Ethics Involvement Needed With Complex Discharges
Moral distress is issue
Ethicists are seeing increasing numbers of consults involving concerns with discharge planning. “This is an even more common ethical issue than end-of-life issues. Those happen regularly but not hourly as with discharges,” says Bob Parke, BA, BSW, MSW, RSW, MHSc, a former clinical ethicist at Humber River Hospital in Toronto.
Discharge planning encompasses multiple ethical issues, including consent, capacity, and autonomy. “The pressure for expedient discharges can risk less-than-thorough assessments and referrals for follow-up care,” says Parke, who worked as a discharge planner in the hospital setting early in his career.
Moral distress stemming from discharge planning needs to be “on the radar screen of ethics,” says Parke.
If patient preferences conflict with clinical recommendations or needed resources are unavailable, it can result in significant moral distress for clinicians. “Not uncommonly, patients would likely benefit from additional support — for example, a home health aide — but don’t qualify for funding,” says Maralyssa Bann, MD, director of hospital medicine at Seattle-based Harborview Medical Center.
Hospital policies regarding potentially unsafe discharges, says Bann, “should take into account an ethical framework for how to frame the discussion, as well as how to support the clinician and patient.”
The following are common scenarios that trigger ethics consults:
• Utilization managers are pressuring family to arrange nursing home admission prematurely.
Because an elderly patient’s cognitive function decreased during hospitalization, a utilization manager pressured the family to start the process of arranging nursing home admission. “Fortunately, there was a good history of the person’s preadmission cognitive and physical function,” says Parke. Clinicians advocated for more time to assess the patient. This included referrals to a geriatric specialist.
“This was met with anger for delaying a discharge plan,” says Parke. A thorough assessment revealed that the patient was experiencing delirium, not dementia. After some additional time and treatment, the patient was discharged home. “If the healthcare team had yielded to expediency, the patient would have been wrongfully discharged to an inappropriate setting,” says Parke.
A good social work assessment and collective advocacy on behalf of the patient contributed to a positive outcome. “Doing the ethically correct discharge required courage and knowledge of the patient,” says Parke.
• The patient wants to go home, but clinicians think it is unsafe.
“While we accept that a capable person has the right to live at risk, we feel moral distress about whether we are doing the right thing discharging the person,” says Parke. This is true for suicidal patients, persons living with substance abuse, frail seniors who live alone, or vulnerable people returning to possibly abusive situations.
A recent ethics consult involved an elderly woman who lived alone with minimal social support, who was hospitalized after a fall. The patient wanted to go home, but the physiotherapist and occupational therapist were concerned about fall risk. In such cases, says Parke, “there is tension between our desire to avoid harm and also respect our patient’s autonomy.”
The ethicist’s first question was, “Is the patient competent to make decisions?” The staff acknowledged that the patient clearly understood that a fall could lead to a serious injury and limit her ability to care for herself. The patient was discharged home despite the staff’s concerns about a serious injury that might be avoidable in a supervised care setting. The clinical team’s ethical obligations included:
- performing a quality assessment, which revealed the patient’s need to get home to care for pets who were unattended;
- making referrals to social workers who identified financial resources to supplement home care.
“We cannot always assume that the optimal discharge plan is being made,” says Parke. Consequently, all team members — including the bioethicist — may need to recommend necessary follow-up care.
Patients do not always agree to the treatment plan. “In these situations, the clinician may be tasked with creating a plan in line with the patient’s desire to maintain independence that feels unsafe,” says Bann.
The ethical dilemma then becomes a debate between respect for autonomy and the principle of beneficence. “Clinicians have a duty to provide appropriate care and benefit to a patient, while the patient has the right to choose an alternative,” Bann says.
• The patient wants to go home and is cleared for discharge, but the family thinks it is unsafe.
After a patient’s recent displays of uncharacteristic anger and forgetfulness, the family requested admission to a long-term care facility. After treatment, both cognitive and physical function improved.
“The patient and staff both started to ask about going home,” says Parke. The family objected. In this case, the team’s ethical obligation included conducting a thorough assessment to determine whether the patient needed assistance with basic activities of daily living.
It turned out that the patient had difficulty hearing. If this communication barrier went undetected, says Parke, “we might have created a discharge plan that did not engage the patient in the decision-making process.”
The ethicist informed the patient’s surrogate decision-maker, who was very reluctant to accept the discharge, that:
- the law allows only the capable person to make his or her own healthcare decisions;
- the role of the surrogate only comes into effect when an individual is found incapable.
The patient was ultimately discharged home over the surrogate’s objections. The team’s ethical obligation at that point, says Parke, was “to ensure that the optimal level of support was planned for when the patient was discharged home, where the patient wanted to be.”
Ethicists are seeing increasing numbers of consults involving concerns with discharge planning.
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