Ethical/moral issue

[dee78]

Background:

Patient is inpatient in an acute care facility due to dialysis non-compliance. Patient had to have security called during admission due to behavior. Patient is verbally abusive to staff and threatens lawsuits any time he doesn't get his way. Patient is to be discharged but claims he will file a lawsuit if discharged without a perm cath for dialysis, he says it hurts when they dialysis through a newly matured fistula. Doctors schedule the placement for the following evening, with orders for him to dialyze and be discharged.

Orders are carried out, patient discharge is completed within 15 minutes of returning to floor. Patient gets ready to go, taxi is called. Patient calls out that he needs his nurse, nurse responds and patient states that he can't leave because no one is at the house he stays at and he won't just sit out in the cold all night.

This is actually quite common in our facility, patients are discharged and we even pay for their cab home but then they refuse to leave. Typically, the patient is put in the cab and sent on their way, even if it is to a homeless shelter. Sometimes security has to be called to escort the patient to the cab.

There are a few things that make this a more ethical dilemma. The discharge is at 2200 on a very cold night. The patient is blind. Patient has been walking up and down the hall on his own and going outside to smoke. Patient is receiving IV pain medication and gets very upset when it is not given when he asks for it, even after being told that he can have it at 00:00.

Do you ask the doctor to allow the patient to stay another night even though there is no medical necessity? If so, do you put stipulations such as no IV pain medication?

Do you call the cab and send him on his way to wherever he wants to go?

Do you call security to escort him to the cab?

[CrunchRN, ADN, RN]

I have a feeling you cannot win for losing in this situation. Wish I had the answer. Maybe provide a voucher for 1 night at a flea bag hotel so he can arrange access to the house in the am?

[HouTx, BSN, MSN, EdD]

Call Social Services/Worker ASAP. This (home situation, psych?) is their baliwick, not yours. I love me some Social Workers!!!

[dee78]

Our case manager was called, he ultimately made the decision that got us all written up.

[psu_213, BSN, RN]

This is why admission planning begins on admission...so that we can try to avoid these situations when the time comes for them to do.

It does seem heartless to discharge this man when he does not have a place to go; however, there are thousands of people in my community who have to spend a night out in the cold. Do I feel bad? Absolutely. However, if we allowed this one individual's unfortunate circumstances dictate that he gets to stay in the hospital, then to whom do we say no? I agree that this is a lose-lose scenario, but social admissions will create an undue burden on a hospital that has finite resources. Get social work involved and they can help to make arrangements for this individual.

[classicdame, MSN, EdD]

agree that planning ahead who will take him home is essential. You cannot withhold pain meds if he is still a patient. In fact, that is a reason for allowing him to stay - pain management. It seems heartless to D/C that late so I think you are stuck with him till a.m. at least. SW and Case Mgr will probably know the patient by now and should be included in planning when he is admitted the next time. I cringe when people say pain meds are not due till-----if his vital signs are ok and he has an order, give the meds. Better for you and for him.

[dee78]

I really don't believe this could have been prevented. He was being discharged to his home and provided a taxi due to lack of family assistance.

I don't think I understand the "meds aren't due til" statement. If the order states q6h but he asks for it after 3, do you give it to him because he says he is hurting? I am a new nurse so I am genuinely curious. If the order states dilaudid IV q6h, PRN for pain. When do you give him more?

[Sun0408, ASN, RN]

If the med is scheduled q6h, that's how often you can give it. If the pt is still in pain, you can call the MD and ask for something else. IV pain medications do not last long so the pt should have something PO as well. As for the situation, the pt is manipulative and he is getting his way. I would not however DC someone so late. Has it happened, of course but usually the pt requests to go that late.

[NurseCard, ADN]

Background:

Patient is inpatient in an acute care facility due to dialysis non-compliance. Patient had to have security called during admission due to behavior. Patient is verbally abusive to staff and threatens lawsuits any time he doesn't get his way. Patient is to be discharged but claims he will file a lawsuit if discharged without a perm cath for dialysis, he says it hurts when they dialysis through a newly matured fistula. Doctors schedule the placement for the following evening, with orders for him to dialyze and be discharged.

Orders are carried out, patient discharge is completed within 15 minutes of returning to floor. Patient gets ready to go, taxi is called. Patient calls out that he needs his nurse, nurse responds and patient states that he can't leave because no one is at the house he stays at and he won't just sit out in the cold all night.

This is actually quite common in our facility, patients are discharged and we even pay for their cab home but then they refuse to leave. Typically, the patient is put in the cab and sent on their way, even if it is to a homeless shelter. Sometimes security has to be called to escort the patient to the cab.

There are a few things that make this a more ethical dilemma. The discharge is at 2200 on a very cold night. The patient is blind. Patient has been walking up and down the hall on his own and going outside to smoke. Patient is receiving IV pain medication and gets very upset when it is not given when he asks for it, even after being told that he can have it at 00:00.

Do you ask the doctor to allow the patient to stay another night even though there is no medical necessity? If so, do you put stipulations such as no IV pain medication?

Do you call the cab and send him on his way to wherever he wants to go?

Do you call security to escort him to the cab?

Just my 2 cents..... when I had my daughter via C section, she ended up having to stay an extra day due to having lost too much weight since birth, but I was all ready for discharge. The hospital therefore was going to let me stay one more night, but I would be strictly what was called "on hotel status". That meant that I would receive no medical treatment but would still be housed in my room.

Maybe the hospital could have done something like this for this patient? He however would have eventually been responsible for coming up with the money for this extra night, out of pocket, since insurance doesn't pay for it.

[BrandonLPN, LPN]

I agree with the poster who said you should pass this off to social services. You shouldn't be expected to be bothered with this anymore than they should be expected to perform nursing duties.

[nurseprnRN, BSN, RN]

I loved the guys who would get their HD or their q12h antibiotics for their IV-drug-abuse-related endocarditis, then check out for the rest of the day with that oh-so-handy big old central line. MUCH easier than screwing around trying to find a vein. They'd come back for their q12 again, and then back to the street.

[Sun0408, ASN, RN]

I loved the guys who would get their HD or their q12h antibiotics for their IV-drug-abuse-related endocarditis, then check out for the rest of the day with that oh-so-handy big old central line. MUCH easier than screwing around trying to find a vein. They'd come back for their q12 again, and then back to the street.

Yep, I worked a renal floor for a year before moving on, this was typical. Sad really, pt in question will be back for sepsis re to that line, I even had some infect it themselves just to get back in the hospital. 3 meals a day, all the snacks and a warm bed.. Not to mention the staff to cater to them