Ethics helps CMs handle difficult cases
Here’s how a panel of ethicists view CM role
Case managers are entering an era of increased accountability at the same time they must carefully allocate scarce resources in a managed care environment. The decision-making process necessary to allocate those limited resources leads case managers not to "right" or "wrong" decisions but rather to the least of all evils, says one health care ethicist.
"Case managers constantly balance competing ethical principles. The decisions that result are not the right’ decision so much as the least worse alternative," says Mark E. Meaney, PhD, a health care ethicist with the Center for Ethics in Health Care at St. Joseph’s Health System in Atlanta. "Under-standing how ethical decisions are made in case management is an excellent way to anticipate potential legal problems before a claim is filed."
"We will all have fewer ethical issues to work through if we say and do the right thing at the right time and let others determine what will be covered," says Mary F. Gambosh, RN, CDMS, CCM, president of Mary F. Gambosh Limited, a case management company in Richmond, VA, and past president of the Case Management Society of America (CMSA) in Little Rock, AR.
The ethical role of the case manager is to help all concerned parties including patients, providers, and family members weigh the clinical, financial, and social consequences of available treatment options, according to a panel of health care ethicists at the recent CMSA conference in Boston. Case managers, especially those in managed care settings, may find themselves increasingly playing the role of mediator, they predict.
To help case managers better understand this new role, the ethics panel presented an ethically complex case adapted from an article that ran recently in Healthcare Forum Journal and then explained the issues and approaches case managers might consider.
Ethics case study: A 2-year-old was found face down in a large bucket of water. He was rushed to the hospital, and on the way he received cardiopulmonary resuscitation. His cardiac rhythm resumed. He was admitted to neonatal intensive care. A few weeks later, a prognosis of persistent vegetative state was made. The child was discharged home. Two years later, he remains unconscious. However, he is loved and treated as a valued family member.
The child develops frequent respiratory infections requiring ventilatory support and occasional pediatric intensive care support. In addition, he is developing contractures that interfere with his home care and may require surgical intervention. Given his prognosis, hospital staff question whether ventilatory support and future surgery are appropriate clinical measures. The health maintenance organization considers the proposed surgery to be heroic. The family insists that everything possible be done to save the child.
"This case is fairly typical of cases that we as case managers find ourselves in," says Catherine Mullahy, RN, BS, CRRN, CCM, president of Options Unlimited, a case management firm in Huntington, NY. "We are now starting to hear the term futile measures’ with increasing frequency health care considered to be futile or inappropriate."
In the previous fee-for-service system, with virtually unlimited funding available for care, any treatment that was clinically possible was considered appropriate and necessary, Mullahy says. "Now we are hearing more discussion about whether or not care is futile or inappropriate, and I’m getting increasingly concerned with the discussions taking place," she says.
"Case managers find ourselves in the middle of these situations. The primary function of the case manager as I see it is to advocate for the patient," Mullahy notes. "In this situation, it is going to be increasingly important. My concern is that too many case managers seem reluctant to speak up for the rights of these individuals, even though we have standards of practice and codes of conduct that require us to be patient advocates."
"We tend to wait and take more comfortable positions. We wait for someone else to speak up for that child. We are waiting for the ethics committee to be formed for someone else to take the first step. I would like to see a heightened awareness, or empowerment, of case managers to speak up and be the patients’ advocate."
You are right in the middle’
"It is true that case managers are often caught in the middle, and I guess that’s where I think they ought to be," Meaney says. "We’re all aware of the consumer protection movement that has recently resulted in legislation in Connecticut that allows for external appeal. The bill provides that once a patient has exhausted all resources for internal appeal, the patient can go outside the health plan and have their case reviewed by specified external sources.
"What I would like to suggest is that the case manager is going to have an increasingly important role as a mediator. Yes, you are patient advocates. That is still number one. However, you are also knowledgeable about the health plan. You are right in the middle. You advocate for the patient, yet you also balance cost and quality. That is very important because the client has confidence in you. In the process of mediation, there is a lot of emotion. It is very important to provide a forum where we can vent these emotions and patients can voice their concerns."
The devil’s advocate
"The whole idea of futility is important to look at, but I’d like to address two issues that relate to the family and the child. This is a harsh view and will upset many case managers," says M. Jan Keffer, PhD, RN, CS, ANP, assistant professor of family health nursing at the Indiana University School of Nursing in Indianapolis. Those issues are:
1. Is the child still a person?
"This individual is valued by the family, but we need to know why he is valued by the family," she says. "I would like to suggest that there is a philosophical difference between having a life and being biologically alive. At this point, it appears that this child is biologically alive but not having a life and having no interests of his own."
2. What are the obligations to the child’s siblings and other members of the health plan?
"It is not necessarily the responsibility of society to give that family everything that it wants for this child, Keffer explains. "The family can elect to act with their own discretionary resources. It is a harsh view, but we also must consider the obligations to the other siblings in the family.
"And what resources will be left for other members of the health plan if the resources are spent on this child?" she asks. "It is possible for people, such as these parents, to make themselves moral heroes at the expense of others."
The good, the bad, and the ugly
"When case management is done well, it is pursuing at least two moral goods. One moral good is patient advocacy, and the other is proper use of resources," says Emily Friedman, a health policy and ethics analyst from Chicago and the author of several books on medical ethics. "In this par-ticular case, I believe the health plan is right."
The key question is "distributed justice," Friedman says. Whenever case managers are faced with a managed care case in which the health plan is pushing for conservative care, they should ask the following questions before jumping to any conclusions:
• What is going to happen to the money and resources saved by our not doing this?
• Who said that doing everything possible for patients is in their best interests?
"Until we start making decisions about what constitutes good managed care and unethical managed care and what constitutes good case management and unethical case management, any situation involving a health plan denying payment will be greeted by cries of rationing, and I think that’s bunk," Friedman says.
[Editor’s note: Look for a new column on case management ethics in future issues of Case Management Advisor. If you have an ethical issue or a specific case study you would like addressed by our health care ethics experts, please send it to: Lauren Hoffmann, Editor, Case Management Advisor, P.O. Box 740056, Atlanta, GA 30374.
For the full text of the article from which this case study was adapted, see: Zoloth-Dorfman L, Rubin SB. Medical futility. Healthcare Forum Journal 1997; (40): 28-33.]
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