Ethics of care extend through discharge

Poor coordination can lead to pitfalls at discharge

Hospital staff have a plethora of ethical duties while their patients are hospitalized under their care, but clinicians need to remember that their duty to provide ethical care extends right up to — and even beyond — the point of discharge, says Emory University ethicist John Banja, PhD.

"There are a number of moments when ethical issues penetrate discharge," Banja says, and those moments typically arise from a lack of coordination and planning. "And the fundamental reason is that the system doesn't work well; somehow, all the lumps and bumps and incoherencies and disconnects that occur in managing patient care come to a crunch, or crystallize, at the point of discharge."

Banja, who since 2005 has been participating as a co-investigator on a federally funded research project focused on improving hospital discharge, says hospitals commonly mishandle discharges in three ways: the patient's projected discharge is a low priority for hospitals, and gets shunted to the bottom of the priority list, meaning social or financial issues that can impact a patient's safe discharge aren't addressed before discharge is in the works. The patient's discharge is delayed for a simple test, consult, or transportation, unnecessarily prolonging the hospital stay; and finally, failure to adequately observe medication reconciliation protocols leads to medication errors.

"This is an ethical issue because one of the things a hospital has to look at is whether its systems work coherently and fluidly to effect a safe and predictable discharge, and often in our hospitals, the systems are not working well together," he explains.

Three components need work

Medication reconciliation, resource allocation, and delays in discharge that leave a patient dressed and waiting for hours before actually leaving the hospital are process breakdowns that most hospitals are ethically bound to improve on, Banja suggests.

The Oakbrook, IL-based Joint Commission credits medication reconciliation — the process of comparing a patient's medication orders to all of the medications that the patient has been taking — as a powerful tool in avoiding medication errors such as omissions, duplications, dosing errors, or drug interactions. The Joint Commission states that medication reconciliation should be done at every transition of care in which new medications are ordered or existing orders are rewritten — changes in setting, service, practitioner, or level of care.

Complete medication reconciliation involves five steps:

  • Develop a list of current medications;
  • Develop a list of medications to be prescribed;
  • Compare the medications on the two lists;
  • Make clinical decisions based on the comparison;
  • Communicate the new list to appropriate caregivers and to the patient.

But just as medication reconciliation can be the key to avoiding medication errors, when done incorrectly, it can introduce medication errors.

"Medication errors related to medication reconciliation typically occur at the 'interfaces of care' — when a patient is admitted to, transferred within, or discharged from a health care facility," The Joint Commission noted in a January 2006 Sentinel Event alert (available at www.jointcommission.org).

"It's not unusual for patients to get the wrong medications, and we can generally attribute that not to a lack of knowledge, but to a system flaw, when the physician doesn't get a complete medical history on that patient," says Banja, who repeats that breakdowns such as this pose ethical concerns.

Another flaw in the discharge process involves "false starts."

"It is not that uncommon for a patient to be told early in the day, 'You're ready to go, just as soon as your labs come back, or the latest X-rays come back. So get ready, you're going home," Banja recounts. "And that information is communicated at 8 a.m., and at 4 or 5 in the afternoon, the patient is still sitting in her room, waiting to go."

This kind of inconvenience falls under the "ethics umbrella," Banja says, "because we say we provide patient-centered care, but it's simply unprofessional to tell a patient that it's time to go, and then they're still there six hours later.

"It's also wasteful, because that person is taking up a bed when someone else could be using it," he says, adding that staying in a hospital longer than is medically necessary can put a patient at risk for other diseases or infection.

Common holdups are waits for last-minute consults, test results, equipment (wheelchair, walker), social services, and transportation, he says. Other delays even higher on the ethical "spectrum" can be attributed to procrastination, Banja says.

"Writing discharge orders is time consuming, and doctors don't get paid well for it," Banja says. "But writing the discharge order is the trigger for everything else to happen." Aside from the low priority assigned to writing orders, he points out that discharge processes aren't standardized across the country, across health care systems, or even from one unit to another within individual hospitals.

Banja and his colleagues have identified a third set of issues hospitals should confront in improving discharge — resource allocation.

"You have a patient who doesn't feel ready to go home, who may be feeling the same symptoms that brought them to the hospital, or, equally troubling, an adult child who said on admission that Mom would be going home with him, but at discharge says Mom can't go home with him after all," Banja describes. "The problem is then where to discharge the frail elderly patient."

A related allocation issue arises when a patient needs one more test, for example, and it's late on a Friday afternoon. "Do you send that patient home and ask them to come back on Monday? That's inconvenient; but it's not good to keep them in the hospital over the weekend when they don't need to be there," he points out.

Learn, then improve discharge process

Banja and his fellow investigators suggest physicians who want to make their patient discharges more ethically sound find out:

  • What is the discharge flow in your hospital over the course of a week? Are certain days higher than others, and why? Do peak discharge days occur for hospital or for patient-centered reasons?
  • Does your hospital have an adequate mechanism for discharging patients over the weekend?
  • If patients are admitted with the same condition, would their discharge date vary according to which day of the week they are admitted?
  • At what point after admission does your treatment team begin determining the discharge date? How is this communicated to the rest of the team?
  • Is there a framework to coordinate the elements of the treatment plan with the projected discharge date?

While case managers may coordinate discharges, the physician writing the order that triggers it all should know how the system works; for example, understanding how writing a discharge order on a Friday afternoon will impact the patient and the process, Banja notes.

And thinking beyond the hospital doors is imperative as well.

"It's difficult to look outside the hospital doors when you're fixated [with providing for the patient] in the present. But a patient with a complex issue — for example, a head trauma — who is going to be going back to a small town in the care of their primary provider and not a specialist in head trauma, who really needs complex psychopharmacological management — are we handing these patients off to a competent provider?" Banja notes. "I have often thought of difficult judgment calls that exist in certain patients when the health care team is saying to each other, 'Who is going to care for him?'"

Source/Resource

For more information, contact:

  • John Banja, PhD, professor, department of rehabilitation medicine; medical ethicist, Center for Ethics, Emory University, Atlanta, GA. E-mail: jbanja@emory.edu.
  • Banja J, Eig J, Williams MV. Discharge dilemmas as system failures. Am J Bioeth 2007;7:29-31.