Ethicists at University Health Network’s Toronto Rehabilitation Institute have seen multiple recent cases involving hospital discharges. All involved patients who wished to return home despite known safety risks and clinicians who were uncomfortable discharging the patient to a setting they viewed as unsafe.
Some recent cases involved a decisionally capable patient wanting to live at risk. Others involved patients who lacked decision-making capacity and failed to comprehend risks. In still other cases, an appropriate discharge location did not exist for a patient due to lack of caregivers or affordable housing in the community.
“At the heart of all of these potentially unsafe discharge situations is a conflict between differing values and principles,” says Kevin Rodrigues, BA, MTS, PhD(c), a clinical ethicist at the health system. These involve the ethical principles of beneficence, nonmaleficence, patient autonomy, and justice.
Rodrigues says these discharge policies can be of great help in these cases by providing:
• clear delineation of the obligations for clinicians and the institution at the time of discharge;
• clarity on the roles of various clinicians involved in the discharge, including physicians, social workers, and pharmacists;
• a conflict resolution process with clear guidance around escalation;
• contact information for various in-hospital and community resources;
• an ethical decision-making framework tailored to discharge planning. “This would be a helpful tool for clinicians as they attempt to balance stewardship of resources and obligations, both ethical and legal, to patients,” says Rodrigues.
Often, clinicians perceive the discharge plan is focused on the question of “What are we obliged to do?” instead of “What should we do?” “If a patient is capable of making a choice to live in unsafe conditions, for instance, to what extent should clinicians advocate for them to consider alternatives?” asks Rodrigues.
System pressures can lead to discharges that are less than optimal. There may be need to open beds for ED patients during volume surges. Funding models compensating patient flow also come into play. Rodrigues says policies should address these questions:
• What are obligations to the system and to the patient, and which take precedence?
• How can discharge practices be made more equitable to avoid perceptions of bias?
• What obligation does the hospital have to ensure that a discharge is safe and sustainable?
“Policies can set appropriate boundaries and the foundations for a more robust and better structured discharge discussion,” says Rodrigues.