AMA Discharges

[SerenityKris]

I am new to Case Management (only about a month in). I'm doing discharge planning for short term rehab patients.

It seems like a lot of the ortho patients seem to decide when they are leaving almost before they get here and I just had my first patient leave AMA yesterday.

There seems to be a lot of debate on what we can do for them when they leave AMA.

Home health? Calling in prescriptions? The ARNP is working on getting the policy clarified from the corporate office on this as it's never actually been spelled out as far as we know.

In the meantime we are in a grey area. Does anyone know where we stand legally on this?

The softie in me says that even though it's an unsafe discharge at least home health and prescribed medications make it a little less unsafe. The other side is... if we are setting them up the same as a regular discharge aren't we essentially encouraging and condoning the behavior?

Thoughts, opinions, facts are all welcome.

Like I said I'm new to case management, and a new grad RN (graduated in Feb). I love this job, but a few years of floor experience would have been VERY helpful.

Thanks in advance.

[nurseprnRN, BSN, RN]

It's not up to you -- or the ARNP-- to make a judgment on "encouraging" or "condoning" any "behavior." Any patient has the right to refuse any care, plan of care, treatment, or hospitalization, at any time. You are (all) still ethically bound (and in most jurisdictions, probably legally as well) to provide for safe discharge plans. Whether or not your patient accepts them is up to him, but you must at least make and offer them, and document that you did, and that he refused them (by signing what used to be called an "AMA form" that outlines your discharge plan as well as the medical plan of care). This includes discharge prescriptions, referrals to outpatient care, home health, transportation if indicated, and anything you would do for anybody.

We don't use the word "compliance," either, if it comes up in these discussions. If you're in the military you comply with orders, but patients are not subject to being ordered around. Medical, nursing, and therapy plans of care are not orders. The patient can adhere to them as he sees fit.

[SerenityKris]

In the end we did end up getting him set up with home health and meds.

We've had another since and the Dr refused to sign the order for home health. I ended up calling the ortho for it and it all worked out.

I just don't see the sense in making an unsafe discharge even unsafer by not providing the same services we would if they waited for a proper discharge.

[SummerGarden, BSN, MSN, RN]

I just don't see the sense in making an unsafe discharge even unsafer by not providing the same services we would if they waited for a proper discharge.

Good for you! When I was a new CM I had my first AMA and it was on a cardiac step-down unit. The patient refused a stent and wanted to go home. I was fortunate that the Cardiologist on the case wrote the case as an AMA but provided discharge instructions after talking to the patient. I also discussed the possible financial obligation the patient might have for going AMA while re-enforcing the doctor's concerns regarding the need to remain in the hospital setting at that time.

However, the staff was confused and they almost did not give the patient anything to include the discharge instructions because of the patient's AMA status. I stepped in and informed them of our ethical obligation to all patients no matter what his/her decisions are regarding participation in medical courses of treatment. In fact, I set up a follow up PCP appointment for the patient to be seen the very next day, which the patient agreed to attend.

Keep up the good work! You did the right thing by your patient.

[nurseprnRN, BSN, RN]

In the end we did end up getting him set up with home health and meds.

We've had another since and the Dr refused to sign the order for home health. I ended up calling the ortho for it and it all worked out.

I just don't see the sense in making an unsafe discharge even unsafer by not providing the same services we would if they waited for a proper discharge.

Exactly. It's not just nonsensical, it's unethical and illegal (if you read your nurse practice act).

One of the things you'll get stronger in as you mature as a nurse is your own sense of how important nursing is to people like this. Never, never, never think it's all about what the physician wants, or that it's all up to the physician, or that if a physician won't do the right thing then that's the end of it and there's nothing you can or have to do.

[danggirl]

Interesting information here. I never knew that when a patient left AMA that discharge instructions etc were required. I've never, ever seen that happen! In fact, one time I left a hospital AMA...the residents wouldn't discuss treatment plans only TELL me what they were going to do...I happened to disagree and offered some alternatives based on my history etc. When they refused to even listen to me, I asked to be discharged home. They refused to discharge me. I consulted the nurse manager, the case manager, and the nursing supervisor and they were ALL with the same attitude as the residents. Feeling trapped I told them I was leaving and the only thing they offered me was an AMA paper to sign! I did not sign it because nothing in that paper had occurred....ie discussion of consequences, etc. I need to get out my Nurse Practice Act and read hospital policy (if one exists) in regards to this type of situation. I would feel so much better with patients leaving AMA if they at least had some minimal instructions. I fail to understand why doctors won't write discharge instructions if a patient wants to leave. Documentation regarding medical advice and the subsequent refusal of that advice should be sufficient to cover the physician and the hospital legally. Always though I have seen it played out exactly the way it did for me...."you don't want to do this, fine sign here and get out". Thanks for the info.

[SummerGarden, BSN, MSN, RN]

I fail to understand why doctors won't write discharge instructions if a patient wants to leave. Documentation regarding medical advice and the subsequent refusal of that advice should be sufficient to cover the physician and the hospital legally. Always though I have seen it played out exactly the way it did for me...."you don't want to do this, fine sign here and get out". Thanks for the info.

I have worked in multiple hospitals and with the exception of a few physicians, all of my Attendings (even when I worked bedside) offered discharge instructions and discussed consequences of the patient leaving unless the patient got up prior and walked away. In which case, he/she documented the AMA as such. For instance, "went to see patient, room was empty." or "patient nowhere to be found."

And as GrnTea has mentioned, it is not the right to refuse to provide teaching or instructions to those wishing to go AMA. The practitioners (nurses and MDs) are opening him/her self up to severe consequences if made accountable. Focusing back on Case Management... The Case Management Society of America teaches the same. A safe discharge regardless of the circumstances is our obligation to our patients.

[d'cm]

If you accept the opinion of some experts that 200,000-400000 people are injured in hospitals yearly, the safest place for anybody able to get themselves up and out is home.