Providers and patients bring different understandings of health and disease to their encounters in the hospital setting. The literature to date only infrequently addresses patient and provider concordance on the reported reason for hospitalization, that is, whether they express this reason in similar ways. An agreement or common ground between such understandings can serve as a basis for future communication regarding an illness and its treatment. We interviewed a convenience sample of patients on the medical wards of an urban (...) academic medical center. We asked subjects to state the reason why their doctors admitted them to the hospital, and then compared their statement with the reason in the medical record. We defined concordance on reported reason for hospitalization as agreement between the patient’s report and the reason abstracted from the chart. We interviewed and abstracted chart data from a total of 46 subjects. Concordance on reported reason for hospitalization was present in 24 (52%) and discordance in 17 (37%); 5 patients (11%) could not give any reason for their hospitalization. Among the 17 patients whose report was discordant with their chart, 12 (71%) reported a different organ system than was recorded in the chart. A significant proportion of medical inpatients could not state their physicians’ reason for admission. In addition, patients who identify a different reason for hospitalization than the chart often give a different organ system altogether. Providers should explore patient understanding of the reason for their hospitalization to facilitate communication and shared decision making. (shrink)

A request to admit a hospital inpatient with motor neurone disease to the hospice generated unusual unease. Significantly, withdrawal of ventilation had already been planned. The presumption that ventilation would be withdrawn after transfer presented a dilemma. Should the hospice accept the admission? If so, should the hospice staff stop the ventilation, and then when and how? Debate centred on the continuity of best interests and the logistics of withdrawing ventilation. The factors making the request contentious identified competing interests (...) within hospice admission decision making that could detrimentally impact on patient care. (shrink)

The goal of the article is to compare methods of financing ARs and ERs based on the data from the 1st half of 2013 and 1st half of 2014 from the K. Jonscher 3rd Municipal Hospital in Lodz. All the stays in the AR/ER in the 1st half of 2013 and the 1st half of 2014 were analysed. Based on the presented data, it can be clearly seen that the new method of financing AR/ER services proposed by the NFZ (...) will beyond doubt have negative outcomes, and will certainly not improve the financial situation of hospitals. (shrink)

Self‐admission to inpatient treatment is a novel approach that aims to increase agency and autonomy for patients with severe psychiatric illness and a history of high utilization of inpatient care. By focusing on brief, preventive hospital admissions in times of increased risk of relapse, self‐admission seeks to reduce the need for prolonged episodes of inpatient treatment. Participants are generally satisfied with the model, which is not surprising given that self‐admission programs allocate a scarce resource—hospital beds—to a select (...) group. However, the patients targeted by these programs are not necessarily those in most need of hospital admission, which may compromise the commonly accepted ‘principle of need’ in allocation of public healthcare resources. In light of the current lack of consistent evidence of the usefulness and cost‐effectiveness of the model, several aspects need to be further studied in order to guide any large‐scale implementation of self‐admission in psychiatry. (shrink)

Admitting hospital patients: a qualitative study of an everyday nursing task In recent years new modes of nursing work have been introduced globally in response to radical changes in healthcare policies, technology and new ideologies of citizenship. These transformations have redefined orthodox nurse–patient relationships and further complicated the division of labour within health‐care. One distinctive feature of the work of registered nurses has been their initial assessment of patients being admitted to hospital, and it is of interest that (...) this area of nursing practice remains central to the registered nurse's role at a time where other areas of practice have been relinquished to other occupational groups. This qualitative study, drawing on conversation analysis and ethnographic techniques, explores this area of everyday nursing work. Initial nursing assessments have attracted considerable interest in the nursing literature, where it is clearly stated that assessments should be patient centred and seen as the important first step on the road to a therapeutic nurse–patient relationship. Results from this study lead to the conclusion that the actual nursing practice of patient assessment on admission to hospital is at odds with the recommendations of the literature and that a more routinised, bureaucratic form of work is devised by nurses as a means of expediting the process of admission. (shrink)

No known cure exists for COVID-19, and medical practitioners are exhausted and at their wits’ end trying to find treatments that prevent patients from ending up in hospital or intensive care, or even dying. A variety of treatments tried by medical practitioners include standard registered medicine, investigational or so-called experimental, unapproved or preapproved medicines, emergency or compassionate-use authorised medicine and pre-market approved medicine. However, the medicines that can be accessed via each of these categories are at different stages of (...) efficacy testing and knowledge about adverse effects, dosages and risks. To obtain ethical and legal informed consent, medical practitioners must deal with a lot of medical uncertainty, and care must be taken to ensure that the patient understands the difference in risks they may be willing to take depending on the medicine’s stage of development. Often additional information is required to obtain ethical consent as opposed to legal consent. A purely legal approach to informed consent, especially when dealing with the medical uncertainties of health emergencies and pandemics, may lead to patients’ consent lacking in enough substance to be truly considered legal and ethical. Informed consent as respect for autonomy in this sense requires more than the patient’s explicit agreement or compliance with a certain treatment proposal. This article explains the difference in consent content attached to each different stage of a medicine’s development, especially considering the additional difficulties posed by obtaining truly informed consent during a pandemic with uncertain characteristics, treatment and solutions. (shrink)

An in-depth analysis of the recent reform in Italian psychiatry reveals that the relevance of these changes transcends national borders. However, these changes are, from the scientific point of view, worth much more than mere biased pragmatic interest. The reshaping of theory made possible by the transformation of Italian psychiatry in fact opens up new prospects for a scientifically founded form of psychiatric care. Thanks to the new Mental Health Act (No. 180 of 1978),2 it has been possible to set (...) up a type of administrative and institutional organization in which the psychiatric hospital no longer constitutes a functional part of the structures of psychiatric care. This reform thus provides the launching path for a real alternative where current psychiatric ideas and working methods can no longer be accepted as the gospel truth. This paper discusses how a correct problem-definition of psychiatric admission can provide a basis for a correct approach to psychopathological behaviour in a setting where the psychiatric hospital has no role to play and for the consolidation of this new practice. (shrink)

Dr. Brown, a hospitalist, admits Mark, a patient transferred from a local jail for management of cellulitis. The patient, who was taken into custody two days prior to hospital admission, has a history of intravenous heroin use. Mark explains that he had been prescribed buprenorphine-naloxone maintenance therapy for opioid use disorder for several years prior to being arrested and had not used other opioids during that time. As a policy, the jail where Mark is detained does not prescribe opioid (...) agonists, and his maintenance therapy was stopped upon his arrival there. Dr. Brown discovers that Mark is diaphoretic and appears distressed. Mark's symptoms suggest to Dr. Brown that, in addition to having cellulitis, Mark is actively withdrawing from opioids. Mark tells Dr. Brown that he has felt “horrible” since his buprenorphine-naloxone therapy was stopped and that he now has intense cravings for opioids. He asks Dr. Brown to help alleviate the withdrawal symptoms. Dr. Brown, who is accustomed to treating opioid withdrawal with opioid replacement therapy, wonders if she should initiate ORT for Mark while he is in the hospital. (shrink)

IntroductionThe COVID-19 pandemic has forced changes in patient care in Mental Health Day Hospitals.ObjectivesTo study the interventions performed in MHDHs during the pandemic in comparison with those performed in other facilities and to analyze the new hospital admissions in both groups.MethodA retrospective multicenter cohort study comparing the interventions received by a group of 161 patients admitted in MHDHs during the lockdown period in Spain with the interventions of another group of 109 patients who were treated at other facilities (...) during lockdown.ResultsMHDHs reduced their face-to-face interventions during lockdown just as much as other facilities but implemented telematic intervention methods to a greater extent. Patients attached to MHDHs during lockdown were admitted significantly less and presented fewer urgent consultations in the following 6 months.ConclusionThe use of telepsychiatry made it feasible to adapt MHDHs to periods of lockdown, being useful to improve the continuity of care during the pandemic. In addition, it was possible to maintain a reduction in hospital admissions in patients treated at MHDHs. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychiatric Hospitalization—Bridging the Gap Between Respect and ControlPaul P. ChristopherIntroductionThis issue of Narrative Inquiry in Bioethics offers varied and somewhat unique perspectives on the experience of psychiatric hospitalization. This commentary highlights a number of salient themes that emerge from reading these essays and attempts to explore how they relate to the broader academic literature on psychiatric hospitalization, particularly with regard to ethical considerations. In reading these narratives, each several (...) times, I was repeatedly struck by the courage required of the authors, both to share their stories publicly and to endure the challenges that the writing process no doubt demanded of them—revisiting and suspending themselves in deeply emotional and, at times, traumatic experiences in order to share the most compelling narrative. Their hard work clearly paid off—the stories are at once intimate and indelible. Still, in many instances, I found myself wanting to know more; to enter the story and sit with the individual through these events; to ask what they were thinking or feeling in a particular situation; to see and hear the world in which they found themselves. Such is the nature of good story telling—the reader, left with the lingering vision created in his mind, turns over the last page, eagerly hoping for more.Narrative ThemesI. Loss of Autonomy or ControlPerhaps the most notable theme had to do with the loss of control or freedom that followed from hospitalization. On first consideration, it may seem odd that this issue appears so often since patient autonomy constitutes one of the fundamental principles of medical ethics. Only under specific circumstances—e.g., when there is a risk of imminent harm—may autonomy be curtailed, and even then only to the extent that is minimally necessary. Yet, as these narratives highlight, there are a multitude of ways in which psychiatric hospitalization engenders actual or perceived restrictions in freedom (Newton-Howes & Mullen, 2011).Consistent with prior research (Goodwin et al., 1999), many of the authors describe a fear or the actual experience of not being able to leave the hospital freely, even when the admission seems to have been voluntary. For example, one writer worries, “I was so afraid that if I ever went ‘in,’ I would never get ‘out’... I thought I would never taste freedom again... alive.” Another describes:When it came time for my possible discharge they told me that I might not get discharged because I was ‘acting up the previous evenings.’ My anxiety level at this point went through the roof. The only reason I was discharged was because my father knew some politicians. If not [End Page 29] for him I would have been a patient there for perhaps years and my life would have been ruined.A third gives this example: “When I asked to sign the form to leave after three days, [the psychiatrist] told me if I did that she would have me committed.” Another writer fears not having any control of how the psychiatrist might approach the treatment: “... I was totally vulnerable... would the doctors blame me, drug me, shock me, kill me?”Somewhat surprising, however, was the fact that so few of the narratives take issue with the decision to hospitalize. This omission is especially striking in light of the fact that prior reports consistently note that a substantial minority (up to nearly half) of voluntarily admitted patients nevertheless experience their admission as coerced (Bonsack & Borgeat, 2005; Hiday et al., 1997; Katsakou et al., 2010; Rogers et al., 1993; Sheehan & Burns, 2011). Because many of these narrators had been hospitalized more than once, the relative absence of expressed resistance to being hospitalized seems strange, particularly when earlier hospital experiences or their aftermath are often described as negative. For example, one individual characterized the time after being released from the hospital as, “My sense of self was questioned. I felt as if I lost my soul.” Another put it this way:When I got out of the private hospital, I felt like my soul had been ripped out of me. I felt like I had a gaping hole in the center of my body... I felt psychically raped, dazed, and confused.Given these... (shrink)

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (...) (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p. (shrink)

The presence of stigmatizing language in the electronic health record (EHR) has been used to measure implicit biases that underlie health inequities. The purpose of this study was to identify the presence of stigmatizing language in the clinical notes of pregnant people during the birth admission. We conducted a qualitative analysis on N = 1117 birth admission EHR notes from two urban hospitals in 2017. We identified stigmatizing language categories, such as Disapproval (39.3%), Questioning patient credibility (37.7%), Difficult patient (21.3%), (...) Stereotyping (1.6%), and Unilateral decisions (1.6%) in 61 notes (5.4%). We also defined a new stigmatizing language category indicating Power/privilege. This was present in 37 notes (3.3%) and signaled approval of social status, upholding a hierarchy of bias. The stigmatizing language was most frequently identified in birth admission triage notes (16%) and least frequently in social work initial assessments (13.7%). We found that clinicians from various disciplines recorded stigmatizing language in the medical records of birthing people. This language was used to question birthing people's credibility and convey disapproval of decision‐making abilities for themselves or their newborns. We reported a Power/privilege language bias in the inconsistent documentation of traits considered favorable for patient outcomes (e.g., employment status). Future work on stigmatizing language may inform tailored interventions to improve perinatal outcomes for all birthing people and their families. (shrink)

We reflect, using a vignette, on conceptual tensions and the value judgements that lie behind difficult decisions about whether or not the older person with dementia should return home or move into long-term care following hospital admission. The paper seeks, first, to expose some of the difficulties arising from the assessment of residence capacity, particularly around the nature of evaluative judgements and conceptual tensions inherent in the legal approach to capacity. Secondly, we consider the assessment of best interests around (...) place of residence, which demonstrates significant conceptual tensions. In addition, ‘best interests’ raise issues around the perception of risk and the perceptions of the family and crucially involve the notions of autonomy and trust. Finally, we not only gesture at some practical considerations based on insights from values-based medicine, but also make the suggestion that we require tighter functional assessments of residence capacity coupled with broader judgements about best interests. (shrink)

Notwithstanding fears of overly permissive approaches and related pleas to refuse euthanasia for psychological suffering, some Belgian hospitals have declared that such requests could be admissible. However, some of these hospitals have decided that such requests have to be managed and carried out outside their walls. Ghent University Hospital has developed a written policy regarding requests for euthanasia for psychological suffering coming from patients from outside the hospital. The protocol stipulates several due care criteria that go beyond the (...) requirements of the Belgian Euthanasia Law. For instance, the legally required first and second consulted physicians should all be psychiatrists and be affiliated with a psychiatry department of a Flemish university hospital. Moreover, euthanasia for psychological suffering can only be performed if the advices of these consulted physicians are positive. Importantly, preliminary reflection by the multidisciplinary Hospital Ethics Committee was introduced to discuss every request for euthanasia for psychological suffering coming from outside the hospital. In this way, the protocol supports psychiatrists faced with the complexities of assessing such requests, improves the quality of euthanasia practice by ensuring transparency and uniformity, and offers patients specialised support and guidance during their euthanasia procedure. Nevertheless, some concerns still remain. (shrink)

Hospitalization is a unique health-illness transition for most elderly people. Whether the patient's health-related needs are met or not often iiifluence his or her appraisal of quality of life during hospitalization. This qualitative study explored the health needs of elderly Chinese male cardiac patients during their hospitalization. Eighteen subjects were recruited from a veterans' hospital in northern Taiwan. These men all lived alone before their hospital admission. Data were gathered using semistructured interviews and then analysed by content analysis. (...) Ninety-four per cent of the subjects described up to three categories of needs: met needs (72%), unmet needs (78%), and expected needs (50%0). Needs that participants believed were met were those for psychological support, spiritual support, tangible support and information. Unmet needs were those for participation in decision making, maintaining daily activities and resuming a preadmission lifestyle. The expected needs included those for learning self-care strategies to maintain their daily activities after discharge from the hospital. The factors that framed the participants' perceptions of different health needs were identified to be lack of family support and locus of control. Finally, a discussion of the context background of this phenomenon, as well as some suggestions for its implications, are provided from a culturally sensitive ethical aspect. (shrink)

BackgroundGeneral practitioners often act as gatekeeper, authorizing patients’ access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners’ experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic.MethodsSemi-structured interviews with Dutch general practitioners working in (...) the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding.ResultsFifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients’ self-determination vs. the general practitioners’ paternalism, (3) the general practitioners’ duty of care vs. the general practitioners’ autonomy rights, (4) the general practitioners’ duty of care vs. adequate care provision.ConclusionsLack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account. (shrink)

The Health (Regulation of Termination of Pregnancy) Act 2018 was commenced on 01/01/2019 in Ireland. The Act provides for legal termination of pregnancy under defined circumstances including for any reason at < 12 weeks gestation; and where two doctors agree there is ‘a condition affecting the foetus that is likely to lead to the death of the foetus either before, or within 28 days of, birth’. As such, abortion for congenital anomaly (CA) can occur at a number of time points, (...) depending on the adjudged severity. Infants born with CAs frequently require significant medical intervention and account for a high proportion of admissions to paediatric intensive care units (PICUs). The purpose of this paper was to evaluate the number of infants with CAs admitted to an Irish PICU in the period before and after the implementation of the Act. All PICU admissions < 1 month of age to a single Irish paediatric hospital between 2012 and 2021 were analysed. CAs were recorded, and the periods before and after the commencement of the Act compared. We found a difference in admissions involving CAs, particularly those related to congenital heart disease involving single ventricle anatomy. It is plausible that this difference was as a result of improved access to abortion services following the implementation of the Act. This article explores the legal conditions related to the abortion of a foetus with a CA in Ireland, and the possible impact of the Independent Review of the Operation of the Health ( Regulation of Termination of Pregnancy) Act 2018. (shrink)

Background and PurposeMany critically ill patients in intensive care units (ICUs) are unable to communicate their wishes about goals of care, particularly about the use of life-sustaining treatments. Surrogates and clinicians struggle with medical decisions because of a lack of clarity regarding patients’ preferences, leading to prolonged hospitalizations and increased costs. This project focused on the development and implementation of a tool to facilitate a better communication process by (1) assuring the early identification of a surrogate if indicated on admission (...) and (2) clarifying the decision-making standards that the surrogate was to use when participating in decision making. Before introducing the tool into the admissions routine, the staff were educated about its use and value to the decision-making process.Project and MethodsThe study was to determine if early use of a simple method of identifying a patient’s surrogate and treatment preferences might impact length of stay (LOS) and total hospital charges. A pre- and post-intervention study design was used. Nurses completed the surrogacy information tool for all patients upon admission to the neuroscience ICU. Subjects (total N=203) were critically ill patients who had been on a mechanical ventilator for 96 hours or longer, or in the ICU for seven days or longer. The project included staff education on biomedical ethics, critical communication skills, early identification of families and staff in crisis, and use of a simple tool to document patients’ surrogates and previously expressed care wishes. Data on hospital LOS and hospital charges were collected through a retrospective review of medical records for similar four-month time frames pre- and post-implementation of the assessment tool.ResultsSignificant differences were found between pre- and post-groups in terms of hospital LOS (F=6.39, p=.01) and total hospital charges (F=7.03, p=.009).ConclusionsProject findings indicate that the use of a simple admission assessment tool, supported by staff education about its completion, use, and available resources, can decrease LOS and lower total hospital charges. The reasons for the difference between the pre- and post-intervention groups remain unclear. Further research is needed to evaluate if the quality of communications between patients, their legally authorized representatives, and clinicians—as suggested in the literature—may have played a role in decreasing LOS and total hospital charges. (shrink)

Current health policy, high‐profile failures and increased media scrutiny have led to a significant focus on patient experience in Britain's National Health Service (NHS). Patient experience data is typically gathered through surveys of satisfaction. The study aimed to support a better understanding of the patient experience and patients' expression of it through consideration of the aspects of the patient experience on NHS wards which are by their nature impossible to capture through patient satisfaction surveys. Existential phenomenology was used to develop (...) an in‐depth exploratory narrative, expressed through the voices of the participants. Data collection involved in‐depth face‐to‐face interviews with 12 purposively sampled participants, with analysis by means of hermeneutics. Though the individuality of each experience was apparent and cannot be overemphasised, common factors emerging from the data included uncertainty and unexpectedness, suffering and finitude, the futility of feedback and bureaucracy and absurdity. Overall, participants demonstrated how their individual personalities and expectations affected their response both to illness or injury and to their hospital admissions, highlighting feelings of vulnerability and voicelessness as a response to hospitalisation. The findings of this study provide useful insight into the patient experience on British hospital wards, and the value of an existential–phenomenological approach is demonstrated. (shrink)

Objectives To conduct an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design Mixed method evaluation involving five substudies, before and after design. Setting NHS hospitals in the United Kingdom. Participants Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention The SPI1 (...) was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration—monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items)—there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for “difference in difference” 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from 17% (63) to 13% (49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening. (shrink)

Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic (...) prognosis. It is hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system. (shrink)

Background Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial (...) optimistic prognosis. It is hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Main body Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Conclusion Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system. (shrink)

This paper examines the ethical conundrum between a hospital's ethos of relieving distress, investigation and treatment, and its concurrent duties under English law to administer tests of decision-making capacity and safeguarding protection where it believes the patient may lack this capacity. Delirium, characterised by a precipitous decline in mental functioning exhibiting the shared symptomology of recoverable depressive disorders and terminal dementia, is not uncommon after emergency admission of elderly patients into acute medical hospital wards. The use of functional (...) capacity testing as a benchmark for decision-making capacity for post-discharge residence has been criticised as outdated, conceptually floored, subjective, lacking central guidance, transparent process, and accountability. A study of patient experience demonstrates the potential for hospital misuse of capacity testing, the failure of functional testing to differentiate decision making capacity from the disability of partial cognitive impairment, and how hospital capacity processes can interact and amplify patient pathology thereby decreasing recovery prospects. Prioritisation of mental capacity obligations above thorough investigation of emergent mental pathology and relief of patient anguish, results in extended detention in medical wards lacking bespoke facilities. Further understanding of patient experience is needed to inform policy with interventions tailored to avoid harm and increase wellbeing. (shrink)

This fascinating study presents a unique history of psychiatry in the twentieth century. It brings together the memories and narratives of over sixty patients and workers who lived, or were employed, in Severalls Psychiatric Hospital, Essex, UK. Personal accounts are contextualised both in relation to wider developments and issues in twentieth-century mental health, and in relation to policies and changes in the hospital itself. Organised around the theme of space and place, and drawing upon both quantitative and qualitative (...) material, chapters deal with key areas such as gender divisions, power relations, patterns of admission and discharge, treatments, and the daily lives and routines of patients and nurses of both sexes. (shrink)

BackgroundBesides balancing burdens and benefits of intensive care, ethical conflicts in the process of decision-making should also be recognised. This calls for an ethical analysis relevant to clinicians. The aim was to analyse ethically difficult situations in the process of deciding whether a patient is admitted to intensive care unit.MethodsAnalysis using the ‘Dilemma method’ and ‘wide reflective equilibrium’, on ethnographic data of 45 patient cases and 96 stakeholder interviews in six UK hospitals.Ethical analysisFour moral questions and associated value conflicts were (...) identified. Who should have the right to decide whether a patient needs to be reviewed? Conflicting perspectives on safety/security. Does the benefit to the patient of getting the decision right justify the cost to the patient of a delay in making the decision? Preventing longer-term suffering and understanding patient’s values conflicted with preventing short-term suffering and provision of security. To what extent should the intensivist gain others’ input? Professional independence versus a holistic approach to decision-making. Should the intensivist have an ongoing duty of care to patients not admitted to ICU? Short-term versus longer-term duty to protect patient safety. Safety and security were key values at stake in the ethical conflicts identified. The life-threatening nature of the situation meant that the principle of autonomy was overshadowed by the duty to protect patients from harm. The need to fairly balance obligations to the referred patient and to other patients was also recognised.ConclusionProactive decision-making including advance care planning and escalation of treatment decisions may support the inclusion of patient autonomy. However, our analysis invites binary choices, which may not sufficiently reflect reality. This calls for a complementary relational ethics analysis. (shrink)

Since 1991, the Patient Self-Determination Act (PSDA) has required all health care institutions that receive Federal funds to inform patients upon admission of their rights to make decisions about medical care and to execute advance directives. Implementation of the PSDA presents a special challenge for state mental hospitals. The relevance and possible negative therapeutic impact of discussing end of life decisions at the time of an acute psychiatric admission has recently been raised in the literature. Other ethical dilemmas arising from (...) the interplay between mental illness and informed consent for medical treatment, particularly for older patients committed to state mental hospitals, have been highlighted by the PSDA. In this article we discuss some of the issues raised by implementation of the PSDA in this setting. (shrink)

This article analyzes doctor–patient communication at admission interviews in an outpatient mental health care service at a public hospital in Buenos Aires, Argentina. These interviews are the first contact between professionals and patients, and they result in the admission or rejection of the latter into the medical institution. In particular, we observe how context, understood as a sociocognitive and scalar concept, is reshaped with gaze direction and agenda-setting through interaction, resulting in three hierarchical spaces which can be represented as (...) degrees in a scale: the public, the private, and the intimate level. This description will allow us to understand a series of communicative difficulties that may result from scale maladjustments, in which professionals interact with patients at different levels and therefore cannot give adequate feedback to satisfy mental health care needs. (shrink)

An acute hospital environment is a confusing place for many patients requiring admission, especially when they are presenting as acutely unwell. This can be particularly difficult for people living with dementia. As cognition changes it is not uncommon for people living with dementia to have difficulties with their ability to orientate to time, place and person. These disorientating moments can lead to personal distress, and at times behavioural changes. As well as being distressing for the person living with dementia, (...) it can also be emotionally and ethically challenging for acute hospital staff, including nurses. One area found to be particularly challenging is the concept of whether actively engaging with a person living with dementia's living truth is deceitful. This raises further questions of what forms of nurse responses to temporal disorientation might be constituted as lying, colluding, or alternatively validating. This article uses autoethnography as a research methodology with which to explore a mental health nurse's lived experience of the challenges of responding truthfully to disorientation and distress in an acute hospital. This article is not attempting to offer conclusive answers to these challenging ethical questions. It is instead re‐opening and re‐visiting the discourse of what is truth in dementia from a personal and professional nurse perspective through a lived narrative. The conclusion to the concept of truth in dementia is complex, nuanced and individualized. However, it is essential that a nurse's response to disorientation and distress is always person and living present focused, and not lie focused. (shrink)

The Hospital Standardised Mortality Ratio (HSMR) is a commonly used measure of hospital mortality that is standardised for age, comorbidities and other factors. By tradition, this statistic has always excluded patients classified as ‘palliative’. The HSMR has never been validated as a reliable measure of quality of care, and it can be very hard to interpret, partly due to difficulties with defining and applying the term ‘palliative’. In this paper, we review the Canadian experience with the palliative status (...) flag, and explain why it is so difficult to define and apply consistently. We also highlight some potential concerns about clinicians labelling inpatients as ‘palliative’ during their admission. Finally, we propose an organisational ethics framework, and six specific suggestions for hospitals to use when publishing statistics such as the HSMR. (shrink)

Members of the Student Clinical Ethics Committee discussed the ethical issues arising in a case referred for consideration – a homeless man presenting to the emergency department of a busy London hospital with recent self-reported suicide attempts. Should he be admitted overnight in order to address a short-term shelter problem? The case study summarises the reflections of the Committee and focusses on the doctor’s duty of care and patient responsibility, benefits of admission and resource considerations.

This paper examines the association of the sociodemographic characteristics of women and the unobserved hospital factors with maternal mortality in Kenya using multilevel logistic regression. The data analysed comprise hospital records for 58,151 obstetric admissions in sixteen public hospitals, consisting of 182 maternal deaths. The results show that the probability of maternal mortality depends on both observed factors that are associated with a particular woman and unobserved factors peculiar to the admitting hospital. The individual characteristics observed (...) to have a significant association with maternal mortality include maternal age, antenatal clinic attendance and educational attainment. The hospital variation is observed to be stronger for women with least favourable sociodemographic characteristics. For example, the risk of maternal death at high-risk hospitals for women aged 35 years and above, who had low levels of education, and did not attend antenatal care is about 280 deaths per 1000 admissions. The risk for similar women at low-risk hospitals is about 4 deaths per 1000. To complement results from the analysis of individual patient records, the paper includes findings from hospital staff reports regarding the maternal mortality situation at the hospitals. (shrink)

BackgroundAlthough the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP.MethodsThis multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively (...) from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan–Meier curve analyses for survival were performed.ResultsOf 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63–81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan–Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001).ConclusionsAfter the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed. (shrink)

Cardiopulmonary resuscitation is frequently performed on patients who, in retrospect, had a very low chance of survival. This is because all patients are ‘For cardiopulmonary resuscitation’ on admission to hospital by default, and delays occur before cardiopulmonary resuscitation can be ‘de-prescribed’. This article reviews the nature of potential harms caused by futile cardiopulmonary resuscitation, the reasons why de-prescription may be delayed, recent legal judgements relevant to timely do not attempt cardiopulmonary resuscitation decision making, and the possible detrimental effects of (...) do not attempt cardiopulmonary resuscitation discussions on end of life care. The moral and operational feasibility of a model in which informed consent must be obtained before cardiopulmonary resuscitation is attempted in some patient groups is then explored. (shrink)

The use of do not resuscitate (DNR) orders in Dutch hospitals was studied as part of a nationwide study on medical decisions concerning the end of life. DNR decisions are made in 6 per cent of all admissions, and 61 per cent of all in-hospital deaths were preceded by a DNR decision. We found that in only 14 per cent of the cases had the patients been involved in the DNR decision (32 per cent of competent patients). The (...) concept of futility is analysed as these findings are discussed. We conclude that determining the effectiveness of resuscitation is a medical judgement whereas determining the proportionality (burden/benefit ratio) of it requires a discussion between doctor and patient (or his or her surrogates). Since the respondents in the cases without patient involvement gave many reasons for their decision that went beyond determining effectiveness, we conclude that more patient involvement would have been desirable. (shrink)

The objective of this paper is to describe the organization and modality of provision of clinical psychology services for those patients who had to be hospitalized due to COVID-19 during the pandemic in Northern Italy. The IRCCS Policlinico San Donato hospital in Milan was converted into a COVID-19 center in March 2020, and all the staff, including the Clinical Psychology Service Team, were diverted to assist these patients. A description is given of how the service was organized and the (...) modalities which were utilized to assist the patients. Following the pertinent ministerial decrees, guidelines, and relevant literature, the patients were followed up through telehealth. A COVID-19 rehabilitation unit was later opened in April 2020, where all patients were seen and followed up by the Clinical Psychology team, the last patient being discharged at the end of June. Details are given about the type of services provided during the hospitalization at the different points in time. At admittance and subsequent isolation, patients indicated by the medical and nursing staff, and those who specifically requested it, were given psychological support. Patients transferred to the COVID-19 rehabilitation unit were all evaluated for anxiety, depression, posttraumatic stress disorder, and sleep disorders both on admission and at discharge when possible. (shrink)

An eighteen‐year‐old with sickle cell disease was admitted to the pediatric hematology service at his local children's hospital for management of an acute pain crisis, one of many such admissions. He had a good relationship with his primary hematologist and primary nurse, but with other health care providers, there was evident friction. Sometimes, he was simply rude, rolling over and pretending to sleep in response to questions about his symptoms. When frustrated or convinced that his pain was not (...) being addressed appropriately, he was prone to yelling and cursing at his nurses. After members of the health care team complained, their supervisor decided to transfer the patient to an adult general medicine service. Reasons cited for the transition included the stressful work environment created by the patient's actions, his refusal to follow directives from staff (although he was generally adherent to treatment), and the hypothetical harm to other young patients who might witness his behavior. Was this a just outcome? Is it ever permissible to deny access to pediatric care to a patient whose best interests would be served by it? Can access be withheld for “bad” behavior, and can transfer of care be wielded as a punishment? (shrink)