Medical Protection’s medicolegal adviser Dr Clare Redmond discusses how to manage a situation where a patient asks to be discharged

Patients from time to time wish to self-discharge. The ability to assess a patient requesting their own discharge from hospital is a necessary skill for all doctors.

Many hospitals have a self-discharge policy, and this should, of course, be followed. The main concern is often whether the patient has the capacity to make the decision over  their own discharge and whether there is a risk of harm to the patient should they be allowed to leave. It is not uncommon that patients don’t wish to hang around to discuss their concerns and decide to self-discharge out of hours, providing little time for a detailed assessment.

When approaching a patient to discuss their request for discharge, it is advisable to gather as much information about their admission and medical history, both from review of their records and discussion with nursing staff. Where possible, discuss the patient with the team responsible for their care, or a more senior member of the team, before you speak to them.

Identifying categories of patients

It can be helpful to bear in mind the three broad categories of patient your assessment should identify:

• The adult patient with capacity to make the decision to self-discharge against medical advice – they are free to leave.
• The adult patient who lacks capacity to make the decision to self-discharge against medical advice – further consideration as to whether discharge is in the patient’s best interests is required.
• The adult patient with evidence of an acute mental disorder where there is the potential for the risk of further deterioration or harm to the patient or others – discussion with the mental health team and possible Mental Health Act assessment required.

In reality, there can be a fourth category of patient – where there is doubt over their capacity to make decisions, where the medical conditions are complex and where the potential consequences of leaving hospital are serious and/or life-threatening. When assessing capacity, it is necessary to ensure you are providing the patient with the information they need, including about risks and benefits, to come to a decision about their care. If your initial assessment of the patient results in you feeling concerned that you don’t have the knowledge or competence to fully discuss their care, you should ensure you discuss the patient promptly with a more senior colleague. Ultimately, difficult decisions around capacity and complex medical treatments may be made by the courts.

Documenting the discussion

Documentation of the discussion with the patient and your assessment is essential. For those patients leaving hospital against advice, ensure you include the information provided about the potential consequences of this decision. Follow-up plans and options for reassessment in the event of deterioration should be explained to the patient. You may need to seek advice from others to confirm these details and to communicate the patient’s departure, ensuring that their GP is informed of their discharge.

Assessing patient capacity

It is common for patients in hospital to become acutely confused or have underlying conditions affecting their capacity. When assessing these patients remember that there is a presumption of capacity.[1] The onus is on you to demonstrate (and document) a lack of capacity, not on the patient to disprove it.

Capacity is decision and time specific.  The capacity required to refuse life-saving treatment is different from that required to decide to have antibiotics for a minor infection.  Capacity fluctuates over time, especially where significant illness is present.

A person lacks capacity if they are unable to:[2]

• Understand the nature and purpose of a particular decision and appreciate its significance for them
• Retain relevant, essential information for the time required to make the decision
• Use or weigh the relevant information as part of the reasoning process of making the decision andtoconsidertheconsequencesofthepossibleoptions,(andtheoptionof notmakingthe decision); or
• Communicate their decision, either verbally, in writing, or by some other means.

Ensure that a thorough assessment of capacity is undertaken where appropriate. Consider who is best placed to make this assessment, it may be a psychiatrist. Carefully document the discussion with the patient and the results of any objective testing, such as the Montreal Cognitive Assessment (MoCA) score. Where there are communication difficulties, consider communication aids or interpreters.

What’s in the patient’s best interests?

For patients who lack capacity, the next step is to ascertain what is in their best interests: this could actually be their discharge from hospital. It is likely that additional time and discussion will be required to come to this decision, depending on who is available at the time you see the patient. Patients who lack capacity to make decisions should continue to be involved in decisions about their care, and the least restrictive option (that will still achieve the purpose) should be chosen. There are a number of individuals who should be consulted about any best interest decision, including anyone with a legal right to make decisions on the patient’s behalf.

If you have any doubt about assessing capacity or the relevant legal framework you should discuss the case with a senior colleague or contact Medical Protection for advice.