Discharge Tomorrow, Shelter Tonight
Sam, 52, has schizophrenia, type 2 diabetes with an HbA1c of 11%, and a foot ulcer last dressed three weeks ago. He has been homeless for three years and has had 14 admissions in six years, each following a decision to stop medication. On day nine of this admission he is no longer agitated but still hears two voices commenting on him; he denies any command to harm himself or others. He refuses the proposed paliperidone palmitate depot because injections make him 'feel trapped', but agrees to 'take tablets when I remember.' He wants to leave tomorrow for a night shelter. The bed manager has flagged pressure and the team plans discharge tomorrow with a two-week supply of oral medication and a GP appointment in six weeks.
1. What is your position as the nurse, and how do you argue it?
Read the worked answer
My position: not 'block the discharge', but 'this discharge is not yet a plan'. Refusing to engage would be as unhelpful as signing it off.
What I would put to the team, concretely:
- The ulcer and HbA1c are the most immediate physical risks, not the voices. An undressed foot ulcer in a man sleeping rough is a route to admission with osteomyelitis or amputation. A GP appointment in six weeks is not a plan for an open wound - dressing appointment within 48–72 hours, and podiatry or tissue viability referral.
- The voices are not the deciding factor; his disengagement from treatment is. Fourteen admissions in six years is a pattern, and repeating the same discharge repeats the pattern.
- Least restrictive and lawful: he is informal and, if he has capacity, he may leave. Detention to prevent a foreseeable relapse is not lawful in most jurisdictions and would damage the only remaining alliance. So the answer is a conditional plan, not a delay for its own sake.
- What the plan needs: ACT or homeless outreach referral made today (not 'on discharge'), medication in a form he will actually take - blister packs, pharmacy delivery, or a supervised option - an advance statement, a crisis line he will use, and a named person who will see him within a week.
- Also flag: the depot is still negotiable, and heat/rough-sleeping advice matters for someone on antipsychotics in summer.
Documented: that I raised these concerns, to whom, and the response.
2. He will not accept the depot. How do you work with that using recovery and harm-reduction principles rather than persuasion?
Read the worked answer
Start by understanding the refusal, because 'feel trapped' is information, not obstruction. Men with this history have often been restrained and injected; a depot can be a bodily reminder of coercion. Exploring that is not indulging him - it is the only route to a medication plan he will keep.
- Widen the options. Different antipsychotic, lower dose, oral with pharmacy supervision, a time-limited trial of the depot with a written agreement about stopping, or a different injection site and a nurse he chooses. 'Depot or nothing' produces nothing.
- Make the trade-offs explicit without moralising. He is the expert on his life; I am the expert on risk. I would say what I know about relapse after stopping, and ask what would make tablets possible - a phone alarm, a blister pack, taking them at the shelter, a weekly check-in.
- Apply harm reduction to the diabetes and the foot, not just the psychosis. One dressing, one meal a day that fits his budget, shoes that fit. Small, achievable, his choice of order. An HbA1c of 11% will not be fixed by a lecture; a healed ulcer is a win he can feel.
- Use his own history as evidence. Fourteen admissions is fourteen data points he owns; asking what he noticed before each one is more persuasive than anything I can assert.
- Advance statement / wellness plan written while he is well, so that the next admission starts from his instructions rather than from scratch.
Documented: his reasons for refusal, the options offered, his choices, and the negotiated plan.
3. The bed manager tells you to 'just get him out - we need the bed.' How do you handle this, and what do you document?
Read the worked answer
Separate the system pressure from the clinical decision, and name both.
- Respond, don't absorb. 'I understand the pressure, and I'm not refusing to discharge him. I'm saying the destination and follow-up aren't in place yet. Give me until this afternoon and I'll have the outreach referral and the dressing appointment confirmed.' That is a nurse solving the problem rather than a nurse blocking the system.
- Use structured communication to the psychiatrist and charge nurse: situation, background, my assessment, my recommendation. The decision belongs to the psychiatrist; my responsibility is to make sure it is made with the information, and to say so if I think it is unsafe.
- Escalate if the pressure becomes coercion - for example, if I am asked to document something I did not observe, or to give him a supply of medication with no follow-up address. That is a professional boundary, not a personality clash.
- Protect the relationship with Sam. He should not experience the discharge as being thrown out; if he hears the ward is under pressure he will conclude he is a nuisance, which is exactly the belief that keeps him away from services.
Documented: the clinical reasoning for the plan, what was offered and refused, his capacity and views, the follow-up arrangements and who confirmed them, the fact that I escalated concerns and to whom, and the time. Objective, dated, no editorialising about colleagues - the record may be read years later by people who were not there.