The ethics of discharge planning for older adults: an ethnographic analysis.

This paper uses ethnographic data to examine ethical dilemmas in discharging elderly persons from the hospital. The focus is on two elements significantly influencing that process, the patient's decisional capacity and the involvement of family members in decision-making. Within the field of bioethics these issues have been discussed in terms of factors compromising the autonomy of the patient and the interdependency of family members. An ethnographic analysis demonstrates how several assumptions in bioethical approaches to these issues are problematic. First, bioethical discussions generally neglect social and structural factors that condition discharge decision-making. The rationality and mental capability of the individuals making decisions are presumed to exist independently of those persons' social contexts; they are also assumed to be concrete properties amenable to objective assessment. Bioethical models further assume that 'the family' is an identifiable ontological unit that exists independently of the setting in which decisions are made and that interdependency is a concrete attribute of familial relations. In contrast, this study shows how discharge planning is an event produced by the interplay among diverse interests. The structure of the discharge planner's role and processes of collective decision-making shape how medical staff perceive and define patients' decisional capacity and the involvement of families. This points to unintentional and unrecognized ways in which the patient's choices and control over decisions can be restricted. The analysis supports attempts to develop bioethical models based on socially grounded principles recognizing the importance of both autonomy and interdependence in long term care decisions.