I've tried to google this in every possible way for hours and hours. Who can sign discharge papers for an adult, mentally-competent, conscious person? If said person is not physically able to do so by herself. She has broken both her arms or wrists, or her dominant hand. Could she somehow put an 'X' herself, or have a friend sign for her, or could she simply leave? (In the USA, btw)
I wish there existed a long-running thread for simple questions that one or two people can answer.
A competent adult signs his/her own papers. If the patient has a busted hand, and "X" will suffice. If the patient is alone and can not sign for a physical reason, I sign for the patient and mark it as "unable to sign." I would allow a friend or relative at the bedside sign the paper with the verbal okay of the patient, and I would note it as such.
Discharge instructions and Consent for Treatment are 2 different things. If you're bleeding out from a GSW, we assume Consent for Treatment is given. We will save your life, even if you later say you're not paying for it or we can screw off.
Discharge instructions? Well, if a patient refuses to sign them, we just make a note that the patient was "non-compliant" and refused to let us give them instructions. Discharge instructions have nothing to do with the hospital getting paid, so all those yahoos who throw them at me? Well, have at it. Still gonna get billed, and it's not anything I have any control over.
When a patient truly is unable to sign, I make sure they understanding everything on the instructions. I make sure the person with them understands as well. Sometimes I write a smiley face in the signature spot, and we call it a day. Having the discharge instructions signed is truly more important to the hospital staff. When John Doe comes back to the ER a week later with a purulent wound 'cause he took 2 days of antibiotics and saved the rest for the next time, we can say, "Well, Mr.Doe, you were given teaching on how to take antibiotics, and you signed that you understood (or Mommy signed for you). Once again, listen carefully...and sign here."
As for simply leaving, patients do that all the time. Patients often complain about waiting for discharge paperwork. They don't understand that the paperwork is about 15 pages long, and a second nurse and I have to initial every page and co-sign that we are giving the correct paperwork to the right patient. It's not as easy as just handing over a piece of paper. I wish it was. So patients leave all the time without their discharge instructions. If they ask me if they can leave, I usually inform them they are a grown adult and if they do not wish to wait for instructions, then they certainly can make the decision to leave. We're not running after you if you leave without your instructions.
HTH. God, I love being an ER nurse.