What Do I Do When My Patient Shouldn't Leave?: An Online Survey of Institutional Policies For Patients Lacking Decision-Making Capacity for Patient-Directed Discharge

Abstract: *This submission is sponsored by the ACLP Med-Psych SIG

Background/Significance: Patient-directed discharge (PDD), previously referred to as discharge against medical advice (AMA), is associated with increased readmission rates and 30-day mortality, yet research is limited on what portion of these patients lack decision-making capacity for PDD (Foster et al., 2023). Patients may lack decision-making capacity for PDD due to underlying general medical conditions such as neurocognitive disorders, delirium, and substance intoxication. PDD continues to be a point of discomfort for clinicians, particularly when the impairment is due to a general medical condition and there is no clear legal basis for an involuntary psychiatric hold (IPH) (Kersten, 2019).

Methods: The authors sent an anonymous thirteen-question survey asking respondents to describe their experiences when patients lack capacity for PDD due to general medical conditions to the ACLP Med-Psych SIG Listserv and a Facebook group for C/L Psychiatrists. The survey was self-exempt through the UC Irvine IRB.

Results: There were 68 responses (n=68). Respondents were primarily practicing consultation-liaison psychiatrists from 28 different states. When holding medically incapacitated patients at their institution: 59% simply document a capacity evaluation; 25% use a formal institutional medical hold; 7% use IPHs; and 3% allow these patients to elope because they have no way to hold them. 76.5% of respondents feel there is a specific need for better policies and procedures in situations where patients lack capacity for PDD due to general medical conditions. 65% of respondents feel uncomfortable or very uncomfortable using IPHs on these patients. 25% of respondents indicated they have discharged a patient who lacked capacity for PDD because their institution had no way of holding them.



Discussion: Generally, in order to abide by nonmaleficence, patients with acute life-threatening general medical conditions who lack capacity for PDD should remain hospitalized. Allowing PDD in these cases would expose the patients to unnecessary harm and expose the providers to liability. Nevertheless, there remain inconsistencies with how these patients remain hospitalized, with some institutions using involuntary psychiatric holds (IPHs), some using capacity evaluations, and some using formalized medical holds, such as the “Medical Incapacity Hold” created by an interdisciplinary team at the University of California Los Angeles (Heldt et al., 2019).

Conclusions/Implications: While C/L psychiatrists are well-equipped to perform capacity evaluations for PDD, there is discomfort with how these situations are handled, particularly when there is no intent for psychiatric hospitalization. Institutions should ensure they have clear policies, aligned with local and state laws, that minimize risk for patients and providers.