Whether you’re watching March Madness, the Olympics, or the World Series … have you ever noticed how the very best teams combine the distinct strengths of individual players to achieve something greater than any one person could accomplish alone? It is that same team mindset that hospice and palliative care bring to improving the quality of life for people with serious or life-limiting illnesses.
At Delaware Hospice, each interdisciplinary team attending to one of our patients includes a primary nurse or certified nurse practitioner; a social worker; and a chaplain—as well as volunteers and certified nursing assistants at the ready should their services be needed. Each team member brings their own unique perspective, talents, and abilities to helping the patient meet their goals.
Let’s take a closer look at the incredible strengths social workers bring to the team. While their contributions are too many to count, here of a few of the highlights.
Social workers:
Clarify the patient’s goals and expectations
At the helm of every care team, you find the patient and their family. The social worker meets with each new patient within five days of enrollment, usually at the same time as the patient’s primary nurse, in order to clarify the patient’s goals, expectations, and unique needs. When expectations or needs surpass the team’s role—for example, if a family expects or needs the patient to receive around-the-clock-care—the social worker helps the family coordinate other outside services.
Every visit, the social worker asks the patient and family, “What’s most important for you?” Those hopes and wishes become our team’s priorities.
Protect the patient’s dignity and right to self-determination
The social worker helps the patient navigate their situation in the best way possible, guided by the patient’s own idea of what good end-of-life or palliative care is. The social worker helps ensure that the patient (or their advocate) makes the ultimate decisions about the best path forward—not the care team or anyone else.
The social worker also helps the family create a safe place in the patient’s home where the patient can feel comfortable and enjoy some degree of privacy, especially if the patient’s movement is restricted. They’ll also discuss ways the family can advocate for the patient’s wishes and interests—including things like setting boundaries and limits for visitors—should the patient become unable or unwilling to speak up for themselves.
Connect families with resources
Did you know that someone on oxygen should register with the electric company to minimize service outages? About the geriatric doctors from the local practice that now make home visits? How to apply for a nursing home slot while your Medicaid Long Term Care coverage is still pending? Our social workers do. They’re walking encyclopedias of outside resources available to patients and their families.
If you’re caring for someone with dementia, the social worker is the one who can help you find a support group—and work with the volunteer coordinator to arrange for someone to stay with your loved one while you attend the meetings! The social worker is the one who makes note of children connected to the family and loops in our New Hope children’s counselor. They’re also the one who can help arrange a temporary in-patient hospice placement if the family needs a break from taxing caregiving duties.
Educate patients about end-of-life care options
It’s hard to make decisions about life-saving and life-sustaining measures when you don’t know exactly what they entail. The social worker fully explains procedures and measures like CPR, feeding tubes, and ventilators so patients can make truly informed decisions about their wishes in the context of their current circumstances. The social worker can also assist patients with creating advanced healthcare directives and legal power of attorney documents.
Become the family’s number one cheerleader
Most families don’t have a medical background. Many have never had a close family member die. The social worker is there to give them the confidence, the knowledge, and the support they need to care for their loved one. They ensure that families know how and when to call us for help. They let them know about the resources out there for them. And for hospice families, they provide education about the dying process and what to expect so families can feel empowered for the journey.
Support their own teammates
As part of a well-oiled team, different team members often provide assistance beyond their own particular roles—without, of course, overstepping their bounds. A patient’s primary nurse will frequently help address a family’s social needs; at the same time, the social worker might adjust pillows, or offer other assistance the family needs during their visit.
At Delaware Hospice, social workers are an integral part of our team approach to providing patients and families with the highest quality care available.
