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165 10 Discharge Planning for a Dying Patient: A Role-Play General Instructions All players should read the general instructions. Before beginning, teachers should review “Using the Role-Plays” in the introduction to Part V. Parties R. Klein, social worker C. Ware, nurse Dr. J. Hathaway, attending physician Bioethics mediator Background Harold Hadoni is a seventy-six-year-old patient with colon cancer who is anxious to leave Perpetual Memorial Hospital (PMH). Mr. Hadoni had a bowel resection with a colostomy. The cancer has now metastasized to his liver and his spine, causing some bladder compromise. He requires heavy nursing care, an IV, and strong pain medication. Mr. Hadoni’s condition is terminal and he wants to die at home. The question of whether to release him from the hospital has become a matter of dispute among staff on Five West of PMH. Dr. J. Hathaway, Mr. Hadoni’s physician at PMH, feels that, although Mr. Hadoni might derive some marginal benefit from continued medical care, nothing more can be done for him in the acute care hospital. Moreover, Dr. Hathaway sympathizes with Mr. Hadoni’s wish to die at home and therefore has issued an order for his discharge. But Nurse C. Ware, head nurse on Five West, believes that it is medically irresponsible to discharge Mr. Hadoni, given what is known about his medical status and his home circumstances. Mr. Hadoni, a widower, lives alone in a secluded area of the county accessible only by a dirt road. He has become estranged from much of his family, except for a twenty-three-year-old granddaughter who lives in the large city of Beaconville, 150 miles away. Mr. Hadoni has caught wind of the dispute and has declared that, as a veteran, he will take nothing less than an “honorable discharge” to his own home on his own conditions. Mr. Hadoni insists that under no circumstances will he die in 166 Bioethics Mediation: A Guide to Shaping Shared Solutions the hospital or in a nursing home. He says he is grateful for all that has been done for him in PMH but that now it is time to get ready to say goodbye. He wants to spend his remaining time in a place that is familiar and comfortable—in the wild, with his trees, his animals, and his memories. Dr. Hathaway is a well-respected physician. Active in a number of local medical society committees, he/she believes that, while medicine’s first responsibility is to the patient, the profession also has a moral and social responsibility to help control health care costs. The best way to do this is to use the appropriate level of care for each patient. Hospitals should be used only when required by the patient’s acute condition. Since Dr. Hathaway has gone public with this sentiment, he/she believes he/she must follow it in the way he/she renders care. To do any less would be to compromise his/her credibility. Moreover, Dr. Hathaway is under pressure to discharge this patient. Mr. Hadoni’s managed care medical insurance policy limits the length of his hospital stay and his number of covered days has almost run out. Nurse Ware has a different view of this case and of the role of hospitals in general . A forty-year veteran of hospital nursing, Nurse Ware has seen trends come and go. But the one principle that has not changed for him/her has been the highest concern for the welfare of the patient. He/She has seen health care providers and hospital administrators become more obsessed with early discharge over the past ten years, causing havoc for many patients and their families. This obsession also has had the unintended side effect of making Nurse Ware’s job more difficult, because the patients who remain in the hospital are far sicker and require more care. Certainly, most patients can manage with a quick discharge. But over the years, Nurse Ware has seen many instances where the interests of the patient have been sacrificed to the concerns of social and administrative efficiency. The case of Mr. Hadoni, Nurse Ware believes, is typical of this trend. A man this sick and with this little support should not be sent home. Although the possibility of nursing-home placement has been raised, Mr. Hadoni is unwilling to sign the papers that would authorize his discharge to a nursing home. Indeed, it is not even clear that a nursing home...

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