By Jeni Miller

Every day, hospital case managers must make decisions — large and small — that affect the lives of their patients. Some of these are ethical decisions — what the case manager “ought” to do in a given situation. Since many decisions must be made quickly, hospital case managers should consider their ethics and plan ahead rather than reacting solely in the moment.

“Ethics are our moral compass in providing care,” says Lisa Bednarz, LCSW, ACM-SW, ASW-G, manager of care coordination and social work at NewYork-Presbyterian Hospital. “They provide direction and guidance in morally distressing situations.”

Bednarz adds that “medicine is rarely linear,” so considering ethics “helps us navigate the inherent ambiguities in the field.”

Encountering Ethical Concerns

Since case managers see it all and might be involved in “morally distressing situations,” how can they plan to confront difficult decisions head-on? The first consideration is becoming aware of some of the most prominent ethical concerns case managers face daily.

According to Patty Kalnberg, LCSW, senior social worker of care coordination and social work at NewYork-Presbyterian Hospital, “Ethical concerns come up most frequently around determining a patient’s capacity.”

She notes case managers should ask if patients “understand the consequences of their choices, such as refusing a treatment or a recommended discharge plan. There is frequently a tension between safety and self-determination.”

Informed consent is an important subtopic that “can also lead to ethical challenges for the treatment team, including the case manager,” Kalnberg explains.

Bednarz and Kalnberg also note another common ethical concern for case managers is surrogate decision-making for “patients without advance directives as well as general end-of-life decisions.” Similarly, they say, ethical challenges can arise when case managers encounter patients of various cultural backgrounds “who may approach information-sharing and decision-making in different ways.”

A final prominent ethical concern involves navigating social issues and ensuring everyone can access healthcare resources equally. “Given the limited healthcare resources in most areas, case managers must ensure open access to care by facilitating efficient delivery of care for all patients,” Bednarz says.

Mitigating Ethical Challenges

Case managers should know how the law intersects with their work and decision-making, and understand cultural issues that might affect decisions.

“It is very important to have knowledge of your applicable federal and state laws and general cultural competency,” Kalnberg explains. “Every hospital has an ethics committee, and anyone, including patients and families, can request a consult. This likely is the best tool at your disposal. There also are ethical frameworks that you can adopt and apply to your practice.”

Hospital ethics committees and social work case managers often use clinical supervision to discuss ethical conflicts. “Nurse case managers can use their direct manager in the same way,” Bednarz says.

Either way, case managers should discuss ethical challenges with an interdisciplinary team and pursue peer support. Through discussing difficult ethical dilemmas, they can create a plan to mitigate potential problems and make the best possible decisions considering the circumstances.

Most importantly, case managers should not bow out of the discussion or be led to believe their perspective is not essential to helping the patient and community. “Case managers have a unique viewpoint: managing the patient as a whole and assessing them in the context of their environment and psychosocial needs,” Kalnberg notes. “Patient needs are often greater than ‘just’ a medical diagnosis or acute illness and may take longer to address.”

Another challenge “lies in the society in which we work and live, where our focus on individualism and warranted protection of personal privacy can often unintentionally exclude families and support persons from decision-making and access to information,” Kalnberg says. “Finally, the professional requirements of regulatory bodies that focus on safe discharge planning can conflict with patient self-determination.”

Developing an Ethical Framework

In addition to regularly checking in with the hospital ethics committee and meeting with an interdisciplinary team, hospital case managers can work to develop their code of ethics through continuing education on the topic. Knowing the plan and referencing it in a moment of ethical conflict can help save time and mental anguish. There is no shortage of resources for training.

Generally speaking, Bednarz shares, each discipline uses its own code of ethics. “For social workers, the National Association of Social Workers has an ethics consultation line for members. Also, many medical schools offer bioethics courses for medical professionals.”

Case managers should be proactive when developing an ethical framework, not only for the sake of their patients, but for their own sake. Making difficult, life-changing decisions daily can take a toll on the case manager’s mental health if not approached with caution and consideration. Regular education, discussion, and planning are necessary to safeguard case managers as they carry out their important work.