As a case manager, you have a plethora of roles, functions, and activities for which you are responsible and a large number of people with whom you must interact to effectively do your job. Simply put, you wear many hats. Your responsibilities can change from time to time depending on what practice setting you may be in, and there are many of those as well. As you already know, case management is a complex, multi-faceted occupation that requires specialized skills, knowledge, and competencies that allow you to effectively meet the needs of your organization and your clients.
One of the core competencies for all case managers is the ability to effectively promote and facilitate advance care planning (ACP). It is one of the many hats that you wear and one that needs to be at the forefront in your practice to ensure that you meet your clients’ needs. Unfortunately, let’s be real, most people don’t like to talk about anything tangentially related to death. Always keep in mind that this really isn’t only about death, but about how to live well for the remainder of our lives. So, I would ask, is it something you address with all your clients, or have you avoided it and put it to the back burner because it just seems too hard or uncomfortable?
The work you normally do lends itself to good ACP because it already incorporates many facets of ACP. According to your Standards of Practice, you are already assessing your clients, developing plans of care, working with them, their family, and caregivers to discuss and implement the plan of care and monitoring, then reviewing that plan periodically. You also integrate with other members of the healthcare team who are involved in your client’s care. You do a fair amount of talking, but, in fact, you be should doing a lot of listening to better understand what matters most to your client. What is important to them is the key to having the goals of care conversation and building a care plan that meets their specific needs and desires.
ACP involves many of the same building blocks as well as the same skills to be successful. Helping clients think through what really matters to them and getting them to better understand their healthcare needs, treatments, and future healthcare trajectory is critical to their care and satisfaction. Helping them understand that there are, perhaps, many options for their care going forward and that you will work to help them carve out the direction they wish to go to live well is also crucial. For so many years, patients received the paternalistic, old school medical mantra of care which is no longer necessary, nor desired. Clients should be encouraged to participate in planning their care now so that they have a say in what happens to them.
Now that our world is faced with COVID-19, more and more people are becoming aware of their need to have these types of conversations, develop an ACP, and complete an advance directive. Some may want to participate in their care and the planning for their future; others may not. However, if you don’t bring it up and help them work through the process, where does that leave the client? You are the manager of their overall care, and if you don’t think enough about ACP to bring it up and work with them on it, where are they left? An opportunity has been lost.
The next question I will ask is whether you have done the personal work of communicating with your loved ones and completing your own ACP. Do you have an advance directive? Have you, like your client, put it off either because of time (lousy excuse), fear, lack of knowledge, or a myriad of other excuses that people use these days when they are pressed on this issue? Knowing what it is like being a procrastinator on the issue, even if you aren’t in other things, is important. You will identify much more closely with your client and appreciate their needs even better. I know that it has probably been a long time since you have been on an airplane. But surely you remember the guidance—”Put your own mask on first; before helping others.” The same is true for advance care planning. It is possible to help others without doing your own planning, but it is certainly easier to do this work if you have been through the process yourself. Conversations with loved ones can be challenging. It is easy to put planning off as other activities overwhelm you or you believe you are too healthy to need one. Having been through the process yourself will leave you in a more empathic place when working with your clients. Remember, it is a gift that you owe yourself and your loved ones.
So what is this gift and why is it so important? Healthcare workers tell us all the time that when a crisis occurs and they ask the question of whether the family has talked about the kind of care a loved one would want, the answer is frequently, “no, we never talked about it,” followed by the gut-wrenching line, “we haven’t got a clue.” Even for patients with cancer or multiple health issues, the conversation has frequently not occurred, for whatever reason. Those left behind have no idea what their loved ones would want and are left guessing. Having the conversation earlier in life helps the clients’ families prepare for when the need arises and won’t leave them flat-footed when they are called upon to help. They will have already considered the issues facing them and know what their loved one would want. The families are not left wondering “Did I do the right thing for Mom?” which is a question that will follow them for the rest of their lives if they have not discussed it earlier, and they will never know the answer for sure. Therefore, it is a gift. A gift of knowledge and information on which they can lean when the time comes. So put your hat on, and have discussions with your client, their friends and loved ones. Help them understand and progress forward with having the conversations and completing their advance directives. The healthcare team and the family will have you to thank, and you will be doing a key function of your profession.
Doing your own advance directive may not be easy, but it is possible and extremely important. I have had an advance directive for years but recently needed to update it. I knew it needed to be done. Did I procrastinate? I sure did. It is so easy to put off until tomorrow things that don’t seem critically important today. There is always one more excuse. But I got it done and, as a result, I was reminded of the challenges and have a better understanding of my clients when they put planning off and say that they haven’t gotten there yet. You will, too! I work with my clients, encouraging them to take it in bite-sized pieces and not try to do it all at once, which makes it much more manageable.
This is where you come in. As their care manager, you will have numerous opportunities to move your clients forward with their ACP, and in doing so, it will help you to refine and enhance their plan of care and your relationship with them. Many care managers I know make advance care planning the foundation of the work they do with their clients. Granted, it is only one of many responsibilities you have, but success here will feed the remaining work that you need to accomplish with and for your client. It will leave your client in a better place moving forward. So grab your ACP hat, become comfortable and familiar with it, put it on, leave it there, and become the very best care manager that you can be. Remember to “have the conversation, and give the gift!”
, RN, FACHE(R), is a consultant, educator, and healthcare ethics advisor with 35+ years’ experience in healthcare. She works with individuals, families, organizations, and healthcare systems to help them understand the importance of advance care planning for themselves, their loved ones and their members.