The Problem of the “Medical Hold” - Ethically Justifiable Management of Patients Without Capacity Who Wish to Leave Acute Care Medical Hospitals

Inpatient medical and surgical treatment teams struggle with managing patients lacking decision-making capacity (DMC) who may not be able to safely care for themselves in the community but wish to leave prior to a physician-recommended endpoint. Clinicians may be conflicted between their professional obligation to promote the patient’s well-being and prevent harm from an unsafe discharge, and their competing obligation to follow applicable laws and respect a patient’s rights to self-determination and to not be held against their will. Some hospital systems have addressed these challenges by implementing so-called “medical hold” policies. These policies delineate a process to hold a patient against their will in a non-mental health hospital to promote their health and well-being. These “medical holds” are conceived as analogous to psychiatric holds yet do not necessarily have the same legal authority or ethical basis. We therefore developed clinically informed ethics guidance for hospital staff across our enterprise using an informed consent-based framework.

This paper will review the developed guidance through the following clinical scenarios: 1) When a patient does NOT require emergency medical care, lacks DMC to provide informed consent for the inpatient treatment, but HAS a surrogate. 2) When the patient does NOT require emergency medical care, lacks DMC to provide informed consent for the inpatient treatment, and does NOT HAVE an authorized or available surrogate. 3) When the patient requires emergency medical care, is unable to provide informed consent and does NOT HAVE a (readily available) surrogate.

David Alfandre, MD MSPH – Senior Healthcare Ethicist – VA National Center for Ethics in Health Care; Robert Sebesta, LCSW, HEC-C – Ethics – VA National Center for Ethics in Health Care; Cynthia Geppert, MD, PhD, MA, MPH, MSB, DPS, MSJ, FACLP, DFAPA, FASAM, HEC-C – Ethics – VA National Center for Ethics in Health Care