Case Management Plan for a terminally ill Patient


Developing a case management plan for a terminally ill patient which is a 65 year old man who is dying from Congestive Heart Failure. 

  • Describe the model of case management you will utilize.

  • Identify actual resources in your local community that is available to your holistic plan of care.

  • Describe what resources are lacking in your community and how you might be able to retain these resources for the patient.

  • Discuss who will be involved in the plan and their roles as well as their time-frames of involvement.

  • Explain clearly how each member of the team will document the plan of care.

  • Describe the role of the case management in the end of life care.

  • Explain how case management will be evaluated in the end.

  • Discuss how you or the team will protect themselves from litigation.

Sample paper

Case Management Plan for a terminally ill Patient

Model of Case Management to Utilize

The model of case management to utilize in this scenario is the Triad Model of Case Management. In applying the triad model of care, the responsibility of the management is subdivided into separate roles. The specific approach to use in this case is the patient, family, and the professional triad. The triad mode utilizes the expertise or knowledge of the entire management team. The model is essential in advancing an interdisciplinary team approach in care management. Three major disciplines are involved in the process, which include social work, utilization management, and the nurse case manager (Cohen & Cesta, 2005). The model is important in that it helps nurses and others involved in care management to identify critical system issues that affect patients in the continuum of care.

The Triad Model of Case Management can enable nurses to alter the course of caregiving with regard to the care recipient and the caregiver by providing each with the freedom to make key decisions in the professional care (Cohen & Cesta, 2005). The triad model is essential in helping nurses to develop collaborations with patients as well as their families to deliver a type of care that enhances mutual relations between the nurse and the client. One of the key strengths of the triad model is that it ensures unique attention is given to each of the case management. On the other hand, fragmented care may arise especially if there is no proper coordination among the care team. The triad model ensures that even by giving assistance to the patient, he/she does not lose autonomy or independence. It is also important for nurses to involve caregivers in decision-making.

Actual Resources in the Local Community that is Available for the Holistic Plan of Care

In utilizing the triad model in patient care, the nurse must explore all the available resources, such as human, financial, and material resources. All these resources should be used to enhance the quality of patient care and in providing the client with personal freedom or independence required. The nurse must ensure that the patient receives necessary resources and at the appropriate time. The nurse determines the materials, equipment, and supplies that the patient needs in order to be more comfortable. After evaluating the client material needs, it is the responsibility of the nurse to ensure that the patient receives the material resources. The materials available in the community to support an individual suffering from congestive heart failure include CPAP machine, oxygen supplies & oxygen therapy devices, sequential air device, a cardiovascular system, renal system, and other life support equipment.

Human resources are also available in the local community and are vital for the holistic plan of care. The human resources available include the nurses providing care as well as those involved in the healthcare team. Family members play a key role in providing care to terminally ill patients. The nurse is responsible for training then family members on various areas of care that may be necessary for the particular patients. The financial resources are also key in the holistic plan of care. It is worth noting that the triad model of care is more expensive compared with other models such as the dyad model. The client finances the total costs incurred in healthcare. Insurance options such Medicaid and Medicare services can help to reduce substantially hospital bill for clients. The health insurance options range from government-run health insurance programs to private health insurance programs, most of which provide comprehensive care to clients.

Related: Nursing Sensitive Indicators

Resources that are lacking in the Community and Ways of Retaining the Resources for the Patients

The Triad Model of Case Management faces a number of resource constraints in its implementation. One of the key challenges is lack of properly trained medical professionals to care for the terminally ill patients. Medical education largely neglects the training of end-of-life care to nurse practitioners. According to Woo, Maytal, & Stern, (2006), only 18 percent of medical students claimed to have received formal training on how to care for terminally ill patients. In addition, about 40% of the respondents felt inadequate to impact younger clinicians with skills about care for the terminally ill patients. As such, there is need for highly trained medical personnel to help the terminally ill patients. Moreover, the study reports that majority of nurses experience a personal discomfort when dealing with the issue of death. In some cases, nurses and physicians may feel that they have failed in doing their work.

A solution to the problem above involves availing proper training to clinicians on end-of-life care. Clinicians should play a critical role in providing care and support to terminally ill patients. The clinicians should focus on approaches that aim at improving the quality of life of patients, rather than taking approaches that aim at curing or prolonging the life of the terminally ill patient. Another resource that is lacking relates to insufficient compensation of clinicians involved in end-of-life care. Medicare services compensate clinicians based on a relative value scale (Woo, Maytal, & Stern, 2006). This means that those involved in performing invasive procedures are likely to attain higher earnings compared to those involved in non-invasive procedures such as end-of-life care. This leads to demoralization of those involved in care of terminally ill patients. In order to attract more clinicians in the area of end-of-life care, there is need to bridge the payment disparity that currently exists. Raising the salaries of those involved in end-of-life care can attract more professionals in the field.

Those involved in the Plan and Time frames of Involvement

There are a number of key participants in the case management plan for the terminally ill patient. The first person involved in the plan is the nursing professional responsible for providing expert care. The nurse determines the materials and the equipment needed by the patient to lead to comfortable life. The nurse offers individualized care to the patient such as prescribing medication for pain alleviation and in enhancing the self-care ability to the patient. The nurse is responsible for helping the patient maintain independence. This is especially in situations where the patient requests for independence. The nurse is supposed develop and maintain a plan of care that suits the patient’s specific needs. Another role of the nurse is to provide guidance to family members on the needs of the patient. The nurse is involved right from diagnostic stage to the late stages when the patient passes away.

The family of the 65-year-old patient is also involved in the care plan. The family plays a critical role in improving the quality of life of the patient. Although clinicians help family members in making critical decisions in end-of-life care, the family has the right to make final decisions, such as where they prefer the death to take place. The family has the right to choose their degree of involvement in end-of-life care. Family members can help in communicating with the patient as well as providing personal care. This depends on whether they wish to provide such care to the patient. The family is involved right from the beginning until the very end of the entire process. It is also important to involve a religious leader. This is because most patients rely on spirituality for support and comfort during their final days. The religious leaders should be involved from the time of diagnosis, and upon the patient’s request.

How Each Member of the Team will Document the Plan of Care

Each member of the team has a critical role to play in documenting the plan of care. Clinicians are responsible for the provision of hospice care. This involves care of the terminally ill patient with regard to the physical, social, emotional, and spiritual aspects. The main goal of the hospice program is to ensure that patients experience minimal pain, restriction or discomfort while in their last days. The nurse has four critical roles to play. First, the nurse is responsible for control of pain through administering proper medication. Second, the nurse manages or prevents any complications that may arise in the treatment process. Third, the nurse maintains the quality of life of the patient. Lastly, the nurse ensures that final needs of the patient and family are fulfilled accordingly.

The family’s role is to provide support to the patient. The family plans the nature of care that they may provide to the patient. For instance, the healthcare facility may be unable to cater to some specific needs of the patient such as choice of foods, which the family can provide. The family also determines whether there is need for patient transfer to another facility of whether to provide home-based care. The religious leader will plan for meetings with the patient in order to cater towards the emotional needs of the patient. Frequent meetings can help address the emotional needs of the patient.

Role of the Case Management in the End-of-life Care

Case management is involved in meeting the patient’s diverse health needs. The process involves the careful monitoring, evaluation, planning, coordinating, and implementing the various options and services necessary for the patient’s health. Case management is concerned with caring for terminally ill individuals, rather than curing or seeking ways to extend their life. In hospice care, most of the services are offered in a home setting, and often using a multidisciplinary team approach. Case management includes palliative care, which entails implementing care and treatment approaches that fulfill the personal values of the patient. Case management thus emphasizes on individual values, comfort, comprehensive & compassionate care, and pain management approaches (Star, 2012). Case management also helps the patient to get the services and support they deserve to lead a quality life. Another role of case management is to counsel the family members of end-of-life care and preparing them to accept the inevitable.

Case management plays a critical role in helping the patient and family members make sound financial decisions. According to Star (2012), case management ensures that patients not only receive quality end-of-life care, but also minimize the financial burden to the patient and the healthcare facility. Case management also ensures that the patient maintains compliance and the family receives the appropriate reimbursement. Case management helps to ensure that the financial matters of the patient are put in order. For instance, case managers may ensure that the patient’s will is in order, process and ensure that all documents relating to beneficiaries are updated, and oversee the establishment of a funeral trust for the patient. Case management also offers grief counselling as part of personal healing.

How Case Management will be Evaluated in the End

It is important to evaluate the effectiveness of case management in helping the patient achieve quality services. In this case, case management can be evaluated based on how well it caters to the priorities of the 65 year-old dying from congestive heart failure. First, case management should ensure that the patient experiences minimal pain during the last days of his hospice care. Pain control should be tailored to suit the patient’s needs. Case management can also be evaluated based on how well it ensures that the patient’s wishes are honored, for instance, through processing and updating the beneficiaries’ records. Case managers must ensure that all the patient’s wishes are fulfilled.

Case management should be able to provide emotional support to the man as well as his family. In case of terminal illness, it is highly likely that the patient and family may experience emotional health issues such as stress or even depression. Case management should be able to address thoroughly such issues through counseling. Lastly, case management will be evaluated based on its ability to provide the patient with choice. The patient should be able to make a choice on the type of service to receive. For instance, the case management should allow patient to choose between home-based care and hospital based end-of-life care.

How the Team will Protect themselves from Litigation

Case managers are at times faced with legal litigation in the end-of-life care. The team will protect itself from litigation by carefully observing the Code of Medical Ethics with regard to the care of terminally ill patients. This code enumerates that physicians are obligated to ensure the patient experiences minimal pain and suffering, and that their autonomy and dignity are upheld throughout the period of care. Pain management is critical in the care of terminally ill patients. In the past, physicians have faced legal litigation due to lack of proper attention or actions to alleviate pain among the patient. The team will protect themselves from litigation by observing the state laws relating to the terminally ill.

Various states have enacted laws guiding the actions that physicians may take in case of terminally ill patients. Majority of states criminalize assisted suicide to terminally ill patients. However, some states such as Oregon have been able to pass laws allowing physician assisted death in terminally ill patients. Another way the team will protect itself from litigation is by observing the rules and regulations outline by the healthcare facility. Every healthcare institution has a set of rules of conduct that guide staff and patients alike. By observing these rules, one may be able abscond from litigation. The ethical code of conduct is an important tool in guiding the behavior of clinicians and other hospital staff alike. Observing the ethical code of conduct can help the team avoid any form of litigation.


Cohen, E. L., & Cesta, T. G. (2005). Nursing case management: From essentials to advanced      practice applications. St. Louis, Mo: Elsevier Mosby.

Woo, J. A., Maytal, G., & Stern, T. A. (2006). Clinical Challenges to the Delivery of End-of-Life             Care. Primary Care Companion to The Journal of Clinical Psychiatry8(6), 367–372.

Star, M. (2012). Care management role in end-of-life discussions. Care Management Journals,    13(4): 1-5.