Optimizing the Social Worker’s Role in Serious Illness Communication
By Catherine Givens, LICSW, ACHP-SW
Teresa, a hospital social worker, was dismayed. “Even though we planned for it, I don’t think I can have that Serious Illness Conversation with my patient, Marcella*,” she told her supervisor. The attending physician had made it clear that the social worker shouldn’t talk with Marcella or her family about health-related goals and priorities, even though Marcella was seriously ill; he even seemed to suggest that the social worker should “stay in her lane.”
“He suggested that I complete a Health Care Proxy with Marcella instead,” Teresa said.
The situation was not only distressing for Teresa as a member of the interprofessional care team, but she also believed it was not in her patient’s best interest to place limits on the patient’s right to explore goals and preferences. Rather than “staying in their lane,” social workers can and should play a major role in serious illness conversations so that patients and families are more likely to experience patient-centered and goal-concordant care and social workers can effectively communicate influencing factors to the providers working on the case.
This approach has long been part of Ariadne Labs’ Serious Illness Care Program. The lab has hosted multiple trainings around the U.S. for a broad range of health care professionals on how to use the lab’s landmark Serious Illness Conversation Guide to ensure seriously ill patients communicate their preferences, priorities, and goals to facilitate shared decision-making. The Guide, a structured communication tool based on best practices in person-centered communication, has been used for training more than 121,000 clinicians nationally and globally.
The Guide is designed to be used by all members of the interprofessional care team. From June 13 to 14, 2023, Ariadne Labs will host a virtual summit on “Driving Equity in Serious Illness Communication and Care” that will bring together a community of serious illness care practitioners.
Social workers are key members of that community. In fact, many of the skills that are prioritized in social work education and training are the very skills essential to sound and effective palliative care practice.
Social Work Skills and Strengths in Serious Illness Communication and Care
Social workers usually develop trust with both the patient and family, friends, or loved ones, and are skilled in supporting patients’ articulated goals and preferences. They may be able to ease unnecessary tension between the family and members of the care teams. Social workers often have a solid knowledge of community resources, as well as behavioral health diagnostic and intervention skills. They are able to identify cultural, ethnic, and spiritual factors that influence patients’ experiences and abilities to take full advantage of treatment plans available to them. Importantly, social workers are adept at interpreting the relationship between many psychosocial factors and medical decisions that influence patients’ outcomes regarding client-driven care and the commitment to goal-concordant care.
Yet there remain significant misunderstandings about social workers’ skill sets, and there are barriers to optimizing their roles in interprofessional, team-based serious illness communication, both early in an illness trajectory as well as at the end-of-life.
For example, in the scenario described above, the attending physician mistakenly assumed that Teresa was planning to talk with their patient about a change in the care plan, possibly even suggesting a transition to comfort care, whereas Teresa’s hope was to engage Marcella and her family in an exploration of Marcella’s goals and preference as her illness trajectory continued to decline. This misunderstanding of the social work perspective led the physician to suggest Teresa “stay in her lane” and help the patient complete a Health Care Proxy.
The irony in this suggestion cannot be overlooked. While many medical providers see the completion of a Health Care Proxy as merely “administrative paperwork,” for social workers, it is also an opportunity to explore hopes and worries in the context of future medical decisions before such decisions need to be made. Some of the richest information available to the interprofessional team comes from these social work-led discussions with patients, often when there is nothing immediately riding on the conversation other than the sharing of goals and worries.
Beyond the completion of the Health Care Proxy, the social worker is able to engage their patients in the exploration of their preferences and worries before their health trajectory worsens. Either conjointly with other team members, or alone with their patients, the social worker can assess the patients’ illness understanding, prognostic awareness, and their information preferences.
Social workers prioritize cultural humility when working with their patients and support persons, assessing the impact of the patients’ cultural, racial, ethnic, and spiritual alignment on their experiences moving forward. So often, medical providers do not have the information that can profoundly impact the success of the treatment plan because they do not understand the effect of culture, race, ethnicity, or religion/spirituality on the patient’s and family’s experiences and motives.
A clear example of this is demonstrated during a subsequent conversation between the social worker, Teresa, her patient Marcella, and Marcella’s family. With Marcella nearing the end of life, the team broached the subject of hospice; in response, the family recoiled, saying, “When someone goes on hospice, they always die.” One family member said, “I heard that they give them extra pain medication to hasten their death. That happened to our aunt when she had cancer.”
The social worker explained that this was more a matter of the patient’s imminent death, regardless of hospice support or not. One of the family members asked, “But what if she gets better?” as they worried that hospice would just “let her die anyway.” Teresa responded, “Then we will have a huge party to celebrate.”
Through the building of trust, the family became more open to transitioning to hospice. With the help of the social worker, the team was also able to come to see the impact of historical racism on Marcella and her family’s views on hospice and was better able to approach the family’s reluctance with understanding and reassurance. Ultimately the family agreed to hospice and their mother was able to die at home, which was her hope.
Thus, a crucial role for a social worker is communication with the medical team. The social worker can provide context for a patient’s preferences, helping interprofessional team members understand why the patient may decide on one course of treatment versus another, or why a family member may have expressed resistance to a certain proposed course of action. This can reduce tension between the family and members of the care team.
Using the Serious Illness Conversation Guide in Social Work Practice
Social workers can and should use Ariadne Labs’ Serious Illness Conversation Guide, and health systems should be open to training in the use of the guide for interprofessional teams that include physicians, nurses, social workers and other clinical staff.
While it is out of the social worker’s scope of practice to provide time-based prognostic information, a social worker may express feelings of uncertainty about a patient’s future, perhaps saying, “While I hope that this isn’t the case, it is hard to predict when another significant medical crisis might occur.” This is often referred to as anticipatory guidance, helping the patient and/or loved ones think ahead and develop Plan B and perhaps even Plan C in preparation should Plan A not go as intended. In situations where a patient and/or support person asks a direct question about a time-based prognosis, the social worker is able to provide reassurance that the medical team can be consulted and the social worker can request that the team returns to the patient with more detailed information.
When exploring patients’ goals, values and priorities, social workers are especially attuned to the psychosocial factors that frequently impact their treatment decisions and the ways they, themselves, can and do communicate such significant information to their interprofessional colleagues. Relying on the skills that are at the foundation of their practice, social workers can ensure that patients and families are far more likely to experience supportive, client-centered, and goal-concordant care, and their interprofessional colleagues will engage in effective communication in treating and interacting with serious illnesses.
Catherine Givens, LICSW, currently works at Brigham and Women’s Hospital in Boston as a Social Work Manager and the Manager for Social Work Education and Professional Development. She has been practicing palliative care for more than 15 years, including training interprofessional medical providers in using Ariadne Labs’ Serious Illness Conversation Guide for nearly nine years.
During the June 13–14th, 2023 Serious Illness Care Program Summit on Driving Equity in Serious Illness Communication and Care, Catherine will be speaking on “Collaborative Conversations: Can Teamwork Really Make the Dream Work?” Register for the CME-eligible virtual Summit to hear from Catherine and our exciting line-up of speakers.
*Note: All patient scenarios are fictionalized. While based on real-life situations, they do not reflect the care of any specific patient.