Exploring Influences on Community-Based Case Managers\u27 Advance Care Planning Practices: Facilitators or Barriers?

Community-based geriatric case managers work with an increasingly frail older population in need of advance care planning throughout the end of life. However, little is known regarding factors that influence their professional practices in this area. This qualitative study used four focus groups to explore case managers\u27 (N = 27) perceptions of facilitators and barriers to advance care planning practices. Themes from the study suggest that case managers view five key influences that appear to either assist or impede practices, depending on case manager\u27s perceptions and experiences. Themes include: (1) Paradox of case management and programmatic realities; (2) extent of family presence and involvement; (3) level of proficiency in advance care planning; (4) degree of client receptivity to planning; and (5) limited communication with providers. The findings suggest that case managers vary in their advance care planning practices by differing perceptions regarding clients, families, professional expertise, program effects, and communication within the network of providers. More research is needed to clarify the factors associated with case managers\u27 divergent advance care planning practices in order to enhance professional practice in this area

The Doctor Will See You Shortly: The Ethical Significance of Time for the Patient-Physician Relationship

Many physicians and health care leaders express concern about the amount of time available for clinical practice. While debates rage on about how much time is truly available, the perception that time is inadequate is now pervasive. This perception has ethical significance, because it may cause clinicians to forego activities and behaviors that promote important aspects of the patient-physician relationship, to shortcut shared decision making, and to fall short of obligations to act as patient advocates. Furthermore, perceived time constraints can hinder the just distribution of physician time. Although creating more time in the clinical encounter would certainly address these ethical concerns, specific strategies—many of which do not take significantly more time—can effectively change the perception that time is inadequate. These approaches are critical for clinicians and health systems to maintain their ethical commitments and simultaneously deal with the realities of time