e-Ethics JULY 2003
Ethical Issues in Discharging
the Frail, Elderly Patient
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Mrs. White, an 81-year-old
woman, was admitted to the hospital
with pneumonia. She lives with
her 84-year-old husband who has
Parkinson's disease. Mrs. White had
been doing the cooking and cleaning,
as well as assisting her husband
with dressing and bathing. She
claims they have been doing "just
fine."
Mrs. White's daughter Ann, who
works full time, takes the patient
shopping on weekends. Ann told
the nurse that her parents have been
having some difficulty managing
lately, so she has been encouraging
them to move to a nearby nursing
home. Limited finances make
assisted living and hiring help unaffordable
options.
Mrs. White will be discharged
in a few days and she will leave with
oxygen, at least temporarily. Both
physical and occupational therapists
have concerns about the patient's
safety, especially in the kitchen.
However, Mrs. White, who is a little
forgetful but otherwise cognitively
intact, refuses any suggestion that
she and her husband make changes
in their living situation. Her physician,
who is also concerned about
safety issues, has requested that
social work become involved in
planning Mrs. White's discharge.
Discussion
Anyone involved in the discharge
planning process knows that
special challenges are inherent in
discharging the impaired elderly
patient. The challenge is especially
difficult when the elderly person is
thought to be incapable of looking
after herself, but nevertheless insists
on going home.
The dilemma in discharge planning
is one of conflicting values. On
one hand, our society deeply values
individual autonomy—that personal
liberty wherein the individual chooses
his or her own course of action.
For those assisting with discharge,
this value creates an obligation to
provide full information and viable
alternatives among which the
patient may choose.
On the other hand, the professional
involved in discharge planning
is also obligated to contribute
to the patient's safety, health, and
well-being after discharge. But
efforts to fulfill this obligation can
become paternalistic, especially
when the professional's concept
of benefits and harms differs from
the patient's assessment—and the
professional's judgment is imposed
on the patient. The most obvious
example occurs when the professional
determines that there is
no alternative for the patient but
"nursing home placement."
The imposition of the professional's
will is often well meaning
and, from the standpoint of safety
and health, may seem the better
decision. But when, alongside
health and safety, "well-being" is
taken into account, things become
less clear. The professional may
see well-being as living in a safe
environment where there are regular
meals, physical assistance, etc.
However, to Mrs. White, like many
elderly patients, well-being clearly
means going back home and caring
for her husband.
This process of offering options
and exploring them takes time and,
with shortened lengths of stay, decisions
must be made fairly quickly.
Unfortunately, the need for timely
discharge often overrides the
patient's and family's need for time
to consider the alternatives. This is
especially true when there has been
a significant change in the patient's
functional ability. The challenge for
all involved in this process is to
make the patient and family aware
of options, including the risks and
benefits of each, and to assist with
decision-making.
When working with a patient like
Mrs. White, who is frail but cognitively
intact, one can usually accept
a decision by the patient that seems
a poor one. People can make bad
choices. However, often the safety
and well-being of others is also of
concern. For example, if her forgetfulness
puts Mrs. White at some risk,
even temporarily, might not Mr.
White, and perhaps others in their
building, also be at risk? Is there an
obligation to them, too? Where
does autonomy fit in this scenario?
The issue becomes even more
complex in working with a patient
who has some cognitive deficits. Does
this patient have the overriding right
to make decisions when judgment is
diminished? Is paternalism more justified
when the patient is cognitively
impaired? One could argue that it is.
However, if there are social supports—
family and community services—to
support and maintain the patient at
home, and if the patient's deficits are
minimal and she wants to go home, this
alternative to placement should at least
be considered.
It would be an overstatement to
suggest that long-term placement in an
extended care facility should always be
avoided. Many factors can make it the
best choice for a physically or cognitively
impaired patient. However, placement
must be seen as one choice, and
rarely the only choice. And it is important
for the professional who is encour-aging
this option to be sensitive to the
meaning that placement in an extended
care facility may have for the patient
and those closest to her.
In discharge planning, the professional's
ethical obligation is twofold.
First, the professional should present all
the options, discuss the pros and cons
of each, then offer an opinion about
what she believes is the best choice, and
why. The second obligation, however,
is to support the patient's and family's
decision. If the decision is for placement,
emotional support may be needed.
If the choice is that the patient will
stay in the community, the discharge
planning responsibility becomes one of
mobilizing the resources that might be
needed and available to ensure the
patient's safety, health, and well-being.
It is important to remember that
decisions made about discharge can
have a profound impact on the patient's
sense of well-being for the remainder of
her life. So it is essential to respect the
patient's wishes and, whenever possible,
make a reasonable effort to honor
them. For Mrs. White, going home is
most likely a viable choice. However,
it would also be appropriate for the
physician to insist that Mrs. White be
amenable to additional assistance,
either from her daughter or community
services, at least for the time being.
This solution would be respectful of
Mrs. White's need to return home, yet
would also attend to the safety of those
around her.
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