MANAGEMENT
DISCHARGE FROM DAY PROCEDURES A PATIENT ARRIVES FOR A SCHEDULED EYE PROCEDURE, TO BE PERFORMED UNDER SEDATION. THEY PLAN TO TAKE THE TRAIN HOME WITH NO SUPPORT PERSON. RUANNE BRELL AND DR PATRICK CLANCY DISCUSS YOUR OPTIONS.
S RUANNE BRELL
ometimes, despite best efforts at explaining discharge requirements, a patient will not have a support person to accompany them home. In such scenarios, practitioners may be concerned about their responsibility if a patient is discharged alone and:
• i njures themselves or someone else when travelling home, or •e xperiences a post-procedure complication.
DR PATRICK CLANCY
In a small number of cases, patients have been harmed and healthcare providers criticised over discharge practices. It appears processes broke down or responsibilities were unclear. Patients may not have been appropriately assessed for discharge, or not clearly advised of the risks of driving themselves. GOOD PROFESSIONAL PRACTICE In assessing a patient’s fitness for discharge, practitioners are expected to exercise clinical judgement, guided by applicable professional and regulatory guidelines. The Australian and New Zealand College of Anaesthetists (ANZCA) 'Guideline for the perioperative care of patients selected for day stay procedures' (PG15) (DSP Guideline) sets out good professional practice for such procedures. It provides patients should only be discharged when a responsible adult is available to transport them in a suitable vehicle (not a train, tram, or bus). A responsible person should stay with the patient at least overnight. You need to ensure patients understand the risks material to their situation. •M ake discharge criteria and expectations clear well before the scheduled date of the procedure so patients can plan appropriately. •W arn of the potential effects and risks of the procedure and any medication. Explain how sedation or medications may affect their ability to resume driving or other tasks and for how long.
•P rovide written and verbal instructions about post-anaesthesia and post-procedural care. Include a contact number and location for emergency medical care if necessary. Once you’re satisfied a patient is well enough to be discharged, there is rarely a legal basis to detain them if they insist on leaving. A patient can only be detained in hospital against their will if they meet the requirements for involuntary admission under the relevant legislation. MANAGING DIFFICULT SCENARIOS It’s helpful to consider in advance some ways to manage potentially difficult scenarios. Patients who plan to leave unaccompanied – If the patient arrives unaccompanied, can they arrange for a support person? If not, it may be appropriate to postpone the procedure. This will be a clinical decision. If you decide to proceed, you may need to advise the patient to stay until the effects of sedation have worn off enough and they can safely leave alone. This assumes your facility has arrangements for staff to stay until the patient has recovered, and that you can transfer them to hospital if there are unexpected complications and they are not going to be able to go home. They should still travel home in a taxi or car, if possible, rather than using public transport. Consider also appropriate follow-up arrangements to ensure someone checks in on the patient the next day. What if they plan to drive? – Practitioners often ask what to do if a patient insists on driving after sedation. Practitioners are expected to advise patients not to drive until they have sufficiently recovered, physically and mentally, but do not generally have a duty to report to the licensing authority.
If the patient insists on leaving, practitioners should obtain a signed confirmation they left against medical advice.
However, if you’re concerned a patient may pose a serious risk to their own health and safety, or they may put someone else at risk, there may be grounds to breach patient confidentiality and report them to the police. This situation can be complex, so seek advice first. Documentation – Always document any information, materials and advice you gave the patient. If the patient insists on leaving, include their signed confirmation they left against medical advice, and your clinical rationale they had capacity to make that decision. Disclaimer: This article is intended to provide commentary and general information. It does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual. circumstances. n
ABOUT THE AUTHORS: RUANNE BRELL is a senior legal advisor in the Advocacy, Education and Research team at Avant with over 15 years’ experience in health and medical law. She also provides advice to Avant’s members via its Medico-legal Advisory Service. DR PATRICK CLANCY is a senior medical adviser at Avant. He has been a doctor for over 25 years and was previously a member of a state medical board. Patrick has presented and written widely on medico-legal topics, with a focus on minimising the risks faced by doctors.
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