Recently, a family acquaintance passed away. It was rather sudden and some suggested it was an avoidable (or at least a delayable) event. However, he neglected to seek medical care for an assortment of vague symptoms. Perhaps, it was because he lacked health insurance or because he feared what he might be told. By the time he sought care, his health deteriorated to the level of unignorable and it was simply too late. He presented to a community emergency department from which he was transferred to a metropolitan medical center where he spent thousands of dollars in diagnostic procedures and treatments. Cancer had spread from colon to liver and beyond. His choice, from a limited list of options, was for hospice care. There was less than 2 weeks between diagnosis and death.

Hundreds of friends and family passed through his hospital room to share a final few words. He was well-known and highly regarded. His life was a model of serving his fellow man while surviving his own adversity. He suffered more than a few tragedies in life. The loss of his spouse and of a child might overwhelm some, but his faith sustained him and he continued to be a great strength to countless others. Even in his last few days, he continued to serve as the supporter of his friends and family. It's something I've seen repeated a few times over the years, especially in situations where death is imminent; the dying person serves as the source of solace. Although he may have suspected what was going on for some time, his failure to take proactive steps in diagnosis and treatment left his family and friends scrambling to process an impending and significant loss.

His acute care continued; test results worsened. His pain level gained ground. There was the matter of selecting a hospice option. He dealt with this alone and chose to move to a facility closer to home. I wondered what those weary eyes took in during those last few days. The nurse administering pain relief, the doctor's regretful looks that more curative work could not be done, or perhaps the case manager struggling to get the hospice transfer accomplished for someone without health insurance. The reality of the situation was that the transfer was of a smooth and compassionate transaction, but we all know that this represents a best case scenario and those situations are few and far between in our harried workday.

So what can case managers do to smooth the rough seas when working with an individual and support systems who may be frozen by the tragedy facing them? As care coordinators, we must be capable messengers of difficult information and the connection point between care team members and others responsible to deliver health care goods and services. Are you prepared and comfortable in a facilitation role during some of the most traumatic and tragic times of people's lives? If your answer is anything less than a hearty "Yes, I am," then now is the time to take stock of your personal beliefs and align your professional responsibilities so that you are capable of providing end-of-life care coordination services. When these topics must be approached, it is critical that they be presented in a bias-free manner; the case manager may end up being the fulcrum of strength and stability in an otherwise emotionally tenuous situation.

Palliative and end-of-life care programs improve the quality of care throughout a patient's illness, not simply at the end of it. Patients and caregivers who utilize these services are often more satisfied with overall care and provider communication. In addition, there is a lower chance of ending up in emergent and intensive care situations where curative measures taken may fly in the face of patient wishes for a dignified end of life.

Although early intervention is desirable, too often discussing end-of-life care coordination remains uninitiated until later in the course of illness. There are some solid reasons for this being the case. In situations such as mentioned initial diagnostic care is sought so late in the disease progression that the time for advanced planning has passed. In these situations, end-of-life care is the priority and transition urgency wins out over development of a comprehensive long-range plan. This is not to infer that the care coordination that occurs is not carefully considered. Simply that there is not more time for the individual, caregiver, and care team to develop a multipronged approach to end-of-life care.

In the acute hospital setting, end-of-life as a care plan topic is lower on the priority list because urgent health and social issues must be addressed during the all-too-brief window of opportunity. Similar is the situation for payer setting care coordinators. Models of payer case management continually blur the lines between utilization managers and case managers. Although utilization manager staff monitor acute care admissions against care paths or diagnosis-specific criterion, the opportunity to address seemingly less important matters is left for someone else because the care to be coordinated is limited to that which will result in the patient moving to a less intense care setting. If an individual is "fortunate" enough to trigger a payer case management referral or an alert provider places a call to the administrative office, there should be at least a glance given to end-of-life matters. It is hard to imagine a more pressing health care barrier than a lack of an end-of-life care coordination plan for a patient facing a terminal condition. However, if a sufficient cost-benefit cannot be realized in taking on a member's case management, that person's file may be closed during initial screening.

Despite these obstacles, part of our case management responsibility is to facilitate care through assessment, opportunity identification, and conscientious care planning. Regardless of when we become involved with an individual's care, we are remiss if we do not investigate and raise questions regarding end-of-life challenges that an individual and the caregiver are likely to face in the coming months, hopefully years. We must not shy away from this topic due to our personal beliefs or biases because in doing so we fail our client miserably. We must support clients to acknowledge and address end-of-life planning as part of their personal responsibility to themselves and their loved ones.

In the case previously presented, despite a legal mandate to do so, the gentleman did not carry health insurance. He minimized early warning signs, including a profound and unexplained weight loss. If friends or family took notice, their concerns were not voiced or acted upon. It was not until a trip to the emergency room that ice-cold reality came into focus. It was then that this gentleman realized he was going to die within a matter of weeks. After the brief acute hospital stay, his organs began to fail and his pain level rose. A hospice bed was secured and the transfer took place promptly. Within 72 hr of arriving, he passed away surrounded by his closest family and friends. He did not appear to be in any pain, nor was he anxious or fighting his destiny. By all accounts, it was a dignified death.

Postscript: His family was left to pick up the pieces that were left behind. They struggle to make sense of his business affairs. It is unknown if there are sufficient assets to pay the mortgage and associated household bills. It is unclear if his survivors face a financially secure future or if they will be forced to sell the family home. These things could have been addressed in an end-of-life case management plan. I think we can do better to help our clients face their inevitable passing. Don't you?