We have seen that the code of professional conduct for case managers is established by CCM Certification and outlines formal statements that declare the standards of ethical behavior for the group (CCMC, 2015). Case managers may, however, belong to other healthcare professions, typically nursing or social work. In addition to the Case Manager Code of Ethics, nurses and social workers have their own codes of ethics. None of these standards are contradictory, but rather confirm one another.
A grasp of the basic principles provides the template for sound decision-making. The way in which clinicians actually arrive at ethical decisions continues to be studied and refined. Clearly ethical and clinical decision-making models must overlap significantly to derive a satisfactory outcome (Dale, 2016; Drumwright, 2015; Kearney & Penque, 2012; Sujdak & Birgitta, 2016).
The Ethical Decision-Making Process
Ethical decision-making is a challenge to case manager professionals, who face both an increase in the number of issues and situations that are increasingly complicated (Marfleet & Trueman, 2013). Ethical decision-making skills can be enhanced by studying cases and developing a strategy for facing ethical issues. Practitioners don’t always have complete control over the situations that confront them. When the welfare of the patient is compromised, the healthcare provider is challenged to manage the situation in the patient’s best interest (Airth-Kindree & Kirkhorn, 2016).
Making decisions is part of everyday living, whether it is deciding when to turn off the stove or how to navigate through heavy traffic. For the most part, these decisions are part of an automatic, and therefore unconscious, process. But there are other decisions, particularly those related to professional practice, that are not automatic. We are often confronted with two equally appropriate choices. Choosing between right and wrong is generally easy and obvious; however, when challenged by choices between two equally good options it becomes more difficult. This is called a right vs. right dilemma. When evaluating the alternatives, both courses of action have positive and negative elements. Right vs. right is an ethical dilemma, whereas right vs. wrong is identified as a moral temptation where the individual knows the right thing to do but consciously chooses the action that is wrong.
Test Your Knowledge
Right vs. wrong may be a moral temptation, but right vs. right is:
- The best of both worlds.
- An ethical dilemma.
- A chance for correct action.
- A political brawl.
Answer: B
All healthcare providers struggle to establish ethical decision-making standards that provide guidance in a challenging practice environment, and the challenge is not unique to case managers. One threat to ethical practice arises from within each profession as a result of materialistic self-interest and from the outside in terms of profit motivation. An example of an ethical dilemma that didn’t exist decades ago but now does due to technology is the result of scientific advances such as mapping of the human genome. Advances in technology made possible some procedures that raise ethical issues as to whether certain things should be done just because they are possible (eg, cloning of animals or even of people).
A wealth of literature exists on the subject of ethical decision-making. A search of this literature reveals that professionals are inconsistent in ethical decision-making (Singer, 2005). The literature speaks of the “science” of decision-making but cautions that human limitations result in inconsistencies in their decision-making skills that professionals acknowledge.
An additional dilemma is that various healthcare professional groups all have different codes of ethics depending on their perspective. For example, physicians focus on “First, do no harm,” while a hospital administrator’s code of ethics focuses on fair and judicial allocation of resources. For generations, the code of ethics for anyone in medicine was based on the physician’s Hippocratic oath. Gradually, healthcare specialties began to develop their own codes.
While they were helpful to establish guidelines, the wide variety and range of codes often created confusion for interdisciplinary groups. In 2000 a group of multidisciplinary healthcare professionals gathered together at Tavistock, England to create one ethics code for all healthcare professionals. This new code, is a step in the right direction to improve quality of care, collaboration, and continuity of care (Stanford & Conner, 2012).
Decision-making is a complex process that involves time needed to think critically with the goal of decreasing uncertainty. At some point, if action was not taken the decision will be made by default. Note that failure to make a decision may place the patient in a potentially harmful situation.
Ethical decision-making is the integration of ethical principles with practical wisdom. Codes of ethics are generally broadly written. They help to identify issues, but they are not meant to serve as a methodology for ethical decision-making. To recognize an action and decide on that action requires both knowledge and skill in the art of ethical decision making.
Patients have the right to expect that their healthcare providers are involving themselves in thoughtful deliberation of ethical issues, with a commitment to take reasonable and rational action. These steps warrant the trust of the patient and society. Unethical, self-serving behaviors result in a loss of trust by patients and their families.
End-of-life issues, caregiver burnout, and right-to-choose plans often challenge the medical team, patients, and families to make complex ethical decisions. This is made even more challenging when the issues involve more than one generation; they may have the same interests at heart but prefer different expressions of them.
Setting priorities is a strategy for all those who are working together to protect a patient’s best interest. Case managers can rely on an ethical decision-making model that is similar to the nursing process, which comprises the steps of collecting data through assessment, defining the problem, identifying possible actions and solutions, implementing the actions, and evaluating the effectiveness and results.
An Ethical Decision-Making Model
Step 1: Recognize and define the ethical issue
Step 2: Collect the Facts
- Who are the parties involved?
- Who has the right/responsibility to make the decision?
- What are the consequences of action?
- What are the consequences of inaction?
Step 3: Identify possible courses of action.
Step 4: Consult with colleagues and appropriate experts
Step 5: Implement, Evaluate and Reassess
Step 6: Document the decision
Test Your Knowledge
Which step is missing in the 6-step process of decision making?
Document the decision, implement your decision,
identify possible courses of action, collect the facts and identify the ethical issue.
- Recognize the ethical issue.
- Identify who has the right and responsibility to make the decision.
- Consult with colleagues and appropriate experts.
- Document the actions taken.
Answer: C
10 Case Studies
The following case studies illustrate situations encountered by case managers (CMs) and help explain the process for resolving ethical and legal dilemmas.
- Transitions of Care
- Home Care
- Pain Management
- Pediatrics
- Perioperative Ethics
- Perinatal Care
- Primary Care
- Professionalism
- End of Life Care
- Special Needs Populations
Transitions of Care
Transitions of care is a common issue that CMs deal with as they help patients navigate from acute care facilities, to rehabilitation facilities, to long-term acute, skilled nursing facilities, home and even hospice settings. Knowing when a patient is ready for discharge and that the patient will have adequate resources for recovery and healing is a challenge.
An obese 79-year-old man needs to be discharged from an acute care hospital after a right sided CVA. He lives with his petite 75-year-old wife who he expects to care for him. They are retired on a limited income. She confides in you secretly that she is afraid she won’t be able to lift him, and their insurance won’t cover additional rehabilitation days, nor do they have savings to pay for in-home care. What is the best, safest, and most economical transition of care choice?
Decision Steps
Step 1: Recognize and define the ethical issue.
It may not be a legal dilemma to discharge the husband back to his own home, but it may be unethical, considering the limited ability of his wife and her expressed fears. The dilemma illustrates the conflicting principles of autonomy (the husband’s) and beneficence (the wife’s inability to shoulder the caregiving task).
Step 2: Collect the facts.
Who are the parties involved? The husband and wife may have different interests. He prefers autonomy, but she fears inability to physically care for him.
Who has the right/responsibility to make the decision? The patient has the right to make the decision for his best interest, however the CM has the responsibility for his safety at discharge.
What are the consequences of action? Sending the patient home without assistance may become dangerous, however sending him to a short-term rehabilitation facility without the ability to pay for it harms the facility.
What are the consequences of inaction? There can be no inaction, as the acute hospital will force a discharge because it cannot allow the patient to remain without promise of reimbursement.
Step 3: Identify possible courses of action.
The options are as open as the mind of the CM to think of creative alternatives. Options could be to look for family and friends who may be able to assist; look for additional payor sources from nonprofit organizations and support groups; explore additional insurance options; and so on.
Step 4: Consult with colleagues and appropriate experts.
The CM may need to expand the book of resources and people who may offer additional options.
Step 5: Implement, evaluate and re-assess.
Once a decision is made, it is ethical to follow up with the patient and his wife to assess how they are both doing. Are adjustments to the plan needed?
Step 6: Document the decision.
Throughout any transition of care, documentation is needed to validate the decision.
Home Care
A common setting for case management is with home health patients. Often the CM is in charge of allocating resources, such as durable medical equipment for home use. What could be ethically challenging with that? Remember that the case manager must balance loyalty to several clients and their insurance companies.
You have been the CM for an 82-year-old man who you helped through a recent hospitalization for a broken hip—and then recovery from pneumonia in a long-term acute care setting. He has become one of your favorite patients because of his smile and his endearing personality. He is so pleasant that you check on him regularly. The care facility says he needs to be discharged tomorrow but you know it will be more comfortable for him where he is because he lives alone.
Your company uses several agencies for home care on a rotation system, but your favorite agency is not on the list at this time. Do you schedule him with your preferred agency anyway, knowing you can keep a few more days until the agency will likely be back on the list, if you document that he needs more physical therapy.
Is that unethical or illegal? What are your options?
Being an effective CM means being objective and in control of personal emotions that may sway simple decisions. Sometimes that is easier said than done. Following the checklist for decision-making can help you systematically keep yourself from acting on prejudices and making unethical decisions.
Pain Management
Because pain is so subjective, it is difficult to judge for another person. What one person considers manageable, another will not, requesting narcotics for relief. Always displaying empathy and compassion for a patient who is in pain is the foundation of good practice for pain management. Because of the serious consequences of addiction and overdosing on opiates, careful management of both the pain and the pain medications is needed.
You are the CM for a construction worker who has been receiving medical attention for an on-the-job back injury. Your primary role has been to act as his advocate in helping him navigate the insurance claim process for medical coverage through his employer. In confidence, he admits to you that he has been struggling with alcoholism and had been drinking the morning he fell at work.
Should you notify his employer or insurance company? That might result in denial of his medical claims and his back injury is real. You have met his wife and children and he is the sole source of income for the family.
Is this a legal or ethical dilemma, or both? What are your options?
Although a primary role of the CM is to be a patient advocate, CMs may also need to advocate for the insurance company or hospital that employs them, which can create a conflict of loyalty. Generally, patients do not fully understand the role of the CM and what can be disclosed without repercussions.
Does the employer have the right to know about the additional medical history of alcoholism or is that breaking HIPAA?
Pediatrics
As has been said, when dealing with a pediatric patient the healthcare professional really has three patients, the child and the two parents. Because parents have the legal rights to make decisions on behalf of the child, helping them understand the issues and their rights is the job of the CM. Legal and ethical dilemmas may result when the parents make decisions against the advice of the medical team. Legally, parents have the right to make or deny medical plans for a child.
You are the CM for a refugee family who is receiving food stamps and has limited financial resources. The parents have refused to have their children immunized because they do not believe in the American medical system. The family wants the children to attend public school and the parents want to sign a form refusing immunizations. The developing country from which they came has a high rate of tuberculosis. One of the children consistently coughs but the mother refuses the doctor and prefers their cultural healer. They cannot receive food stamps unless they are seen and cleared by a medical provider.
Is this a legal or ethical dilemma? What are your options? Do they still have the right to refuse treatment?
The CM must first confirm what their legal rights are and what stipulations are placed in order for them to receive food stamps, free immunizations, housing, and so on. Do they understand what the immunizations are for? Who needs to be involved? How do you document your decision?
Perioperative Ethics
Ethical dilemmas in the perioperative setting can be seen frequently in TV’s hospital dramas. Case managers may be involved in managing patients transitioning in and out of surgery. Some Affordable Care organizations or MMOs even dedicate CMs within a hospital setting to check on their patients and help navigate a sometimes very confusing perioperative process.
A patient’s living will states he does not want mechanical ventilation to sustain his life and it is recorded by his primary care doctor but the document does not make it to the hospital’s medical record. During a difficult surgery, the patient has a cardiac arrest and is put on mechanical ventilation. The wife of the patient now wants the patient to remain on life support and ventilation and states she doesn’t remember him ever completing an advance directive. She claims she has the right to make the decision as his wife. The prognosis is poor for a quality recovery.
Is this an ethical or legal dilemma? What are the options? You could continue with mechanical ventilation while the patient is in a medically induced coma for recovery, approach the hospital ethics committee for guidance, hold a family meeting to discuss the matter, obtain a court order to ventilate the patient, or simply withdraw the mechanical ventilation support.
According to the law, the advance directive, which clearly states no mechanical ventilation is wanted, would direct the medical team to withdraw support. Generally, the medical team will wait until it is deemed medically clear what the brain function is before they pursue the issue. In the meantime, the CM needs to at least produce a copy of the advance directive from the primary care provider’s office.
Perinatal Care
Dealing with pregnant mothers who pose a risk to their unborn child can create both legal and ethical dilemmas.
A 17-year-old pregnant female, married, refuses treatment that is considered medically beneficial to both her and her fetus. Even after medical education regarding the safety of the treatment potential adverse effects and benefits, she still refuses. The CM is called in to help with the case.
What is the most appropriate action? Going through the decision steps can help identify the problem, options, and solutions. Options could include: not initiating treatment because that is the patient’s right to refuse; obtaining a court order to initiate treatment because the patient is risking the life of the unborn fetus; calling the baby’s father to get him to consent to treatment; submitting a query to the child abuse hotline; approaching the hospital ethics committee for a decision. Is this an ethical or legal issue, or both?
According to the law, the mother has the right to refuse treatment. Period. Yes, the decision can be clouded and difficult when the medical staff disagree with the decision, but the legal standard makes the decision of the medical staff easy—they have to allow the mother to deny the treatment. Legally, although the future mother is a child herself, and not a legal adult, she is considered an emancipated minor based on the following criteria:
- Homeless, or graduated from high school
- Parent
- Married
- Financially independent
Primary Care
Many case managers help manage patients for physicians and advanced health practitioners and physician assistants in large primary care settings. They may be assigned a caseload and asked to follow up with patients having chronic conditions such as congestive heart failure, anticoagulation medication, diabetes, hypertension, COPD, and cancer. Largely, the role of the CM is to be an advocate for patients by explaining procedures, clarifying medical terminology to confused patients, and even helping manage resources for durable medical equipment, doctor’s office visits, and transportation. Knowing who the resources are in the patient’s community can make a huge difference in the successful outcomes of the patient.
Even small decisions like how much time to spend with one patient over another can create distress for a caring CM who has limited time and resources.
You are the case manager for a patient who has recently been diagnosed with colon cancer and given a poor prognosis. The patient asks you not to say anything to the patient’s spouse. The patient calls you daily to discuss feelings and concerns about the diagnosis and proper testing and treatments. You know the spouse cares greatly and would be devastated to not know about the diagnosis. You find yourself taking more time with this patient than the other ones in your caseload this week and worry that it is unfair to the other patients. You also feel you are limiting resources for the patient by not involving the spouse.
Is this an ethical or legal dilemma? What are your options? What are your resources?
Balancing confidentiality and rationing resources is a difficult challenge for case managers. Going through the steps of the ethical decision-making process can help you navigate your own feelings and professional obligations.
Professionalism
Unfortunately, professional and ethical conduct is not innate. Behaving unprofessionally or unethically—even in ignorance—can happen, although it is not tolerated well in the medical profession. How you respond to your own professional or ethical mistakes will define you as either a good or bad case manager. Steps to ethical behavior can be learned, practiced, and improved. The great balance for case managers is to reduce costs, improve patient’s health, and deliver a positive experience of healthcare.
You are in the grocery store with your spouse and one of your patients walks by to greet you and wants to discuss issues that you were involved in helping to manage for him. What is your best response?
Is this an ethical or legal dilemma to discuss his case while your spouse is listening? How would you handle the situation? Would you confirm or deny this is your patient? Would you ignore the question of both the patient and your spouse and walk away?
Yes, this could be both an ethical and legal dilemma because it is a HIPAA violation. Your spouse has no need to hear the information, and disclosing anything in front of your spouse puts the patient’s private health information at risk. A textbook answer may be to state that you cannot say whether that is your patient and ask to be excused, at the risk of offending the patient.
End of Life Care
When a patient reaches the end of life, it is a difficult passage for everyone involved. Although the primary emphasis is rightfully focused on the patient, it is often the family members that create ethical and legal dilemmas when normal protocols are challenged—such as honoring the patient’s advance directives, power of attorney, and financial beneficiaries after the death. Often the death is easier than the weeks or months that precede it. A compassionate and legally savvy CM can help decrease the grief by communicating clearly with the family and patient about expectations, procedures, and legal boundaries.
A 46-year-old woman with stage 4 breast cancer is discussing treatment options with the care team. The patient has chosen to refuse chemotherapy, radiation, or surgery as the first round of chemotherapy several months ago made her extremely ill. She has felt weak, tired, and hopeless. She expresses “Just let me die.” She is declared competent by Psychiatry. Her husband wants her to continue with the treatment because they have four children at home.
What is the legal or ethical dilemma? What are the options? You could give the treatment as this is considered life-saving; you do not give the treatment as it is considered active euthanasia; you do not give treatment as that is the patients wish; or you give treatment because if you don’t you are legally liable for negligence.
In this case, as with all competent adults, the woman has the right to choose or deny medical treatment. Not giving treatment, although that is considered passive euthanasia, is still the patient’s right to choose. Often when our emotions become involved we believe it is an ethical dilemma, when it may truly only be a legal choice. Either way, admittedly it is difficult to allow people to refuse treatment when we believe it can help them. Ultimately the patient’s Living Will takes precedence.
Special Needs Populations
Patients with special needs and disabilities can present with many challenging ethical dilemmas as the medical team tries to balance the values of autonomy with helping the patient avoid unintended harm. Mental incompetence poses an additional challenge as legal consent for treatments must come from a parent, spouse, or next of kin. It is often the CM who can help a family navigate the challenges by knowing about resources.
A 30-year-old male patient with Down Syndrome lives on his own in a humble apartment and even has a job that allows him to support himself financially. His parents live nearby and check on him regularly. The patient has type 2 diabetes mellitus and has struggled with foot care and managing new medications on his limited budget. On examination, it is discovered that one of his feet has necrotizing gangrene and needs to be amputated to avoid further injury and infection to the full leg. He insists he is fine and can live on his own and take care of himself. He is refusing medical care and the recommended amputation. You are the CM for this patient and have been called in to assess resources, options, and come up with solutions.
What are your options? You could get a court order for the surgery. You could get consent from the parents. You could allow the patient to make his own decision at the risk of expanding the gangrene. Is this an ethical or legal dilemma?
Legally, if the patient demonstrates complete self-neglect and unawareness, a surrogate decision-maker such as the parent can make the decision for him.
Apply Your Knowledge
How did you respond to each of the case studies? Did you recognize an ethical or legal dilemma in each one? What did you see as resources and options that weren’t presented? How would you have handled each case?
Remarks and Resources
Case managers may no longer defer ethical decision making to other healthcare providers, such as physicians, with whom they share patient responsibility. They must recognize their responsibility as autonomous practitioners to work on ethical quandaries in order to find a reasonable solution that is in the best interest of the patient. To accomplish this professional mandate, case managers must know ethical principles and be able to apply the principles effectively to ethical situations and then to analyze the outcomes.
Resources
Certified Case Manager Certification (CCMC). (2017, December). Cultivating moral resilience: Balancing heart and mind for a better practice and better you. Retrieved from https://ccmcertification.org/sites/default/files/issue_brief_pdfs/ccmc-dec2017.web_.pdf.
Certified Case manager Certification (CCMC). (2017, April). Do the right thing: Excellence and ethics in case management webinar. Retrieved from https://ccmcertification.org/archived-webinars/do-right-thing-excellence-and-ethics-case-management.
Certified Case manager Certification (CCMC). (2015, February). Foundational principles: Newly revised Code of Professional Conduct provides a framework for ethical, high-quality care. Retrieved from https://ccmcertification.org/sites/default/files/issue_brief_pdfs/23_-_updated_code_of_conduct.pdf.
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