Difficult AMA situations

I've never dumped anyone in the grass, but I have escorted people in their own wheelchairs safely off the property and left them on the street corner. They have the right to make decisions that I don't understand or agree with.

If someone is physically incapable of leaving, and no one will come pick them up, they're stuck with me while case management and social services sort things out.

I've never heard of pulling a dialysis catheter on an AMA patient who will continue to need dialysis. I'm curious as to how common that is.

She needs to be medicated before the dressing changes. She also needs to be talked down during this painful procedure.

Psych and social services should have already been consulted.

No way are they are leaving on my watch. 

NRSKaren, to clarify RN's don't remove permacaths at my facility either. Patients go to IR for that at my facility, but they certainly don't let homeless and/or drug users leave with PICCS or permacaths to the streets for several reasons. Consulting psych would have been a good idea, thanks!

This is going to hinge mostly upon the patient's capacity to make the decision to leave AMA. Just a review: Capacity is generally an assessment by providers (exact process may vary by state); competency is determined through court/legal proceedings.

If there is any concern that the patient doesn't have the capacity to make the decision to leave AMA then the providers need to assess and document that and they are the ones whose professional opinions would determine whether or not the patient should be disallowed from leaving AMA.

If the patient demonstrates adequate capacity then they are allowed to make their own choices.

Complicated cases may require ethics committee, etc.

Remember that these decisions are not upon you as the nurse. If your patient expresses a desire to leave AMA you are obligated to inform the responsible service/provider right away.

-Agree that pain/difficult symptoms must be controlled

-Agree with the additional avenues mentioned by NRSKaren - knowing that these are supplemental and do not take the place of informing the responsible provider and requiring them to help actively manage the situation.

I like the idea of involving Pastoral Services. Pts always seemed to respect the ministers or sisters; at least they were mostly polite when speaking with them.

Perhaps that would be an opp'ty for some critical time to be garnered and could allow for better decision-making by the pt.

As long as it is cleared by the attending, and the patient is competent to make that decision, I see no problem with it. I don't get emotionally invested. 

Re: the patient with wounds...after addressing pain and anxiety (maybe she needs sedation?) for wound care sessions...if she still doesn't want her wounds cared for, then maybe a palliative consult is needed?  Palliative care at my hospital isn't just end-of-life care, and they are good at talking patients through the logic of establishing goals of care.  I think palliative services should be involved any time the patient wants to leave specifically because they can't tolerate the medically-necessary care. 

If the patient elects to become comfort-care-only, this could also open up placement opportunities (nursing home vs rehab vs hospice house.)  It will still be challenging if there's no safe discharge plan (I don't think hospice will do a home visit to a car).

You can’t hold people against their will.  They have a right to leave.  I’m also wondering if this patient is being properly medicated for painful dressing changes.  You don’t respond to that question.

All lines and IVs are removed before leaving AMA.  Most of our dialysis catheters are IJ Permacaths.  They can’t leave the hospital with those.  
 

But unless they were on some kind of mind altering medication they have a right to leave.  In my many years of nursing I’ve seen one patient put on a 72 hour hold.