Safety and Ethical Considerations in Discharging Patients to Suboptimal Living Situations

Abstract

a physiatrist, is part of an interdisciplinary team that provides comprehensive services for people with conditions that result in long-term cognitive and physical limitations, such as stroke, spinal cord injury, amputation, major trauma, and brain injury. Dr. Wayne and the rehabilitation team are meeting with Martha, a 45-year-old woman who has spent the last six weeks in an acute inpatient rehabilitation unit. Martha sustained a T12 complete spinal cord injury and a moderate traumatic brain injury as the result of a car accident.Dr. Wayne is pleased with Martha's rehabilitation course and overall adjustment to her injuries. Martha is able to use a manual wheelchair without assistance for mobility and is independent with her bowel and bladder management. She has also made excellent progress from her traumatic brain injury and has been evaluated to make sure she is competent to make her own decisions. Based on her functional and medical status, Martha is ready for discharge, and she wants to go home with her 22-year-old son, Brett, who lived with her prior to her accident. The social work team has secured disability status for Martha, and her social security disability payments-which Martha hopes will be enough to cover her bills-will begin in a month. Dr. Wayne hopes to discuss some of the issues related to the current discharge plan with Martha and Brett.A physical therapist has performed a home evaluation and noted that the apartment is not optimal for Martha. The bathroom is too narrow to maneuver her wheelchair, and there are no handrails near the toilet and shower to help with her transfers. Her apartment unit also lacks an appropriate ramp to allow Martha to enter and exit the apartment without assistance. While the initial discharge planning identified these concerns, Brett has refused to find more appropriate housing for his mother, stating that he prefers to stay in the same apartment. The social work team members who have interviewed Brett say that his only employment is doing odd jobs for others in the apartment building. Without Martha's income in the last four months, the electricity in the apartment had been turned off once. The nursing staff has also raised some concerns about Brett's behavior with his mother and report that he smells of alcohol when he visits her on the rehabilitation unit. Many of his visits with his mother end in his becoming angry and raising his voice at her before he stomps out of the hospital. Despite these concerns, both Martha and Brett insist that she will be safe at home.www.amajournalofethics.org 506

Who Gets to Determine Whether Home Is “Unsafe” at the End of Life?

“…Prior articles have analyzed the ethical concerns of unsafe discharges in detail. [9][10][11] Briefly, when pa-tients wish to return home against initial medical recommendations, treatment teams may focus on the principles of beneficence and nonmaleficence, as exemplified by the desire to minimize harm, and justice, in which clinicians consider resource allocation and risks that a home discharge poses to family members, caregivers, and home health professionals. However, autonomy is important to consider as well.…”