By Jeanie Davis

Is your patient living in a tent city? Refusing surgery? Requesting alternative cancer treatments only?

Every day, case managers face pressure to achieve optimal outcomes in a multitude of scenarios. At the core of each case is the patient’s understanding of medical care, their ability to think critically, make decisions about their care, and use good judgment.

Case managers must help their patients in their medical “journey,” says Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, owner of EFS Supervision Strategies. “The case manager’s primary function is to advocate for their patients. A big component of advocacy is walking through the journey with them.”

Capacity, competency, coping, and choice are the core considerations every case manager should examine with each patient, she explains. The patient’s judgment, she adds, will influence their decisions — and the case manager will have little influence on this.

Capacity to Understand

Capacity is the first factor the case manager must ascertain, says Fink-Samnick. “Is the patient capable of understanding and engaging in informed consent about their own care and treatment? This capacity will determine decision-making and discharge planning.”

Does the patient understand the purpose, consequences, and benefits of proposed interventions? What about treatment and medications? Can the patient participate in a discharge planning process, or develop an appropriate plan to ensure positive health outcomes?

Capacity is a consideration, for example, when a homeless patient presents at the emergency department (ED). That patient may be oriented to place and time. He or she chooses to live in the woods and does not consider himself or herself homeless, says Fink-Samnick.

“The patient understands that they have a condition caused by unclean living conditions; they don’t wash their hands often,” she says. “They understand that clean water and antibiotics will help their condition and overall health. While their camp doesn’t have clean, running water, a discussion of options reveals that a recreational center up the road has clean water they can use. This patient has the capacity to understand, and can make decisions about their care. They can provide informed consent, which is a big factor in terms of the hospital and liability.”

Competency to Make Decisions

That patient’s lifestyle may not reflect sound judgment, but that is a subjective observation, says Fink-Samnick. “He has shown he has capacity, and he has shown he has competency — the ability to make decisions.”

When capacity is under question, competency also is questioned, she explains. A person who is disoriented may not have the capacity to understand his or her condition or treatment options. If that is the case, they likely will not be competent to make decisions about treatment.

While a case manager, social worker and/or physician may question the patient’s capacity and competency, a judge must decide on competency. “This is a legal rendering on the patient’s ability to make their own decisions,” says Fink-Samnick.

This decision affects all communication with the patient and family. Is the patient mentally sound to make decisions about medical issues? Does a patient with congestive heart failure or another chronic condition understand the need to make behavioral changes to prevent complications? Does the patient have the capacity to understand the diagnosis, consequences if they undergo treatment, and if they do not? “The case manager must be able to make that assessment,” she says.

In today’s world, every patient is complicated, Fink-Samnick adds. “Social workers, case managers, and nurses must know how to conduct a basic mini-mental status assessment. At the least, most healthcare professionals can determine if a patient has capacity. Only a court of law can determine competency.”

Commonly, older adults may appear very confused and incompetent, she explains. “Yet they may simply have a urinary tract infection, and an antibiotic changes their picture completely. Or, they may have a medical reaction that is affecting their clarity.”

Incompetent is a different picture entirely: The patient is extremely disoriented and cannot fully understand risks or implications of avoiding treatment. “This person’s financial affairs and home environment may be in complete disarray, and the situation unsafe,” says Fink-Samnick.

Incompetence can be difficult to prove, as people may fluctuate in their lucidity, she adds. They may provide inconsistent information at admission, but answer behavioral health questions very well. There may not be sufficient need to hospitalize that patient, but medication may be necessary to stabilize them.

Competency is based on a series of mental status exams. A psychiatrist (and possibly a physician) will perform a full psychiatric evaluation. A judge will review the reports and make the determination. Patients are deemed incompetent when they consistently demonstrate they cannot think or act in their own best interests and are truly unsafe.

Coping Behaviors

A medical condition can stir many emotions, including anger and fear. The patient’s coping process can affect his or her acceptance of or resistance to decisions. The patient’s coping ability can determine whether he or she is ready to choose a treatment.

The case manager must show empathy for the patient’s coping process — not anger, says Fink-Samnick. “How would you feel in their situation?”

Case managers must remember the coping process takes time. Unfortunately, time is a valuable commodity not often available in today’s fast-paced healthcare setting. While you may feel impatient at times, it is important to develop the skills and patience required. Communication is at the heart of this process.

“We have to be attentive to all the patient and family’s emotions — what’s very evident, and what’s beneath the surface,” says Fink-Samnick. “Not everyone adjusts quickly to a life change. Imagine how you would feel with an unexpected diagnosis or prognosis — uncontrolled diabetes, congestive heart failure, stage four cancer. Dealing with that change is different for everyone. It takes a while to process the emotions.”

Can the person cope with his or her current life situation? What are the patient’s emotions? Is the patient angry, resistant? Can they think about death and dying? Defense mechanisms can be positive or negative; the patient may be in denial, rationalizing their circumstances, or avoiding social interactions.

“If the patient can’t cope, the discharge planner must show empathy — not anger or frustration,” says Fink-Samnick.

Ask the patient and the family how they are feeling. “Let them tell you how they’re doing, how upset and frustrated they are,” she explains. “Don’t just rush in with their discharge plan. Sit in silence with them a little bit. Don’t devalue how they’re feeling.”

She encourages case managers to learn a basic understanding of human behavior and communication with patients and their families. Not every environment will include a social worker trained in family therapy to guide the process.

“Case management is about looking at the very big picture of assessment: medical, physiological, cognitive, behavioral health, social,” she says. “It’s wholistic with a ‘w’— physical health, wellness, psychological, and the social determinants of health.”

Choice in Care Planning

When the case manager has helped patients and families through this process, it is time to prepare them to make choices, says Fink-Samnick. “You have to have a relationship with them to ask about preferences, cultural diversity, treatment choices, timing, and when to stop treatment.”

When case managers and patients develop trust, it can make all the difference in facilitating even the most challenging discharge planning processes. “All these factors lead to the patient’s decision-making ability. They can rationally choose their own medical treatment, or choose to refuse treatment. A competent patient can make their own end-of-life decisions,” she says.

For example, if a patient with end-stage ovarian cancer refuses further treatment, her choice is the final word. Even if her family vehemently disagrees, her decision stands, she explains. “If they’re alert, oriented, and able to make their needs known, they are competent.”

Another patient is advised to change eating habits to improve his medical condition, another common example. “But if they love fried chicken and insist on eating that way, it’s their choice. They may be showing awful judgment, but they are competent to make the decision.”

The Power of Communication

Communication is the fifth “C” in patient care. Communication that shows respect for the patient must be at the heart of every process, says Fink-Samnick. “We take the patient seriously. We don’t interrupt the patient when they’re talking. We take into account the patient’s language and literacy levels, to ensure they understand.”

The case manager will ask questions guiding the patient toward treatment choices, discharge choices, and end-of-life choices based on their preferences, including cultural rituals.

In these discussions, the case manager must understand the factors involved in these choices, respect them, and continue to act as advocates for these patients, she says. “That’s the power of establishing a relationship with the patient and helping them through the journey. You’ve engaged them, you’ve come to understand them, and you can help them make choices that are aligned with their values.”