Case Management Insider

Every day, the case management department faces multiple dilemmas over ethics

Countless clinical decisions must be made in hospitals

By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

When case managers think about ethical dilemmas, they are thinking about much more than when to discontinue a ventilator, or to stop treatment, or any of the myriad of clinical ethical decisions that must be made every day in hospitals throughout the United States. They are thinking about what to do for the patient who has no insurance but needs continuing care services in the community, or the homeless patient who does not want to apply for Medicaid, or the patient who wants to come to your hospital but who would be out of network.

These are examples of what are referred to as "case management ethics," also known as organizational ethics. Organizational ethics are typically non-clinical problems, but they ultimately might have an impact on the patient's clinical course. Organizational ethics are the ethics of an organization, and how an organization ethically responds to internal or external factors. Organizational ethics express the values of an organization to its employees and/or other entities irrespective of governmental and/or regulatory laws.

Organizational ethics deal with an organization's behaviors as they relate to individuals represented by that organization. Examples might include patients, providers, or employees. This ethical minefield is something that case managers and case management directors deal with every day. Unfortunately, they often deal with these dilemmas in a vacuum because the organization does not have a structure or formal mechanism for addressing them.

Conflicts arise for case management when there are conflicting parties for whom the case manager must advocate. For example, tension might arise when the case manager is caught between his or her patient advocacy responsibilities and gate-keeping advocacies. When these issues arise, how are they addressed? To whom are they taken for consideration? Who makes the final decision? If you work in a typical case management department, these problems might be solved by one person, often the director of case management. Ask yourself, "Is that really fair"? Should one person be forced to make a decision that might have a huge financial or other negative impact on the organization? Or should the decision-making be shared, with appropriate parties weighing in on the problem and its solution?

Surely no one would expect one individual person to make a decision about terminating a ventilator, yet case managers make decisions on behalf of the hospital every day, and they are decisions that might have broad ramifications.

Case management in the acute care setting provides a framework and a delivery model that bridges the gap between the clinical world and the financial world. By virtue of straddling these two worlds, ethical dilemmas will arise. It is impossible to avoid them. For the case manager who has to address these issues on a frequent basis, do not take them on alone. Use your "chain of command." Discuss these issues with your immediate supervisor, and bring them up in staff meetings. It is likely that others have faced, or will face, a similar problem. We can all learn from each other.

The difficulty with ethical issues is that each and every one of them is unique and must be handled as such. Even if your hospital does not have an organizational ethics committee, you should not attempt to solve these problems alone. Discuss your issues with all appropriate departments and disciplines so that you can make the most informed decision possible.