EXECUTIVE SUMMARY

Patients refusing to leave the hospital for weeks, or even months — despite being medically cleared for discharge — are a growing problem, according to ethicists interviewed by Medical Ethics Advisor. Some ethical considerations include the following:

  • Patients may justifiably fear poor outcomes outside the hospital setting.
  • Other patients in need of hospitalization are prevented from being admitted.
  • Limited options are available for difficult-to-place patients.

Some patients are refusing to leave the hospital for weeks or even months, despite being medically cleared for discharge. Regardless of the underlying reasons, it’s an ethically challenging situation that can sometimes lead to litigation.1,2

“I’ve been aware and thinking about this problem for at least two decades, and it seems to be worsening,” says John D. Banja, PhD, a medical ethicist at the Center for Ethics at Emory University in Atlanta.

Some patients no longer require ICU care, but the discharge planner cannot find an appropriate placement site. “So, the facility gets stuck with this individual, and someone has to pay for it — which the facility often does by simply eating the costs,” says Banja.

Facilities often are caught off guard by threats of lawsuits if the patient is discharged. “Frequently, such families — sometimes the patient himself — are very clever, threatening, frightening, and manipulative. So, they get their way,” says Banja.

Banja sees a need for legal immunity for hospitals that discharge patients to reasonable sites over the objections of families. “Such legislation would lay out criteria that if a hospital could show it accommodated them, they would be impervious to a lawsuit,” says Banja, adding that litigation alleging negligent discharge would still be possible if the family could show that the criteria were not met.

The end result, says Banja: “Hospitals will keep taking losses on these patients, driving costs up — which they will then pass on to patients, their families, insurance companies, and Medicaid.” Politicians refuse to take on this thorny issue, in large part because it ultimately would mean raising taxes, he says. “Consequently, this is one more piece of the disaster in the making for 21st century healthcare,” says Banja.

Fairness, Justice Are Issues

Taking up an ICU or acute care rehab bed when a less intense, less costly care setting is appropriate “raises a serious issue of fairness and justice in how we utilize medical resources,” says Wayne Shelton, PhD, professor at the Alden March Bioethics Institute at Albany (NY) Medical College.

Keeping someone in the hospital who is ready for discharge prevents other patients in need of hospitalization from being admitted. Thus, physicians and hospital administration have to be firm in cases where patients clearly are ready for discharge, and have a viable discharge plan in place, says Shelton. “It is reasonable to inform the patient they must leave the hospital,” he argues. “To do otherwise is to not fulfill the obligations of a hospital as an institution charged with caring for the sick who require hospitalization.”

Does a patient have the right to remain in the hospital when that level of care clearly is not required? “From a nonmaleficence point of view, keeping patients in the hospital when they don’t require hospitalization is very concerning,” says Shelton, noting the significant risk of hospital-acquired illnesses.

However, poor reimbursement for nursing home care and limited options available for difficult-to-place patients are a reality. “Hospitals and facilities such as nursing homes are all protecting their own financial interests — and have few, if any, common interests in sharing the burdens of caring for difficult patients,” notes Shelton.

There are limited options available for hard-to-place patients — some of whom the facilities know and refuse to accept. “Hospitals are left in a bind, leaving nurses and social workers to desperately seek all viable options,” says Shelton.

Some patients want to go home, but caregivers feel completely overwhelmed by their needs. “We ask patients and their caregivers to do at home, now, many of the things we used to provide in the hospital setting,” says Cheyn Onarecker, MD, MA, chair of the Healthcare Ethics Council for The Center for Bioethics & Human Dignity. Onarecker also is an adjunct professor of clinical ethics at Deerfield, IL-based Trinity Graduate School.

Good communication is essential to a successful discharge. “But there are many reasons why good communication is difficult in a busy hospital,” says Onarecker. If the attending physician is unavailable at the time the caregivers are in the patient’s room, care instructions are not complete.

“It may be that the primary caregiver cannot be present at just the right time for the medical team to provide careful instructions,” says Onarecker. Contradictory information sometimes is given by different healthcare professionals.

“There may be specific reasons that would make discharge a bad idea,” adds Onarecker. In one case, the patient’s husband — the primary caregiver for his ill wife — had a heart attack just before the patient was discharged. In another case, the patient’s room at home was not big enough for the hospital bed, so the family did not want him discharged until other arrangements could be made.

“The common element in most of these situations is that good communication is not happening,” says Onarecker.

This is sometimes true throughout the hospital stay. Doctors and nurses come and go without explanation, and tests are performed without the results being conveyed. “Folks just don’t feel they are being listened to,” says Onarecker. “When that happens, it is almost predictable that the family is going to be upset when they hear their loved one is being discharged.”

Onarecker finds that in most cases, once the patient and family feel like their concerns are being addressed and they are given adequate information, they relax and begin making plans for discharge. “Most of the time, there are real issues that need to be addressed,” says Onarecker. “It is rare that a patient or family becomes resistant for no reason.”

‘Nuts and Bolts’ of Discharge

Robert N. Swidler, Esq, vice president of legal services for St. Peter’s Health Partners in Albany, NY, has authored several papers on difficult discharges.3,4 He says the following ethical questions should be considered involving the decision to discharge over the objections of the patient or family:

  • How much weight should be given to the patient or family member’s preference to stay in the hospital?
  • Is there a legitimate benefit to the patient in staying longer, or in leaving sooner?
  • Will allowing the patient to stay longer, or discharging the patient sooner, cause more harm?
  • Is allowing the patient to stay harming other patients who need the bed, or staff, or the hospital’s mission?

“In my view, the more difficult ethical issues arise after the decision is made to discharge the patient over objection,” says Swidler. These relate to the nuts-and-bolts decisions about exactly how to implement the discharge.

“How can the hospital oust the objecting patient from a hospital room, and from the building?” asks Swidler. “Obviously, the hospital can’t wheel a nonmobile patient into the street.” Hospitals must consider the following:

  • under what circumstances it can use security to force a mobile, seemingly healthy patient to leave;
  • whether transportation to the patient’s home or post-acute care will be arranged;
  • whether it is ethical to turn off the TV in the patient’s room and stop bringing food.

Answering these questions largely turns on the patient’s status post-discharge. “After discharge papers are signed, is the person in the bed a patient or trespasser?” asks Swidler.

If a patient or family is refusing discharge, ethicists sometimes are called upon to help resolve the situation. “Sometimes, an ethics consultation may provide new perspectives and, at times, open doors,” Shelton says.

Discussions with the patient, family surrogate, or a representative from a nursing home may lead to a resolution. “If nothing else, we can provide support to the care team that they are doing all they can to find an appropriate discharge,” says Shelton. Ethicists can provide a clear rationale for clinicians as to why asking a patient to leave against his or her wishes is justified.

Julie M. Aultman, PhD, director of the bioethics program and a professor in the department of family and community medicine at Northeast Ohio Medical University in Rootstown, has been involved in multiple ethics consults where the patient refuses to leave the hospital.

“Their motivations to stay are usually driven by fear of medical decline or a future emergency outside the hospital setting,” says Aultman. Such fears are sometimes justified, as with rural patients who live hours from the hospital. “Some of these patients may not survive the trip back to the hospital if they were to experience an emergency at home,” says Aultman. Extensive patient education — and even resources including home care — don’t necessarily allay these patients’ fears.

Some patients are unable to return to their homes due to complex medical conditions or unsafe home environments, but reject the idea of being discharged to a nursing home. “The thought of going to a nursing home, particularly state facilities for our underserved populations, is worse for some patients than staying in the hospital,” says Aultman. Ethicists help in the following ways:

  • all possible options are evaluated;
  • the values and goals of the patient, healthcare team, and others are identified;
  • it’s determined whether there is a genuine conflict of values;
  • support, mediation, and education are offered.

A recent case involved a chronically ill patient and his family, who feared the patient’s health would decline at home. “The patient’s medical history revealed the reality of his fears,” says Aultman. Shortly after each of seven previous discharges, the patient was rehospitalized due to poor home care, lack of adherence to medications, and social stressors in the home environment.

“To make matters more complex, the patient was told by one of his specialists he could stay in the hospital ‘as long as he needed to,’ despite the patients’ unhealthy dependence on the hospital staff,” says Aultman. Ethicists made recommendations for reducing, if not eliminating, the barriers to effective home care.

Regardless of the specifics of each individual case, says Aultman, “The rights and responsibilities of the hospital and medical team, judicial use of hospital resources, risks associated with hospitalizations, and the patient’s story — including her values, needs, and goals — are all important ethical considerations.”

REFERENCES

  1. Gluck F. Lee Memorial sues to evict another ‘John Doe’ patient. News-Press, June 2, 2016. http://newspr.es/2r3lNcD.
  2. Stuart C. Hospital Asks Leave to Boot Cranky Patient. Courthouse News Service, Oct. 18, 2013. http://bit.ly/2r2KNkh.
  3. Jankowski J, Seatrum T, Swidler R, et al. For lack of a better plan: A framework for ethical, legal and clinical challenges in complex inpatient discharge planning. HEC Forum 2009; 21(4):311-326.
  4. Swidler R, Barreiro A, Horwitz J, et al. A conversation about difficult inpatient discharge decisions. NYS Bar Assn Health Law J 2009; 14:108-125.

SOURCES

  • Julie M. Aultman, PhD, Director, Bioethics Program/Professor, Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown. Phone: (330) 325-6113. Fax: (330) 325-5911. Email: jmaultma@neomed.edu.
  • John D. Banja, PhD, Center for Ethics, Emory University, Atlanta. Phone: (404) 712-4804. Fax: (404) 727-7399. Email: jbanja@emory.edu.
  • Cheyn Onarecker, MD, MA, Director, Family Medicine Residency Program, St. Anthony Hospital, Oklahoma City. Phone: (405) 272-7494. Email: cheynd@outlook.com.
  • Wayne Shelton, PhD, Professor, Alden March Bioethics Institute, Albany (NY) Medical College. Phone: (518) 262-6423. Fax: (518) 262-6856. Email: sheltow@mail.amc.edu.
  • Robert N. Swidler, Esq., VP Legal Services, St. Peter’s Health Partners, Albany, NY. Phone (518) 525-6099. Email: Robert.Swidler@sphp.com.