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Tuesday, January 23, 2024

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).


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.