Mr. Ankeal is a 44-year-old male with end-stage renal disease (ESRD) and multiple other chronic conditions, including chronic pain. He has been on hemodialysis for eight months but has struggled significantly with the treatment. Estranged from his family and without close friends, he has been moving between outpatient dialysis centers for several months due to repeated behavioral issues.

Recently, at one clinic, he threatened several members of the nursing staff and threw empty soda cans. This behavior mirrors incidents at other facilities from which he has been dismissed. He is always apologetic after these outbursts, explaining that his pain causes him to act out.

During his current hospital admission, however, his demeanor has been markedly different. He has been polite, engaging in friendly conversation with staff, and there have been no complaints about his behavior. Mr. Ankeal reports that his pain is better managed in the hospital, which helps him “keep his spirits up.”

Although he is now medically cleared for discharge and has no clinical reason to remain hospitalized, the care team has been unable to find an outpatient dialysis clinic willing to accept him due to his documented behavioral history. Staff members are willing to write letters attesting to his improved behavior during this admission, but the clinics contacted so far have declined to accept him. The team is now uncertain how long he should remain in the hospital.