Medical Protection’s Medicolegal Adviser Dr Clare Redmond discusses how to manage a situation where a patient asks to be discharged
Read this article to:
- Understand the steps to consider when an adult requests their discharge
- Learn what you are required to do when assessing patient capacity and considering best interests
Junior doctors are increasingly being asked to talk to patients who are looking to self-discharge. There are reports of rising numbers of self-discharges from hospital,1 and the ability to assess a patient requesting their own discharge from hospital is a necessary skill for all new doctors.
Many hospitals have a self-discharge policy, and this should, of course, be followed. The main concern is often whether the patient has the capacity to make the decision over their own discharge and whether there is a risk of harm to the patient should they be allowed to leave. It is not uncommon that patients don’t wish to hang around to discuss their concerns and decide to self-discharge out of hours, providing little time for a detailed assessment.
When approaching a patient to discuss their discharge, it is advisable to gather as much information about their admission and medical history, both from review of their records and discussion with nursing staff. Where possible, discuss the patient with the team responsible for their care, or a more senior member of the team, before you speak to them.
Identifying categories of patients
It can be helpful to bear in mind the three broad categories of patient your assessment should identify:
- The adult patient with capacity to make the decision to self-discharge against medical advice – they are free to leave.
- The adult patient who lacks capacity to make the decision to self-discharge against medical advice – further consideration as to whether discharge is in the patient’s best interests is required.
- The adult patient with evidence of an acute mental disorder where there is the potential for the risk of further deterioration or harm to the patient or others – discussion with the mental health team and possible Mental Health Act Assessment required.
In reality, there can be a fourth category of patient – where there is doubt over their capacity to make decisions, where the medical conditions are complex and where the potential consequences of leaving hospital are serious and/or life-threatening. When assessing capacity, it is necessary to ensure you are providing the patient with the information they need, including about risks and benefits, to come to a decision about their care. If your initial assessment of the patient results in you feeling concerned that you don’t have the knowledge or competence to fully discuss their care, you should ensure you discuss the patient promptly with a more senior colleague. Ultimately, difficult decisions around capacity and complex medical treatments may be made by the courts.
Documenting the discussion
Documentation of the discussion with the patient and your assessment is essential. For those patients leaving hospital against advice, ensure you include the information provided about the potential consequences of this decision. Follow-up plans and options for reassessment in the event of deterioration should be explained to the patient. You may need to seek advice from others to confirm these details and to communicate the patient’s departure, ensuring that their GP is informed of their discharge.
Assessing patient capacity
It is common for patients in hospital to become acutely confused or have underlying conditions affecting their capacity. When assessing these patients remember that there is a presumption of capacity enshrined within the Mental Capacity Act (2005)2 in England.and the Adults with Incapacity (Scotland) Act 2000 in Scotland.3 The onus is on you to demonstrate (and document) a lack of capacity, not on the patient to disprove it.
Make sure you complete a thorough assessment of capacity where appropriate. Remember that you must be able to demonstrate evidence of an impairment or disturbance in the functioning of the mind or brain of the patient (whether temporary or permanent), and that this impairment is preventing decision-making over leaving hospital, for the first stage of the capacity assessment to be met.
Document the discussion you then have with the patient. Ensure you highlight your conclusion that the patient does not understand the information you are providing (about the decision to self-discharge and the consequences), cannot retain this or cannot use the information provided to weigh up their choices and come to a decision. Where there are communication difficulties, consider communication aids or interpreters.
What’s in the patient’s best interests?
For patients who lack capacity, the next step is to ascertain what is in their best interests: this could actually be their discharge from hospital. It is likely that additional time and discussion will be required to come to this decision, depending on who is available at the time you see the patient. Remember that the Mental Capacity Act (2005) and the Adults with Incapacity (Scotland) Act 2000 make clear that patients who lack capacity to make decisions must continue to be involved in decisions about their care, and the least restrictive option (that will still achieve the purpose) should be chosen. There are a number of individuals who should be consulted about any best interest decision, including anyone with a legal right to make decisions on the patient’s behalf.
If you have any doubt about assessing capacity or the relevant legal framework you should discuss the case with a senior colleague or contact Medical Protection for advice. It is important to note that mental capacity legislation varies between the different nations within the UK and that Northern Ireland currently does not have specific legislation.