The Decision of Discharging a Patient from the Hospital: Case (Neurological) Report with Legal Implications

Abstract

Patient safety is an important aspect of patient care following the discharge from the hospital (having gone through the required treatment). A transition from hospital care to domestic care/community care to a discharged patient is another complex factor that might have a bearing in the decision-making of a treated/operated patient due for discharge. However, the pressure on premier government medical institutions to cater to the awaited patients of chronic and severe diseases remains a vital consideration to bail out the lives of impending threats. Delayed discharges may have a financial implication on the one hand and hospital-borne infections on the other hand, which may be difficult to treat in immune-compromised state/vulnerable subset of patients. Unplanned discharges without thoughtful planning may result in readmission and misappropriation of limited resources at medical institutions. A thorough explanation of risks, warnings, care, support system, need for readmission, accessibility, communication, and facilitat.ion remain important considerations while discharging the patient. However, limited high-level government medical centers and pressure to accommodate other sick patients may force treating clinicians to discharge the patients at optimal levels of their clinical recovery, in countries like India.

Keywords

hospital discharge - patient safety at discharge - patient care following discharge - hospital policy - SOP

Introduction

It is important to improve the discharge process, because such a process may cause appropriate usage of the health care system and the economy of the patient's family. Unplanned readmission and discharge preparedness of the patients are closely linked with various discharge issues.[1] In a few cases where patient requirements and needs are not satisfied, it may cause readmission again after the discharges.[2] It was found that among patients who were readmitted again within a month or early after discharges, 23% may suffer either drug-related adverse events or other illnesses causing severe morbidities.[3] The purpose of the law on this aspect is to maintain a balance between the staff and patients including patient empowerment, thereby enhancing their power and influence within the existing health care system.[4] The literature available from the western countries suggests that high priority is given for more involvement of patients in the health care system, and a lot of challenges may be faced if patients have lack of determination and autonomy. In a country like ours, where tertiary health care systems are evolving gradually, the decision to discharge patients mainly lies with the treating clinician. This study presents a case involving a complaint from a discharged patient of a Apex Trauma care facility for determining the patient's responsibility and decision-making regarding their post-treatment discharge from this center against the wishes of their kin.

Case Summary

A 38-year-old patient was admitted with a road traffic injury after being hit by an autorickshaw while walking under the influence of alcohol. The patient experienced loss of unconsciousness and seizures. The patient was offered initial treatment and care at the district hospital, where the treating physician suspected a clot in the brain for which the patient was referred to a higher center. The patient presented to the apex trauma center with a pulse rate of 126/min, blood pressure of 120/70 mm Hg, SPO₂ of 100% on room air, random blood sugar of 76, and Glasgow coma scale (GCS) score of E2V1M3. Local examination revealed a sutured wound on the right side of the scalp. Noncontrast computed tomography (NCCT) of the head, FAST (Facial dropping Arm weakness Speech difficulties and Time to call emergency services) (ultrasonography [USG] of the abdomen), and chest and pelvis X-ray were normal. An abdomen USG showed an enlarged fatty liver with grade 2 Medical Records Depertment (MRD) and an enlarged spleen. The CT scan of the head was also normal. The patient was under alcoholic intoxication. Given a low GCS score, neurosurgery consultation was taken and their advice was incorporated in the treatment, although no clot was found in the brain parenchyma. The patient was a known alcoholic for 15 years with a daily intake of 150 to 200 g/d. He was treated at the department of gastro-medicine for chronic alcoholic liver disease and Model for End stage Liver Disease (MELD)-29, Computerized Tomgraphic Perfusion (CRP)-9/5, DF 90.2 Cut, Annoyed, Guilty and Eye (CAGE) 4/4 with moderate ascites. Considering his low GCS score of E2V1M3 and type 1 respiratory failure, he was intubated and shifted to the trauma intensive care unit (ICU) for further management. Serial investigations were done and keeping in mind his chronic decompensated liver disease, opinions of gastro-medicine, herpetology, nephrology, and radiology were sought and their bits of advice were incorporated in the treatment. Transfer references were also sent to the gastro-medicine and hepatology departments (situated 1.5 km away). The patient was provided with standard ICU care as per established protocol by multidisciplinary teams of gastro-medicine, nephrology, critical care medicine, and trauma ICU.

As there was a need for prolonged mechanical ventilation and the associated risk of nosocomial infection, surgical tracheostomy was done by the ear, nose, and throat (ENT) team after obtaining informed written consent from the relatives. After the tracheostomy, the patient was weaned off from the ventilator and over time was weaned from oxygen support as well.

Given his preexisting disease, chronic liver disease with chronic renal impairment, the patient's relatives were repeatedly counseled to take the patient to a hepatologist for further management. Patient attendants were intermittently trained for tracheostomy care, Ryle's tube feeding, and other nursing care. The patient was shifted out of the ICU in a stable condition. He was discharged with satisfactory general condition after 2 weeks, with advice to attend gastro-medicine, nephrology, and herpetology outpatient department (OPD) for further management.

The patient's brother complained that his brother was discharged under pressure and without proper consent, and he had taken his brother away from the hospital under pressure and indicated that he would file a complaint with the regulatory bodies of India, if his brother was not readmitted soon.

Discussion

Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other primary, community, or domestic environments. This highlights that hospital discharge is not an endpoint, but rather one of multiple transitions within the patient's care journey.[5] The organization and provision of this transitional care typically involve multiple health and social care actors who need to coordinate their specialist activities, so that patients receive integrated and, importantly, safe care. The inherent complexity of coordinating a large number of actors, often based in distinct organizations, leads to the view that hospital discharge can be a vulnerable, time-dependent, and high-risk episode in the patient pathway.[5]

Approximately 30% of older patients experience delay in hospital discharges, which can expose them to extra risks in the hospital, and also physical and emotional risk, which may cause nonavailability of indoor patient beds and extra burden in the form of additional cost. Patient recovery may be affected, including suffering complications, in cases of unplanned or premature discharges or discharges without appropriate arrangements for onward care. In one study for older people, it was found that the readmission rate doubles in 28 days.[5]

Such poorly planned or delayed discharges are one of the biggest challenges in the integration of health and social care. Delayed discharges are caused by (1) communication gap, (2) discharge planning missing proper assessment, (3) discharge notice served inadequately, (4) inadequate involvement of the patient and their family members, (5) overlooking of informal care reliance, and (6) due care not provided to vulnerable groups who need specialized attention. All this evidence underscores the need for improvement in discharge policies and proper planning with the involvement of health and social care agencies with an aim to achieve better integration.

There is a lack of a commonly agreed model for discharges. In 2010, a new workbook about discharges was published with the help of the Institute of Innovation and Improvement. Eight steps have been formulated for patient discharge and transfer from the hospital ensuring a timely and safe transition:

• All settings and individuals should have effective communication.

• Services should be aligned with continuity of care.

• Transfer with care including discharges backed with system.

• Management plans for clinical discharge should be clear.

• Transfer and discharges should be identified in time with clear-cut date in advance.

• Coordinators should lead for identified names.

• Time to time review and audit by the organization.

• Planning for discharge should be proactive with 7 days a week and 365 days.

Once the patient is discharged from the hospital back to community involving itself a complex system and vulnerability with various personnel and actors in the chain. This system and chain itself very problematic and need to be addressed including environment and professionals.[5]

The patients themselves are stakeholders in the process of discharge, but unfortunately they are overlooked in this process. It is usually found that the stressful environment of the hospital leaves a patient feeling disconnected with the treating doctors not paying enough attention and giving enough time to the patient. This coincides with Hesselink et al's results, one of the contributing factor in the process of in efficient discharges.[1] [6] To achieve efficient and effective discharges, accurate information about discharges should be assessed by the hospital staff.[1] Communication gaps, misperceptions, lack of information prior to discharge, and disrespectful and insensitive approach by doctors sometimes make patients feel uncomfortable.[6] It is revealed from the interviews of various patients that the role and leadership of the doctor are clearly defined in the process of discharge. The role of nursing leadership should be clearly defined and there should be no ambiguity. The doctor, as an expert, and the nurse, as the leading situation handler, should be confident and competent to perform their given roles under different situations.

The process of discharging patients requires improvement by involving the experiences and desires of the patients and focusing on a patient-centric approach. The discharge process requires improvement in continuity of care and accessibility.[6] All measures that are applied and taken in the reconciliation process are to ensure better communication and dialogue between the patient and the health care staff as the information handover between various health care providers is essential for improving patient's adherence to medications and, above all, for preventing errors in prescribed drugs and medications.[6]

As per our constitution, the right to health is an integral part of the right to life, which is guaranteed under part 3 of the Indian constitution. However, sections 87 and 88 of the Indian penal code deal with experts acting in good faith. Section 87 states that “nothing which is not intended to cause death or grievous hurt which is not known by the doer to be likely to cause death or grievous hurt, is an offence by reason of any harm, which it may cause, or be intended by the doer to cause, to any person above 18years of age, who has given consent whether expressed or implied to suffer that harm, or by reason of any harm, which it may be known by doer to be likely to cause to any such person who has consented to take the risk of that harm is not an offence, as is the Roman maxim too” (volenti non fit injuria, i.e., he who consents cannot complaint of it).[7] Section 88 of the Indian penal code states that “Act not intended to cause death, done by consent in good faith for persons benefit is not offence.”[7]

In the present case, a known alcoholic suffering from chronic liver and kidney diseases, was referred to an apex trauma center for investigation and treatment of a head injury, which was ruled out by investigations. An emergency treatment was performed by the trauma team, despite the fact that the patient did not have apparent traumatic brain injury. The treating clinician tried to investigate the case further in consultation with the concerned clinicians of different departments to transfer the case to the gastro-medicine department. The patient could not be transferred because of either nonavailability of bed or other constrains. The treating doctor of the apex trauma center discharged the patient in a satisfactory condition for further follow-up and treatment in respective departments for his chronic diseases, either following his admission there or on an OPD basis. It is worth nothing here that the clinician is empowered to take the decision of admission, investigations, treatment, intervention, surgery, prognostications, and future course of their patient following an informed consent. How can the same clinician become a poor decision-maker at the time of discharge of their patient? We believe they have enough wisdom to take such decisions too. It is important to note that many patients, particularly their relatives, resist discharge from public medical institutions due to the need for further nursing/hospital care during the convalescence period, because their families are unable to provide adequate care for the ailing patient at home. In India, the medical services in premier government institutions are mostly free or nearly free of cost along with kitchen facilities (even for a single caregiver relative); hence, relatives do not want a discharge till they think that recovery is enough as per their requirement. It is difficult for medical institutions to retain such patients in hospitals, particularly for neurological cases, where recovery may take a year or more or may not occur beyond a certain level. Recovery from severe head injury, paraplegia, or hemiplegia/focal neurological deficit may not occur in many cases, indicating a prolonged admission in the hospital for months and years, if the clinician goes by the wisdom of the patient and their relatives. Such admissions/transfers may be possible at peripheral hospitals for nursing and routine medical care, but not at higher centers with high turnover of patients. This scenario is reverse for corporate hospitals, where an early discharge is desired by the patient and their relatives for financial reasons as the cost of treatment is too high. Often, clinicians in government medical institutions face pressure to transfer partially treated or operated cases from corporate hospitals to meet financial demands. Hence, it is mandatory to formulate the norms for discharges and transfers of patients in public medical institutions along with strengthening of services at peripheral government hospitals.

Conclusion

Discharging a patient following treatment is a complex issue, particularly in countries with limited resources of high-order medical services, that is, tertiary care institutes. A thorough explanation of risks, benefits, warning, care, support system, and need of readmission should be explained to the family before discharging the patient. At the same time, an accessibility to health system, communication, and integration with supportive health system for the concerned case should also be given due consideration. However, the clinician who is efficient and proficient to make the decision for admission, investigation, management, prognostication, and future course of their ailing patient has all the expertise and wisdom to make decision for the discharge of his patient following a thorough explanation and consent. The scenario in public medical institutions is different, where the patient does not want to be discharged till he or she or their relatives feel that the patient has sufficiently recovered as per their wisdom. The norms for discharge of a patient (following treatment) and transfer policies from corporate medical hospitals to government medical institutions need to be formulated on ethical grounds to avoid undue pressure on experts in public medical facilities. Hospital policies and standard operating procedures (SOPs) in consultation with all stakeholders may be developed. However, the clinician on rounds may have the final say and should be the decision maker for such patients.

Conflict of Interest

None declared.

• References

• 1 Hesselink G, Schoonhoven L, Plas M, Wollersheim H, Vernooij-Dassen M. Quality and safety of hospital discharge: a study on experiences and perceptions of patients, relatives and care providers. Int J Qual Health Care 2013; 25 (01) 66-74
• 2 Flink M. Patients' Position in Care Transitions: An Analysis of Patient Participation and Patient-Centeredness. Stockholm, Sweden: Karolinska Institute; 2014
• 3 Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003; 138 (03) 161-167
• 4 Krook M, Iwarzon M, Siouta E. The discharge process-from a patient perspective. SAGE Open Nurs 2020; 6: 2377960819900707
• 5 Waring J, Marshall F, Bishop S. et al. An ethnographic study of knowledge sharing across the boundaries between care processes, services and organizations: the contributions to “safe” hospital discharge. NIHR J Library 2014; 2 (29) x
• 6 Krook M, Iwarzon M, Siouta E. The discharge process: from a patient's perspective. SAGE Open Nurs 2020; 6: 1-9
• 7 Gaur KD. General exceptions. In: Textbook on the Indian Penal Code. 4th ed.. New Delhi: Universal Law Publishing Co; 2009: 161-163

Publikationsverlauf

Artikel online veröffentlicht:
22. April 2025