Ethical and Legal Issues Facing Case Managers


Difficult situations, a disorganized health care system, and the existence of financial constraints influencing life-altering choices sometimes raise ethical issues. A multidisciplinary team of doctors, nurses, and therapists, all of whom have different backgrounds, specializations, and viewpoints, will also be involved. The professional case manager is at the heart of this often-difficult interaction, advocating for the patient while also attending to the concerns of all parties.

Case management is increasingly regarded an area in and of itself because of the importance placed on ethical and legal conduct (Sortedahl et al., 2018). Whether trained or not, case managers must ensure that their actions and decisions are consistently in accordance with ethical and statutory guidelines. These demands reflect the growing intricacy of case management and the expanding obligations that case managers encounter regularly. In other words, case managers are likely to meet ethical and legal difficulties on a regular basis. They may be conceived of as murky zones where the distinctions between good and bad are hazy and imprecise.

Patients will benefit from the advancements in healthcare technology in the future. The patient and those who care for them face many dilemmas and decisions that are not always clear, which adds to the stress. Decisions sometimes come down to a trade-off between life quality and life quantity, as well as what is economically realistic considering a patient’s medical insurance and financial ability. The choices and the consequences of such actions might be emotionally intense.

The case manager is frequently the first point of contact for the patient and his or her family or support system when they are searching for answers and knowledge to make well – informed choices. When there is a strong sense of connection and trust between the case manager and the family, the latter will ask the former questions that put him or her in a dilemma (Sortedahl et al., 2018). For example, “What would you have done if you was your relative?” This is the precipice of an ethical problem: assisting families in understanding their options but refraining from influencing or swaying their judgments.

By adhering to the Code and professional codes of ethics for their respective professions, Certified Case Managers (CCMs) are obligated to conduct themselves in an ethical manner. Case managers are also provided with direction from the Code, which helps them practice in accordance with the best standards of professionalism.

Case managers are, above all, defenders for the customer or patient. Problems might develop even when the case manager, who is certified by the board has the best of intentions. Ethical and legal problems may arise when the patient’s choices or wishes diverge from those of his or her supportive family. The case manager can be required to arbitrate an accord, but he or she must respect the preferences of the patient so long as there are no concerns about the patient’s competency.

The CCMC and other professional organizations promote ethical practice among its members. Although there is cynicism within the public regarding medical decisions, there is also a sense that determinations are motivated by monetary reasons and not the wishes of patients or their support systems. Case managers may encounter this misconception when discussing the financial aspects of a care decision with a patient or their family/support system. Specifically, how much insurance will pay and how much the patient would have to contribute.

Some treatment options may be inaccessible to individuals due to a lack of financial means, which can cause an ethical issue. For example, how to communicate with an individual about financially restricted treatment options, and how to speak for a client whose medication options are not reimbursed by insurance.

Focusing on Care Transitions

The case manager’s first job is to speak for the client, which includes following their request to remain in the facility for longer than the medical team recommends. The case manager collaborates with the payor to approve extra offerings and treatments. It is essential to educate the health care staff and the patient all through the journey, even more so if the insurer denies the extra care and an appeal is unsuccessful. Nonetheless, even if the case manager feels the appeal is unlikely to succeed, the he or she must proceed. This is important because it demonstrates compliance with the ethical criterion of client representation.

Conflicts within a family may sometimes lead to ethical concerns, especially if a cherished one is nearing the end of his or her life. Assessing how an elderly patient copes with day-to-day activities might provide light on the size and effectiveness of their support network. Patients are more likely to provide details about their family’s characteristics, such as discord and fights, after they have built trust with their case manager (Sortedahl et al., 2018). Disputes amongst family members about their beloved one’s capacity to care for oneself, their prognoses for recuperation, and the subsequent optimal stage of therapy could fall on the case manager.

Family interactions may be tricky, and the case manager is pushed into the midst as they strive to help the patient and provide details regarding treatment alternatives. Coordination and communication and choice regarding patient care objectives at the healthcare facility demands that treatments be implemented that take into account patients, families, and healthcare providers in this clinical environment (You et al., 2015). However, case managers must remember that their first obligation is to the client and no one else. It is critical to communicate clearly and consistently to guarantee that everyone receives the same news at the simultaneously.

Transitions in care are inevitable junctures that might produce ethical difficulties. For instance, the person and his or her support system/family may have conflicts with one another, as well as with the prescribing doctors and other practitioners, and with the care settings. Emotions have a role, especially amongst family members (Powell & Tahan, 2008). For example, one family member may feel the beloved is safer in a specialized nursing center, whereas another wishes for the beloved to remain at home. Individuals and their support systems are significantly affected by functional impairment and changes in interpersonal dynamics.

As a beloved physical state worsens, the preexisting tension and disagreement will certainly become stronger. Reversing roles may be difficult, especially when the adult child is already responsible for caring for the aging parent (Powell & Tahan, 2008). As a result, the case manager may serve as a mediator between the patient and his or her loved ones. While the case manager teaches and assists, regard for the person’s right to independence and self-determination in decision making is required under the ethical principle of autonomy.

Ethical Burnout and the Quadruple Aim

Case managers have additional challenges from their high caseloads and everyday obligations due to the emotional anguish associated with difficult cases and hospice situations. This includes the numerous ethical problems arising from opposing parties. Case managers are likewise taking on more responsibilities, sometimes to the extent of feeling anxious and overburdened. For many case managers, attempting to de-stress by operating over during their free time, such as on the weekends, becomes a never-ending loop that only makes things worse (Powell & Tahan, 2008).

As Fink-Samnick observes, such stresses can confront individuals who are “well-intentioned, highly trained, and prepared” and who strive “to perform the highest quality effort possible, toward ensuring that the expectations of patients, their caregivers, and other stakeholders are met” (Fink-Samnick, 2017, p. 249). The impact of a heavy caseload further compounds the stress of facing increased moral dilemmas and difficult choices faced by patients and their support systems/families.

Although case managers are generally not direct patient care providers, they must still meet several important legal and regulatory requirements. Case managers must educate their clients about treatments and side effects and keep accurate progress logs and client response. Certification is available in the field of case management and is a good thing to have as a measure of the case manager’s competency and knowledge.

Case managers are legally obligated to obtain informed consent from their clients or from a designated family member or other person for all treatment, medications or procedures. This includes informing the client about the risks of opting out of a suggested treatment. The case manager must educate the client about the benefits and risks of proposed treatment and be certain that this education is presented in a form that the client can understand. The client should not be coerced or intimidated into accepting treatment and must also be given the opportunity to ask questions and receive answers. Informed consent must be obtained in writing as well as verbally and the client must be mentally capable of understanding all aspects of the treatment

Topic Summary

As case managers engage in self-care, they not only care for themselves but also act as role models for others in the health care field. Case managers demonstrate the importance of finding ways to de-stress to live healthier, more balanced lives. Achieving better balance also helps case managers keep perspective about what it means to be an advocate. It is not about having a “perfect” outcome; ethical dilemmas often have no perfect solution. Rather, advocacy means ensuring that the patient’s voice is heard and his/her goals determine patient-centered practice.

Case management practice will never be free of ethical dilemmas; that appears impossible given the fragmentation of the health care system and the nature of case management that tasks practitioners with solving or resolving difficult and complex problems. Therefore, it is incumbent on all case managers to accept that they will likely encounter ethical dilemmas in the course of practice. At the same time, they must maintain ethical and legal standards, as required by the Code and as stipulated in standards of practice defined by the role and function study (Tahan et al., 2016). These expectations increase the complexity faced by case managers; however, the guiding principles of the practice-in particular, advocacy for the patient-will, will help clear the gray areas and keep the lines from being blurred.


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