Meet them where they are?


I don’t remember if it’s the very first thing you hear in an MSW program, but I do remember hearing it frequently: “meet the client where they are.” I think of it as a chant, said in unison, ad nauseum, because it was said so often. But that’s because it is one of the most important foundations of our work. We cannot force our patients or clients to do what we think they should do; rather, we have to join them where they are, in their addiction, their illness, their family struggle, and help them find a way forward.

The thing is, that can be hard to do sometimes.

The other day I went to a house to do hospice consents. This is a big part of my job: I explain what hospice can provide at home and discuss with the patient and family what their goals of care are and if we can help them meet those goals with hospice. Not everyone I talk to is ready for hospice; some people can’t get over the word itself or there’s one more treatment they want to try. On the flip side, every so often, I enter a home where the patient is already beginning to die. Hospice can help, but it’s a little late in the game. It also adds a layer of complexity to the admission conversation; if I don’t already have a relationship with the family, how can I begin to tell them that their loved one is going to die?

This particular consent signing was one of those late admissions. This patient had been receiving palliative home care and the family was reluctant to start hospice. There were a lot of emails from management about treading lightly, especially because the patient wanted to continue some treatments that were not benefitting her anymore. I walked into the house already a little anxious, feeling the pressure from above to get the paperwork signed by a hesitant family. Then I met the patient and could see very quickly she was nearing the end of her life.

“Meet them where they are” is a fine sentiment. I agree with it whole heartedly. But standing in front of that patient and her husband, talking about hospice at home and continuing medications that were probably not going to help her anymore, I was torn. Someone would have to tell them that she was dying. Not to be cruel or pushy, but because part of our job as hospice workers is to help people prepare for death. And this woman did not have a lot of time left.

But could I be the one to tell them? I had never met this woman before; I’m not a nurse or a doctor. I’ve been doing this for five years and I’m quite confident that I know what dying looks like. But those emails stuck in my mind; this family wasn’t there yet.

And so, I tread lightly. I spoke with the husband about keeping her at home, in a hospital bed, rather than calling 911 when her heart stopped. He agreed to that. I called the nurse and asked her to visit as soon as possible. I made delicate statements like, “it seems like things are changing.” He agreed. When the patient’s son asked me how much time I thought was left, I gently told him I didn’t think it would be long. The look on his face devastated me.

She died a couple of days later, peacefully and at home, after the nurse and another social worker visited to offer the family some support and help them prepare. I think the family was ready, or as ready as anyone ever is. But I keep thinking about them. Should I have been more aggressive? Is there a place in between “meet them where they are” and “tell the hard truth?”

I’m confident that I did my job: I started the conversation that my team members eventually finished. That is, after all, why we work together in a team; these are not one and done conversations. I was still and present; I used silence and held the space so that the family could ask difficult questions. Should I have pushed harder? Said more? When we meet the client where they are, does that mean we shouldn’t push to move them forward?

I suspect the answers to these questions depend on the situation. Still, this is a case that will be on my mind for a while yet. Examining our practice is an important part of our work. I’ll keep turning it over in my mind from time to time, adding it to the other cases I wonder about. What are some of yours?