Don’t avoid bringing up a difficult subject

Talk to your clients about advance care planning

End-of-life care may be the most difficult subject you’ll take up with your clients, but you’ll be doing them a big disservice if you don’t discuss it.

"A lot of it boils down to people being able to communicate on topics they don’t want to talk about, but people need to know that if they don’t talk about it, they don’t get what they want. If they don’t tell someone the fact that they don’t want to be kept alive on a ventilator, they will be kept alive on a ventilator," says Michael J. Demoratz, LCSW, CCM, PhD, a case manager in private practice who specializes in care for catastrophically ill patients.

Demoratz suggests bringing up the subject of advance care planning gradually with your clients and raise it again until they make a decision.

Some people, particularly older people, think that if they have an advance directive they won’t get treatment. That’s why the conversation needs to be part of every initial interaction by case managers, Demoratz adds.

Questions that should be addressed include use of ventilators and other equipment, artificial feeding and hydration, antibiotics, cardiac medications, pulmonary resuscitation efforts, and whether to be transferred to a hospital emergency department.

The conversation always takes more than 15 minutes when it is first initiated, so allow plenty of time, Demoratz says.

Discuss with the client and family where they are in understanding the disease process, suggests Judith Black, MD, senior products medical director for Pittsburgh-based Highmark Blue Cross and Blue Shield.

Determine if patients understand whether they will get better and whether the treatment they are considering will help them meet their goals, Black advises.

"The case manager can be a facilitator to help the patient and family make the right decision," she says.

Recognize that end-of-life decisions are a process and not just a one-time issue.

"People shouldn’t think they can complete the form and they’re done. All health conditions can change," Black says.

Encourage your clients to designate an individual to make health care decisions for them and to talk to that person about what they want. "Some-times the member has designated someone to make the decision, but they never talk to them," she says.

If a client says his or her advance directives are in order, gently ask him or her to show you proof.

"When they meet face to face with a patient, I suggest that case managers ask to see all the medications a patient is taking rather than simply asking if they are taking their pills. In the same way, I would ask to review the advance directives with a patient to make sure they are up to date and complete, comments Catherine Mullahy, RN, CRRN, CCM, president of Options Unlimited, a Hunting-don, NY, case management company.

Be prepared for clients who resist discussing the subject. For instance, young people may shy away from the subject or feel that they don’t need to act.

When she talks to her clients, Mullahy compares the preparation of advance directives to the wisdom of preparing a will and reminds them that such measures are wise for everyone, from newlyweds to retirees.

With older clients, who may fear losing control of their own lives, Mullahy points out that the medical directives are a kind of insurance policy that enables individuals to take care of their own medical futures and remain the decision maker regarding their health care.

Be aware that you may encounter unspoken misperceptions about why you are raising the end-of-life issue.

"When a case manager represents a managed care organization, she is sometimes met with skepticism or cynicism about her motives in asking certain questions. Because of our close affiliation with money matters, case managers should anticipate some resistance, not only due to talking about death but also due to the feeling that we might be more interested in holding onto health care dollars than in appropriate care," she says.