Frequently patients wish to self-discharge from hospitals. This article pertains to adult patients only (18y+) and these patients can be broadly split into three groups:
- Those that lack capacity as defined by the Mental Capacity Act (MCA) with a ‘disease of mind or brain’. These patients may be in for their mental health disorder or physical health disorder. They may be under a mental health section but are usually not.
- Those with capacity: these patients are described as “leaving against medical advice” as they understand the hazards of leaving
- Those that leave/abscond before capacity has been assessed or it was never questioned during their stay
Reminder on Capacity
Do read the GMC guidance on capacity, which reminds us that patients have presumed capacity. Thus patients need to have a ‘disease of mind or brain’ before their capacity can be questioned. Additionally, capacity is decision specific so the same patient may refuse a cannula but may not have the capacity to self-discharge. It is often difficult to differentiate between lacking capacity & merely making a decision with which the healthcare team disagree. Therefore have a very low threshold to escalate – these conversations & decisions are complex and often require senior input.
Always think about the risk to oneself (neglect, falls) & to others – particularly in patients with psychiatric conditions. You may need to consider the mental health act.
Reading the background information
- What’s their diagnosis and management plan?
- How long have they been on the ward?
- Did anything happen or seem to trigger the patient’s request to self-discharge?
- How did they express their desire to self-discharge?
- Can a nurse provide a handover of what things have been like? How have they been interacting with others?
- Has anyone been to visit?
- Consider whether there may be psychiatric conditions making the situation more complex
- Check if they are informal or admitted under a section
- If they do have a psychiatric condition, consider asking the psychiatry team to assist you. This is an absolute requirement if they are sectioned under the Mental Health Act
- Consider asking a nurse to come with you, especially if you haven’t met the patient before – it can be more reassuring if there is a familiar face, and they have much more experience with how the ward can work, e.g. around patients being given leave
Meet with the patient
- Try to understand their reasons for their self-discharge, and empathise with the patient. Wards can be quite restricting places that are noisy & scary when surrounded by ill people.
- They may have previously agreed to come into hospital. What has changed?
- Have they been to hospital before? What has their experience been like? For a first time patient, it can often be scary, and some reassurance goes a long way.
- Explain their diagnosis & management plan. Use this as an opportunity to assess their capacity (can they understand the reason for admission & risks of discharge, weigh up the pros and cons, retain the information long enough to do so and communicate their decision?).
- What do they plan to do when they leave?
- Consider if the patient is asking for leave instead; this can often be around getting things from home, seeing children, looking after a pet.
- Ask about smoking, alcohol and recreational drugs – sometimes patients want to leave due to suffering from withdrawal symptoms, and, fear the consequences of admitting this, or are not aware that PRN medication can help
- For patients with psychiatric conditions
- You must consider risk – particularly of suicide and harm to others
- Do they have a plan to manage their mental health? E.g. will they be willing to have the home treatment team involved?
- What is their support network like? Do they have someone who can be with them when they leave – suicide risk is highest for the first 72 hours after discharge
(1) Those that lack capacity
- This must be escalated to the senior medical & nursing teams.
- A key principle of the MCA is that the least restrictive option is used. Consider the risks of immediate discharge on the patient, those around them & the ability to safely & reasonably deliver your treatment plan whilst addressing their wish for discharge. Use of GP, ambulatory care, relatives & other healthcare professionals can help support this.
- If it is felt that it is appropriate to stop them leaving, try to de-escalate before restraining/sedating or calling security. Follow local guidelines which may include calling particular teams or keeping them whilst awaiting a full Deprivation of Liberty Safeguards (DoLS) assessment.
- Document their lack of capacity & why. Inform the nurse in charge & consultant of what has occurred & that they lack the capacity to leave.
- If the patient has a psychiatric condition, do involve the psychiatric team
- Carry out a full MSE and risk assessment – does the patient need a mental health act assessment – i.e. a mental disorder of nature and degree, and a risk to themselves/ or others
- Remember self-neglect/ deterioration in mental health is considered a risk to themselves
- As an FY1, and not fully registered with the GMC, you cannot complete a section 5(2). However, you could advise a nurse to consider a section 5(4) until an FY2 or more senior doctor can attend. These powers can be used until a Mental Health Act assessment can be completed
- Capacity could inform a decision for a Mental Health Act assessment
- If the patient has already absconded:
- Inform the site manager, security, nurse in charge & the rest of the team including the consultant. Provide a description so the patient can be located.
- Search for the patient. The security team will likely know the quickest exits & use CCTV to check the grounds
- If the patient isn’t found, discuss with senior staff whether the police need to be informed
- The police will want to know their demographic details, address, GP, a description & the circumstances of how and when they left. The police will decide whether there is reasonable cause to find & restrain the person.
(2) Those with capacity leaving against medical advice
- Provide thorough documentation of your discussions & why you believe they have capacity giving examples of how they demonstrated each of the 4 requirements to have capacity
- Consider if a period of leave is beneficial? Check that plans fit in with ward rules (there is usually an evening curfew).
- Your job is to make this as safe as possible. This does not mean you’re condoning their self-discharge, but simply you’re providing your fundamental duty of care
- Consider different options e.g. oral antibiotics, home team/district nurse follow up, review by GP, community mental health team. Discuss these options with the patient to identify what they find acceptable then discuss with your seniors about which is the best option
- Discuss the case & these options with a consultant as they have ultimate responsibility for the patient therefore its courteous to let them know what’s happening to their patients!
- Explain that it might take time to facilitate their self-discharge e.g. to obtain discharge medications. Ask if the patients are willing to stay or if they can return to pick them up.
- Inform the nurse in charge & consultant of the outcome & plan
(3) Those whose capacity has never been assessed
- Check if they are still there or if they can be found on hospital premises. Then manage as above if you find them
- If they have absconded & cannot be found, consider whether there is a reasonable possibility that they lack capacity (e.g. a ‘disease of mind or brain’). The nursing staff & responsible consultant can help but remember patients do have presumed capacity.
- If on review of the notes & discussions with members of the healthcare team, there is a reasonable possibility that patients lack capacity then discuss these patients with seniors as per above with a view of considering whether the police need to be called to find & restrain them.
Written by Dr David Morris (Psychiatry SHO)
Edits by Dr Akash Doshi CT2
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