The illusion of discharge and the transition fracture

He was diagnosed with metastatic hepatocellular carcinoma, and during his hospitalization, we did the standard work of our specialty; we controlled symptoms, managed acute complications, and conducted the conversations that allowed him to record his advance directives. Nothing technically remarkable. What was built there, and which no medical record accurately captures, was the perception that there was a place where his questions belonged.

When the patient was discharged, the plan was to keep up with his regular oncology follow-up, but his needs were far more than just his cancer treatment. Our hospital lacked an outpatient palliative care service to which we could refer him. He was, in the most literal sense, discharged from continuity of care. We also referred him to an internal medicine service, hoping for a broader perspective that might address some of his needs. It was not enough.

His questions mounted in the following days, not due to any shortcomings on the part of the specialists who had treated him; they were matters that went beyond the medical: what the progression would be like, how to talk to his children, how to stay active and independent, and how to cope with the fear of dying in pain.

It is impossible not to see the irony in this, for, unlike isolated acute events, leaving the hospital is not the end of an event but the transfer of care to an unprotected environment. The healthcare system insists on applying the logic of “episodes of care” to a disease that demands exactly the opposite: continuous adaptation and an uninterrupted flow. To discharge someone from what should be continuous care exposes the flaw in our model.

This wasn’t something we chose to do; it was the result of a model not designed to provide palliative care capable of accompanying the patient throughout his journey, whenever and wherever he needed it.

I believe that colleagues working in health systems very different from my own will recognize this pattern. Specialized palliative care tends to be organized where hospital infrastructure already exists, in major centers, but the further you get from those cities, the scarcer it becomes.

However, a lack of services explains less than it seems; during periods when my service actually offered a dedicated outpatient palliative care clinic, adherence was low. Patients with clear indications, specific needs, and questions, some of whom had been cared for by the same team as inpatients just days earlier, did not show up (even those with strong therapeutic bonds, a good understanding of their disease, and care plans already in place). Paradoxically, the service ceased to exist due to empty waiting rooms, at the same time our inpatient specialty consultation team was handling an unprecedented volume.

Availability is not the same as access

Even if that patient had access to a specialized service for follow-up care, there is no guarantee he would have gone. Before every scheduled appointment, a silent calculation takes place: are the effort of getting dressed, the reliance on someone else for transport, and the time spent waiting in a room worth the conversation? For this population, a missed appointment is not a sign of disengagement; it is a rational response to a burden that the traditional outpatient model sometimes places entirely on the person least able to bear it (Kirby et al. Reference Kirby, Griffin and Heavin2025).

We sometimes describe outpatient palliative care as undersupplied, yet we discuss its positioning and distribution far less than we should. Furthermore, it is organized around a level of mobility that our patients, by the very nature of their disease trajectory, are progressively losing. A model that requires the most severely ill patients to travel even more, adding to an already crowded healthcare schedule (let’s not forget disease-modifying treatments), is not just underfunded; it is misaligned with the population it intends to serve.

The screen as a space of presence

It is precisely in the face of this dysfunctional model that telemedicine reveals itself not merely as a technological convenience but as an ethical imperative that offers presence (Krieckemans et al. Reference Krieckemans, Cavolo and Casaer2025). It acts as a bridge for this transition, extending the hospital’s safety net into the living room and preventing a sense of acute abandonment. The literature echoes this clinical perception, suggesting that patients view it as a support system that facilitates remaining at home, and that regular video contact helps strengthen the bond and trust with the care team over time (van Gurp et al. Reference van Gurp, van Selm and Vissers2015).

For a long time, a specialty so deeply rooted in listening, touch, and sustained eye contact viewed the screen with suspicion. However, the teleconsultation inverts the logic of effort; the “silent calculation” shifts, and the vital energy that would have been spent in traffic or in a wheelchair is preserved for what truly matters to the patient, a trade that proved no less effective than an in-person consultation (Greer et al. Reference Greer, Temel and El-Jawahri2024).

There is also a potential additional benefit: visual aids allow the team to see the patient in their real-life context. By entering the patient’s home, the team establishes a connection that the hospital bed and the clinical atmosphere of the doctor’s office rarely permit. This dynamic subverts the power asymmetry of traditional care, in which the patient is merely a visitor on our turf (Steindal et al. Reference Steindal, Nes and Godskesen2023).

Teleconsultations also reconfigure who is present in the room. A regular hospital appointment typically accommodates one caregiver, often whoever could take the day off or lives closest. A video call allows a daughter in another city, a son between shifts, and anyone else important for the patient to join the same conversation. This collective participation is not merely supportive; it is also protective against communication noise.

Enthusiasm is easy to build; the real test is whether it holds under pressure.

Limits, equity, and the true reach

Promoting equity by providing access to those facing geographical barriers is a common argument among proponents of remote care; however, a caveat is in order: it should serve as a complement, not a substitute.

Despite recent advances driving the use of digital tools, particularly following the COVID-19 pandemic, evidence of their effectiveness remains limited. Significant questions persist regarding implementation and the scope of benefits, highlighting the need for more robust studies (Payne et al. Reference Payne, Tanner and Hughes2020). Naturally, telemedicine has its own limitations; it introduces new barriers, such as the different weight of shared silence during a video call or the absence of a reassuring hand on the shoulder when delivering bad news. Furthermore, there is a genuine risk of creating a new layer of inequity driven by the digital divide, leaving behind those lacking technological literacy or access to quality internet, not to mention that complex physical assessments will still require in-person care (Steindal et al. Reference Steindal, Nes and Godskesen2020). Therefore, based on current evidence and the intrinsic limitations of purely digital care, a hybrid model appears to be the most appropriate strategy, balancing the indispensable presence of face-to-face encounters with the continuous reach of teleconsultations (van den Bergh et al. Reference van den Bergh, Muente and van Barschot2026).

We cannot trade depth for convenience. Yet, for cases like that of my patient, who already had an established relationship with the team and was previously assessed in person during hospitalization, telemedicine offers a tool that can provide a sense of security. More importantly, it enables continued follow-up with a specialized team, ensuring he is not abandoned during such a vulnerable time.

When I referred that patient, I was trying to solve an access problem using the only resources I had: physical facilities and in-person appointments. However, reach cannot be bought through outpatient clinics or buildings; it is built by empowering an existing team to go where the patient needs it.

The infrastructure of presence

A screen is a medium, not a care model. The failure of continuity is not just geographical; it is profoundly structural. If we simply add teleconsultations to an already overburdened inpatient team, this won’t solve fragmentation; it will just shift hospital burnout into the virtual space. For telemedicine to function as the ethical bridge it promises to be, health systems must redesign workflows. This means establishing “virtual transitional care” models and allocating protected hours for inpatient teams to conduct remote multidisciplinary follow-ups. We cannot expect a new technology to fix a broken continuum if we refuse to adapt the way clinical time is valued and structured (Collier et al. Reference Collier, Appachoo and Frey2025).

We have long asked whether a palliative care service is offered at a particular location, but the question we ought to ask, and which is far more difficult, is whether it actually reaches the patient. The patient did not ask for an outpatient clinic; he asked if he could go on. These are not the same thing, and the difference between them is what this essay attempts to name.