Because it is often the only source of help available on weekends, the hospital emergency room must function as a social as well as a medical agency. In this situation, the social worker can help patients who have psychosocial problems that the medical staff are not trained or willing to handle. This article identifies the types of difficult patients frequently encountered in the emergency room and the specialized social work techniques that can help them.

Advance directives, which allow a person to record preferences for end-of-life care in case of incapacity, have been underused in home care. In this study, thirty home care clients, who were either elderly or persons with AIDS, were offered the opportunity to execute individualized advance directives and to include issues of specific importance to them. Twenty-three completed and signed their documents; nearly all expressed wishes, fears, and concerns that are both not always adequately addressed and not necessarily capable of "yes" or "no" answers. These are discussed and explained, with guidelines for clinicians.

The recent Patient Self Determination Act (PSDA) gives patients the right to exercise greater control over the care they receive from health care facilities and programs during the final phases of their lives. Social work can make important contributions to health care facilities as they develop policies and programs for implementing the Act's provisions about advance directives and refusal and withdrawal of treatment.

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