Ethical Dilemmas in Discharge Planning for Patients with Alzheimer's Disease
Cummings, Sherry M., Cockerham, Clifford, Health and Social Work
The importance and complexity of ethical considerations in health care settings are widely recognized (Beauchamp & Childress, 1994; Gadow, 1980; Robbins, 1987). Since the time of Hippocrates, the moral obligation of physicians to use their knowledge and skill to promote the welfare of patients has been a fundamental tenet of the medical profession. Likewise, the ethical comportment of nurses has long been understood as essential to the provision of quality patient care (Aroskar, 1980). Although the moral discourse surrounding social workers' role in health care settings has advanced considerably in the past two decades (Abramson, 1981, 1983; Blumenfield & Lowel, 1987; Proctor, Morrow-Howell, & Lott, 1993; Reamer, 1990), the dilemmas faced by social workers and the ethical impact of their decisions are not as widely recognized.
Social workers have played a pivotal role in health care since hospital social work was first introduced in 1905 (Abramson, 1981). Discharge planning - the development of an effective and comprehensive strategy to meet the posthospitalization needs of patients - is a major component of hospital social workers' responsibilities. The development of such a plan requires that social workers interact closely with patients, family members, medical staff, and community agencies. The varying needs and competing interests of these parties must be integrated to establish a viable plan that allows for the continued recovery of the patient. Although in many hospitals nurse case managers have assumed responsibility for monitoring patient care and discharge, social workers often deal with the most complex situations, in which ethical dilemmas frequently occur.
Discharge planning has become even more critical to patient welfare since the introduction of diagnosis-related groups (DRGs) in 1983 and the remarkable growth of managed care and capitation in the current decade. DRGs gave rise to the trend toward decreased lengths of patient hospital stays (Coulton, 1988; Stuen & Monk, 1990). Managed care and capitation have resulted in further reductions in days in acute care (Wickizer, Lessler, & Travis, 1996; Woodside, Bodne, Tonnesen, & Frazier, 1991). In addition, these strategies, which emphasize outpatient care, have led to the restriction of hospital admissions to those patients with the most critical needs (Cole, Reed, Babigian, Brown, & Fray, 1994; Schlesinger, Dorwart, & Epstein, 1996). Therefore, social workers must work more rapidly to develop plans for patients requiring increased care to complete their recovery after discharge (Coulton, 1988; Kosecoff et al., 1990). Ethical dilemmas may arise as social workers attempt to address the needs of the patient while balancing the competing demands of the health care organization, the medical staff, and the patient's family members.
Ethical dilemmas in discharge planning are associated with the development of less-than-adequate discharge plans (Morrow-Howell, Proctor, & Mui, 1991). Ethical dilemmas also tend to increase the required case management time allocated by social workers, thus becoming a contributing factor in the rising cost of care. Furthermore, cognitive impairment in a patient contributes to ethical complications; fluctuating confusion in a patient, difficulties in determining a patient's competence level, and conflicting assumptions about a patient's ability to participate in planning activities create divergent views about what actions are morally correct (Dunkle, Coulton, MacKintosh, & Goode, 1982, Proctor et al., 1993).
When treating patients with dementia, moral conflicts commonly arise when decisions must be made about a patient's right to know his or her diagnoses (Drickamer & Lachs, 1992; Post & Foley, 1992), competence and capacity for self-determination (High, Whitehouse, Post, & Berg, 1994; McGovern, 1991), quality of life (Cassel & Goldstein, 1988; Howard & Rockwood, 1995; Lawton, 1994), and the management of illness and termination of care (Rhymes & McCullough, 1994; Robbins, 1987; Sachs, 1994). …