Patient Refuses To Leave The Hospital? Stay Calm! Don't Panic!

A reader asked me a recent question about what to do if a patient refuses to leave the hospital after being discharged by their physician.    I wonder if you could do a post on when a patient refuses to leave the hospital. I just ran into this and I wonder how others handle it.  

What should doctors do if patients stay against their advice?  At some point in their career, most physicians will experience a patient who refuses to leave the hospital.    My first recommendation is not to get emotional about it.  I used to hate these situations, but not anymore. I calmly play by the rules and let the patient understand their options.  I let science and money guide the process.  Most of the time, patients will leave once they understand their responsibilities.   Sometimes it's the patient that refuses to leave.  Sometimes family members refuse to let grandma be discharged in the condition they see her in.  Whatever the reason, some patients simply refuse to leave after receiving dismissal orders.  What should the physician do in these situations?  Play by the rules.

If the patient has Medicare, here are the regulations guiding your decision making process.

  •  You give them The Letter.  It's called An Important Message From Medicare About Your Rights and it details a patient's rights in the hospital.  
  • This requirement can be found in The Federal Register / Vol. 71, No. 227 / Monday, November 27, 2006 / Rules and Regulations
  • On April 3rd, 2007 CMS published a question and answer detailing the final ruling titled Notification of Hospital Discharge Appeal Rights (CMS- 4105-F).
  • They followed that up on May 25, 2007 with a MLN Matters publication for providers detailing the final rules that took effect on July 2nd, 2007.
In a nutshell, this  Medicare policy  says if a Medicare beneficiary refuses to accept the recommendation of discharge from the hospital, they can appeal the physician's discharge.  In the case of Nebraska, CIMRO of Nebraska is the quality improvement organization (QIO) authorized by Medicare to review inpatient services provided for Medicare patients. Once the appeal is filed with CIMRO, the physician reviewer has  about 24 hours to either agree or disagree with the physician's decision  to discharge the patient from the hospital.   If the QIO agrees with the physician, the patient is notified that Medicare will stop paying for their care at that time and the patient will be responsible for all subsequent hospital charges.  If the patient disagrees with their decision, they can request an expedited reconsideration if requested before the end of their decision for nonpayment.

I have never had a patient decide they didn't want to leave if they knew their insurance coverage ended immediately.  What are the rules for patients with private insurance?  I don't know.  I'm sure every insurance company is different.  Most patients will leave without force if they are told their insurance will stop paying after their physician writes discharge orders.

How should the physician handle the uninsured drug seeker who doesn't care about the money and refuses to leave?  I don't do anything. If I make a determination that discharge to the community is safe and in-patient hospitalization is not necessary, the patient can throw the biggest tantrum they have ever thrown but  my decision still stands. I will simply write discharge orders and stop seeing the patient.   I could not, in good conscious, continue to bill the patient for medically unnecessary care if they choose not to leave.  These patients often have personality disorders and are considered hateful by staff.  The term hateful patient was coined in 1978 under four main categories.
  1. dependent clingers (eg, borderline or dependent personality disorders)
  2. entitled demanders (eg, narcissists)
  3. manipulative help-rejecters
  4. self-destructive deniers
If  the hospital wants to call their security or the police  to escort the patient out, so be it. In some states, patients can be charged with trespassing for refusal to leave the hospital on discharge.   What happens next  is a decision for the hospital and their policies and procedures to determine.  I have performed my duty as a physician. I am not an enforcer.  I am not a cop. I am not a social worker or a Priest.   Don't let the moochers get you down. Play by the rules and empower the patient to let their wallet do the talking.  And if all else fails, call the police!

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7 Outbursts:

  1. Once discharged, the patient who does not vacate the hospital room is in many jurisdictions considered trespassing and can be arrested by the police for the same. Usually it never comes to that, and private hospital security officers usually escort the patient to the edge of the hospital grounds.

    Of course, nothing can prevent them from marching to the E.D. to try to start the process all over again.

  2. Ugh. Hate this situation. I actually had one chronic pain/drug seeking patient call his/her mother who marched to the hospital administration and complained about me and the patient's care, and that I was NOT working up the patient appropriately. God, I love patients and their chronic narcotics!
    And yes, the patient was in the health care field, (of course!)

  3. Listen. Nod. Smile.

    Give him/her necessary guidance, send the patient on his/her trajectory, and move on.

    We can't always help, yet we should never fail to try.

  4. My own hospital gives patients 24 hours to leave. If they don't leave, security hauls them out.

  5. Had this problem yesterday. The patient has a psychiatric history (probably schizoaffective but also with antisocial personality disorder). Everyone questioned whether I needed to consult a psychiatrist, but he wasn't delusional, hallucinating, depressed, manic, confused or suicidal. He just didn't want to go. I wrote the order, told the nurses to call me if he threatened anything (then I could do a psych hold and get a psych bed) and left. Security escorted him out but he never got angry or violent. Thanks for wasting my time - he just didn't like his assisted living facility and wanted us to find a new one for him.

  6. I deal with this on the occasional intractable headache admission the ER dumps on me when I'm on call. I just tell them their insurance coverage ends, and make it clear they know what the hospital charges by the day. They get out FAST. The headaches usually get better, too (at least mine do).

  7. re:schizoaffective patient not wanting to leave.
    It was just reverse psychology. If he/she demanded to leave the psychiatrist would have found him/her to be sick.


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