It’s a difficult yet common scenario: A patient with complex care needs does not have a reliable caregiver at home to assist with implementing his or her post-discharge care needs.
In these cases, it’s necessary to determine if the patient has the capacity to make the decision, says Erin Sarzynski, MD, MS, an assistant professor of geriatric medicine at Michigan State University in East Lansing.
“If the patient does have capacity, then a clinician is challenged to facilitate the discharge against his or her better judgment,” Sarzynski says.
If Sarzynski is concerned about a patient’s welfare post-discharge, she works with case management to create a contingency plan. This could include having family or friends check on the patient and arranging home healthcare services or sub-acute rehabilitation care, which may be a viable option for up to 30 days post-discharge if the patient was admitted for at least three nights under inpatient status.
“However, if the patient lacks capacity to make the decision to return home without a reliable caregiver, then the clinician must determine who is the proxy decision-maker,” says Sarzynski. If the patient has not previously appointed a durable power of attorney for healthcare, it is necessary to contact next of kin, or in some cases apply for a court-appointed guardian.
“Thereafter, clinicians must arrange post-discharge care with input from the proxy decision-maker,” says Sarzynski.
In some cases, an elderly, frail patient is determined to go home alone, “and nobody thinks it’s a good idea. That becomes a serious issue sometimes,” says Wayne Shelton, PhD, professor at the Alden March Bioethics Institute at Albany (NY) Medical College.
Physicians and nurses have an ethical obligation to ensure that the discharge is safe, says Shelton. This includes the safety of the patient’s caregiver. “A spouse may have the best of intentions, but has health problems of his or her own,” he says. If the spouse is clearly unable to care for the patient, the bioethicist may need to become involved to discuss other options. “You may have to talk about sending the patient to a nursing home, which may be something they don’t want to talk about,” says Shelton.
Ethicists can begin the discussion by making sure that patients and family understand the risks involved. “Basically, we try to get them to reconsider their decision,” says Shelton. “We explain that they risk getting in worse shape medically.”
Shelton says it’s “virtually impossible” for ethicists to tell an elder person with capacity who has made up his or her mind to go home that he or she can’t do so, regardless of the risks. “We do have patients who leave against medical advice. Even if it entails some risk, we can’t stop them,” says Shelton.
The clinical team struggles with seeing a patient leave, knowing it’s likely unsafe. “Sometimes the patient comes back with additional problems,” Shelton says. “This is one of the prices we pay for autonomy.”
“Safe discharge” laws preclude hospitals from discharging patients who don’t have a safe plan for continued care after they leave a hospital. “This has become a real challenge with regard to uninsured patients,” says Janet L. Dolgin, PhD, JD, co-director of the Hofstra University Bioethics Center in Hempstead, NY. Dolgin is also director of Hofstra University’s Gitenstein Institute for Health Law and Policy.
“Mostly, now, this is relevant to undocumented immigrants, who are not generally covered by Medicaid or state exchanges,” notes Dolgin. Hospitals are required by the Emergency Medical Treatment and Labor Act (EMTALA) to accept all “emergency” patients, but nursing home facilities are not. In fact, nursing homes are typically reluctant to accept patients whose care costs will go uncovered.
“Thus, hospitals have sometimes kept patients long after the patients were not well-served by continued hospital care because no safe discharge options were available,” says Dolgin.
Ethicists can offer valuable mediation if there’s disagreement as to whether a particular patient should be discharged. “Sometimes meetings among clinicians, patients, patients’ family members, social workers, or hospital administrators can shape options that seem acceptable to everyone involved,” says Dolgin.
The following are other ethically challenging scenarios involving hospital discharges:
• A patient is medically cleared for discharge, but refuses to leave the hospital.
“There are a variety of reasons why patients stay in the hospital longer than they need to. This is a big problem in healthcare,” says Shelton.
Several recent ethics consults at Albany Medical College have involved this very scenario. Sometimes it’s a family member who objects to the discharge on the grounds that the receiving facility is too far away.
“This raises the question of how far is too far for the family, if there is no local place for the patient to go to,” says Shelton. “There are limited options for other places patients can go.”
If a patient or family strongly objects to the discharge, ethicists sometimes work with clinicians to find a way to accommodate them to some extent. “We can usually work things out and negotiate an extra day. It’s not a hard science — these things are negotiable in terms of decision-making,” says Shelton. “But there are limits.”
One reason is that keeping patients hospitalized who are medically ready for discharge is simply not in the patient’s best interest. “The hospital is not a place to be, unless you really need to be there,” says Shelton. “And it’s certainly not in the best interest of the healthcare system because it costs a whole lot of money.”
Ethicists try to get across that the patient doesn’t need the level of care he or she is receiving in the hospital, and that the patient is better off in a long-term care facility. “People can get quite comfortable having nurses and doctors taking care of them here,” says Shelton. “It’s a communication challenge.”
• Case managers and social workers can’t find a facility willing to accept the patient.
“Some patients have a reputation for being difficult, and nobody wants to take them,” says Shelton. “Facilities sometimes push difficult patients on each other, protecting their own turf.”
The next step may be unclear if one facility after another flatly refuses to accept a particular patient. “This has raised some questions about the role of the ethics consult,” says Shelton. “It’s not really our role to call nursing homes and talk about discharge planning.” However, Shelton occasionally has stepped in to make such calls. “Strictly speaking, it’s not something we should be doing,” he says. “But it tends to get people’s attention.”
• Clinicians are pressured by hospital administrators to discharge patients.
Hospital administration recently alerted Sarzynski of “high census,” with a request to discharge patients in the early morning. At the time, one of her patients was a homeless man medically ready for discharge, but a severe weather advisory had been issued. “These cases are difficult to navigate,” says Sarzynski.
The primary ethical issue is non-maleficence, says Sarzynski. The homeless patient is the clinician’s primary responsibility, she says — not patients waiting to be admitted to the hospital. “Even so, it’s best to negotiate a compromise that enables the largest number of patients to receive the medical care they need, thereby meeting the ethical principle of utilitarianism,” says Sarzynski.
Sarzynski chose to discharge the homeless patient in the evening, with explicit instructions to stay overnight in the hospital lobby — a warming center — before departing the next day. “Thankfully, the case manager was able to provide a meal voucher as well,” says Sarzynski.
While Sarzynski did feel pressure to proceed with a potentially unsafe discharge, in the end she felt that the hospital did support her contingency plan. “In the end, I believe we met both ethical principles: non-maleficence and utilitarianism,” says Sarzynski.
Such plans require a team effort, however. “It’s an excellent example of the role a bioethicist can play: offering nuanced solutions that enable members of the medical team to negotiate clinical problems,” says Sarzynski.