Ethicist: Case Managers Can Fairly and Ethically Handle Patient Refusal to Discharge
In this Q&A, Trevor Bibler, PhD, MTS, assistant professor at the Center for Medical Ethics and Health Policy at Baylor College of Medicine, explains the ethical dilemma of transitioning patients who refuse to leave the hospital.
HCM: Why do you believe this once-rare circumstance of patients refusing to leave the hospital has been increasing? What types of social and cultural factors may be at play?
Bibler: Based on our internal numbers, I believe we’ve had an uptick in situations like this — difficult discharges or refusal of recommended discharge — since the pandemic began.
I think the pandemic has had an effect on it. Here are a few reasons why: One, patients may very well be justified in feeling that being in the hospital is safer than being in a two- or three-bedroom apartment with other people. A few patients I’ve had come from multigenerational households, and may be well justified in thinking that if they go back to their place, they might get COVID. Or, they might think a long-term acute care facility sounds good, but they’re very worried about getting sick.
One person I talked with was very concerned that the nursing home did not require employees to be vaccinated. She was thinking, “You’re sending me there, and I might have masks, but it could still spread through the mask.”
Other folks in this situation often don’t have a lot of resources, and they might feel like the discharge plan you’re describing is an ideal they cannot afford.
I think the social safety net that patients might hope is in place often isn’t in place for them. It’s not an exaggeration to say that food scarcity is a big deal. If you are a patient who is getting three meals a day and a bed, that can be a huge deal for some people — especially if they feel vulnerable in their community.
A lot of the difficulties related to issues like this are social problems that we see manifestations of at the bedside. They require social solutions, and we need policies and processes to best help these folks.
My disposition is one of inquiry and empathy. There’s a reason why someone wants to be here rather than in their home. In my mind, because I have a nice home, that is jarring. But people have their reasons. Some might think this is the safest place for them to stay.
HCM: How can case managers improve their own understanding and empathy of these situations?
Bibler: What I do as the ethicist is try to recognize and meet the person where they are. On one level, it’s a good thing they found a place where they feel safe. You and your colleagues are doing something good. This person feels safe and is somewhere they want to be. Where do we go from there?
As an ethicist, I try to figure out what the patient’s goals are. A lot of times, folks are refusing to go to the long-term care facility because they don’t have a good understanding of how much support they’ll actually have there. Be clear about what other institutions are, what they have to offer, and how they’re a natural step in allowing patients to fulfill their goals.
You’re trying to promote their autonomy, to make sure they get the best care possible. [Tell patients], “We have good news for you. The next thing is you’ll go to a place to get a certain type of specialized care. You’re not abandoned, and you’ll still feel safe there.”
Often, when people reject the recommendations of the healthcare team, it’s because they don’t trust the healthcare team. If you trusted the person who is talking to you, you might say, “They want what’s best for me. I trust this healthcare team to recommend something good for me.” When there’s no trust, that is sometimes why [discharge] is rejected.
Figure out what that person’s true interests are to build trust. Focus on their interests and the motivations that led to that decision. I find this is more consistent with what good patient care looks like.
I think about both the empathetic aspect and how to get buy-in to the plan. What orients me are the goals I have, the goals the patient has, and the goals the healthcare team has. If they’re consistent and the same, how can we think creatively on this next step in the patient’s care to fulfill that goal?
In this Q&A, Trevor Bibler, PhD, MTS, assistant professor at the Center for Medical Ethics and Health Policy at Baylor College of Medicine, explains the ethical dilemma of transitioning patients who refuse to leave the hospital.Subscribe Now for Access
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