Dismiss (verb). To decide that something or someone is not important and not worth considering – Cambridge English Dictionary

If you were to walk into any government hospital or clinic setting in South Africa and ask any health care professional currently working there, to describe their work environment, you will easily hear the words: stress, pressure, tension and demanding circumstances to name a few. After having worked at various state healthcare institutions, I can personally add my own experience of the pressures felt in these settings, one of them regarding earlier patient discharges. Patients, in the public health system of South Africa, seem to be discharged very quickly without being looked at holistically. Personally it felt as though long term complications for these patients were not always considered. This then begs the question, are patients being discharged or dismissed?

During one of my clinical rotations I was placed at a tertiary state hospital, where I experienced various health care professionals working in the same space, an increased patient load as well as a working environment where minutes were vital. During this block one repetitive ethical problem I faced, almost to a point where it occurred on a daily basis, was early patient discharges. Doctors would continuously pressure us (the physio students) to mobilize patients, so that they could be discharged. The problem was not physically mobilizing the patients but doing it within the time frame required by the doctors.

On one specific afternoon, I was given a new patient after lunch whose referral was, as most others, for mobilization. Not knowing what type of surgery the patient had, I went to assess only to find that it was a 58 year old lady who had an above knee amputation. While I was reading the patient’s file 2 major things stood out to me. Firstly, she had a previous amputation (meaning she now had bilateral amputations) and secondly her discharge forms were already filled in and signed by the doctor. This meant that the patient was already discharged and the nurses were instructed to keep her in hospital until the physio came to see her before arranging her transport home. In this scenario, the referral for “mobilize” meant that a wheelchair needed to be issued for her, but this was a problem in itself seeing that there were no wheelchairs available at that time, due to lack of resources. Not only was it a long struggle to eventually find her an appropriate and available wheelchair on that day, but the biggest issue I had with this whole situation was that the patient was robbed of essential and crucial education, treatment and rehabilitation. Not only was she robbed of crucial treatment, but this early discharge situation violated at least 2 of her rights. According to the National Patient’s Rights Charter, a patient has the right to partake in decisions regarding matters affecting his/her health as well as the right to continuous care (HPCSA, 2008). Both these rights were being violated in this situation. There was so much that this patient needed to be taught, but due to the overcrowded health system and increased patient load, my time only allowed for 35 minutes with her. Although she was medically stable for discharge, she was not at all ready rehabilitation wise. She still had to be taught transfers, self-management, secondary medical complication prevention, strengthening exercises etc. I felt angered towards the whole situation and also saddened as I knew this patient was most probably going to have a difficult time adjusting at home. It was also scary knowing that she was going to be sent home so underequipped and unprepared – what if something were to happen to her at home? Could legal action be taken against me? The worst part of this whole scenario was that even after raising my concern to the doctor regarding her discharge, the patient was not admitted anymore when I returned the next day.

In an ideal world, all health care is based on the model of patient-centered care. Patient centered care is a health care approach where the focus is shifted away from the surrounding factors and contributors (such as doctors, nurses and other environmental factors) and shifted more towards the patient. It emphasizes the relationship of the patient and health-professionals as well as the patient’s involvement in his/her care (Delaney, 2017). With this type of approach the patient’s beliefs and values towards health is regarded as important and doctors are not merely prescribing and instructing without these inputs, such as in the past. This approach was developed as a more defined holistic approach to treatment as it views patients as a psychological whole (Delaney, 2017). Not only has this approach showed improved adherence to treatment plans, but also better health outcomes and improved patient satisfaction (Delaney, 2017). Another important result of PCC is that is associated with decreased length of hospitalization and reduced readmission rates (Delaney, 2017). In an ideal world the whole MDT would also be involved in the discharge decisions and their inputs would all be regarded as important. Studies have shown that effective multidisciplinary teamwork and good leadership are crucial aspects for effective and successful discharge planning (Pethybridge, 2004).  According to Goodman (2016), discharge decisions require the input of the multidisciplinary team in order to ensure that the correct and successful discharge protocol is followed. In this ideal situation, all of these necessary parts of health care would be present as well as sufficient staff and health professionals to tend to all the patients.

Unfortunately, we do not live in an ideal world and the current reality of the South African health system, is far from this world. The South African health system is under immense pressure to provide adequate services to the growing population and growing burden of disease (Mayosi & Benatar, 2014). Mismanagement and mal administration occurs in numerous hospitals country wide, which contributes to limited and in some cases absent resources (Malan, 2011). This leads to some hospitals being underutilized while some hospitals are over strained. Since 1994, various inequalities have been addressed and social progress has been made, but the health of the majority of South Africa remains tormented by the burden of infectious and non-communicable diseases and the lack of adequate human resources to provide care for the growing population, which includes immigrants (Mayosi & Benatar, 2014). According to Stats SA (2017), 47 million South Africans do not have medical aid, meaning that this growing population is dependent on the government health system for care. Health can directly and indirectly be linked to poverty and social inequalities, and in a country like South Africa where poverty affects the larger population, these links can be seen very clearly. The lack of access to basic necessities such as clean water, proper nutrition and sanitation, adequate housing conditions, completed vaccinations and a proper education all negatively contribute to an individual’s health (Mayosi & Benatar, 2014). All of these shortcomings in poverty can be associated with disease. Currently South Africa accounts for 17% of the global HIV burden, while it only represents 0.7% of the global population, and it also reports the highest number of XDR TB cases globally (Mayosi & Benatar, 2014). South Africa is also one of the most unequal societies in the world, with a Gini coefficient (which measures relative wealth) of 0.7 (Mayosi & Benatar, 2014). All of these factors contribute to the current health situation in South Africa and the growing burden of disease. This population then turns to the South African health system for care, which then leads to oversaturation and intense turnover pressures in state health institutions and ultimately to the main ethical dilemma of patients being discharged too soon (Mayosi & Benatar, 2014). More in depth problems and details regarding state hospitals can in this article by Times Live.

The current burden of disease and need for health care from the public, is more than what the health care system can handle and more than what it was developed to handle, which is evident in the image above taken in the waiting room at a hospital in Soweto. Health professionals in South Africa are especially pressured to maintain their required stats and turnover numbers (no. of patients seen monthly) and provide adequate health care to the large pressing population requiring these services, resulting in increased work related stress (Govender & Mutunzi, 2012). Working with doctors and nurses in state institutions, opened my eyes to the intense working environments and pressures they experience. Having been exposed to this, I can understand the reasoning as to why patients are discharged so quickly. These health professionals often make life changing decisions in minutes and they have to try and tend to a very large sick population in short periods of time with minimal staff members, but even knowing this, the fact still stands: patients are being discharged pre-maturely and this is an ethical problem.

Discharge decisions are currently being made by doctors alone and the multidisciplinary teams are not involved or seen as important when it comes to discharge decisions. One important aspect of discharged that I noticed during clinical practice, was that allied health professional inputs regarding patient discharges are not always taken into consideration, which contributes to the problem of patients being mismanaged and discharged too early. According to a study done by Smith, Fields & Fernandez (2010), physical therapists play an important role in patients discharge planning. It was found that patients are 2.9 times more likely to be readmitted to an acute setting if the physical therapists discharge recommendations were not implemented. Often general practitioners, the primary health care givers, lack time and do not do discharge consultations with patients (Hesselink et al., 2012). Patients are not involved in their discharges, patients’ emotions, resources and support is not taken into account with discharges and appropriate post-discharge follow up programs are not explained or developed (Hesselink et al., 2012). This leads to patients feeling unprepared for post discharge demands, family members that are not ready for home care and patients experiencing anxiety when it comes to discharges (Hesselink et al., 2012). All of these factors contribute to readmissions and poor health outcomes of the patient post-discharge (Hesselink et al., 2012). This is where the responsibility of other health professionals like physios come in, to help prepare patients adequately for discharge. In these hospital settings (particularly at the hospital I was placed) patients are often discharged early with follow up referral letters to visit their nearest clinic, but according to a study done by Cichowitz et al. (2018), it was found that there are major discrepancies between the post-discharge care prescribed by the health providers and what patients are actually able to achieve. Often patients do not have the means or resources to attend these follow up appointments and another major concern is that most of appointments can only be made in a few months, leaving the valuable key transition time unutilized (Cichowitz et al., 2018).

These early discharges cause a viscous repeating cycle of admissions, discharges and re-admissions, which ultimately adds to the already large population that require state health care and it also has a financial implication, as subsequent health care costs for one patient could double or even triple (Mayosi & Benatar, 2014).

This is a type of ethical problem that cannot be solved in a moment or in a day, seeing that there are multiple intricate aspects to this problem of early discharges. A solution to the issues and challenges experienced in our health system, contributing to pre-mature discharges, would be to address social determinants of health on a national level (Mayosi & Benatar, 2014). The health system (top to bottom) should be strengthened to facilitate and improve universal coverage (Mayosi & Benatar, 2014). Ultimately the root of the problem, namely poverty and social inequalities have to be addressed on a governmental level, but knowing this, my question to myself was: what can I do to prevent this from happening. Looking at the role I can play in preventing patients from being discharged when they are not ready, in order to ensure that the patient has the best possible health outcome and to prevent his/her readmission. The roles of the MDT and the physical therapist in patient discharges was emphasized above and I agree with these important roles. I think one important task that I can undertake is to try and be firm and assertive when it comes to discussing my concerns regarding patient discharges in a professional manner. I should improve my reasoning and ensure that I can properly explain my decisions and professional opinion to other members of the health team. Even though this might not solve the problem of early discharges, I should also acknowledge that I have limited time with each patient and thus plan informative and specific treatments, utilizing my time well in order to educate, treat and prepare patients as much as I can for discharge.

Pre-mature discharges is an ethical problem experienced by various health professionals in South Africa and the ultimate solution involves multiple management levels on a national and provincial level, but despite this, I believe we as health workers should acknowledge the roles we can play in refraining from this practice.

References

Cambridge.org. (2019). Cambridge.org. Retrieved 23 September, 2019, from https://dictionary.cambridge.org/dictionary/english/dismiss

Cichowitz et al. (2018). Hospitalization and post-discharge care in South Africa: A critical event in the continuum of care. PLOS One, 13(12). Retrieved 25 September, 2019, from https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0208429&type=printable

Delaney, L.J. (2017). Patient-centred care as an approach to improving health care in Australia. Collegian, 25(1), 119-123.

Goodman, H. (2016). Discharging patients from acute care hospitals. Nursing Standard, 30(25), 52-60.

Govender, I & Mutunzi, E. (2012). Stress among medical doctors working in public hospitals of the Ngaka Modiri Molema district (Mafikeng health region), North West province, South Africa. South African Journal of Psychiatry, 18(2), 42-46.

Hesselink, G. et al. (2012). Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Quality & Safety, 21(1), 39-49.

HPCSA. (2008). Hpcsa.co.za. Retrieved 23 September, 2019, from https://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_3_patients_rights_charter.pdf

Malan, M. (2011). Mail & Guardian. Retrieved 24 September, 2019, from https://mg.co.za/article/2011-07-22-mismanagement-a-huge-problem

Mayosi, B.M & Benatar, S.R. (2014). Health and Health Care in South Africa — 20 Years after Mandela. The New England Journal of Medicine, 371(14), 1344-1353.

Pethybridge, J. (2004). How team working influences discharge planning from hospital: a study of four multi-disciplinary teams in an acute hospital in England. Journal of Interprofessional Care, 18(1), 29-41.

Sibeko, D. (2018). In this file picture, queues of people wait to be treated at Chris Hani Academic Baragwanath Hospital, Soweto [Image]. Retrieved from https://www.iol.co.za/the-star/news/foreign-nationals-burdening-south-african-health-system-motsoaledi-18129406

Smith, B.A, Fields, C.J & Fernandez, N. (2010). Physical Therapists Make Accurate and Appropriate Discharge Recommendations for Patients Who Are Acutely Ill. Physical Therapy Journal, 90(5), 693-703.

Statistics South Africa. (2017). Statssa.gov.za. Retrieved 6 September, 2019, from http://www.statssa.gov.za/?p=10548