Self-discharging patient Flashcards
You are the medical SHO oncall overnight covering the AMU. The nurse in charge tells you that Miss Smith, a 28-year-old woman, who was admitted earlier today, wants to be discharged. She was admitted with pyelonephritis and has been started on IV antibiotics. She is telling the nursing staff she feels much better and needs to get home. The nurse does not think Miss Smith should be allowed to leave as she still has several days left of treatment. He has asked you to come and speak with the patient.
How would you approach this patient?
This scenario raises the issues of patient autonomy and capacity
I would start by trying to find out more information, as I don’t know any background surrounding the admission. I would start by reading the notes and speaking with the nurse in charge. Then, I would speak with the patient and find out why she wants to leave.
It could be that she feels much better after the first dose of antibiotics and it has not been fully explained to her that antibiotics are most effective if given over several days intravenously.
It could also be that she has legitimate reasons for why she wants to leave - a) young children - who is looking after them? b) concerns for work etc - I would explore these with her.
After doing this, I can assess the issue of capacity. Capacity is assumed unless there is a reason to doubt otherwise. If I would have a reason to doubt her capacity, I would proceed to a formal capacity assessment.
If she insists on discharging herself, I would:
* Explain why I believe that she should stay in the hospital and explain **the risks **of her discharging herself against medical advice
* I would have her sign the discharge against medical advice form
I would still aim to maximise patient safety, as beneficence is a key ethical principle. I would offer give her an FP10 form for oral antibiotics appropriate to treat uncomplicated pyelonephritis. I would also safety net her and ask her to follow up with her GP.
Patient autonomy - one of the basic principles of medicine, which states that every person has the right to make informed decision about their healthcare and that healthcare professionals should not impose their own beliefs or decisions upon their patients
Capacity - a person’s ability to process information and make an informed decision about their care in a way that is in line with their beliefs, values, and preferences
What do you understand by capacity?
Mental capacity is the ability to make decisions by yourself.
The Mental Capacity Act 2005 states that every adult has the right to make this or her own decisions and that capacity should be assumed until proven otherwise. All individuals should be encouraged and empowered to make their own decisions. Individuals have the right to make decisions that may seem unwise to others.
How do you assess capacity?
Assessing capacity is a two stage test
- If there is no impairment of mind (stage 1) then the patient can be assumed to have capacity
- If there is an impairment of mind, then to demonstrate capacity the patient must
* Understand the information relevant to the decision
* Retain the information
* Weigh up the information in the decision making process
* Communicate the decision
Do you still have a duty of care to the patient if she self-discharges?
The first ethical principle in medicine is beneficence, which means I must act in the patient’s best interests. The patient wants to leave and so I must act to ensure that she is safe. I would make sure that she understands what to look out for with regards to any signs of worsening infection and impress upon her that she should seek medical help if she is deteriorating. I can provide her with medication on discharge and make sure that she has follow-up arranged.
What would you communicate to her about the antibiotics?
It is important that the patient understands the risks with not completing a full course of antibiotics. The likelihood of bacteria developing resistance to antibiotics increases if the full course is not given. If the patient were determined to leave then I would discuss the case with the microbiology team to see if there is an oral alternative. I would make sure a urine sample has been sent and ask the patient to return to ambulatory care in a few days to review the results. This would also act as a good way to safety net, allowing us to review the patient early and potentially pick up any complications.
