When Mr N, a 37-year-old nurse practitioner, learned that his former patient had died recently in a house fire, he was shocked and saddened. He had last seen Mr P only 2 days prior, when he was being discharged from the hospital. There had been so much positive change in the patient during his 2-month stay that Mr N was optimistic that the patient would continue to improve.

The patient had been brought to the hospital 2 months earlier by his ex-wife and daughter. They had found Mr P, who was 63 years of age, severely intoxicated in his home and were very concerned about his living conditions. The family told hospital staff that Mr P lived alone in a trailer home with no running water. They described the home as unsanitary with fire hazards. They pointed out burns on Mr P’s hands and suggested he had gotten them when items in his home caught fire.

Mr P was examined by emergency department staff and subsequently admitted to the hospital with diagnoses that included hepatic encephalopathy, possible alcohol withdrawal, deterioration of functional status, and a neglected state. Mr N was one of the hospital staff assigned to Mr P’s care. An emergency psychiatric evaluation conducted by a psychiatrist on the day after admission concluded that Mr P’s alcohol addiction was potentially lethal and that he likely suffered from significant cognitive impairment that would be slow to resolve.

One week after he was admitted, Mr P was examined by a neuropsychologist who was unable to complete the entire testing process because of Mr P’s poor motivation and lack of effort; nevertheless, the neuropsychologist concluded that Mr P did not have the capacity to manage his finances or make informed decisions regarding his health.

The patient’s daughter and ex-wife were appointed guardians after a hearing. The guardianship order stated that they could act “only as necessitated by Mr P’s actual mental and adaptive limitations.”

Meanwhile, Mr P wanted to leave the hospital, and an aide had to be assigned to ensure he did not. Over the next 6 weeks, Mr P’s condition improved. His hepatic encephalopathy was being treated, he was not drinking alcohol, and he was eating well and resting. Mr N, who spoke with the patient every day, noticed a marked change in Mr P’s mental status and coherence. Based on this improvement, the neuropsychologist who had examined him 6 weeks earlier was asked to conduct a follow-up assessment. This time, his findings about the patient were strikingly different. He described the patient as alert, friendly, pleasant, and very cooperative. Mr P told the physician that he was looking forward to returning home and planned to quit drinking (although without therapy or group support). After completing the examination, the doctor concluded that Mr P did have the capacity to manage his finances independently and make better informed decisions regarding his health.

Based on this evaluation, the hospital decided to discharge the patient; however, his guardians objected. The issue was referred to the hospital’s attorney, who concluded that the guardianship was limited in that the guardians could only make decisions for Mr P when he was not capable of making them himself.  As it was determined that he was now capable, Mr P should be allowed to decide whether he could return home independently.  Mr P wanted to go home.

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Mr N was asked to assess whether Mr P should be discharged. Based on his own assessment and after reviewing the medical record, including the neuropsychologist’s second report, and conferring with the other treating clinicians, Mr N concluded that Mr P had sufficient capacity to manage his own affairs and decided to discharge him. As part of the discharge plan, Mr N scheduled appointments for Mr P with his primary care provider, an outpatient pain clinic, and a community case manager. He also recommended that Mr P participate in alcohol abuse treatment and gave him a list of community resources that were available. Mr P’s daughter was notified that he was being discharged. She objected to the discharge, but when Mr N offered to arrange for a taxi to take Mr P to her home, the daughter declined. Mr P left the hospital that day with a friend.

Mr P’s daughter and ex-wife went to see him the next day and found him intoxicated. One day later he died as a result of a fire that destroyed his entire home.

Mr N was stunned at the news, and a few months later was stunned again after being informed that the hospital was being sued. The patient’s former guardians were alleging that the hospital was negligent for discharging Mr P over the objections of the guardians, and that the discharge plan failed to meet the standard of care. The case went to trial.