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Ethical Dilemmas in Home Care Case Management of the Elderly
By Ross Peters
August 2003

A health care case manager's job is to both provide the best care for elderly clients and to distribute the resources available to them by their employing agency in the most equitable manner. This suggests a conflict between the two goals and the creation of ethical dilemmas. And working difficulties of home care case managers are increasing due to a more challenging health care environment. These challenges include a rapidly aging population, a move against the institutionalization of seniors and the need to contain rising health care costs.

Pressures on health care workers include a greater number of seniors requiring care, hospital downsizing and reduced hospital stays, funding not being transferred from acute care to community care as planned by health authorities, a high rate of patient relapse and insufficient long term care beds. The competition between health care professionals for the right to control and distribute scarce finances is also increasing the need to better manage resources in the provision of health care.

The study examined the experiences of 89 established health care case managers in five urban and five rural areas of Canada to identify ethical dilemmas and other issues faced by these managers in their work. Overall, case managers felt frustration over the lack of support for their efforts. A lack of resources and few health care agency policies to address their working concerns were cited as evidence for this frustration.

Four main themes emerged in relation to ethical concerns and dilemmas. One was that of equity or fairness of resource distribution. For example, why should eligibility for long-term health care of children end just because they become adults? Procedures to determine what services a client needs are often standardized and therefore do not allow for different client realities. A particularly great challenge is that of deciding whether to provide a little bit of badly needed care to many people or expensive care to a few to keep them in their homes.
Another theme concerned the provision of long-term benefits to clients -- e.g. how to apportion services over time so that as more care is needed, more service could be offered. A third theme concerned the ethics of taking decisions for clients that may be potentially harmful. A fourth theme concerned client autonomy. For example, clients may be denied the choice of a specific health care worker due to health care "reform". Client victimization by health care workers or family caregivers may also be a problem. Ethical issues also relate to the problem of a client's freedom of choice when the client is cognitively impaired. How, for example do you deal with a client that refuses services that can be of benefit?

Other ethical issues include the bending of agency rules to be able to increase the type or amount of services for a client. Sometimes case managers unwillingly put clients into a nursing home because the co-ordination of services for home health care is too difficult or not cost effective. Non-ethical issue identified by case managers include the lack of qualified home support workers, insufficient housing options for hard-to-place clients, long waiting lists for services and poor co-ordination between government ministries and health care agencies.

Value of the Study. The findings described should give an early warning to those charged with setting long term health care policy and to agencies concerned with hiring, keeping and supporting case managers. The latter are thought to be one of the most pressured segments of the health care industry. With scarce resources and more client need, case managers are at a disadvantage and play precarious roles as they have no voice in major decisions affecting the system of care provided.

The study illustrates the very complex ethical dilemmas and situations faced by case managers in long term health care community settings. There is difficulty in reconciling cost containment and the need to meet assessed clients' health care needs. Clear criteria are needed to make judgments and set priorities. Case managers need specialized training in making complex judgments affecting clients and the training needs to include client and family definitions of need and services to be provided.

Changes that would reduce some of the ethical conflicts experienced by case managers include adequate funding of long-term care, better management of client wait lists, more supportive housing options and better teamwork by home care support workers. The study was reviewed by a B.C. health authority executive who said that there was little unanimity among key health care stakeholders about problems or solutions as there are differing and competing interests and needs. General suggestions to ease the role conflicts of case managers were offered.

Reference: Elaine Gallagher, Denise Alcock, Elizabeth Diem, Douglas Angus, Jennifer Medves. "Ethical Dilemmas in Home Case Management." Journal of Healthcare Management, 47:2, pp 85-97, Mar/Apr (2002).

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