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Every person
should be afforded the opportunity to discuss with a clinician the options
they have to choose from when facing a life threatening injury or
illness. Whether the person is able
to make decisions for him or her self or whether the discussion occurs with a
family member or guardian, the clinician should be as thorough and objective
as possible in providing information about care options. Individuals often are unclear about such
things as the different approaches to ventilatory assistance, for
example. They may not understand that
nutrition can be delivered both intravenously as well as through the gut and
that a feeding tube need not be permanent.
They also may not understand that advance directives can be changed at
any time. Ideally these conversations
should be undertaken before the life-threatening situation is at hand. In the same vein, discussions about the
advisability of using desensitization and/or restraints should be
undertaken. The goal is always to seek
the least restrictive approach that maintains safety while assisting with
care.
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Everyone’s care
is “managed” in some fashion and resources are finite. “Cost” can be limited by such things as
increased queuing time or limitations in coverage. The win-win, however, occurs when early, relatively inexpensive
care is provided (e.g. preventive services or early in the illness care) that
prevents later, expensive care (e.g. ER visits and hospitalizations or
treatment disability resulting from illness or injury). Individual clinical case management can
help reduce costs both in the short term, e.g. by shortened hospital stays,
as well as the long term, e.g. through care coordination.
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As always,
quality of life should be the primary focus and functional capability is one
of the most important keys to quality.
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