Medically stable for discharge…
In my consults work as a Geriatrician I am often contacted when teams get stuck with discharge planning.
The patient is medically stable for discharge but they or their loved ones say they are not ready.
There is a wider discussion to have about the role of hospital inpatient care and how this intersects with primary care, outpatient specialist healthcare and other support services in the community.
There is a bigger picture question how does our healthcare system meet the complex needs of patients and their supporters in a sustainable way, across the healthcare continuum.
However, this blog post focuses on communication tips for exploring discharge planning concerns and options when there is a mismatch in expectations.
This is advice is for discussions with patients who have capacity to engage in discharge planning discussions their supports / family members.
Medically stable for discharge?
The ward round notes say “medically stable for discharge”
You’ve been tasked with updating the patient or carers that discharge has been planned for the following morning.
Working through your job-list later that day you pick up the phone.
There’s hesitation or silence at the other end as you explain that everything has resolved and it’s time for home. And then the questions start.
Or you are speaking in person, the relative may be silent, express dismay, or they may display other reactions like frustration.
Or you’re at the bedside talking to your patient, and now they’re calling other family members for back up…
How do you prepare to discuss discharge plans over the phone?
What now?
Whilst we hope that we don’t get to the point of discharge with mismatched expectations, in the increasingly fast-paced world of hospital medicine decisions can move quickly.
With increasing use of hospital discharge coordinators, nurse unit managers and rotating medical teams its also possible the person communicating about discharge may not have been part of the discharge decision, but find themselves in the position of communicating the decision, and deciphering the response.
This is a classic case of mismatched agendas, and its an opportunity to resolve this positively for the patient.
Responding to cues is going to be vital for this conversation and the first cue is your own. If you notice yourself feeling perplexed, at a loss or other emotions - take this as a cue that there is some information gathering to do. If you notice yourself thinking
How do I solve this?
Why the sudden change of plan?
Don’t they know their plan is unrealistic!
That should be your cue to find out more and ask yourself: Do they know what we know? Do we have the same understanding? What assumptions am I making about what they already know?
This is also a cue to be sure that they are medically ready, and double-check that no outstanding issues have been missed.
Ask yourself a couple of questions?
Have I got enough information about the issue and the reasons for the mismatch?
What can I understand about the differing points of view?
The following are some suggestions for these discussions both in person and on the phone.
How to respond in the moment?
Firstly being in hospital is usually) a time of worry and concern for people even when the reasons are positive such as long awaited operation. Recognising your patients/family’s context is important.
Crucially don’t fear the “can of worms” you might open in exploring their concerns - understanding what’s important is valuable data, and a fast track to being able to resolve the issue.
Recognising your own concerns and pressures is also helpful particularly when you were not part of the earlier discussion.
Consider how you can most be helpful at this point and seek help from your team if your need. This might look like getting more information from the team on the round especially if you predict there may be disagreement with the plan. It may also look like a joint discussion including allied health, a social worker, discharge planning coordinator or nurse unit manager
Structuring the conversation
Make sure you’ve introduced yourself and role clearly and you understand who is in the room, particularly if there are several people
Phone conversations on speaker can be really helpful as they allow carers to get real time support from family and decrease their cognitive load in remembering and relaying information. If you’re comfortable with this, welcome the other listeners, get their names and ask about their relationship to the person
Pick up on cues and respond to them
(On the phone) “I notice that you’ve gone quiet, could you let me know what’s on your mind?” (Open question)
“It sounds like you have some concerns about this plan can you tell me more about your worries?” (Open question)
Respond to emotions
Notice and respond to any emotions - remembering they may appear as non-verbal cues or verbal cues. They may sound like questions or even demands. It’s tempting to respond with more facts to help reassure. Notice yourself doing this and remember to also respond to the emotions you suspect may be present. Ask-Tell-Ask can be helpful for this.
“I can imagine it must be frustrating to hear mixed messages about the discharge plan, I’m sorry for this.” (pause)
“So I can help to clarify things can you tell me what you’ve already been told?” (Ask)
If yes give information (Tell) taking care to break it into 1-2 short pieces and pause each time
“Is this something you have had a chance to discuss before?” (Ask)
Consider using the above skills to respond to emotions during the conversation. You may need to use a skill multiple times to provide enough support.
Explore Ideas Concerns and Expectations
Ideas: what do they understand about their condition, the treatment, what inpatient care can offer, what recovery will look like post hospital?
Concerns: What are they most worried about related to being at home
Expectations: What are they hoping for? (What information did they receive about what to expect and where from?)
“Thanks for sharing your concerns, it sounds like this plan feels unexpected or early to you.” (Pause) “Can you tell me more about what you understand/what your worries are?
You can start with open questions and progress to clarifying questions. Remember to look for, recognise and respond to emotions throughout, this can be a stressful discussion for many.
What to do about the mismatch?
You’ll need to address it directly, also remembering there is a person or several people managing the outcomes of your recommendations. If the possible compromise makes sense e.g. a person highly dependent on a carer who is not physically available until the following day, it’s reasonable to adjust the plan. If reassurance is needed about supports post discharge you can clarify these.
If the concerns are more indistinct you will need to reestablish some expectations about was is possible in hospital and what is appropriate to address in the community. This is where your own emotions may rise (worry, dread) about breaking the news that a longer hospital stay isn’t possible.
As with breaking any unwelcome news break this information into smaller chunks and watch for your patient’s response, responding in turn to the emotions that they may express.
“I can hear that you are feeling worried about going home, it can feel stressful going from hospital to home”
“I hear your frustrations about the change in planned that it feels sudden”
It may also be useful to explain that hospital discharge is not only about facilitating ongoing recovery in the community but also about the avoidance of hospital related complications.
“I understand that you feel safer here”
“Hospital is the right place to be when you are very sick, however we do know that, once a person is well, being in hospital can increase their risk of infections, falls and other complications. (Pause) at this point it is much safer to be at home”
If a discharge option that sounds unlikely to be successful is raised acknowledge/summarise the active planning and also gently challenge the suggestion.
“I note you say your daughter is going to look after you” (pause) “From what we have seen in hospital as your health as changed, it looks like your care needs would be too much for her to manage…”
“I hear what you’re saying, you’d prefer not to go to residential care would rather stay in hospital for two more weeks until things are better…” (pause) “Unfortunately it sound like the things preventing you living at home have been going on for many months and I think they would be unlikely to improve at this point”
What if your patient says “I am not going to (x discharge destination)!”
I find it useful in this situation to ask about their discharge plan and try to avoid getting into a circular discussion with my recommendations vs their refusal.
“I hear what you’re saying you, what are you planning to do, what other possibilities are you considering?”
Then you can have a discussion about options, exploring each in turn, there’s even a chance you might identify another feasible one.
Closing the conversation
Confirm the discharge plan including any followup, travel arrangements and services. Offer additional written information including a patient discharge summary if this is an option at your health service.
At the end of the discussion if your patient or the family member is showing signs of ongoing disappointment with the outcome it is fair to acknowledge this too.
“Thanks for having the discussion”
“I can see that this outcome was not what you were expecting but thank you for talking this through so we could make some plans”
Final Thoughts
Ideally we would not discover mismatched expectations at the point of discharge, because we plan early discussions with clear consistent communication about discharge plans.
However, plans change, preferences evolve, emotions arise. It is helpful to be prepared for those instances which may become more complicated.
The above are some suggestions when you are thinking about discharge planning discussions, adapt them to suit your own authentic communication style.
Think about how you will plan your next discharge planning conversation.
