A difficult discharge

Myrna is an elderly woman who until recently lived alone in the community. She has a long history of heavy alcohol use and has permanent related neurological deficits, including severe balance problems. She has had a number of falls in the community and has had repeated hospitalizations.

She is currently an inpatient on a subacute unit, where she has been for several months. She requires a wheelchair for mobility and at least one person to help her transfer, and has plateaued in her rehabilitation. She no longer needs to be in hospital, but discharge planning is complicated. She was living in a small walk-up apartment that was not wheelchair accessible, and was evicted during her hospitalization because several months’ rent were in arrears . Despite her health concerns, she has not been found to be incompetent on capacity assessments, and continues to make her own health care decisions.

Staff are not at all convinced she has insight into her current health situation. Myrna has repeatedly said she will not move to a personal care home and in the past has even been reluctant to accept home care help. In fact, she has informed her health care team that she would prefer to die than move to a PCH, and would leave if she was forced. She appears to have the capacity to leave against advice, and has demonstrated concrete plans to do so. She has three children who live in other cities, and all feel strongly that Myrna should be discharged home, as per her wishes.

It is clear to the health care team that this would be neither practical nor safe. There appear to be no settings where Myrna can receive appropriate care and support that would be acceptable to her, but there are very real concerns about her safety and the safety of anyone living in proximity if she is on her own.

The team has convened a meeting of the ethics committee to discuss this complicated discharge.

Questions for discussion and consideration:

1. What are the ethical principles in conflict?
2. What are the team’s obligations?
3. What are the options for discharge? What are the risks and benefits of each option?
4. What is the right thing to do? Why do you think so?