SHM Converge Scientific Abstract ePoster Gallery-What to Do When Patients Want to Go: Hospitalist Guidance for Discharge Prior to Medical Recommendation

Pdf Summary

This presentation describes a hospitalist algorithm for managing patients who want to leave the hospital before medical recommendation. The authors note that hospitals often lack a clear, consistent process for these situations, so they developed a practical approach that integrates medical, ethical, and legal considerations.

They reviewed the literature, consulted clinical ethics and legal counsel, and iteratively refined the algorithm with stakeholder feedback. The goal is to help clinicians decide whether a discharge should be treated as:
- <strong>AMA discharge</strong>: when leaving is likely to cause imminent risk of significant harm
- <strong>Patient-directed discharge</strong>: when discharge is not ideal but is still reasonably safe
- <strong>Safety hold</strong>: for patients who lack capacity, do not meet psychiatric hold criteria, and face imminent medical danger if they leave
- <strong>Psychiatric hold</strong>: only when impaired capacity and danger are due to psychiatric illness

A central concept is <strong>imminent risk of significant harm</strong>, meaning serious harm likely to occur soon after discharge, at a level comparable to risk to life or limb. Capacity is described as decision-specific and based on a patient’s ability to make an informed, reasoned choice aligned with personal values.

Key recommendations include:
- Patients with capacity may refuse care, even life-saving treatment.
- AMA discharge should be reserved for cases with imminent serious harm.
- If discharge is not imminently dangerous, patients may leave even if they lack capacity, though legal/risk teams should be notified.
- Surrogate decision-making depends on state law, surrogate type, and risk level.
- Legal, ethics, or risk management should be contacted when uncertainty exists.

The slides include case examples showing how the algorithm applies across medical, psychiatric, and capacity-related scenarios.

Asset Subtitle

Herrick Fisher

Meta Tag

Author List Abhishek Goyal, Cristina Toledo-Cornell, Emma Melton, Herrick Fisher, Lindsay R. Semler, William Feldman

Category Innovations

Concept Patient-Directed Discharge

Concept Against Medical Advice Discharge

Concept Decision-Making Capacity

Concept Psychiatric Hold

Concept Safety Hold

Distinguished Non-Finalist

Presenter Organization Brigham and Women's Hospital, Harvard Medical School

Presenting Author Herrick Fisher

Track Transitions of Care

Keywords

hospitalist algorithm

AMA discharge

patient-directed discharge

safety hold

psychiatric hold

decision-making capacity

imminent risk of significant harm

surrogate decision-making

medical ethics

legal risk management

Patient-Directed Discharge

Against Medical Advice Discharge

Decision-Making Capacity

Psychiatric Hold

Safety Hold