Discharge from the Hospital

Definition

Discharge from the hospital is the point at which the patient leaves the hospital and either returns home or is transferred to another facility such as one for rehabilitation or to a nursing home. Discharge involves the medical instructions that the patient will need to fully recover. Discharge planning is a service that considers the pa tient's needs after the hospital stay, and may involve several different services such as visiting nursing care, physical therapy, and home blood drawing.

Description

Hospitalization is often a short-term event, so planning for discharge may begin shortly after admission. The physicians, nurses, and case managers involved in a patient's care are part of an assessment team that keeps in mind the patient's pre-admission level of functioning, and whether the patient will be able to return home following the current hospital admission. Information that could affect the discharge plan should be noted in the patient's medical record so that it will be taken into account when discharge is being scheduled. The primary questions include:

• Can this patient return to his or her preadmission situation?
• Has there been a change in the patient's ability to care for him- or herself?
• Is the patient in need of services to be able to care for him- or herself?
• Which services will the patient need?
• Are there mental health needs that must be met?
• Does the patient agree with the discharge plan?

While a person has been in the hospital, physicians other than the primary care physician have been in charge of the patient's care. Good discharge planning involves clear communication between the hospital physician(s) and the primary care physician. This may be done by telephone and/or in writing. The information to be conveyed includes:

• a summary of the hospital stay
• a list of test and surgeries performed, with results
• a list of test results still pending
• a list of tests needed after discharge, such as a repeat chest x ray
• a list of medications the patient is being discharged with, including the dosage and frequency
• a copy of the patient's discharge instructions
• when the patient should see the primary care physician for a follow-up appointment
• the plan for outpatient treatment, such as home intravenous antibiotics or parenteral nutrition to ensure that responsibility for this treatment has been clearly transferred and that the primary care physician accepts the treatment responsibility
• discharge instructions to the patient on activity level, diet, and wound care

Before leaving the hospital, the patient will receive discharge instructions that should include:

• an explanation of the care the patient received in the hospital
• a list of medications the patient will be taking (the dosage, times, and frequency)
• a list of potential side effects of any newly prescribed medications
• a prescription for any newly prescribed medications
• when to see the primary care physician for a follow-up appointment
• home care instructions such as activity level, diet, restrictions on bathing, wound care, as well as when the patient can return to work or school, or resume driving
• signs of infection or worsening condition, such as pain, fever, bleeding, difficulty breathing, or vomiting
• an explanation of any services the patient will now be receiving, such as for a visiting nurse, and to include contact information

The term discharge planning may be used to refer to the service provided to help patients arrange for services such as rehabilitation, physical therapy, occupational therapy, visiting nurses, or nursing home care. This service may be provided by a case manager or by the hospital's social service department. The patient may request this service, or the physician may make the request in the form of a referral to the department. The patient will need to be evaluated to see what services he or she requires, as well as what services he or she qualifies for (such as meals-on-wheels), or what services the patient's insurance will cover. The patient may be discharged home with a visit from a visiting nurse later the same day to assess the patient's need for these services and to make arrangements for him or her in the home. A person may be discharged home only when certain equipment such as a hospital-style bed and oxygen has been delivered to the home. If a patient feels he or she is being discharged before he or she is ready, the patient can file a complaint with the hospital's ombudsman.

A follow-up from the hospital staff, either physician, nurse, or case manager, should take place within two weeks of discharge to review the results of any tests that were done in the hospital that came in after the patient was discharged, to remind the patient of the follow-up appointment with the physician, to see if the patient has any questions about any new medications that were added in the hospital, and to be sure that no problems arose after discharge that have not been addressed. Such follow-up calls help to ensure a successful recovery.

A patient may experience a complication or an adverse effect as a result of care received in the hospital. The complication may be due to medication that was given, or from a test or surgery performed. In the February 2003 issue of The Annals of Internal Medicine, researchers reported how often these adverse effects arose, and how severe they were. Patients were interviewed by telephone a few weeks after discharge. About 20% had experienced an adverse effect such as a new or worsening symptom, medication-related problems, the need for an unexpected visit to the doctor, or death. Of the 20%, about one third had preventable adverse effects, and another third had problems that would have been less severe if they had received proper medical care. Three percent developed permanent disability.

See also Admission to the hospital.

Resources

BOOKS

Wachter, Robert M., Lee Goldman, and Harry Hollander, editors. Hospital Medicine. Baltimore: Lippincott Williams & Wilkins, 2000.

PERIODICALS

Forster, A. J., et al. "The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital." Annals of Internal Medicine, 138 (February 2003): 161–167.

ORGANIZATIONS

The American Hospital Association. One North Franklin, Chicago, IL 60606.

National Center for Health Statistics. National Hospital Discharge Survey, Vital Health Stat. 153 (November 2002): 1–194.

National Institute on Aging. <http://www.nih.gov/nia>.

Esther Csapo Rastegari, RN, BSN, EdM

The Gale Encyclopedia of Surgery: A Guide For Patients And Caregivers
Copyright © 1999 by The Gale Group.
Published by The Gale Group. All rights reserved, including the right of reproduction in whole or in part in any form.

Constructive Discharge

The term "constructive discharge" describes a situation in which an employee is forced to quit a job because the employer has made working conditions intolerable. Working conditions may be considered intolerable if, for example, the employee is discriminated against or harassed, or if he or she suffers a negative change in pay, benefits, or workload for reasons that are not performance-related. In most cases, an employee who voluntarily leaves a company—as opposed to one whose employment is terminated by the company against his or her will—is not entitled to unemployment benefits and loses the right to sue the company for wrongful termination.

But the law recognizes constructive discharge as an exception to this rule. "In an increasing number of cases, employees are quitting their jobs, filing wrongful discharge suits against their former employers, and—here's the kicker—coming out a winner," J.D. Thorne wrote in an article for Small Business Reports. "The courts have reasoned in these cases that the employers made the workers' jobs so unbearable that they would rather quit than suffer more abuse. Being compelled to quit was much the same as being unfairly discharged. This claim, commonly known as constructive discharge, essentially excuses the employee from being the one to sever the employment relationship."

LEGAL STANDARDS AND APPLICABLE PENALTIES

In order to sue successfully on the basis of constructive discharge, an employee must prove in court that the working conditions he or she experienced were intolerable. In addition, the employee must prove that the intolerable conditions were directly attributable to the employer. In other words, the employer either created the intolerable conditions intentionally or allowed them to exist. Some courts differ about the degree of employer intent required for constructive discharge, but as the San Diego Business Journal observed, most agree that the following must occur: 1) The employer's conduct effectively forced the employee to resign; 2) A continuous pattern of employer misconduct existed; 3) Conditions were so egregious and intolerable that any reasonable person would have quit.

The most common problems cited by employees in constructive discharge complaints include a loss of pay or benefits, an abnormal increase or decrease in workload, or discrimination under the Americans with Disabilities Act, equal employment opportunity laws, or unfair labor practice statutes. Constructive discharge suits may also be triggered when an employer is abusive toward an employee, particularly when that employee is a member of a protected class by virtue of gender, race, or age. Improper disciplinary actions can also be cause for a constructive discharge complaint, although employers can criticize employees' job performance and deny benefits for reasons that are business related.

In recent years, as the number of legal actions related to constructive discharge have increased, some states have strengthened the burden of proof for employees. Rather than simply proving that working conditions were intolerable, some employees now must also show that the employer knew about the poor conditions and could have remedied the situation. "Unless an employee can prove that you deliberately made working conditions so intolerable that the worker was forced to quit, then a court probably won't find the company guilty of constructive discharge," Thorne explained.

Some states also require employees to notify their employer of the problem and give them a fair chance to fix it. The idea behind such measures is to make it unnecessary for employees to quit in order to see their problems resolved, as well as to prevent employers from being blind sided by employees who quit and then sue for wrongful discharge. In Arizona, for example, employees must provide 15 days' written notice of their intention to quit for cause. The employer then has that time to make necessary changes in working conditions. If the employee is not satisfied with the employer's response and still decides to quit, then he or she is entitled to file suit for constructive discharge. The Arizona law does provide an exception, however, for employees who encounter working conditions so serious that they must leave the company immediately.

On the other hand, some courts have expanded the definition of constructive discharge to enable employees on leave to suit their employers. "An employee may still be successful in a constructive discharge lawsuit even though the employee never quits the job, if the company deliberately allowed such an intolerable workplace situation to exist that the employee ends up on permanent unpaid medical leave," explained Mary-Kathryn Zachary in Supervision. "[The court] held there was no real difference between the situation of an employee who quit because of intolerable working conditions or one who became disabled and placed on leave as a result of such conditions…. Thus, an employee may successfully bring a constructive discharge case without actually terminating employment."

The penalties a company can face if a former employee sues successfully for constructive discharge can be severe. As Thorne noted, the usual penalties include both back pay (the amount of wages the employee would have been paid had they continued working for the company up until the time of the lawsuit) and front pay (an amount based on the employee's remaining work years and the expected length of time it will take him or her to find a similar job), as well as reimbursement of attorney fees. There also may be monetary damages, compensatory damages for pain and suffering or mental distress, and punitive damages of up to $300,000 in some discrimination cases. Employees who win constructive discharge cases are usually not reinstated, however, because it would be counterproductive to return them to an intolerable working environment.

HOW TO AVOID CONSTRUCTIVE DISCHARGE LAWSUITS

Small business owners can take a number of steps to strengthen their defenses against charges of constructive discharge. One option is to implement a formal complaint system and encourage employees to make use of it. These systems, when effectively implemented, give the company a chance to rectify problems before they lead to lawsuits. Another recommendation is to establish and follow company guidelines for informing employees of performance problems and taking disciplinary action. "Don't unnecessarily put the employee in a 'sink or swim' situation," counseled the San Diego Business Journal. "Conduct regular training sessions. Ensure employees receive performance feedback regularly and understand company expectations." In addition, small businesses should ensure that any necessary downsizing measures are undertaken using objective rather than subjective criteria.

Another important suggestion for small business owners is never to change the conditions of employment in order to get employees to resign rather than having to fire them. "Attempts to force an employee to resign by making working conditions intolerable or changing job duties, is not a good idea," wrote Kristen Gerencher in InfoWorld. In fact, such attempts can have a deleterious impact on the morale of supervisors or other employees charged with implementing such a strategy. Instead, companies should always follow their standard procedures for discipline and termination. These procedures should include probation periods for employees with performance problems. It may also be helpful to request a letter of resignation from employees who quit voluntarily and keep it on file as evidence of their reasons for leaving the company. Finally, exit interviews should be made mandatory for all employees who leave the company. The exit interview gives management an opportunity to iron out differences with employees who quit with hard feelings toward the company.

But the best policies a small business can follow to avoid being sued for constructive discharge, however, are to promote fair management practices and stamp out any negative environmental conditions that begin percolating the workplace. After all, a healthy working environment not only helps keep constructive discharge lawsuits away, but also promotes over-all business success. "The best advice, as always, is to play it straight with employees," Thorne wrote. "There's no substitute for allowing them to air grievances, correcting problems with working conditions, and disciplining them fairly for unsatisfactory work."

FURTHER READING:

Gerencher, Kristen. "Tackling Terminations." InfoWorld. March 1, 1999.

"How to Prevent Constructive Discharge." San Diego Business Journal. November 8, 1999.

Mesritz, George D. "Constructive Discharge and Employer Intent: Are the Courts Split over a Distinction without a Difference?" Employee Relations Law Journal. Spring 1996.

Thorne, J.D. "Who Says Quitters Never Win?" Small Business Reports. October 1994.

Turco, Frank. "Law Expected to Put Employee Suits to Rest." Phoenix Business Journal. June 13, 1997.

Zachary, Mary-Kathryn. "Supreme Court Resolves Questions, Raises Others, With HIV Ruling." Supervision. November 1998.

SEE ALSO: Employee Termination

Encyclopedia of Small Business
Copyright © 1999 by The Gale Group.
Published by The Gale Group. All rights reserved, including the right of reproduction in whole or in part in any form.

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