ETHICAL DILEMMAS IN HOME HEALTH CARE: A Social Work Perspective

Article excerpt

The survey in this article examined several factors related to the frequency and difficulty of resolving four ethical conflicts in a national sample of 364 home health care social workers. Ethical conflicts regarding the assessment of mental competence, self-determination, and access to services were moderately frequent and difficult to resolve, whereas conflicts over implementing advance directives were infrequent and not difficult to resolve. Each ethical conflict involved multiple stakeholders. Multiple regression analyses revealed significant predictors of the frequency and difficulty of resolving the ethical conflicts. Implications for practice and administration in home health care and social work education are discussed.

Keywords

advance directives

ethics

high-technology home health care

home health care

Medicare

reimbursement policy

Recent changes in health care such as improved health care technology and the economic pressure of managed care have led to shortened hospital stays (O'Neil & The Pew Health Professions Commission, 1998) and a movement in the delivery of health care, induding social services, to community-based settings (Berkman & Volland,1997; Simmons, 1994). One of these community-based settings is home health care. During the 1990s home health care was one of Medicare's fastest growing benefits. Total Medicare spending on home health care rose from 3.2 percent ($3.7 billion) in 1990 to 9 percent ($17.8 billion) in 1997 (U.S. Department of Health and Human Services, 1999).

The expansion of home health care has been attributed to several factors, including liberalized government regulations regarding coverage of services, the Prospective Payment System's focus on abbreviated hospital stays, and the development of high technology for home-based care. The growing number of people over age 65, an increase in the number of HIV/AIDS patients, and children and adults with complex medical conditions, all of whom are living longer, also have contributed to the growing use of home health care (Kane, Kane, & Ladd, 1998; O'Neil & The Pew Health Professions Commission, 1998; Thomas & Payne, 1998).

The expansion of home health care offers new opportunities for social work practice (Egan & Kadushin, 1999). However, home health care also confronts workers with distinctive ethical dilemmas arising from limited community resources, restrictions on the type and amount of care funded, the challenges of chronic and acute illness, and the need to accommodate the multiple perspectives of patients, families, agencies, and reimbursement sources (Collopy, Dubler, & Zuckerman, 1990; Egan & Kadushin, 1999).

Despite the movement toward community-based care, and the potential for ethical conflicts to arise in home health care, empirically based research in this area is scarce. This study sought to provide this information by examining ethical conflicts in social work practice in home health care.

LITERATURE REVIEW

Most of the literature reviewed in this section is based on philosophical or conceptual discussions. Only four of the empirical articles that examined ethical conflicts in home health care included social workers in their samples (Clemens, Wetle, Feltes, Crabtree, & Dubitzky, 1994; Davitt & Kaye, 1996; Egan & Kadushin, 1999; Healy, 1998).

An ethical dilemma occurs when social workers must choose between two contradictory ethical principles or directives, or when every alternative would result in an undesirable outcome for one or more individuals (Loewenberg & Dolgoff, 1996). Ethical dilemmas also involve conflicts between interested parties or stakeholders who have an investment in the issue under consideration. Conflicts may arise between patients, families, agency staff, and government regulations or third-party reimbursement sources (Clemens et al. …