Panel debates CM role in case of convicted felon

Should you advocate for society’s outcasts?

Case managers have always been viewed as patient advocates. But how do you approach that role when your client is an individual nobody cares about? As a case manager, are you ethically obligated to advocate for society’s most vulnerable and detested individuals?

In the second case debated by a national panel of health care ethics experts at the recent Case Management Society of America conference in Boston, panelists discuss a difficult case playing itself out in the state of Georgia.

Ethics case study: A 35-year-old prisoner serving the sixth month of a 30-year sentence for armed robbery and rape is found unresponsive in his cell. He is transported to the hospital, where he is diagnosed with a massive cerebral hemorrhage, possibly as a result of long-term cocaine addiction. Within 24 hours of surgery, the prison system’s parole board informs the hospital that the prisoner’s sentence has been commuted.

The hospital’s case manager is immediately concerned about what percentage of the hospital’s costs will be reimbursed. She examines the discharge options. In the meantime, the prisoner has regained consciousness and may have rehabilitation potential. However, the rehabilitation prognosis is unclear.

The only next of kin is a sister, who refuses to take the prisoner. The case manager considers approaching the sister with a proposal that rehabilitation will be provided only if the sister promises in writing to take the prisoner home if attempts to find a nursing home placement fail.

"This patient is a particular kind of road kill on the bridge to the 21st century," says Emily Friedman, a health policy and ethics analyst from Chicago and the author of several books on medical ethics. "In terms of nursing home placement, he has three strikes against him: He is young, male, and has felony record. Nobody cares what happens to him. Society is out to stick the sister with him, but what if she has good reason to deny sheltering him? What if he took her savings and spent it on cocaine? What if the person he raped was their mother?"

Society’s undesirables need and deserve the support of a case manager more than other patients, she argues. "Case managers have a particular moral duty to represent people who can’t fight back and who most people would just as soon drop down a well," Friedman says. "It takes a certain type of courage to fight the social bigotry attached to certain diagnoses or injuries. If this same man had received an injury while bungee jumping off a bridge, he would have people coming forward to support him."

The job of the case manager in this case is to find the appropriate place in the health care system for this patient, she says. "If he is no longer appropriate for the acute care setting, perhaps he should be in a rehabilitation facility."

Case managers faced with undesirable clients must put aside their emotions and those of other interested parties and seek balance, says Mark E. Meaney, PhD, a health care ethicist with the Center for Ethics at St Joseph’s Health System in Atlanta. "Emotions run high when you begin to weigh issues of distributed justice. This man has obviously committed heinous acts for which we would like to see him punished. But the case manager must recognize and help all parties balance the difference between distributed justice and procedural justice.

"The case manager must remain focused on issues of fair allocation of scarce resources and the balance of cost and quality," Meaney says. "The case manager must be able to present this case to an ethics committee in such a way that ensures this person will be treated as an individual deserving of consideration."

The balance of scarce resources is never simple, adds Catherine Mullahy, RN, CRRN, CCM, president of Options Unlimited, a case management firm in Huntington, NY. "We have at least two conflicting case management values here — patient confidentiality and the need for financial reimbursement," she notes. "It would no doubt expedite his rehabilitation placement if we did not share his substance abuse and criminal history with the facility, but is that the right thing to do?" Mullahy says the case manager must weigh these questions:

• Does the fact that his sentence has been commuted make it a nonissue?

• Who are we protecting by not disclosing this information?

• Does the facility have a right not to take this individual?

No substitute for experience

"I’m concerned that new case managers are entering the field and finding themselves faced with these responsibilities for the first time with little or no experience," Mullahy says. "Experienced case managers must mentor the next generation. We have codes of conduct and standards of practice. We need to take them out of the bottom drawer of our desks and use them actively in the way we conduct our business. While this individual may indeed be deemed ‘road kill,’ he is an individual deserving of no less consideration than any one of us."

Complex problems such as those presented in this case deserve the input of more than one person, Mullahy says. "Managed care organizations and other payer groups need to spend more energy on developing ethics committees. Case managers, with their sense of accountability and responsibility, are the perfect professionals to help form and serve on those committees."

A holistic approach

The case manager has an obligation to make sure this patient is not lost in the system, adds M. Jan Keffer, PhD, RN, CS, ANP, assistant professor of family health nursing at Indiana University School of Nursing in Indianapolis. "The case manager also must not forget the sister. Not only is the patient involved, but his sister is also being pressured and needs support. I have always taught a holistic approach. The sister is part of the picture. We must have a better understanding of what is going on with her in order to find an appropriate solution.

"There is no one perfect, right medicine for every single case. It takes consensus building," Keffer says. "That’s why ethics committees are so essential. They help protect individuals, the resources of payers and providers, and the rights of all concerned. Yet ethics committees should ot become policemen, peer review vehicles, or quality assurance committees. They should serve only as an advisory group to providers and patients. One person alone cannot and should ot make such difficult decisions."

(Editor’s note: For more information on case management ethics standards and guidelines, see Case Management Advisor, April 1997, pp. 63-66.)