Hospital Discharge: The Ethical Approach

Physicians and nurses have both an ethical and a legal obligation to ensure a patient will be discharged safely.

To do so, hospitals have “safe discharge” laws that require hospitals to provide patients with a continuing care plan upon discharge. Many endocrinologists may be faced with patients who have diabetes and are ready for discharge but refuse to leave, or those who need to go to skilled nursing care, but insist they want to go home. Hospitals particularly struggle with undocumented immigrants, as state exchanges or Medicaid does typically not cover them.

As these incidences gain prevalence, many hospitals now hire clinical ethicists or attorneys who specialize in ethics to sit on their review boards. A recently published article in Medical Ethics Advisor addressed ethical issues that arise when hospitals discharge patients, and the ethicist’s role in ensuring the discharge is safe and mediating disagreements regarding discharge.

In some cases, the attending physician may have written orders for discharge, but the patient refuses to leave. Ethicists can become involved in the discussion and negotiate for the patient to stay at the hospital for additional time. However, given the expense and risks associated with a prolonged hospital stay, extending a hospitalization is unlikely. Ethicists may communicate reasons why the patient should move to a receiving facility more successfully than clinical staff can.

When a receiving facility refuses to accept a patient with a reputation for being difficult, ethicists usually refrain — and may be prohibited – from intervening. However, ethicists may decide to call the receiving facility if the situation demands intervention.

Ethicists can help a number of other ways:

· They can help negotiate a compromise when hospital administration pressures clinicians to release patients

· They can help ensure hospitals meet their obligations to current patients while balancing the needs of incoming patients

Given the evidence, experts suggest that when physicians and nurses face difficult discharges, they should consider consulting an ethicist who may be able to mediate and develop a solution that meets everyone’s needs.