A fictional 81-year-old treated for pneumonia is listed for discharge. A relative says they are unusually quiet, cannot follow the medication plan and were awake and frightened overnight.
Listen for the assumption.
Their observations are stable and the infection markers improved, so transport has been booked.
What new information should make us stop the discharge process?
The acute change from baseline suggests hypoactive delirium. We need assessment, reversible causes and a fresh decision about capacity and discharge safety.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- 4AT is abnormal when completed by a trained clinician
- Bladder is palpable and a sedating medicine was added overnight
- The person cannot retain or weigh the proposed medication changes
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
We should investigate pain, retention, constipation, hypoxia, infection, medicines, sleep and sensory impairment rather than reach immediately for sedation.
And involve the patient and family. The system pressure to complete discharge must not become a clinical finding.
I will document the change from baseline, 4AT, causes addressed, capacity assessment and new discharge criteria.
What must remain explicit.
- Use a validated delirium assessment performed by a competent practitioner.
- Manage delirium first when distinction from dementia is difficult.
- Use the least restrictive safe approach and communicate the diagnosis at discharge.
Where reasoning fails.
- Missing hypoactive delirium
- Treating transport time as a discharge criterion
- Equating delirium automatically with incapacity
New delirium features compared with baseline are [summary]. Assessment is [result], likely contributors/actions are [details], and capacity for [specific decision] is [assessment]. Discharge is paused pending [clear safety criteria].
Which operational pressures in your workplace could make a team overlook a change from baseline?