Discharge Home Against Family Wishes After Stroke
An occupational therapist in a public hospital is assessing a 68-year-old man 12 days after a left middle cerebral artery stroke. He has mild expressive aphasia, right arm weakness (Medical Research Council grade 3), and walks 15 m with a quad cane and standby assistance. He wants to go home alone to a fourth-floor walk-up flat. His daughter, who lives nearby, says he cannot cope and asks the team to recommend a nursing home. The patient understands his deficits, repeats the discharge risks, and consistently chooses home. He scores 24/30 on the Montreal Cognitive Assessment; the therapist notes he forgets to lock his door in practice and becomes frustrated with multistep meal preparation. He has no formal Lasting Power of Attorney. A home visit is booked in 48 hours. The team meets tomorrow to decide the discharge recommendation.
1. How should the therapist approach the disagreement between the patient and his daughter, and what would justify supporting discharge home?
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The therapist should separate the clinical recommendation from the legal question of capacity. Capacity is decision-specific: the patient must understand the relevant information, retain it, weigh it, and communicate a choice. A MoCA score of 24 and one missed door-locking step do not automatically remove capacity. The therapist should explore the patient’s values, insight, and routine, and use supported decision-making: a written checklist, photographs, a trial of meal preparation with cues, and a structured home visit. The family meeting should acknowledge the daughter’s fear, explain that all options carry risk, and clarify what support can realistically be arranged. Supporting home discharge is reasonable if the patient consistently understands the risks and benefits, can weigh them, and a safety plan reduces avoidable harm: medication blister packs, a personal alarm, home care, meal support, and a review date. If he cannot weigh the risks, the team should use a best-interests process with the daughter, doctor, and social worker. The therapist documents functional evidence and recommendations, not a final legal determination.
2. What should the 48-hour home visit and team recommendation cover?
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The home visit should test the real environment rather than rely on ward performance. The therapist should assess the fourth-floor walk-up, handrails, lighting, stair fatigue, toilet and shower transfers, kitchen safety, bedroom layout, door locks, phone access, medication storage, and the route to the lift or exit. The patient should perform meaningful tasks with the cues he would actually receive, and the therapist should note safety awareness, fatigue, and frustration thresholds. The team should identify equipment, home care hours, a medication system, emergency contacts, and a first-72-hours contingency plan. The recommendation should be framed as a graded trial with review, not a binary choice between home and nursing home. The daughter’s involvement should be negotiated, not assumed. The therapist should document observed performance, the patient’s stated choice, the risks discussed, and the safeguards agreed. A nursing home recommendation would be justified only if the evidence shows he cannot safely participate in decisions or a support plan cannot manage serious, imminent risks.
3. If the patient later says he will refuse all home support, what should the therapist do?
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The therapist should first reassess capacity for that specific decision, not assume that refusal equals incapacity. The discussion should identify the exact risks-falls on stairs, missed medications, poor nutrition, inability to summon help-and explore the patient’s reasons and preferred alternatives. Less intrusive options should be offered, such as a daily check-in call rather than a live-in carer, or a trial of one service. Social work, the treating doctor, and the daughter should be involved as appropriate. If the patient has capacity and accepts the risks after informed discussion, the therapist documents the refusal, the risks explained, the safety plan, emergency contacts, and follow-up arrangements. If there is no capacity or an imminent risk of serious harm, the therapist escalates to a senior clinician, ethics or legal channels, and uses the least restrictive option. The therapist should not abandon the patient or simply record “non-compliant.”
4. What documentation would best protect the patient and the team?
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Documentation should be factual, time-stamped, and decision-focused. It should record the patient’s own words about discharge, the specific risks he was given, the questions he asked, and how he weighed the options. It should include the daughter’s concerns and what she was told, the home visit findings, standardized and observational assessment results, equipment trials, and the support plan with named responsibilities. The therapist should note that capacity is decision-specific and describe the evidence for the conclusion without claiming a legal determination. If there was disagreement, record who was consulted, what options were offered, and why the final plan was chosen. A clear review date and triggers for readmission or escalation are essential. Good documentation shows that the team respected autonomy, mitigated foreseeable harm, and acted within scope. It also makes the reasoning transparent if the discharge is later questioned.