Some children and adolescents brought to emergency departments (EDs) with behavioral or psychological issues end up languishing there for days or even weeks because there are no good transfer options. Even if the patients are cleared to be discharged home, sometimes the parents refuse to pick up the child.
“As a society, we have an ethical obligation to these families to provide the care these children need,” says Vincent Staggs, PhD, director of biostatistics and epidemiology core at Children’s Mercy Kansas City and professor of pediatrics at the University of Missouri-Kansas City School of Medicine.
Parents often are faced with an impossible choice. They must decide whether to bring home a child who poses a threat to self and others, or risk a child abandonment charge. “The criteria for acute psychiatric hospitalization are so high that children are often discharged only to be rehospitalized within weeks or days — and retraumatized in the process,” Staggs reports.
One family agreed to pick up their child from the ED, only to find police waiting to escort the child out of the facility. The child had threatened to assault hospital staff if sent home. “The staff told the parents the child was no longer assaultive, yet felt the need to have the police, not their own uniformed security or trained mental health staff, remove the child from the facility,” Staggs recalls.
Shortly after discharge from the hospital, the child logged multiple police encounters, along with six ED visits and acute hospitalizations. “In one case, he was discharged from a facility, despite his parents’ pleas, and was back in the ED after another call to police less than 24 hours later,” Staggs says.
The child assaulted a pediatrician, a mental health liaison, his sister, and his parents before the family finally gave up trying to find residential treatment for him. At that point, the family refused to pick up the child from the hospital. “It was the only way they could keep him and their other children safe,” Staggs says.
Some parents spend months searching in vain for placement in a psychiatric residential treatment facility. “The country’s pediatric mental health system is profoundly broken and underfunded,” Staggs stresses.
Even if an open bed is available, some facilities refuse to admit a child with a history of violence and poor engagement in therapy. “That is the very sort of child who needs placement for care outside the home,” Staggs says.
For other facilities that are contracted, in-network providers with an insurance company falsely tell parents they do not accept insurance. “They do so knowing that insurance companies often refuse to pay for care beyond 30 days, long before a child has received sufficient treatment for their illness,” Staggs explains.
The cost of these residential programs is exorbitant — often $650 or more per day. Parents who empty their retirement accounts or their children’s college savings to pay for nine or more months of treatment have no guarantee their child’s treatment will work. “Not surprisingly, some parents resort to leaving their child at the hospital,” Staggs notes. It forces the state to take custody and find the treatment their child needs. “Even if they end up on the state’s abuse/neglect list for child abandonment, at least they know their child and any other children in the home are safe,” Staggs says.
These systemic problems are impossible for individual clinicians or ethicists to solve. However, ethicists can educate staff on the complexity of these situations, and the agonizing dilemma the parents face. “It is easy for clinicians to judge parents for what may appear to be child abandonment, without knowing the full context,” Staggs says.
Leaving the child at the hospital may be the parents’ last, desperate attempt to place their child in psychiatric treatment. Parents are looking for a way to protect their family from further injury and trauma. “The last thing a family in that situation needs is shaming from an unsympathetic clinician,” Staggs says.
If the parent or guardian refuses to pick up a child with behavioral health issues, the ethical considerations are what is best for the child (primary) and what is best for the parents or guardians (secondary), according to Jay Brenner, MD, FACEP, medical director of the Community ED at SUNY Upstate Medical University. Ethicists can help clinicians by clarifying the family’s concerns to hopefully reach a reasonable solution. “Formal ethics consults may be helpful if a family meeting needs to be navigated with an independent, impartial observer or mediator,” Brenner suggests.
Ethicists can help clinicians think about the situation through an ethical lens. Why are the parents or guardians refusing discharge? Is obtaining follow-up care a problem? Do the parents or guardians have important information to share about their child? Does the child feel safe at home? “Unethical responses would be to ignore parents’ concerns, and force a discharge before fully vetting these concerns,” Brenner cautions.
Good hospital policies could help clinicians prepare proactively. For example, policies can outline specific justifications for a parent or guardian refusing a discharge of their child (e.g., new information about an episode of aggressive behavior or suicidal threat). “Ethicists can help hospitals prepare for the inevitable influx of these requests by vetting such policies and educating clinicians on their options,” Brenner offers. Parents or guardians are exhausted and unable to find help for their child’s significant behavior issues, says Julie M. Aultman, PhD, director of the medical ethics and humanities program at Northeast Ohio Medical University in Rootstown.
Some believe the hospital is the only option. “Alternatively, we have had situations where adolescent and teenage patients refuse to leave the hospital and will make every effort to stay,” Aultman reports.
Some of those patients engaged in self-harming behaviors or threatened suicide. “The hospital environment, with 24-hour care and attention, multiple meals, warm bed, other patients to socialize with, and television, is better than home and school environments,” Aultman explains.
There are complex ethical concerns with these cases. Clinicians must consider ethical responses if they identify abuse and neglect in the home, violence and bullying in schools, or parents or guardians who lack proper support and training to care for children with mental health issues. “Clinicians must carefully balance harms and benefits,” Aultman cautions.
Ethical decision-making is needed for when and where to discharge patients. “Ethicists can be of value in holding discussions with clinicians and patient care committees on what the patient needs and whether the hospital is capable of meeting those needs,” Aultman suggests.
Sometimes, clinicians identify a facility willing to take the patient, only to find it is too far away, too expensive, or there is a long waiting list. “These issues unearth a much larger ethical problem — of mental healthcare in the U.S., and the lack of professionals, community care teams, resources, and outpatient and inpatient facilities,” Aultman says.
Parents often are faced with an impossible choice. They must decide whether to bring home a child who poses a threat to self and others, or risk a child abandonment charge. The criteria for acute psychiatric hospitalization are so high that children might be discharged only to be rehospitalized within weeks or days — and retraumatized in the process.
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