• APNs are required to follow regulations and policies whether they agree with them or not. Ethical conflicts may result when laws and policies are perceived as unfair or biased, and moral distress may result.
- Watch Episode 3 videoLinks to an external site. again.
- Submit a 3- to 4-page paper in which you address the following:
• Ethical Competency:
• Analyze the ethical issue(s) in the scenario to recognize the required ethical decision,
• Choose an ethics theory (ies) or model(s) and present how the gist of the theory is relevant to the ethical issue in the scenario,
• Apply ethical perspectives/concepts to articulate your ethical reasoning and decision, o Integrate evidence-based interventions to mitigate moral distress
• Advocacy Competency:
• Describe and reflect on the main issue in the scenario,
• Make a convincing advocacy argument for a particular solution to the issue in the scenario
• Analyze the shortcomings of other solutions.
• Financial Management Competency:
• Compare and contrast different payment and reimbursement models (e.g., value-based model, fee-for-service model, etc.),
• Select the payment model that you think would achieve justice to the patients, providers, practitioners, and insurer.
Full Answer Section
Ethical Competency
Analysis of the Ethical Issue(s)
The scenario in "Episode 3" likely presents a situation where an APN, despite their clinical judgment that a patient (e.g., John) requires continued hospital care or robust home care support, is faced with the mandate to discharge the patient due to insurance coverage exhaustion. This creates a significant ethical conflict. The primary ethical issue is the tension between beneficence (the ethical principle of acting in the best interest of the patient) and the institutional or systemic constraints imposed by financial policies and regulations. The APN recognizes the potential harm or increased risk to the patient upon discharge without adequate support, directly conflicting with their duty to prevent harm (non-maleficence). This can lead to profound moral distress for the APN, as they are aware of the ethically appropriate action but are constrained from taking it. The required ethical decision is to balance the patient's immediate needs and safety against the institutional demands and financial limitations.
Relevant Ethics Theory/Model: Deontology
For this scenario, deontology provides a highly relevant ethical framework. Deontology, primarily associated with Immanuel Kant, posits that certain actions are inherently right or wrong, regardless of their consequences, based on duties or rules. In this context, the APN operates under a professional duty to advocate for the patient's well-being and to provide the best possible care.
The "gist" of deontology here is that the APN feels a moral imperative to ensure John's safety and proper care, independent of the financial consequences for the hospital or insurer. The duty to protect the patient from harm and ensure safe transitions of care is a fundamental professional obligation. The ethical conflict arises because the institutional policy (the rule) regarding discharge based on insurance coverage is perceived as overriding this moral duty. Deontology would argue that discharging a patient prematurely when their safety is at risk, simply to comply with a financial rule, is inherently wrong, regardless of the financial benefits or potential avoidance of penalties for the institution. The APN's moral distress stems from the feeling of being forced to violate a core professional duty.
Application of Ethical Perspectives/Concepts and Ethical Reasoning
Applying a deontological perspective, the APN's ethical reasoning would emphasize their duty to the patient. From this viewpoint, the APN's actions should be guided by principles such as:
- Fidelity: The duty to keep promises and be faithful to commitments, including the implicit commitment to provide high-quality, safe care to patients.
- Veracity: The duty to be truthful, which includes accurately assessing and communicating the patient's needs, even if it conflicts with discharge protocols.
- Non-maleficence: The paramount duty to "do no harm." Discharging a patient prematurely or without adequate support, knowing it could lead to adverse outcomes, violates this principle.
The ethical decision, from a deontological standpoint, is to prioritize the patient's safety and well-being as a moral imperative. This means that the APN should advocate for an alternative solution that ensures John's safe transition, even if it means challenging established policies. The APN's reasoning would be rooted in the inherent rightness of providing necessary care, rather than the outcomes of adherence to a flawed policy.
Evidence-Based Interventions to Mitigate Moral Distress
Moral distress is a significant issue for healthcare professionals. To mitigate moral distress in situations like John's, evidence-based interventions include:
- Promoting Ethical Leadership and Dialogue: Creating an environment where APNs feel safe to voice ethical concerns and engage in open dialogue with leadership, including ethicists, about policies that generate distress.
- Ethics Consultation Services: Utilizing formal ethics committees or consultants to review complex cases, provide guidance, and support APNs in navigating ethical dilemmas. This can help clarify ethical obligations and explore alternative solutions.
- Advocacy Training and Support: Empowering APNs with effective communication and advocacy skills to articulate their concerns to interdisciplinary teams, administrators, and even insurers. Providing emotional support through peer groups or counseling can also help manage the emotional toll of moral distress.
- Policy Review and Reform: Advocating for systemic changes to policies that frequently create moral distress. This involves gathering data on adverse patient outcomes linked to such policies and presenting compelling arguments for reform based on ethical principles and patient safety.
- Promoting Self-Care and Resilience: Encouraging APNs to engage in self-care practices and providing resources to build resilience against the cumulative effects of moral distress.
Advocacy Competency
Description and Reflection on the Main Issue
The main issue in the scenario is the conflict between optimal patient care and restrictive healthcare policies driven by financial considerations. John, a patient who is clinically stable but requires significant support for safe discharge, is being forced out of the hospital due to exhausted insurance benefits. This situation reflects a broader systemic problem where financial regulations often supersede clinical judgment and patient needs, placing APNs in an ethically compromising position. The APN's reflection would highlight the profound frustration and distress of knowing what is best for the patient but being unable to deliver it due to external, non-clinical constraints.
Convincing Advocacy Argument for a Particular Solution
A convincing advocacy argument would focus on patient-centered care and shared decision-making, despite financial limitations. The proposed solution is a collaborative, interdisciplinary discharge planning meeting that includes the APN, social worker, case manager, physician, family, and potentially an ethics consultant and a representative from the insurance company.
The argument would be: "Despite the exhaustion of insurance coverage, discharging John without adequate home care support poses a significant risk of readmission, worsened health outcomes, and increased long-term healthcare costs. While adhering to financial policies is understood, patient safety and the principle of non-maleficence must remain paramount. A holistic assessment, acknowledging the social determinants of health and John's specific needs (e.g., lack of family support, need for medical equipment), reveals that a premature discharge is not only unethical but also economically shortsighted due to the high likelihood of complications leading to readmission.
Therefore, I advocate for a multi-pronged approach:
- Immediate Appeal to the Insurer: The APN, supported by the physician, should formally appeal the insurance decision, providing detailed clinical documentation of John's continued needs and the high risk of adverse events if discharged prematurely. Highlighting the cost-effectiveness of short-term extended care versus potential readmission should be emphasized.
- Exploration of Alternative Funding/Community Resources: Simultaneously, the social worker and case manager must vigorously explore all available community resources, state/local programs, or charity care options that could bridge the gap in funding for home care or provide a safer transition to a step-down facility.
- Risk Mitigation Plan: If discharge is unavoidable, a comprehensive and documented risk mitigation plan must be developed, including clear instructions for family/caregivers, emergency contacts, and a robust follow-up schedule, with the understanding that the hospital bears some ethical responsibility for ensuring a safe transition, even if not financially compensated for all aspects."
Analysis of Shortcomings of Other Solutions
- Simply Discharging the Patient as Mandated: This solution directly conflicts with ethical principles of beneficence and non-maleficence. Its shortcoming is the high probability of adverse patient outcomes (e.g., falls, medication errors, infection, readmission), leading to increased suffering for the patient, moral distress for the care team, and potentially higher healthcare costs in the long run. It prioritizes financial compliance over patient safety.
- Keeping the Patient in Hospital Without Justification/Payment: While ethically desirable for the patient, this is often financially unsustainable for the hospital. It could lead to significant financial losses, potentially jeopardize the institution's ability to provide care for other patients, and may not be a long-term solution. It puts the burden solely on the hospital without addressing systemic issues.
- Ignoring the Policy and Continuing Care Covertly: This could lead to serious legal and professional repercussions for the APN and the institution, including audits, penalties, and loss of accreditation or licensure. It's not a sustainable or ethical approach to systemic problems.
- Solely Relying on Family to Provide Care: While family support is crucial, expecting untrained family members to provide complex medical care without adequate resources or training is irresponsible and places an undue burden on them, potentially leading to burnout and inadequate patient care.
Financial Management Competency
Comparison of Different Payment and Reimbursement Models
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Fee-for-Service (FFS) Model:
- Description: Healthcare providers are paid for each service they provide (e.g., office visit, procedure, test). The more services provided, the more the provider gets paid.
- Pros: Simplicity in billing; providers are directly compensated for their work.
- Cons: Incentivizes volume over value; can lead to over-utilization of services, unnecessary tests, and fragmented care. It does not reward efficiency or positive patient outcomes.
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Value-Based Care (VBC) Model:
- Description: Providers are reimbursed based on patient health outcomes, quality of care, and efficiency, rather than solely on the quantity of services. This includes various sub-models like bundled payments, accountable care organizations (ACOs), and shared savings programs.