- Email: [email protected]
Identifying and Addressing the Hidden Reasons Why Patients Refuse Discharge From the Hospital
Psychosomatics 2016:57:18–24
Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine.
Review Article Identifying and Addressing the Hidden Reasons Why Patients Refuse Discharge From the Hospital Jo Ellen Wilson, M.D., John Shuster, M.D., Ama A. Rowe, M.D., Sheryl B. Fleisch, M.D., Amanda Wilson, M.D., Stephen E. Nicolson, M.D.
Background: Consultation-liaison psychiatrists are often asked to evaluate patients who refuse discharge from a medical facility. Literature to guide clinicians on the management of these patients is very limited. Objective: This article seeks to explain this phenomenon through a case series, provide a differential diagnosis of patients who request to stay in the hospital, as well as provide clinicians with direction in the management of these difficult situations. Methods: We discuss a case series of 3 patients treated at a large academic medical center, who refused discharge, discuss potential differential diagnoses, and provide management recommendations to guide clinicians. Discussion: Providing care for a patient who refuses discharge can present several
dilemmas for the treatment provider. Additionally, patients who refuse discharge may face emotional, physical, and financial costs secondary to continued unnecessary medical hospitalization. A variety of psychiatric conditions may contribute to a patient's desire to stay in the hospital. Conclusions: Patients who refuse medical discharge can present unique challenges for hospital-based medical providers as well as consultation psychiatrists who care for these patients. Careful consideration of diagnostic etiologies as well as coordination of care across the treatment team may be required to manage these unique and challenging cases. (Psychosomatics 2016; 57:18–24)
INTRODUCTION
differential diagnosis for the sources of this behavior. Although there are many types of patients who refuse discharge, we selected 3 particularly challenging patients at our institution to represent this variety and provide a guide for an approach to management.
Consultation-liaison psychiatrists are frequently asked to evaluate patients who do not adhere to the medical recommendations of the primary treatment team. A common request is to assess a patient who desires to leave the hospital against medical advice. A psychiatrist can also be consulted to evaluate a patient who refuses discharge from the hospital when there is no medical indication for continued admission. As a guide for care and management, the published literature on the approach to patients who refuse to leave the hospital is considerably smaller when compared with that of patients who request to leave against medical advice. In this article, we present 3 patients who would not comply with discharge from the hospital and discuss a 18
www.psychosomaticsjournal.org
Jo Ellen Wilson,: Supported by the Office of Academic Affiliations, Department of Veterans Affairs, VA National Quality Scholars Program and with resources and the use of facilities at VA Tennessee Valley Healthcare System, Nashville, TN. Received April 23, 2015; revised October 26, 2015; accepted October 27, 2015. From the Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN (JEW, JS, AAR, SBF, AW, SEN). Send correspondence and reprint requests to Jo Ellen Wilson, M.D. Department of Psychiatry, Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South, Nashville, TN 37212.; e-mail: [email protected] Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine.
Psychosomatics 57:1, January/February 2016
Wilson et al. CASE PRESENTATIONS Case 1 Mr. A, a 45-year-old HIV-positive man with oxygen-dependent chronic obstructive pulmonary disease (COPD), bipolar disorder, and alcohol and cocaine use disorders, was admitted to the hospital with a COPD exacerbation. He averaged 1 to 2 hospitalizations per month for several years, each typically 1–2 weeks for COPD exacerbations, substance detoxification, or the treatment of common ailments such as pain, cough, and cold. Before his most recent admission, he had become homeless after being asked to leave his transitional housing because of continued substance use. Following treatment for his COPD exacerbation, he was medically cleared for discharge to the men's shelter by the primary team when he reported that he was suicidal, prompting a psychiatry consultation. On interview, Mr. A reported that he had burned many bridges and stated he finds the hospital a “comforting place” where he knows “I will get good care.” He asked the psychiatry consultant if he could be transferred to the psychiatric hospital “just for a week or so” because he felt that he could secure housing during that period. He stated that if the medical team discharged him to a shelter, he would immediately come back to the emergency department, because he refused to live on the streets any longer. After multidisciplinary discussions, given Mr. A's history of multiple readmissions and likelihood of another COPD exacerbation should he be discharged to the shelter, the team opted to keep him in the hospital for an additional 2 weeks, as social work, case management, and multiple nonprofit organizations assisted in finding him a more permanent housing solution with hopes to reverse the cycle of frequent chronic hospitalizations. Though the prolonged admission to a tertiary care medical center for nonmedical reasons was not an ideal use of hospital resources, the safety of continued monitoring and treatment of his COPD was weighed against the lack of adherence and likely substance abuse relapse should he be sent to the shelter, where he would have no place to store his medications and oxygen tank. Case 2 Mr. B, a 20-year-old man with a history of migraines and a remote history of attention-deficit/hyperactivity Psychosomatics 57:1, January/February 2016
disorder, was admitted to the hospital with a severe headache. He was treated with intravenous fluids, promethazine, prochlorperazine, magnesium, caffeine, and diphenhydramine, but symptom improvement did not occur until he was treated with gabapentin and methylprednisolone. Following improvement of his symptoms and a negative finding on medical workup (including lumbar puncture and neuroimaging studies), Mr. B was discharged home on hospital day 2 with a diagnosis of status migrainosus and with prescriptions for prochlorperazine, promethazine, and gabapentin. No follow-up was scheduled as Mr. B voiced his preference to arrange his own medical and mental health appointments. He requested a prescription for narcotic pain medications, which was declined. After discharge, Mr. B never left the medical campus and almost immediately presented again to the emergency department with multiple complaints including migraine headache, seizure, and dystonic reaction (attributed to prochlorperazine intake by Mr. B). He was evaluated, medically cleared, and discharged from the emergency department 3 separate times, but he did not leave the medical campus. The psychiatry department was consulted again on his fourth emergency department presentation within 24 hours of his initial discharge. He was calm during the interview, without signs of confusion, agitation, or psychosis. He denied suicidal ideation and did not exhibit symptoms of an active mood, anxiety, or psychotic disorder. A review of the state prescription database revealed that during the previous 12 months, Mr. B had filled 22 opioid prescriptions from 15 different providers at 11 different pharmacies. When this information was discussed with him, he remorsefully admitted that he had an addiction to opioid medications and that he continued to return to the emergency department to obtain them. He was invited to collaborate in formulating a workable outpatient plan of care that addressed his needs, and he was agreeable to treatment for substance dependence and supportive therapy for life stresses. He was discharged home without further incident. Case 3 Mrs. C, a 29-year-old woman with history of an unspecified eating disorder, depression, pyoderma gangrenosum, and chronic lower extremity wounds for 2 years secondary to reported bilateral brown www.psychosomaticsjournal.org
19
Management of Discharge Refusal recluse spider bites, was admitted to the plastic surgery service for final bilateral skin graft surgery. She had multiple prior lengthy admissions for intravenous immunoglobulin administration and wound debridements, as well as 8 prior skin grafts that subsequently failed. Her treatment was complicated by repeated falls, splitting staff, drug seeking, and dramatic behaviors. The hospital course was further complicated by recurrent anemia of unknown etiology requiring transfusions, fever of unknown etiology, and failure to comply with weight-bearing status and nutritional needs. When she was told that the plastic surgery service recommended a final skin graft trial, she voiced disappointment that the surgical team was not giving her the same kind of attention she had received in previous admissions. On the day of planned discharge, she refused to allow the plastic surgery service to take down her wound dressings to assess the skin grafts and refused to leave the hospital. When asked why, she stated that she would not leave the hospital because she knew her grafts would fail as they had in the past. After the psychiatry service completed an extensive medical record review, they met with the internal medicine, plastic surgery, and dermatology teams; collateral information was obtained from her mother, and there was enough documentation to warrant diagnoses of factitious disorder and opioid dependence. Mrs. C's mother was ultimately able to get her to comply with the examination of her wounds. Following the final dressing change and wound care, Mrs. C attempted to walk on crutches in the hallway and nearly fell. The psychiatry service believed she was attempting to sabotage her discharge and placed her on increased observation by staff for the rest of the day until she was eventually transported against her wishes on a wheelchair from the hospital to her mother's care. DISCUSSION The 3 cases presented above highlight many of the issues involved with patients who do not want to leave the hospital. Firstly, in all 3 cases, there was a concealed motive for discharge refusal that needed to be uncovered. In the first case, Mr. A was seeking shelter; in the second case, Mr. B's intent was to obtain opioids; and in the third case, primary gain was sought. Secondly, in each of the cases, the uncovered motive was relatively longstanding, likely contributed to the patients' presentation to the hospital, and could 20
www.psychosomaticsjournal.org
have been “discovered” much earlier. In the first case, Mr. A became homeless just before admission. In the second case, Mr. B admitted that he came to the hospital seeking pain medication because of chronic opioid addiction. The case of Mrs. C was even more extreme, as much of the evidence for the diagnosis came from documentation in previous hospital admissions. A timely diagnosis of factitious disorder may have saved Mrs. C from multiple admissions and surgeries. Finally, though substance abuse is not the primary issue in cases 1 and 3, it is present in each, as well as in other cases of discharge refusal that we have seen. Substance abuse should be high on the list of considerations in patients who refuse discharge and should be uncovered early in the admission so that patients can receive the proper treatment. Ideally, discharge planning, in collaboration with the patient, should begin early during hospitalization as the admitting team begins to lay the groundwork to help the patient meet their goals of care. Our case series suggests that admitting teams and hospitalists should be vigilant in looking for and addressing nonmedical issues that contribute to admission and discharge problems. As the phenomenon of discharge refusal is not well studied, the extent of problems caused by discharge refusal is not clear. Evidence suggests that proactive psychiatric consultation is feasible and helpful in identifying mental health barriers to discharge and decreasing length of stay.1 In especially challenging situations, primary medical teams and psychiatric consultants may benefit from the involvement of hospital or health system management to find resources to assist patients with unusual needs or who have difficulty managing their illness outside the hospital. Some institutions have developed complex care management services to meet the challenges of finding an appropriate and mutually satisfying discharge plan for patients with complicated medical, behavioral, social, and economic problems.2 As health care systems focus on populations of patients, such services are likely to be more readily available to aid the primary team with discharge planning, which may decrease the likelihood of discharge refusal. These management teams are in a position to collect data that may improve our understanding of discharge refusal and its treatment. Management Not all patients who refuse discharge have the issues highlighted in our 3 patients. Many may be confused Psychosomatics 57:1, January/February 2016
Wilson et al. TABLE.
Possible Solutions for Psychosocial Causes of Discharge Refusal
Reason for discharge refusal
Potential interventions
(1) Homelessness (2) Inability to pay for medication
Referral to housing sources Pharmacy payment program, indigent medications provided by pharmacy, and choosing more affordable medications Safety assessment and domestic violence shelter Treat any lingering withdrawal symptoms; consider maintenance medication; NA/AA; and residential treatment facilities Communicate with court, police Attempt to recruit additional support; referral to case management services if appropriate PT/OT/ST evaluations and referral to appropriate services (inpatient or outpatient rehabilitation, home health) if indicated Provide a bus pass or taxi ride to a safe desired location and check eligibility for transportation services
(3) Domestic violence (4) Fear of relapse on substance of abuse (5) Avoidance of arrest/incarceration (6) Lack of social support (7) Fear of inability to care for physical needs (8) Lack of transportation
NA/AA ¼ narcotics anonymous/alcoholics anonymous; PT/OT/ST ¼ physical therapy/occupational therapy/speech therapy.
about their medical diagnoses, have anxiety about their disposition, or believe that the medical team has not sufficiently addressed their medical problems. Thus, the first step in management of discharge refusal should be to confirm that a reasonable medical evaluation has been completed and that no untreated illness or disease process underlies the reason for the patient's refusal to discharge. It is important to ask patients if they have any questions about their illness, treatment, prognosis, or discharge plan. Some patients may have trouble articulating their concerns or may be embarrassed to discuss family or social problems. Thus, it is important that the medical team consider social reasons why patients might refuse discharge from the hospital (Table). The primary medical team as well as the consultant should routinely screen all patients for social needs that might delay or pose a barrier to discharge. The earlier in an admission this is done, the more likely the problem can be addressed before discharge. Social work consultations can prove particularly beneficial in clarifying the unique social needs of the individual patient and elucidating exactly how the treatment team can assist the patient with a safe discharge from the hospital on completion of the medical workup and treatment. If the patient appears to have a cognitive problem, or the patient's logic in refusing discharge does not make sense, it should be determined if the patient has the capacity to refuse appropriate disposition. Capacity for medical decision making can be evaluated in a variety of ways. At our institution, we routinely refer to Appelbaum criteria for assessment of Psychosomatics 57:1, January/February 2016
an individual patient's capacity for medical decision making. According to Appelbaum, to have capacity to make medical decisions, the individual patient must be able to display competency in 4 basic criteria: (1) communicate a clear choice, (2) understand the relevant information, (3) appreciate the situation and its consequences, and (4) reason about treatment options. If a patient cannot complete 1 of the 4 steps, he or she does not meet the minimum threshold criteria to display capacity for his or her own decision making.3 If a patient does not have capacity to refuse discharge, the treating team should identify a surrogate decision maker to assist with a safe and appropriate disposition for the patient who is refusing discharge. If the patient is able to articulate a reason for staying, which is amenable to problem solving, such as requiring transportation and needing additional understanding of his or her diagnosis or treatment, then the issue should be adequately addressed, and the patient should be discharged. Such a scenario occurred with Mr. A. If the patient is unable to give a reason for staying that can be reasonably addressed, then the team should look further into the patient's records and to collateral sources to gain information that may help in uncovering an explanation for discharge refusal, as in Mr. B’s case. Obtaining consent from the patient to speak with family members is usually necessary, as speaking with collateral sources against a patient's wishes is allowable only if the safety of the patient cannot be assured by any other means, though this may vary by jurisdiction. If the patient refuses to grant access to collateral sources (and there is no urgent safety issue), www.psychosomaticsjournal.org
21
Management of Discharge Refusal or if no revealing information can be found, then consideration of a psychiatric differential diagnosis is in order, with special attention given to anxiety, somatic symptom and related disorders, factitious disorder, substance misuse, and malingering. For patients with psychiatric diagnoses that are thought to be contributing to discharge refusal, there are many potential steps in management. Patients with depression or anxiety may benefit from psychotherapy or medication management. Those with substance use disorders may need detoxification or rehabilitation referrals, such as Mr. B. Patients with somatic symptom disorders, such as functional, neurologic, and illness anxiety disorders, are difficult to treat in the inpatient medical setting. Management involves a nonjudgmental approach including acknowledgment of the distress that their symptoms are causing, reassurance that fatal etiologies have been ruled out, and suggestion of a “face-saving” treatment option such as physical therapy or rehabilitation.4–6 For example, a patient with pseudoparalysis could be offered a short course of home physical therapy. Patients with factitious disorder are driven by an unconscious need to “play the sick role,” but often refuse to see a psychiatrist and may even leave the hospital if asked to see one.7 Patients with malingering often complain of severe disability despite a lack of functional decline. Other clues to detect malingering include inconsistencies in reported symptoms and observed behavior, symptoms that are either too consistent or too bizarre.8 They may also fail to cooperate with evaluation and refuse prescribed treatment.9 At times, some patients, including Mr. A, may voice suicidal statements on recommendation that they be discharged from the inpatient setting. Conditional, also known as manipulative or contingencybased suicidality involves the premise that “if” this does or does not occur, “then” I will commit suicide.10,11 Assessing suicidality given these constraints can be confusing and paralyzing for trainees and advanced physicians alike. Although risk factors for suicide, such as history of suicide attempts, age, sex, and history of psychiatric and substance use disorders, can be collated in an attempt to determine “suicide risk,” it is challenging to determine risk in someone who states he or she might harm himself or herself should a future event occur. At some level, conditional suicidality itself is a protective factor, because one is stating that he or she expects a future will exist.12 22
www.psychosomaticsjournal.org
Bundy et al.13 recommend 6 steps when facing a patient who expresses contingency-based suicide: a clinician must (1) define and document the clinical situation, (2) assess and document current suicide risk, (3) document modified dynamic or protective factors, (4) document the reasons for continued care in the inpatient medical setting are not indicated, (5) document the discussion of discharge with the patient, and (6) consult with a colleague. When someone expresses conditional suicidality, it is important to attempt to understand “why” without feeling the need to “give in” to demands such as continued hospitalization or pain medications. This “why” can be the key to avoid repeat or prolonged hospitalizations and can improve relationships with treatment providers. Finally, though not ideal, involuntary removal from the hospital grounds should be considered in patients who either are unwilling to engage reasonably in the discharge process, as occurred with Mrs. C, or who have complex needs that cannot be accommodated in the inpatient medical setting. Examples of such complex needs would include patients with factitious disorder, malingering, severe somatoform illness, and anxiety, who do not meet commitment criteria to a psychiatric facility but would no longer benefit from further stay in an inpatient medical environment. For patients who need to be forcibly removed from the hospital, planning is needed to improve the chances of a smooth discharge, including having the primary team and consultants in agreement, contacting the risk management service, alerting security, gathering all the patient's belongings, and offering medication to calm an anxious or agitated patient.14 As with all medication administration, an informed consent should be obtained from the patient (or his or her surrogate) including that discharge from the facility that immediately follows. Detailed documentation of workup, treatment, and resources offered would be helpful for the next treatment team to see should the patient return to the same hospital and to minimize legal risk. Patients who refuse medical care either explicitly or implicitly can stir up many negative emotions in the health care team,15 but patients who refuse to leave the hospital may pose particular challenges to the relationship between the consultee and consultant. This rift may be particularly likely if there is an expectation that the psychiatric consultant can easily resolve the situation (i.e., admit to inpatient psychiatry). Because Psychosomatics 57:1, January/February 2016
Wilson et al. of this spoken or unspoken expectation, the primary team may feel that psychiatric reasons are the primary cause of discharge refusal. The psychiatry consultant can provide a brief but explicit review of the requirements for transfer to psychiatry (including involuntary treatment) as well as the goals of such transfer. Additionally, it is helpful to clarify that some psychiatric conditions are best treated as an outpatient to avoid regression and to foster independence and functionality. For example, the treatment modality best suited for many somatic symptom and illness anxiety disorders, after a thorough medical workup, is outpatient treatment including cognitive-behavioral therapy16 and regular follow-up directed by the primary care provider.17 Legal Considerations Physicians must take hospital, state, and federal guidelines into account when patients refuse to leave the hospital. Under federal regulations, hospitals are required to inform Medicare patients at the time of admission that they have a right to file an appeal if they feel they are discharged prematurely. Medicare does allow discharges to be challenged by patients, and an independent reviewer, a quality improvement organization, has 24 hours to make a decision. According to the “Notification of Hospital Discharge Appeal Rights” (CMS-4105-F), a patient can appeal on the day of discharge and stay in the hospital without financial liability until at least noon of the day after the quality improvement organization notifies the hospital, the beneficiary, and the physician of its decision.18 Therefore, during the appeal, a beneficiary cannot be discharged without his or her consent. Many states have similar guidelines for their Medicaid beneficiaries. In Tennessee, for example, hospitals are required to give patients with TennCare (the state of Tennessee's Medicaid program) advanced notice of their discharge 2 business days before planned discharge, including their right to appeal. However, the notice also states “Federal and State law and the TennCare rules say we can only pay for care that is medically necessary … .”19 Medicare programs dictate that discharge planning occur during hospitalization (preferably on admission), include the patient in the process, and offer the patient choices. In 1994, Health and Human Services released the Conditions of Participation Psychosomatics 57:1, January/February 2016
rules detailing discharging planning mandates for all Medicare participating hospitals and expanded it to all hospitals via the Social Security Act Sections 1861.20 Choice in discharge planning is a legal right. Multiple agencies, federal law, and state law provide regulatory oversight and assurance of patient choice in the discharge planning process. These are detailed in Medicare's Conditions of Participation for Hospitals at the federal level, Medicaid requirements and state licensing laws for hospitals (varying by state), individual health care provider contracts, the National Committee for Quality Assurance, and the Joint Commission standards.21 The timing of discharge is determined by the clinician and is based on medical need. A patient does not have the legal right to remain medically hospitalized once one is deemed to no longer meet criteria for inpatient level of care.21 Substantial tort law exists supporting hospitals in this matter. The judicial system has sided with hospitals in recognizing court orders to evict patients, suing patients for costs of medical care incurred by unnecessary medical stays, and enacting criminal trespassing statutes. In Lucy Webb Hayes National Training School v. Geoghegan, 281F. Supp. 116 (D.D.C. 1967), the court states: “It [the hospital] has a moral duty to reserve its accommodations for persons who actually need medical and hospital care … hospitals have a duty not to permit their facilities to be diverted to the uses for which hospitals are not intended.”22 Patients who fail to leave the hospital assume both financial and legal burden once the hospital has adequately addressed all procedural rights. The economic burden of unnecessary medical inpatient days ultimately is assumed by the patient, institution, insurers, and patient's family.21 CONCLUSION Patients who decline recommendations to leave the hospital present a unique challenge for hospital-based providers and consultation psychiatrists. A thoughtful approach, which considers the broad range of possible etiologies of this behavior and applies clear but careful intervention, can prevent both patient harm and misuse of limited inpatient clinical resources. Early or proactive psychiatric consultation is warranted to assist hospital teams in identifying barriers to discharge and help manage these potentially difficult cases. www.psychosomaticsjournal.org
23
Management of Discharge Refusal
References 1. Desan PH, Zimbrean PC, Weinstein AJ, Bozzo JE, Sledge WH: Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team. Psychosomatics 2011; 52(6):513–520 2. Hong CS, Siegel AL, Ferris TG: Caring for high-need, high-cost patients: what makes for a successful care management program. Issue Brief (Commonw Fund) 2014; 19: 1–19 3. Appelbaum PS: Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med 2007; 357(18):1834–1840 4. Shapiro AP, Teasell RW: Behavioural interventions in the rehabilitation of acute v. chronic non-organic (conversion/ factitious) motor disorders. Br J Psychiatry 2004; 185: 140–146 5. Abbey SE, Wulsin L, Levenson JL: Somatization and somatoform disorders. in Levenson JL, editor. Textbook of Psychosomatic Medicine. Washington, DC: American Psychiatric Publishing; 2011, pp. 261–290 6. Raj V, Rowe AA, Fleisch SB, Paranjape SY, Arain AM, Nicolson SE: Psychogenic pseudosyncope: diagnosis and management. Auton Neurosci 2014; 184:66–72 7. Savino AC, Fordtran JS: Factitious disease: clinical lessons from case studies at Baylor University Medical Center. Proc (Bayl Univ Med Cent) 2006; 19(3):195–208 8. Resnick PJ: Faking it: how to detect malingered psychosis. Curr Psychiatry 2005; 4:13–25 9. Braun IM, Greenberg DB, Smith FA, Cassem NH: Functional somatic symptoms, deception syndromes, and somatoform disorders, in Massachusetts General Hospital Handbook of General Hospital Psychiatry, 6th edition, In: Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF, (ed) Philadelphia: Saunders Elsevier; 2010, pp. 173–188 10. Sifneos PE: Manipulative suicide. Psychiatr Q 1966; 40(3): 525–537 11. Gutheil TG: Suicide, suicide litigation, and borderline personality disorder. J Pers Disord 2004; 18(3):248–256
24
www.psychosomaticsjournal.org
12. Gutheil TG, Schetky D: A date with death: management of time-based and contingent suicidal intent. Am J Psychiatry 1998; 155(11):1502–1507 13. Bundy C, Schreiber M, Pascualy M: Discharging your patients who display contingency-based suicidality: 6 steps. Curr Psychiatry 2014; 13(1):e1–e3 14. Moran JR, Gross AF, Stern TA: Staying against advice: refusal to leave the hospital. Prim Care Companion J Clin Psychiatry 2010; 12:6 15. Groves JE: Taking care of the hateful patient. N Engl J Med 1978; 298(16):883–887 16. LaFrance WC, Jr., Reuber M, Goldstein LH: Management of psychogenic nonepileptic seizures. Epilepsia 2013;54 (Suppl 1):53–67 17. Gerstenblith TA, Kontos N: Somatic symptom disorders, in Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2nd edition, In: Stern TA, Fava M, Wilens TE, Rosenbaum JF (eds). Philadelphia, Elsevier, 2016, pp. 255–264 18. CMS. 42 CFR Parts 405, 412, 422, and 489 Medicare Program; Notification of Hospital Discharge Appeal Rights; Final Rule. November 27, 2006. Available from: https://www.cms.gov/Medicare/Medicare-General-Infor mation/BNI/Downloads/CMS-4105-F-.pdf [cited October 22, 2015] 19. Amerigroup. Member Handbook Amerigroup Community Care, Tennessee. 2013. Available from: https://providers.amer igroup.com/ProviderDocuments/TNTN_CAID_MHB_ENG. pdf [cited October 22, 2015] 20. Chiplin AJ: Breathing Life into Discharge Planning. Elder L J 2005; 13(1):1–83 21. Schlairet MC: Complex hospital discharges: justice considered. HEC Forum 2014; 26(1):69–78 22. Lucy Webb Hayes National Training School v. Geoghegan, 281F. Supp. 116 (D.D.C. 1967). Available from: http://law. justia.com/cases/federal/district-courts/FSupp/281/116/ 1575358/. Accessed October 22, 2015
Psychosomatics 57:1, January/February 2016
Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine.
Review Article Identifying and Addressing the Hidden Reasons Why Patients Refuse Discharge From the Hospital Jo Ellen Wilson, M.D., John Shuster, M.D., Ama A. Rowe, M.D., Sheryl B. Fleisch, M.D., Amanda Wilson, M.D., Stephen E. Nicolson, M.D.
Background: Consultation-liaison psychiatrists are often asked to evaluate patients who refuse discharge from a medical facility. Literature to guide clinicians on the management of these patients is very limited. Objective: This article seeks to explain this phenomenon through a case series, provide a differential diagnosis of patients who request to stay in the hospital, as well as provide clinicians with direction in the management of these difficult situations. Methods: We discuss a case series of 3 patients treated at a large academic medical center, who refused discharge, discuss potential differential diagnoses, and provide management recommendations to guide clinicians. Discussion: Providing care for a patient who refuses discharge can present several
dilemmas for the treatment provider. Additionally, patients who refuse discharge may face emotional, physical, and financial costs secondary to continued unnecessary medical hospitalization. A variety of psychiatric conditions may contribute to a patient's desire to stay in the hospital. Conclusions: Patients who refuse medical discharge can present unique challenges for hospital-based medical providers as well as consultation psychiatrists who care for these patients. Careful consideration of diagnostic etiologies as well as coordination of care across the treatment team may be required to manage these unique and challenging cases. (Psychosomatics 2016; 57:18–24)
INTRODUCTION
differential diagnosis for the sources of this behavior. Although there are many types of patients who refuse discharge, we selected 3 particularly challenging patients at our institution to represent this variety and provide a guide for an approach to management.
Consultation-liaison psychiatrists are frequently asked to evaluate patients who do not adhere to the medical recommendations of the primary treatment team. A common request is to assess a patient who desires to leave the hospital against medical advice. A psychiatrist can also be consulted to evaluate a patient who refuses discharge from the hospital when there is no medical indication for continued admission. As a guide for care and management, the published literature on the approach to patients who refuse to leave the hospital is considerably smaller when compared with that of patients who request to leave against medical advice. In this article, we present 3 patients who would not comply with discharge from the hospital and discuss a 18
www.psychosomaticsjournal.org
Jo Ellen Wilson,: Supported by the Office of Academic Affiliations, Department of Veterans Affairs, VA National Quality Scholars Program and with resources and the use of facilities at VA Tennessee Valley Healthcare System, Nashville, TN. Received April 23, 2015; revised October 26, 2015; accepted October 27, 2015. From the Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN (JEW, JS, AAR, SBF, AW, SEN). Send correspondence and reprint requests to Jo Ellen Wilson, M.D. Department of Psychiatry, Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South, Nashville, TN 37212.; e-mail: [email protected] Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine.
Psychosomatics 57:1, January/February 2016
Wilson et al. CASE PRESENTATIONS Case 1 Mr. A, a 45-year-old HIV-positive man with oxygen-dependent chronic obstructive pulmonary disease (COPD), bipolar disorder, and alcohol and cocaine use disorders, was admitted to the hospital with a COPD exacerbation. He averaged 1 to 2 hospitalizations per month for several years, each typically 1–2 weeks for COPD exacerbations, substance detoxification, or the treatment of common ailments such as pain, cough, and cold. Before his most recent admission, he had become homeless after being asked to leave his transitional housing because of continued substance use. Following treatment for his COPD exacerbation, he was medically cleared for discharge to the men's shelter by the primary team when he reported that he was suicidal, prompting a psychiatry consultation. On interview, Mr. A reported that he had burned many bridges and stated he finds the hospital a “comforting place” where he knows “I will get good care.” He asked the psychiatry consultant if he could be transferred to the psychiatric hospital “just for a week or so” because he felt that he could secure housing during that period. He stated that if the medical team discharged him to a shelter, he would immediately come back to the emergency department, because he refused to live on the streets any longer. After multidisciplinary discussions, given Mr. A's history of multiple readmissions and likelihood of another COPD exacerbation should he be discharged to the shelter, the team opted to keep him in the hospital for an additional 2 weeks, as social work, case management, and multiple nonprofit organizations assisted in finding him a more permanent housing solution with hopes to reverse the cycle of frequent chronic hospitalizations. Though the prolonged admission to a tertiary care medical center for nonmedical reasons was not an ideal use of hospital resources, the safety of continued monitoring and treatment of his COPD was weighed against the lack of adherence and likely substance abuse relapse should he be sent to the shelter, where he would have no place to store his medications and oxygen tank. Case 2 Mr. B, a 20-year-old man with a history of migraines and a remote history of attention-deficit/hyperactivity Psychosomatics 57:1, January/February 2016
disorder, was admitted to the hospital with a severe headache. He was treated with intravenous fluids, promethazine, prochlorperazine, magnesium, caffeine, and diphenhydramine, but symptom improvement did not occur until he was treated with gabapentin and methylprednisolone. Following improvement of his symptoms and a negative finding on medical workup (including lumbar puncture and neuroimaging studies), Mr. B was discharged home on hospital day 2 with a diagnosis of status migrainosus and with prescriptions for prochlorperazine, promethazine, and gabapentin. No follow-up was scheduled as Mr. B voiced his preference to arrange his own medical and mental health appointments. He requested a prescription for narcotic pain medications, which was declined. After discharge, Mr. B never left the medical campus and almost immediately presented again to the emergency department with multiple complaints including migraine headache, seizure, and dystonic reaction (attributed to prochlorperazine intake by Mr. B). He was evaluated, medically cleared, and discharged from the emergency department 3 separate times, but he did not leave the medical campus. The psychiatry department was consulted again on his fourth emergency department presentation within 24 hours of his initial discharge. He was calm during the interview, without signs of confusion, agitation, or psychosis. He denied suicidal ideation and did not exhibit symptoms of an active mood, anxiety, or psychotic disorder. A review of the state prescription database revealed that during the previous 12 months, Mr. B had filled 22 opioid prescriptions from 15 different providers at 11 different pharmacies. When this information was discussed with him, he remorsefully admitted that he had an addiction to opioid medications and that he continued to return to the emergency department to obtain them. He was invited to collaborate in formulating a workable outpatient plan of care that addressed his needs, and he was agreeable to treatment for substance dependence and supportive therapy for life stresses. He was discharged home without further incident. Case 3 Mrs. C, a 29-year-old woman with history of an unspecified eating disorder, depression, pyoderma gangrenosum, and chronic lower extremity wounds for 2 years secondary to reported bilateral brown www.psychosomaticsjournal.org
19
Management of Discharge Refusal recluse spider bites, was admitted to the plastic surgery service for final bilateral skin graft surgery. She had multiple prior lengthy admissions for intravenous immunoglobulin administration and wound debridements, as well as 8 prior skin grafts that subsequently failed. Her treatment was complicated by repeated falls, splitting staff, drug seeking, and dramatic behaviors. The hospital course was further complicated by recurrent anemia of unknown etiology requiring transfusions, fever of unknown etiology, and failure to comply with weight-bearing status and nutritional needs. When she was told that the plastic surgery service recommended a final skin graft trial, she voiced disappointment that the surgical team was not giving her the same kind of attention she had received in previous admissions. On the day of planned discharge, she refused to allow the plastic surgery service to take down her wound dressings to assess the skin grafts and refused to leave the hospital. When asked why, she stated that she would not leave the hospital because she knew her grafts would fail as they had in the past. After the psychiatry service completed an extensive medical record review, they met with the internal medicine, plastic surgery, and dermatology teams; collateral information was obtained from her mother, and there was enough documentation to warrant diagnoses of factitious disorder and opioid dependence. Mrs. C's mother was ultimately able to get her to comply with the examination of her wounds. Following the final dressing change and wound care, Mrs. C attempted to walk on crutches in the hallway and nearly fell. The psychiatry service believed she was attempting to sabotage her discharge and placed her on increased observation by staff for the rest of the day until she was eventually transported against her wishes on a wheelchair from the hospital to her mother's care. DISCUSSION The 3 cases presented above highlight many of the issues involved with patients who do not want to leave the hospital. Firstly, in all 3 cases, there was a concealed motive for discharge refusal that needed to be uncovered. In the first case, Mr. A was seeking shelter; in the second case, Mr. B's intent was to obtain opioids; and in the third case, primary gain was sought. Secondly, in each of the cases, the uncovered motive was relatively longstanding, likely contributed to the patients' presentation to the hospital, and could 20
www.psychosomaticsjournal.org
have been “discovered” much earlier. In the first case, Mr. A became homeless just before admission. In the second case, Mr. B admitted that he came to the hospital seeking pain medication because of chronic opioid addiction. The case of Mrs. C was even more extreme, as much of the evidence for the diagnosis came from documentation in previous hospital admissions. A timely diagnosis of factitious disorder may have saved Mrs. C from multiple admissions and surgeries. Finally, though substance abuse is not the primary issue in cases 1 and 3, it is present in each, as well as in other cases of discharge refusal that we have seen. Substance abuse should be high on the list of considerations in patients who refuse discharge and should be uncovered early in the admission so that patients can receive the proper treatment. Ideally, discharge planning, in collaboration with the patient, should begin early during hospitalization as the admitting team begins to lay the groundwork to help the patient meet their goals of care. Our case series suggests that admitting teams and hospitalists should be vigilant in looking for and addressing nonmedical issues that contribute to admission and discharge problems. As the phenomenon of discharge refusal is not well studied, the extent of problems caused by discharge refusal is not clear. Evidence suggests that proactive psychiatric consultation is feasible and helpful in identifying mental health barriers to discharge and decreasing length of stay.1 In especially challenging situations, primary medical teams and psychiatric consultants may benefit from the involvement of hospital or health system management to find resources to assist patients with unusual needs or who have difficulty managing their illness outside the hospital. Some institutions have developed complex care management services to meet the challenges of finding an appropriate and mutually satisfying discharge plan for patients with complicated medical, behavioral, social, and economic problems.2 As health care systems focus on populations of patients, such services are likely to be more readily available to aid the primary team with discharge planning, which may decrease the likelihood of discharge refusal. These management teams are in a position to collect data that may improve our understanding of discharge refusal and its treatment. Management Not all patients who refuse discharge have the issues highlighted in our 3 patients. Many may be confused Psychosomatics 57:1, January/February 2016
Wilson et al. TABLE.
Possible Solutions for Psychosocial Causes of Discharge Refusal
Reason for discharge refusal
Potential interventions
(1) Homelessness (2) Inability to pay for medication
Referral to housing sources Pharmacy payment program, indigent medications provided by pharmacy, and choosing more affordable medications Safety assessment and domestic violence shelter Treat any lingering withdrawal symptoms; consider maintenance medication; NA/AA; and residential treatment facilities Communicate with court, police Attempt to recruit additional support; referral to case management services if appropriate PT/OT/ST evaluations and referral to appropriate services (inpatient or outpatient rehabilitation, home health) if indicated Provide a bus pass or taxi ride to a safe desired location and check eligibility for transportation services
(3) Domestic violence (4) Fear of relapse on substance of abuse (5) Avoidance of arrest/incarceration (6) Lack of social support (7) Fear of inability to care for physical needs (8) Lack of transportation
NA/AA ¼ narcotics anonymous/alcoholics anonymous; PT/OT/ST ¼ physical therapy/occupational therapy/speech therapy.
about their medical diagnoses, have anxiety about their disposition, or believe that the medical team has not sufficiently addressed their medical problems. Thus, the first step in management of discharge refusal should be to confirm that a reasonable medical evaluation has been completed and that no untreated illness or disease process underlies the reason for the patient's refusal to discharge. It is important to ask patients if they have any questions about their illness, treatment, prognosis, or discharge plan. Some patients may have trouble articulating their concerns or may be embarrassed to discuss family or social problems. Thus, it is important that the medical team consider social reasons why patients might refuse discharge from the hospital (Table). The primary medical team as well as the consultant should routinely screen all patients for social needs that might delay or pose a barrier to discharge. The earlier in an admission this is done, the more likely the problem can be addressed before discharge. Social work consultations can prove particularly beneficial in clarifying the unique social needs of the individual patient and elucidating exactly how the treatment team can assist the patient with a safe discharge from the hospital on completion of the medical workup and treatment. If the patient appears to have a cognitive problem, or the patient's logic in refusing discharge does not make sense, it should be determined if the patient has the capacity to refuse appropriate disposition. Capacity for medical decision making can be evaluated in a variety of ways. At our institution, we routinely refer to Appelbaum criteria for assessment of Psychosomatics 57:1, January/February 2016
an individual patient's capacity for medical decision making. According to Appelbaum, to have capacity to make medical decisions, the individual patient must be able to display competency in 4 basic criteria: (1) communicate a clear choice, (2) understand the relevant information, (3) appreciate the situation and its consequences, and (4) reason about treatment options. If a patient cannot complete 1 of the 4 steps, he or she does not meet the minimum threshold criteria to display capacity for his or her own decision making.3 If a patient does not have capacity to refuse discharge, the treating team should identify a surrogate decision maker to assist with a safe and appropriate disposition for the patient who is refusing discharge. If the patient is able to articulate a reason for staying, which is amenable to problem solving, such as requiring transportation and needing additional understanding of his or her diagnosis or treatment, then the issue should be adequately addressed, and the patient should be discharged. Such a scenario occurred with Mr. A. If the patient is unable to give a reason for staying that can be reasonably addressed, then the team should look further into the patient's records and to collateral sources to gain information that may help in uncovering an explanation for discharge refusal, as in Mr. B’s case. Obtaining consent from the patient to speak with family members is usually necessary, as speaking with collateral sources against a patient's wishes is allowable only if the safety of the patient cannot be assured by any other means, though this may vary by jurisdiction. If the patient refuses to grant access to collateral sources (and there is no urgent safety issue), www.psychosomaticsjournal.org
21
Management of Discharge Refusal or if no revealing information can be found, then consideration of a psychiatric differential diagnosis is in order, with special attention given to anxiety, somatic symptom and related disorders, factitious disorder, substance misuse, and malingering. For patients with psychiatric diagnoses that are thought to be contributing to discharge refusal, there are many potential steps in management. Patients with depression or anxiety may benefit from psychotherapy or medication management. Those with substance use disorders may need detoxification or rehabilitation referrals, such as Mr. B. Patients with somatic symptom disorders, such as functional, neurologic, and illness anxiety disorders, are difficult to treat in the inpatient medical setting. Management involves a nonjudgmental approach including acknowledgment of the distress that their symptoms are causing, reassurance that fatal etiologies have been ruled out, and suggestion of a “face-saving” treatment option such as physical therapy or rehabilitation.4–6 For example, a patient with pseudoparalysis could be offered a short course of home physical therapy. Patients with factitious disorder are driven by an unconscious need to “play the sick role,” but often refuse to see a psychiatrist and may even leave the hospital if asked to see one.7 Patients with malingering often complain of severe disability despite a lack of functional decline. Other clues to detect malingering include inconsistencies in reported symptoms and observed behavior, symptoms that are either too consistent or too bizarre.8 They may also fail to cooperate with evaluation and refuse prescribed treatment.9 At times, some patients, including Mr. A, may voice suicidal statements on recommendation that they be discharged from the inpatient setting. Conditional, also known as manipulative or contingencybased suicidality involves the premise that “if” this does or does not occur, “then” I will commit suicide.10,11 Assessing suicidality given these constraints can be confusing and paralyzing for trainees and advanced physicians alike. Although risk factors for suicide, such as history of suicide attempts, age, sex, and history of psychiatric and substance use disorders, can be collated in an attempt to determine “suicide risk,” it is challenging to determine risk in someone who states he or she might harm himself or herself should a future event occur. At some level, conditional suicidality itself is a protective factor, because one is stating that he or she expects a future will exist.12 22
www.psychosomaticsjournal.org
Bundy et al.13 recommend 6 steps when facing a patient who expresses contingency-based suicide: a clinician must (1) define and document the clinical situation, (2) assess and document current suicide risk, (3) document modified dynamic or protective factors, (4) document the reasons for continued care in the inpatient medical setting are not indicated, (5) document the discussion of discharge with the patient, and (6) consult with a colleague. When someone expresses conditional suicidality, it is important to attempt to understand “why” without feeling the need to “give in” to demands such as continued hospitalization or pain medications. This “why” can be the key to avoid repeat or prolonged hospitalizations and can improve relationships with treatment providers. Finally, though not ideal, involuntary removal from the hospital grounds should be considered in patients who either are unwilling to engage reasonably in the discharge process, as occurred with Mrs. C, or who have complex needs that cannot be accommodated in the inpatient medical setting. Examples of such complex needs would include patients with factitious disorder, malingering, severe somatoform illness, and anxiety, who do not meet commitment criteria to a psychiatric facility but would no longer benefit from further stay in an inpatient medical environment. For patients who need to be forcibly removed from the hospital, planning is needed to improve the chances of a smooth discharge, including having the primary team and consultants in agreement, contacting the risk management service, alerting security, gathering all the patient's belongings, and offering medication to calm an anxious or agitated patient.14 As with all medication administration, an informed consent should be obtained from the patient (or his or her surrogate) including that discharge from the facility that immediately follows. Detailed documentation of workup, treatment, and resources offered would be helpful for the next treatment team to see should the patient return to the same hospital and to minimize legal risk. Patients who refuse medical care either explicitly or implicitly can stir up many negative emotions in the health care team,15 but patients who refuse to leave the hospital may pose particular challenges to the relationship between the consultee and consultant. This rift may be particularly likely if there is an expectation that the psychiatric consultant can easily resolve the situation (i.e., admit to inpatient psychiatry). Because Psychosomatics 57:1, January/February 2016
Wilson et al. of this spoken or unspoken expectation, the primary team may feel that psychiatric reasons are the primary cause of discharge refusal. The psychiatry consultant can provide a brief but explicit review of the requirements for transfer to psychiatry (including involuntary treatment) as well as the goals of such transfer. Additionally, it is helpful to clarify that some psychiatric conditions are best treated as an outpatient to avoid regression and to foster independence and functionality. For example, the treatment modality best suited for many somatic symptom and illness anxiety disorders, after a thorough medical workup, is outpatient treatment including cognitive-behavioral therapy16 and regular follow-up directed by the primary care provider.17 Legal Considerations Physicians must take hospital, state, and federal guidelines into account when patients refuse to leave the hospital. Under federal regulations, hospitals are required to inform Medicare patients at the time of admission that they have a right to file an appeal if they feel they are discharged prematurely. Medicare does allow discharges to be challenged by patients, and an independent reviewer, a quality improvement organization, has 24 hours to make a decision. According to the “Notification of Hospital Discharge Appeal Rights” (CMS-4105-F), a patient can appeal on the day of discharge and stay in the hospital without financial liability until at least noon of the day after the quality improvement organization notifies the hospital, the beneficiary, and the physician of its decision.18 Therefore, during the appeal, a beneficiary cannot be discharged without his or her consent. Many states have similar guidelines for their Medicaid beneficiaries. In Tennessee, for example, hospitals are required to give patients with TennCare (the state of Tennessee's Medicaid program) advanced notice of their discharge 2 business days before planned discharge, including their right to appeal. However, the notice also states “Federal and State law and the TennCare rules say we can only pay for care that is medically necessary … .”19 Medicare programs dictate that discharge planning occur during hospitalization (preferably on admission), include the patient in the process, and offer the patient choices. In 1994, Health and Human Services released the Conditions of Participation Psychosomatics 57:1, January/February 2016
rules detailing discharging planning mandates for all Medicare participating hospitals and expanded it to all hospitals via the Social Security Act Sections 1861.20 Choice in discharge planning is a legal right. Multiple agencies, federal law, and state law provide regulatory oversight and assurance of patient choice in the discharge planning process. These are detailed in Medicare's Conditions of Participation for Hospitals at the federal level, Medicaid requirements and state licensing laws for hospitals (varying by state), individual health care provider contracts, the National Committee for Quality Assurance, and the Joint Commission standards.21 The timing of discharge is determined by the clinician and is based on medical need. A patient does not have the legal right to remain medically hospitalized once one is deemed to no longer meet criteria for inpatient level of care.21 Substantial tort law exists supporting hospitals in this matter. The judicial system has sided with hospitals in recognizing court orders to evict patients, suing patients for costs of medical care incurred by unnecessary medical stays, and enacting criminal trespassing statutes. In Lucy Webb Hayes National Training School v. Geoghegan, 281F. Supp. 116 (D.D.C. 1967), the court states: “It [the hospital] has a moral duty to reserve its accommodations for persons who actually need medical and hospital care … hospitals have a duty not to permit their facilities to be diverted to the uses for which hospitals are not intended.”22 Patients who fail to leave the hospital assume both financial and legal burden once the hospital has adequately addressed all procedural rights. The economic burden of unnecessary medical inpatient days ultimately is assumed by the patient, institution, insurers, and patient's family.21 CONCLUSION Patients who decline recommendations to leave the hospital present a unique challenge for hospital-based providers and consultation psychiatrists. A thoughtful approach, which considers the broad range of possible etiologies of this behavior and applies clear but careful intervention, can prevent both patient harm and misuse of limited inpatient clinical resources. Early or proactive psychiatric consultation is warranted to assist hospital teams in identifying barriers to discharge and help manage these potentially difficult cases. www.psychosomaticsjournal.org
23
Management of Discharge Refusal
References 1. Desan PH, Zimbrean PC, Weinstein AJ, Bozzo JE, Sledge WH: Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team. Psychosomatics 2011; 52(6):513–520 2. Hong CS, Siegel AL, Ferris TG: Caring for high-need, high-cost patients: what makes for a successful care management program. Issue Brief (Commonw Fund) 2014; 19: 1–19 3. Appelbaum PS: Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med 2007; 357(18):1834–1840 4. Shapiro AP, Teasell RW: Behavioural interventions in the rehabilitation of acute v. chronic non-organic (conversion/ factitious) motor disorders. Br J Psychiatry 2004; 185: 140–146 5. Abbey SE, Wulsin L, Levenson JL: Somatization and somatoform disorders. in Levenson JL, editor. Textbook of Psychosomatic Medicine. Washington, DC: American Psychiatric Publishing; 2011, pp. 261–290 6. Raj V, Rowe AA, Fleisch SB, Paranjape SY, Arain AM, Nicolson SE: Psychogenic pseudosyncope: diagnosis and management. Auton Neurosci 2014; 184:66–72 7. Savino AC, Fordtran JS: Factitious disease: clinical lessons from case studies at Baylor University Medical Center. Proc (Bayl Univ Med Cent) 2006; 19(3):195–208 8. Resnick PJ: Faking it: how to detect malingered psychosis. Curr Psychiatry 2005; 4:13–25 9. Braun IM, Greenberg DB, Smith FA, Cassem NH: Functional somatic symptoms, deception syndromes, and somatoform disorders, in Massachusetts General Hospital Handbook of General Hospital Psychiatry, 6th edition, In: Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF, (ed) Philadelphia: Saunders Elsevier; 2010, pp. 173–188 10. Sifneos PE: Manipulative suicide. Psychiatr Q 1966; 40(3): 525–537 11. Gutheil TG: Suicide, suicide litigation, and borderline personality disorder. J Pers Disord 2004; 18(3):248–256
24
www.psychosomaticsjournal.org
12. Gutheil TG, Schetky D: A date with death: management of time-based and contingent suicidal intent. Am J Psychiatry 1998; 155(11):1502–1507 13. Bundy C, Schreiber M, Pascualy M: Discharging your patients who display contingency-based suicidality: 6 steps. Curr Psychiatry 2014; 13(1):e1–e3 14. Moran JR, Gross AF, Stern TA: Staying against advice: refusal to leave the hospital. Prim Care Companion J Clin Psychiatry 2010; 12:6 15. Groves JE: Taking care of the hateful patient. N Engl J Med 1978; 298(16):883–887 16. LaFrance WC, Jr., Reuber M, Goldstein LH: Management of psychogenic nonepileptic seizures. Epilepsia 2013;54 (Suppl 1):53–67 17. Gerstenblith TA, Kontos N: Somatic symptom disorders, in Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2nd edition, In: Stern TA, Fava M, Wilens TE, Rosenbaum JF (eds). Philadelphia, Elsevier, 2016, pp. 255–264 18. CMS. 42 CFR Parts 405, 412, 422, and 489 Medicare Program; Notification of Hospital Discharge Appeal Rights; Final Rule. November 27, 2006. Available from: https://www.cms.gov/Medicare/Medicare-General-Infor mation/BNI/Downloads/CMS-4105-F-.pdf [cited October 22, 2015] 19. Amerigroup. Member Handbook Amerigroup Community Care, Tennessee. 2013. Available from: https://providers.amer igroup.com/ProviderDocuments/TNTN_CAID_MHB_ENG. pdf [cited October 22, 2015] 20. Chiplin AJ: Breathing Life into Discharge Planning. Elder L J 2005; 13(1):1–83 21. Schlairet MC: Complex hospital discharges: justice considered. HEC Forum 2014; 26(1):69–78 22. Lucy Webb Hayes National Training School v. Geoghegan, 281F. Supp. 116 (D.D.C. 1967). Available from: http://law. justia.com/cases/federal/district-courts/FSupp/281/116/ 1575358/. Accessed October 22, 2015
Psychosomatics 57:1, January/February 2016