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Navigating the Bermuda Triangle’ of ethics
Strategies for hospital case managers
By Toni G. Cesta, PhD, FN, FAAN
Commission for Case Manager Certification
Rolling Meadows, IL
Hospital case managers routinely face what I call the "Bermuda Triangle" of case management ethics. The top of the triangle is the clinical concern, encompassing the medical and treatment needs of the patient. On the right are the financial concerns, and on the left are the legal and ethical issues. In the middle of this triangle is the patient.
For the case manager, navigating this Bermuda Triangle is challenging, given the complexity of the issues and the ramifications that a decision in one area has on the other two. The best course of action is to fully understand the issues involved, to identify the ethical dilemmas, and to seek the advice of supervisors or hospital administration.
To further this understanding, let’s consider each point of the triangle. Starting at the top, the clinical concerns relate directly to the needs of the patients that come into the acute-care setting. As care is rendered, one of the considerations is the length of the hospital stay, which will require a review to be given to the insurance or managed care company.
This brings us next to the financial point of the triangle. The hospital case manager must balance hospital resources and the length of stay with the needs of the patient. For example, let’s say the targeted length of stay for a pneumonia patient is four days. The goal would be to optimize those four days so that treatment will progress according to plan.
What happens, however, if on the fourth day the patient is not moving along as expected toward the desired outcome? Perhaps there’s a medical complication or a clinical setback. The insurance company recommends the patient be discharged and that intravenous antibiotic treatment be continued at home.
The hospital case manager, however, is concerned that the patient lives alone and may not be able to manage his or her own care cognitively or physically at home, even with a visiting nurse. After concerns are discussed with the insurance company, the recommendation still is to move the patient to home-based care.
This dilemma puts the hospital case manager at the third leg of the triangle, facing legal and ethical issues. The case manager does not believe it is appropriate to discharge the patient. Yet, keeping the patient at the hospital will mean that reimbursement will end. What should the case manager do?
As case managers, we sometimes are asked whether we advocate for the hospital or for the patient. I believe the correct answer is both, because we have to realistically balance the needs of both.
In practice, we always favor the needs of the patient, while keeping in mind what’s best for the organization as well. The balancing act can be difficult, and hospital case managers should not try to tackle these difficult ethical dilemmas alone.
Case managers may seek guidance from the Case Management Society of America Standards of Practice, as well as the code of conduct or ethics to which they are bound by licensing or certification.
In addition, case managers can use their chain of command as a tool to find the best solution. For individual case managers, this means turning to the department director or manager to whom they report. Physician advisors also may be asked to speak to the insurance company as an advocate, urging that the patient’s stay be extended.
For case management directors and supervisors, the issue can be escalated to hospital administration or the hospital’s ethics committee.
As clinical, financial, and legal/ethical issues arise, more hospitals are turning to their ethics committees for advice. While these groups have often addressed end-of-life issues, we are seeing a growing trend toward the formation of organizational ethics subcommittees to address financial and reimbursement issues.
In the hypothetical example, if the insurance company would not authorize an extended stay, the hospital would likely absorb the additional costs. Legally and ethically, there is an obligation to keep the patient in the hospital until discharge is deemed to be safe. While this decision may be a costly one for the hospital, in this example the extended stay is determined to be the best and safest decision for the patient.
When it comes to ethical dilemmas that confront hospital case managers, here are some key points to keep in mind:
Most important, case managers should know they are not alone as they navigate through the perilous waters of ethical dilemmas. They have others to rely on for guidance toward the safe harbor of the best decision for all involved.
In its column, the CCMC explores ethical issues for various areas of the case management field. We welcome your questions and feedback, by contacting us at email@example.com.
[Editors note: Toni G. Cesta, PhD, RN, FAAN, is director of case management at St. Vincent’s Hospital in New York City. The CCMC has awarded the certified case manager (CCM) credential to more than 26,000 case management professionals since 1992. The CCMC is the only certifying body for case management professionals that is accredited by the National Commission for Certifying Agencies. URAC also has determined that the CCM credential is a recognized case management certification. For more information or to obtain an application for the CCM, contact the CCMC at (847) 818-0292 or visit the web site at www.ccmcertification.org.]