CMs struggle with ethical dilemmas
CMs struggle with ethical dilemmas
Professional groups offer guidance
You were trained to render care, not consider costs. Your education focused on the patient, not the marketplace. But the health care delivery system changed radically, and now those two diverse domains are converging. As a case manager, you are caught tightly in the middle, trying to balance quality patient care and economic constraints.
"Nurses and social workers are educated to be caretakers and guardians of patient welfare. The cost-cutting principles of managed care create ethical concerns that are enormous," explains Sheila O’Connell, RN, CCM, who has worked with local health care ethics committees. O’Connell is president of Home & Hospital Medical Personnel, a home health agency in Verona, NJ.
That balance is the foundation for the ethical dilemmas you face daily in your practice. "The real fundamental problem in health care today is that we cannot provide care without concern for cost, yet we lack the outcomes data that would enable us to get a better handle on what is truly beneficial to the patient," says John Banja, PhD, a medical ethicist and associate professor at the Emory University Center for Rehabilitation Medicine in Atlanta.
"Health care professionals are unclear about exactly how much particular treatments cost, and which treatments or factors affect positive outcomes. You may feel that a rehab patient’s recovery was due to a particular therapy, but in fact, it may have more to do with the support and motivation provided by his night nurse," Banja says.
Cost constraints combine with other marketplace pressures to present case managers with still more ethical questions. "Early in my career, I found myself as a case manager in this new world without the tools to deal with financial issues and business aspects of health care. Even in my relatively small company, I was approached by drug and medical equipment company reps with incentive offers for client referrals, or offered gifts, such as theater tickets," says Catherine Mullahy, RN, CRRN, CCM, president of Options Unlimited in Huntington, NY. Mullahy chairs ethics committees for both the Commission for Case Manager Certification (CCMC) in Rolling Meadows, IL, and the Case Management Society of America (CMSA) in Little Rock, AR.
"If this was happening to me, I knew it was happening to other case managers, and I recognized that we had no tools to guide us in our decision making when these situations arose," she adds.
Conflicts in cyberspace
The marketplace may be the largest contributor, but it is not the only area of the health care delivery system causing case managers ethical heartache. Technology has played a big role in the changing face of health care delivery and developed faster than either the case law or practice standards that professionals depend on for guidance, says Linda Chalmers, BSN, RN, CRRN, CDMS, CCM, WCLA, catastrophic team leader for Zurich Services in Shaumberg, IL, and chair of the CCMC board. "The electronic patient record presents many ethical dilemmas for case managers. What do you do about including sensitive information about a patient on the electronic patient record when you know that there are many people who could potentially access the patient record?" she asks. "They don’t teach us how to deal with these things in school. It’s culture shock for professionals as they move from clinical practice where the patient is the center of all care to the payer side."
The school of hard knocks’
Chalmers developed her own ethical decision-making skills in the "school of hard knocks," she says. "I have also relied on peer networking and local professional organization meetings. It helps to say, Gee, I encountered this situation,’ and develop a dialogue with other professionals to see how they would handle it," she says.
Early last year, CMSA sent an ethics statement to its members. Last November, the CCMC board developed and approved a code of professional conduct, which it mailed to all certification- holders in January. "We wanted case managers to have a document that they could hold up and say, No, this is against our standards of practice and code of conduct.’ We also wanted to give case managers a list of thou shalls’ and thou shall nots’ to give them some guidelines on how to behave ethically," says Mullahy, who worked on the CCMC code of professional conduct.
The CCMC code lists general principles, rules of conduct, and guidelines for 28 areas common to case management practice; guidelines and procedures for processing complaints; and penalties for code violations. Specific areas of conduct covered in the code include:
• records maintenance, storage, and disposal;
• conflicts of interest;
• termination of case management services;
• advertising of case management services;
• solicitation of rebates or other remuneration for client referrals.
Possible sanctions against certification-holders found to have violated the new CCMC code of professional conduct include:
• reprimand;
• probation;
• suspension of certification;
• revocation of certification.
Breathing life into the code
"My experience with professional codes of conduct is that they give good general principles, or kind of a representation, for what a conscientious health care professional is like. They stress things like truthfulness, duty, and patient advocacy," Banja says. "What you cannot ask a code to do, because they are simply not geared to do so, is to resolve individual cases."
Case managers agree. "It is one thing to receive a code of conduct or an ethics statement from your professional organization, and another to make it a living document. It is hard enough to read all the materials you must read and do all the tasks you must do each day without trying to incorporate something new," O’Connell says.
CMSA hopes one of its latest projects will give case managers a decision-making guide to resolve individual cases and make the CCMC code and CMSA ethics statement "living documents," says Marlys Severson, RN, BSN, CCM, president and chief executive officer of SCM Associates in Cypress, CA, and president of CMSA.
"Our challenge now that we have a standard of practice from CMSA and a code of professional conduct from CCMC is to give case managers a tool they can use to resolve issues as they arise. We’re trying to come up with a process for ethical case management decision making," Severson explains.
To develop this tool,CMSA’s ethics committee is conducting a qualitative research project using an open-ended questionnaire. Developed by Mullahy and Mark Meaney, PhD, professor of ethics and philosophy at St. Joseph’s University and Wharton Business School in Philadelphia, the questionnaire was sent to the CMSA board for approval in late February.
Learning from the best
CMSA plans to send it to 100 leading case managers from a variety of disciplines and practice settings, Severson explains. "The questionnaire attempts to find out how good case managers make decisions," she says. For example, areas covered on the questionnaire include:
• What character traits are necessary for ethical case management? List them and place them in order of importance.
• Give specific examples of conflicts you have worked through. How did you resolve those challenges? What were the actual decisions you made?
"We’re looking for commonality. Once those questionnaires are processed, our ethics committee plans to sit down with eight to 10 of the case managers and flush out the process, dig a little deeper, and use those areas that are common to all good case managers to develop a process that we can teach other case managers," says Severson. (For further discussion of qualitative research methods, see story, p. 66.)
The waiting game
Ethical dilemmas, however, will not wait until this new tool is available. In February, news that scientists in Scotland had successfully cloned a sheep rocked the scientific community, and medical ethicists worldwide convened to discuss the implications for the future.
In the meantime, there are steps you can take to minimize your risk for ethical conflicts in the ever-changing scientific and economic environment that shapes health care delivery in the ’90s, say case managers.
"Some organizations have ethics committees, but this is a new behavior, and ethics committees are hard to implement. Few case managers can take time out of their practice to serve on ethics committees," O’Connell says. "We sometimes use our quality assurance meetings to address ethical conflicts."
Prevention may be the best way to deal with ethical dilemmas. "I don’t assume that case managers I hire will know how to handle difficult situations," says Mullahy." Part of our training for new case managers goes over ethical conflicts common to our practice and clearly defines how we handle ourselves in each situation," she says.
Severson attempts to minimize ethical conflicts through clear communication with clients. "We avoid putting ourselves in the decision-making role by making it clear to clients that our role is to be a facilitator. If you state your role clearly, you minimize the potential to get caught in the middle," she notes.
For example, when she handles a workers’ compensation claim, she makes it clear to the client that any information about the cause of the injury will be shared with the payer and the employer. "Tell them, If you tell me, I have to tell the payer.’ You can keep yourself out of a lot of trouble." (Clear communication also can prevent legal actions. For further discussion of legal concerns in case management, see Case Management Advisor, March 1997, pp. 41-43.)
Conflict is inevitable
Of course, there is no way to avoid all conflict, and ethics is not a black and white issue with only one right answer for every situation, stresses Banja. "Ethics is a way to adapt to what is going on around you. You use your common sense, constitutional law, common law, spiritual values, your upbringing, your education and training, and you throw it into a pot and try to come up with something that will get you through to the next day.
"Ethics is a constant process of adapting to a changing world. You just keep trying to find a way to uncover good and decent solutions and lead a meaningful life," he says.
[Editors’ note: For more information about the CCMC code of professional conduct, contact: CCMC, 1835 Rohlwing Road, Suite D, Rolling Meadows, IL 60008. Telephone: (847) 818-0292.
For more information about the CMSA ethics statement, contact: CMSA, 8201 Cantrell Road, Suite 230, Little Rock, AR 72227. Telephone: (501) 221-9068.]
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