Academic journal article Care Management Journals

Ethical Decision-Making Made Easier: The Use of Decision Trees in Case Management

Academic journal article Care Management Journals

Ethical Decision-Making Made Easier: The Use of Decision Trees in Case Management

Article excerpt

Case managers have never before faced the multitude of difficult ethical dilemmas that now confront them daily. Legal, medical, social, and ethical considerations often fly in the face of previously reliable intuitions. The importance and urgency of facing these dilemmas head-on has resulted in clear calls for action. What are the appropriate legal, ethical, and professional parameters for effective decision making? Are normatively sensitive, but also practically sensible protocols possible? In an effort to address these concerns, Alternatives for the Older Adult, Inc., Rock Island, Illinois established an ethics committee to look into possible means of resolving or dissolving commonly occurring dilemmas. As a result of year-long deliberations, the committee formulated a decision-making strategy whose central apparatus is the decision tree-a flowchart of reasonable decisions and their consequent implications. In this article, we explore the development of this approach as well as the theory that underlies it.

Case Study A

A long-time client becomes bedbound as her body gives out before her keen mind and will. The case manager regrettably determines that state-funded in-home service has reached its maximum and that this service now minimally meets her needs. Twenty-four-hour facility care is recommended, but because her home and memories are the center of her life, the client refuses nursing home care.

Case Study B

With discolored, rigidly edematous legs, the client shakes her head adamantly refusing to seek the medical treatment urged by her case manager. Even though her decision may be a deadly one, it reflects her preference for homeopathic care rather than physician-directed treatment.

A glance at decisions made by case managers in the field of chronic care points to the need for a clear course of deliberation. Case managers face immediate dilemmas involving a client's self-determination with respect to medical treatment or levels of care. Case managers usually approach these ethical dilemmas without formal education in ethical theory or frameworks and have little time to deliberate value issues when confronted with crisis situations which can result in harm.

The urgency of developing sensible "situational" protocols has not gone unnoticed. Kane and Caplan (1993) note: "Case managers are, therefore, forced to consider matters of ethics and matters of competent practice simultaneously" (p. 4). More recently, Kane, Penrod, and Kivnick (1994) remarked that case managers often feel that "few institutionalized or systematic procedures to assist case managers with ethical problems [exist]. Solitary or informal methods such as discussion with supervisors or colleagues or both are by the far the most frequent approach" (p. 10). Accordingly, they conclude that:

Guidelines are needed to help case managers and those employing case managers to examine when and what compromises of the autonomy principle are appropriate and how case managers could be equipped with the knowledge and skills necessary for them to serve as "decision referees." ... It is critical that the case managers in the trenches identify needs, define problems, and suggest appropriate structural responses in the organizations where case managers practice, (p. 12)

The complexity of case management decisionmaking has been the focus of year-long deliberations by the ethics committee of Alternatives for the Older Adult, Inc., Rock Island, Illinois. In the course of these discussions, the committee formulated numerous "decision trees" for the ethical dilemmas often faced by case managers. This article explores the development of these decision trees and their role in resolving dilemmas faced by case managers working in the field.


Alternatives for the Older Adult, Inc., a not-for-profit case management agency, serves chronically ill elderly in a 10-county area in western Illinois. …

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