The Discharge Destination Dispute
Mr. Bianchi, 82, was admitted for a hip fracture after a fall. He has mild dementia (MoCA 22), lives alone in a second-floor walk-up, and has no local family. PT notes he needs moderate assistance to walk and cannot negotiate stairs. The hospital team wants to discharge him to a skilled nursing facility (SNF) for rehab. He refuses, saying, 'I'm going home. I've lived there 40 years.' His daughter in another state agrees with the team. The discharge planner has a SNF bed available tomorrow; home care could start in 3 days. He is not formally incapacitated and can state his preference clearly. He becomes agitated when the SNF is discussed and once tried to leave the unit.
1. How do you weigh his refusal against safety, and what process do you use?
Read the worked answer
This is a conflict between autonomy and safety in a patient with borderline capacity and no safe home setup. Process, not a snap decision:
- Assess capacity for this decision. Can he understand that he cannot manage stairs, appreciate that this applies to his second-floor home, reason about the risk, and express a consistent choice? Mild dementia does not automatically mean incapacity, but the agitation and elopement attempt warrant a formal assessment.
- If capacitated: his refusal stands, but you must make the discharge as safe as possible - do not simply send him home unsupported.
- If not capacitated: identify the appropriate surrogate decision-maker per state law and pursue the least-restrictive safe option.
Judgment point: 'He might fall' does not override a capacitated refusal, but 'he prefers home' does not excuse you from building the safest possible home plan. The exam rewards holding both truths.
2. Assume he is found to have capacity. What concrete plan makes a home discharge defensible?
Read the worked answer
Build a bridge plan that closes the specific gaps PT identified:
- Stairs: arrange a stair-negotiation session with PT before discharge, or a temporary ground-floor arrangement; if neither is possible, document the residual risk and the patient's informed acceptance.
- Home care: expedite start (request earlier than 3 days), with PT and nursing for mobility and fall prevention.
- Safety equipment: grab bars, bedside commode, and a personal emergency response system.
- Medication and cognition: pill organizer, simplified regimen, and a check-in call schedule.
- Contingency: a written 'if you fall or can't get up' plan and a named contact.
- Documentation: record that he was informed of the risks of home versus SNF and chose home; note the daughter's disagreement and that his decision governs if he has capacity.
Reasoning standard: a defensible discharge is one where the risks were named, mitigated where possible, and accepted by a capacitated patient.
3. How do you handle the daughter's disagreement and the agitation/elopement behavior?
Read the worked answer
Daughter: acknowledge her fear, share the capacity finding, and enlist her as a partner in the home plan (check-in calls, coordinating local supports) rather than as an adversary. Clarify the legal hierarchy: if he has capacity, his decision controls; her role is support, not substitution.
Agitation/elopement: treat it as a clinical signal, not just noncompliance. Screen for delirium (new confusion, infection, pain, medication effects) - a change from baseline in a patient with dementia is delirium until proven otherwise. Reduce triggers (repeated SNF discussions, unfamiliar staff), use calm reorientation, and involve the daughter by phone for reassurance. Escalate to the medical team for delirium workup and, if needed, geriatric psychiatry.
Judgment point: the elopement attempt should prompt a delirium screen, not a label of 'difficult patient,' and not an automatic capacity override.