Do you have a process if you disagree with discharge of a patient?

[Codeblue1982]

I was wondering if any of you have a policy that allows you to go up a chain or consult someone if you disagree with the discharge of a patient. I had an IMC patient whose blood pressures were in the 200's and the physician was adamant about discharging the patient. I spoke with the medical director who tried to intervene this caused more problems which caused the pcp to tell me since I know everything she is signing off and I am responsible for managing the patient....no I am not making this up. After speaking with the patient and their family I told them they could go back through the ED or call the equivalent of a rapid response to get the ICU physicians over hoping they would intervene. We chose the rapid response route which worked. I do not think keeping this patient should have been such an issue. I am hoping maybe we can develop a policy at my hospital addressing issues such as these. If anybody has input I would appreciate it.

[HouTx, BSN, MSN, EdD]

WOW - just WOW. Your courage and commitment to patient advocacy makes me proud to be a nurse. :)

Your question prompted me to take a look at our policies - and I didn't find one that specifically addresses the issue of disagreement about discharge. However, we do have one that addresses disruptive physicians & I think that your doc's behavior falls into this category.

In my organization (we're a faith-based system), our go-to group for tough issues is the Ethics Committee but this issue seems to be too clear cut for them. We have very clear criteria for determining whether a patient is eligible for discharge. If the patient does not meet those criteria, then the insistent physician is violating an established P&P. This would be referred to the Chief Medical Officer & handled by Medical Exec Committee - hopefully they will discipline the offending doc.

Kudos to you - you are my hero.

[Mommy&RN, BSN, RN]

Way to go! That was pt advocacy at its finest. I would have incident reported about the physician.

[Codeblue1982]

Thanks for the input, unfortunatly there is no clear discharge criteria or policy regarding disruptive physicians. The medical director I spoke with did inform me that many complaints have been brought to her about this MD but they do not have a culture of interfering with each others practice and decision making, and will only make suggestions. I did fill out an incident report as soon as it was determined the patient was staying with us. I am going to go through all of the channels to try and see what can be done to develop a policy for situations like this.

[Mommy&RN, BSN, RN]

Good job!

[sadiemae1123]

Why didn't the medical director assume care after the PCP threw his little hissy fit? If this is an ongoing problem with this doc then it sounds like the director needs to have a serious discussion with disciplinary action with the PCP.

[NYbabyRN, BSN, RN]

Wow, you did a great job but this type of behavior from the physician is horrible. I have had instances somewhat similar to this were the primary physician did not want to address a critical patient situation, but never a discharge situation. This behavior is unacceptable, but they somehow seem to get away with it.

[Esme12, ASN, BSN, RN]

GOOD FOR YOU!!!!!!!!!!!

What a donkey! Where I have worked the department head would intervene. As well as risk management.

Report him to the board.

What a donkey.

[MunoRN, RN]

I've worked at a place with a similar issue and the 'policy' was to discharge the patient directly to the ER.

[LadyFree28, BSN, LPN, RN]

Way to go! That was pt advocacy at its finest. I would have incident reported about the physician.

I would've incident reported that physician as well.

Great job!

[nurseprnRN, BSN, RN]

The policy you seek is the ANA Scope and Standards of Nursing Practice (ANA, 2010) (available at Amazon, cheap), which is binding on all RNs regardless of venue or state nurse practice acts (and most of those are liberally copied from the S&S anyway).

I think that the first thing you would cite would be Standard 7, Ethics, which states in part:

The registered nurse ...

... Takes appropriate action regarding instances of illegal, unethical, or inappropriate behavior that can endanger the best interests of the healthcare consumer or situation.

... Speaks up when appropriate to question healthcare practice when necessary for safety ...

Also, if you haven't already, report this to the hospital risk manager directly. S/he may get the incident report, but you can go down to the office and give a verbal report so there's a face to go with the name, as it were. RMs take this sort of thing VERY seriously.

[ICU56]

House supervisor. Any time a MD (or anyone else) decides to ignore the best interests of the patient, a quick call and something gets done fast. We are pretty much the only game in town, or at least the biggest, I've seen what happens to docs who get on our bad side...They lose privileges or leave the county. Not that they don't still have 1000x more leeway than an RN...

Great job advocating for the patient though!