Why Do Patients AMA? "Against Medical Advice"

[Natasha A., CNA, LVN]

I work at a rehab hospital pyschiatrics and chemical dependancy from ages 18-60 and I volunteered to help seek solutions and improve patient satisfaction. I've researched that one of the main reasons why patients "self-discharge" is because of the lack of physician-patient communication, in addition to wait time for admission, lack of meal preparation based on diets, patients not being involved with there treatments, etc I need to help with solutions and one thing I read is to have a patient advocate. What other ideas can I submit to my performance improvement team? How can we improve communication?

[classicdame, MSN, EdD]

you are on the right track. The trick is to merge the patient's expectations with what you can deliver. Start preaching that on day 1. Everone wants a quick cure and recovery can take years. Help empower them by providing tools for coping. Ask how they can use those tools. Ask for their suggestions. We have an alcholic in our family. He refuses rehab because the medicine makes him feel funny. Evidently being homeless, jobless, friendless does not.

[Natasha A., CNA, LVN]

Thanks for that information. You know what, I did read a study about majority of those who AMA are homeless. I also did read about "self help groups" for spiritual and cultural support or to have an on-call pychiatric service for patients to talk to at any given moment. The only situation is adding extra staff costs money. I'm thinking our healthcare staff doing a "patient complaint" survey per shift. For example, I work nights and we had a patient that's on a NAS, no added salt diet, and we didn't have any food for that patient because the kitchen forgot. The patient was upset and we had to try to calm them down.

I also ran into an occasion when a patient was in a trauma state and the FIRST thing the Rn said was "Do you want your night meds?" Then the Lvn said "Do you want to go back to your room?" The patient just looked at us with a blank stare. I asked "is there anything on your mind?" "Do you want to talk about it?" And the patient slowly started opening up. The moral of the story is, I feel that sometimes the nurses need to be a little sympathic and not rush the patients to "bed".

I understand how a patient advocate is a great solution because its the "voice" for the patients in the facility.

I will ask my boss the schedule and groups we already have and see if we need more self-help groups plus ask if healthcare staff can do monthly role play or communication training.

Anything else?

[Natasha A., CNA, LVN]

Is there a way I can do a survey by asking alcoholics and drug addicts as to why they dislike rehabs and how we can improve it to make them comfortable of going?

[Fiona59]

I work acute care. Our AMA's are usually gang members who don't want to discuss their injury. One told me his drugs were better at home.

[loriangel14, RN]

I have had patients with ETOH history that left so they could go home and drink. Usually they leave because they don't want to comply with treatment.

[NickiLaughs, ADN, BSN, RN]

Impatience or realizing they aren't getting the narcotics they want...

[Meriwhen, ASN, BSN, MSN, RN]

Honestly, one of the greatest reasons my patients (psych) AMA is because they are not allowed to smoke. We provide nicotine replacement, but it's just not the same to them. I had one go AMA and then return the next day, and he told me flat-out that smoking was why he did it. I'm actually surprised he returned...usually, they check out for that smoke and never come back.

Other reasons for AMA:

• Not getting the medications they wanted--another common one among my CD patients
  
• Patient not ready for recovery
  
• Dislike restrictive psych hospital environment
  
• Doctor-patient relationship not satisfactory to patient
  

[dudette10, MSN, RN]

I work at a rehab hospital pyschiatrics and chemical dependancy from ages 18-60 and I volunteered to help seek solutions and improve patient satisfaction. I've researched that one of the main reasons why patients "self-discharge" is because of the lack of physician-patient communication, in addition to wait time for admission, lack of meal preparation based on diets, patients not being involved with there treatments, etc I need to help with solutions and one thing I read is to have a patient advocate. What other ideas can I submit to my performance improvement team? How can we improve communication?

Good idea, but can I ask you (and whoever else is reading this and thinking, "That's the answer!") a favor? If anyone goes with the patient advocate idea, please empower the advocate to not only root out the cause but also do something about it. In other words, don't allow the advocate to collect all this information, then give a to-do list to the primary nurse. If the patient is unhappy with the diet or timing, the advocate should call the doc or dietary to make adjustments. If the patient is waiting for admission, the advocate should facilitate the admission, rather than telling the nurse, "Drop everything and do this admission now."

Also, the advocate should update the nurse on the patient's preferences/problems and the primary RN should integrate the findings into her practice with the patient, but can the advocate be as considerate of the RNs time as she is of the patients? Too many times, we are pulled away from our patient care duties to talk about stuff. On especially busy days, all I hear is "cheeseburger, cheeseburger" because I'm too busy thinking about how to make up the lost time.

So many grand ideas are thought up which nurses are expected to carry out, but very few ideas take into consideration the workload of the primary nurse. I've seen ideas implemented--usually involving additional paperwork or things that relate to nonessential patient care--and they aren't done. Reminders to do them, and they still aren't done. All because our time isn't taken into consideration.

[canoehead, BSN, RN]

OP, not trying to be snippy...but sometimes therapeutic communication is used instead of just solving the problem. For example...you patient on the NAS diet would be calmed much faster if you had a way to feed them. The smokers could try all the different nicotine replacement systems, and pick one that they can live with rather than patch or AMA. People that have to stay on the unit get to try the equipment/videos in the exercise room, and when they get home they know what they like. If you can balance restrictions with opportunities hopefully patients see the advantage of sticking it out through the program. Don't take away a coping mechanism until you have something to replace it with.

[martymoose, BSN, RN]

AMA? they didnt get what they wanted, ie drugs, meals, smokes.etc.Other reason is they DID get what they wanted, so they can go now. An example is chf pt. Got their lasix. Now breathing fine. Wants to leave so won't have to eat this "crappy" food.