Be careful in disputes during end of life

When there is an emotional situation, such as a life-threatening injury or illness, family behavior can be unpredictable. As a case manager responsible for coordinating patient care, you could find yourself in the middle of a family dispute on what steps should be taken to care for a dying relative.

If you know the patient’s wishes and the family doesn’t want them carried out, you, as a case manager, are bound to follow the patient’s wishes, asserts Stuart Brock, CCM, JD, an associate with the law firm of Womble Carlyle based in Winston-Salem, NC.

That’s why case managers should take a proactive approach with patients, especially if they are elderly, to make sure they have advanced directives in place to avoid legal hassles and family squabbles over their last wishes, Brock advises. In the best-case scenario, when a patient is in critical or terminal condition, a case manager will assemble the patient’s advance directive documents and put them in the file. If you can’t do that, document that you have had the discussion with the patient or the next of kin, he says.

Even if the documents are in place, family members may balk at carrying out their relative’s living will. In other cases, you may encounter questions of whether or not the patient has the capacity to make a decision about his or her health care. Your risk when issues of advance directives arise vary with your practice areas, but if you are involved in direct care and the care is not consistent with the patient’s choices, you could be at risk and so could your organization.

"We are living in a litigious society, and health care costs are soaring because of malpractice costs and the cost of litigation. Of course, case managers act in the best interest of their patients, but they also must manage the risk to themselves and their organizations. They can’t serve their clients if they aren’t operating as an entity," Brock says.

If it appears that there may be a dispute about end-of-life care for a patient, immediately ask the risk management department of your organization to become involved. The risk managers can guide you through the legal system and get the courts involved if necessary, Brock says. Involve social workers to work with the family and help deal with issues before they become volatile, he suggests.

Use your case management skills to smooth things over initially and then involve the next level, which is risk management. You don’t want to be alone in these situations, Brock says. "Case managers don’t want to be making decisions without involving the family as much as they can. Case managers can usually assess early on the family dynamics and can begin the education and diplomacy process," he says.

Keep in mind that case managers are being named among the defendants in more lawsuits and must take steps to protect themselves and their organizations. "In the current litigious state of our societies, case managers, as a part of an interdisciplinary practice, can be affected in many ways by malpractice lawsuits," Brock says.