Discharge to a skilled nursing facility is sometimes recommended in order to ensure continued independent community living for frail patients. Conflicting views as to what’s best for the patient sometimes raise ethical concerns.
To learn more about the disposition decision-making process, researchers looked at the factors associated with the surrogate’s decision to discharge to a skilled nursing facility instead of home.1 Of the 182 community-dwelling patients in the study, 133 were discharged to a skilled nursing facility and 49 went home.
“The most interesting ethics issue from our study centers around the outcomes when family members and hospital staff expressed different opinions,” says Jennifer L. Carnahan, MD, MPH, MA, the study’s lead author and a scientist at Indiana University’s Center for Aging Research, focusing on care transitions, especially from the skilled nursing facility setting to home.
Even when physical therapy recommended a skilled nursing facility placement, the family sometimes disagreed. “The way this typically comes up is when there is disagreement between the medical team and the caregivers about the optimal discharge destination for patients with impaired decision-making,” says Carnahan.
If the family member objected to a skilled nursing facility placement, the patient often would be discharged home. “This suggests that there is disagreement about whether a skilled nursing facility or going home with family is in the best interests of the patient,” says Carnahan.
Is It ‘Safe Enough?’
For the clinical team, the question frequently becomes what is “safe enough,” says Laura K. Guidry-Grimes, PhD, a clinical ethicist at the University of Arkansas for Medical Sciences in Little Rock. The patient’s decision-making abilities, their level of social and financial support, and the severity of their medical condition all should be considered. The following are some common scenarios:
• patients without decision-making capacity are unable to identify worsening symptoms, understand the need for treatment or monitoring, or know when to reach out for medical help;
• the patient’s home presents safety concerns, such as a gas stove that the patient tends to leave on, unhygienic spaces, or a heater that does not work;
• family members want to take an incapacitated patient home, but there is no one available to monitor the patient.
“We see cases where families dismiss healthcare aides, which makes the patient especially dependent on the diligence and competence of family,” says Guidry-Grimes. Many patients need extensive rehabilitation or skilled nursing help, but lack insurance or financial resources to cover the cost. Facilities also can deny patients if they are too full or if the patient presents psychiatric complexities. “Some facilities are much better run than others,” adds Guidry-Grimes. “For clinicians who have these insights, even discharge to a facility can seem far from ideal.”
Capacity Is Issue
If the patient is his or her own decision-maker, these questions are important from an ethics standpoint, says Guidry-Grimes:
• Does the patient adequately understand that the discharge is considered unsafe and what other options are available?
• What additional barriers might be affecting the patient’s decision?
• Are there any ways to further enable the patient’s autonomy interests?
“The patient might feel coerced by family not to accept placement into a facility,” says Guidry-Grimes. Institutional pressures to discharge patients when they are medically ready are another complicating factor. “It can be ethically reasonable to allow the patient a little more time to think through the options, perhaps with support from pastoral care or a loved one,” says Guidry-Grimes.
For patients who lack decision-making capacity, “the ethical issues become mountainous,” says Guidry-Grimes. “We see many cases where these patients are incapable of caring for themselves in the most basic sense.”
A congestive heart failure patient could start out with a manageable disease that becomes increasingly dire because of failure to take medications. Unhygienic environments and exposure to the elements can further exacerbate medical problems.
“What can be particularly tricky, ethically speaking, is when these patients still express clear preferences for unsafe discharge,” says Guidry-Grimes. Patients’ preferences carry ethical weight, even if they are not authorized as their own decision-makers.
“Some negotiation on discharge might be possible based on what the patient expressly prefers,” says Guidry-Grimes. When incapacitated patients do not have a surrogate decision-maker, there are additional obstacles to getting them into any facility. For one thing, no one is available to sign consents.
“These situations are ethically challenging,” says Guidry-Grimes. Staff often feel uncomfortable restraining the patient or coercing them to stay in the hospital until adult protective services or a public guardian takes responsibility. The alternative also is ethically problematic. “Giving in to the patient means that healthcare staff are knowingly allowing a vulnerable patient to go to an unsafe situation,” says Guidry-Grimes.
For incapacitated patients who have surrogate decision-makers, request for an unsafe discharge raises questions about the ethical appropriateness of the surrogate.
“A surrogate should have a demonstrated interest in the patient’s welfare and make decisions that are reasonably consistent with the patient’s known values and interests,” says Guidry-Grimes. She recommends that ethicists facilitate safe discharges by:
• helping staff think through these issues proactively before a distressing case occurs;
• working with healthcare teams to address common questions that arise when a patient or surrogate requests something that appears unsafe;
• providing training on capacity evaluations, criteria for surrogate decision-makers, institutional policy, and local law.
“The more we can help healthcare teams think through these issues as a team, the better,” says Guidry-Grimes.
1. Carnahan JL, Inger L, Young RS, et al. Factors associated with posthospital nursing facility discharge for patients with impaired decision-making. J Am Med Dir Assoc 2018: 19(10):916-917.
• Jennifer L. Carnahan, MD, MPH, MA, Center for Aging Research, Indiana University, Indianapolis. Email: firstname.lastname@example.org.
• Laura K. Guidry-Grimes, PhD, Assistant Professor/Clinical Ethicist, University of Arkansas for Medical Sciences, Little Rock. Email: email@example.com.