Looking Ahead: Traumatic Brain Injury, Ethics, and Discharge Planning

Abstract

D ISCHARGE PLANNING is a process fraught with ethical issues including safety concerns, informed refusals, and the lack of access to healthcare and social services for continuing care. Discharge dilemmas were common in my 16 years working in disability and rehabilitation ethics at the Rehabilitation Institute of Chicago, now the Shirley Ryan AbilityLab, a freestanding rehabilitation hospital with comprehensive brain injury rehabilitation services. We struggled with discharge dilemmas without clear-cut solutions, often amplified by the personal, familial, and social variables associated with traumatic brain injury (TBI). What if someone has met the goals of rehabilitation and has incrementally regained cognitive function but is unable to participate in discharge planning because they are not yet able to demonstrate capacity? What about a refusal to go to a skilled nursing facility (SNF) when a surrogate has consented but the person with TBI refuses? What about the person who could be discharged home if they could afford caregivers?The challenges are layered. At the individual level, the injury itself can impact problem-solving and planning. People with TBI may have waxing and waning capacities and the ability to participate in decision-making. Their impairments may be related to judgment and future safety concerns. Families and surrogates often make discharge decisions that have far-reaching consequences such as long-term institutionalization. They are confronted with limited choices. Some options are limited based on individual characteristics such as the sequelae of the injury. Others are structural and relate to health insurance coverage, geography, and broader questions of access to appropriate services.In this piece, I will consider 3 key ethical concerns in discharge planning from inpatient brain injury rehabilitation: who decides and how decisions are made; the

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