicians, we must move away from fragmented health care focused on acute illness and move toward disease management across the health care continuum. An important component of this transition is having open and honest conversations with patients and families about end-of-life care for chronic conditions.

Many people understandably try to plan for end-of-life care by drafting advance directives. Advance directives are one's health care instructions in writing to speak for them and make their wishes known in preparation for when they are no longer able to speak for themselves. Types of advance directives include talking directly to your health care provider and family, organ and tissue donation, health care representative, living will declaration, life-prolonging procedures declaration, psychiatric advance directives, out of hospital "do not resuscitate" declaration, and power of attorney. However, not everyone has advance directives, and many who do have them do not communicate their plan to their physicians and families effectively (Indiana State Department of Health, 2004). Difficult issues can arise when families aren't aware of advance directives or don't agree with other family members on steps that should or should not be taken at the end of life. A great deal of work can go into resolving such disputes, but if families and physicians can't work out an agreement, then the dispute may go to court. Families, physicians, and other health care providers should do everything they can to ensure that a patient's wishes are respected and that care provided or withdrawn is done so in the best interest of the patient (American Medical Association, 2012).

End-of-life discussions must be specific to each individual patient. When it is determined that a patient has an incurable illness, it is important to have a multidisciplinary approach to care coordination. The case manager is instrumental in leading discussions with members of the health care team, patients, and families. Care teams can work together with patients and families to improve quality of life, manage pain, and prevent admissions to the hospital. Members of the multidisciplinary team can include each physician or provider involved in the patient's care-a case manager, a social worker, a chaplain, a respiratory therapist, a physical therapist, the patient, family, and others as indicated. A multidisciplinary approach to care coordination allows the same consistent information to be communicated. …

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