Safe Enough: Subjective Determinations in Hospital Discharge for Patients With Medical Complexity

Determining whether a discharge plan is safe relies on both objective and subjective evaluations. These safety determinations are often made with the goal of having children reintegrated into their community. In the case of pediatric mechanical ventilation via tracheostomy, the stakes for discharge home are high given potential morbidity and mortality risk if there are insufficient services in place. Clinical practice guidelines recommend that these children have continuous monitoring from a nurse or trained caregiver. However, this monitoring recommendation has led to unintended delays in discharges due to nursing shortages and limited caregiver availability. Conflicts can then arise about whether patients should remain hospitalized indefinitely until nursing is secured, be discharged home without adequate nursing support, or be placed in a long-term care facility until criteria are met. Important ethical considerations when addressing this conflict include the legal obligation to ensure children are properly integrated into their communities, the biases and racism that may impact which families are deemed as being unable to provide a safe environment, and the harm associated with the clinical team overriding a parent's decision about their child's care and recommending state intervention. To balance the medical goal of maximizing safety with the ethical standard of respecting autonomy and the civil rights that children with disabilities have to receive care at home, we must reconsider how safety is evaluated by seeking an integrated approach that provides a shared understanding of best practices and values between the clinical team and family in defining "safe."