How to deal with out-of-state patients’ last wishes

Advance directives may not be valid in your state

Here are some scenarios you may encounter as a case manager:

  • A patient has terminal cancer and comes to your city to live out his last days with his daughter. He has a living will, but his daughter is reluctant to follow it. How do you make sure his final wishes are carried out?
  • An elderly patient is traveling through your state or visiting on vacation and has a heart attack and is unconscious. How do you determine who makes the health care decisions for the patient?

These situations are complicated by the fact that the patient resides in one state and is sick in another. And because each state’s laws are different, it may be difficult to enforce a living will or health care power of attorney signed in another state, points out Stuart Brock, CCM, JD, an associate in the insurance, governmental, and tort litigation practice group of Womble Carlyle, a Winston-Salem, NC, law firm.

Case managers in certain parts of the country often must manage the care of someone from a different state with different laws.

For instance, a case manager in Florida or somewhere along the I-95 corridor is likely to encounter "snow birds" who have a heart attack or illness on their way to and from their Florida homes.

Since people are governed by the laws of the state in which they receive treatment, this could pose a problem with patients’ legal documents.

In these cases, a patient’s living will or health care power of attorney may be invalid, depending on the laws of the state in which they are receiving treatment.

"Case managers have a legal obligation to make sure their patients’ choices are honored. It may be difficult to carry out the patients’ wishes in these cases, especially if there is a contentious family member," Brock says.

When Brock spoke on legal issues in elder care at the Case Management Society of America conference in June, he encountered story after story of horrible end-of-life situations that could have been avoided.

"It’s really troubling when there are four or five family members and some want one thing and the others want another," Brock says.

If a case manager in any setting encounters someone from out of state, he or she needs to know that the patient generally is covered by applicable laws in the state where he or she is being treated.

During the initial visit, the case manager should ask the patient if he or she has advance directives or, if they are unconscious, ask a family member for the documents. If the documents are at the patient’s home, ask to have them forwarded to you.

"Case managers must deal with delivering services in a way that is consistent with the patient’s best interests. Sometimes the choices of the patient and the patient’s family do not coincide," Brock says.

That presents a problem that is complicated when the patient does not have legally constituted advance directives in place, which could minimize problems with a patient’s last wishes.

Brock suggests asking any out-of-state patients whose case you manage how often they are in your state. If it is likely they may encounter a similar situation, be proactive and educate them about what they need to do to protect themselves, he adds.

That way, they can take care of their advance directives following your state laws so next time they become ill in the state, they’re protected.

Do your in-state patients a favor and let them know that their advance directives may not be valid in another state. That way, if they have a vacation home or often visit grandchildren in another state, they can prepare advance directives according to that state’s laws as a backup.