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How to face down ethical dilemmas in case management
Remember, your primary role is being an advocate for the patient
If you’re a typical case manager, you are faced with ethical dilemmas several times a day. "The job is pressure-filled. Case managers are under pressure from insurers to contain costs, from employers to return people to work. They may be working with other health care professionals and don’t think they are acting ethically. They have a lot
of daily dilemmas to work through," according to Susan Gilpin, JD, chief executive officer of the Commission for Case Manager Certification (CCMC) in Rolling Meadows, IL.
Here are some ethical issues you may deal with:
The primary role of the case manager is to be a patient advocate. While case managers are accountable to different stakeholders — employers, insurers, physicians — the patient’s well-being should be their first consideration, says Mindy Owen, RN, CRRN, CCM, chair of the ethics committee and a member of the executive board of the CCMC.
"If we look at it from an ethical standpoint, keeping in mind our advocacy role, we should think about: If this was my mother, my child, or my husband, is this the way I would want it handled?" Owen adds.
The biggest part of an ethical decision is differentiating to whom the case manager owes his or her allegiance, Gilpin points out.
"In the best of all worlds, everybody wants what is best for the patient and there is no conflict, but that’s not always the case," she adds.
Case managers sometimes have to rely on their own intuition and moral compass to get a sense that there is something wrong, Gilpin says.
In the case of being pressured to return a patient to work or to move him or her too quickly to another level of care, the case managers’ loyalty clearly should be to the patient, she adds.
Gilpin notes a conference during which one person told of coordinating care for an injured patient. Because of the nature of the person’s disability, she knew that the patient was covered by the Americans With Disabilities Act but didn’t feel it was her duty to the patient to let him know, she says.
"It was interesting to see people react to this because they knew it was wrong. Most of the people at the conference knew she had a role to play to advocate for the person but withheld it because she thought it would anger the employer who was paying her," Gilpin says.
Case managers who are under pressure to maintain the cost of treatment might be reluctant to mention to a patient that there is another test the physician should have performed on them, she adds.
There are instances where the person receiving services from the case manager doesn’t understand the case manager’s role and doesn’t understand what the case manager has to disclose and to whom.
There are instances where the case manager may be working directly for the employer or the insurance company and the client thinks the case manager is working only for him or her.
"These are instances where the case manager needs to clearly explain his or her role to the individual receiving services at their very first meeting. There should be no misunderstanding of what the case manager can do and can’t do with regard to what insurance will cover and to whom they report what information," Gilpin says.
Case managers doing things that are not in their scope of practice is one of the most prevalent ethical problems, Owen adds.
"Case management is an advanced practice and one that is fairly new in the health care practice arena. There is an assumption by the public that we can do things that aren’t in our scope of practice," she says.
For instance, case managers may step over the bounds by making decisions in terms of medical treatment.
"They can recommend, but sometimes they go beyond just recommending because they believe they are in a position to be a decision maker of medical treatment. I believe strongly that this is not the role of the case manager and not what they are trained to do," Owen says.
If case managers truly want to design a medical treatment plan, they need to go to school and become a physician. If they want to help the physician with health care issues around the treatment plan that falls within the scope of practice, they are on the right track, she says.
Case managers should be concerned about and report to physicians about safety issues, environmental issues, and financial issues, all of which revolve around medical treatment, but they absolutely should not order drugs or treatments, Owen says.
"This doesn’t happen in a malicious or neglectful way, but sometimes case managers are put into those positions, especially in the insurance arena, by the job or the position they hold. I’m not sure it’s in anybody’s best interest," she says.
Do you have an ethical question?
Beginning next month, representatives of the Commission for Case Management Certification will begin a new column that answers your questions on ethical issues facing case managers today. If you have an ethical question or concern, fax or e-mail it to Mary Booth Thomas, (770) 939-5823 (fax); e-mail: email@example.com.