Case study: What should CM do for cancer patient?

Expert shares ideas for putting theory into action

Case managers are advocates for patients. But the role and responsibilities of the case manager change throughout the continuity of each case. As your patients move from an acute stage, to a chronic stage, to a dying stage, their needs change, and that changes your professional responsibility, says M. Jan Keffer, PhD, RN, CS, ANP, associate professor of family health nursing at Indiana School of Nursing in Indianapolis. She examines the ethical role of the case manager across the continuum of care in this case study:

Ethics case study: A 64-year-old man was sent to a urologist at his health maintenance organization (HMO) with symptoms of benign prostatic hypertrophy. During a blood test for prostate specific antigen, his level returned significantly elevated. The test was repeated with similar results and a biopsy was performed. He was diagnosed with stage I prostate cancer.

Case management response: The first step is to educate the patient about treatment options available at this early stage, Keffer says. "You might help him develop a list of questions to bring with him to his next appointment with the urologist, or help him access information on the Internet, or send him materials you have collected. We are assuming this is an educated man with computer access at home. You must always gear your interventions to the education level of the patient. However, Internet access currently is available at many public libraries, so this type of resource should be available to most patients."

Your response might be slightly different if the patient was at stage IV rather than stage I. "What if the patient tells you, I know all about radical prostatectomy with node removal, but I’ve also heard about internal and external radiation, and I want to try that instead.’ Unfortunately, the new internal radiation therapy is not covered by his HMO."

Keffer suggests you consider these possible case management responses at this stage:

• Inform the patient this procedure is not covered, but you will work with him to try to get the procedure paid in other ways.

• Search for a funding organization or check for secondary insurance coverage.

• Negotiate with the HMO for benefit acceptance. Argue that the internal radiation will cost significantly less than the surgery and an inpatient stay.

Let’s say your patient decides the radical surgery would be his best chance for a cure. During the surgery, he suffers a myocardial infarction and ends up in intensive care. Two days later, he has a stroke. After two weeks, the hospital informs you it can do no more for him and suggests he be transferred to an extended care facility. Eventually, your patient recovers from his MI and stroke and is well enough to return home. It’s been nine months, but he’s dying, and he’s in a great deal of pain.

Some appropriate case management responses Keffer suggests for this stage in the patient’s treatment include the following:

• Refer the patient to a pain clinic.

• Suggest an intrathecal pain treatment.

• If the HMO will not cover intrathecal pain management, check to see if it is possible through a local hospice.

• Determine whether your patient is appropriate for hospice care.

• Encourage the patient to sign a living will and durable power of attorney, if he hasn’t done this at an earlier stage.

"Remember, it is your responsibility to keep the patient involved. If he wants to be aggressive and keep fighting, send him back to the Internet. See if there are any experimental studies he may qualify for," Keffer suggests. "Your ethical decision making is a continual process that keeps the patient in the center of this complicated health care delivery structure we all deal with. You must explain to the patient and the family as early as possible what the options are at each stage and then stay the course with them.

"The bottom line is to keep the lines of communication open and base decisions on the patient’s benefit and on how that benefit can be obtained within the system," she says. "If you always base your decision on complete information within a reasoned process, then you’re doing your job."