Social work interventions in death and dying

Death and dying processes require sensitive discussion between patients, next-of-kin, and inpatient providers (i.e., attending/hospitalist physician) to facilitate decision-making and coordination of care. Social workers can facilitate such communication and may coordinate meetings between relevant persons. Additional relevant persons (i.e., specialist physicians) may also be identified by examining the most recent progress notes in the patient medical record. Prior to the meeting, the social worker should work with patients and next-of-kin to formulate questions for each provider. The social worker should make a copy of the questions to keep as a reference. During the meeting, the social worker should introduce all parties involved and track whether each of these questions has been answered, reframing as necessary to ensure patient and next-of-kin understanding. At the conclusion of the meeting, the social worker should ask whether the patient or next-of-kin has any additional questions beyond what was indicated in the list and ask the providers whether they have any additional relevant information to offer. Also, the social worker should ask about a plan and method for future correspondence and then handle it accordingly. After the meeting, the social worker should review the questions and answers with the patient and next-of-kin to ensure that everyone is on the same page.

Life-sustaining treatment and comfort measures

Life-sustaining treatment includes invasive and non-invasive treatments that attempt to sustain life when a patient is not able to do so on his or her own. Life-sustaining treatment may include cardiopulmonary resuscitation, intubation and/or ventilation, and artificial nutrition and hydration. Patients may or may not have indicated the types of interventions they would like to have in the event that they are confronted with a life-threatening condition. Wishes may be indicated in a formal legal document, such as a living will. Patients may or may not have requested to have these procedures performed under certain circumstances and/or for a specified duration of time.

Comfort measures only (CMO) indicates that a patient would like to forgo life-sustaining treatment, meaning that he or she has chosen to not pursue interventions (both invasive and non-invasive) to treat an underlying terminal medical condition. The goal of care thus transitions to keeping the patient comfortable.

Social work interventions

Discussion surrounding life-sustaining treatment and comfort measures is directed by a qualified medical professional such as a trained physician, nurse practitioner, or physician assistant. Social workers may assist in scheduling provider meetings with patients and their respective healthcare agents, and we may attend these meetings and support the patient and healthcare agent throughout the decision-making process. Social workers assess each patient’s understanding of the material being delivered. In the case of ambivalence surrounding interventions that may pose a risk to a patient’s health (i.e., CPR being performed on a frail, elderly patient), the social worker collaborates with patients and healthcare agents to assess and deepen understanding of these risks in order to support better informed healthcare decisions. Should a patient decide not to pursue treatment further, a qualified medical professional should complete necessary CMO documentation. Likewise, should a patient choose not to receive certain interventions such as resuscitation and intubation, a corresponding do not resuscitate (DNR) and do not intubate (DNI) form or order would need to be completed and/or ordered, respectively.

For more information, see Social Work: Strength-Based Practice in Hospital Case Management.