For Clinicians, Discharge Safety Is a Growing Ethical Concern
September 1, 2023 3 minutes read
By Stacey Kusterbeck
More often, clinicians are asking ethicists questions such as, “Is this discharge plan ethical?” It seems clinicians are distressed over what they consider to be unsafe decisions.
“As ethicists, we talk to clinicians about how we need to keep in mind the social realities of where our patients are coming from,” reports Elizabeth Sivertsen, MBE, CCRN, HEC-C, a medical ethicist at Grady Health System, an Atlanta-based safety net health network.
Clinicians create a treatment plan based on what they believe is in the patient’s best interest. For various reasons, sometimes the plan is just not feasible.
“That can be very hard for our medical staff,” Sivertsen says.
A recent ethics consult involved a homeless woman with a history of HIV infection and schizophrenia. The woman reported trauma over a previous restraining episode. Clinicians believed strongly that inpatient placement was the only way to keep the patient safe and off the streets, but the patient strongly rejected this plan. “We had to consider the socioeconomic factors, and the social determinants of health, that led her to this point,” Sivertsen says.
In cases like this, ethicists help the clinical staff find an ethically acceptable alternative to which the patient will agree. “As ethicists, we coach medical staff to be a little more humble, sometimes, in what we can achieve for our patients,” Sivertsen explains.
For instance, some patients with mild dementia insist on returning home, yet the environment is unsafe and there is no family support. Ethicists strive to respect a patient’s autonomy while concurrently protecting the patient from harm. “It might take some creative thinking to support the patient’s independence as long as possible, in a less-than-ideal setting,” Sivertsen notes.
A patient may lack capacity for complex decision-making, but still can express a preference more generally on how they want to live their life. Clinicians worry that discharging the patient home is allowing him or her to assume a risk they do not understand fully. “The ethical answer isn’t always to override the patient and put them in the safest place possible. Yes, there are risks of harm, but we have to balance that out with other concerns,” Sivertsen explains.
Ethicists must weigh the potential risk for harm against taking away a patient’s independence and autonomy. “Sometimes, unfortunately, the families aren’t in the picture. We may have to consider taking away a patient’s control of their lives and looking to appoint a guardian,” Sivertsen says.
Ethicists have become familiar with the community resources that can mitigate risks of unsafe discharges. In some cases, clinicians can give the patient a chance to remain independent, but with home health support. In some cases, home health support is not an option because the patient is unhoused, and adamantly refuses placement. Understandably, clinicians are distressed about discharging these patients from the hospital to live on the streets. “Ethicists explain that it could be ethically acceptable, but we need to mitigate the risks as much as possible by providing supportive care,” Sivertsen stresses.
Depending on the situation, that could take the form of street medical teams, mobile health providers, or behavioral health support for patients living with long-standing mental health issues requiring psychiatric follow-up. Clinicians are ethically obligated to prevent harm and to promote good.
“But in an acute care setting, we cannot solve society’s ills. Try as we might, we can only do so much,” Sivertsen laments.
Sometimes, just hearing that reassurance from ethicists helps providers feel less distressed about the situation. “As ethicists, we often deal with uncertainty in end-of-life cases,” Sivertsen notes. “Here, it’s just a different type of uncertainty.”
More often, clinicians are asking ethicists questions such as, “Is this discharge plan ethical?” It seems clinicians are distressed over what they consider to be unsafe decisions. Clinicians create a treatment plan based on what they believe is in the patient’s best interest. For various reasons, sometimes the plan is just not feasible.
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