Critically ill pts wanting to go AMA?

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I will not go into many specifics but basically I had a critically ill patient who wanted to leave AMA, but expected the nursing staff to help him/her out to a taxi. This person had an unresolved medical issue that obviously warranted critical care, had many invasive lines, was alert and oriented enough at this point to say he/she wanted to go home but was physically incapable of doing so. No family to carry her out. Just us.

So, yeah, sticky situation!

I understand that every patient has the right to leave AMA, but what happens if the exit involves way more than just signing an AMA form and walking out? What if the hospital staff, who believe that it would be in this patient's best interest to leave, seem to have to participate in the patient leaving? What if I loaded this person onto a wheelchair and something happens between my unit and the lobby?

What do you do these situations? Have you encountered this situation in your career? What does your hospital have to say about situations like these?

Thanks guys!

Specializes in retired LTC.
It if is a case where the patient would be a danger to themselves if they left it is also possible to have them involuntarily committed/ treated. I see orders like that for a lot of our transfers, patient is unsafe to go home, if attempts to leave AMA consult psych to start the comittment process
Can you grab them fast enough before they get to the door?

We are talking about patient rights here - they have the right to leave, even if it is a STUPID, UNNSAFE decision.

And thinking about the AMA pt in a taxi - who does he think will get him OUT of the taxi and into his home? Like up his steps???

Like others have said, this is an interesting question.

Specializes in ED; Med Surg.

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The nursing supervisor in this case not only lost his job, he lost his license. The BON stated that the supervisor should have made sure the man got home. I followed this case closely and many attempts were made to talk him into staying. He signed the form and still the hospital was sued, jobs and licenses lost. You just can't protect people against themselves.

Specializes in Oncology/Haemetology/HIV.

At one previous place of employment, we had an AMA sign out and then die in the driveway. Pt had been admitted with DVT, was over 400 lbs, grossly noncompliant diabetic with cardiovascular disease. The pt got into a serious argument with his MD and the staff over his noncompliance issues and insisted on signing out AMA. His family assisted him to the car, whereupon he collapsed and coded. They couldn't get him back. To my knowledge, there were no legal fall out from it, as the patient was completely competent and had the risks fully explained to him.

Specializes in PCCN.

why do pt's have to be so stupid?

So many times we ask ourselves, "why did you bother coming in in the first place" if there was no intention of complying with treatment???

I'm one of those nursing staff who has to deal with this ALL THE TIME:banghead::banghead::banghead::madface:

In my experience, if the patient is not impaired ( key word here) and the AMA form is signed ,along with a physician signature .. we discontinue any lines and are no longer responsible for transportation, prescriptions, etc. To assist the patient in leaving the facility actually puts you at risk.

Sayonara don't let the door hit ya in the tookas.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

I've had a patient leave AMA from the ICU.

I was quite a bit younger and prettier then. I walked out of report to assess my patient who had cardiomyopathy and was post-cardiac cath. He had a femoral sheath in place, and as I approached the bed, he flipped his covers off, exposing his (less than) manly parts and invited me to take a closer look. I put on gloves, flipped the blanket back over his member and assessed the cath site. At that point, he said if I wasn't going to be any fun, he was going home. Turns out, he was serious. The doctor was called, and told the patient he could go home, but if he left with the sheaths in, "you'll either bleed to death or lose your *&^%$# leg." The patient, whose initials were A.H. (after the rectal sphincter) agreed to having the sheath pulled, but was out of the hospital (under his own steam) in less than an hour.

Before the end of my shift, he was back in the ER in full blown CHF. He went home and harvested his marijuana crop, drank a 12 pack of beer and ate a couple of pepperoni pizzas. I had the dubious pleasure of re-admitting him to the same bed, which housekeeping hadn't even gotten around to cleaning yet.

Specializes in Psych.
Can you grab them fast enough before they get to the door?

We are talking about patient rights here - they have the right to leave, even if it is a STUPID, UNNSAFE decision.

And thinking about the AMA pt in a taxi - who does he think will get him OUT of the taxi and into his home? Like up his steps???

Like others have said, this is an interesting question.

Yep it is possible to grab them before they leave, happens all the time. Security is notified and the patient is not allowed to leave. If said patient does leave and the involuntary commitment paperwork is filled out, the police arrest them and bring them in.

Yes, it is a patient right issue and they have to meet certain criteria for this to be an option, but it can be done. It often happens when a patient is in the ICU/medical post suicide attempt but in the state i live in patients can be committed for not being able to provide basic care for themselves.

Someone mentioned that legally, an AMA signed by a competent patient is sufficient protection for your licence. Personally, I would document as well that I discussed death and morbidity with the patient.

To me what is interesting is the discussion of moral obligations, beyond wwhat is the minimal legal requirement. Obviously this is a big part of the discussion because most of us are uneasy with the scenario even when the legality of it is clear.

The question I ponder is what is the difference between a pt who threatening suicide and the septic pt going AMA home to a certain death. Ultimately, both will die without intervention, but only one is routinely placed on an involuntary hold. Why is that?

Specializes in ICU.

At the last hospital I worked for we were not allowed to help the AMA patient out, nor were we allowed to call transport. If they couldn't walk to the door they needed to have a support person that could get them there. I guess they were worried about some type of lawsuit if they fell on the way out.

No, I have not read my hospital's AMA form yet. I am at home but I did look up other hospital's published AMA forms. I do not know if the AMA criteria lists I am seeing are facility-specific or in accordance to state law or similar governing body but you've piqued my curiosity.

Looking at the forms still do not give me a picture of what an AMA "exit" for a patient who is incapable of walking and liable to pass out/hemorrhage/code etc. from unit to lobby.

Am I obligated to help them to the door?

What if they refuse to be touched and have invasive lines?

What if they do code?

Here's a link to Stanford Hospital policy regarding AMA. They tell the staff to help the person to the exit and to arrange transportation if necessary. Would be interesting to see what other hospitals policies are.

http://medicalstaff.stanfordhospital.org/bylaws/documents/AMA_Patients_Leaving_Hospital_Against_Medical_Advice_10_11.pdf

I've had a patient leave AMA from the ICU.

I was quite a bit younger and prettier then. I walked out of report to assess my patient who had cardiomyopathy and was post-cardiac cath. He had a femoral sheath in place, and as I approached the bed, he flipped his covers off, exposing his (less than) manly parts and invited me to take a closer look. I put on gloves, flipped the blanket back over his member and assessed the cath site. At that point, he said if I wasn't going to be any fun, he was going home. Turns out, he was serious. The doctor was called, and told the patient he could go home, but if he left with the sheaths in, "you'll either bleed to death or lose your *&^%$# leg." The patient, whose initials were A.H. (after the rectal sphincter) agreed to having the sheath pulled, but was out of the hospital (under his own steam) in less than an hour.

Before the end of my shift, he was back in the ER in full blown CHF. He went home and harvested his marijuana crop, drank a 12 pack of beer and ate a couple of pepperoni pizzas. I had the dubious pleasure of re-admitting him to the same bed, which housekeeping hadn't even gotten around to cleaning yet.

Great example.

But "member"? :roflmao: Haven't heard it called that in a while.

I am in the insurance biz and we call our customers members. How am I going to keep a straight face now?

Great example.

But "member"? :roflmao: Haven't heard it called that in a while.

I am in the insurance biz and we call our customers members. How am I going to keep a straight face now?

I am just about to leave the house but I am delighted at all the replies.

As for members, at least when someone is being a total rhymes-with-nick, you can safely call them a very valued member and grin inwardly!

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