Jim is a hospital case manager who serves on the hospitals length of stay committee. He has worked long enough to remember with fondness the good old days when it was easy to extend a patients hospitalization a few days if the patient needed more time to master a complex care routine or if the family needed respite. In todays world of increasingly diminishing revenues and tight regulations, there is little wiggle room for compassionate exceptions to length of stay. His hospital serves a large indigent population and it is not unusual for patients to lack any family caregivers which makes placement post discharge challenging. Jim has always put the needs of patients and families first and he is growing increasingly frustrated with the relentless pressure from senior administration to move em all out the quicker the better.
At the last length of stay meeting, a colleague muttered, were not exactly dumping our patients via taxi on Skid Row but were getting close. Jim is wondering how other hospitals are handling the growing problem of decision making for patients who lack decision making capacity, have no advance directives, and no legal representative or surrogate.
The Standards of Practice for Case Management (2010)
The Ethics Standard states that a case managers primary obligation is to his/her clients. Furthermore, the Ethics Standard recognizes that laws, rules, policies, insurance benefits, and regulations are sometimes in conflict with ethical principles: beneficence (to do good), nonmalfeasance (to do no harm), autonomy (to respect individuals rights to make their own decisions), justice (to treat others fairly), and fidelity (to follow through and to keep promises). In such situations, case managers are bound to address such conflicts to the best of their abilities and/or seek appropriate consultation (page 20).
Consider the following scenarios:
Jim isnt ready to abandon his commitment to patients and accept the new rules of doing business. He uses a monthly regional case managers meeting to explore what is happening in other hospitals and isnt surprised by the frustrations his questions unleash. He asks if other case managers are willing to form a task force to study the problem and hopefully identify strategies that will be helpful to all. Colleagues from four area hospitals agree to work with him. One suggests involving the ethicists at each facility to participate in the work and another shares that his facility has a policy addressing decision-making for unrepresented patients that might be helpful for others. Cheered by this enthusiasm, Jim feels more confident about his ability to be faithful to the promises he implicitly makes to each of his patients to be their advocates. He knows he wont win every battle, but hopes that better decision making processes will result in more decisions that put the best interests of these vulnerable patients first.
Jim is tired of always being the one who puts the needs of patients first. He is tired of being accused of not appreciating todays fiscal challenges and of being willing to bankrupt the hospital. He is tired of accusations that he is not a team player. He wonders how the work he once loved has become such a drag. He can either settle for doing the best he can in his present environment and shut down the inner voice telling him this isnt enough, or seek to work in another department or facility. A new position might solve the moral distress he is feeling when he cannot act on his personal and professional values undermining his integrity and authenticity but it wont help the patients he leaves behind.