Ethics: Brain bleed sign out AMA

Published

Hey guys,

I have an ethical delimna I just witnessed my colleague went through. We work in the ER. Unofficial motto of "stabilize and move".

His patient had a brain bleed with midline shift. He was awake and alert oriented to name place and time. No obvious deficiencies in mentation. Our facility is not stroke certified. He is suppose to be transferred to a stroke certified facility.

The ambulance is on our unit with a rn transport.

The pt at this time refuses to be transferred to the contracted facility. A member of the transport team, not the rn, refuses to take the pt because the pt refuses to be transferred. What we would have done was to just force the pt onto the transport gurney and have him taken to the facility let them deal with it over there. But the one team member refused, so we can't. We called family members, notified house supervisor, all the higher ups, tried to persuade pt but still refused.

Eventually we had the pt sign out ama as there was nothing we could do for him. He refused treatment. His girlfriend called a taxi and they went home. He's gonna go to sleep and not wake up.

He was not a psych pt. Should a 5150 be placed on him due to danger to self? (I remind you that he's alert oriented x3, no history or psych behavior.)

What do you guys think? Was it right? Was there something else that could have been done.? Should be have been forcibly transferred? What should have been done?

I'm interested to know how you would handle this ethical issue.

Up Vote Up Vote ×

Hopefully it is well documented he refused treatment and leave it at that. Some people who may not necessarily be suicidal are okay with dying.

Up Vote Up Vote ×
Specializes in Adult and Pediatric Vascular Access, Paramedic.

If the patient is alert and oriented and is capable of understanding the risks of not being transferred or signing out AMA you CANNOT take them against their will. The transport RN did the right thing. The exception would be if the physician felt the patient was suicidal or homicidal ideation or that he or she was not capable of making rational decisions because of a cognitive issue.

I work on the ambulance and we run into this a lot with patients who really need to go to the hospital, but that are refusing. It is kidnapping if you take someone who is refusing, but that is alert and oriented AND aware of the consequences.

This isn't really an ethical or a psychiatric issue. The patient refused care and he or she was alert and aware of what was going on. It's the patients body, they have a right to make decisions with regards to what they want done with that 'body'.

I am going to take a wild guess that this person had either drug or alcohol addiction, as those patients frequently sign out AMA even if you tell them they may die, because they know they will not get their "fix" in the hospital. He may wake up and be totally fine, just because he has a head bleed doesn't mean he is going to die.

Annie

Up Vote Up Vote ×
Specializes in Med/Surg, Ortho, ASC.

"What we would have done was to just force the pt onto the transport gurney and have him taken to the facility let them deal with it over there."

And you would force him how? That would have been a moral and ethical violation. Your team should be thanking that transport person for helping you avoid all sorts of potential liability and legal issues.

Your post almost most makes it sound as if you were drawing on past experience - do you routinely force folks against their stated will?

Up Vote Up Vote ×
Specializes in Med-Surg.

I don't think this is an ethical issue. You have an AOx4 patient refusing medical care. As long as he was thoroughly educated on the risks of refusing transfer and treatment, and this was all thoroughly documented, then having him sign out AMA would be the correct thing to do. The transport was right to refuse.

Up Vote Up Vote ×
Specializes in EMT since 92, Paramedic since 97, RN and PHRN 2021.

"People have the right to make bad decisions" is what I tell family members when someone is refusing to go. I present all the pertinent information I can for the patient to make an informed decision. I will try to convince them to go but ultimately if they don't want to, well I'm not gonna force them. That would be a violation of the law.

Usually if they are going south and still refusing I will go into another room , still within view, and wait for them to either not be oriented or go unconscious, once that happens implied consent takes over and I don't need them to give the ok

Up Vote Up Vote ×
Specializes in SICU, trauma, neuro.
He was not a psych pt. Should a 5150 be placed on him due to danger to self? (I remind you that he's alert oriented x3, no history or psych behavior.)

This would be a gross violation of a pt's right to autonomy, and THAT would be an ethical issue. Where would that end? Pt refuses necessary surgery for CA, put a 5150 on him due to "danger to self?" He'll die without it. What about a postpartum Jehovah's Witness pt with a hgb of 2.5 (let's say for the sake of argument she's in a critical access hospital and doesn't have the latest in bloodless surgery immediately available) who refuses a blood transfusion, put a 5150 on her due to "danger to self?" She'll die from a hgb of 2.5.

Does any refusal of treatment make a pt suicidal? Does nobody have the right to die of natural causes? Are pts obligated to comply with a medical plan of care, to spare US the perception of being involved in their death?

You say that it was not the transport RN that refused to transport? So the RN would have been willing to kidnap and falsely imprison an a&o pt who refused treatment--if only that non-RN EMT-P wouldn't have refused? Shame on that RN.

Up Vote Up Vote ×

You can't force someone who is alert and oriented, capable of processing/understanding risks/benefits of treatment into treatment of any kind.

When I worked neuro stepdown, I had a patient with a chronic subdural that was huge, and had a 1-2cm midline shift. NO deficits. Found incidentally, was not the reason the patient went to the ED. Was admitted, observed, etc. I believe the patient eventually had surgery to decompress the chronic subdural (but there was some time lapse before surgery - not that that detail mattered much, it wasn't acute).

Not all bleeds are going to require surgery, particularly if the patient is stable and THAT stable. Not all patients are candidates for surgery. Not that this is your (or my) decision to make, just stating a fact. Some things are just non-survivable even if intervention is tried. Also - it could be that the patient, alert and oriented, didn't want that type of hospitalization, or to have to have brain surgery. More often than not, patients do not make miraculous comebacks following surgery.

Your coworker did their job - they assessed the patient, handled the situation appropriately in caring for them and arranging for transport. The patient was given the facts about their diagnosis and refused treatment. As long as it's documented? Nothing you or anyone else could have done differently. If they were confused or had a decreased LOC, sure...but that wasn't the case.

Up Vote Up Vote ×
Specializes in Emergency Medicine.

The only ethical dilemma here is you forcing a pt onto a litter for transfer- you do know that you laying hands on a pt forcing them to do something, while aaox4, is assault. You can get into serious trouble and put your license in serious jepordy. Did anyone even tell the pt he was being transferred? Does not sound like it bc he refused when they were there. At least someone in this situation had enough sense to stop this before it got out of hand. You need to review policies and a pts rights and know the difference between a sane person acting within their rights before you either harm someone or get in serious trouble. What would you do if you were the pt in this situation?

Up Vote Up Vote ×
What we would have done was to just force the pt onto the transport gurney and have him taken to the facility let them deal with it over there.

Not a lawyer, but I think the technical term for this is kidnapping.

I find it concerning that you and your coworkers seem to think that this is an acceptable option.

Up Vote Up Vote ×

What kind of bleed? Was it chronic? Subarachnoid, subdural, intraparenchymal? Asymptomatic? Why did he come to the ER in the first place? I ask all of these questions because someone like this doesn't necessarily die all of a sudden. Symptoms come on gradually and can still be treated with success later in some cases. Maybe he didn't realize the seriousness and will when he can't walk and talk too well. His call.

Up Vote Up Vote ×
Specializes in Emergency Medicine.
Not a lawyer, but I think the technical term for this is kidnapping.

I find it concerning that you and your coworkers seem to think that this is an acceptable option.

Also- why would you want to make this someone else's problem? Way to throw other nurses under the bus.

Anyways, I doubt OP will come back bc we aren't backing her up on forcing the pt to do something they did not want.

Up Vote Up Vote ×
+ Join the Discussion