The doctor asks for a family meeting to gather more information. She explains why she hadn’t already hospitalized the patient. This explanation was needed because the patient’s spouse is upset that “you aren’t taking my husband’s condition seriously, why didn’t you call me the minute he showed up to clinic? My brother is a doctor—and he says you should have ordered the echocardiogram on my husband weeks ago! “

Now, our simple, stepwise approach is no longer sufficient. The terrain has now become rugged, with multiple perspectives about the landscape and many hilly challenges brought into focus. The doctor’s own reputation is now on-the-line. She is worried about litigation and anger in the family. She may feel betrayed by the patient, yet hopefully will not express her anger toward the patient or blame the patient for this rugged terrain she now finds herself in. No one said being a doctor was going to be easy. This newly rugged terrain requires a much more rigorous and team-based approach. The doctor decides to admit the patient to the hospital to help expedite the work-up now that the rugged terrain is much clearer.

In the discharge example of a complicated problem, the discharge becomes rugged when it’s discovered that the patient has no family and no insurance to cover the discharge medications. She is homeless and has refused to fill out her Medicaid paperwork. She also has a personality disorder and takes out her anger on the staff. Members of the staff feel fearful when approaching the patient. They will only see her with a security person being present—to assure that the staff member is safe. There is a question as to whether the patient can make her own decisions as her behavior while in the hospital has been erratic. There is some suspicion that she may be injecting a substance through her IV. Staff have found her lethargic in the middle of the day—yet the doctors are not prescribing any sedating medications.

Many extra steps must be added to the otherwise simple discharge processes. Substance use questions must be asked. Specialists must be called in to help clarify mental capacity. A shelter must be found that will accept a patient with an evolving mental health challenge that is as yet ill-defined. It’s likely the patient, in her current state, can leave the hospital. Yet it’s equally likely that she will be back in the Emergency Department within a couple of days—making this now rugged problem merge toward a dilemma. Is it better to just keep him or her in the hospital or to discharge, knowing she will be back in a number of days, likely in much worse shape?

From Problem to Dilemma

Doubt creeps into the minds of those who much prefer the routine discharge planning process when each step can be followed in sequential fashion. Even a rugged problem with a more definite outcome seems appealing now. But this problem has reached a level of complexity that more than one pathway now seems important to consider. Scenarios begin to emerge with different rugged terrain to cover. None are seeming simple nor completely safe for the patient or the healthcare team.