Every story has a beginning, middle, and ending. In the beginning of the story, we are introduced to the characters, and the story line is developed. Next, we have the middle of the story, or the plot. The story then finishes with the ending, and many times it is "[horizontal ellipsis] and they lived happily ever after."

I think undergoing an endoscopic procedure is a similar scenario. In the beginning, we are introduced to the players: the patient, the family, and the endoscopy staff. Then we have the plot, in which the patient undergoes the "trials and tribulations" of the procedure. Finally, we finish with the patient's recovery and discharge home to, of course, live happily ever after [horizontal ellipsis] or so we think.

I was reviewing the Society of Gastroenterology Nurses and Associates (SGNA) Online Discussion Forum and realized that there are many problems with discharge of patients and drivers to take these patients home. It is clearly a challenge to find someone to take people home after a procedure. Many people do not have extended family nearby. Some find it difficult to take time off work themselves for testing, let alone ask a spouse, significant other, relative, or neighbor to take part of his or her day off work. In the elderly population, grown children may not live nearby, and friends may not drive. Who can be there for them and take them home?

It was interesting in reviewing the Discussion Forum to note that some units require the driver to be there throughout the process. Some SGNA members noted that they had support from their physicians for this approach, whereas others did not.

Does it matter what type of sedation the patient received in considering his or her discharge from the unit as attended versus unattended? Even in the most controlled situations, is discharging a patient into someone else's care a foolproof approach? Who is liable if problems occur?

The best situation for any of us is one in which someone accompanies the patient to the procedure and remains there until it is completed. This individual can be there to listen to the procedural findings and the discharge instructions (assuming the patient has authorized this release of information). This appointee then can take the patient home and stay with the patient for awhile afterward to make sure there are no problems.

But what about situations that are not ideal? These involve the patients who knowingly deceive us. They tell us they have a driver-but in reality do not. I personally know of a case in which a patient drove herself to the procedure site. After the procedure, the designated driver was called. The driver arrived and left with the patient. Once they got to the parking lot, however, the patient got in her car and drove around town doing errands while the driver went on his or her own way.

I have known of other patients who refused to stay at the procedure site, storming out because they did not have someone to accompany them home per hospital/unit policy. What do we do? Can we legally detain them? We know that these people have been given drugs that may impair their judgment and make them drowsy or sick. How do we protect the patient, the public, and ourselves? Are we liable if they get behind the wheel of a vehicle and are involved in a motor vehicle accident, hurting not only themselves but also another person? Are we free of liability if we had them sign a discharge summary stating that they should not drive after the procedure? Should we call the police?

What about keeping the patient in recovery longer? Is there a perfect time that the medications will be out of the patient's system? Is insurance going to pay for longer hours in a recovery area to allow the patient to be free of the effects of medication? What about using reversal agents? If we can reverse the effects of the sedation drug or drugs, is it okay to allow the patient to drive?

I know when I see patients in the office and we start to talk about scheduling procedures, they often expect me to become a social worker and figure out who will be with them if there are problems with the preparation and how they will get home after the procedure. It often is amazing the number of people who can live and work in a community for years but say they have no one who can help them. I do not know whether this is a sad thing about a society in which people cannot help one another or whether the individual patient has never gotten involved with others and reciprocated being available to his or her friends. Are there people who are not undergoing procedures because of transportation issues?

This is a problem that has many aspects. If we are involved with patients, family members, or friends who are undergoing endoscopic procedures, this challenge is something we need to consider. In the Discussion Forum, one unit had an agreement with a local health agency to transport the patient to and from the procedure and care for the patient afterward. The cost was listed as $16 per hour with an 8-hr minimum ($128.00). This may be an inexpensive alternative for some, whereas a person on a limited income may not be able to afford this.

There are many questions we need to consider in discharging a patient home:

* What is the general health of the patient being discharged? For example, does the patient suffer from comorbid health problems such as diabetes or heart disease?

* What is the patient's age?

* What is the patient's condition at discharge (vital signs, nausea or vomiting, dizziness)?

* How does the patient anticipate going home?

* Does the unit have a secondary plan if there is no driver?

* Can a driver leave someone for his or her procedure and come back later, or must the driver remain in the unit?

* What is the unit plan if it is found out that someone is going to drive the patient home after the procedure?

Again, there are no clear-cut right or wrong answers, but these are important questions for us to ponder and discuss to obtain the best outcomes for all involved.