Ethics, Legal, and Regulatory Considerations
Core concepts
Know the ethical principles: autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity. Informed consent requires capacity, disclosure, understanding, and voluntariness. Capacity means the patient can understand relevant information, appreciate consequences, reason, and express a choice; competence is a legal determination. Advance directives, POLST, guardianship, and surrogate decision-making have specific rules. HIPAA permits minimum-necessary disclosures for treatment, payment, and operations, with special protections for certain information. EMTALA governs emergency screening and stabilization. Scope of practice, negligence, conflict of interest, and resource allocation are also tested.
Traps
A family member cannot override a capacitated patient's decision. "Legal" is not always "ethical," and "clinically appropriate" is not always "covered." Do not disclose more than necessary or assume a signed form proves understanding. Ethics committees support, but do not replace, the patient's decision-making when capacity is intact.
Worked example
A capacitated patient refuses SNF placement after a stroke. The case manager should confirm understanding and capacity, address barriers, offer a safe home plan with services, document informed refusal, and escalate only if safety cannot be managed.
Rule of thumb
Before an ethical or legal question is answered, identify who holds decision-making authority and whether capacity is intact.