Ethics: Brain bleed sign out AMA

[Kbig2]

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.

[Kbig2]

Well, we eventually let the patient go. As everyone pointed out, they have the right to do so.

I just felt like this pt really didn't understand what exactly is going on.

My force comment was a related to a psych patient who was on a hold and transferred out to another facility.

I say didn't quite understand because this pt (87 years of age) was of Korean ethnicity. Especially the older generation, They have a tendency to believe they are fine if they "feel" fine, such as not showing any s/s of sickness. I know this because I had a similarly aged patient few months back who came in with severe sepsis. Rectal temp of 104.7. Korean speaking only. Refused treatment because he said "I'm fine, I feel good, I go home." BP started at 150s/80s, and after couple hours he suddenly started dropping to 100s/60s, then minutes into 80s/40s. We got a translator to explain to him and still refused treatment. After few more times of getting to convince him, he eventually agreed when he stated "feel weak, tired". We threw a central line in him, and upon closer inspection, he's actually had multiple central lines inserted, started pressors.

We did not force him, he just didn't understand or was in denial until he actually started seeing/ feeling s/s of it himself.

Back to brain bleed pt,

I guess I just felt like he didn't really understand the full extent of what was really happening.

Or maybe I just don't understand why he refused...

Maybe another question is what you would have done in this situation? Would you have liked for this pt to stay in the ER even though can't treat? Any other possibilities?

I'm just trying to have a discussion.

(I don't know much about the pt, all I know was he was Korean speaking only, 87 years old, came to er for fall and laceration to back of head.)

[ED Nurse, RN]

Well, we eventually let the patient go. As everyone pointed out, they have the right to do so.

I just felt like this pt really didn't understand what exactly is going on.

My force comment was a related to a psych patient who was on a hold and transferred out to another facility.

I say didn't quite understand because this pt (87 years of age) was of Korean ethnicity. Especially the older generation, They have a tendency to believe they are fine if they "feel" fine, such as not showing any s/s of sickness. I know this because I had a similarly aged patient few months back who came in with severe sepsis. Rectal temp of 104.7. Korean speaking only. Refused treatment because he said "I'm fine, I feel good, I go home." BP started at 150s/80s, and after couple hours he suddenly started dropping to 100s/60s, then minutes into 80s/40s. We got a translator to explain to him and still refused treatment. After few more times of getting to convince him, he eventually agreed when he stated "feel weak, tired". We threw a central line in him, and upon closer inspection, he's actually had multiple central lines inserted, started pressors.

We did not force him, he just didn't understand or was in denial until he actually started seeing/ feeling s/s of it himself.

Back to brain bleed pt,

I guess I just felt like he didn't really understand the full extent of what was really happening.

Or maybe I just don't understand why he refused...

Maybe another question is what you would have done in this situation? Would you have liked for this pt to stay in the ER even though can't treat? Any other possibilities?

I'm just trying to have a discussion.

(I don't know much about the pt, all I know was he was Korean speaking only, 87 years old, came to er for fall and laceration to back of head.)

There aren't other possibilities- if a translator was used and the pt was able to explain the risks of leaving and the condition, then they leave AMA. Keeping them at a facility that can't do anything is pointless. A bleed isn't a death sentence- it is dependent upon the type. Many just reabsorb. It sounds like he was 100% stable- if it was a life endangering bleed he would have had sxs and possibly neurological deficits. You have said nothing to convince me this pt was in danger when going home. The most the other hospital probably would have done was observe the pt and then discharge.

[RiskManager]

From a risk management standpoint, I agree with the comments above. If we are convinced that the patient is clinically competent to make a decision and this is documented, we provide the necessary education and warnings, and we get their signature on a AMA form, we must respect their decision and let them go.

[Pangea Reunited, ASN, RN]

I get a lot of elderly Korean patients and they do tend to refuse everything. They're often intelligent and seem oriented, but if you keep digging, you often discover that they're not completely oriented. I try very hard to get family involved in these types of situations. They will often trust and cooperate with family even though they're totally unreasonable with staff.

Honestly, I wouldn't be comfortable letting a head injury/brain bleed patient of this nature walk out without family involvement or at least a psych or social service consult. Just the fact that he ended up at an ER, was diagnosed with something potentially very serious, and then decided to leave would be a red flag. I understand refusing treatment ...but why go to an ER in that case?

[roser13, ASN, RN]

"Especially the older generation, They have a tendency to believe they are fine if they "feel" fine, such as not showing any s/s of sickness. I know this because I had a similarly aged patient few months back who..."

[COLOR=#333333]One example of the same race, same age does not confer general knowledge about that race or age. Again, you are making vast assumptions about this patient, which you are not entitled to do. [/COLOR]

[ED Nurse, RN]

I get a lot of elderly Korean patients and they do tend to refuse everything. They're often intelligent and seem oriented, but if you keep digging, you often discover that they're not completely oriented. I try very hard to get family involved in these types of situations. They will often trust and cooperate with family even though they're totally unreasonable with staff.

Honestly, I wouldn't be comfortable letting a head injury/brain bleed patient of this nature walk out without family involvement or at least a psych or social service consult. Just the fact that he ended up at an ER, was diagnosed with something potentially very serious, and then decided to leave would be a red flag. I understand refusing treatment ...but why go to an ER in that case?

OP has told us nothing about the pt besides being a "brain bleed." We have no idea what the type of bleed was, presenting sxs, why they were in the ED, if they are in thinners, vital signs, lab values. I am starting to gather that OP does not know any of these things, from what has been stated, it wasn't even her pt. But, back to the bottom line- you let the pt leave AMA. If the pt was only Korean speaking, I'm sure there was probably family there and aware of the situation- yet again, I have to speculate bc OP has not provided the pertinent facts of this case; I'm also staring to speculate the reason for that.

[kbrn2002, ADN, RN]

I haven't read all the replies yet but I bet they are all pretty much in line with mine. There is no ethical dilemma here. A patient that is A & O and cognitively able to understand the risks of refusal when explained is well within their rights to refuse treatment including a transfer to a different facility. Unless there is a court order stating otherwise you have no right to force treatment, doing so is actually illegal and can get you in a heap of trouble.

I am concerned that forcing transfer upon this patient was even a little bit of a consideration. To me that is the ethical dilemma.

[Pangea Reunited, ASN, RN]

OP has told us nothing about the pt besides being a "brain bleed." We have no idea what the type of bleed was, presenting sxs, why they were in the ED, if they are in thinners, vital signs, lab values. I am starting to gather that OP does not know any of these things, from what has been stated, it wasn't even her pt. But, back to the bottom line- you let the pt leave AMA. If the pt was only Korean speaking, I'm sure there was probably family there and aware of the situation- yet again, I have to speculate bc OP has not provided the pertinent facts of this case; I'm also staring to speculate the reason for that.

True ...there is plenty of information missing. OP stated that patient and "girlfriend" left in a taxi. I'm wondering who the "girlfriend" is and where they were headed. Board and care? Home? Why don't either of them drive? It could be for a simple reason or a more complicated one.

I also wonder what the patient was attempting to do when he fell and hit his head ...and why was a taxi called instead off 911 for a head injury?

There's just too much that suggests the patient may not be competent, to me. I could be wrong, but I would want to explore the issue before letting him taxi off into the night.

[ED Nurse, RN]

True ...there is plenty of information missing. OP stated that patient and "girlfriend" left in a taxi. I'm wondering who the "girlfriend" is and where they were headed. Board and care? Home? Why don't either of them drive? It could be for a simple reason or a more complicated one.

I also wonder what the patient was attempting to do when he fell and hit his head ...and why was a taxi called instead off 911 for a head injury?

There's just too much that suggests the patient may not be competent, to me. I could be wrong, but I would want to explore the issue before letting him taxi off into the night.

Where does it say he was a head injury? They were sending him to a stroke hospital, not a trauma facility. I don't know if I'm missing something but I don't see anywhere it says head injury.

[Pangea Reunited, ASN, RN]

Where does it say he was a head injury? They were sending him to a stroke hospital, not a trauma facility. I don't know if I'm missing something but I don't see anywhere it says head injury.

That was also added information in the OP's second post...

"(I don't know much about the pt, all I know was he was Korean speaking only, 87 years old, came to er for fall and laceration to back of head.)"

[ED Nurse, RN]

That was also added information in the OP's second post...

"(I don't know much about the pt, all I know was he was Korean speaking only, 87 years old, came to er for fall and laceration to back of head.)"

Why sent him to a "stroke" hospital then? That is a trauma transfer- I work at a level one, you don't transfer a fall for a stroke- if stroke is suspected you consult neuro but trauma is primary.

[Pangea Reunited, ASN, RN]

Why sent him to a "stroke" hospital then? That is a trauma transfer- I work at a level one, you don't transfer a fall for a stroke- if stroke is suspected you consult neuro but trauma is primary.

Good question. I was wondering how he even showed up to get diagnosed if he felt fine and acted fine ...then like magic, the OP added some more information.