Background

Overview

When a patient intends to self-discharge or refuse treatment against medical advice, it can be worrying. If a patient persists in their decision, the conversation may become challenging, and communication might break down. It is crucial to remain calm, non-judgmental, and objective. Effective communication skills are essential to explore the reasons for these decisions. This can help clarify misunderstandings or suggest potential alternatives.

The goal is to ensure the patient is fully informed about their decision, including its risks, benefits, complications (including death), and alternatives. If they have the capacity to self-discharge, their decision must be respected, and they cannot be detained against their will. In these circumstances, your role is to ensure their self-discharge is safe, without judging their decision.

Assessing capacity

Failing to assess capacity before self-discharge or refusing treatment is negligent. Always assess capacity using a two-step process:

  • Is there any impairment or disturbance of the mind?
    • This includes conditions like dementia, delirium, psychiatric conditions, or unconsciousness.
  • Does this disturbance impact decision-making?
    • Use ‘UR With Capacity’ to help assess:
      • Understanding: Can they understand intervention details, including its indications, risks, benefits, and the risks of not having it done?
      • Retaining information: Can they hold on to the information long enough to make a decision?
      • Weighing up information: Can they weigh the pros and cons to make a decision?
      • Communicating the decision: Are they able to communicate their decision?

Some scenarios require careful consideration:

  • Alcohol/drug use
  • Mental capacity impairment due to conditions like delirium
  • Diagnosed or suspected psychiatric conditions, such as acute psychosis and its causes
  • Children under 16 years old cannot self-discharge without parental involvement

Capacity assessments are decision-specific. Lacking capacity in one area does not mean the person lacks capacity in another. Each decision must be assessed separately.

People with capacity and self-discharging

If someone with capacity decides to self-discharge, it is their responsibility. However, this does not stop them from receiving treatment. For example, they may refuse one test but accept another. They may still need medication and follow-up appointments.

The discussion with the patient should be thoroughly documented. This includes their reasons and the full documentation of the capacity assessment.

People who lack capacity and self-discharging

De-escalation and detaining patients

If a patient lacks capacity and wants to self-discharge, escalate the situation to senior staff. Sometimes, a decision must be made in the patient’s best interests against their will. The least restrictive option should always be used.

When preventing someone from leaving is necessary, try de-escalation first. Use measures like sedation or calling for security only if needed. The patient’s GP, relatives, friends, or other health professionals can help persuade the patient to stay.

Hospitals may have specific teams or protocols for keeping patients in hospital while awaiting a full Deprivation of Liberty Safeguards (DoLS) assessment. In cases of a suspected or confirmed psychiatric condition, consider involving psychiatric services and conducting a Mental Health Act (MHA) assessment.

An FY1 doctor cannot detain someone under the MHA but can request a qualified clinician to do so until an MHA assessment is completed.

If the patient has already left

If a patient has already left, inform a senior, site manager, security, and the relevant team. Security may search for the patient. If necessary, the police may be involved to find the patient.

OSCE Tips and Scenarios

Possible scenarios

Some scenarios you might encounter include:

  • A patient refuses admission, even after discussing the risks of refusing.
  • A patient refuses admission due to concerns about tests or treatments, such as disliking intravenous treatment and cannulas.
  • A patient refuses admission because of care commitments.
  • A patient refuses admission because they are unaware of the suspected or confirmed diagnosis and the severity of the situation.
  • A patient requests alternative treatment. For example, they prefer treatment in the community instead of in the hospital with intravenous treatment.
  • A patient is unhappy with the need for admission for what they perceive as a non-concerning issue, such as nausea and vomiting due to bowel obstruction.

Tips for the station

Explore their understanding first. Before explaining anything, always tailor your discussion based on what the patient already knows. Asking about their current understanding helps you decide what to explain and how much, and also identifies other possible issues that need addressing.

Never make assumptions. A patient having dementia or any other condition that could predispose them to lacking capacity does not mean they automatically lack capacity. Assess capacity each time for every decision, as it is specific to each decision.

Use a systematic approach. Follow a structured method when assessing a person’s capacity. Work through each principle step-by-step. The examiner may ask you to present your capacity assessment. Doing this systematically shows your understanding and ensures nothing is missed. For example, “I feel this patient lacks capacity because they cannot understand the information, retain it long enough to make a decision, and cannot weigh up its pros and cons. Even though they can communicate their decision, they do not have capacity as all of these criteria have not been met.” Reiterate that you would assess capacity for each intervention separately, as capacity is decision-specific.

Be clear about serious complications and death. Do not avoid discussing serious and life-threatening risks, including death. During the station, explicitly mentioning ‘death’ is essential. Being unclear about this may result in immediate failure. Although discussing death can be awkward, it is a necessary part of the conversation.

Know your next steps and the limits of your competence. If asked about the next steps and you believe the patient lacks capacity, state that you would first document your assessment. Then, you would speak to your senior before filling out any consent forms. Your senior would decide on the patient’s behalf in their best interests.

Mistakes people make

Some mistakes made include:

  • Not exploring patient perspectives: Failing to understand the background leading up to the current situation, the patient’s viewpoints, and concerns.
  • Not exploring patient expectations and negotiating: Ignoring the patient’s expectations and preferences. Failing to negotiate and suggest a plan of action.
  • Lack of clear consultation closure: Not concluding the consultation with a clear plan. Leaving patients uncertain about the next steps.
  • Monologuing and/or jargon: Engaging in one-sided communication. Not facilitating a dialogue and using language that is difficult to understand.
  • Being unable to explain why admission is necessary: The patient must fully understand the risks of their decision and the possible consequences.
  • Inadequate responses to questions: Failing to confidently and accurately address questions. Not responding to concerns, leading to confusion and dissatisfaction.
  • Failing to mention death: When a decision carries the risk of death, it is essential that the patient understands this. Use the word ‘death’ clearly and avoid paraphrases like “pass away”.
  • A lack of knowledge and an over-reliance on seniors and leaflets: Depending excessively on senior advice or leaflets to fill knowledge gaps. Underestimating their own responsibility in patient care.
  • Not understanding professional limits: Offering to perform tasks beyond their competence and not recognising the limits of their grade level.

Key Communication Skills

Explaining

Use ICE: when explaining information, focus on the patient and use their ideas, concerns, and expectations (ICE) throughout the discussion. Avoid asking multiple questions in rapid succession. Instead, gather their ICE at the start and address them as they come up.

Chunk and check understanding: divide information into manageable segments. After each segment, confirm understanding by asking, “Does that make sense?” or “Is there anything else you’d like to ask about that part?”

Avoid medical jargon: use simple language that the general public can understand. For example, say ‘underactive thyroid’ instead of ‘hypothyroidism’.

Be honest, clear, and sensitive: communicate information directly but with sensitivity. Ensure the patient understands important details, including risks of serious or life-threatening complications. Use clear, straightforward language, and do not shy away from discussing severe outcomes, such as death.

Know your limits: Be aware of your competence and what you can offer. When discussing next steps, remember to consider if you need to consult with a senior or another team member.

Empathy

Empathise appropriately: reflect the patient’s emotions and offer reassurance. Make sure not to provide false reassurance or promise outcomes you cannot guarantee. Assure the patient that you will do your best to help. For example, if a patient is worried about a diagnosis, you might say, “It is natural to be worried about a new diagnosis, but we are here to help and address any concerns you might have.”

Acknowledge feelings without colluding: recognise the patient’s feelings but avoid colluding or taking sides. If a patient is angry with a colleague, you could say, “I understand how this situation might make you feel that way.” Do not take sides.

Breaking bad news: when delivering bad news, first explore the events that led to the current situation. Assess what the patient already knows and has experienced before providing any explanations. For example, if a patient has undergone several tests for possible cancer and is anxious about the results, find out what they know about the tests before discussing the findings.

Potential Ideas, Concerns, and Expectations

Some ideas, concerns, and expectations include:

  • “What’s going to happen next?”
  • “I can’t stay here; I need to take care of my partner.”
  •  “Why can’t I go home?”
  • “Why am I being told what to do?”
  •  “If I feel better now, why can’t I leave?”
  •  “Can’t I take medication at home instead?”
  • “I don’t like needles; can’t something else be done?”
  • “I don’t have anything with me. I can’t go home and get my things.”
  • “My friend/loved one is overreacting; I don’t think it’s this serious.”
  • “I don’t want to waste time and resources.”

Approach

Introduction

  • Wash your hands and introduce yourself by stating your full name and role.
  • Confirm the patient’s identity: ask for their full name, date of birth, and any preferred name.
  • Explain the purpose of the conversation and gain consent: “I’d like to discuss your care and the next steps.”

Background

Explore the patient’s background:

  • Events leading up to now: What has happened so far?
  • Current feelings: How are they feeling at the moment?

Briefly explore their history:

  • Past medical history: What other medical conditions do they have?
  • Drug history: Are they taking any regular medications?
  • Allergies: Are they allergic to anything?
  • Social support: Who is at home and what support do they have?

Explore their understanding and ICE:

  • Understanding: What do they know about their situation?
  • Ideas and concerns: Are there any worries they have?
  • Expectations: What do they hope to achieve from this consultation?
  • Confirm the direction of the conversation: “So you would like to discuss the next steps. Is that alright?”

Explanation and discussion

Information gathering

Gather what they know:

  • Tests and management: Has anyone informed them about what is currently happening?
  • Suspected diagnosis: Have they been told what they might have?
  • Next steps: Have they been informed about what will happen next?
  • Feelings about admission: If they are reluctant to be admitted, ask why.

Admission/treatment explanation

Discuss why admission or treatment is recommended. Tailor the discussion to their ICE and understanding:

  • Diagnosis: What do they or might they have?
  • Investigations: Why are these tests necessary?
  • Management: How will they be managed and why is this necessary?
  • Indications: Why is admission or treatment recommended?
  • Benefits: How will this help them?
  • Risks: Clearly explain all risks, including serious complications and death. Use the term ‘death’ explicitly.
  • Reassurance: Assure them that hospital admission is only for cases where it is absolutely necessary.

Negotiation and problem resolution

Negotiate alternatives or compromises based on their ICE. Avoid making unrealistic promises. Consider the following:

  • Items from home: Can a relative or friend bring necessary items like chargers or medications?
  • Community treatment: If suitable, could they receive oral treatment at home instead of intravenous treatment? Could their GP or a district nurse manage their care?
  • Period of leave: Check ward rules for any curfews or practicalities regarding leave.
  • Trying alternatives first: For example, see if oral antibiotics could be used instead of intravenous antibiotics by consulting the infectious diseases team.

If they agree to compromises, inform them that you need to discuss these with a senior. Do not promise anything without approval.

Patient still refuses

Assess capacity if the patient refuses treatment. Normalise and reassure them when checking their understanding. “Just to make sure I’ve explained everything properly, I’d like to check your understanding of this information. This is something we do with everyone in these situations. Could you tell me in your own words why we want to do this?”

  • Indications: Can they explain why the treatment was recommended?
  • Benefits: Can they describe the benefits of the treatment?
  • Risks: Can they list the risks involved?
  • Serious complications and death: Can they identify any serious or life-threatening complications, including death?
  • Risks of non-intervention: Can they outline the risks of not undergoing the treatment?
  • Reiterate that death could occur.

Can they communicate the decision?:

  • Communicating the decision: Can they state what their decision is?
  • Clarification: Is this their final decision?

Their responsibilities

If they have capacity, remind them of their legal right to choose, though this would be against medical advice:

  • Care responsibility: They will be responsible for their care if they become unwell or need further help, as they cannot be monitored in hospital.
  • Self-discharge letter: They must fill out a self-discharge letter, a legal document acknowledging discharge against medical advice.
  • Documentation: The discussion will be documented, and their GP will be informed so they are aware of any changes in their condition.

Explain what happens next:

  • Sorting out discharge: This will take some time to arrange, including collecting discharge medications and the self-discharge form.
  • Ask if they can wait: Can they wait or return later to collect discharge items?

Summary and concluding

Summarise and clarify what has been discussed:

  • Confirm the details and acknowledge the risks: “So to summarise, you do not wish to undergo this intervention and understand the risks, including the risk of death?”
  • Stress that the final decision is against medical advice and is theirs to make.

Check that all questions have been addressed:

  • ICE: Have their ideas, concerns, and expectations been acknowledged?
  • Invite further questions: Do they have any additional questions?

Advice and next steps

Advise on self-care measures:

  • Safety netting: Inform them of specific signs and symptoms to monitor and what actions to take if they occur.
  • Preventing recurrence: Advise on measures like stopping smoking, following medication instructions, and offer help with these.

Finishing

  • Senior discussion: Inform them that you will need to discuss their case with a senior first.
  • Offer time to think: If possible, give them time to consider their decision.
  • Let them know they can change their mind: Remind them they can get in touch if they reconsider.
  • Offer leaflets, early follow-up, and future contact: Provide relevant materials and offer future contact with yourself or another team member.
  • Thank the patient and document the discussion.

Practice OSCE Station

Instructions to candidate

You are a junior doctor working in the Emergency Department. Michael Roberts is a 55-year-old man who has been evaluated in the department. He requires admission for further investigations. Michael would like to discuss his admission.

Please address his concerns and answer any of his questions.

Duration: 8 minutes

Simulated patient script

Name: Michael Roberts
Age: 55 years old
Presenting Complaint: Severe chest pain and shortness of breath.
Clinical Findings:

  • Physical Examination: Mildly elevated blood pressure, normal heart rate, and breath sounds.
  • Initial Investigations: ECG shows some ST-segment elevation and cardiac biomarkers are slightly elevated.

Background Information:

  • Medical History: Type 2 diabetes, controlled with oral medication, history of hypertension.
  • Family History: Father had a myocardial infarction at age 60.
  • Social History: Non-smoker, consumes alcohol socially, works as a construction manager, lives with spouse and two teenage children.

Ideas, concerns, and expectations (ICE):

  • Ideas: Michael is concerned that his chest pain is not severe enough to be admitted and does not see the need for further investigations. Michael feels that his condition is manageable and that he is being overly cautious.
  • Concerns: He is worried about being away from work and home responsibilities, and is frustrated about being admitted for what he perceives as a minor issue. He is anxious about the impact of being admitted on his personal and professional life, and he feels his time is being wasted.
  • Expectations: Michael expects to be given more information about why he needs to stay in the hospital, the seriousness of his condition, and what the next steps are. He wants a clear explanation and reassurance about the necessity of admission and what will happen if he leaves against medical advice.

Questions:

  1. “Why do I need to be admitted? I don’t think my condition is that serious.”
  2. “What further tests are required and what will they reveal?”
  3. “Can I go home and come back if I need to?”
  4. “What happens if I refuse to stay and leave now?”

Feedback

  • Understanding the situation: Did the candidate seek to understand the situation from Michael’s perspective and acknowledge his concerns?
  • Listening and responding: Did the candidate listen attentively to Michael’s concerns and respond appropriately, providing clear information about the necessity of admission?
  • Exploring expectations and negotiation: Did the candidate explore Michael’s expectations and negotiate mutually agreed next steps, ensuring Michael understands the seriousness of his condition?
  • Capacity and consent: Did the candidate assess Michael’s capacity to make decisions and provide information about the consequences of self-discharging?
  • Clear decision and strategy: Did the candidate end with a clear decision and strategy for managing Michael’s care, including the implications of leaving against medical advice?
  • Patient-centred approach: Did the candidate maintain a patient-centred, sensitive, and professional approach throughout the consultation?
  • Key clinical or ethical Issues: Did the candidate cover all relevant key clinical or ethical issues, including the need for further investigations and handling self-discharging?

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