Seriously Ill Patients Have Unmet Needs at Discharge
March 1, 2025 3 minutes read
By Stacey Kusterbeck
After a patient with cancer was discharged and readmitted multiple times, his family provided some concerning feedback. The family found palliative care very helpful on the inpatient side but said that transitions of care needed improvement. “It’s very common that patients feel hospitalization and discharge are something that happens to them, rather than something they are playing a role in,” says Aaron A. Kuntz, MD, a palliative care physician in the Division of General Medicine at Beth Israel Deaconess Medical Center.
Kuntz and colleagues wanted to better understand patient and caregiver experiences with the hospital discharge process. The researchers interviewed 11 patients and four caregivers who received palliative care during a hospitalization.1 The patients and caregivers described lack of clarity on the next steps and needing more education on post-discharge services.
The researchers conducted follow-up interviews with some of their colleagues at the hospital to find out what they thought about the participants’ viewpoints. Overall, their colleagues acknowledged that the findings reflected what they saw in their own everyday practice: Many patients had low rates of illness understanding and a low sense of empowerment. However, the healthcare providers were surprised that palliative care was not perceived as part of the discharge process — despite daily discussions between treating teams and palliative care consultants. “They were also surprised by the frequency of post-discharge issues, such as difficulties with home services and symptom management,” says Kuntz.
To address these troubling issues, the researchers are piloting a post-discharge clinic program involving palliative care fellows. Nurse coordinators attempt to schedule follow-up appointments within two weeks of hospital discharge. The fellow physicians and the clinical pharmacist meet with the patients to review their hospitalization, functional status, and current medications. “The biggest focuses right now are on medication reconciliation, coordinating with the primary care physician and oncologist regarding home services, and symptom follow-up,” reports Kuntz.
The department also is looking at making these changes:
- closer collaboration with case management colleagues to identify needs for home resources sooner;
- standardizing check-in between case management and palliative care team members;
- creating educational resources regarding home services to give to patients prior to discharge.
Kuntz says that ethicists’ input would be valuable when considering the large-scale effect of a given program or intervention to improve the discharge process. Specifically, Kuntz says ethicists can consider these questions regarding palliative care:
- What is the hospital’s duty to palliative care patients at discharge? Since those patients have complex needs, does it necessitate a different discharge process?
- What is the hospital’s duty to patients post-discharge? What is the hospital’s responsibility if planned home services fall through?
- How can clinicians create a balance between shortening length of stay and meeting patient needs?
- What is a realistic illness understanding that can be reached prior to hospital discharge, especially for cancer patients with a treatment plan pending?
Many interviewed patients had cognitive dysfunction, were relying on caregivers, or had diagnostic tests pending at discharge. This raises the question of whether having a complete understanding of illness is realistic for those patients prior to discharge. Ethicists potentially can be of help in these cases, suggests Kuntz. “Our inpatient ethics team is often involved when patients receiving palliative care have been admitted for extended periods,” reports Kuntz. Ethicists are particularly likely to be involved if patient and caregiver hopes are not likely to be achieved by the current plan or care. Ethicists also get involved when there are few or no options for safe discharge.
In general, though, ethicists are not considered part of the discharge process, nor are they commonly involved after hospital discharge. “But there is an important ethical question there regarding how likely some discharged patients are to reach their goals,” says Kuntz. The ethical concern is that patients may consent to a plan of care, working under the assumption they will reach a certain health outcome, when their hoped-for outcome is not likely. “Perhaps ethicists could be involved at a system level to help decide how likely a plan of care has to be to succeed before it should be offered. Or ethicists can help determine if programs focused around these issues are just, and appropriately balance autonomy and nonmaleficence,” offers Kuntz.
Reference
- Kuntz AA, Chen VH, Ambady L, et al. Is routine discharge enough? Needs and perceptions regarding discharge and readmission of palliative care patients and caregivers. Am J Hosp Palliat Care. 2025; Jan 5. doi: 10.1177/10499091241311222. [Online ahead of print].
Aaron A. Kuntz, MD, a palliative care physician in the Division of General Medicine at Beth Israel Deaconess Medical Center, wanted to better understand patient and caregiver experiences with the hospital discharge process. The researchers interviewed 11 patients and four caregivers who received palliative care during a hospitalization. The patients and caregivers described lack of clarity on the next steps and needing more education on post-discharge services.
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