Difficult AMA situations

[CaliRN2019, BSN]

I am curious to know how everyone handles difficult AMA situations. Those who can just get up and go home are one thing. We have a huge homeless population and I have come into some questionable situations where I am unsure what the ethical thing to do is. What about the 02 dependent homeless patient who probably won't even make it off hospital property before collapsing? Or a homeless person who can't walk? Do I just wheel them out the hospital door and dump them on the ground and walk away? I had a very difficult patient, covered in massive wounds, lived in her car, not ambulatory, who would cry to leave AMA during her daily ( very extensive) wound/dressing changes. She had a boyfriend but he was not going to pick her up. So if I let her leave AMA I would have had to wheel her out and put her on the ground. Not to mention I would have had to remove her new dialysis line ( we never discharge homeless drug users to the streets with lines in). Needless to say I didn't let her leave during my shift even though she asked for it several times (only during dressing changes). She was able to make decisions but completely unable to care for herself. I was afraid for her, but also my license since it would have felt so wrong just dumping her on the grass. What is the right thing to do? 

[Sour Lemon]

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.

[NRSKarenRN, BSN, RN]

Actions I've taken in the past with those requesting AMA but unable to care for themselves:

1.  Notify attending of AMA request.  With patients unable to care for themselves, suggest Psych eval to confirm competency.
2. Contact Social Service for Eval for SS discharge planning needs.
3. Consider Pastoral Care consult -- some just need to talk/review life events that wound them up in position.
4.  Reinforce they have a right to sign-out AMA but you are unable to assist them in leaving. Sometimes walking through a situation, patient will reconsider request.
5. Dialysis catheters ie Quinton only removed by docs/Residents in my facility.

Competent, able to walk, argumentative-- notify attending, quickly whip out AMA form for signature.  Patient walked out without signing,  document on bottom of form.   In Philly if they walked out AMA prior to IV removal, we' d request Police safety visit to encourage hospital return to ED who'd remove IV. 

 

[Been there,done that, ASN, RN]

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. 

[CaliRN2019, BSN]

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!

[JKL33]

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.

 

[amoLucia]

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.

[Diltiazem Diva, BSN]

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. 

 

[marienm, RN, CCRN]

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).

[LovingLife123]

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.

[Corey Narry, MSN, RN, NP]

From a provider's perspective, there is a lot more involved in the discharge process and patient's leaving AMA is no exception. After all, providers are also responsible and these subset of patients are high risk for bad outcomes and mortality.

Generally, providers follow these steps:

1. Does patient have capacity. Does patient understand the risks.  Does the patient have ability to make decisions.  As mentioned, providers make that determination but as a rule, if there is doubt, a Psych consult may be needed.

2. Is this a voluntary decision by the patient or are there other forces that are influencing that decision.

3. Did you seek multidisciplinary efforts to mitigate the patient's decision. Did you involve social work, case management, community resources?

4. Are there treatment alternatives that can be offered outside the hospital setting?

5. Did you establish aftercare and harm reduction. Providers should still offer out-patient follow up. Advise to return to ED for issues.

6. Document...this can not be stresses enough.