Difficult discharge post syncopal episode

Question 1

An 85 year old non-english speaking female has been in hospital for 3 days under your team following a syncopal episode, for which no cause was found despite routine blood tests, serial ECGs and a CT brain. You are told on the ward round to discharge her, but her children insist she stay in hospital until a cause is found. How would you manage this situation?
Introduction

Answer 1

Goals are;

• discuss with patient and children to understanding their ideas around her presentation and their ongoing concerns, utilising a translator so that the patient is informed through the discussions
• reassure family regarding the adequate amount of testing ruling out any serious causes
• ensure safety netting and arrange a follow-up GP appointment.

Question 2

Difficult discharge - History

Answer 2

History

• ensure patient and children understand the situation
• screen for any new symptoms previously unaware of
• check patient and family understanding of management plan and the tests that have been conducted
• utilise appropriate translator throughout consultation

Question 3

Difficult discharge – Examination

Answer 3

Examination

- ensure vitals stable, no new sx

Question 4

Difficult discharge – Investigations

Answer 4

Investigations
- no further investigations required at present, review the results from each investigation, relay any appropriate information to the family.

Question 5

Difficult discharge – Management

Answer 5

Management
engage in constructive family discussion;
Key considerations
- capacity of patient and family
- environment: quiet, peaceful
- need for translator
- avoid medical jargon and utilise visual aids where necessary

• Discern families key concerns, and underlying beliefs/cultural components, past experiences, anecdotal evidence
• ensure patient understands being looked after, not neglected, best place is home right now, explain risks associated with being in hospital, particularly as an elderly person.
• Explain the processes undertaken to rule out sinister causes
• utilise MDT, engage social worker in consultation if relevant
• Important to emphasise that care is not being stopped; engage in appropriate safety netting including GP referral for follow-up, tell patient when to come back and what symptoms to watch out for, consider involvement of aged care services/ACAT assessments
• escalate the matter to senior staff if there is still refusal of proposed discharge