AREAS OF CONFLICT: DISCHARGE FROM HOSPITAL
This particular area can be fraught with problems and has come to the government's attention. There are now very strict guidelines given to hospitals concerning the discharge process and these guidelines must be followed. The ideal should be as follows.
The medical problem is over, the person treated and looking forward to returning home. Any carers involved are happy and have met with the hospital staff concerning the discharge. Mobility problems have been identified and a home visit has been carried out by the hospital therapy staff. Prior to discharge the multi-disciplinary team meet and all contribute their views. A care plan is agreed with the patient and family and is written up by the social worker. If this requires a lot of new services, the community care manager either automatically agrees it or calls a case conference. A discharge date is set and each member carries out any special tasks (social worker will order services after talking with patient and carer, the ward staff order the ambulance, the junior doctor will write a discharge note and organize any medication to go with the patient). Patient and carer are kept informed of all actions as is the GP and the discharge goes ahead uneventfully. The key is communication.
Unfortunately many discharges do not resemble the above at all. Many excuses are given but inevitably the failure is in communication. There are no easy answers but wards and professionals alike should not get away with bad practice. If the discharge procedure goes wrong then the people concerned should know about it. Vigorous complaints are one way to change and hopefully improve the service. No one likes to complain but without such guided criticism mistakes will continue to occur. Complaining itself is no easy process but again this has been recognized by government and each hospital has a complaints procedure which should go into action immediately, offering a reply within 14 days. To ensure that the problem gets looked into the complaint must be in writing and preferably addressed to the service manager and/or the hospital's public relations officer (customer service). In very serious cases a copy of the letter should also go to the hospital's chief executive. This is not to say that many difficulties cannot be resolved by speaking to the various people concerned but a change of practice needs a letter.
A special difficulty occurs when a carer feels that a person cannot return home. This happens extremely frequently, and I have seen a vast increase in this particular problem since the NHS and community have been so starved of resources. What seems to happen is that the admission to hospital because of an acute illness provides the break needed in which a total evaluation can occur of the difficulties at home as suffered by the patient and carer. There is always a long history of increasing failure to cope at home, with either no other help sought or that help having failed in some way. It is at its most desperate when dealing with the elderly mentally confused, where the resources are indeed limited. Bear in mind that carers have to be pretty desperate to say 'No' to the massed authority of the hospital hierarchy.
If a carer feels concerned about the impending discharge of a relative, then they must speak out as soon as possible. In many cases discussion with the various team members involved will allow for a compromise, in that more help is provided if possible. If this does not allay fears sufficiently, the carer and other people involved should meet up with the consultant concerned; it may be appropriate to invite others to this meeting, such as the social worker dealing with the case, etc. In cases of real conflict then a case conference should be held, involving the multidisciplinary team as well as the carers, community agencies involved and the person concerned. Carers should ask for such a meeting if they are really unhappy about an impending discharge; it allows for everyone to say their piece and for the carer especially to point out the realities of life to the other conference members. The point of the conference is to arrive at a solution acceptable to everyone.
Where the patient is able to communicate well, their wishes are paramount, and if they want to return home then as much as possible will be done to ensure this. Often this involves the taking of considerable risks, and carers are sometimes counseled to accept-this. Where the patient is mentally frail, however, and not able to vocalize their wishes clearly, the task is harder. The choice is usually between the patient going home against the carer's wishes and entering some form of institution. These decisions are never easy and there are pressures on both sides. On the consultant's mind is his/her commitment to other people who need the beds and services of the hospital, as well as the multidisciplinary team's appraisal of whether or not a return home is feasible. The carers on the other hand have often been through it all before. Their concern for a relative may be so great, however, as to cloud their judgment and not allow them to see alternatives. There are no easy answers. The two sides must trust each other and in most cases a reasonably amicable solution is found. The equation at the moment is far too heavily weighted in favour of the hospital; the needs of consumer and carer have to be more forcibly stated and, more importantly, acted upon.
*91/128/5*
GENERAL HEALTH
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