Yes, you should have. This is a significant treatment/change of status issue. The physician should have been promptly informed that the person was asking to leave AMA.
In pediatrics, these kinds of decisions would be made by child protection, social work and legal.
I had a patient whose parents took him AMA a couple weeks ago (I'm not a floor nurse but the patient is on service with my company for infusion). He spiked a low grade temperature after discharge was planned and the hospital told his mother protocol was to stay for a 48 hour rule-out with IV antibiotics since he has a central line. She left with him. When his blood cultures came back positive, the hospital attempted to call them back but they didn't show. After a few hours, the police were promptly dispatched to his home to collect him and CPS is now involved.
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.
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.
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.
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
Not necessarily. Totally separate and apart from a petition for involuntary psychiatric commitment, a licensed physician has the right (some would argue, the responsibility) to detain someone against her/his will on the basis of having determined that, in her/his professional opinion, the individual lacks, at the present time, the mental capacity to make an informed decision to leave, and that it would be unsafe to allow the individual to do so and, in that case, to detain the person against her/his will. The concept of capacity is somewhat similar to the concept of competency, but it is a medical concept and decision, not a legal one. I realize the general public has v. little awareness of the concept of capacity to make informed decisions, but I'm always surprised, when these issues come up on this site, how many nurses seem unaware of the concept and applications.
I work on the psychiatric consultation and liaison service of a large academic medical center, and we get consulted frequently to make determinations about whether individuals have the capacity to make decisions about all kinds of things -- to leave the hospital AMA, to refuse surgery or other lifesaving treatment, to refuse placement, etc.
Not necessarily. Totally separate and apart from a petition for involuntary psychiatric commitment, a licensed physician has the right (some would argue, the responsibility) to detain someone against her/his will on the basis of having determined that, in her/his professional opinion, the individual lacks, at the present time, the mental capacity to make an informed decision to leave, and that it would be unsafe to allow the individual to do so and, in that case, to detain the person against her/his will. The concept of capacity is somewhat similar to the concept of competency, but it is a medical concept and decision, not a legal one. I realize the general public has v. little awareness of the concept of capacity to make informed decisions, but I'm always surprised, when these issues come up on this site, how many nurses seem unaware of the concept and applications.
I work on the psychiatric consultation and liaison service of a large academic medical center, and we get consulted frequently to make determinations about whether individuals have the capacity to make decisions about all kinds of things -- to leave the hospital AMA, to refuse surgery or other lifesaving treatment, to refuse placement, etc.
I had a patient try to leave AMA. If they would have left, they would have died. They were high on all kinds of things when they came in. Pt was mad they couldn't eat. Surgeon was paged and he made the decision to not allow her to leave, but paperwork had to be filled out and sent to a judge. The judge approved it and we actually convinced the pt to stay without letting them know they were not allowed to leave.
It's both a medical and legal concept. But not up to the nurse as the OP is being told. I'm sure also that each state has their own laws regarding AMA.
Not necessarily. Totally separate and apart from a petition for involuntary psychiatric commitment, a licensed physician has the right (some would argue, the responsibility) to detain someone against her/his will on the basis of having determined that, in her/his professional opinion, the individual lacks, at the present time, the mental capacity to make an informed decision to leave, and that it would be unsafe to allow the individual to do so and, in that case, to detain the person against her/his will. The concept of capacity is somewhat similar to the concept of competency, but it is a medical concept and decision, not a legal one. I realize the general public has v. little awareness of the concept of capacity to make informed decisions, but I'm always surprised, when these issues come up on this site, how many nurses seem unaware of the concept and applications.
I work on the psychiatric consultation and liaison service of a large academic medical center, and we get consulted frequently to make determinations about whether individuals have the capacity to make decisions about all kinds of things -- to leave the hospital AMA, to refuse surgery or other lifesaving treatment, to refuse placement, etc.
I agree but at no time in the description of the OPs case was the patient involuntarily comitted for psychiatric treatment. That being the case, the nurse cannot and by all means for their own safety should not physically prevent the patient from leaving. The provider needs to be contacted to make the decision to allow AMA or not. If provider says no to AMA, as I believe the OP believes would have happened, then said provider better have the proper paperwork being completed for an involuntarily comittment. Otherwise what happens is you have a doctor or whomever saying patient can't leave but no safe way of preventing them from leaving. In the event that that patient is on an un locked medical unit it puts the nurse in a tough spot. A patient that was deemed by a provider to be not safe to leave, from what I believe to be true (I'm willing to be wrong) without having any appropriate signed documentation of this cannot be physically or chemically prevented from leaving. A system must be in place to ensure the safety of the staff and patient.
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.
And what is their great idea for safely stopping the patient? I actually think I'm drifting a little away from topic but this kind of talk from supervisors bothers me. If you tried to convince them to stay and that didn't work and they still wanted to sign AMA. What are you expected to do in the time between calling the provider for AMA discussion and the time that discussion actually takes place.
That supervisor sounded like he/she cared more about the hospital's tail than OP's license or patient's rights. You simply cannot restrain someone against their will. We're not talking about a psychiatric patient who's committed here.
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.
In the case of locked ward Psych patients, at least in the states where I have worked, a patient can be held for 72 hours without having the opportunity to see a Judge if the patient is deemed to be a risk to self or others.
But there was a time limit of 30 minutes between the time the pt said he wanted to leave and the time we had to contact the doctor about it. And the paperword had to be timed to have started within those 30 minutes. Some doctors could not actually be reached within such a short time span, so we had to turf that situation to the Nurse Manager on Days and the House Sup at other times. She or he would then
get the Chief of Psychiatry involved.
Such requests to leave AMA were almost never refused but the rules had to be followed.
We can do a psych hold (ER), with the doctor's order. If the doc says cannot leave, security will restrain them for us. When someone starts getting antsy, and poses a threat to self or others, bam! on a hold. We have 2 lockdown seclusion rooms. Hate to do those though, the charting is massive. If all they want is drink, we let them go; ward off DTs by self medicating (& have no inclination whatsoever to quit drinking).
If they've been medicated, it gets a little iffy; but still comes down to the MD ordering a hold or not.
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.
Of course you notify the MD. The patient wants to leave Against Medical Advice. You would notify the person giving that advice. The responsibility for the decision to let them leave or not is on the provider.
I agree but at no time in the description of the OPs case was the patient involuntarily comitted for psychiatric treatment. That being the case the nurse cannot and by all means for their own safety should not physically prevent the patient from leaving. The provider needs to be contacted to make the decision to allow AMA or not. If provider says no to AMA, as I believe the OP believes would have happened, then said provider better have the proper paperwork being completed for an involuntarily comittment. Otherwise what happens is you have a doctor or whomever saying patient can't leave but no safe way of preventing them from leaving.[/quote']
Once again, it is entirely possible to detain someone against her/his will, completely apart from and in the absence of a psychiatric commitment, if the attending physician determines that the individual lacks the mental capacity at that time to make an informed decision about leaving AMA. No petition or court order, no legal paperwork. Just documentation of the attending's considered professional opinion. The individual can be restrained if necessary to keep her/him from leaving. Same as people can be sent to a SNF, or given medication or even have surgery, over their refusal if they are found to lack the mental capacity to make an informed decision about refusing. It's not a decision anyone makes lightly or without concern for the individual's rights (in my experience), but it is "a thing." Are people really not aware of this?
In the case of an individual being determined to lack capacity to make a specific healthcare decision (leaving AMA, surgery, placement, whatever), the team turns to a POA (if there is one) or family members for substituted judgment and to develop a plan. If there are no family or support people available, the treatment team can consider pursuing an emergency guardianship (depending on the severity of the situation; if it's just a matter of the individual staying in the hospital another day or two to complete detox, finish treatment, whatever, that probably wouldn't be considered necessary). But all of that can happen after the individual is kept from leaving the hospital.
From what little you describe, it's hard to determine whether the patient had capacity to make the AMA decision nor whether they might be considered a danger to themselves. Part of the capacity determination is insight... whether can the patient articulate the reason for their admission and the risks of leaving.
The very first step should have been calling the physician. If they said, "they can't leave" then respond, "doc, are you saying that this patient lacks capacity to make this decision?" If the doc affirms then the patient must be *reasonably* prevented from leaving. I put in the reasonable part because we are nurses, not guards, cops, bouncers, etc... if I can't safely stop them from leaving then they leave anyway and I call the cops.
elkpark
14,633 Posts
Yes, you should have. This is a significant treatment/change of status issue. The physician should have been promptly informed that the person was asking to leave AMA.