LEARNING ACTIVITY

Critique the behavior and the responses of the agent(s) in the ethical case provided.
Write your thoughts in a separate sheet of paper.
An ethical dilemma found in a case study
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

I will never forget my biggest ethical dilemma. It happened when I was a director of case
management at a large medical center in New York City. It was the day after
Thanksgiving. I was at work, but a lot of people in administration were off that day. I
received a page from the director of critical care medicine. He was covering the ICU that
day and wanted to transfer a patient to our hospital from another state. I knew the
patient he was referring to, because the patient recently had been in our hospital for a
six-month length of stay, and the patient's discharge plan had been difficult and
complex. The doctor explained to me that the patient had been readmitted to a hospital
in another state, but that his wife wanted him to return to our hospital because she knew
the nursing and medical staff and felt more comfortable there. The doctor wanted the
patient in our hospital too, because he felt it was "the right thing to do for the patient"
and would improve continuity of care.
Since I knew the patient and his wife, and I also knew that the admission would be out-
of-network and probably not reimbursable, I found myself faced with a classic
organizational, or case management, ethical dilemma. I explained to the doctor that the
transfer would not be approved by the patient's managed care insurer, as the care the
patient required could be provided at an in-network hospital. I was concerned that the
patient would have another long stay, entirely without payment to the hospital. The
doctor understood my concerns, but he wanted to put the needs of the patient and his
wife above those of the hospital. In this classic conflict, he was exhibiting beneficence.
Beneficence is defined as an ethical principle that directs the healthcare professional to
take action to promote the well-being of his or her patients.
I, on the other hand, was advocating for a decision that addressed the financial needs of
my employer, the hospital. However, since my decision had a direct impact on the
patient, the patient's wife, and the potential quality of care of the patient, I found myself
faced with a difficult decision. Without anyone to share the decision-making burden with
me, I considered the wishes of the patient's wife against the financial needs of the
hospital. In my initial response to the physician, I denied the admission and cited the
financial risk at hand and the potential non-reimbursement to the hospital.
Needless to say, the physician was not happy with my decision and provided me with a
list of reasons why I had made the wrong decision. His beneficence was front and
center! I considered his argument, as well as what I had told my case managers and
case management students many times: "when in doubt, err on the side of the patient. If
you do this, no one can fault you for your decision.” I finally agreed to the transfer. The
outcome was not pretty. The patient came to our hospital that day. He stayed in acute
care for several months and ultimately was transferred to our acute rehab unit. The
entire stay was nine months. And we got paid for none of it. So, ask yourself. What
would you have done in this situation? Perhaps, if I'd had an organizational ethics
committee and could have taken my dilemma to them, the outcome might have been
different. Even if it hadn't been different, at least I would have had the power of the
committee behind me to support my decision.

Toni G. Cesta, Ph.D., RN, FAAN is a founding partner of Case Management Concepts,
LLC, a consulting company which assists institutions in designing, implementing and
evaluating case management models in the acute care, emergency department and
outpatient settings. Dr. Cesta writes a monthly column called "Case Management
Insider" in the Hospital Case Management newsletter in which she shares insights and
information on current issues and trends in case management. Dr. Cesta has held
positions as Senior Vice President — Operational Efficiency and Capacity Management
at Lutheran Medical Center in Brooklyn, New York where she was responsible for case
management, social work, discharge planning, utilization management, denial
management, bed management, the patient navigator program, the clinical
documentation improvement program and systems process improvement. The biggest
ethical dilemma she experienced was the day where she received a page from the
director of critical care medicine and a patient wanted to transfer to their hospital from
another state. The doctor wanted the patient in there hospital because he felt it was the
right thing to do for the patient and would improve continuity of care. Since she knew
the patient and his wife, and she also knew that the admission would be out-of-network
and probably not reimbursable, she found herself faced with a classic organizational, or
case management, ethical dilemma. She explained to the doctor that the transfer would
not be approved by the patient's managed care insurer, as the care the patient required
could be provided at an in-network hospital. She was concerned that the patient would
have another long stay, entirely without payment to the hospital. The doctor understood
her concerns, but he wanted to put the needs of the patient and his wife above those of
the hospital. In this classic conflict, he was exhibiting beneficence. Beneficence is
defined as an ethical principle that directs the healthcare professional to take action to
promote the well-being of his or her patients. She, on the other hand, was advocating
for a decision that addressed the financial needs of her employer, the hospital.
However, since her decision had a direct impact on the patient, the patient's wife, and
the potential quality of care of the patient, she found herself faced with a difficult
decision. Without anyone to share the decision-making burden with her, She considered
the wishes of the patient's wife against the financial needs of the hospital. Her initial
response to the physician, she denied the admission and cited the financial risk at hand
and the potential non-reimbursement to the hospital. In the end, she finally agreed to
the transfer even though she was sure that they got paid for none of it.
After I have red and examined the case study of an ethical dilemma it's all about
decision making with the factors that needed to consider and emotion that needed to
select the most suitable way of acting. First, from analyzing the situation of Toni Cesta
is understandable and valid because she’s just worried of her employer and to her co-
employee, all medicine that they used are not free, all her decisions is based on what
she feel that day. Second, the doctor decision was right because as a doctor he's
priority is to save the lives. In contrast, the rational decision should be not readmitted
again in the hospital because the patient and wife have no capability to pay the bills.
The emotion blocked to decide what is right based on her job description. Third, the
physician also right based on the emotion response because life is more important than
money. All their reasons and choices are ethical because they are just swayed by their
emotions, Toni Cesta was worried because the patient had been in their hospital without
paying the bills, and it is also unfair to the other patients who pay their bills, who find
ways to pay their bills. In this time, there’s nothing free. In the end she still accept the
patient even though she knows that they will not pay. She accept it even though she
knows that her employer will scold her. I understand Toni Cesta because she study
hard just to be in her position today and I also understand the doctor who wants to
accept the patient because he pitied and he also want to save the patient. In conclusion,
Ethical dilemmas often involve disagreements between the physician and patient or
between healthcare workers. They arise from value conflicts, both professional and
personal. Clinical ethics support providers must be fit for purpose and knowledge of
ethics is not the only requirement. The providers must adhere to legal constraints and
give consideration to the policy and procedures of the institution too. Their methods of
identification, analysis of the value conflicts, and recommendations should be
structured, consistent and transparent. By providing the expertise, being consistent and
by the inclusion of the referrers in the discussion/debate, this may facilitate their
acceptance into the medical ethics community as players in the ethical world, which is
necessary for the service to succeed. Otherwise the service may be deemed
amateurish and there will be a reluctance from their intended users to seek their advice.
They will be doomed to failure as the service will be considered as "just another
committee" set up to satisfy a mandatory requirement.
References:
https://www.emedevents.com/speaker-profile/toni-g-cesta