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Advocate versus abdicate
Patricia McCollom, MS, RN, CRRN, CDMS, CCM, CLCP
T
he Code of Professional Conduct for Case Managers, adopted by the Commission for Case Manager Certification, says, “Because case management exists in an environment that looks to it as a solution
for many of the problems in the health care delivery and payer systems, case managers frequently find themselves in ethical dilemmas.” This article describes two cases in which ethical dilemmas present in complex ways and describes potential solutions. The discussion is designed for individual case managers to reflect on their own practice and discuss with colleagues what case managers do and how they improve relationships and quality of service to clients. Case 1: Scott Scott is an 18-year-old man who experienced partial- to full-thickness burns on bilateral lower extremities while working. He had worked only 2 weeks after graduating from high school before the
injury occurred. He was referred by the workers’ compensation insurance company for case management (CM) within 24 hours of injury. Upon initial assessment in the hospital, he was diagnosed with uncontrolled diabetes and obesity (5’8” tall and 280 pounds). Scott was requiring significant amounts of pain medication, had refused controlled meals, and was getting fast food and high-fat snacks from outside the hospital through his mother. The treatment plan consisted of daily dressing changes, with whirlpool baths and debridement. Risk factors were
identified as noncompliance, uncontrolled pain, and potential for failure to heal. With these elements in mind, the case manager facilitated a team meeting with nursing, the physical therapy staff responsible for dressing changes and nutrition, Scott, and his mother. The outcome of the meeting resulted in improved protein intake and referral to a pain specialist for more adequate pain control. After 8 additional inpatient days, Scott was discharged to home with oral pain medication, a peripherally inserted central catheter (PICC), and home care for January/February 2004
TCM 43
the line. He was to return to the hospital daily for dressing changes and wound debridement. The surgeon anticipated grafting Scott’s left leg within 2 weeks. At 5AM on the second day after discharge, Scott’s mother contacted the case manager in clear crisis. Scott’s pain medication was not working, the physician had not returned her calls, and she did not know what to do. She was advised to take him back to the emergency department of the hospital for further evaluation. Scott was readmitted to the hospital for pain control, daily dressing changes, and wound debridement; morphine was administered intravenously during the latter. Three days into this admission, the case manager received a call from the claim representative, “I received a call from the hospital’s utilization review (UR) nurse. She stated that there is no reason for Scott to be an inpatient because he is taking oral pain medication and the IV morphine can be set up for him on an outpatient basis. She said he would not meet criteria for a group health plan, and they think his mother doesn’t want him at home—she wants the hospital to babysit. She went on to say his problems are the result of noncompliance because “he went out in the heat to watch a car race.” (For the record, the patient had attended the race, but he sat in an air-conditioned radio booth with his legs elevated—a physician-approved position.) After the claim representative asked the case manager to intervene and “check out what is going on,” the case manager contacted the UR nurse and made an appointment for a meeting at the facility. They talked and reviewed Scott’s medical record again. The case manager noted that the physician had not discharged the patient and that IV morphine continued to be required for dressing changes. The risk factors were reviewed with the UR nurse, with the additional point that the patient resided in a rural area, complicating access to care if an emergency arose. The case manager then called the surgeon to discuss the case status, explaining the nurse’s position. The physician agreed to review the medical record and TCM 44
January/February 2004
examine the patient that afternoon. Late that evening, the physician called the case manager and said, “I cannot discharge this young man when he continues to require morphine during debridement. What if he had the morphine during the outpatient treatment and had a latent reaction after returning home?” He also said that he would monitor the patient during the next 48 hours, and if no narcotic was necessary, he would discharge him.
Though a diagnosis of severe diabetic neuropathy exists, the agency staff indicated that she does not move her legs “because she does not want to…” Three days later Scott was discharged to home, with orders to return to the hospital for daily dressing changes and debridement. The PICC line was discontinued. The next day, during outpatient treatment, the physician observed the wound sites and determined that skin grafting should be completed the following day. Scott was readmitted for surgery 26 hours after discharge. This case manager clearly faced multiple ethical dilemmas, including potentially exerting undue influence to affect the outcome of care, maintaining objectivity, and recognizing the potential for harm to the patient. In comparing the case manager’s actions with the Case Man-
agement Society of America’s Standards of Practice, advocacy, a specifically defined role function for the case manager, was of concern. The author asks the reader to reflect and respond: What do you believe the case manager’s accountability was in this case? Case 2: Linda Linda was referred for assessment to develop a life care plan. Twelve volumes of medical records demonstrated her long history of catastrophic illness and medical complications. When the case manager arrived for an on-site assessment, Linda was lying in a hospital bed in front of a picture window in the living room. Although a ramp had been constructed at the front of her home, the rest of the house, other than entry to the kitchen, was inaccessible. Her medical diagnoses were insulindependent diabetes, severe diabetic neuropathy, hypertension, debilitated mobility (she required a wheelchair), depressive disorder, urinary incontinence with suprapubic catheter, generalized pain in lower extremities with allodynia, diabetic enteropathy, anemia, coronary artery disease with prior myocardial infarction and cerebral anoxia, and an S/P colostomy. Linda’s husband unloaded and loaded tractor trailers (semis) for a living, usually 10 hours daily, although his work periods varied sometimes. Linda relied greatly on him for direct care and emotional support. A home health aide assisted Linda with a bed bath, dressing, and transfer to her wheelchair in the morning, drained the bed bag, and checked the colostomy bag. The aide spent 1.5 to 2 hours providing care, then returned midday to assist Linda back to bed. Homemaker services and Life-line services were provided through a state waiver program. The couple had no transportation for Linda because she was unable to transfer into a car and used a power chair. Linda had not been outside of her home in 3 years, other than by ambulance for hospital admissions. As the case manager gathered data, it became clear that more care was necessary than that being provided. The case manager began collaborating with the Department of Human Services to re-
evaluate this woman for more care. As a result of this collaboration, services were increased, and the couple was able to purchase a used wheelchair-accessible van. Modifications were covered under the waiver. The next step was to meet with the home care provider to discuss the plan of care. When asked to schedule a meeting, the home health agency nurse manager who answered the call said, “We have been working with this patient for some time, and we know what she needs. We do not need a meeting.”
If the case manager does not advocate and strive for consensus among all parties in a case such as this, who will?
Again, ethical mandates arise for competence and objectivity. The ethical principle of autonomy is raised as well—have the providers demonstrated understanding and respect for the client? If the case manager does not advocate and strive for consensus among all parties in a case such as this, who will? Professional Obligations As case managers, we have accountability to advocate for clients. The Standards of Practice define advocacy as “the act of recommending, to plead the cause of another; to speak or write in favor of.” As case managers, this advocacy must take place, despite the knowledge that it can create a conflict between professional ethical responsibility and the need to wisely use limited health care resources. However, if case managers do not advocate, accountability is abdicated. ❑ Patricia McCollom, MS, RN, CRRN, CDMS, CCM, CLCP, is president/nurse consultant of Management Consulting & Rehabilitation Service & LifeCare Economics in Ankeny, Iowa. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. YMCM 127 doi:10.1016/j.casemgr.2003.10.010
The Department of Human Services social worker intervened and arranged a meeting. While the meeting was congenial, the home health agency viewed the patient’s needs differently than the case manager did. Comments were made suggesting a poor understanding of this woman’s clinical presentation. Though a diagnosis of severe diabetic neuropathy exists, the agency staff indicated that she does not move her legs “because she does not want to…” Though she has urine leakage with a suprapubic catheter, the response was, “She always has had leakage.” Though she is depressed, the agency said, “A social worker saw her once, and she declined to accept any options offered.” The case manager continued to advocate for increased care, and by the end of the meeting, reached an understanding that a reassessment would take place to determine Linda’s needs and care options. Two days later, Linda was admitted for a gastric hemorrhage. After successful treatment, Linda returned home and learned that the home health agency declined to offer increased care. The case manager’s call to the agency resulted in the nurse manager curtly saying, “She doesn’t need any more care, and we won’t give any more care!” The case manager in this case is in a very difficult position. Having received the referral for life care planning and having assessed Linda’s needs, the case manager chose to serve as an advocate and attempted to coordinate better services. The patient and her husband have limited understanding of the various systems that support her care. The Department of Human Services social worker, while serving as an advocate, had limited understanding of the complex medical and psychosocial influences in this case and required assistance to increase services under the state waiver. The home health provider appeared to lack understanding and respect for the patient and her needs altogether. January/February 2004
TCM 45
T
he Code of Professional Conduct for Case Managers, adopted by the Commission for Case Manager Certification, says, “Because case management exists in an environment that looks to it as a solution
for many of the problems in the health care delivery and payer systems, case managers frequently find themselves in ethical dilemmas.” This article describes two cases in which ethical dilemmas present in complex ways and describes potential solutions. The discussion is designed for individual case managers to reflect on their own practice and discuss with colleagues what case managers do and how they improve relationships and quality of service to clients. Case 1: Scott Scott is an 18-year-old man who experienced partial- to full-thickness burns on bilateral lower extremities while working. He had worked only 2 weeks after graduating from high school before the
injury occurred. He was referred by the workers’ compensation insurance company for case management (CM) within 24 hours of injury. Upon initial assessment in the hospital, he was diagnosed with uncontrolled diabetes and obesity (5’8” tall and 280 pounds). Scott was requiring significant amounts of pain medication, had refused controlled meals, and was getting fast food and high-fat snacks from outside the hospital through his mother. The treatment plan consisted of daily dressing changes, with whirlpool baths and debridement. Risk factors were
identified as noncompliance, uncontrolled pain, and potential for failure to heal. With these elements in mind, the case manager facilitated a team meeting with nursing, the physical therapy staff responsible for dressing changes and nutrition, Scott, and his mother. The outcome of the meeting resulted in improved protein intake and referral to a pain specialist for more adequate pain control. After 8 additional inpatient days, Scott was discharged to home with oral pain medication, a peripherally inserted central catheter (PICC), and home care for January/February 2004
TCM 43
the line. He was to return to the hospital daily for dressing changes and wound debridement. The surgeon anticipated grafting Scott’s left leg within 2 weeks. At 5AM on the second day after discharge, Scott’s mother contacted the case manager in clear crisis. Scott’s pain medication was not working, the physician had not returned her calls, and she did not know what to do. She was advised to take him back to the emergency department of the hospital for further evaluation. Scott was readmitted to the hospital for pain control, daily dressing changes, and wound debridement; morphine was administered intravenously during the latter. Three days into this admission, the case manager received a call from the claim representative, “I received a call from the hospital’s utilization review (UR) nurse. She stated that there is no reason for Scott to be an inpatient because he is taking oral pain medication and the IV morphine can be set up for him on an outpatient basis. She said he would not meet criteria for a group health plan, and they think his mother doesn’t want him at home—she wants the hospital to babysit. She went on to say his problems are the result of noncompliance because “he went out in the heat to watch a car race.” (For the record, the patient had attended the race, but he sat in an air-conditioned radio booth with his legs elevated—a physician-approved position.) After the claim representative asked the case manager to intervene and “check out what is going on,” the case manager contacted the UR nurse and made an appointment for a meeting at the facility. They talked and reviewed Scott’s medical record again. The case manager noted that the physician had not discharged the patient and that IV morphine continued to be required for dressing changes. The risk factors were reviewed with the UR nurse, with the additional point that the patient resided in a rural area, complicating access to care if an emergency arose. The case manager then called the surgeon to discuss the case status, explaining the nurse’s position. The physician agreed to review the medical record and TCM 44
January/February 2004
examine the patient that afternoon. Late that evening, the physician called the case manager and said, “I cannot discharge this young man when he continues to require morphine during debridement. What if he had the morphine during the outpatient treatment and had a latent reaction after returning home?” He also said that he would monitor the patient during the next 48 hours, and if no narcotic was necessary, he would discharge him.
Though a diagnosis of severe diabetic neuropathy exists, the agency staff indicated that she does not move her legs “because she does not want to…” Three days later Scott was discharged to home, with orders to return to the hospital for daily dressing changes and debridement. The PICC line was discontinued. The next day, during outpatient treatment, the physician observed the wound sites and determined that skin grafting should be completed the following day. Scott was readmitted for surgery 26 hours after discharge. This case manager clearly faced multiple ethical dilemmas, including potentially exerting undue influence to affect the outcome of care, maintaining objectivity, and recognizing the potential for harm to the patient. In comparing the case manager’s actions with the Case Man-
agement Society of America’s Standards of Practice, advocacy, a specifically defined role function for the case manager, was of concern. The author asks the reader to reflect and respond: What do you believe the case manager’s accountability was in this case? Case 2: Linda Linda was referred for assessment to develop a life care plan. Twelve volumes of medical records demonstrated her long history of catastrophic illness and medical complications. When the case manager arrived for an on-site assessment, Linda was lying in a hospital bed in front of a picture window in the living room. Although a ramp had been constructed at the front of her home, the rest of the house, other than entry to the kitchen, was inaccessible. Her medical diagnoses were insulindependent diabetes, severe diabetic neuropathy, hypertension, debilitated mobility (she required a wheelchair), depressive disorder, urinary incontinence with suprapubic catheter, generalized pain in lower extremities with allodynia, diabetic enteropathy, anemia, coronary artery disease with prior myocardial infarction and cerebral anoxia, and an S/P colostomy. Linda’s husband unloaded and loaded tractor trailers (semis) for a living, usually 10 hours daily, although his work periods varied sometimes. Linda relied greatly on him for direct care and emotional support. A home health aide assisted Linda with a bed bath, dressing, and transfer to her wheelchair in the morning, drained the bed bag, and checked the colostomy bag. The aide spent 1.5 to 2 hours providing care, then returned midday to assist Linda back to bed. Homemaker services and Life-line services were provided through a state waiver program. The couple had no transportation for Linda because she was unable to transfer into a car and used a power chair. Linda had not been outside of her home in 3 years, other than by ambulance for hospital admissions. As the case manager gathered data, it became clear that more care was necessary than that being provided. The case manager began collaborating with the Department of Human Services to re-
evaluate this woman for more care. As a result of this collaboration, services were increased, and the couple was able to purchase a used wheelchair-accessible van. Modifications were covered under the waiver. The next step was to meet with the home care provider to discuss the plan of care. When asked to schedule a meeting, the home health agency nurse manager who answered the call said, “We have been working with this patient for some time, and we know what she needs. We do not need a meeting.”
If the case manager does not advocate and strive for consensus among all parties in a case such as this, who will?
Again, ethical mandates arise for competence and objectivity. The ethical principle of autonomy is raised as well—have the providers demonstrated understanding and respect for the client? If the case manager does not advocate and strive for consensus among all parties in a case such as this, who will? Professional Obligations As case managers, we have accountability to advocate for clients. The Standards of Practice define advocacy as “the act of recommending, to plead the cause of another; to speak or write in favor of.” As case managers, this advocacy must take place, despite the knowledge that it can create a conflict between professional ethical responsibility and the need to wisely use limited health care resources. However, if case managers do not advocate, accountability is abdicated. ❑ Patricia McCollom, MS, RN, CRRN, CDMS, CCM, CLCP, is president/nurse consultant of Management Consulting & Rehabilitation Service & LifeCare Economics in Ankeny, Iowa. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. YMCM 127 doi:10.1016/j.casemgr.2003.10.010
The Department of Human Services social worker intervened and arranged a meeting. While the meeting was congenial, the home health agency viewed the patient’s needs differently than the case manager did. Comments were made suggesting a poor understanding of this woman’s clinical presentation. Though a diagnosis of severe diabetic neuropathy exists, the agency staff indicated that she does not move her legs “because she does not want to…” Though she has urine leakage with a suprapubic catheter, the response was, “She always has had leakage.” Though she is depressed, the agency said, “A social worker saw her once, and she declined to accept any options offered.” The case manager continued to advocate for increased care, and by the end of the meeting, reached an understanding that a reassessment would take place to determine Linda’s needs and care options. Two days later, Linda was admitted for a gastric hemorrhage. After successful treatment, Linda returned home and learned that the home health agency declined to offer increased care. The case manager’s call to the agency resulted in the nurse manager curtly saying, “She doesn’t need any more care, and we won’t give any more care!” The case manager in this case is in a very difficult position. Having received the referral for life care planning and having assessed Linda’s needs, the case manager chose to serve as an advocate and attempted to coordinate better services. The patient and her husband have limited understanding of the various systems that support her care. The Department of Human Services social worker, while serving as an advocate, had limited understanding of the complex medical and psychosocial influences in this case and required assistance to increase services under the state waiver. The home health provider appeared to lack understanding and respect for the patient and her needs altogether. January/February 2004
TCM 45