An Ethical Framework for Addressing Complex Hospital Discharges: Articulating Organizational Commitments in Care Setting Transitions

Abstract: Complex hospital discharges—in which a stabilized patient cannot leave the hospital due to constraints on, and/or objections to, placement options—are ubiquitous in acute care but have only recently garnered attention from healthcare ethicists. Complex discharges are frequently beset with systemic social barriers, such as financial constraints, inadequate long term care, and scarce community resources for patients with challenging health needs; correspondingly, such cases are perceived as ‘stalemates.’ Three clinical-ethical approaches to addressing complex discharges have been proposed: principlism (e.g., weighing patient autonomy against just stewardship of hospital resources), virtue ethics (promoting a “virtue of acknowledged dependence” in providers), and bioethics mediation (facilitating communication and trust between stakeholders). While these approaches appropriately establish a role for healthcare ethicists in complex discharges, in this paper I argue that they are insufficient. Specifically, in order to weigh the value of justice, actualize acknowledged dependence, or mediate between stakeholders in complex discharges, it is necessary to articulate a normative account of the healthcare organization’s role and responsibilities in facilitating patient transitions from hospital to community. While the precise nature of these responsibilities will vary according to the hospital’s patient population, I identify and discuss three areas in need of specification: assessment and provision of community resources for complex needs, partnership and coordination between the hospital and long term care facilities, and legislative advocacy. I conclude with recommendations for how practicing ethicists can articulate and promote these institutional commitments, such as routine presence at long length of stay committees and/or complex care rounds.