Case Study

Palliative Care Social Work: Connecting with Family when You Need Them the Most

Mr. S, aged 62, was a frequent visitor to the local emergency room because of congestive heart failure. His trips to the ER were his only medical care. He often arrived in respiratory distress and was typically admitted for 7 to 10 days until stabilized.

Mr. S lived in a small apartment over a store. The building had no elevator, and the staircase was very narrow. Mr. S was one of three tenants in the building. Typically, he was transported home from the hospital by ambulance and was carried up stairs on a stretcher. He was usually deposited in his recliner, which he slept in, and did not leave the apartment again until his next visit to the ER. He managed to move around his small apartment by leaning on furniture, etc.

He received Meals on Wheels and often ordered additional meals from the local Chinese take-out restaurant in a storefront down the block. Occasionally, neighbors shopped for him and got him cigars, which he enjoyed smoking. The local liquor store delivered his inexpensive brand of beer on a weekly basis. He said he drank it to calm his nerves. The beer, cigars, and Chinese food made his condition worse. He did take his medicines after discharge from the hospital, but that lasted only as long as the visiting nurse came by. He used oxygen occasionally, although it was prescribed for continuous use. After each hospitalization, the nurse’s visits typically became less frequent over time owing to restrictions in his medical insurance coverage. He had been a construction worker and had union-related medical insurance that was generous regarding hospital coverage but less so regarding outpatient care.

Although only 62, Mr. S looked much older. He had never married, but had a sister living in a nearby town who was 4 years younger and in poor health. She frequently argued with him about his situation and asked him to live with her, but this made him angry, and he often stopped talking to her for periods of time.

As Mr. S’s visits to the ER became more frequent and his hospital stays grew longer, he was referred to the hospital's palliative care team. Because he had no regular physician, the palliative care team overseeing his treatment during each admission gave him some continuity of care, which he had never received before. Social workers on the hospital floor had helped him numerous times with arranging his discharges, but the social worker was different each time. Once the palliative care team was involved, however, he was assigned to the team’s social worker, who saw him at each admission. Mr. S refused to have medical appointments as an outpatient, even when offered transportation because his medical insurance would only cover ambulance service if he was admitted to the hospital.

Upon first meeting the team’s social worker, Mr. S told her a nurse usually visited a few times after he was discharged and that he did not need welfare. Essentially, he refused to be engaged until his next admission. Because his condition had deteriorated, the social worker explored his living situation and he became very defensive, yelling that he would not go to a nursing home. This was clearly a great fear. Although living in a compromised and often dangerous situation, Mr. S felt safest in his own apartment. When the social worker asked permission to call his sister, he agreed, hoping that the social worker would convince her to leave him alone. The meeting with Mr. S’s sister revealed that he had been a binge alcoholic most of his adult life. However, she was sympathetic because Mr. S had had a hard life. While he was often difficult and at times verbally abusive, she felt she "owed it to him" to try to help him. Their mother had been physically abusive, and Mr. S had always tried to protect h is sister, even though that put him in more danger. Their mother abandoned them when Mr. S was 17, and they lived with their grandmother, who died when Mr. S was 19. Mr. S had raised her until she married an older man at age 18. She was now a widow and a breast cancer survivor and suffered with chronic pain from rheumatoid arthritis. Her daughter lived nearby and was a help to her.

The sister said she never spoke about the past, and in fact her own daughter did not know as much as she told the social worker. The social worker encouraged her to tell her daughter her story because it was a story of survival and resilience and something to be proud of. The family history gave the social worker insight into Mr. S's life choices and difficulties and helped her to understand why Mr. S did not connect well with others and was often combative. She wondered if Mr. S suffered from depression and "treated" it with alcohol. When she met with Mr. S and shared with him what his sister had shared, Mr. S indicated that it was ancient history and didn’t matter any more. Nonetheless, he was appreciative of the social worker’s empathy and praise for his efforts to protect and help his sister.

The social worker shared the family history with the health care team, and Mr. S was approached about a psychiatric consult the next time he was admitted. He yelled that he was not crazy when he was admitted but the hospital was driving him crazy. He demanded to be discharged although his condition was too unstable. The social worker explained that he was sicker than usual and reviewed what the doctors had told him about the severity of his symptoms compared to previous admissions. She told him the team was concerned that without his beer, he did not have anything to calm his nerves and brought up the subject of meeting with a psychiatrist again. He said that if he could not go home, he would need to see a psychiatrist because he was a prisoner in his room. Mr. S gave the psychiatrist a hard time but agreed to take a fast-acting mood stabilizer and to work with a physical therapist so that he could perhaps leave his bed.

The health care team concluded that Mr. S would be unable to go home and recommended a subacute nursing home placement but also agreed to a hospice referral as a backup plan. When the social worker asked the doctor to discuss the two plans with Mr. S before she addressed the plans with him, the doctor agreed but asked her to attend the bedside meeting as well. After giving Mr. S the information about his prognosis and possible plans, the doctor left the room. Mr. S shared with the social worker that he knew he was going to die but did not want to die in the hospital and would rather die in the street than go to a nursing home. The social worker pointed out that his medical insurance required the hospital to make applications to nursing homes, but hospice care also would be explored. When the hospice nurse screener said he could not receive hospice care at home because there was no care partner, he yelled at her. The hospice program knew about Mr. S because it was connected to the same visiting nurse service that had been trying to help him at home.

The social worker set up a family meeting with Mr. S, his sister, and her daughter to discuss the real possibility of transfer to a nursing home. Mr. S was very subdued and simply said he wanted to die before there was a nursing-home bed for him. His niece told him she was very thankful that he had protected and helped her mother when she was young and unable to protect or care for herself. The niece wanted to repay Mr. S by offering to have him stay in her home and have the hospice program care for him there. Mr. S cried and agreed to the plan and thanked the social worker for giving him a family when he needed one the most. Mr. S was discharged with hospice to his niece’s home and died 10 days later surrounded by his family.

Discussion Questions

1. Using Table 3, the biopsychosocial health needs and formal services required to address them, answer the following questions regarding this case:

   a) Of the seven areas of need outlined in the table, what information do you have for each?

b) Which of the seven areas was most prominent in the assessment and development of a treatment plan for the short term and long term with this family?

c) Identify services used to meet each need.

d) What psychosocial theories were used for the intervention approach, e.g., ecosystems, strengths perspective, trauma theory, social network theory, cognitive theory?

2. With so many different potential problems, what prompted the palliative care social worker to get permission to contact Mr. S’s sister?

3. Discuss the possible role of his mother’s abuse to his current behavior.

4. What prompted the palliative care social worker to ensure that everyone involved knew about Mr. S’s early care of his sister?

5. When a situation involves multiple problems, as was the case with Mr. S, why did the palliative care social worker emphasize his early care of his sister? Discuss the role of emphasizing the client’s strengths, rather than his problems (drinking, not using oxygen, refusing alternative care options).

6. Discuss the role of a team approach in the care of a client, such as Mr. S. What are the pros and cons of having a physician discuss the actual prognosis with such a client in the social worker’s presence and of having her discuss and develop realistic options with the social worker? What are the pros and cons of meeting with the family before meeting with the psychiatrist and the hospice nurse?

7. How does this case illustrate gaps in the current system of care? How might social work take leadership in developing a care system that would address these gaps in the current service structure?

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