Background     Unresolved financial and legal issues can be a source of intense suffering and adversely impact a patient’s ability to cope with the extreme challenge of advanced illness.  This Fast Fact will introduce readers to financial/legal distress in patients with advanced illness, as well as ways to help ameliorate it including Medical-Legal Partnerships (MLP). 

Patients at higher risk of financial/legal distress include those who express concern about:

• Finances:  particularly patients who are uninsured, the sole wage earner in their family, or who are seeking particular benefits/statuses such as Social Security Disability, service-connection benefits for veterans, etc.  
• Dependents:  particularly if the patient is a single parent with children under 18 years; in a same-sex partnership in which the surviving partner does not have parental or guardianship rights for the minor children; or if the patient has disabled children of any age.
• Family:  particularly patients with no close relatives, or who have key relationships which are not legally recognized (e.g. unmarried couples, particularly same-sex partnerships). 
• Legal Status:  particularly immigrants who do not have citizen status in the country they reside in.

Screening for and responding to distress     Clinicians can ask patients Are there any particular financial or legal concerns you have in light of your [advanced illness]?  Some concerns can be addressed with a referral to a hospital or clinic social worker, such as completion of a heath care agent/health care power of attorney document (in most states), or application for publically supported insurance.  Other concerns, such as completion of financial wills; establishing financial trusts; appealing denial of disability benefits; ensuring acceptable guardianship for minor children; and addressing immigration concerns for a dying patient or her/his survivors, will need legal advocacy.  MLPs are an increasingly available method to provide legal advocacy for patients who cannot otherwise afford it.

Components of a MLP   MLPs are usually hospital-based alliances among hospital-based clinicians, social workers, institutions, and community legal advocates to assist patients with legal issues in need of rapid resolution, targeting patients who cannot afford legal assistance or whose situation is exigent. Community legal advocates generally work pro-bono and on behalf of the patient (they do not represent the hospital’s interests). Hospital-based MLPs can assist clinicians and patient-clients in identifying and addressing needs regarding legacy planning, guardianship for minor children, future planning documents, and financial resources. Legal advocates may be able to 1) meet patients and their families at the bedside to rapidly assess medical-legal needs, 2) go to court on behalf of the patient/family, and 3) follow up with the patient/family once they are discharged.

Issues addressed by MLP consultation

• Finances:  What is the usual source of household income and current source of household income? Has the patient/client applied for Social Security Disability?  Are there arrears on rent or mortgage that will impact survivors?  Does the patient-client have adequate health insurance? If not, has a Medicaid or other public assistance application been made? Any denial of benefits needing an appeal?
• Dependents:  Are there any minor children?  Is there a need for guardianship planning?
• Family:  Any problematic legal relationships between patient and family members or domestic partners?
• Planning:  Has the patient-client completed advance care planning documents?   How are survivors to be provided for? What are the patient’s assets, life-insurance? Does the patient-client have or want a will? 

Tips on starting a MLP

• Identify a community legal advocate.  Places to start include:
  • The  Legal Services Corporation (LSC), a federally funded organization enacted by US Congress with the mission to provide high-quality civil legal advocacy to low income individuals. The LSC provides a list of all of legal advocates in all fifty states by county and/or region. The LSC web-site is http://www.lsc.gov.
  • The state or county bar association in your region. Many bar associations support a formal pro bono program.  More information can be found at:  http://www.americanbar.org/aba.html
  • Law Schools with either a public interest or health care clinic for students.
  • A local Public Interest Law firm/group providing civil (not criminal) legal advocacy.

• Once an advocate is identified, discuss the type of patient/client to be served and the range of legal advocacy needed. Clarify roles and ensure the legal advocate does not unnecessarily duplicate services (e.g. by social workers). The ideal legal advocate should be willing to meet at the bedside, work “on call” and have experience to address a range of legal needs.
• Financial arrangements of legal advocacy vary and include volunteer work, support from grants or direct contribution from the institution. 

References

1. Klimmek R, Snow D, Wenzel J.  Insurance-related and financial challenges reported by managed care enrollees with breast cancer.  Clin J Oncol Nurs.  2010; 14(5):598-606.
2. Rodabaugh K, Hammond M, Myszka D, Sandel A. A Medical-Legal Partnership as a component of a palliative care model. J Palliat Med. 2010; 13(1): 15-19
3. Zuckerman B, Sandel M, Lawton E, Morton S. Medical-legal partnerships: transforming health care. Lancet. 2008; 372:1615-7.

Author Affiliations:  Stonybrook University Medical Center, Stony Brook, NY (LH); Suffolk Law Services Committee, Islandia, NY & Stony Brook University School of Nursing, Stony Brook, NY (DS).

Version History: Originally published September 2011; Copy-re-edited and weblinks updated August 2015.