Ethical, Legal, and Regulatory Considerations
Principles in practice
Autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity anchor case management decisions. Autonomy governs a capable adult's right to accept or refuse care. Justice governs fair allocation when resources are scarce - a distinction- and policy-based process, not a first-come rule. Fidelity means keeping commitments and avoiding conflicts of interest, including those created by payer or vendor relationships.
Legal and regulatory landscape
Know informed consent and the elements of negligence: duty, breach of duty, causation, and damages. Understand confidentiality and the minimum-necessary standard under HIPAA, mandatory reporting of abuse and neglect, guardianship and surrogate decision-making, advance directives and the Patient Self-Determination Act, ADA obligations, and state nurse practice acts. The medical record is a legal document; document objectively, contemporaneously, and without opinion. Know fraud and abuse basics, including prohibitions on inducements and improper referrals.
Traps
The recurring trap is paternalism labeled advocacy - overriding a capable patient "for their own good." Others: sharing health information with family without authorization; equating something legal with something ethical, or the reverse; assuming an advance directive equals a do-not-resuscitate order; and answering a conflict question without identifying who holds decision-making capacity.
Rule of thumb
Capacity first, then values, then document. Ask who is authorized to decide and what the patient has said they value - then record the decision and its rationale.
Worked example: A patient without capacity has no advance directive and family members disagree about aggressive treatment. The case manager confirms the legal hierarchy for surrogate decision-making under state law, requests an ethics consult, and ensures the substituted-judgment discussion is documented.