Many patients are admitted to health care facilities (eg, acute and postacute hospitals, palliative care units, long-term care [LTC] facilities) under the care of a family physician. Challenging situations can arise where patients express a desire to go home despite the health care team’s assessment that this would pose safety risks to the patient. In these situations the legal and ethical considerations—such as patient autonomy, professional responsibility and liability, and risk management—are nuanced and the best course of action is not always clear, which can cause moral distress for physicians and other health care team members.1-3
Although there is a plethora of literature on patients leaving against medical advice,1,2,4-24 there is a lack of similar guidance for situations where patients with some degree of cognitive impairment, who are medically stable but still have care needs, seek discharge (ie, “at-risk patients”). This is an important issue for Canadian family physicians, who need a clear understanding of potential options and processes. This paper outlines a practical framework for physicians based on guiding legal and ethical principles to facilitate in-the-moment decision making when an at-risk patient expresses a desire to leave an inpatient setting. We present a case of a patient wishing to leave hospital and describe how our framework helps guide physician decision making.
Case description
Mr M. is a 72-year-old patient with some degree of cognitive impairment (Montreal Cognitive Assessment score of 19 out of 30) who has been admitted to a postacute hospital in Ontario for rehabilitation following surgical repair of a hip fracture. Upon admission he was deconditioned, unable to mobilize independently, and required assistance with activities of daily living. He can now mobilize independently with a walker but the physiotherapist believes he remains at risk of falling on stairs, and the nursing team notes Mr M. is unable to maintain adequate perineal hygiene without assistance. He is participating minimally in the rehabilitation program recommended by the multidisciplinary health care team and wants to go home. Mr M. lives alone in a townhome with the bedroom and washroom on the second floor. He is unwilling to modify his home to make it a safer space and will not accept home care or other community support services to mitigate risks. There are also concerns regarding social isolation and its impact on the patient’s quality of life. While the care team is encouraging Mr M. to go to LTC to meet his needs, he insists on returning home. He values his independence and dignity, strongly believes he will manage at home, and insists that his quality of life will be substantially better at home than in LTC. Although he has some degree of cognitive impairment, he is able to articulate what life at home would look like for him. The team remains uncomfortable with the idea of discharging him to this environment given the risks.
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.
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 home1,2,8; 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.
Case resolution
The team decided Mr M. did not meet the criteria for an application for psychiatric assessment and he did not present an imminent risk to himself or others if he were to leave (options D and C, respectively). While Mr M. was emphatic that he wanted to go home, he agreed to stay until at-home support and community services could be set up (option B leading to option A). The team discharged him home once these services had been arranged. The clinical team continued to have some discomfort because the situation was not ideal. However, the team believed the decision was appropriate because a reasonable plan could be put in place to meet Mr M.’s immediate needs such that the risk of harm was not sufficient to warrant detention or restraint.
Conclusion
Situations where an at-risk patient expresses a desire to leave an inpatient setting can be complicated and may cause moral distress for physicians and other health care team members. The framework described here can help health care providers navigate challenging situations with a thoughtful, compassionate, and individualized approach with options based on guiding legal and ethical principles.
Acknowledgement
We thank Dr Lesley Wiesenfeld and Dr Mark Lachmann for their support in the initial stages of the project and their insightful comments on the tool kit. We also thank Anita Ramadhin from the Hennick Bridgepoint Hospital Health Science Library for her assistance with the literature search.
Notes
Editor’s key points
▸ Situations at health care facilities involving at-risk patients expressing a desire to go home can be complicated and may cause moral distress for physicians and other health care providers.
▸ Authority to keep a patient in a facility against their will is limited by law and decision makers must address legal, professional, and ethical obligations. A framework that incorporates legal and ethical considerations and provides a compassionate and individualized decision-making approach can help physicians navigate these challenging situations.
▸ When evaluating options, it is important to remember that risks can be either negative or positive (ie, potential for harm vs a potential opportunity loss) and to take patient-specific circumstances, values, and wishes into account.
Points de repère du rédacteur
▸ Il se produit des situations, dans des établissements de santé, où des patients à risque expriment le désir de retourner chez eux. Ces situations peuvent être compliquées et causer une détresse morale aux médecins et à d’autres professionnels de la santé.
▸ Les pouvoirs de garder un patient dans un établissement contre son gré sont limités par la loi, et les décideurs doivent prendre en compte leurs obligations juridiques, professionnelles et éthiques. Un référentiel qui présente les facteurs juridiques et éthiques à considérer, et qui propose une approche de la prise de décision individualisée et empreinte de compassion peut aider les médecins à composer avec ces situations difficiles.
▸ En évaluant les options, il importe de se rappeler que les risques peuvent être négatifs ou encore positifs (p. ex. un potentiel de préjudice par rapport à une perte d’opportunité), et qu’il faut tenir compte des circonstances spécifiques au patient, de ses valeurs et de ses souhaits.
Footnotes
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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