Planning older people's discharge from acute hospital care: linking risk management and patient participation in decision-making

This paper reports findings from a pilot qualitative study which aimed to develop a methodology to explore older patients' participation in discharge decision-making. The study involved 5 months' ward-based observation and formal interviews with older patients and ward staff in a care of the elderly department of a district general hospital in Scotland. A purposive sample of 22 older patients was recruited, selected to give adequate representation across age, gender, condition and type of ward. Findings suggest that participation in decision-making was linked to systems of risk management. Discharge planning relied to a large extent on formal assessments of patients' cognitive and physical ability. This system prevented older patients from expressing their views in terms which came naturally to them, and staff had therefore little reason to trust patients' competence to manage and to take part in decision-making. This, in turn, meant that ambiguous or difficult decisions about risk were circumvented or postponed through referral and assessments, rather than openly addressed. These dynamics excluded both patients and staff from active decision-making, something which, in turn, removed all parties' control of the situation and produced new risks. Two case studies are presented to illustrate and support this analysis.