A 40-year-old male patient, Patrick, is admitted to your unit with self-reported suicidal ideation. His history reveals a decade of homelessness and almost daily methamphetamine use. You see from his file that he has been admitted to psychiatric facilities multiple times under similar circumstances. He consistently denies any previous self-harm or suicide attempts and has a pattern of not following through with scheduled outpatient appointments or rehab referrals after discharge. He quickly reports a cessation of suicidal thoughts by the second day, with no neurovegetative signs of depression observed. You arrange a meeting with the substance use counselor, who recommends admission into a local addiction treatment program. However, Patrick dismisses the suggestion as a waste of time. After four days, you continue to see no signs of depression or other psychiatric conditions that require hospitalization, so you initiate a conversation about his discharge and explain he will receive referrals to community resources and outpatient services. Patrick responds by saying, “If you kick me out, I’ll kill myself, so legally you can’t discharge me! I know my rights!” You strongly suspect the patient is malingering and consult with unit staff, all of whom agree with you.

Scenarios such as this pose a significant challenge. Patients can seem to be manipulating the health care system, occupying beds that could be allocated to other patients with more pressing needs. What can you do in this situation? An “administrative discharge” is one viable course of action. This involves discharging a patient who is resistant to leaving yet does not exhibit a clinical need for continued inpatient care. In this article, we delve into the intricacies of the administrative discharge process. 

To begin, let’s review common patient profiles that demonstrate resistance to discharge. They generally fall under two classifications: deceptive and disruptive.

Deceptive patients 

Deceptive patients feign or exaggerate symptoms for secondary gain. Malingering is diagnosed when individuals fabricate or overstate symptoms for tangible benefits, such as food, shelter, or financial gain. Conversely, individuals with factitious disorder, previously known as Munchausen syndrome, deliberately produce or feign symptoms, but their motivation lies in the benefits of taking on the “sick role,” like attention and sympathy. As a result of their deceit, these patients put themselves at risk of receiving unnecessary treatments, medications, or procedures (Yates GP and Feldman MD, Gen Hosp Psychiatry 2016;41:20–28).

Disruptive patients

Disruptive patients breach unit rules or engage in harmful behavior, undermining the safe and structured environment essential for other patients’ recovery. Common examples of disruptive behavior include:

• Violating unit rules by introducing prohibited items, such as drugs or weapons
• Engaging in aggressive acts, whether physical or verbal, toward staff or fellow patients
• Manipulating or negatively ­influencing other patients, ­possibly encouraging them to partake in counterproductive behaviors like substance misuse

Interventions like behavioral contracts and increased supervision can help, but if patients repeatedly violate unit protocol in a disruptive fashion, you may want to consider an administrative discharge. This is particularly necessary when the individual’s continued presence is more detrimental than beneficial to themselves and others.

“Therapeutic discharge”?

We sometimes refer to administrative discharges as therapeutic discharges because, despite being involuntary, they serve the patient’s interests by reducing iatrogenic harm and deterring dysfunctional behaviors like fabricating symptoms or disrupting the unit. Additionally, these discharges aid the health care system by preventing misuse of resources. For an excellent review of the therapeutic discharge process, see Taylor JB et al, Gen Hosp Psychiatry 2017;46:74–78.

Discharging patients against their will: When and how?

1. Begin with a comprehensive risk assessment—review any past self-harm behaviors and the patient’s current mental state to ensure that the risk of self-harm following discharge is minimal, even if the patient escalates their threats. 
2. Inform the whole team of the discharge plan but do not inform the patient yet. The goal is to have the discharge process completed so that the window between the patient learning of the discharge and their actual exit is as brief as possible. 
3. Go as a team to inform the patient of the discharge, with security nearby. Security will usually have to escort the patient off the premises, not just to the door.

The exit conversation

Be concise and avoid asking open-ended questions or engaging in debates. Focus on the resources you are providing, like community mental health services, addiction treatment facilities, and shelters. Apply this approach consistently even when a patient continues to request to remain hospitalized. In case the patient wants to discuss their symptoms, briefly acknowledge their concerns and then refocus on the resources available to help them. 

Here’s an example of what you might say: “We know you’re going through a lot, especially with those thoughts you’ve been having about self-harm. It shows us how important it is for you to keep getting help in the long term. We’ve got some good places in mind that can support you, like local mental health centers, programs to help with addiction, and safe places to stay if you need them. We’re here to make sure you’re not alone in this and to help you find the best support for what you’re facing.”

Managing escalations

Expect some patients to escalate their suicidal threats during the discharge process. While it’s important to acknowledge these threats, it’s equally crucial to adhere to the established discharge plan. If a threat becomes more severe, you might consider addressing the provocative nature of the escalation, particularly if it’s in response to unfulfilled demands. Carefully weigh the pros and cons of taking a confrontational stance, taking into account the patient’s history (eg, past violent behavior) as well as situational factors like their current level of acuity.

In the uncommon event that threats are made against you or the staff, it’s important to communicate that these threats are taken very seriously, and to make sure that security is on standby to involve the police if necessary. Often, patients will retract their threats when faced with the presence of security personnel. It’s essential to handle threats against staff or specific targets in the community as legal issues, rather than psychiatric ones. For guidance on how to manage these situations, refer to the “Sample Scripts for Discharge Conversations” box.

Reconsidering discharge decisions

Feeling uncertain at the last minute due to a patient’s unstable condition is a common occurrence. If you feel the need to take a moment to reassess, it’s important to do so. However, ensure that you communicate to the patient that the discharge plan is still going ahead. Acknowledge their current state of distress, confirm that they can stay in the hospital for a short period to calm down, but make it clear that the discharge process will proceed. Occasionally, patients may decide to discharge themselves after one or two hours. Should this happen and the patient is stable enough to leave, make sure to comprehensively document the reasons justifying the discharge in their medical record.

And always be mindful of biases. Racial, ethnic, and socioeconomic prejudices can affect your judgment and lead you to hastily conclude that a patient is behaving deceptively and that discharge from the treatment setting is justified.

Documentation and follow-up

After discharge, ensure your documentation is thorough and includes full risk assessments, reasons supporting the decision to discontinue inpatient care, and a detailed account of the discharge proceedings. If there’s any discomfort among staff about the discharge or about future plans for the patient, give them an opportunity for discussion. Notify hospital risk management of the discharge and don’t forget to debrief with the ED, alerting them to the possibility of the patient’s return.

Your note might say something like: “Patient showed no signs of depression or imminent self-harm risk and denied any past self-harm attempts. Patient declined recommended addiction treatment and expressed intent to self-harm only upon discussion of discharge, suggesting malingering. Discharged with referrals to community resources and outpatient services after team consensus, with no incidents during the process. Alerted ED about potential return and debriefed with unit staff postdischarge. Risk assessment indicated low risk for imminent self-harm.”

Patrick refuses to budge from the day room. Nurses pack up his belongings, while the team’s social worker compiles a list of nearby shelters, addiction treatment programs, and other outpatient resources, along with bus directions. Security staff approach, and the patient rises from his seat, exiting the unit in their company. Later in the day, you receive a call from the local rehab program, informing you that the patient has voluntarily admitted himself.

Carlat Verdict 

Administrative discharges pertain to the discharge of partners against their will. Typical scenarios involve patients who exhibit deceptive behavior,  like repeated violations of unit rules. Administrative discharges can be “therapeutic” by preventing unnecessary treatments, discouraging maladaptive behavior, and reducing the strain on health care resources. Ensure a thorough pre-discharge evaluation, maintain a firm and direct approach during the exit conversation while offering outpatient support, have security on hand to address potential threats or aggression, and ensure meticulous documentation throughout the process.

Editor’s note: CHPR would like to acknowledge valuable insights from Drs. Scott R. Beach, John B. Taylor, and Nicholas Kontos on the topic of therapeutic discharges.