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For nurses working in utilization review, choosing to approve or deny care proves a daily test to their ethical resolve. They weigh their responsibility to patient need against medical necessity provisions under managed care organizational guidelines, and provide the “yea” or “nay” on medical procedures.

The family of a hospice patient decides after admittance that they want their loved one back on life-extending medications—while remaining at the hospice. The parent of a child treated for lacerations at an emergency room demands an alternative (but medically unnecessary) second dressing, and wants the insurance company to pay for it.

For nurses working in utilization review, choosing to approve or deny care proves a daily test to their ethical resolve. They weigh their responsibility to patient need against medical necessity provisions under managed care organizational guidelines, and provide the “yea” or “nay” on medical procedures.

“It’s often difficult for nurses to follow protocols because they hear the emotion behind the need or behind the request, and they want to take care of that,” said Sue Ellen Bell, Ph.D., RN, an associate professor and researcher at Detroit’s Wayne State University College of Nursing.

Some decisions are black-and-white, and others are as gray as the hairs that utilization review nurses grow fretting over tougher choices. Dealing with these dilemmas is becoming more crucial for these nurses, say experts, as the ranks of the uninsured in America grow and pressure mounts to contain costs through siphoned care parameters.

Increasingly, many are facing these choices on their own without ethical guidance or support from their managed care organizations, according to a recent study by Bell published in Nursing Administration Quarterly.

A large majority of utilization review nurses interviewed in the study said their organizations lacked formal ethics committees. Less than 10 percent of those surveyed said their employers had a process in place for dealing with ethical issues in the utilization review environment.

This represents a critical shortcoming, Bell said, because utilization review RNs are frequently the final arbiter in the approval chain.

“In utilization review, I think the nurses are much more autonomous than they are in a hospital setting,” Bell said. “The [utilization] cases usually only go to a physician if there’s some sort of appeal or there’s some question the nurse has in making the decision.”

Many with a background in the utilization review field, including Bell, said recognition of the primacy of patient need in the nurse’s code of ethics has grown substantially within the managed care field during the past decade.

“Utilization review has evolved significantly,” said Shelly Martin, MHSA, RN, president-elect of the American Association of Managed Care Nurses in Glen Allen, Va. “We want to make sure the patient gets everything they need in the benefit plan. I think, for the most part, utilization review nurses are looking for reasons to approve the care.”

“The role of the nurse has to be that of patient advocate, and that doesn’t change because the nurse changes to a managed care position,” said Rhonda Sortullu, RN, a member of the board of directors for the association.

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