Non-medical Discharge: Navigating Legal, Regulatory, and Ethical Considerations
Hospitals may wish to discharge patients for a variety of non-medical reasons (e.g., if the patient is being violent towards staff, patients, or visitors; if the patient is exhibiting racist behavior). However, administrative discharge of patients for non-medical reasons is a more complicated legal and regulatory issue for hospitals than it is for physician practices who wish to terminate a relationship with a patient.
For hospitals, a variety of factors may impact the decision to discharge a patient for non-medical reasons. These factors may include, but are not limited to, the following:
- Federal laws and regulations, including the Emergency Medical Treatment and Labor Act (EMTALA), the Americans with Disabilities Act, the Rehabilitation Act, and Title VI of the Civil Rights Act
- State laws
- State hospital licensing requirements
- Joint Commission and other regulatory agency requirements
- Ethical considerations, such as those from the American Medical Association
- The condition of the patient (e.g., Is the patient stable for discharge? Is the patient delirious/cognizant of their actions? Does the patient have a stable environment to be discharged to?)
- The reason(s) for dismissal
- The stage of admission the patient is currently in
- Where the behavior occurs (e.g., the emergency department [ED])
- Whether the patient has been informed about the expectations of their behavior (e.g., a patient code of conduct)
If a hospital receives Medicare or Medicaid payments, the hospital will have to document legitimate reasons for the "divorce" in order to ensure that no reasonable person could interpret the reasons for discharge or banning as based on factors that would constitute illegal discrimination, such as race, gender, inability to pay, source of payment, or religion.
In addition, where the inappropriate behavior happens can matter. For example, if the incident occurs while the patient is in the ED, it may trigger EMTALA, which requires the hospital, at a minimum, to screen and stabilize the patient. EMTALA also requires a hospital to provide an EMTALA screening exam to a patient who seeks care in the ED—even a patient who has otherwise been banned. Hospitals are also required to provide care to people with substance abuse disorders.
Organizations may want to review their patient and visitor handbooks and revise them to state that unacceptable behavior, including physical violence and threatening behavior, can lead to discharge restrictions on visits. In addition, organizations may require patients to sign a security contract acknowledging they are aware of the provisions for acceptable behavior and the consequences of failing to follow them.
ECRI strongly urges any hospital that wants to implement a policy for administrative discharge of patients to obtain an advisory opinion from its legal counsel to reinforce that policy. In addition, the hospital should consult its ethics committee for all cases in which administrative discharge is being considered.
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