When patient resists discharge plan, what to do?
When a patient who is medically ready for discharge and mentally competent to make his or her own decisions is unwilling to accept referral to a setting his or her health care team feels is safe and appropriate, is it feasible to take a step back and allow the patient to try?
"It has always bothered me that we don't give patients the opportunity to try something," says Kenneth Berkowitz, MD, chief of Ethics Consultation for the Veterans Health Administration (VA) National Center for Ethics in Health Care. "We have no way in our system to say, 'Why don't you just try that for a week, we'll see how it goes and then we'll see if you still would rather go back to your home.' I really don't think we're set up within VA, or even as a country, to do that."
Berkowitz moderated a recent conference on ethical issues that arise when a patient insists on a discharge plan that the health care team believes is unsafe. When a patient wants to go home, for example, but home doesn't offer a safe or supportive enough environment, Berkowitz says, the health care team should be working far in advance of discharge to try to meet the patient's goals as well as those of the treatment team.
"The ethical values that come into play in discharge decisions include autonomy, independence, quality of life, safety, protection of patient well-being, and the professional integrity of the health care team," Berkowitz points out.
When the patient's wishes are at odds with the recommendations of health care providers, Berkowitz says there are tools that can "close this gap between theory and practice," including:
- Communication that targets the patient's goals, and time for mutual negotiation;
- Education that targets what may be the patient's lack of full appreciation of how difficult it may be for him or her to live safely in the environment they choose;
- Alternative care that, while a compromise for both sides, safeguards patient safety and is more palatable to the patient.
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