Discharge Planning with Older Adults: The Influence of Social and Political Systems and Contexts

Discharge planning is a complex process in which intersections of competing norms, demands and expectations often beget ethical challenges. Returning home or moving to a more supportive setting can have tremendous personal, social and financial implications for older adults and families. Institutional concerns with patient safety and expedience can overshadow healthcare professionals’ commitments to client-centred approaches. In light of many competing demands and agendas, it can be unclear what is driving discharge-planning processes and outcomes. The research purposes were to 1) explore perspectives of older adults, family members, and healthcare professionals engaged in discharge planning from inpatient rehabilitation; 2) examine the influence of underlying beliefs, valued approaches and conventional processes on participants’ perspectives, behaviours and practices, and on discharge-planning outcomes. Using a microethnographic case study method, observations and interview data were generated from five case studies, each consisting of an older adult, involved family members and healthcare professionals. Taking a critical bioethics perspective and using relational autonomy theory, this research examined how social and political contexts shaped discharge-planning processes and outcomes. Discourses of aging-as-decline, beliefs privileging healthcare professionals’ expertise and conventions guiding discharge planning marginalized older adults. The prioritization of safety and focus on discharge superseded approaches to maximize function: the stated aim of rehabilitation. A profession-centric approach and the focus on safety and discharge from the time of admission intersected to promote 24-hour care recommendations in all cases. Taking a critical bioethics perspective informed by relational autonomy revealed that discharge planning was driven by paternalistic norms and that the ‘best interests’ of older adults were aligned with ‘protecting physical safety’ at the expense of any other considerations, thereby marginalizing older adults and impeding client-centred practice. These findings suggest that adopting a relational approach could promote practices that uphold older adults’ agency and align professional responsibilities with intended program aims.Ph