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Voluntary discharge and hospital readmission: ethical and legal healthcare implications

 

Alta voluntaria y reingreso hospitalario: implicaciones �ticas y legales en salud

 

Alta volunt�ria e readmiss�o hospitalar: implica��es �ticas e legais para a sa�de

 

 

 

 

 

 

 

 

 

 

 

Correspondencia: g.solorzano@uc.cl

 

Ciencias de la Salud y Pol�ticas

Art�culo de Investigaci�n

 

* Recibido: 30 de noviembre de 2023 *Aceptado: 22 de diciembre de 2023 * Publicado: �03 de enero de 2024

 

 

I.            Pontificia Universidad Cat�lica de Chile.

Abstract

The present research addresses the issue of the ethical and legal implications of voluntary discharge and readmission in the hospital area, taking into consideration that a patient's decision to request voluntary discharge from the hospital may have various motivations, such as the desire to continue the home treatment, financial difficulties, or disagreement with clinical management. The objective of this research focuses on analyzing the depth of the ethical, legal and healthcare implications of voluntary discharge and hospital readmission. Among the main results obtained, it is observed that voluntary discharge is a right that must be duly informed, reasoned and documented when exercised by a competent patient. The health team must do everything possible to guarantee a safe transition home, establishing the necessary measures to reduce avoidable risks of unplanned re-entry. Effective communication and solid coordination between levels of care are essential for continuity of care after discharge. There is still much to advance through research into these complex phenomena, to better understand their impact on clinical outcomes and the experience of patients and their families.

Keywords: Etica; Law; Voluntary discharge; Hospital readmission.

 

Resumen

La presente investigaci�n aborda el tema de las implicaciones �ticas y legales del alta voluntaria y reingreso en el �rea hospitalaria, tomando en consideraci�n que la decisi�n de un paciente de solicitar el alta voluntaria del hospital puede tener diversas motivaciones, como el deseo de continuar con el tratamiento domiciliario. , dificultades financieras o desacuerdo con la gesti�n cl�nica. El objetivo de esta investigaci�n se centra en analizar la profundidad de las implicaciones �ticas, legales y sanitarias del alta voluntaria y el reingreso hospitalario. Entre los principales resultados obtenidos se observa que el alta voluntaria es un derecho que debe ser debidamente informado, motivado y documentado cuando es ejercido por un paciente competente. El equipo de salud debe hacer todo lo posible para garantizar una transici�n segura a casa, estableciendo las medidas necesarias para reducir los riesgos evitables de reingreso no planificado. La comunicaci�n efectiva y la coordinaci�n s�lida entre los niveles de atenci�n son esenciales para la continuidad de la atenci�n despu�s del alta. A�n queda mucho por avanzar a trav�s de la investigaci�n de estos complejos fen�menos, para comprender mejor su impacto en los resultados cl�nicos y la experiencia de los pacientes y sus familias.

Palabras Clave: �tica; Ley; Alta voluntaria; Reingreso hospitalario.

 

Resumo

A presente investiga��o aborda a quest�o das implica��es �ticas e legais da alta volunt�ria e da readmiss�o no �mbito hospitalar, tendo em considera��o que a decis�o do paciente em solicitar a alta volunt�ria do hospital pode ter motiva��es diversas, como o desejo de continuar o tratamento no domic�lio , dificuldades financeiras ou discord�ncia com o manejo cl�nico. O objetivo desta pesquisa centra-se em analisar a profundidade das implica��es �ticas, legais e sanit�rias da alta volunt�ria e da readmiss�o hospitalar. Dentre os principais resultados obtidos, observa-se que a alta volunt�ria � um direito que deve ser devidamente informado, fundamentado e documentado quando exercido por paciente competente. A equipa de sa�de deve fazer todo o poss�vel para garantir uma transi��o segura para casa, estabelecendo as medidas necess�rias para reduzir os riscos evit�veis de reentrada n�o planeada. A comunica��o eficaz e a coordena��o s�lida entre os n�veis de cuidados s�o essenciais para a continuidade dos cuidados ap�s a alta. Ainda h� muito a avan�ar na investiga��o destes fen�menos complexos, para melhor compreender o seu impacto nos resultados cl�nicos e na experi�ncia dos pacientes e das suas fam�lias.

Palavras-chave: �tica; Lei; Descarga volunt�ria; Readmiss�o hospitalar.

 

Introduction

A patient's decision to request voluntary discharge from the hospital may have various motivations, such as the desire to continue treatment at home, financial difficulties, or disagreement with clinical management, among others¹. However, this decision carries risks if the patient's clinical condition is not resolved, which could lead to unplanned readmission².

Readmissions represent a growing problem globally, with rates that vary between 5% to 20% depending on the country and type of hospitalization³. In Chile, a study revealed that 13.2% of patients discharged for Community Acquired Pneumonia (CAP) required readmission in the following 30 days⁴.

This article analyzed the depth of the ethical, legal and healthcare implications of voluntary discharge and hospital readmission, identifying good practices for their proper management for the benefit of patient safety.

 

Ethical aspects of voluntary registration

Patient autonomy is a fundamental ethical principle in clinical practice⁵. This implies that the patient has the right to decide about his or her medical care, including requesting voluntary discharge even when treatment has not been completed⁶. However, for this decision to be valid it must meet certain ethical criteria⁷.

The first corresponds to the patient's mental capacity, sufficient to understand his clinical condition and the consequences of his decision. This requires being free of mental disorders such as delirium, dementia or active psychiatric disorders. Furthermore, the patient must receive clear, timely and complete information about their clinical condition, available therapeutic options, expected risks and prognosis, adapted to their educational level.

On the other hand, the decision to discharge voluntarily must be voluntary and free of any coercion or undue incentive. It must be determined that there are no external factors that are forcing the patient's decision. Furthermore, the health team has the ethical obligation to ensure these criteria before granting a voluntary discharge, prioritizing at all times the well-being and objective interests of the patient⁶.

Finally, it should offer appropriate recommendations on outpatient follow-up, self-care, or the need for timely readmission if clinical deterioration occurs after hospital discharge². These explanations must be duly documented in the clinical record.

 

Legal aspects of voluntary registration

Law 20,584 on the Rights and Duties of Patients, enacted in Chile in 2012, legally established the right of the competent patient to reject recommended medical treatments or procedures, which includes the option of requesting voluntary discharge even against the criteria of the medical team8. Likewise, article 14 of said law specifically states that: �The person may refuse to receive treatment or suspend it. Your refusal to treatment must be recorded in writing in your clinical record or in an additional document, which will record that you have been informed of the consequences derived from your decision.

Therefore, refusal of hospital treatment with a request for discharge is a right that must be respected. The document signed by the patient legally exempts the health team from liability for adverse consequences, as long as complete information has been provided and diligence has been exercised in the discharge process⁸. However, the medical team maintains the ethical obligations already mentioned in terms of confirming decision-making capacity, providing exhaustive information on risks and verifying the absence of coercion in the decision⁸.

 

Hospital readmission

Readmission is defined as the new admission of a patient who had recently been discharged for the same diagnosis or a related condition³. Unplanned readmissions, that is, those that occur unexpectedly due to a complication or relapse, are an important indicator of the quality of care and continuity of care after hospital discharge^2,9.

Among the main factors associated with unplanned readmissions have been pointed out; premature hospital discharge or inadequate preparation prior to discharge, errors or complications during the initial hospitalization, post-hospitalization adverse effects due to lack of adherence to outpatient treatment. Likewise, exacerbation or relapse of the underlying disease due to poor outpatient follow-up and development of new health problems unrelated to the index hospitalization.

On the other hand, identifying the reasons for each readmission through a thorough case review allows us to detect opportunities for improvement in hospital care and continuity of care. Some proposed strategies correspond¹⁰; optimize preparation for hospital discharge with patient education, improve coordination between care levels, ensure an adequate transition of care to home, reinforce adherence to outpatient treatments and finally, facilitate accessibility to follow-up consultations.

 

Good practices when applying for high volunteer

When faced with a patient's request for voluntary discharge, whether verbal or written, the following good practices are recommended^6,7; The first corresponds to comprehensively evaluating the patient's decision-making capacity, considering possible organic or psychiatric factors that limit it, such as cognitive impairment, delirium, depression or anxiety.

In addition to, providing the patient and their family with clear, timely and adapted information about their current clinical situation, available therapeutic options, expected prognosis with and without hospital treatment, and possible risks or complications both when refusing treatment and after premature discharge, inquire carefully. Empathy about the reasons, expectations and values that underlie the request for voluntary discharge, and try to resolve any underlying doubts, fears or concerns, explain in simple language the possible risks of early discharge in your particular condition, and the need for follow-up. narrowed down by your treating doctor.

Likewise, how to leave a written record in the clinical record of the entire information process carried out and the decision to reject treatment and voluntary discharge freely expressed by the patient or their representatives, efficiently coordinate follow-up care, delivering a complete discharge report to the patient. patient and carrying out interconsultations that ensure continuity of care and finally, provide education on alarms that should motivate an urgent re-consultation to the emergency service in the event of decompensation.

 

Final considerations

Voluntary discharge is a right that must be duly informed, reasoned and documented when exercised by a competent patient. The health team must do everything possible to guarantee a safe transition home, establishing the necessary measures to reduce avoidable risks of unplanned re-entry. Patient-centered and trust-based medicine requires maintaining a balance between respect for the patient's autonomy and clinical beneficence, without falling into paternalism that invalidates the patient's right to choose.

A detailed and comprehensive analysis of the contributing factors in each case of readmission allows us to identify opportunities for continuous improvement in the quality and safety of care. Effective communication and solid coordination between levels of care are essential for continuity of care after discharge. There is still much to advance through research into these complex phenomena, to better understand their impact on clinical outcomes and the experience of patients and their families.

 

References

Smith, D.B. et al. (2013). Discharge against medical advice: causes and consequences. Mayo Clinic proceedings, 88(6), 613�620. https://doi.org/10.1016/j.mayocp.2013.04.009

Le�n-Salinas, A. et al. (2020). Predictive factors of early hospital readmission: Addressing patient needs. Enfermer�a Cl�nica (English Edition), 30(1), 23-27. https://doi.org/10.1016/j.enfcle.2019.04.102

Van Walraven, C. et al. (2011). The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract, 17(5), 947-56. https://doi.org/10.1111/j.1365-2753.2010.01549.x

Sald�as, F. et al. (2018). Thirty-day readmission rate for adult patients with community-acquired pneumonia is similar between public and private hospitals in Chile. Ther Adv Respir Dis, 12, 1-9. https://doi.org/10.1177/1753465818754778

Beauchamp, T.L., & Childress, J.F. (2013). Principles of biomedical ethics. Oxford University Press, USA.

L�pez, L., Varsi, C., & Sox, C.H. (2009). Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med, 4(7), 403-6. https://doi.org/10.1002/jhm.474

Smith, A.K., & Lunde, S.J. (2010). Discharge against medical advice: ethical considerations and professional obligations. Virtual Mentor, 12(6), 455�458. https://doi.org/10.1001/virtualmentor.2010.12.6.ccas3-1006

Herrera, F., & Merino, J.M. (2019). The patient's right to refuse medical treatment in Chile. Issues in Law & Medicine, 34(2), 165-184.

Hern�ndez-Barrera, V., Martinez-Huedo, M.A., Carrasco-Garrido, P., Lopez de Andres, A., Jimenez-Trujillo, I., & Jimenez-Garcia, R. (2017). Hospitalization rates for ambulatory care sensitive conditions in Spain: Inter-regional variability and temporal evolution. Public Health, 144, 86-95. https://doi.org/10.1016/j.puhe.2016.11.005

Santa-Ana-Tellez, Y. et al. (2013). Diabetes mellitus, hypertension and hospital readmission rates. Journal of Diabetes and its Complications, 27(1), 56-60. https://doi.org/10.1016/j.jdiacomp.2012.10.001

 

 

� 2023 por los autores. Este art�culo es de acceso abierto y distribuido seg�n los t�rminos y condiciones de la licencia Creative Commons Atribuci�n-NoComercial-CompartirIgual 4.0 Internacional (CC BY-NC-SA 4.0)

(https://creativecommons.org/licenses/by-nc-sa/4.0/).