Patient Refusal to Leave the Hospital: And Now What?
The physicians, nurses and hospital staff are faced with a dilemma of a patient refusing to leave regarding how to professionally, ethically, humanistically get the patient out of the bed, out of the room and out of the hospital when no further hospital treatment is necessary and there are other patients needing hospitalization and a hospital bed waiting in the emergency room for admission. For the professionals, this demand by the patient to remain a hospitalized patient against recommendations for discharge is frustrating, emotionally upsetting and presenting uncertainty as to how to handle the situation.
I present this real hospital dilemma to you, my visitors, to get your take on this variation of patient behavior and how you, speaking from the point of view of a patient, not part of the hospital medical staff or administration would handle it. Any suggestions? ..Maurice.
Graphic: From Google Images and modified by me using ArtRage and Picasa3.
posted by Maurice Bernstein, M.D. @ 1:11:00 PM
26 comments
26 Comments:
These types of professional patients most often don't
need hospitalization in the first place. Most are drug
seekers, homeless and those seeking disability often
through pseudo seizures. These patients are constantly
on their call button and never happy with the food.
They are primarily self pay and don't ever expect to
pay their bills. Many of these patients already own the
Hospital several hundred thousand as it is. They are the
new scourge of healthcare. If the physician discharges
you, then you are discharged. If you don't leave,then the
hospital should have you arrested for trespassing.
Your mommy dosen't live here and no, you
don't get to sit in bed watching cartoons and eating all
day with someone at you beck and call.
PT
PT, one suggestion I read was simply to remove the television set from the hospital room.
But, PT, pretend you were the doctor in the room with the patient and the patient refused to accept a discharge, how would you specifically follow up on that response--what would you specifically say next and/or what would you specifically do? What would you need to know to make an appropriate response? ..Maurice.
Maurice
I have a nice cold glass of white zinfandel
waiting for me after this post. I say that because
patients often think they can hold the hospital
hostage with their ridiculous demands. Don't
get me wrong, I am the biggest patient advocate
you will meet,to a point. Now, once a physician
discharges the patient, that is it. The physician is
no longer required to see that patient. In fact,
medicare and medicaid will stop paying once the
physician enters the discharge code.
If the patient has regular insurance the same
rules apply, payment begins to cease once discharge
orders are submitted. If the patient is a drug seeker
and refuses to leave the hospital this is what will
occur. The house supervisor is notified, security is
notified and the ex-patient is escorted out,end of
discussion. The hospital has the right to call the
police and have the patient arrested and as I have
mentioned in my first post, seen this happen.
Often, during the busy winter season patients
are discharged to make way for very ill patients who
need that bed. Would it be appropriate for an acutely
ill patient to be held in the emergency room because
some drug seeker is refusing discharge.
PT
PT, don't you think that every patient who summarily refuses discharge should be still professionally evaluated regarding the medical/psych/social basis for that patient's refusal? That may not take more than a few minutes of questioning and attentive listening and constructive evaluation. This evaluation should be in place of an immediate, ad hoc, order to "leave!". As a general consideration not necessarily specific to the present discussion but shouldn't doctors attempt to be therapeutic, if possible, even if it seems that the patient is fighting them? Doesn't the doctor-patient relationship and the professional responsibility to the patient last even beyond the utterance of the word "discharged"? ..Maurice.
An article "Staying Against Advice: Refusal to Leave the Hospital" written in the Primary Care Companion of the Journal of Clinical Psychiatry 12(6) 2010, provides some insight as to how to handle these patients.
♦ Patients who stay against medical advice are challenging and often frustrate general hospital staff.
♦ While the reasons people refuse to leave are limitless and sometimes difficult to ascertain, determining the motive is an important first step to managing these patients.
♦ Clinicians should be swift to discharge the patient as soon as he/she is medically cleared. The discharge plan should be coordinated with the nursing staff and hospital security staff, who should be present when the discharge plan is explained to the patient. The clinician should speak in measured tones and avoid negotiating with the patient. ..Maurice.
Maurice
Certainly, those issues are discussed during the
discharge process. Consider during the early 70's
a cholecystectomy would require 5 to 7 days of
hospitalization. Today, through improved surgical
techniques and laparoscopy, it's almost on an out
patient basis. Decreased hospital stays through
managed care with the expectation of improved
quality care and decreased costs has been the
goal.
Patients are and frequently discharged with
the expectation that they follow-up with their general
practitioner. The problem is, many don't have one
and as you know upon discharge a case manager
always reviews the patients chart and does so even
before discharge orders are written.
PT
I actually wonder more about the opposite. What if I want to go but they won't officially discharge me? Would I have to physically push my way past a wave of nosy nurses or threaten to sue someone? Do they have the right to keep me and my clothes seperated?
Anonymous, what you suggested is called "patient leaving against medical advice" (AMA). The hospital cannot restrain you from leaving with your clothes but they request you sign a form taking responsibility for the medical consequences of your decision. Some patients just leave and don't sign but as long as there is evidence that the hospital offered the form, the legal and ethical aspects are no different. Those patients who leave AMA are not necessarily provided with medication or followup. Also, patients who want to leave AMA and whose mental state poses a suicide risk or hazard to others may be restrained by legal means. Often, attention by the hospital staff to better communication with the patient regarding the reasons for the patient's decision and detailing by the staff regarding the reasons for further hospitalization may prevent am AMA action. ..Maurice.
The poster who described the Medicare notice for discharge process is correct; while it is helpful to ascertain what is "driving" the refusal to discharge, the fact must be faced that some people just find it easier to remain in the hospital rather than take care of themselves (or their family). If the family and patient have been invited to participate in realistic discharge planning, refuse all options, and continually delay, something must be done. I am actually facing this in my own practice now. (Dry alchoholic family member). Very difficult and a waste of a hospital bed. Other level of care more appropriate.
Anonymous from today, if the patient has to return home from the hospital to a dry alcoholic family member, maybe it would be appropriate for the hospital social worker contact that family member and help direct that person into AA meeting or other psychological support. If the hospitalized patient sees that there is hope for relief from the being exposed to the alcoholic's bizarre behavior, this would motivate the patient to leave the hospital. Just a suggestion, if this hasn't been already attempted. ..Maurice.
I was discharged against my will. I was admitted from the ER with heel fracture. I needed surgery and a second admission would be required after swelling had reduced enough to do so. I was I the ER for about 8 hours before being taken to a room. My insurance coverage would be much less liability for me had they kept me there. The doctor who first took my case then referred me to a surgeon who did foot surgeries was the one insisting I go home. I had several legimate besides the money why I wanted to stay. I had only managed to hold down 1 of the 3 meals I had while there, very little reliable help at home, and the medications I could get in the hospital via IV. The doctor who insisted I go home said there was no medical reason to keep me there in the interim between then and the upcoming surgery. I had the surgery at a different hospital with the surgeon recommended by the first ortho guy who insisted I go home. I fell no less than 3 times, am married to an alcoholic and made the Dr. Aware of that fact as well. I don't drink. I wanted to stay for the skilled nursing care. I cried to one of my nurses apologizing if I had been a problem and she hugged me saying no honey you were a great patient you didn't complain, you always said Thank You even if they were drawing blood, not something you requested. They had moved my porta potty to my bedside and I was able to get myself up and off the bed without assistance and would call them and notify them I was going to go and then again when I returned to bed safely. I was trying to not bother them with constant requests. Maybe I shouldn't have been so indepandant and willing to take care of some things my self. I want to sue the pants off the Dr. Who made me leave. I have already voiced my complaints to the hospital and filed a formal complaint. Sometimes the patient who doesn't want to leave has legimate reasons. While I am not a drog addict the drugs I got in my IV where much more effective and I was in much less pain then when I got home and had to take meds orally. I continued to throw up as the meds had a lot of Tylenol which upset my stomach. I have a question to ask Should I sue the Dr or not?
Anonymous from today, with regard to your last question: can you explain in which way the doctor caused injury or damage to you? If you can, then your question would be something for a lawyer to answer. ..Maurice.
They want to stay because its the closest they have ever been to God-like care and consideration in their lives.
I'm surprised that the number of patients who refuse to leave the hospital is so low. If many of the 47 million people on government welfare knew that they could stay in the hospital, why won't they? It's probably a better quality of life for many of them, plus they continue to get their welfare checks. It's just human nature in action.
BJTNT
Hi, I have a jaw that's crap. It has dislocated 13 times in 2 weeks. I have been doing the 40 mile round trip to the hospital nearly every day some times twice a day. I can't afford to keep going especially as I don't drive and £46 in a taxi daily is expensive and I have two children (4 & 6). I go into hospital get my face relocated then they send me home. I have asked and asked and asked to have something done that's more permanent but they refuse to help. I have also been refused a 2nd opinion (against the law). I am wondering if I go into the hospital for the 14th time in complete agony and refuse to leave until something is corrected will I be breaking the law too? I can not cope with this anymore I am in constant pain I can't eat as my teeth don't line up and if I have liquid food I just end up vomiting I have lost 2.5 stone I'm all bone. Help please!
Moo, I put your concerns up on a bioethics listserv and one ethicist already came up with the following response which appears sympathetic with your concerns. I hope this helps you to know that others are concerned with your troubles. ..Maurice.
"Isn't this the heart of 'shared decision-making'? Should the patient be asked for their thoughts about their illness, and the management being offered? Could we caregivers listen with compassion and empathy? Yes.
Once seeing the problem from the Pt.'s point of view could the medical team come up with a plan that would arrive at joint agreement and compromise? Very likely.
I think so 95% of the time. And end with better cooperation on all sides. And a better feeling about ourselves; Pt. and medical team."
Here is a link to the American Medical Association's 2012 statement on "Physician Responsibilities for Safe Patient Discharge from Health Care Facilities". ..Maurice.
Hello fellow bloggers. I am posting on this discussion to get some feedback about my family's dilemma. The hospital at which my mother currently is a patient is working to have her discharged. My mom had an accident in which she had a left craniectomy to save her life from a traumatic brain injury. She is no longer in a coma, however, she is unable to properly respond to commands, has half her skull in a fridge awaiting to be put back on, is incontinent and has a G-tube which supplies nutrients to her through a section of her abdomen as she cannot properly feed herself, let alone us feed her. Unfortunately, she was uninsured at the time of the accident and we are currently awaiting MediCAL. The hospital is an acute care facility, which I understand discharge patients when the intensive portion of care is finished. Due to being uninsured and pending on mediCAL, long term nursing facilities will not accept her, especially when unable to pay the substantial fees up front. Our family is wide-spread and in-home patient care is close to impossible. The physician predicts it is about three weeks out until the replacement of the skull. With her current status of her condition, are we right to appeal discharge? Especially since we are due to come back in such a short amount of time? Thank you for your input
TC
TC, a hospital assuming responsibility for the treatment and care of a patient cannot discharge home and abandon the patient if the patient has no capacity for taking care of their medical condition that is related to the hospital admission. In your mother's case, her status is that of uncompleted brain surgery with need for specialized nursing attention. This means if the hospital has decided to delay completion of the surgery and the patient still needs that specialized attention, it is the responsibility of the hospital, through their social workers, to find a skilled nursing facility to provide that interim care. If none can be found for whatever reason, the hospital must continue to attend directly to the patient during this period of surgical management.
To the Anonymous lady talking about not leaving and suing the Doctor.
YOU are what's wrong with America. First of all, of course medications work better through IV, they go straight to your blood stream, so the onset is quicker. But just because they work better and a faster onset, doesn't you use that technique. You only use IV path if the patient cannot tolerate oral.
And second, the hospitals job is to take care of SICK patients. Not provide shelter or attention for someone that can take care of themselves. You just admitted that you could independently operate fine and take it oral medications. Therefore, you were purposely holding a bed that a patient who was really ill could have used, but instead, you would rather have a baby sitter.
I work in the hospital, and most of the patients I see are great. I'm a mid-level physician. Love to see my patients get better. But there is 1 in 4 patients that absolutely refuse to leave for these reasons. And I'll tell you right now, you irritate and frustrate the entire Hospital Staff. I don't care what that nurse said to you. He/She went back to the supervising nurse/doc and told them the opposite. I see it everyday. Slugs/Leeches is what the term is used in the hospital.
A physician wants nothing more than to help sick patients. But if you are not sick, and just want the comfort of having someone take care of you, then all physicians want absolutely nothing to do with you.
I'm frustrated just typing this based on the audacity and arrogance of patients that come into a hospital and EXPECT care. It is a privilege to get care, and apparently our society forgot that. When you walk into a hospital and challenge a Doctor/PA/NP/Nurse, you are deliberately offending them. They went to school to do this, they spent years preparing, studying, sacrificing to just aide others while they are ill. For you to tell them they are wrong, is nothing but an insult.
Remember next time while you are laying in bed from a post-surgery on a foot, that you are sitting in a bed that someone that needs a new valve in their heart, someone who suffers from neuropathy from Diabetes, someone that had a heart attack, stroke, etc. You are the reason they may not have a bed and are awaiting care.
Makes me sick how patients think they know more than Professional Healthcare staff.
Anonymous from today, your frustration is understandable and is not limited to physicians but all the hospital staff who are involved in the case.
One aspect of this hospital issue which I don't think I previously offered for consideration is how does the patient look at the specific relationship between the doctors, nurses and the hospital staff in relation to the patient themselves. Is it one of a customer in a common sales or service business? In that case, the "businessman" may be considered to attempt to provide service to the customer at the customer's request and judgment. However, in a professional-patient relationship within a hospital setting, the burden for diagnosis and therapy is set by professional skills of the healthcare providers and while the patient retains informed consent (to consent to a professional decision), informed dissent (unlike a business relationship) by the patient has no place in this healthcare provider/hospital-patient relationship. That is, a patient cannot expect the medical community to respond to every contrary decision by the patient which the profession finds inappropriate to the patient's clinical status. Inappropriate procedures, inappropriate medications and inappropriate hospital stay is not an acceptable order by a patient which the hospital and healthcare providers must accept and follow.
In situations such as the subject of this thread, the patient cannot be legally abandoned by physician and hospital. The absence of abandonment can be shown and fulfilled by intensive social service work to find appropriate care and living conditions elsewhere including hospitals which would accept the patient's requests. If this was attempted and failed in a reasonable length of time, the patient can be through various methods removed from the hospital. ..Maurice.
I actually stumbled upon this post as I was trying to determine my tights as a patient. I also happen to be a nurse. I have been dealing with a medical issue for over a month now with no answers as to what is wrong with me and I'm frustrated. My next appointment with a rheumatologist isn't until September and....I'm desperate. I'm fatigued, hurt so much that I can barely pick up a glass some days. Out of desperation I have considered going to the ER and refusing to leave until I finally get some kind of answers. So from a patient's perspective remember you are dealing with people who really on the physicians to HELP them. It shouldn't take months to figure out anything.
You need to up your game with patients like me. Don't blow them off!
As a nurse, you should also know that you will not get an answer to your chronic condition through an ER visit. That is something you follow with your specialist through trial/error and ongoing assessment. I would hope that you do not go to the ER acting that way, not because it is annoying, but because you should know better.
-ER nurse.
And now the current story in the news about a hospital attempting to hold the patient within the hospital against her wishes and those of her parents even though the hospital stated that the patient had the mental capacity to make her own medical decisions while a patient there:
From today's CNN posting
..Maurice.
There is certainly more to this story that’s not being told. The patient is an adult and can make her own decisions, but was she able to? Did she have Advance Directives and did her parents have power of attorney? In most cases a patient can leave ama ( against medical advice) provided they are not a danger to themselves. One fact for certain is this, as an inpatient if you want to be transferred to another hospital you have to discharge yourself and then present to another medical facility, the hospital will not do it for you unless the current facility has determined that they cannot provide a specific level of care that you require.
I have seen some very strange dynamics in the past play out regarding patient’s and the nurses who make suggestions that the patient is unfit to make decisions. Compounded with the fact that the nurses assume the parents have bad intentions and all the dynamics are playing out unbeknownst to the physicians until the last second. The hospital should have consulted legal before calling the police, furthermore, I don’t see anything in this article that has to do with compassion. If the patient had been male there never would have been a stink I can assure you of that. I think as this article reflects some nursing staff just put their nose in the family’s business where it dosen’t belong.
PT
Actually, PT, what is missing in the course of this story is that the hospital did not inform the parents and patient and staff to an hospital ethics committee meeting and not leave decision making to the nurses or to a last minute physician decisions. There was a much more ethical and legal approach to the decision-making than deciding to calling the police.
As a member of two hospital ethics committees over the past several decades, I know that what seem to be fixed conflicts between the various stakeholders can be resolved by an ethics meeting where all stakeholders attend. ..Maurice.
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