to AMA or not to AMA?

elkpark · Jun 6, 2017

In the places I've worked over the years, that decision would not be made by an individual RN; the request would be reported to the physician, and the physician would determine what actions to take, whether that involves letting the person leave, telling the individual that s/he can't leave, getting a stat psych eval and holding the individual until that can be done, whatever.

Capacity is a complicated issue. Being fully oriented does not automatically mean the individual has the capacity to make an informed decision to leave. The presence of the hallucinations does not automatically mean s/he doesn't. IMO, that kind of decision is outside the scope of practice for an RN. In the facilities in which I've worked, only attendings have the authority to make a determination about allowing people to leave AMA.

Sour Lemon · Jun 6, 2017

a couple hours ago, a patient was admitted for;
"alcohol withdraw; visual hallucinations"
patient has a 1:1 sitter
currently experiencing visual AND auditory hallucinations
has a psych consult with the psychologist in the AM.
social worker consulted for being homeless
however, patient is alert and oriented to name, place, DOB... is still experiencing visual AND auditory hallucinations. but wants to AMA.
do i let this patient leave? will i get in trouble, knowing the patient was mentally impaired?

If they left AMA on my shift, it would be from running out the door. I definitely wouldn't have them sign AMA paperwork. A lot of our withdrawal patients get IV ativan which seems like it complicates the issue even more. I feel like I can't give someone IV ativan and then let them run into traffic or hop on a bus.

LovingLife123 · Jun 6, 2017

It's not up to the nurse. It's up to the doctor. There are legal ramifications and you have to get a court order to hold someone against their will.

Flatline, BSN, RN · Jun 6, 2017

As a general rule of life, in and out of the hospital, unless there is a real and immediate danger of serious harm or death to others or themselves it is generally frowned upon to physically restrain someone in any situation.

It's like a Vit C · Jun 6, 2017

It is a violation of human rights to hold that person against they're will unless they are directly a danger to themselves or others and have been committed for mental health treatment and should be in a locked unit. Competency is not a medical decision and only a judge can declare someone incompetent. That being said my impression of your role in the situation is as follows. Knowing that you feel the patient is in danger do your best to convince them to stay for treatment. If they refuse call MD to sign AMA. If MD refuses and patient wants to leave make sure IV is out and never physically stop them. You don't want a patient leaving with an IV. If MD gives a problem because they ordered fluids then have them come down to the unit and explain it to them. Ok now for the final part. To really cover your butt tell the patient that you and the MD feel he is unsafe to leave however I cannot stop you. Tell them that if they decide to leave that you will have to call security and that security will try to convince them to stay. No patient in the situation you're describing should be physically or chemically restrained. If after being warned that you will call security patient still wants to leave then let them and call security. Afterward document everything.

newnurse925 · Jun 6, 2017

i consulted the nurse supervisor, and she said i'd get in deep **** if anything happens to him because he's not in the right state of mind. it's probably not a good idea to let him leave. she's been an ICU and ER charge nurse for over 20 years, so i took her word for the gospel.

another experienced nurse on my unit told me "if that was MY patient, i would not let the patient leave. since it's yours, let him AMA." and chuckled. i'm not sure what that's supposed to mean. i did convince him to stay until the MD sees him in the morning. i did not use and physical or chemical restraint.

Orca, ADN, ASN, RN · Jun 6, 2017

i consulted the nurse supervisor, and she said i'd get in deep **** if anything happens to him because he's not in the right state of mind. it's probably not a good idea to let him leave. she's been an ICU and ER charge nurse for over 20 years, so i took her word for the gospel.
another experienced nurse on my unit told me "if that was MY patient, i would not let the patient leave. since it's yours, let him AMA." and chuckled. i'm not sure what that's supposed to mean. i did convince him to stay until the MD sees him in the morning. i did not use and physical or chemical restraint.

Again, not a nurse's call. It's fine to have an opinion about this, but there is also a fine line between holding someone for safety and unlawful imprisonment. The determination regarding whether a patient is a danger to himself or others must be made by a licensed provider. Unless the patient is on a legal hold (which must be initiated by a provider), he is technically free to leave AMA. You could probably justify keeping him long enough for a provider to evaluate him, but a decision would have to be made at that point whether to pursue commitment proceedings or allow the patient to leave AMA. If he ran out the door before the provider arrived, the police wouldn't even pick him up.

newnurse925 · Jun 7, 2017

sorry. just 1 more question:

should i have notified the MD?

i just told the patient "it's probably not safe for you to leave, otherwise you would have been discharged; instead of being admitted." "it would be best to hang out until the MD sees you in the morning." "they have a specialist on your case, also"

i feel like i did keep the patient against his will, because i never got the MD involved and told him he wanted to AMA.

thanks for the replies.

Here.I.Stand, BSN, RN · Jun 7, 2017

I'm pretty sure their withdrawal sx would improve if he got some EtOH in him.

I'd be more concerned about the legal ramifications of false imprisonment and battery, personally. Plus, like the others have said it's not the RN's call.

A while back while floating to the MICU, we had a pt who had been intubated for airway protection with a BAC of 0.4. I'm not sure what he'd been on for sedation, but he self extubated before I came on, and he was loudly demanding to leave. The MDs had verbally said they'd discharge him, but no orders were in yet. They did shortly after, but I had decided I would not physically stop him if he got sick of waiting. He even held up his hand which had a noticeable tremor, and he said "If I don't get a drink soon, I WILL go into withdrawal." He had ZERO motivation to get help, so yeah I thought "you should leave and get a drink." That's easier for EVERYONE than chasing our tails with a Valium protocol.

Were your colleagues actually suggesting that after the MD had met with the pt and signed the AMA form, that the RN should force him to stay?

Here.I.Stand, BSN, RN · Jun 7, 2017

I also had a pt leave AMA....maybe 90 minutes? after receiving tPA. The neuro resident and the nursing supervisor both spoke with her; at that point she relented and "agreed" to stay if she was free to go outside to smoke. (if you don't ever work with tPA, the protocol is 24 hours of bedrest with very frequent neuro checks -- q 15 min x2 hrs, q 30 min x6 hrs, and then hourly.) I could not agree to that demand, and everyone else agreed with me. If nothing else, we'd be jeopardizing our stroke program! So she left AMA. That's potentially much more dangerous than your pt leaving, but I never heard another word about it. Again, it wasn't my decision.

sallyrnrrt, ADN, RN · Jun 7, 2017

In my state, the first patient bill of rights, includes the right to refuse treatment

And unless the patient las legally committed to locked unit.......otherwise, considered not honoring patient bill of rights