Approach to working with at-risk patients expressing a desire for discharge

Discussion

Based on applicable Ontario law and guiding ethical principles, the proposed framework (Figure 1)^25-28 outlines 4 options that physicians can use, alone or in combination, to help determine what to do when an at-risk patient requests discharge. When evaluating options it is important to consider the patient’s specific circumstances, values, and wishes. There is often a focus on decision-making capacity in these instances. Capacity is context- and decision-specific, and individuals are presumed capable of a decision unless there is reason to believe otherwise. Decision-making capacity is important when determining authority to consent to treatment (and for admission to LTC, which has a specific consent process); however, consent is not required for discharge from hospital. Capacity is also not determinative of whether a specific patient should be discharged nor of whether there is authority to detain a patient in hospital.

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Figure 1.

Framework to facilitate in-the-moment decision making when an at-risk patient expresses a desire for discharge: Legislation cited is specific to Ontario.

This tool provides a rigorous framework for working through these issues. However, physicians are encouraged to seek ethical and legal advice (eg, from the Canadian Medical Protective Association) for individual challenging cases if necessary. Although the framework was developed based on Ontario law, it can be adapted for use across Canada based on provincial or territorial legislation. We will now apply the 4 options to Mr M.’s case.

Option D. Working our way from most restrictive to least restrictive options (moving from right to left in Figure 1),^25-28 we begin with option D: keeping the patient in hospital under the Ontario Mental Health Act.²⁸ This requires that the legal test for detaining an individual for psychiatric assessment be met and may involve transferring the patient to an appropriate psychiatric facility for assessment. Mental health forms should be used only if the physician thinks the patient could benefit from psychiatric treatment, not as a means to hold an individual if they do not meet the clinical criteria set out in law. Since the physician did not think that Mr M. would benefit from psychiatric assessment, the team considered the remaining options.

Option C. A patient can legally be restrained only to address an imminent risk of harm to the patient or others (under common law for a time-limited period) or as authorized by a plan of treatment to which the patient or their substitute decision maker has consented in accordance with the Ontario Health Care Consent Act²⁶ and the Patient Restraints Minimization Act²⁷; this requires using the minimal restraints necessary and in accordance with the hospital’s least restraint policies. Patients have the right to health care that promotes dignity, independence, and freedom of movement. Restraints must be used only when absolutely necessary to prevent serious bodily harm or to give the patient greater freedom or enjoyment of life. While the team recognized that there was some risk of harm in the event of discharge, they did not believe that Mr M. met the criteria for including detention or restraint in his overall care plan.

Option B. Another possibility is for the health care team to discuss options with the patient to have him stay in the facility temporarily while discharge is explored and arranged. Ongoing informed consent for the plan of care in the facility is required by law under the Health Care Consent Act.²⁶ It is important to work with the patient to address concerns. This could include reviewing with the patient the purpose of the admission, associated treatment and overall goals of care, and risks associated with going home^1,2,8; working with Mr M. to understand what is most important to him, his reasons for wanting to go home, his concerns about ongoing support in the home, and his reluctance to modify his home for safety; and exploring ways to address his concerns and needs (eg, treating any substance use withdrawal, room change, day pass).^{1-4,8,15,22-24,29-31} This can help with navigating discharge options with the patient and inform revisions to his care plan so that having him stay during the discharge planning process is more agreeable to him (eg, incorporating goals and activities that are meaningful to the patient).^{1,2,20,22-24,29} Patient-centred communication strategies can assist physicians with having these sometimes challenging conversations.^12,19,20,29 It is important to look for family members or friends who can help reinforce the rationale for the recommended treatment plan and address the patient’s concerns and needs (eg, care of a family member or pet).^1,2,13,30

Option A. The final option is to discharge Mr M. with the best possible negotiated plan using a harm reduction approach.^{1-4,8,12,15-17,20,22} Under Ontario’s Public Hospitals Act, the attending physician (or appropriate designate) is required to discharge a patient who no longer needs care provided in hospital.²⁵ When there are ongoing care needs and patient safety considerations, the discharge plan should include patient and family engagement and education, follow-up instructions (eg, appointments with a family physician), medication prescriptions, and community and at-home support services.^{1-4,8,12,15-17,20,30-32} Exploring a home visit to determine what community and at-home support services might benefit Mr M. may be a good option, if he is agreeable.^31,33 This can help Mr M. and the team better understand his needs and how he may cope in the community (eg, he may do better than anticipated).

It is important to remember that quality of life is defined by each individual and risks (ie, uncertainty of outcomes) can be either negative or positive (ie, potential for harm vs a potential opportunity loss).^3,34-36 Reducing one risk may increase another; for example, addressing physical risk by sending Mr M. to LTC may be at the expense of his social and emotional well-being if, to him, it means losing independence and dignity.^3,33-36 It is important to ensure that beneficence, nonmaleficence, and safety are balanced with the patient’s autonomy, dignity, and humanity. Using this approach will support a clinically and ethically appropriate discharge.