What Is It That You Want Me To Do? Guidance for Ethics Consultants in Complex Discharge Cases

Omelianchuk, A., Ansari, A.A. & Parsi, K.

HEC Forum (2023).

https://doi.org/10.1007/s10730-023-09517-y

Abstract

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is “stuck” in the hospital and the ethics consultant is called to help get the patient “unstuck.” These encounters, which we call “complex discharges,” are beset with tensions between the interests of the institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process.

The article is paywalled.  Please contact the author for full copy.

Here is my summary:

• Ethics consultants face diverse patient situations, including lack of desire to leave, potential mental health issues, and financial/space constraints.
• Fair discharge processes are crucial, through mediation or multidisciplinary committees, balancing patient needs with system limitations.
• "Conveyor belt" healthcare can strain trust and create discharge complexities.
• The ethics consultant role is valuable but limited, suggesting standing "complex case committees" with diverse expertise for effective, creative solutions.

In essence, this summary highlights the need for a more nuanced and collaborative approach to complex discharges, prioritizing patient well-being while recognizing systemic constraints.

What Is Wrong With Discharges Against Medical Advice (And How to Fix It)

By David Alfrandre and John Henning Schumann
JAMA
First published November 11, 2013

Here is an excerpt:

It is time to rethink the approach to this issue. For a profession accountable to the public and committed to patient-centered care, continued use of the discharged against medical advice designation is clinically and ethically problematic. Designating a discharge as against medical advice is a clinical practice without standards, legal requirements, or demonstrated benefits to patients, and there is evidence of its harm. The more relevant and pressing question should be, “Why would you discharge a patient against medical advice?” Without a compelling answer to that question, continued use of the practice does not seem justified. Taking leadership on this problem through enhanced research, teaching, and quality patient care ensures that the profession will honor its commitment to providing patient-centered care and improving clinical outcomes.

The entire article is here.

Thanks to Gary Schoener for this information.

Calling for an End to Phony Military Discharges

Letter to the Editor

New York Times

Originally published March 3, 2012

To the Editor:

“Branding a Soldier With ‘Personality Disorder’ ” (front page, Feb. 25) scratched the surface of an important military scandal.

I have been investigating personality disorder discharges for the last six years. In that time, I’ve interviewed dozens of physically wounded soldiers who were booted from the military with a phony “pre-existing personality disorder,” which prevents the soldiers from receiving disability and medical benefits. They even have to give back a chunk of their signing bonus.

Soldiers severely wounded in combat are finding out on their final day in uniform that they will never get disability benefits — and they now owe the military thousands of dollars.

I have also interviewed military doctors about being pressed by their superiors to misdiagnose wounded soldiers. One doctor told me of a soldier who came back with a chunk missing from his leg. His superior pressured him to diagnose that injury as personality disorder.

The numbers in this scandal are staggering. Since 2001, the military has discharged more than 31,000 soldiers with personality disorder, at a savings to the military of over $17.2 billion in disability and medical benefits.

Barack Obama had been at the forefront of this issue. As a senator, he put forward a bill to halt all personality disorder discharges. But as commander in chief, he has done nothing to halt these fraudulent dismissals.

The American people should confront the president and the Republican presidential candidates with this question: As commander in chief, what actions will you take to keep these phony personality disorder discharges from devastating another military family?

JOSHUA KORS

New York, Feb. 26, 2012

The writer is a freelance reporter.

Branding a Soldier With ‘Personality Disorder’

By James Dao

Capt. Susan Carlson

The New York Times

Originally published on 2/24/12

Capt. Susan Carlson was not a typical recruit when she volunteered for the Army in 2006 at the age of 50. But the Army desperately needed behavioral health professionals like her, so it signed her up.

Though she was, by her own account, “not a strong soldier,” she received excellent job reviews at Fort Leavenworth, Kan., where she counseled prisoners. But last year, Captain Carlson, a social worker, was deployed to Afghanistan with the Colorado National Guard and everything fell apart.

After a soldier complained that she had made sexually suggestive remarks, she was suspended from her counseling duties and sent to an Army psychiatrist for evaluation. His findings were shattering: She had, he said in a report, a personality disorder, a diagnosis that the military has used to discharge thousands of troops. She was sent home.

She disputed the diagnosis, but it was not until months later that she found what seemed powerful ammunition buried in her medical file, portions of which she provided to The New York Times. “Her command specifically asks for a diagnosis of a personality disorder,” a document signed by the psychiatrist said.

Veterans’ advocates say Captain Carlson stumbled upon evidence of something they had long suspected but had struggled to prove: that military commanders pressure clinicians to issue unwarranted psychiatric diagnoses to get rid of troops.

“Her records suggest an attempt by her commander to influence medical professionals,” said Michael J. Wishnie, a professor at Yale Law School and director of its Veterans Legal Services Clinic.

The entire story is here.