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Palliative Care in Long-Term Care Settings: Resources for Social Workers
By Mercedes Bern-Klug, PhD, MSW

I have a magnet on my file cabinet that reads “Youth is a gift; old age is an art.” The quote inspires me because I believe that the social work profession has much to offer older adults who are perfecting the art of aging. As a social work researcher who focuses on long-term care issues, my goal is to use the power of research and the values of social work to build the knowledge base that can enhance the experience of living with advanced chronic illness, especially for people living in nursing homes.

While people of any age can experience advanced chronic illness, most who do are older adults. As a social worker, I understand the experience of older adulthood and advanced chronic illness from a systems perspective (nursing home residents, family, and staff), a person-in-environment perspective, and a strengths perspective. I am a strong supporter of the philosophy and practice of palliative care in long-term care settings because a palliative approach enhances residents’ dignity and self-determination. A palliative approach to long-term care is consistent with the core values of social work.

What Is Palliative Care?
Palliative care is a philosophy of care in which a patient’s comfort is of utmost concern. Comfort includes physical, emotional, and spiritual support. In the context of the nursing home, the term “resident” rather than “patient” is used to emphasize the setting as a place of residence. A palliative care philosophy considers the resident in his or her wholeness. The resident is recognized as having physical, psychological, social, and spiritual concerns. By addressing these concerns in ways consistent with the resident’s values and preferences, the care providers—including social workers—can help enhance the resident’s quality of life. That is the main goal of palliative care: quality of life.

According to the report of the National Consensus Project on Quality Palliative Care, “Palliative care expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, helping with decision making, and providing opportunities for personal growth. As such, it can be delivered concurrently with life-prolonging care or as the main focus of care.” The report discusses the following eight domains of quality palliative care that apply regardless of setting:

1. structure and processes of care;
2. physical aspects of care;
3. psychosocial and psychiatric aspects of care;
4. social aspects of care;
5. spiritual, religious, and existential aspects of care;
6. cultural aspects of care;
7. care of the imminently dying patient; and
8. ethical and legal aspects of care.

Responsibilities of Nursing Home Social Workers
The responsibilities of social workers in nursing homes can vary based on the type of facility (postacute care, rehabilitative care, and/or long-term care, veterans’ home, etc.), the values of the nursing home leadership, the social worker’s skills, the characteristics of the residents, and other staff members’ qualifications. Not all nursing home social workers have earned a degree in social work. A recent nationally representative study of nursing home social service directors reported in the Journal of the American Medical Directors Association revealed that about one half of social service directors have either an undergraduate or graduate degree in social work.

Qualified social workers have many opportunities to work with residents, family members, and fellow staff members regarding psychosocial issues, transitions of care, resident rights, and palliative care. The NASW document “Standards for Social Work Services in Long-Term Care Facilities” reports that social work services should focus on the following areas: the social and emotional impact of physical or mental illness or disability, the preservation and enhancement of physical and social functioning, the promotion of the conditions essential to ensure maximum benefits from long-term health services, the prevention of physical and mental illness and increased disability, and the promotion and maintenance of physical and mental health and an optimal quality of life.”

While the specific parameters of the social work role will vary among nursing homes, the figure below (from “Social Work in Long-Term Care and Aging: Decreased Health Care Costs, Increased Quality of Life) illustrates key aspects of the social work role as applied to long-term care settings, including nursing homes.

Figure 1: Social Work Role in Long-Term Care Settings

The Role of Nursing Home Social Workers in Palliative Care
Nursing homes that embrace a palliative care philosophy develop a culture that is more centered on residents’ wants and needs than on staff schedules and convenience. While aiming to provide excellent medical and nursing care, nursing homes focused on palliative care also value excellent psychosocial and spiritual care. The social environment is as important as the physical environment. As social workers are the lead psychosocial experts in nursing homes, they can influence the way that palliative care needs are anticipated, identified, and addressed.

I recently edited a book, Transforming Palliative Care in Nursing Homes: The Social Work Role, that builds on the work of the National Consensus Project for Quality Palliative Care by applying their eight domains of care to the nursing home setting and, more specifically, to the social work role. In the book, a vision of palliative care for nursing homes is developed as well as a vision for the social work role, as summarized here:

Palliative Care and the Nursing Home Social Worker’s Role:

• Social workers are well prepared educationally and experientially to work with residents (including those with dementia) and their family members.
• Social workers have access to clinical supervision.
• Social workers help to gauge the extent to which the nursing home social environment is supportive of quality of life for residents, family, and staff and are empowered to exercise leadership to enhance the setting, as appropriate according to the needs and desires of residents, family, and staff.
• Social workers are part of a team that anticipates and addresses family members’ concerns and then evaluates interventions for effectiveness.
• Social workers are part of a team that anticipates and addresses resident psychosocial concerns—including those related to declining health status—and evaluates interventions for effectiveness.
• Social workers connect residents and family members with community resources and assist residents in moving out of the nursing home if that is their wish.
• Social workers are able and willing to train fellow staff members in recognizing and addressing resident and family psychosocial challenges.
• Social workers are an active part of extending the reach of palliative care principles and resident rights to all residents.
• Social workers identify and honor their own psychosocial needs.
• Social workers have the skills and willingness to advocate for improved palliative care at the individual, facility, community, and public policy levels.

By applying social work values, skills, and knowledge to delivering care—including palliative care—in the nursing home setting, we can support resident quality of life. When elders experience a high quality of life, they can  focus on their art—the art of taking full advantage of the gift of years. When elders focus on the art of aging, the whole society learns important lessons about human potential. It is a privilege to grow old, and it is important to learn the art of aging from the experts themselves.

— Mercedes Bern-Klug, PhD, MSW, is a John A. Hartford faculty scholar, associate professor at the University of Iowa (UI) School of Social Work, and director of the UI Aging Studies Program.

Resources
There are many resources available to social workers wanting to enhance their capacity to work with older adults. The John A. Hartford Foundation’s Geriatric Social Work Initiative (www.gswi.org) and the Council on Social Work Education (www.cswe.org/CentersInitiatives/GeroEdCenter.aspx) can enhance social workers’ understanding of the needs and capacities of older adults, including in long-term care and palliative care settings. The Institute for Geriatric Social Work at Boston College has learning modules for social workers (www.bu.edu/igsw). In addition, the NASW (www.naswdc.org/aging.asp) and the Social Work Hospice and Palliative Care Network (http://www.swhpn.org) have information geared toward social workers who work with older adults and/or with palliative care. Finally, the University of Iowa hosts a listserv for any social worker interested in nursing home issues
(www.uiowa.edu/~socialwk/NursingHomeResource/index.html).

The country needs many more social workers prepared to conduct research in areas related to aging. If you are interested in earning a doctoral degree in social work, please visit www.gadephd.org.