Ethics Case Study: Developing a safe, successful discharge plan

January 21, 2015 § Leave a comment

Starting this month, Dually Noted will regularly present an ethics case study from the Commonwealth Care Alliance Ethics Committee. As described in our Fall 2014 provider/partner newsletter In Common, the Committee holds monthly meetings to explore complex and important ethical questions faced by our members and clinicians. The primary mission of the Committee is to educate clinicians and support them in delivering care that conforms to the highest ethical standards.

This month’s case study concerns “Susan,” a middle-aged woman currently residing in a skilled nursing facility who is requesting a discharge home.  Her Commonwealth Community Care One Care Team is having difficulty finalizing her discharge plan.

The background:
Susan was diagnosed with neurodegenerative disease several years ago. The disease has progressed rapidly, causing a significant decline in her functional abilities. She previously lived at home with her elderly parents and sibling but has been a resident in a skilled nursing facility since the end of last year after a hospitalization. Over the past two years, she has only spent one overnight at home.

Since her recent enrollment in One Care, the focus of her care plan has been on discharge home.              

A number of efforts have been made to develop a discharge plan, including an assessment of her family’s home for accessibility and an evaluation for appropriate Durable Medical Equipment (DME). Also, over the past few months, there have been several group meetings with the member, family, LTSS (Long-Term Supports & Services) Coordinator, and Commonwealth Community Care One Care Team to address a safe discharge home.

A Commonwealth Community Care (CCC) Occupational Therapist (OT) has made several visits to the home and has received mixed messages from the family.  For example, the parents will allow Susan to use a bathroom that does not have a shower once she comes home,. They also ruled out Susan living in the most accessible room with the most accessible entrance, thus requiring CCA to install a long ramp and make extensive renovations to the home. Also, Susan’s sibling, who lives at the parents’ home, has made statements indicating ambivalence to having Susan discharged home. Other problems have stemmed from plans to accommodate the DME that Susan requires, including a hospital bed, specialty mattress, wheelchair, lift system, and commode.

There has also been much discussion as how to provide the extensive amount of personal care that Susan needs. The parents, who are home during the day, are too elderly and frail to offer any personal care and can just assist with meals. They prefer a Home Health Aide (HHA) for the day and evening hours. The sibling works during the day but agreed to cover the needed Personal Care Attendant (PCA) hours overnight, when Susan requires assistance with turning in bed. The plan also calls for the member to go to a day program a few times each week for socialization. The day program will also be able to shower the member when she is there.

The ethical case:
From an ethics standpoint, this case focuses on the challenges inherent in developing a safe and successful discharge plan. The care team must balance two competing ethical principles: autonomy and beneficence (doing good).  Any discharge plan must respect the member’s autonomy – Susan’s ability to make decisions for herself – while also addressing the care team’s concerns about beneficence – planning for a safe discharge to her home.

The Ethics Committee noted that as much as we try to prioritize autonomy as our guiding ethical principle and provide patients with authentic options, there are limits to autonomy: an individual cannot exercise autonomy if the circumstances, in this case the home and family environment, are unable to support an individual’s preferences.

The Ethics Committee was moved by the member’s personal history. Prior to her illness, her entire life had been lived with her family in that house.  Not only had she lost her physical abilities to function independently but her parents were frail and failing.  Her sister, the only able-bodied member of the household, was overwhelmed with her caregiving duties.  The fact that the family was equivocal and uncertain in undertaking Susan’s care in the home is understandable.  Susan’s heart-felt desire to return home is also understandable.

The Ethics Committee also understood the care team’s concerns about the member’s safety and how to ensure a successful discharge to her home. The main stumbling-block was the family’s understandable ambivalence about Susan coming home, and how that ambivalence found expression through an unwillingness to support the safest and most appropriate discharge plan.

Accommodations appear to be available that will provide some elements in a care plan, including home health aides caring for Susan during the day and evening, her sister being available during the night, and access to a shower (as long as she continues to go to the day program), but other important features, in particular easy access to the home, remain missing. Of equal concern is whether the family is fully committed to Susan returning home. Their ambivalence raises concerns that they’re looking for ways to sabotage discharge home or, once Susan is home, that they’ll promptly return her to an institutional care setting.

In answer to the question “Should this member be discharged to home?” the Ethics Committee concluded “yes,” ideally, but only if the family was willing to meet the team half-way and express their commitment to the plan by allowing appropriate supports to be put in place to optimize Susan’s safety and well-being. That is, only if conditions are established that would allow Susan to exercise her autonomy and fulfill her preference to live at home.

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