Sometimes, a patient is medically OK to leave the hospital. But, for other reasons, the clinical team perceives the discharge as unsafe. Ethics can help “when conflict of opinions arises amongst the care team as to the best way forward,” says Nico Nortjé, PhD, MA (Psych), MPhil, HEC-C, a clinical ethicist at The University of Texas MD Anderson Cancer Center in Houston.
For some patients, there are no caregivers at home. Others may be living in unsafe conditions. Ethicists can help by “brainstorming scenarios, and trying to connect resources accordingly,” Nortjé offers.
Andria Bianchi, PhD, a clinician-scientist and bioethicist at University Health Network in Toronto, says ethicists can help in real time during complex discharge consults. Bianchi offers these examples:
- A patient is admitted to a physical rehabilitation facility and learns to use a rollator walker, but cannot walk independently. When the patient is clinically stable and the team starts to plan for her discharge, they learn the patient lives by herself in a four-story walk-up apartment. The patient is adamant about remaining there, and has no desire to move to a more accessible building.
- A patient is admitted to the hospital and seems to struggle with medication management. When the patient is medically stable and about to be discharged, the team learns the patient has no family or friends and lives in the shelter system. “Ultimately, there are minimal-to-no supports available for the patient. The patient’s health will almost inevitably decline as a consequence of being insecurely housed,” Bianchi laments.
In either case, an ethicist can help the team grapple with the discharge complexities “in a reflective, thoughtful, and methodical way,” says Bianchi.
Other times, clinicians have their own beliefs about patients living in seemingly risky scenarios, but the patient’s perspective is different. For instance, a patient who has lived in the shelter system for 30 years may not see his or her living conditions as inherently bad, risky, or unsafe. “In other circumstances, it may be the case that a discharge is, in fact, unsafe, and the team is trying to figure out how to mitigate potential harms,” Bianchi says.
Options exist that teams will only think of if an ethicist poses certain questions. Despite best efforts, clinicians still can remain uncomfortable with the discharge. “Ethicists can help clinical teams unpack the moral distress that may arise as a consequence of the discharge,” Bianchi offers.
Kevin Rodrigues, BA, MTS, a clinical ethicist at University Health Network’s Toronto General Hospital, often sees patients who are in vulnerable housing situations or are experiencing homelessness. “Additionally, patients whose living situations are unable to accommodate new medical realities and levels of ability could pose serious risks,” Rodrigues says.
Some patients are capable of understanding the risks and choose to live at risk. Others have limited housing options. Still others are incapable of understanding the risks, and options are limited. “Safety is a complex ethical issue when it comes to discharge,” Rodrigues says.
It involves questions of autonomy but also larger questions of justice. “Hospitals must face the question: How far do their obligations to maintain safety extend?” Rodrigues asks.
In one recent case, an elderly patient was brought to a hospital by ambulance after neighbors found the patient lying on the floor at home. “The patient was not coping well at home, but insisted on being discharged back into an environment viewed as unsafe,” Rodrigues says.
In another case, a capable patient wanted to be discharged home, but clinicians suspected domestic abuse was occurring. “Ethicists can explore the options available, within our legal obligations,” Rodrigues says.
In these complex cases, clinicians may ask questions like “Is this the right thing to do? Shouldn’t we do more?” Ethicists can help facilitate discussions where values are in conflict. “Ethicists can also bring a justice lens to the discussion as, often, the brunt of discharge burdens fall on patients of lower socioeconomic status,” Rodrigues says.
Ethicists can ensure all ethical obligations are met, “those to the patients being discharged, those to patients who may require hospital resources currently or in the near future, those to the community, and those to professional integrity,” Rodrigues adds.