For most patients, discharge readiness hinges on objective data — vital signs or test results. For patients who are victims of violence, clinicians also must consider more subjective factors, such as safety.
“We don’t always identify this as an ethical question. Instead, we talk about a ‘difficult disposition,’” says Allan Peetz, MD, MPH, FACS, a practicing trauma surgeon and assistant professor of surgery in the division of acute care surgery at Vanderbilt University Medical Center.
Some patients still want to be discharged, even knowing they are at risk for additional violence. “We have to adapt, and consider that, and do the best we can with the resources we have,” says Peetz, faculty in Vanderbilt’s Center for Biomedical Ethics and Society.
Peetz saw clinicians struggle with these cases. Although the facts of individual cases differed, the common ground was patients did not necessarily meet medical criteria for admission, but everyone involved in the case agreed it was unsafe for the person to go home. Sometimes, clinicians advocated for “social admission” to buy some time to hopefully devise a safer discharge plan. “It’s often unclear what the ‘right’ thing to do is. The social context can sometimes play a part in the decision to admit the patient,” Peetz admits.
Peetz and colleagues decided to explore this subject from an ethical perspective.1 “In trauma and acute care surgery, moral decision-making is unique. The way we go about answering ethical questions is different, due to the clinical constraints,” Peetz explains.
Researchers surveyed 60 emergency physicians (EPs) and 20 trauma surgeons. Participants were given hypothetical cases of patients who sustained minor injuries from intimate partner violence, gun violence, and elder abuse. The patients in the scenarios did not require medical admission, but did not feel safe leaving the hospital. Trauma surgeons and EPs differed somewhat in their ethical perspectives and practices:
• Trauma surgeons were more likely than EPs to offer patients “social admission” for the sole purpose of buying more time to create a safe discharge plan, and less likely than EPs to view social admission as inappropriate resource use;
• In cases of intimate partner violence, EPs were more likely than trauma surgeons to support patient autonomy with a potentially unsafe discharge plan;
• EPs were more likely than trauma surgeons to believe that in cases of elder abuse, admission could facilitate change in the victim’s social situation;
• Trauma surgeons were less likely than EPs to support patient autonomy after gun-related violence with a potentially unsafe discharge plan.
“Emergency medicine providers evaluated the challenges somewhat differently than trauma surgeons,” Peetz observes. “But we all feel the obligation to try to use the medical institution to benefit patients who are victims of violence.”
Decision-making in such cases always is going to be somewhat subjective. Physicians must rely on clinical judgment, along with available resources and information. “We can’t do a blood test to find out if it’s safe for someone to go home,” Peetz notes. “What’s important is that the decision is made using an ethical framework.”
REFERENCE
1. Wallace MW, Boyd JS, Lee A, et al. The ethics of discharge planning after violent injury. Am Surg 2023; May 30: 31348231180914. doi: 10.1177/00031348231180914. [Online ahead of print].
Decision-making in these cases always is going to be somewhat subjective. Physicians must rely on clinical judgment, along with available resources and information. What is important is to make the decision using an ethical framework.
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