NURSES face a variety of ethically challenging and complex scenarios. Consider this example: a patient who is admitted chooses to leave the hospital and initiates their own discharge before their healthcare team recommends they do so. This event, called a patient-initiated discharge, is sometimes referred to as “leaving against medical advice.” When patients who are deemed capable of making their own healthcare decisions exercise this right and choose to leave on their own, healthcare professionals can face an ethical dilemma, or a conflict among values. Ethical dilemmas typically occur in healthcare when there are tensions among four ethical principles: respect for patient autonomy; beneficence, which means to do good; nonmaleficence, which describes a clinician's duty to do no harm; and justice, which means being fair. These conflicts arise partly because healthcare culture often places a premium on the principle of beneficence. Valuing and prioritizing beneficence can sometimes conflict with what patients value, including their autonomy and their right to make choices about decisions that affect them. Using a case study, this article describes ethical considerations in supporting a capable patient who chooses to initiate her own discharge and what an ethical response entails.
What is a patient-initiated discharge?
A patient-initiated discharge can be ethically challenging for nurses. One to two percent of patients hospitalized in acute care leave on their own.1-3 When patients withdraw their consent for healthcare and elect to leave, nurses can become concerned about patients missing out on expected treatment benefits and/or incurring harm as a result of nontreatment. Evidence supports some of these concerns: In addition to any missed treatment benefits and harm from nontreatment, patient-initiated discharge increases the risk of hospital readmissions, repeated ED visits, and mortality.2,4
Despite the potential benefits that patients may gain from healthcare and hospitalization, and despite the risks they may encounter from not accepting healthcare and hospitalization, a patient's right to consent and refuse are fundamental aspects of patient autonomy. Central to a patient's right to consent and refuse, however, is their capability to make a choice on a healthcare decision, disposition decision, or the like. Capability refers to the person's ability to understand and apply the information provided to make a choice that is consistent with the person's own preferences.5 When we think about a nurse's responsibilities and an ethical response in these scenarios, a key consideration the team should keep in mind is to assess the risks of harm and identify any interventions that can reduce the harm identified to a tolerable level.
MS is an 84-year-old female with newly diagnosed heart failure (HF). She had been feeling increasingly short of breath and fatigued. Six days earlier, she felt lightheaded and had a racing heartbeat after a walk. An ambulance was called, and she was admitted to the cardiac ICU for nonsustained ventricular tachycardia and fluid overload. The clinical team prescribed I.V. diuretics, low-dose inotropes, and electrolyte monitoring and replacement. MS required supplemental oxygen via nasal cannula. Prior to this new diagnosis and acute HF event, she had no significant health history and minimal encounters with the healthcare system. MS lives alone in a one-level house and has been independent with all her daily activities.
Frequent clinical assessments and noise in the ICU at night are difficult for MS and she sleeps poorly as a result. The nurses' notes indicated that MS was confused after dinner the day before and was not oriented to time or place. She agreed to treatment for her sleep disorder and seemed to settle after midnight, but in the morning she reported that she still felt exhausted and frustrated after another night of interrupted sleep.
During morning care, MS states her intention to leave the hospital, despite the medical team recommending several more days of acute hospital care. The team is concerned because MS had recently been confused and the team believes she needs ongoing active medical care.
The ethical question
The clinical team in this case faces two options: decide that MS is free to withdraw her consent to hospitalization and treatment as she wishes and allow her to leave, or decide to clarify her decisional capability and explore and offer all options to support MS to minimize any harms related to her choice. The second option is the best answer. Why?
The clinical team is concerned about MS's choice to leave for two reasons. First, she is still benefiting from I.V. diuretics and inotropes and further diagnostics are pending. Leaving the hospital now may result in missed benefits and possible harm. Second, MS was recently confused and disoriented to place and time, and thus there are concerns about her ability to understand the risks and benefits in her choice to go home before she is medically discharged.
In ethical terms, MS's case raises the following question: How can the clinical team balance a capable patient's right to refuse or withdraw consent to healthcare (respect for autonomy) with promoting the patient's well-being through healthcare interventions (beneficence) and minimizing risk of harm (nonmaleficence)? MS's situation is an example of a decision to live at risk. Young and Everett proposed a helpful and clearly articulated ethical decision-making algorithm to help clinicians intervene in an ethical way when patients make decisions that their clinicians believe pose a risk of harm to themselves or others.6
The ethical response
Clinical teams have an ethical obligation to offer the lowest-risk and least-intrusive measures that could mitigate risk of harm.6 As Young and Everett suggest, MS's clinical team can begin by assessing the risks of harm in terms of both likelihood and severity.6
In this case, the clinical care team should identify possible risks (for example, worsening HF, unmanaged symptoms, or potential insurance issues) to MS. In the team's view, some of the risks, such as MS missing ongoing HF medication, are likely and relatively serious. Therefore, the team considers interventions that will reduce those risks to a tolerable level. According to Young and Everett, the intervention should:
- be effective
- be least intrusive and least restrictive
- not cause greater harm than it seeks to prevent
- be fair
- be acceptable to the patient and include the patient's input.
After identifying different interventions that could reduce the risk of harm to a tolerable level, the team explores the question of whether MS is currently capable of making the decision to leave the hospital, particularly because she was disoriented to time and place last night. She was fully oriented this morning and is clearly articulating her desire to leave. The physician meets with MS and determines that she currently understands that she has HF and the effects and consequences of continuing and discontinuing her current healthcare plan. MS is demonstrating an ability to think through her healthcare options, including leaving the hospital, and she is clearly communicating why she is making this choice. The physician determines that MS has the capacity to make the decision to leave the hospital and to decide whether to accept the safety plan or not.
The team then presents the risk-mitigation plan to MS and invites her to share more about why she wants to leave so that any potential solutions (for example, changing rooms, using ear plugs) can be identified that might help her reconsider leaving. The team explains that if she chooses to leave despite efforts to resolve her concerns, they will review her medications and replace the I.V. medications with oral medications, which they explain is likely less effective but will have some benefit compared with no medication. The physician updates the diagnostic requisitions so MS can access the tests as an outpatient. The primary nurse also speaks with MS and learns that she worries her sleep will not improve, even with options aimed at reducing the disruptions and noise. MS also shares that she is worried about her dog, which was being looked after by a neighbor.
MS is grateful for the team's efforts to help her return home and she identifies no barriers to filling her prescriptions, attending her follow-up cardiologist appointment, or returning to the hospital to complete her diagnostic tests. In a “teach-back” exercise, MS demonstrates good understanding of the safety plan and patient education content and is willing to take the resources offered so she will know what to do if she needs to return to the hospital. Team members document MS's informed refusal and the follow-up information offered, including education and detailed conversations with the options, assessed risks, and the safety plan that was accepted.
Discussion and nursing implications
Ethical dilemmas arise from situations where tensions between values and principles exist. In the case study above, tensions were evident among the ethical principles of respect for autonomy, beneficence, and nonmaleficence. Value tensions were also evident: Team members were valuing MS's safety, whereas MS was valuing her independence and comfort. Resolving an ethical dilemma involves a decision-making process that gives weight to differing values and perspectives and seeks a decision that can be explained and defended.
The scenario described above can be especially challenging because nurses believe patients will benefit from treatments and may incur harm without them. However, the ethical response in this scenario requires nurses to assess the risks of harm with the patient's decision, offer interventions that can reduce the harms identified to a tolerable level, and document the plan for at-home treatment.
Several nursing implications can be identified from this case study. First, nurses should understand a capable patient's rights to make choices about decisions that impact them. When a capable patient makes a decision that poses risks of harm to themselves, nurses should also know their responsibilities and ethical obligations in terms of contributing to a care plan that mitigates those risks of harm to a tolerable level. Finally, ethical dilemmas can be sources of stress and nurses should know what resources are available within their organization to support the teams facing these difficult scenarios.
1. Mitchell JE, Chesler R, Zhang S, et al. Profile of patients hospitalized for heart failure who leave against medical advice. J Card Fail
2. Chin J, McDougall R. An ethical approach to discharge against medical advice. Camb Q Healthc Ethics
3. Villarreal ME, Schubauer K, Paredes AZ, et al. Leaving against medical advice after emergency general surgery: avoiding a two-hit effect. J Surg Res
4. Clark MA, Abbott JT, Adyanthaya T. Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge. Acad Emerg Med
5. Karlawish J. Assessment of decision-making capacity in adults. UpToDate. 2020. www.uptodate.com
6. Young J, Everett B. When patients choose to live at risk: what is an ethical approach to intervention. BCMJ