Ethical Issues in Discharge Planning

A Learning Module for Effective Social Work Practice with Older Adults Compiled by Dr. Robin P. Bonifas, MSW, PhD Arizona State University School of Social Work

Acknowledgements

 The development of this curriculum module was made possible through a Gero Innovations Grant from the CSWE Gero-Ed Center's Master's Advanced Curriculum (MAC) Project and the John A. Hartford Foundation.

Overview

 Review of NASW Code of Ethics applicable to discharge planning  Example ethical decision making models  Common ethical dilemmas arising in discharge planning  Potential interventions for addressing common ethical dilemmas  Additional interventions and community resources to facilitate discharge planning

Common Issues

  Relative to discharge planning with older adults, there are two primary underlying issues that commonly contribute to ethical dilemmas:   Older adults whose cognitive capacity for informed decision making is questionable.

Disagreement exists among members of the health care team and/or client’s family regarding the appropriateness of discharge to a lesser care setting. Let’s review what the NASW Code of Ethics has to say about these areas…

NASW Code of Ethics

 Related to decision-making with questionable capacity… 

When social workers act on behalf of clients who lack the capacity to make informed decisions, social workers should take reasonable steps to safeguard the interests and rights of those clients.

Source: http://www.naswdc.org/pubs/code/code.asp

NASW Code of Ethics

 Related to decision-making with questionable capacity… 

In instances when clients lack the capacity to provide informed consent, social workers should protect clients clients ’ ’ interests by seeking permission from an appropriate third party, informing clients consistent with the clients ’ level of understanding. In such instances…seek to ensure that the third party acts in a manner consistent with clients ’ wishes and interests…take reasonable steps to enhance such ability to give informed consent.

Source: http://www.naswdc.org/pubs/code/code.asp

NASW Code of Ethics

 Related to disagreement among team members including the family… 

Social workers for whom a team decision raises ethical concerns should attempt to resolve the disagreement through appropriate channels. If the disagreement cannot be resolved, social workers should pursue other avenues to address their concerns consistent with client well-being.

Source: http://www.naswdc.org/pubs/code/code.asp

NASW Code of Ethics

 Related to disagreement among team members including the family… 

Social workers should not allow an employing organization’s policies, procedures, regulations, or administrative orders to interfere with their ethical practice of social work. Social workers should take reasonable steps to ensure that their employing organizations’ practices are consistent with the NASW Code of Ethics.

Source: http://www.naswdc.org/pubs/code/code.asp

Next, let’s look at what is meant by the term “ethical dilemma.”

Ethical Dilemmas

 Occur when an individual has to choose between two or more conflicting ethical standards.

Resolving Ethical Dilemmas

 There is no one right answer and there is no easy answer!

 Codes of ethics provide guidelines, but don’t necessarily tell us what to do.

 Using a hierarchical ethical decision-making approach can help you achieve an acceptable resolution.

 Three examples…

Ethical-Decision Making Model

(Corey et al, 2003)

1.

Identify the problem.

2.

3.

4.

5.

6.

7.

8.

Identify the potential issues involved.

Review relevant ethical guidelines.

Know relevant laws and regulations.

Obtain consultation.

Consider possible and probable courses of action.

List the consequences of those various courses of action Decide on what appears to be the best course of action.

1.

Ethical-Decision Making Model

( NASW Arizona Chapter)

What are the facts?

2.

3.

4.

5.

Are there ethical considerations?

Identify the sections of the Code that apply.

Consider the impact of values.

Consult regarding agency policy, licensing and legal requirements, standards of practice.

6.

Consider any additional factors, e.g. the prevailing standards of practice.

7.

Assess the various stakeholders involved and who stands to benefit from each option.

8.

Determine the best option using the Code as a guide.

Caution: Ethical Decision-Making Models

 Mattison (2000) reminds us that utilizing an ethical decision-making model doesn’t result in bias-free decisions.

 Our values still come into play utilizing an ethical decision-making model and we may not be aware of it!

 Consider also employing Mattison’s model to heighten your awareness of how your personal values enter in to ethical decision-making.

Implement Decision

Resolution Identifying which Priorities/Oblig ations to Meet Foremost and Justifying the Choice of Action Identifying Possible Courses of   Action Benefits/Costs Projected Outcomes Identifying Principles in the Code of Ethics which Bear on the Case Identifying Value Tensions Separating Practice Considerations and Ethical Components Background Information/Case Details Ethical Decision Making Model (Mattison, 2000)

Additional Considerations

 Negotiating ethical dilemmas and decisions in general is a life-long learning process.  Mattison (2000) offers a series of reflective questions to consider after addressing an ethical dilemma.

 The idea is that over time, the answers to these questions can help identify patterns of potential bias that influence your ethical decision-making…

Value Assessment Questions

 To what extend did my personal values or philosophies influence the preferred choice of action?

 To what extent did legal obligations influence my decision in this case?

 Was I willing to act outside of legal obligations if doing so meant serving the client best interests?

 To what extent did adhering to agency policy influence my decision in this case?

 If agency policy conflicted with outer obligations to the client, was I willing to act outside of agency policy?

 To what extent did my role in the agency influence my choice of action?

Now that you know about ethical dilemmas in general and potential ethical decision making models…

…Let’s consider some specific ethical dilemmas commonly arising when working with older adults.

 

Example Ethical Dilemmas in Discharge Planning

An older adult wants to return home or to a lesser level of care, but… 1. Members of the care team fear he or she (or a caregiver) is unable to manage self care or monitor an unstable medical condition.

2. In the above scenario, community resources would create a safe discharge situation, but the client and/or the client’s family refuses such intervention.

3. His or her spouse/partner is reluctant or unwilling to have him/her at home.

4. The living environment is in poor condition or hazardous in some way.

5. He or she has been unsuccessful with multiple discharges in the past resulting in overuse of the emergency room, unnecessary debility...etc.

Let’s look at considerations and potential resolutions for each of these situations…

Example 1: Care Team Perceives Discharge Unsafe

 First of all, it is important to remember clients’ rights to self determination and autonomy - clients have the right to make poor decisions.

 However, the role of the social worker is different in this situation depending on the client’s cognitive capacity for decision making.

  If the client has capacity, the focus is on ensuring the client is making an informed decision and reassuring the care team, which includes the family, about resources to maximize safety.

If the client does not have capacity, the focus is identifying someone who can act on the client’s behalf and exploring alternatives for creating a safe discharge in respect of the client’s wishes.

Example 1: Considerations Related to Clients with Cognitive Capacity

 

For the client

 Promote informed consent - this involves educating the client about the team’s concerns related to his or her safety and potential consequences associated with an unsafe discharge.

 Review and encourage the use of resources to maximize safety - this involves identifying services the client will need in a lesser care environment for the discharge to be successful.

For the care team

 May not be aware of resources available to enable older adults to live safely in their own homes; reviewing these resources can eliminate concerns.

 May be worried about remote dangers that should not trump client autonomy and self determination, i.e. “If there were a fire, he would have difficulty escaping.”

Example 1: Considerations when a Caregiver Does Not Appear Able to Provide Care

 This is primarily an issue when a client lacks decision making capacity.

 Sometimes family members or other caregivers wish to care for a client in a lesser care environment, but there are concerns about their ability to do so.

 For example, a frail older woman who weights 85 pounds intends to help her 250 pound spouse in and out of bed when he cannot bear weight.

 In this situation, family/caregiver education is an important intervention.

Example 1: Considerations when a Caregiver Does Not Appear Able to Provide Care

 Approaches to family/caregiver education:  Convene a team conference with them to review the client’s level of care and specific care needs.

  Have the individual assume full responsibility for care for a period of time while in a safe environment (i.e. work a 4-hour shift as his/her loved one’s caregiver in the nursing home) so he/she is fully informed of what to expect in terms of care.

  Often this will result in the family member realizing for themselves that the care is too much and they will either not be able to do it or will need to have outside support.

Alternatively, sometimes family members will actually do well, relieving the team’s fears about their ability.

Try a short trial visit in the lesser care environment, say 24-48 hours, with planned return to the higher care setting to debrief re: problems encountered.

Example 2: Considerations When the Client/Caregiver Refuse Necessary Services

 Again, it is important to remember clients’ rights to self determination and autonomy clients have the right to make poor decisions.

 However, sometimes what seems to be a “poor” decision is based on misinformation or other concerns; it is important for social workers to explore factors contributing to the the refusal of services deemed necessary by the care team.

Example 2: Considerations When the Client/Caregiver Refuse Necessary Services

 Potential factors contributing to service refusal:   Cost - sometimes clients and their families don’t feel recommended services are (or will be) affordable.

   Have referred agency review associated costs with them; sometimes services are not as much as anticipated.

Assist client/family to access sources of financial support such as Medicaid.

Reframe costs as in terms of future savings, i.e. paying a little for care now will prevent costly hospitalizations in the future.

Discomfort with the thought of strangers in the home.

  Validate this concern, it is uncomfortable having unfamiliar people help with intimate tasks in one’s private domain.

Arrange for client/family to meet potential service providers ahead of time to minimize anxiety.

Example 2: Considerations When the Client/Caregiver Refuse Necessary Services

 Additional factors potentially contributing to service refusal:     Misunderstandings regarding the purpose of recommended services.

Feelings of guilt or shame related to not being able to provide all care independently.

Recommended services don’t fit client/family’s cultural belief system.

Past negative experiences with similar services.

Example 3: Spouse/Partner Unwilling to Have Client Return Home

 This is one of the most heart-wrenching ethical dilemmas to deal with and can bring up many issues of counter-transference; good self-care and supervision is important.

 Things to keep in mind:  Client has a right to return to his or her own home.

    Spouse/partner has a right not to provide care if this is something he or she is uncomfortable with.

There may be a history of domestic violence or other traumatic relationship issues contributing to spouse/partner’s reluctance.

Spouse/partner may be unaware of support services available to assist with care management.

Client may be at risk for elder abuse.

Example 4: Living Environment is Unsafe

   The client’s cognitive capacity plays a role here.

For client’s with capacity, living environments deemed “unsafe” may simply represent differences in lifestyle choices between client and care team.

 For example, client’s home is cluttered, smells like cats, and there are dirty dishes and dust everywhere, but is not actually hazardous in any way --> lifestyle choice  Social worker’s role: advocate for client and educate team, offer services to assist client with home management.

If home is in disrepair, infested with rats, covered with mold and rotting garbage --> hazardous situation indicative of deeper problems.

 Social worker’s role: further assessment regarding client’s capacity and whether interventions can make home livable; recognize that sometimes it is just not possible for clients to return home

Example 5: Multiple Failed Discharge Attempts

   This is where client’s rights may be superceded by the rights of society - clients who insist on discharge to lesser care environments only to repeatedly decompensate and require lengthy hospitalization shortly after discharge are very costly to the health care system.

 However, it is still important to assess whether all services were provided to ensure a successful discharge, i.e. Did caregiver receive sufficient training re: client’s needs?

Clear limits and expectations need to be set with these types of clients (“client” meaning either the patient him/herself or the family).

Often third party payers will intervene in these situations and refuse to provide coverage or fund discharge services.

Resources and Interventions to Facilitate Discharge Planning

 Example interventions:   Multidisciplinary team planning meetings Family/caregiver education  Family/caregiver care delivery practice sessions in supervised environment    Short trial visits to lesser care environments Pre-discharge home assessments to identify ways to enhance safety and make caregiving easier.

Discharge follow up calls to assess how things are going, pinpoint problems early before situation deteriorates.

Resources and Interventions to Facilitate Discharge Planning

 Example resources:           Home health care - Medicare funded; provide continued rehabilitation and/or caregiver training for a limited period of time.

Home care - Private pay or Medicaid-funded; provide custodial care to augment family care for extended periods of time.

Adult day care - Off site care for several hours during the day while family caregiver(s) work or attend to other duties.

Home-delivered meals Chore services-assist with housekeeping duties and grocery shopping Minor home repair services Transportation services Lifeline emergency alert systems - allow clients to alert family, neighbors or others of emergency situations even if can’t get to the telephone Medication reminder/safety check-in calls Adult Protective Services - for cases of self-neglect or elder abuse

References

 National Association of Social Workers (1996). Code of Ethics. Retrieved from http://www.naswdc.org/pubs/code/code.asp

.

 Corey, G., Corey, M., & Callanan, P. (2003). Issues and ethics in the helping professions, 6th edition. Pacific Grove, CA: Brooks/Cole.

 Mattison, M. (2000). Ethical decision-making: The person in the process. Social Work, 45(3), 201-212.