Discharge process is a balancing act
Weigh autonomy vs. patient safety
"Currently, there is no national policy governing discharge planning."
So noted Barbara Chanko, RN, a health care ethicist who was one of the speakers in a Veterans Health Administration national ethics teleconference in late May.
Using three scenarios based on real-life situations, ethicists from the National Center for Ethics in Health Care of the VHA sought to illustrate how ethics policies are often easy to develop in theory, but those theories "may sometimes be quite difficult to implement," according to Chanko.
"VHA is committed to ensuring that each patient is treated in the most appropriate care setting for his or her condition, and discharged to an environment that is safe," she said. "VHA is also committed to shared decision-making with patients."
What can make discharge planning so difficult is the fact that some patients prefer a plan for discharge that the healthcare team believes is unsafe. An unsafe environment, says Chanko, is "one that the team considers to lack the necessary medical and/or social support to meet the medical needs of the unique patient."
Such a living situation might be an unclean home where the patient is at risk of infection, or where neglect or abuse is demonstrated by caregivers or others in the home. In an attempt to evaluate a particular living situation, the health care team asks the patient to report, conducts and independent report and asks for a report from the patient's family, as well.
"The ethical values that come into play in discharge decisions include autonomy, independence, quality of life, safety, patient well-being and the professional integrity of the health care team," Chanko says. "A patient who has decision-making capacity has the right to have his or her decisions respected where treatment choices or refusals are concerned."
Members of the health care team, however, have their own professional standards to uphold, and are "obligated to promote patient well-being and to protect patients from harm whenever possible," she says.
In the first scenario, a patient with severe mobility impairment wished to be discharged to live at home, although the health care tema felt that he was not able to care for himself appropriately and should not be discharged to his home, as a consequence. However, while hospitalized, the patient had continued paying rent on his home, an apartment, for several months. Also, two psychiatric evaluations had found that the patient had decision-making capacity.
"The ethics committee reminded the health care team that safety was not the only important value in this cases — autonomy was also," Chanko says.
Ultimately, the ethics committee persuaded the health care team to release the patient to his own home by arguing that "absent strong justification to take away the patient's liberty rights," he should be released to an apartment with additional resources.
Offering a summary of the ethical analysis behind this recommendation by the ethics committee, Chanko noted, "First of all, a patient with capacity has to right to choose a particular quality of life that is consistent with his own values. As with other treatment choices that are accepted or refused, the quality of life chosen by the patient may or may not be one that members of the ethics committee and the health care team would choose for themselves, or for others that they care for. Or may not be the safest choice."
A second scenario hinged on a capacity assessment of an 84-year-old male who was determined not to have capacity to make a decision about the environment to which he would be discharged, and also did not understand the seriousness of his medical condition. However, his only relative, a niece, had twice placed him in a nursing home, and in each instance, the patient left the nursing home, saying he wanted to return home instead.
Susan Owen, PhD, also a health care ethicist participating in the audioconference, defined a capacity assessment as "a clinical determination made by the clinician who is in charge of the patient's care." If mental illness is a factor, often there is also a consultation from a mental health practitioner.
"It is important to note that decision-making capacity is not an all-or-nothing phenomenon," Owen says. "Ethical practice requires that clinical capacity be understood as decision-specific. Although mental or physical impairment may cause someone to lose all decision-making capacity, some people have the capacity to make one choice, but not another."
According to Owen, "sound" decision-making requires four essential elements:
—the capacity to communicate choices;
—the capacity to understand relevant information;
—the capacity to appreciate the situation and its consequences;
—the capacity to manipulate information rationally.
Kenneth Berkowitz, MD, chief of ethics consultation at the VHA, noted that "assessing decision-making capacity is not always value-neutral," i.e., health care practitioners sometimes make decisions subjectively.
Also as noted in a 1990 New England Journal of Medicine article, titled "When Competent Patients Make Irrational Choices," Owen said, "It is difficult in both theory and practice to distinguish irrational prefrences from those that simply express different values, attitudes and beliefs. The effort must nonetheless be made in order to safeguard the patient and his or her autonomy."
A patient, or his or her surrogate, also have the capability to challenge the primary health care provider's assessment regarding decision-making capacity, if either party disagrees with the results of the assessment. The patient or surrogate would do this by contacting the patient advocate or by requesting a consultation with the local ethics team, Owen says. Beyond that, if no resolution could be reached, the issue would be referred to the chief of service or chief of staff for resolution.
Within the health care team itself, the primary provider holds the ultimate authority in disagreements over a capacity determination or assessment. Even then, that provider's decision can be challenged by contacting the chief of service or chief of staff.
For all stakeholders in a discharge planning decision, mutual goal-setting is the key, and Chanko offers several questions that should be considered toward this end, including:
—"Do I understand why my patient made this decision?
—What are the patient's goals?
—Can I help my patient identify a different course of action that will enable him or her to honor the same goals and values?
—What are my goals in this situation?
—Are there intermediate goals on which I could focus?
—Are there medically acceptable alternatives, even if they're less desirable, that my patient my accept? In other words, are there ways that I can meet my patient's goals and provide good clinical care?"
As with much of health care, good communication seemed to be the key ingredient to resolving disagreements, and not just at the point where a discharge plan is being developed or implemented.
As Berkowitz noted, ". . . at the beginning of the admission and throughout the hospitalization, the patient, family and provider should be continually working toward a mutual understanding of goals of care and agreed upon solutions that promote these goals."
Sources
For more information, contact:
- Kenneth Berkowitz, MD, chief, ethics consultation, National Center for Ethics in Health Care, Veterans Health Administration (VHA).
- Barbara Chanko, RN, MBA, health care ethicist, VHA.
- Susan Owen, PhD, health care ethicist, VHA.
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