When working with vulnerable populations, one of the unfortunate realities is that some clients will die. Death is part of life. Even when exercising professional boundaries, there is a bond formed with clients. With death, we need closure – even when a client is palliative and our work with clients was catered to the best possible end of life support. There are also pragmatic steps that must be considered in the event of a death that are best thought about and explained prior to a case manager or other staff member dealing with a client’s death.
Not all deaths have the same response from workers and organizations and we need to acknowledge that. The violent death of a middle age client may stir up different emotions than an older client that has been receiving care for several chronic illnesses. A sudden death through something like a heart attack may have a different reaction than a drug overdose. The death of a child in a family that a case manager is working with may cause different feelings than a suicide. And so on. I am not suggesting that any particular cause of death is better or worse than another. It is just different. Even though a staff member may be professionally objective, personal values and perceptions may still influence how we process any particular death.
Some communities have homeless memorials. There are different approaches to how the matter of death is considered in these memorials. In some communities it is just people that died on the street or in shelter. In others, the memorials only account for people that died when it is seen as a direct result of his/her homelessness. Some communities may consider anyone for the memorial that was homeless at any point in their life, while others only include people that were homeless at the point of their death. Regardless, communities should be acknowledged for taking the time and making the effort to remember those who are no longer with us that were part of the group of homeless people in that community.
Because the people we serve will have a (hopefully small) percentage that will pass away, I’d like to offer some suggestions on:
- the emotional impact;
- what practitioners need to consider when working with a vulnerable and often medically frail population;
- how it can make our practices better; and,
- data considerations.
On the emotional impact, we need to consider how the death of any particular client impacts the case worker and support organization, as well as the friends and family of the deceased. Just like each type of death may bring about a different response, so too must we consider that each case manager may have a different perspective on death or dealing with death. Memorials may help bring closure for some, while others may want time to reflect on their practice and not attend a memorial. Some case managers may want to debrief with a professional counselor, while others do not need or see the necessity of doing so. Team Leaders/Supervisors that express empathy are important to providing the right level of support to each case manager based upon the unique circumstances of any particular client death rather than taking a “one size fits all” approach.
And the same goes for the friends and family of the deceased. This brings with it some potential privacy concerns that have to be delicately navigated. Assuming a place of sharing and disclosure, there are instances where friends or family will look to the case manager for comfort or closure to the death, when this is outside the area of expertise or expectation of the worker. Some may look for answers or opportunities for blaming amidst his/her grief. Others may look to the organization or the case manager to arrange all burial or memorial activities, when this may be outside the purview of the case manager or the organization.
When considering emotional impacts, it is very important to draw upon the best possible resources within the community rather than expecting in all instances all of the necessary experience and expertise lies with the case manager or organization. Death in our culture has various interpretations based upon values, principles, spirituality, customs, rights, and religion. Those with training on navigating this milieu of interpretations are more likely to help people deal with loss and grief, hopefully in keeping with the practices and beliefs of the person that passed away. I applaud faith-based service providers that take time to consider that the person that passed away and was receiving services from them may have had a different faith or spiritual beliefs than their own, and go to great lengths to work with other faith groups in the community (even ones that aren’t service providers) to be truly person-centered even in burial and memorial.
There are also some pragmatic issues that must be considered when it comes to death of clients. When support work is occurring with vulnerable populations, I think it is important for support workers to consider that this type of case management work may very well be an investigation waiting to happen when there is a death, whether that is through a coroner or other legal means. If housing case management work is professional work (and I believe it is) then it is essential that each case manager is appropriately documenting each interaction with each client, the case plan, and activities. Information must be up to date (I recommend daily), following professional standards for accuracy and privacy. Should a subpoena ever compel a case manager to turn over their documentation or copies thereof, completeness and accuracy of the notes and demonstrated effectiveness in professional delivery ensure that the support services were beyond reproach. When a death is being investigated is not the time to be coming up with excuses of why there was a lag in entry of case notes or trying to fill in the holes of the narrative of supports up to the point of death.
Ensuring there is an appropriate, clear organizational policy for when a case manager or other staff member encounters a client that has died is also important. Back to the emotional impacts, this can be a remarkably unsettling experience that I am not sure anyone ever gets desensitized to. It has also been my experience that staff tend to never forget the first time they encountered a deceased client, regardless of the circumstances of the death. Nonetheless, regardless of whether the death seems to be of natural or suspicious causes – or any cause for that matter – organizations must train their staff and outline expectations of staff on exactly what it is they should do in what order if someone is found dead. Complicating matters or raising suspicion even in the most unintended way is problematic. Many organizations have taken the step of having a Board approved policy that was informed by a legal or police professional on how exactly these circumstances should be dealt with.
In some communities it is also appropriate for the head of the Continuum of Care of Service Manager to also be informed of a client death. There are legal issues related to privacy in this matter that may also need to be navigated. However, in more than one instance I have seen a client death become a news item for media. When the CoC, Service Manager and/or other appropriate community leaders are not informed, being blind-sided by the news can cast them in an inappropriate, and even uncaring, light.
How can client deaths make service and support practices better, as well as potentially make improvements to the support delivery system? Through appropriately debriefing each death and examining aggregate data from service delivery, each death – regardless of circumstance – can inform future improvements to services for other clients. It may not prevent all future deaths, but it makes sure that there is sensitive value considered to each death. For example, a death from a violent cause may help inform future approaches to risk assessment and safety planning. A death from chronic disease may help improve street outreach efforts to locate the most medically vulnerable, through the likes of the Vulnerability Index. A death from lack of treatment or detection of a chronic ailment may point to the need to better connect with health care resources in the community. A death from improperly treated illness or premature discharge may help inform how the health care community and health and homelessness service community better work together in an integrated fashion while someone is an inpatient, as well as in discharge planning. A death from a suicide may be reason to re-examine crisis planning and the connection between clients and community crisis supports.
And then there is the matter of data. Unfortunately, many data systems and annual reports fail to appropriately account for those clients that passed away. For example, how does a client’s passing impact the overall percentage of people that remain housed? Are they considered permanently housed (unable to lose housing) if they were housed when they die? Is there a separate section in reporting that should account for all of those individuals that passed and the percentage of all people housed in a program that passed away? Under what circumstances may it be appropriate to aggregate the total number of deaths by the types of deaths (e.g., natural causes, etc.) Communities need to take the time to grapple with this data issue. Otherwise, deaths of clients may be inappropriate reflected in reports of how a particular program is performing and/or the disposition of clients after being housed.
Death will happen amongst the clients we serve and support in housing. If this has not yet happened to someone who is a case manager, it likely will in the future. Taking the time to thoughtfully consider how we debrief from the experience, learn from the experience, and provide information on these instances is important for all organizations and workers.