Hospital Discharge: Could it be a bit more hospitable?

I may be one of the few people on the planet who invested my second language studies in Latin. And yes, it probably would have been more practical to study a language people actually speak!

While having a working knowledge of Latin has been helpful for crossword puzzles, at other times my intellectual curiosity simply gets the best of me. A recent call about a hospital discharge experience piqued my curiosity about where the words “hospital” and “patient” and come from. Hospital comes from the Latin word “hospes,” which essentially means a guest or stranger. It’s also the root for words like hostel, and hospitality. “Patient” comes from the Latin word “patior,” to suffer. So from these Latin roots it’s easy to understand why we might consider hospitals to be “a special place of care for guests/strangers who are suffering.”

This word study also sheds light on why some hospitals have become more “hotel-like” fueling our expectation that they have an obligation to take care of us when circumstances prevent us from taking care of ourselves. At the same time with the increasing cost of care and demands on hospitals, especially at discharge, too often we experience them as not such caring places.

Marilyn’s sister, Annie,* fell on a Saturday afternoon. Annie had been disabled for some time from multiple sclerosis and depression, but was living alone in her own apartment. Marilyn called Annie’s primary care doctor, and was told to go to the nearest ER. Annie’s ankle was broken.  Instructed not to put any weight on her leg, as she was being discharged, the nurse gave her the name of a medical supply company to order a wheelchair, and scheduled Annie to see an orthopedic surgeon late the next week.

Marilyn was panicked. Annie’s apartment wouldn’t accommodate a wheelchair, and the only shower was in a bathtub. Marilyn worked full time and knew that Annie would not be content to sit on the couch all day, unable to get to bathroom on her own, or to stand to prepare food. And the accident had really made her MS symptoms and depression worse.

She asked the emergency room doctor why they were sending Annie home – after all her ankle was fractured, she was obviously going to have to be in a wheelchair and there was no one to take care of her at home. Wasn’t the hospital responsible for keeping her until arrangements could be made?

Being treated in the emergency room isn’t the same as being admitted to the hospital. While hospital emergency rooms are mandated by law to provide care to anyone who walks in the door without regard to their ability to pay, they don’t have a legal obligation to manage or support what happens after that care is delivered.

In Annie’s case, after the usual wait to be seen in the ER, she was X-rayed, and a diagnosis was made. A splint was applied, and a follow up doctor’s appointment was scheduled. Thus endeth the ER’s obligation to Annie.

The fact that she lived alone, and that a wheelchair wouldn’t get through the front door was essentially immaterial. Marilyn and Annie were on their own to figure out what to do. Unless.

Unless Annie had been admitted to the hospital after she was seen in the emergency room. Let’s say she needed immediate surgery on her ankle. She might have been prepped for surgery and taken straight from the emergency room. Surgery completed, she’d be taken to a room and her in-patient care would begin.

In this case, when the hospital admitted Annie for in-patient care, modeled largely after Medicare guidelines, most assume an obligation to make sure that the patient has a “safe discharge.” While this is an ethical standard, the laws governing this vary from state to state. So as you might imagine, what exactly defines a safe discharge is somewhat open to interpretation.

Hospitals have to evaluate the capacity of the patient to make an informed decision about their care, whether a patient has a reliable caregiver at home, and if not, what other resources can be applied to assure the patient’s safety. It’s a complicated process. Patients and their caregivers want to be prepared, but this report from Kaiser Health News makes clear it’s the exception rather than the rule.

If a hospital discharge has been “sprung” on you or a loved one, and you know there will be issues with safe and adequate care consider these options:

  • If you are being discharged from the emergency room without being admitted, expecting the hospital to help with care at home may not be realistic. Still, they may have a social worker for the emergency room that can help put a contingency plan together.
  • If you’ve been admitted, start thinking about what’s going to happen when you leave the hospital sooner rather than later. Discuss your living situation with the medical team, as well as involving family and friends in the discussion.
  • While you may not know exactly what care will be needed, ask to meet with the discharge planner assigned to your floor. Usually a licensed social worker, these professionals can help patients and family understand options and build a care plan. Click here for some guidelines on how to approach this.
  • Try to negotiate additional time with the treating physician. While hospitals can’t keep patients indefinitely, if it is taking more time than expected to make care arrangements, sometimes the treating physician can justify a patient staying an extra day or two before discharge.
  • Don’t be surprised if you get a list of options from a hospital but no real recommendations. Hospitals are often pressured to discharge patients quickly and the burden of completing a care plan falls on the family. Identifying the best medical equipment supplier, rehab facility or home care agency and support can be daunting. If a discharge feels premature or unsafe, or you need help evaluating options, a private patient advocate can help.

*Name and some details changed to protect patient confidentiality.

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