BY STEPHANIE BERKNER, LCSW, CDP
Social workers are routinely faced with ethical challenges that require a balance of compassion, impartiality, and clinical judgment to properly navigate. Patient and family conflict is a common issue within medical case management settings. Complex family dynamics can often test boundaries and push unrealistic expectations and demands upon case managers who are expected in practice to approach these situations with neutrality and respect for autonomy. Social workers must adhere to ethical standards that maintain confidentiality and put client-centered care at the forefront while maintaining a delicate balance between support and guidance to family members.
Family Conflict Considerations
Family conflict often comes to a head when it is time to make critical care related decisions related to a loved one. Several years ago, I worked with a family who were at odds with end-of-life decision making. The conflict between siblings had reached a point of contention that eventually resulted in litigation as neither party could agree on what was in the best interest of the patient. The patient had been in a non-responsive state for several months post cerebrovascular accident with no noted signs of cognitive or physical improvement. Despite treating physicians noting that recovery would be next to impossible, the patient’s daughter was adamant that they be given every opportunity to treatment while her brother, who was named power of attorney for healthcare, expressed a desire to implement comfort care through hospice admission. The patient did not have a physician’s order for life sustaining treatment (POLST) form in place but had previously had discussions with both children about their wishes in the event of a medical emergency.
Approaching this situation from an ethical lens required focus on the patient themself, their wishes and the reality of their prognosis while also being sensitive to the impact this would have on the family as a whole. Despite the stress of the conflict between siblings, we worked to ensure a professional medical ethics consultation was arranged along with physician-led family discussions that ensured both children felt heard and understood while also keeping the patient’s medical status and their wishes at the forefront of these conversations. This allowed the family to better understand the decision-making process and feel comfortable with the care decision ultimately made for the patient.
Importance of Confidentiality
Confidentiality is an ethical standard that can be challenged in medical settings, especially when mandated reporting may be required. Social workers and medical professionals as a group are mandated reporters and therefore required to break confidentiality when a client may be at risk of harm to self or others. Confidentiality serves as a tenant of establishing patient trust and building relationships but oftentimes the understanding of the implications can be difficult for others to comprehend. Social workers should set confidentiality standards early in patient interactions to ensure all parties are aware of limitations within their practice.
In working with the elderly population, adult children may feel entitled to the sharing of protected medical information as a means of better understanding and advocating on their loved one’s behalf. However, it is imperative that social workers obtain client informed consent and educate the patient on how this information may be used. If a patient does not authorize consent for release of information, navigating this discussion with an adult child will be necessary and may be challenging.
An example of this situation would be when an adult child of a former patient requested intervention on behalf of the discharged patient. The child shared that their elderly parent had been experiencing significant cognitive decline and they were concerned about what their sibling would do with their parents’ estate. The child asked for information related to the case manager’s last interaction and to formulate a clinical opinion based on this interaction pertaining to the functional status of their parent in an effort to use this information as justification for the implementation of decision-making authority and helping to remove their sibling as potential decision maker.
The case manager explained that the patient had been discharged from services several months prior and that this would not be possible. The adult child continued to contact the case manager and others in the department. The case manager was concerned about the report and consulted with their clinical supervisor to determine the best course of action. Ultimately, they were able to explain that they would do their due diligence to ensure the patient’s wellbeing but that sharing information would not be possible due to not having the patient’s consent to do so and reviewed the parameters that would warrant breaking this confidentiality threshold.
Best Practices for Ethical Dilemmas
Ultimately there are a number of practices that can be utilized by case managers to ensure they address ethical dilemmas appropriately. This can include peer consultation, which allows for collaboration with colleagues to navigate complex client matters and determine next best steps. Supervisory consultation can also be sought to ensure that organizational and clinical standards are being upheld in an effort to minimize risks to the client as well as the clinician. It may also be beneficial to review the National Association of Social Worker’s (NASW) Code of Ethics, which sets the standard for the profession as well as provides a foundation for navigating matters of concern within practice. Ethical dilemmas that are not easily solved utilizing clinical peer or supervisory consultation may benefit from an Ethics Board review which allows for comprehensive oversight from a team of experts with a focus on objectivity and ensuring ethical standards are at the forefront of the decision-making process. In conclusion these practices allow for the protection of client rights and safeguard case managers within their clinical practice.
Stephanie Berkner has been with Arosa Chicagoland since 2014 and currently serves as an Area Director responsible for local operations and oversight of clinical staff. She is a Licensed Clinical Social Worker (LCSW) in the state of Illinois and is a Certified Dementia Practitioner (CDP.) Stephanie holds a master’s degree from the Loyola University Chicago School of Social Work and received her undergraduate degree at Colorado State University. Throughout her career she has served as a professional guardian, advocate and care manager to individuals with age-related frailties, medical complexities and mental health care needs.
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