Critically ill pts wanting to go AMA?

[Cuddleswithpuddles]

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!

[morte, LPN, LVN]

i don't see anything in the link about nrsg supervisor....

Hospital Launches Investigation After Man Discharged in Storm Found Dead in Snowbank | Fox News

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.

[NRSKarenRN, BSN, RN]

From Newspaper report June 21,2010:

Nurse’s license revoked because of patient’s death

Two and a half years after the death of Reid Emery outside the Down East Community Hospital, a state board has revoked the nursing license for the nurse supervisor at the hospital who allowed Emery, who was elderly, disoriented and heavily medicated, to be discharged during a severe snowstorm and without means of transportation. Emery's body was found the next day near the hospital entrance.

On June 4, the Maine State Board of Nursing revoked the nursing license of John Zablotny, 44, of Steuben for incompetent nursing practice and unprofessional conduct……

Zablotny's employment with DECH ended three weeks after the incident, on January 21, 2008. DECH then filed a complaint concerning Zablotny with the board of nursing on February 1, 2008, and another complaint was filed by Emery's sister, Sally Emery, on February 26, 2009….

…Emery's death triggered investigations by state and federal agencies that regulate health care facilities, which eventually led to DECH's receiving a conditional state operating license and nearly losing Medicare and Medicaid funding. The hospital's operating license was fully restored last March, after DECH underwent a quality improvement process.

Emery had been admitted to DECH on December 27, 2007, for treatment of abdominal pain. During the day on January 1, 2008, a snowstorm developed and Emery, while still receiving pain medication, began asking to leave the hospital, according to a press release from the Attorney General's Office. Nurses advised him that he was too weak to leave the hospital and that his family was not able to return to the hospital to provide him with transportation because of the storm.

That evening, Zablotny, the supervising nurse, provided Emery with a form for the patient to sign if he was leaving the hospital against medical advice. According to the release, prior to Emery's discharge, Zablotny failed to review Emery's medical records to determine his medical status, which included the medications administered to the patient. Zablotny failed to properly assess Emery's medical condition and ignored the advice of other staff members that Emery was confused and weak. Emery signed the discharge form, and Zablotny pointed him to the front exit of the hospital unescorted. Against the advice of hospital staff, Zablotny did not call the local police department. He also did not check to see if Emery had transportation or a specific destination and did not ensure that he was properly clothed.

[cardiacfreak, ADN]

This recently happened at my hospital with a post-op CABG patient who still had pacer wires. The house supervisor contacted a local judge and the patient was emergently detained for 24 hours. Security was posted outside of his door so that he couldn't elope. The surgeon came in the next day and clipped his pacer wires and discharged him.

I just don't understand some people.

[Lola Lou, BSN]

I have followed this situation closely as well. The problem with this specific incident it that the man was disoriented. If the patientt was oriented and left AMA I think that the nursing supervisor would still have his job and license.

Hospital Launches Investigation After Man Discharged in Storm Found Dead in Snowbank | Fox News

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.

[imintrouble, BSN, RN]

Serial troponins climbing, EKG changes, chest pain, and the patient left AMA.

True story.

You just can't predict what people will do, or who they'll blame

[dudette10, MSN, RN]

Serial troponins climbing, EKG changes, chest pain, and the patient left AMA.

True story.

You just can't predict what people will do, or who they'll blame

Someone upstream mentioned involuntary holds for suicidal or self-harm patients, and asked what's the difference in wanting to go AMA out of impatience and/or anger about "service." This story drives the similarity home.

I mean you gotta be crazy to leave after the ED staff said, "You are having a heart attack, and you could die if you leave." With straight up chest pain patients wanting to leave, I always wonder why they walked into the hospital in the first place!!

[wheeliesurfer]

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 is my thought on the situation:

If the pt is AOx4 they have the right to refuse any and all treatment. If they choose to sign out AMA then they need to have all lines removed (part of treatment) and be shown the door. I don't think there is anything saying that you have to/can't help them down to the lobby, but I personally would not, just to end my caring relationship (responsibility to care for) with the patient. If the pt was as you said, unable to get him/herself down to the cab on their own and had no one to care for them at home, I would try to get social services involved to see about contacting someone to get an involuntary hold as they would be unable to care for themselves if an emergency arrived.

Lastly, you asked about what would happen if they passed out/hemorrhaged/coded before they got to the door. If I were a nurse in the area of the event I would treat it as any guest visiting the building. As a nurse, you have a duty to treat, so you would have to treat the (now) patient no matter what. Unless the person has a signed DNR, once a person is unresponsive you have implied consent to treat a condition that a reasonable/prudent person would want treated (of course within the scope of your training).

I would call a code and more than likely that pt would end up right back on your unit.

[psu_213, BSN, RN]

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.

I agree. Just saying "discussed risks of going home AMA" probably won't cover you if something bad happens to the pt later.

[Been there,done that, ASN, RN]

This recently happened at my hospital with a post-op CABG patient who still had pacer wires. The house supervisor contacted a local judge and the patient was emergently detained for 24 hours. Security was posted outside of his door so that he couldn't elope. The surgeon came in the next day and clipped his pacer wires and discharged him.

I just don't understand some people.

I think I finally understand.

PEOPLE have lost control over their lives when they become PATIENTS.

They feel the need to regain that control.

An additional issue is many patients have addiction problems. They need to get back to the booze, the cigarettes, the drug of choice.

I discovered that a patient needed to leave for a GAMBLING addiction. He NEEDED to leave to play the ponies that day.

Talked it out with him.. placed his bet for him.. he remained inpatient.

[psu_213, BSN, RN]

I would show them the door and give them the directions out. Hopefully they would realize they are not well enough to make it on their own. If I push them out in a w/c the pt is not going to get a full picture of what it is like to "go it" on his/her own.

If they pass out on the way, then an RRT is called and taken to the ED (just like for any non-patient who passes out/codes, etc.). They may come right back to the same bed, but that would be a new admission.

[beshacohen]

I can understand an A&O x4 patient at risk of death wanting to sign out AMA. Some people just don't want to die in a hospital or nursing home. Some people are terrified of the thought of losing control. To some people, death in a taxi or a driveway is a better option than months or years of life hooked up to machines, or lying in a bed getting stage IVs.

I watched my dad go that way. I can see their point.

[withasmilelpn]

I would ask the patient how they expected to get from the taxi to their house/apartment? No nurses to help then. You need to make it on your own steam if your going AMA. Or find someone to help you do it that's not associated with your facility.