Take a patient-centered approach when you talk with patients and family members about end-of-life options and find out what they need and want before making suggestions, says Joseph D. Rotella, MD, MBA, HMDC, FAAHPM, incoming chief medical officer of the American Academy of Hospice and Palliative Medicine and a hospice and palliative care physician for 15 years.
Start the discussion by asking the patient and family members what they understand about the illness and treatment and if there are gaps in their knowledge, give them the information they need. Explore their goals, hopes, fears, and needs and come up with a care plan with the help of the medical staff.
Address their primary goals, Rotella says. A patient’s goal might be to spend more time at home or to have more support for his wife as the family copes with the illness. There may be closure issues or relationships they want to rekindle.
“So many things could be going on. When you find out what patients want, it’s easy to connect the dots and talk about how the palliative care team or hospice services can help,” Rotella says.
Many times, when Rotella’s team has been called for a hospice consultation, patients say that their goal is to go home. “They say they would like to be comfortable but not too drugged and not have to go right back to the hospital. We tell them that hospice is perfect for them,” he says.
Case managers are aware of patients’ clinical conditions, psychosocial issues, and family dynamics, which puts them in a good position to identify patients who could benefit from hospice care, says Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare, with headquarters in Chicago. Since they already have a relationship with the patient and family, they are the obvious person to bring up the subject once the physician has communicated the diagnosis, she adds.
Start the conversation by saying, “This has to be a very difficult time for you and your family,” suggests Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY, case management consulting firm.
Then ask if the patient has thought about how he or she would like to be treated. Explain that patients have a right to refuse or accept treatment and bring up advance directives as a tool to help them plan.
“Most advance directives are prepared at a lower reading level, but patients still might not understand. Case managers should explain the document and what it means,” Mullahy says. Explain what could happen if they don’t have a plan in place, she suggests. For instance, when patients have an acute episode and come to the ED, they will be treated and possibly admitted unless they have something in writing stating they no longer want aggressive treatment.
“A question about advance directives should be part of the case management assessment, but case managers also should make it a part of their everyday practice to ask open-ended questions of patients and their family members,” says Patrice Sminkey, RN, chief executive officer for the Commission for Case Manager Certification. For instance, ask patients about their healthcare goals over the next weeks, months, and years.
If patients are reluctant to discuss their end-of-life wishes, point out that if they don’t make a decision about what happens at the end of life, someone else will. Remind them that they will be relieving their loved ones of the responsibility to make a decision, Sminkey says.
Describe the benefits and the risks so people can make informed choices, Mullahy says. Get as specific as you can. For instance, say, “Your oncologist says that if you have more chemo, this is the likelihood of it working,” she says. Make sure they understand that if they don’t choose chemo, it doesn’t mean they are going to die in pain, she adds.
Case managers cannot order palliative care or hospice care. That is why case managers need to work closely with physicians and suggest those patients who might benefit from one of these services, Sallee points out. But not all doctors are comfortable with an end-of-life discussion, she says.
“It’s a tricky conversation and case managers need to develop a close relationship with physicians to have that conversation. Case managers need to be assertive and communicate in a collaborative way, but be comfortable making suggestions that would lead to improved patient care and outcomes,” she adds.
Start by talking to the treating physician about the diagnosis and comment that the patient appears to be nearing the end of life. Mention that the patient and family are having trouble coping and could use some help.
“Point out that patients prefer being at home instead of in a hospital and that hospice care provides a lot of support in the home from nurses, counselors, and aides. Point out that when patients at the end of life don’t have a referral for hospice, they lose the benefits of having support as they near the end of life,” Sallee says.
Rotella advises care managers to take a patient-centered approach when they talk to physicians about a hospice or palliative care consultation. Make sure you are informed about the patient’s goals and work with the physician to come up with a plan that takes what is important to the patient into consideration and goes beyond just taking care of the disease, he suggests.
Take a patient-centered approach when you talk with patients and family members about end-of-life options and find out what they need and want before making suggestions.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content