AMA discharges

Keep in mind that leaving AMA is not really a discharge. It is leaving against medical advice. In order to write the patient prescriptions and such the doctor would have to call it a discharge. If the doctor agrees to discharge even though he feels it places the patient at risk then he risks his license. It would be a HUGE liability to treat that as a discharge. The point is that the patient is educated on the risks of leaving but chooses to do so anyway. The fact that the patient chose to leave even after being educated on the risks is charted by the nurse and the patient signs the AMA paperwork, which protects the physician. Otherwise if the patient has an adverse outcome from leaving they could say the physician never explained the dangers of leaving the hospital and they believed the discharge was appropriate. Remember that as a nurse we should also be concerned that the patient could later claim they were discharged without being informed of the danger. Having a patient sign the AMA paper and charting that they were educated on the potential risks of leaving protects nursing staff as well.

At my hospital, leaving AMA does not mean you won't get prescriptions to take home. Many of our doctors are very accommodating, even though they don't agree with the patient's decision. AMA forms are still filled out and signed.

In most cases, though, people leave with nothing. The average AMA patient leaves quickly and without much warning- sometimes through a window. There simply isn't time for prescription-writing ...even if the doctor does happen to be on the unit at that time.

At every place I've worked we don't withhold any treatments or other medical care that the patient is still consenting to just because they decline a particular recommendation. If an ED is a CMS participant, which the vast majority are, then they are required to follow the Federal Patient Bill of Rights which requires that patients who refuse any treatment or recommendation not be punished by withholding other aspects of care. You can certainly withhold treatments, medications, etc that would no longer be safe given a particular refusal, ie a patient who doesn't want their BG checks but wants the high end of their sliding scale insulin. Ideally, if a physician does chose a "my way or the highway" view of things then nursing staff are there to advocate for basic nursing principles, including that a patient's plan of care must take into account the patient's views, including what they want and don't want.

We handle an AMA discharge just like any other, even if it's the patient initiating the discharge rather than the physician, the physician still writes for discharge meds, they dictate a discharge summary, etc.

At every place I've worked we don't withhold any treatments or other medical care that the patient is still consenting to just because they decline a particular recommendation. If an ED is a CMS participant, which the vast majority are, then they are required to follow the Federal Patient Bill of Rights which requires that patients who refuse any treatment or recommendation not be punished by withholding other aspects of care. You can certainly withhold treatments, medications, etc that would no longer be safe given a particular refusal, ie a patient who doesn't want their BG checks but wants the high end of their sliding scale insulin. Ideally, if a physician does chose a "my way or the highway" view of things then nursing staff are there to advocate for basic nursing principles, including that a patient's plan of care must take into account the patient's views, including what they want and don't want.

We handle an AMA discharge just like any other, even if it's the patient initiating the discharge rather than the physician, the physician still writes for discharge meds, they dictate a discharge summary, etc.

See, this is how I feel it should be. I am no lawyer but interpret the law as you do and an very uncomfortable with the policy esp in these days if high deductibles and cost shares-some people just can't afford to "watch and wait" inpatient for something that is very unlikely to happen anyway.

Thanks to those who responded- I guess I'm glad to see some other hospitals do this differently.

Ideally, if a physician does chose a "my way or the highway" view of things then nursing staff are there to advocate for basic nursing principles, including that a patient's plan of care must take into account the patient's views, including what they want and don't want.

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The problem here is the nursing staff have adopted this attitude as well and get almost snotty with pts who ask for a prescription for, say an inhaler when leaving- "you're leaving AMA you get nothing" is the usual reply. I am glad I'm not the only one in the world who thinks this is wrong- though maybe the only one in this hospital.

Keep in mind that leaving AMA is not really a discharge. It is leaving against medical advice. In order to write the patient prescriptions and such the doctor would have to call it a discharge....Having a patient sign the AMA paper and charting that they were educated on the potential risks of leaving protects nursing staff as well.

(The above was cut at the ... because I cannot bold or underline quotes- sorry!)

I understand completely having the pt sign AMA papers. I agree that is necessary. What I don't understand is why, if the AMA papers and discharge summary (I assume your doctor's still write one? ) can't state that you are being given xx po meds that you have been taking here but by leaving will not be getting yy...these are the risks, etc. How does that bring any more liability than, say a pt leaving AMA after asthma or copd flare due to finances, not being given scripts/instructions for their inhalers and prednisone which may have been all they were receiving by that time anyway and there is a bad outcome? I personally feel like THAT is a huge liability.

It depends if they have a legit reason for being in the ER or not. The ones who are agitated and wont wait for discharge instructions anyway sign the form and leave. Otherwise we will give scripts and dc instructions. It depends on the doc too and how the patient is behaving and why they came to the ER.

Just wondering what everyone's workplace policies are regarding AMA discharges- I'm wondering mostly about acute inpatients but also ED or SNF or psych. My hospital does not provide any prescriptions when someone goes AMA-no antibiotics if confirmed infection, obviously no controlled drugs, no inhalers for asthma pts-nothing-period.

I'm thinking this is to try to convince the pt to stay. But I am more of a harm reduction believer and am wondering if this really is the right thing to do? After all a pts right to refuse has been established legally...but should that mean that they get no tx if they leave, even when there's a good chance the position abx or whatever would be successful? (Example- someone getting iv abx until full cultures and sensitivity come back despite the fact that resistance to all po abx is very unlikely in this case and you can always call with results or pt can return if they get worse. )

I absolutely understand that people take a risk leaving AMA. At the same time I have seen people held for ridiculous reasons for days. Regardless they have the right to understand the risk and leave. How do your facilities handle these discharges? Do you provide prescriptions, referrals etc or just wave goodbye? Am I totally crazy to think that if a pt is convinced to leave that we should at least consider providing prescriptions etc, or is the blanket "you get nothing" the best way to go?

Leaving AMA means just that. Against Medical Advice. Meaning "Stay here and you will get treatment. Leave and you won't". It's not a discharge. At most facilities I've worked at, while most patients will get a taxi voucher if they don't have a ride home, if you leave AMA you don't even get that. I see nothing wrong with that because they're making the choice (and not usually because they're the breadwinners of their households and want to work, etc-it's usually because they're not getting what they think we should be doing for them).

We just had a guy tonight leave AMA just after the shift started and guess who's back in the ER?

He left because he wasn't getting the dilaudid he wanted when he wanted it and I'm sorry, I'm not sympathetic to that (he also didn't belong in ICU, but that's another story:cheeky:). He signed the paperwork to leave and yes, we waved goodbye and wished him godspeed.

Hospitals are a business too and if we gave out pain medication, taxi vouchers, pants, slippers, and blankets to each person for just threatening to leave AMA, that would do no one any good.

I in NO way mean to sound condescending, but are you a new nurse? I only ask because I think some of us are jaded from seeing so much over our years of work and, personally, if someone's holding up a bed (an ICU bed in this case) just because he wants dilaudid, I'd rather see him go and make room for a trauma or an MI that will actually need/take my help. You can't help them all and if they're consenting adults, it's their choice. It's not like we are sending them home and for no reason.

My 2 cents anyway

xo

The problem here is the nursing staff have adopted this attitude as well and get almost snotty with pts who ask for a prescription for, say an inhaler when leaving- "you're leaving AMA you get nothing" is the usual reply. I am glad I'm not the only one in the world who thinks this is wrong- though maybe the only one in this hospital.

That's so rude! Even if you think things you're not supposed to say them...some people have no tact. I think the problem is that most people who leave AMA aren't doing it to "do right by someone else" (go back to work, pick up their kids, care for their dying mom, etc), it's usually for petty things like the nurses not being in the room enough, not enough pain medication (when they're getting exactly what they were on at home and are in for a totally unrelated thing), etc and that gets old.

I can't imagine knowing a doctor who wouldn't give a scrip for a rescue inhaler if asked nicely, unless they know the patient should still have more at home or something like that. That's not ok. However, there are usually minimal rewards for leaving AMA.

xo

I wonder if the AMA patient did get the prescriptions for antibiotics and inhalers, would they even get filled?

I just say OK, notify the doctor, notify the charge and House Supervisor, get the paperwork signed and escort them out the door. Too many people threaten to leave as though it's supposed to matter significantly to me or get me to scramble to do things I'm not supposed to. My quick response of "OK, let me get the papers ready", seem to catch some of them by surprise.