Ethics requires CMs to look beyond data
September 1, 1999 5 minutes read
Ethics requires CMs to look beyond data
Ethical CM requires accountability
Health care is a business. Money is exchanged for a service provided, and that money is necessary to make the system work. But when case managers apply business terms to their patients, they risk losing the ability to provide accountable, ethical, patient-centered care.
"When I call my patient a client’ or a customer,’ I don’t have the same responsibility or accountability to that individual as I do when I call the individual a patient," says Carol Taylor, CSFN, PhD, MSN, RN, assistant professor and ethicist at Georgetown University School of Nursing in Washington, DC. "There is a profoundly ethical dimension to this concept. If all I know about the people entrusted to my care are the numbers associated with their illness, all I can do is address their pathology. I know nothing about how the disease affects this individual or the individual’s family. And I can’t develop an appropriate, holistic care plan."
Using power compassionately
"Case managers must recognize that their patients are immeasurably better or worse by who they as professionals choose to be on any given day of their practice," she says. "There was a sister in our order dying of ovarian cancer. It was one of the worst, most painful [deaths] I’ve ever seen. One day, she told me, When I first got sick, it didn’t matter how people treated me because I knew who I was. As I’ve gotten weaker, I’ve become whoever people make me. If they come in and move me like I’m meat, then I am meat.’"
That’s the power case managers have over the patients they work with, notes Taylor. "That’s the power we hold. How will we use it? How do we look at systems of care in terms of making people feel like they are human beings?"
For Taylor, it’s imperative that experienced case managers work with younger, less experienced case managers to establish guidelines for ethical, accountable practice. "There is a shortage of qualified, experienced case managers in this country. We are taking nurses and social workers with less and less experience and putting them into case manager roles where they are working solo," she notes. "They don’t have the experience to draw on. They only know what the book says, and we are in danger of delivering cookbook care. The repercussions of their inexperience will come back to you. What if you are the next case manager an individual meets? The public is deciding what we are about and what they think about us based on the actions of other case managers they encounter."
For example, she says, what if an elderly woman tells the case manager she doesn’t believe her husband’s pain medicine is working. The case manager says "I’ll look into it" but never does. "That couple doesn’t just distrust that case manager. If I’m the next health care professional they met, they won’t trust me, either. It will make my job harder." (For information on the qualities of an ethical case manager, see p. 141. For suggested assessment activities, also see p. 141.)
Taylor says there are six elements case managers can be taught to help them provide more accountable and ethical care. They are:
1. Affective element. "This is my capacity to be moved by the patient entrusted to my care," explains Taylor. "The professional caregiver has an obligation to move beyond any personal regard they have for an individual and say, Here is a human being in need,’ even if this is the patient from hell and you don’t like this person, you have an obligation to care," she says. "That is how being a professional caregiver differs from being some one else. We have an obligation to be moved by groups in society that don’t have anybody else to be moved by their plight."
2. Cognitive element. "This means that you are not just moved by your patient’s plight, but you know how to improve their current state," she says. "If I’m a daughter, and my mother is in a postoperative stage and I don’t know how to relieve her pain, that doesn’t make me a bad daughter. However, if I’m the mother’s case manager or her nurse or her surgeon, and I don’t know how to relieve her pain, I am a deficient caregiver. An accountable case manager must be both caring and competent."
3. Volitional element. "I can be moved by the people in my care. I can know how to help the people in my care. However, if I don’t take action to improve their state, I’m worthless," she says.
4. Imaginative element. "This goes back to building relationships. This is my ability to find out the unique needs of the individual in my care," she explains. "Do I really know what this individual needs and wants?"
For some elderly patients, pneumonia may be a blessing, she notes. "You may have a patient who says, Hallelujah, I’ve been waiting to die.’ There are others who say, Oh, no. I’m not ready yet.’ Which is your patient? Do you know? Should you make the patient comfortable at home, or do you rush to the hospital for IV antibiotics? How can you develop an appropriate plan, if you don’t know your patient’s wishes?"
5. Motivational element. "We have many motivations for what we do. For health care professionals, the primary motivation has to be a commitment to secure the interests of the people we serve," says Taylor. "We are seeing legislative attempts to fix the evils of managed care because the public no longer trusts us or sees us as having the power to fix those evils for them."
6. Expressive element. "I must express my caring in such a way that it is perceived as caring by my patient and my patient’s family," she says. "You can express yourself in verbal and nonverbal ways. Every time you look at your patient, you can leave the impression that the patient is an object, a job to be done, or a person of worth. Every time you interact with your patient, you will give one of three messages: Drop dead.’ You are nothing.’ You are worthy, and I care about you.’"
Case managers face ethical dilemmas daily, notes Taylor. "The question is, what do I allow to happen? Is this illegal as well as immoral? We can’t fight every battle, but do we understand which battles must be fought? The key is that internal voice," she explains. "If a situation makes you uncomfortable, don’t turn off your discomfort. Pay attention to that discomfort. The day you turn off that discomfort, [resign] and sell shoes, but don’t do health care."
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