Discharging a homeless patient from hospital raises ethical issues which are compounded when the patient is from outside the United Kingdom. This article begins with an extended case study of a 30-year-old homeless man from Lithuania describing his complex medical and social needs. It is best practice for all homeless patients to have their housing needs planned for prior to discharge, but this is made more difficult by the United Kingdom’s ‘hostile environment’ policy which creates a subclass of homeless (...) people who are not eligible for support. This means healthcare professionals discharge patients back to homelessness, even when this is likely to adversely affect their health and dignity both directly and indirectly through impairing access to care for chronic conditions. Policies in health and social care which compel professionals to treat some patients with second-class care undermine the ethics of healthcare professions. (shrink)

The ethical obligation to provide a reasonably safe discharge option from the inpatient setting is often confounded by the context of homelessness. Living without the security of stable housing is a known determinant of poor health, often complicating the safety of discharge and causing unnecessary readmission. But clinicians do not have significant control over unjust distributions of resources or inadequate societal investment in social services. While physicians may stretch inpatient stays beyond acute care need in the interest of (...) their patients who are experiencing homelessness, they must also consider the implications of using an inpatient hospital bed for someone without the attendant level of medical need. Caring for patients in an inpatient setting when they no longer require acute care means fewer beds for acute care patients. And when a patient who is experiencing homelessness declines a medically safer option such as a skilled nursing facility, then clinicians may be faced with the sole option of discharge to the street, which raises troubling questions of nonmaleficence and social justice. Here we investigate the different forms of injustice that play out when patients are discharged to the street, and offer a map of the interwoven ethical responsibilities of clinicians, hospitals, and skilled nursing facilities. (shrink)

Mrs. Smith's eyes filled with tears as she said, “I feel like I've done something wrong. Are they punishing me because I've been refusing therapy and won't go to a nursing home?” She acknowledged that she hadn't always listened to her doctors but said that she knew better now and wanted to go home and see if she could make it work. Many staff members at our rehabilitation hospital had explained their safety concerns to her, and some had enlisted her (...) adult daughter, with whom she lived, to convince her too. The rehabilitation team had called on the ethics consultation service, of which I am a part, to help figure out whether Mrs. Smith had the capacity to make an informed refusal of discharge recommendations. (shrink)

A growing number of discharges at acute-care hospitals involve patients who are undocumented and lack legal status. Because such patients are ineligible for public assistance, long-term care facilities will routinely deny them admission. These discharges become complex discharges because of such financial barriers. If local family support is unavailable, discharging such patients to a safe and suitable location becomes increasingly difficult. These complex discharges implicate a number of ethical principles. We describe such complex discharge cases, apply various ethical frameworks, (...) and call for potential policy solutions to address this growing ethical concern. (shrink)

Preterm discharge effects: Relationship between the maternal experience and newborn's psychobiological regulation The purpose of this study is to investigate how the past experiences of mothers and their potentially traumatic events during pregnancy may have influenced the processes of psychobiological self-regulation and cognitive development in a child born preterm. Eighty children who had a gestational age of < 32 weeks were examined at the 9th month of the corrected age. The mothers and children were divided in two groups: multipara (...) mothers and their children and the primipara mothers and their children. These children were examined on the basis of sleep disorders, nutritional problems and mental development. Perinatal data from clinical observations and data from standardized developmental tests were used to describe the differences. The children of primipara mothers who had unexpected preterm delivery presented major incidences of sleep disorders while the children of primipara mothers, who programmed preterm delivery, presented a major incidences of nutrition problems. The predictability of preterm delivery has a major influence on the capacity of newborns for self-regulation in the case of primipara mothers. (shrink)

Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care. Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU admission criteria. Such discharge criteria can be interpreted differently by different healthcare providers, leaving a clinical void where misunderstandings of patients’ readiness can conflict with perceptions of what readiness means (...) for patients, families, and healthcare providers. In considering ICU discharge readiness, the use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and how clinicians might weigh these principles in their decision-making process. This article examines the concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy [respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify factors that help determine discharge readiness within critical care environments that will ultimately promote safe and effective ICU discharges for patients and their families. (shrink)

During a clinical ethics fellow’s first week of independent supervised service, two unhoused patients on the same floor were resisting the medical team’s recommendations to discharge. In the team’s view, both were medically stable and no longer required hospitalization in an acute setting. The medical team suspected malingering for both. The social worker and case manager had employed their usual means of gentle persuasion and eliminating psychosocial barriers to no avail. Rather than call the police, the attending physician, social (...) worker, and case manager decided to call ethics. These cases lead the fledgling fellow to consider the appropriate role for ethicists in difficult discharge cases. The article analyzes each case, evaluates their similarities and differences in the context of suspected malingering, and comments on ethical issues surrounding cases of suspected malingering. Finally, I reflect on the value and importance of developing and maintaining epistemic and professional independence. (shrink)

In this article we wonder how a person can discharge the political responsibility for supporting and benefiting from unjust social structures. Firstly, we introduce the concept of structural injustice and defend it against three possible objections: ‘explanatory nationalism’, a diachronic interpretation of the benefits of industry-led growth, being part of a social structure does not automatically mean being responsible for its negative consequences. Then, we hold that both Iris Marion Young’s ‘social connection model’ and Robin Zheng’s ‘role-ideal model’ provide (...) clear indications on how to unload responsibility for supporting/participating in unjust social structures, but fail to explain how to get rid of responsibility for unjust enrichment. We maintain that both models should be complemented with a global redistributive scheme that allows to disgorge the benefits that are unfairly obtained in the global economic system, besides undertaking collective transformative actions and assuming ideal-role responsibilities. (shrink)

In this article I present four central challenges for Hennie Lötter’s book Poverty, Ethics and Justice. The first criticism takes issue with Lötter’s focus on social rather than global justice. Though he seems to be concerned with poverty everywhere, he takes social rather than global justice as the primary unit of analysis and this leads to a certain blindness to the ways in which discharging duties to the poor is a global not just society or state level project. My alternative (...) perspective also gives us more insights into the nature of our duties to one another and can accommodate a wider range of duties. A second set of concerns revolves around what we must do to discharge our duties to the poor and what we need to know to help effectively. We come to appreciate that helping effectively is no easy matter and supplying more guidance would be helpful. Third, after discussing some relevant empirical research, I also discuss the kinds of initiatives that deserve support, that can act as rough guidelines for would-be assisters. These more simplified guidelines do not place such heavy epistemic demands on those aiming to help. Fourth, I explore whether we can offer some more guidelines for determining which of many plausible policy initiatives we should support, given that there are many good ideas and limited resources. I offer one guideline for choosing among what appear to be plausible policies to support. (shrink)

In February 2016 a twelve-month-old asylum seeker, who came to be know as Baby Asha, was transferred from Nauru and hospitalized in Brisbane. This case came to public attention after Doctors refused to discharge Asha as she would have been returned to detention on Nauru. What in other circumstances would have been considered routine clinical care, quickly turned into an act of civil disobedience. This paper will discuss the ethical aspects of this case, along with its implications for clinicians (...) and the broader healthcare community. (shrink)

Discharge planning for vulnerable infants and children is a collaborative, inter-disciplinary, decision-making activity that is grounded in the ethical complexities of clinical practice. Although it is a psychosocial intervention that frequently causes moral distress for professionals and has the potential to inflict harm on children and their families, the process has received little attention from ethicists. An ongoing study of the transition of technology-dependent children from hospital to home suggests that the ethical issues embedded in the discharge-planning process (...) may be concealed by dominant cultural values, institutional policies, clinical standards, historical precedents, and legal regulations. (shrink)

‘Terminal discharges’ are carried out in Singapore for patients who wish to die at home. However, if due diligence is not exercised, parallels may be drawn with euthanasia. We present a theoretical discussion beginning with the definition of terminal discharges and the reasons why they are carried out in Singapore. By considering the intention behind terminal discharges and utilising a multidisciplinary team to deliberate on the clinical, social and ethical intricacies with a patient- and context-specific approach, euthanasia is avoided. It (...) is hoped that this will provide a platform for professionals in palliative medicine to negotiate challenging issues when arranging a terminal discharge, so as to avoid the pitfall of committing euthanasia in a country such as Singapore where euthanasia is illegal. It is hoped that a set of guidelines for terminal discharges may someday be realised to assist professionals in Singapore and around the world. (shrink)

In response to a competitive environment, hospital administrators are pressuring physicians to discharge Medicare patients “sicker and quicker” and to transfer indigent patients from their emergency rooms. This paper compares health administrators' ethics to public expectations regarding financially motivated hospital transfers and discharges. Health administrators use balancing strategies: code morality, survivalism, mission dependency, and tithing. Public expectations, exemplified in P.L. 99–272, P.L. 99–509, and recent case law, are based on norms of potential for patient harm and patient occupancy. These (...) norms are morally preferable to those of health administrators; they reinforce the value of identified lives and the reliability of the health care system. (shrink)

Pratt, Zion, and Loff (2012) correctly point out that most international clinical research (ICR) is not intended to address the vast inequities in access to health care between developed and develo...

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals’ roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses’ interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in‐depth insight into the (...) perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty‐five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses’ absence from morning rounds, one‐way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision‐making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse–physician interactions and the current context of nursing care. (shrink)

An ethically sound discharge from the hospital can be impeded by a number of factors, including a lack of payor for a patient’s care, a lack of appropriate discharge options, and a lack of authority to sign a patient into a long-term facility. In some cases, the primary barrier involves the patient’s lack of financial decision-making capacity.When a patient’s income comes primarily from government assistance, financial decision making is connected to both the individual’s well-being and to fair allocation (...) of resources. Taking away another person’s financial independence is a substantial intrusion on autonomy and should not be considered lightly. However, poor management of funds can lead to homelessness, medical noncompliance, vulnerability to financial exploitation, and other threats to human flourishing. As with medical decision-making capacity, poor decisions alone do not invalidate an individual’s right to self-determination. And as with medical decision-making capacity, such determinations should not be made ad hoc or be capricious, but should rely on sound assessment criteria. When there are justified concerns that a patient may be vulnerable due to limited financial decision-making capacity, an evaluation should be completed and a surrogate payee be sought, when appropriate. (shrink)

Every day around the country, patients are discharged from hospitals without difficulty, as the interests of the hospital and the patient tend to align: both the hospital and the patient want the patient to leave and go to a setting that will promote the patient’s continued recovery. In some cases, however, this usually routine process does not go quite as smoothly. Patients may not want to leave the hospital, or they may insist on an unsafe discharge plan. In other (...) cases, there may simply be no good place for the patient to go. These complex hospital discharge situations often involve ethical, legal, financial, and practical considerations, but the ethical issues inherent in these dilemmas have received only sporadic attention from clinical ethicists at best, leaving patients, providers, administrators, and caregivers unsure about what to do. When the ethical issues are in fact brought to light, analysis usually proceeds based on a consideration of the principles of autonomy, beneficence, nonmaleficence, and justice. However, principled analysis often fails to present patients and providers with a satisfactory solution, as the principles inevitably conflict. In this paper, I argue that difficult discharges are ethical dilemmas worthy of scholarly attention that goes beyond principlism, and I argue that providers and those involved in discharge planning ought to cultivate what philosopher Alasdair MacIntyre calls “virtues of acknowledged dependence” in order to care for these patients and their families. I first trace the current conversation about difficult discharge and show that the principled approach to resolving discharge dilemmas is not sufficient. I then argue that a new approach is needed, and to that end, I offer practical ways in which MacIntyre’s account of the virtues of acknowledged dependence may help patients, providers, and family members to navigate issues of difficult discharge. (shrink)

In this article I investigate the nature of the moral duties that citizens of a legitimate state have towards emigrants. A large part of the literature dedicated to the normative study of the migration phenomenon focuses on two major topics: the brain drain phenomenon and the legitimacy of restricting immigrations. If the first of these concerns the moral obligations that individuals have towards a state and their co-nationals, the second regards the policies that a state can justifiably adopt in order (...) to manage migration flows. With the exception of temporary labor migration, less discussed in the literature are the moral duties that we have towards those citizens who chose to emigrate. My answer is that a state has neither more, nor less responsibilities towards its emigrants than it has towards the other citizens. However, the particular way that it can discharge those duties have to pay attention to each citizen’s particular situation, so that public policies dealing specifi cally with the emigrants are required. If we embrace a sufficientarian position, we could see how public policies have to be forged in order to be morally justifiable. I compare in the article two potential ways in which a state could try to discharge its moral duties towards emigrants. The first consists in promoting policies that focus on reverse migration. The second is based on cooperating with host societies and ensuring that emigrants’ rights and well-being are protected to the fullest degree. I argue that the second proposal is the one that can be morally defended, and is in line with moral defenses of reformed temporary labor migration programs which would take into account the rights and legitimate interests of migrants (Baubock and Ruhs: 2022). (shrink)

“At-own-risk discharges” or “self-discharges” evidences an irretrievable breakdown in the patient–clinician relationship when patients leave care facilities before completion of medical treatment and against medical advice. Dissolution of the therapeutic relationship terminates the physician’s duty of care and professional liability with respect to care of the patient. Acquiescence of an at-own-risk discharge by the clinician is seen as respecting patient autonomy. The validity of such requests pivot on the assumptions that the patient is fully informed and competent to invoke (...) an at-own-risk discharge and that care up to the point of the at-own-risk discharge meets prevailing clinical standards. Palliative care’s use of a multidisciplinary team approach challenges both these assumptions. First by establishing multiple independent therapeutic relations between professionals in the multidisciplinary team and the patient who persists despite an at-own-risk discharge. These enduring therapeutic relationships negate the suggestion that no duty of care is owed the patient. Second, the continued employ of collusion, familial determinations, and the circumnavigation of direct patient involvement in family-centric societies compromises the patient’s decision-making capacity and raises questions as to the patient’s decision-making capacity and their ability to assume responsibility for the repercussions of invoking an at-own-risk discharge. With the validity of at-own-risk discharge request in question and the welfare and patient interest at stake, an alternative approach to assessing at-own-risk discharge requests are called for. The welfare model circumnavigates these concerns and preserves the patient’s welfare through the employ of a multidisciplinary team guided holistic appraisal of the patient’s specific situation that is informed by clinical and institutional standards and evidenced-based practice. The welfare model provides a robust decision-making framework for assessing the validity of at-own-risk discharge requests on a case-by-case basis. (shrink)

The discharge of older people from hospital at night is a topical and emotive issue that has recently gained media attention in New Zealand and the United Kingdom, including calls to prevent it occurring. With growing pressures on hospital capacity and ageing populations, normative aspects of hospital discharge are increasingly relevant. This paper therefore addresses the question: Should older people (say, over eighty years old) ever be discharged home from hospital during the night? Or given safety concerns, should (...) regulation against the night-time discharge of older people be put in place? Employing a principlist lens to bioethics, this paper considers key principles or values involved, including discharge safety concerns, personal preference and consent, the risk of remaining in hospital, and broader considerations around discharge policy. These points act as a possible framework for further research and discussion of normative aspects of hospital discharge. Overall, this paper argues that while discharge safety concerns must be properly acknowledged and addressed, it can still sometimes be appropriate for an older person to leave hospital at night. The option of night-time discharge should therefore remain open to people of all ages. (shrink)

How do we respond to the patient who no longer needs inpatient care but refuses to leave the hospital? Complex hospital discharges commonly involve consideration of legal, financial, clinical, and practical issues. Yet, the ethical and contextual issues embedded in complex inpatient discharges are of concern and have not received adequate attention by medical ethicists. The aim of this work is to encourage clinicians and administrators to incorporate a justice rubric when approaching inpatient discharge dilemmas. This paper presents justice (...) as the ethical principle most neglected in situations involving complex discharges and suggests that a justice focused lens allows clinicians and administrators to move beyond notions of patient autonomy in crafting morally responsible hospital discharge decisions that reflect efficient stewardship of an appropriate share of medically indicated services. This issue deserves additional attention from medical ethicists in the future. (shrink)

We discuss experimental support for the existence of a corollary discharge signal of attention movement control and its formulation in terms of the corollary discharge of attention model of attention movement . The data is from fMRI, MEG and EEG activity observed about 200 ms after stimulus onset in various attention paradigms and in which the activity is mainly sited in parietal and extra-striate visual areas. Moreover the data arises from neural activity observed before report of a subject’s (...) experience occurs. The overall experimental support for the existence of a copy of the attention movement control signal generates, it is suggested, a viable route to explore the relation between this signal and human consciousness, as concluded in the paper. (shrink)

Terminal discharge or discharging terminally ill patients from hospitals in Tanzania as any other end-of-life care decision does not go without moral dilemma. Although the resolutions of end-of-life care decisions in hospitals in Tanzania focus much on material order rather than moral order, this paper shows the moral imperative of terminal discharge. The paper picks one of the controversial bioethical moral issues that are always raised in end-of-life decisions; ‘the distinction between human beings and human-person’ and analyzes it (...) through linguistic categories of Kiswahili language. From the reflections on the semantic charge of human beings (binadamu in Kiswahili) and human-person (mtu in Kiswahili), it is possible to infer that their distinction holds to moral criterion that may influence terminal discharge in Tanzania. The former is a quality that is inborn in so far as anyone who is born as a human being has nature humanity (ubinadamu). The latter, however, introduces a nuance according to which the moral component enables to take humanity away from animality up to humanness (utu). The question is that of knowing, in terminally ill discharge, whether the end-of-life decision makers act out of humanity (ubinadamu) or humaneness (utu). (shrink)

The meaning of being a middle‐aged close relative of a person who has suffered a stroke, 1 month after discharge from a rehabilitation clinicThe sudden and unexpected impact of stroke may have a stressful affect on close relatives. To illuminate the essential meaning in the lived experience of a middle‐aged close relative of a person who has suffered a stroke, narrative interviews were conducted with 10 close relatives of people who had suffered their first stroke where both parties were (...) aged over 18 and under 65. A phenomenological‐hermeneutic interpretation of the narratives was then conducted. Three intimately intertwined themes emerged during the analysis: ‘being called to mission’, ‘feeling lost and set adrift’ and ‘struggling to keep going’. The middle‐aged close relatives felt unreflectively duty bound. There was a struggle with suffering and enduring the process of coping with life and overcoming a feeling of helplessness. Life turned out to be a struggle with overwhelming feelings. They felt alienated in a restricted life situation, disconnected from themselves and others, and from a world that supports feelings of being lost and set adrift (i.e. feeling homeless). Strength was found in moments when the situation improved, in being related to oneself and others, and when feelings of normality were regained. (shrink)

There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.

Using conversation analysis, this study investigates how Japanese rehabilitation team members use their geographic knowledge to search for long-term care facilities for stroke survivors in multidisciplinary team interactions. The study uncovers the orderly use of decision rules during discharge planning activities by exploring the following two questions: What decision criteria are discursively used? In what order are the criteria handled through sequential operations? The data comprise 65 video-recorded rehabilitation team meetings and ethnographic information regarding local care facilities and patients’ (...) residential addresses. The analysis shows that the participants deal with decision criteria in an orderly manner. They identify the type of facility and location preferred by the patient’s family and search for a facility accordingly. Moreover, they routinely select facilities closer to the patients’ and their families’ homes. However, these rules are modified if the family’s choice is inappropriate, or when a facility in a different location is preferred by the family. The study contributes to the conversation analytic understanding of interprofessional decision making and prioritization through the analysis of orderly methods of search procedures interactively accomplished by participants in ongoing medical team interactions. (shrink)

This article argues that the moral right to be discharged only for good cause and like rights can be contracted away by employees in appropriate circumstances. It maintains that the rights in question are not inalienable, and that there is nothing irrational about an employee''s wishing to deal them away. It also maintains that inequalities in bargaining power between employers and employees are insufficiently pervasive to justify a flat ban on the alienation of these rights. For a waiver of such (...) rights to be valid, however, employees must have full knowledge of its terms.The question addressed here bears on several legal and policy issues affecting termination of the employment relation. If employees can contract away their right to a goodcause discharge, the American doctrine of employment at willmight find justification in the face of that right. In addition, the alienability of such discharge rights may be necessary to justify express disclaimers of wrongful discharge liability and the waiver provision of the new U.S. Draft Uniform Employment-Termination Act. (shrink)

The purpose of this study is to investigate the current state of post-traumatic growth and identify its influencing factors in discharged COVID-19 patients. PTG refers to individual experiences of significant positive change arising from the struggle with a major life crisis. This descriptive cross-sectional study used the convenient sampling method to recruit 140 discharged COVID-19 patients in Hunan, China. The results show that the PTG of the discharged COVID-19 patients was positively correlated with self-esteem, post-traumatic stress disorder, coping style tendency, (...) and social support, but negatively correlated with the time from onset to diagnosis. Our findings could provide guidance on improving the psychological state and well-being of discharged COVID-19 patients. (shrink)