- Email: [email protected]
How ethical principles affect case management: A real-life example
ETHICS by Michele Nielsen, RN, CCM, CRC, COHN-S, CPDM, CLCP
Five ethical concepts govern case management (CM) practice: • Autonomy—the patient’s freedom to choose his or her own treatment course • Beneficence—the case manager’s responsibility to promote good and be the patient’s advocate • Nonmaleficence—first, do no harm • Justice—fair and objective treatment of all parties (eg, allocation of health care resources based on individual need in a fair manner) • Veracity—telling the truth
T
he word ethics derives from the Greek root ethos, which is related to character or the positive qualities that distinguish one per-
son from another. Ethics is society’s version of ideal conduct for an individual or professional. The demands of ethical duties usually exceed those of legal standards, which are minimum standards of conduct. TCM 68
May/June 2002
Case Study I am the external nurse field case manager for Mike M, an extremely difficult patient whose treatment requires active use of all my ethical principles. Mike is now 48. When he was 27, he was struck on his neck, head, and arm by a chain or cable at work, sustaining an acquired brain injury. He was comatose for 5 months after the injury and declared permanently and totally disabled. Hemiplegic on his left side, Mike has been diagnosed with depression (for which he takes Paxil) and has slurred speech, balance difficulties, and impulsive behavior. He lives in his own single-story home in a small town in Washington and has a care provider a few hours a day. He had been in an assisted living facility before he moved away from Seattle to return to his childhood location. Mike initially was referred to me for case management in November 1999 when he
THE AMERICAN NURSES ASSOCIATION CODE OF ETHICS Nurses should provide services with respect to human dignity. Nurses should safeguard the client’s right to privacy. Nurses need to safeguard patients from the incompetent, unethical, and illegal practices of others. Nurses assume responsibility and accountability for our individual nursing judgments and actions. Nurses maintain competence in nursing. Nurses exercise informed judgment and use individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others. Nurses contribute to the ongoing development of our profession’s knowledge.
moved. Fortunately, a physiatrist (physical medicine and rehabilitation) was practicing in this location, and an appointment was made with Dr. MacInnes (names have been changed) as soon as possible. When I first saw Mike, his home had no refrigerator or bathroom safety rails, floor tiles were broken, and the rooms were feces-stained and incredibly dirty. I arranged home health care for several hours a day, 5 days a week. However, the care agency discontinued services shortly thereafter because employees could not be persuaded to care for Mike because of his inappropriate behavior, which included sexual innuendo, rudeness, and yelling. The ethics of allowing a patient to remain independent although he is a potential danger to himself (autonomy) caused me to try to think creatively. Another issue for case managers is professional and legal liability. Because of these concerns, I called Washington’s Adult Protective Services (APS), which assessed Mike’s situation in early December 1999. No action was taken because, according to the APS report, Mike “acknowledges that he has difficulty retaining caregivers and understands the risk of not having services. He is alert and oriented and capable of making decisions.” The original care providers resumed their services when Mike agreed to be more cooperative. However, they were discontinued again in late February 2000 because of Mike’s continued verbal abuse and sexual innuendo. As the case manager, I located another home health agency willing to take this difficult
Nurses participate in our profession’s efforts to establish and maintain conditions of employment conducive to the high quality of nursing care. Nurses participate in our profession’s effort to protect the public from misinformation and misrepresentation and maintain the integrity of nursing. Nurses collaborate in promoting community and national efforts to meet the health needs of the public.
patient. Mike and I also drove to foster homes in the area to see if he would enjoy living independently in a situation where assistance and meal preparation were available. Mike did not want to leave the independence of his own home, so this option was not pursued. In the interim, the second home health agency discontinued its services in June 2000, citing the same reasons as the first—verbal abuse and sexual innuendo.
went to the local ED. Although the ED physician thought Mike was making poor decisions for his protection, he was not found to be incompetent. During my vacation in July 2000, the insurance company instructed my colleague to close our file because the patient was not being compliant. Six months later, I was asked to resume CM because Mike had mishandled his money, was without a telephone, and had no personal care. Mike had gone for
Armed with a digital camera and with Mike s permission, I photographed conditions within the home, such as overflowing trash, a broken toilet, and feces on the walls. For the second time, I enlisted the help of APS. Unfortunately, the social worker visited Mike immediately after a friend had bathed him and cleaned his home. Again, no action was taken because Mike was found to be competent. Shortly thereafter, he fell at home and, when a friend came over and discovered him,
6 months with no care except that provided by an occasional friend. He occasionally went to the local hospital on his motorized scooter, where personnel had him talk with the social worker, who in turn called the workers’ compensation insurance company and requested resumption of CM. May/June 2002
TCM 69
AN ETHICIST’S PERSPECTIVE
MARK MEANEY, PHD
Michelle Nielsen addresses four interconnected issues regarding the relation of ethics to case management: professional integrity, dual relationships, weighing of beneficence and autonomy in conflicted cases, and future harm. Some health care professionals use the principle of respect for autonomy to justify abandonment. They reason that noncompliance is an exercise of the patient’s right to self-determination. Moreover, they rationalize that, if they continue to pursue the patient’s good despite noncompliance, they will be patronizing the patient. Nielsen’s case analysis betrays a much more subtle understanding of the relationship between the principles of beneficence and respect for autonomy. She saw Mike’s vulnerability. She entered into negotiation with him to fulfill her professional obligation to pursue her client’s good. She “creatively” resolved conflict to meet his needs. Nielsen is successful because of two essential ingredients: professional integrity and process. First, she possesses habits of the mind that make her a great case manager. Moral discernment provides her with a vision: the good of clients, employer organizations, the practice of case management, and society generally. She perceives each case as a means to benefit these different stakeholders. Her actions also illustrate the strength of will required of case mangers in conflicted cases. Second, Nielsen’s actions suggest a more or less formal ethical decision process with six steps. In Step 1, she reflected on her dual relationships before accepting the case. Veracity is essential to mediate dual relationships. In Step 2, she identified all relevant stakeholders. Step 3 requires that relevant stakeholders define and agree on the ethical conflict. In this case, beneficence, respect for autonomy, and justice conflicted. In Step 4, Nielsen listed alternatives that addressed the ethical conflict and tried to predict each alternative’s effect on relevant stakeholders. She then evaluated the alternatives in Step 5 based on consequences, ethical and legal principles, and her own professional values. In Step 6, she implemented the decision, communicated the decision to relevant stakeholders, and followed up to address remaining negative consequences. Nielsen saw that multiple stakeholders had moral claims on her actions. If she lacked professional integrity, she might have ignored any number of stakeholders. In which case, she would have biased the outcome in ways that would have been harmful to those affected by her decisions. Mark Meaney, PhD, is the executive director of the Institute for Clinical and Corporate Ethics in Liberty, Mo. He can be reached at (816) 792-5523 or [email protected].
The condition of Mike’s home when I returned after 6 months was appalling. Armed with a digital camera and with Mike’s permission, I photographed conditions within the home, such as
was necessary to consider a legal guardianship to protect him. This is defined as a “legal relationship created by the courts to protect and manage the person and/or property of a living
After all, his independence is the most important thing to him, and if he loses his home, he no longer will have control. bugs flying out of his now-existent but broken refrigerator, overflowing trash, broken toilet, and feces on the walls. Although Mike wished to remain independent, my concern for his safety was growing. I told him I would not do anything without his knowledge, but it TCM 70
May/June 2002
person who is too young, too old, too ill, or too incompetent to handle his own affairs.” Once again I called APS, which visited Mike but said he would not be declared incompetent by a judge and forced to move where he did not want to move.
Mike missed several appointments with his primary care physician and his rehabilitation specialist, either because he forgot, had no transportation, or simply did not wish to go. When I took Mike to his physiatrist in July 2001, I showed the physician the digital pictures of Mike’s home. MacInnes wrote a contract that he, Mike, and I signed. It read, “I, Mike M, agree to allow care assistance in my home to help with cleaning, personal hygiene, meals, etc. If I do not permit them to assist me in my home on an ongoing basis, I will agree to move to a group home.” One last agency within this small community agreed to care for Mike only if a professional janitorial service cleaned and sanitized the home before services started and a plumber installed a new toilet. Mike now receives 4 hours of care—2 in the morning and 2 in the afternoon—7 days a week. Mike and one male caregiver have established trust to the point that Mike has given Lance a key to his home. Previously, Mike often locked caregivers out. Mike’s independence includes going to a local restaurant on his scooter, so sometimes he is not at home but cleaning can proceed. The greatest concern now is Mike’s financial status. Although he receives sufficient income from workers’ compensation (permanent and total disability payments) and Social Security disability income to meet his expenses, he runs out of money by the third week of each month because, being fully independent, he withdraws his money from the local credit union and plays Washington’s lottery games. By the end of each month, he doesn’t have enough money to eat. Another contract was written with Mike authorizing me to assist with his finances. However, the workers’ compensation insurer does not wish to undertake liability for this, and Mike doesn’t want to lose any independence. Mike is at risk of losing his home, which is fully paid for, because of nonpayment of property taxes. My plan is to analyze his income and spending and advise him so he will discipline himself. After all, his independence is the most important thing to him, and if he loses his
home, he no longer will have control. He understands this possibility and says he is willing to listen. Ethical Choices It would be tempting as a case manager to choose gray areas of the above-mentioned ethical principles. Although it would have been easy to take pictures of his home without Mike’s knowledge, veracity is an important concept. Once a patient discovers I have not been truthful, will he trust me again? What would I have done if Mike had not given permission? I simply would have acceded to his wishes. However, I would have discussed the importance of this documentation for MacInnes. By this time in my relationship with Mike, enough trust had been established that this discussion could have occurred. The other principles of autonomy, beneficence, nonmaleficence, and justice can be demonstrated throughout the CM provided. CM does not exist in a vacuum. When a case manager is involved with a patient for a long time, a dual relationship can occur. This ethical issue is the least understood but most serious. If I assume more than one role or neglect my
attempts to balance obligation to the patient, his family, and the insurer, it is possible to lose my objectivity. Therefore, I must involve other services and providers. In Mike’s case, APS, the physicians, and the care providers have all been important members of this team. More than 20 years have passed since Mike’s brain injury. Two facets of his personality are to deny and avoid. He still believes he could drive a car, for example, if one were available. He does not think about the future, including the fact that he will lose his house if he does not save money to pay his property taxes. He has not given any thought to aging and what he may do when he cannot live alone any longer. It is crucial that CM plans consider the long term for Mike’s overall benefit (beneficence). Peter Drucker said, “Long-range planning does not deal with future decisions but with the future of present decisions.” Longterm CM, preferably with the same team, will promote Mike’s best treatment (nonmaleficence) and coincidentally save the insurer money (justice).
• Who is the focus of my advocacy? • Whose values have supremacy? • Who determines competence? Although Mike has been living with his disability for 20 years, he still hopes. Mostly, his hope is to be independent as long as he lives. Within ethical principles, it is my duty to help make this happen. Within ethics, it is also important to prepare Mike for the future and, as Drucker says, help him make wise decisions today that will affect his future. ❑ Michele Nielsen, RN, CCM, CRC, COHNS, CPDM, CLCP, is a case manager with Medical Vocational Planning in West Linn, Ore. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/124504 doi:10.1067/mcm.2002.124504
Ethical dilemmas I still encounter while working with Mike include:
May/June 2002
TCM 71
Five ethical concepts govern case management (CM) practice: • Autonomy—the patient’s freedom to choose his or her own treatment course • Beneficence—the case manager’s responsibility to promote good and be the patient’s advocate • Nonmaleficence—first, do no harm • Justice—fair and objective treatment of all parties (eg, allocation of health care resources based on individual need in a fair manner) • Veracity—telling the truth
T
he word ethics derives from the Greek root ethos, which is related to character or the positive qualities that distinguish one per-
son from another. Ethics is society’s version of ideal conduct for an individual or professional. The demands of ethical duties usually exceed those of legal standards, which are minimum standards of conduct. TCM 68
May/June 2002
Case Study I am the external nurse field case manager for Mike M, an extremely difficult patient whose treatment requires active use of all my ethical principles. Mike is now 48. When he was 27, he was struck on his neck, head, and arm by a chain or cable at work, sustaining an acquired brain injury. He was comatose for 5 months after the injury and declared permanently and totally disabled. Hemiplegic on his left side, Mike has been diagnosed with depression (for which he takes Paxil) and has slurred speech, balance difficulties, and impulsive behavior. He lives in his own single-story home in a small town in Washington and has a care provider a few hours a day. He had been in an assisted living facility before he moved away from Seattle to return to his childhood location. Mike initially was referred to me for case management in November 1999 when he
THE AMERICAN NURSES ASSOCIATION CODE OF ETHICS Nurses should provide services with respect to human dignity. Nurses should safeguard the client’s right to privacy. Nurses need to safeguard patients from the incompetent, unethical, and illegal practices of others. Nurses assume responsibility and accountability for our individual nursing judgments and actions. Nurses maintain competence in nursing. Nurses exercise informed judgment and use individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others. Nurses contribute to the ongoing development of our profession’s knowledge.
moved. Fortunately, a physiatrist (physical medicine and rehabilitation) was practicing in this location, and an appointment was made with Dr. MacInnes (names have been changed) as soon as possible. When I first saw Mike, his home had no refrigerator or bathroom safety rails, floor tiles were broken, and the rooms were feces-stained and incredibly dirty. I arranged home health care for several hours a day, 5 days a week. However, the care agency discontinued services shortly thereafter because employees could not be persuaded to care for Mike because of his inappropriate behavior, which included sexual innuendo, rudeness, and yelling. The ethics of allowing a patient to remain independent although he is a potential danger to himself (autonomy) caused me to try to think creatively. Another issue for case managers is professional and legal liability. Because of these concerns, I called Washington’s Adult Protective Services (APS), which assessed Mike’s situation in early December 1999. No action was taken because, according to the APS report, Mike “acknowledges that he has difficulty retaining caregivers and understands the risk of not having services. He is alert and oriented and capable of making decisions.” The original care providers resumed their services when Mike agreed to be more cooperative. However, they were discontinued again in late February 2000 because of Mike’s continued verbal abuse and sexual innuendo. As the case manager, I located another home health agency willing to take this difficult
Nurses participate in our profession’s efforts to establish and maintain conditions of employment conducive to the high quality of nursing care. Nurses participate in our profession’s effort to protect the public from misinformation and misrepresentation and maintain the integrity of nursing. Nurses collaborate in promoting community and national efforts to meet the health needs of the public.
patient. Mike and I also drove to foster homes in the area to see if he would enjoy living independently in a situation where assistance and meal preparation were available. Mike did not want to leave the independence of his own home, so this option was not pursued. In the interim, the second home health agency discontinued its services in June 2000, citing the same reasons as the first—verbal abuse and sexual innuendo.
went to the local ED. Although the ED physician thought Mike was making poor decisions for his protection, he was not found to be incompetent. During my vacation in July 2000, the insurance company instructed my colleague to close our file because the patient was not being compliant. Six months later, I was asked to resume CM because Mike had mishandled his money, was without a telephone, and had no personal care. Mike had gone for
Armed with a digital camera and with Mike s permission, I photographed conditions within the home, such as overflowing trash, a broken toilet, and feces on the walls. For the second time, I enlisted the help of APS. Unfortunately, the social worker visited Mike immediately after a friend had bathed him and cleaned his home. Again, no action was taken because Mike was found to be competent. Shortly thereafter, he fell at home and, when a friend came over and discovered him,
6 months with no care except that provided by an occasional friend. He occasionally went to the local hospital on his motorized scooter, where personnel had him talk with the social worker, who in turn called the workers’ compensation insurance company and requested resumption of CM. May/June 2002
TCM 69
AN ETHICIST’S PERSPECTIVE
MARK MEANEY, PHD
Michelle Nielsen addresses four interconnected issues regarding the relation of ethics to case management: professional integrity, dual relationships, weighing of beneficence and autonomy in conflicted cases, and future harm. Some health care professionals use the principle of respect for autonomy to justify abandonment. They reason that noncompliance is an exercise of the patient’s right to self-determination. Moreover, they rationalize that, if they continue to pursue the patient’s good despite noncompliance, they will be patronizing the patient. Nielsen’s case analysis betrays a much more subtle understanding of the relationship between the principles of beneficence and respect for autonomy. She saw Mike’s vulnerability. She entered into negotiation with him to fulfill her professional obligation to pursue her client’s good. She “creatively” resolved conflict to meet his needs. Nielsen is successful because of two essential ingredients: professional integrity and process. First, she possesses habits of the mind that make her a great case manager. Moral discernment provides her with a vision: the good of clients, employer organizations, the practice of case management, and society generally. She perceives each case as a means to benefit these different stakeholders. Her actions also illustrate the strength of will required of case mangers in conflicted cases. Second, Nielsen’s actions suggest a more or less formal ethical decision process with six steps. In Step 1, she reflected on her dual relationships before accepting the case. Veracity is essential to mediate dual relationships. In Step 2, she identified all relevant stakeholders. Step 3 requires that relevant stakeholders define and agree on the ethical conflict. In this case, beneficence, respect for autonomy, and justice conflicted. In Step 4, Nielsen listed alternatives that addressed the ethical conflict and tried to predict each alternative’s effect on relevant stakeholders. She then evaluated the alternatives in Step 5 based on consequences, ethical and legal principles, and her own professional values. In Step 6, she implemented the decision, communicated the decision to relevant stakeholders, and followed up to address remaining negative consequences. Nielsen saw that multiple stakeholders had moral claims on her actions. If she lacked professional integrity, she might have ignored any number of stakeholders. In which case, she would have biased the outcome in ways that would have been harmful to those affected by her decisions. Mark Meaney, PhD, is the executive director of the Institute for Clinical and Corporate Ethics in Liberty, Mo. He can be reached at (816) 792-5523 or [email protected].
The condition of Mike’s home when I returned after 6 months was appalling. Armed with a digital camera and with Mike’s permission, I photographed conditions within the home, such as
was necessary to consider a legal guardianship to protect him. This is defined as a “legal relationship created by the courts to protect and manage the person and/or property of a living
After all, his independence is the most important thing to him, and if he loses his home, he no longer will have control. bugs flying out of his now-existent but broken refrigerator, overflowing trash, broken toilet, and feces on the walls. Although Mike wished to remain independent, my concern for his safety was growing. I told him I would not do anything without his knowledge, but it TCM 70
May/June 2002
person who is too young, too old, too ill, or too incompetent to handle his own affairs.” Once again I called APS, which visited Mike but said he would not be declared incompetent by a judge and forced to move where he did not want to move.
Mike missed several appointments with his primary care physician and his rehabilitation specialist, either because he forgot, had no transportation, or simply did not wish to go. When I took Mike to his physiatrist in July 2001, I showed the physician the digital pictures of Mike’s home. MacInnes wrote a contract that he, Mike, and I signed. It read, “I, Mike M, agree to allow care assistance in my home to help with cleaning, personal hygiene, meals, etc. If I do not permit them to assist me in my home on an ongoing basis, I will agree to move to a group home.” One last agency within this small community agreed to care for Mike only if a professional janitorial service cleaned and sanitized the home before services started and a plumber installed a new toilet. Mike now receives 4 hours of care—2 in the morning and 2 in the afternoon—7 days a week. Mike and one male caregiver have established trust to the point that Mike has given Lance a key to his home. Previously, Mike often locked caregivers out. Mike’s independence includes going to a local restaurant on his scooter, so sometimes he is not at home but cleaning can proceed. The greatest concern now is Mike’s financial status. Although he receives sufficient income from workers’ compensation (permanent and total disability payments) and Social Security disability income to meet his expenses, he runs out of money by the third week of each month because, being fully independent, he withdraws his money from the local credit union and plays Washington’s lottery games. By the end of each month, he doesn’t have enough money to eat. Another contract was written with Mike authorizing me to assist with his finances. However, the workers’ compensation insurer does not wish to undertake liability for this, and Mike doesn’t want to lose any independence. Mike is at risk of losing his home, which is fully paid for, because of nonpayment of property taxes. My plan is to analyze his income and spending and advise him so he will discipline himself. After all, his independence is the most important thing to him, and if he loses his
home, he no longer will have control. He understands this possibility and says he is willing to listen. Ethical Choices It would be tempting as a case manager to choose gray areas of the above-mentioned ethical principles. Although it would have been easy to take pictures of his home without Mike’s knowledge, veracity is an important concept. Once a patient discovers I have not been truthful, will he trust me again? What would I have done if Mike had not given permission? I simply would have acceded to his wishes. However, I would have discussed the importance of this documentation for MacInnes. By this time in my relationship with Mike, enough trust had been established that this discussion could have occurred. The other principles of autonomy, beneficence, nonmaleficence, and justice can be demonstrated throughout the CM provided. CM does not exist in a vacuum. When a case manager is involved with a patient for a long time, a dual relationship can occur. This ethical issue is the least understood but most serious. If I assume more than one role or neglect my
attempts to balance obligation to the patient, his family, and the insurer, it is possible to lose my objectivity. Therefore, I must involve other services and providers. In Mike’s case, APS, the physicians, and the care providers have all been important members of this team. More than 20 years have passed since Mike’s brain injury. Two facets of his personality are to deny and avoid. He still believes he could drive a car, for example, if one were available. He does not think about the future, including the fact that he will lose his house if he does not save money to pay his property taxes. He has not given any thought to aging and what he may do when he cannot live alone any longer. It is crucial that CM plans consider the long term for Mike’s overall benefit (beneficence). Peter Drucker said, “Long-range planning does not deal with future decisions but with the future of present decisions.” Longterm CM, preferably with the same team, will promote Mike’s best treatment (nonmaleficence) and coincidentally save the insurer money (justice).
• Who is the focus of my advocacy? • Whose values have supremacy? • Who determines competence? Although Mike has been living with his disability for 20 years, he still hopes. Mostly, his hope is to be independent as long as he lives. Within ethical principles, it is my duty to help make this happen. Within ethics, it is also important to prepare Mike for the future and, as Drucker says, help him make wise decisions today that will affect his future. ❑ Michele Nielsen, RN, CCM, CRC, COHNS, CPDM, CLCP, is a case manager with Medical Vocational Planning in West Linn, Ore. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/124504 doi:10.1067/mcm.2002.124504
Ethical dilemmas I still encounter while working with Mike include:
May/June 2002
TCM 71