A patient generally leaves the hospital inpatient unit in one of four ways. He transfers to another unit in the hospital; she is discharged to home or to an outside facility; he leaves against medical advice; or she dies.

In the first instance, a patient is typically transferred from one unit to another because of a change in his condition. For instance, if his condition worsens, he may go from an acute care floor to an intensive care unit; alternatively, he may transfer from the ICU to an acute care floor if he becomes stable enough to warrant this move, or if he is designated palliative or end-of-life care. Sometimes, a patient starts out on a medicine floor for evaluation, and ends up on a surgical floor after he is determined to need surgery.

In the second case, a patient is formally discharged to home or to another facility, such as an assisted living community, rehab center, skilled nursing home or hospice. Nurses know that discharge planning begins at the time of a patient’s admission. When a patient is admitted, his nurse develops a plan of care. From the plan of care, she develops a discharge plan. The typical discharge plan involves other members of the patient’s health care team, such as a social worker, case manager, physical and/or occupational therapist, dietitian or nutritionist, and provider. The plan addresses post hospital needs including activities, medications, diet, wound care, and management of conditions (such as diabetes). Discharge planning should include patient and family education. Because patients and family members are often exhausted or overwhelmed, patient education should be given in small doses, and reinforced as appropriate.

A less common (and less than ideal) way for a patient to leave a facility is “against medical advice,” commonly referred to as AMA. Obviously, it is not in anyone’s best interest for a patient to leave against medical advice. This type of abrupt departure generally entails a lot of conversations (sometimes including pleading and long explanations) with health care personnel and family members. If the patient remains determined to leave AMA, she is usually asked to sign a paper stating that she is leaving AMA. At times, AMA departures involve the police, as in cases where patients don’t tell anyone that they are leaving (and thus are considered “missing” until they can be located).

The final way for a patient to leave the facility is through death. Whether or not the death is “expected,” any patient’s demise can be difficult for family members and staff alike. Every facility has protocol and policies for postmortem care and documentation. Some facilities provide staff resources for debriefing and grieving. Others do not. Chaplains may be available to console affected parties. Unfortunately, as with other forms of patient departure from the facility, nurses are generally expected to continue with assigned patient loads; most of us barely have time to miss a beat after the death of a patient. This can be stressful from a practical point of view, as patient deaths entail extra documentation as well as communication with family members and other providers. In addition to the practical stress involved in losing a patient through death, there is an inevitable emotional reaction. But when, where, and how can nurses find time and resources to cope with the death of a patient? We are often too busy to process each death, and these events can have negative cumulative effects on our psyches.

Even when a patient does not die, nurses sometimes grieve over a patient’s departure from the hospital. This is especially true when the patient is discharged to hospice care. In these cases, there is a palpable sense among patient, family and staff  that the nursing staff is bidding the patient a final farewell. It can be hard to find appropriate words in these instances. Statements like “see you later” or “take care of yourself” sound insincere and awkward at best.

I have watched, sadly and steadfastly holding my face in a supportive position, as terminal patients leave our floor for end-of-life care. Inevitably, they appear to be propped ridiculously high in the air. Although they are safely strapped to a stretcher, they always look precarious and frail as they roll alongside uniformed ETM workers. Many times, their trembling hands remain outstretched in my direction, having weakly pulled their arms away from my parting embrace. I still see so many pairs of intently watching eyes, lock silently on mine, as each patient is rolled away, often quietly thanking me and my colleagues for our care. Even the largest man seems somehow vulnerable and small on the elevated stretcher; delicate bundles suspended on rumbling gurneys amidst the constant rush of hospital activity and bustling medical personnel.

Does your facility provide formal methods for debriefing staff after the death of a patient? How do you prepare your patients for discharge? Do you ever have trouble saying Goodbye?