Discharging a patient AMA

[Tweety]

Most of my coworkers when discharging a patient AMA just get them to sign the form and it's a "there's the door, don't let it hit you on the way out" kind of attitude.

I've always tried to give some semblence of d/c instructions, such as what to look out for, how to care for wounds, what kind of followup they need, when to come back to the ER, etc. similar to other discharges. Sometimes for the indigents I give them a few dressing supplies, etc.

Although my last AMA I gave him the MD's number, only to be told by the MD that when "when a patient goes AMA, I drop them and don't give them my number". I can understand that. Point well taken.

I'm not talking a major d/c like a person leaving normally, but I try to at least not send the patient blindly out on their own either.

What do you say? What do you do?

[UM Review RN, ASN, RN]

I do the same, Tweety.

I actually think (if I can find the case, I'll post the link) there's a reported case of a patient going AMA from the hospital after being a chronically noncompliant patient as well as leaving the hospital before he had a cardiac cath. Pt died, hospital and doctor were successfully sued. I guess they were supposed to hogtie him and drag him into the Cath Lab or something, right?

Sometimes it just don't make sense.

[UM Review RN, ASN, RN]

I've heard people tell patients "you're insurance company will not pay if you go AMA".

I seem to remember many years ago to never say this to a patient, but I can't understand the rationale.

Anyone?

Coercion?

It might make the patient feel forced to stay and do everything ordered, which takes away the patient's right to refuse.

[Daytonite, BSN, RN]

You can't make a patient do anything they don't want to do, including stay in the hospital. We're not policemen. This is America, people. All you can do is advise these patients of what they need to do for follow up care and what to do if they need emergency help. We have to leave our attitudes out of it, no matter how hard they want to jump out and strangle some of these patients. It is their right to walk out of the hospital and keel over and die.

[Tweety, BSN, RN]

nevermind. Sorry.

[Tweety, BSN, RN]

You can't make a patient do anything they don't want to do, including stay in the hospital. We're not policemen. This is America, people. All you can do is advise these patients of what they need to do for follow up care and what to do if they need emergency help. We have to leave our attitudes out of it, no matter how hard they want to jump out and strangle some of these patients. It is their right to walk out of the hospital and keel over and die.

We're in agreement. Are you talking to anyone in particular. Any attitude in particular that was exhibited in this thread. I'm a bit confused by your response.

That a patient can AMA themselves isn't in question. It's how to go about it when they make up their mind. I certainly don't beg and plead. I'm quite matter of fact. Last time I worked it was "you're ruptured globe could get infected and you could loose your eye. You won't be getting perscriptions or IV pain meds, but here's your eyedrops you've been taken here. ". Another time it was "you're lacertated spleen could bleed out and you could die. Here's what to look out for, dizzyness, blah blah blah."

I just don't take the approach of: patient: I want out of here. nurse: sign this form and there's the door.

I think they need to be clear on what the medical advice is that they are leaving against. :)

[Altra, BSN, RN]

Coercion?

It might make the patient feel forced to stay and do everything ordered, which takes away the patient's right to refuse.

This is a reality of many insurance plans, and an understandable one. They're paying for a prescribed plan of care/course of treatment. A patient absolutely has the right to refuse, to leave the hospital AMA, and to keel over on the sidewalk & die -- that right doesn't translate into the insurance company's obligation to pay for it.

I document, document & document some more when a patient/family seems to be gearing up to leave AMA. I always stress what to look for as far as exacerbation of symptoms and reiterate that they are welcome to come back at any time. Under no circumstances do they get analgesics or other meds to go.

[CarVsTree]

I've been a nurse for 8 months now and we have patients leave AMA. Lots ETOH, Drug abusers...

I personally have not had a pt. go AMA

Are there any legal implications related to giving discharge instructions? I'm not sure if there would be, just wondering.

[TachyBrady]

I agree with sjt. If the pt is receptive, I inform them of the dangers, risks, things they can do for themselves (as is the case of someone that signs out because he'she doesn't have medical coverage and can't afford the expense).

I had a first the other day with a pt with a psych history. She came out to the nurses station and said she is either going AMA or would like to be transferred to another hospital. I told her factually, objectively, that I would page the doctor about a possible transfer. Well, she obviously didn't like that answer because 5 minutes later she walked out. One half hour later she came back!!!!!! stating she decided she'd better stay in the hospital after all!! I've never had an AMA pt change their mind. I treated her as if she'd never left. Despite bizarre behaviors, I am still out for what is best for the pt, no matter what the situation.

[letina]

I've heard people tell patients "you're insurance company will not pay if you go AMA".

I seem to remember many years ago to never say this to a patient, but I can't understand the rationale.

Anyone?

I'm relatively new to nursing in the US but I did observe a nurse advising a patient who wanted to leave AMA that if he had to return to the hospital due to complications arising from leaving AMA, then there's a chance his insurance company wouldn't pay for treatment of said complications.......made sense to me. Also, I've seen patients who want to go AMA because they have no insurance in the first place and worry themselves about who's gonna pay for all this?

[Hoozdo, ADN]

You can't make a patient do anything they don't want to do, including stay in the hospital. We're not policemen. This is America, people. All you can do is advise these patients of what they need to do for follow up care and what to do if they need emergency help. We have to leave our attitudes out of it, no matter how hard they want to jump out and strangle some of these patients. It is their right to walk out of the hospital and keel over and die.

Speaking of walking out of the hospital.......a couple of weeks ago in ICU, I had a double BKA wanting to leave AMA. He had no wheelchair and was homeless. He might have had the right to walk out.......but not the means

:trout:

Needless to say, he did not leave AMA!

[AM-RN]

Part of nursing is being a patient advocate. Any patient may choose to leave against medical advice. If the situation allows, I try to provide basic discharge instructions, including we are here 24/7 and should you change your mind, we will be happy to see you at that time. I document patient verbally understands risks associated with leaving AMA. I also document each and every interaction that lead to the AMA d/c...."pt verbalizes desire to leave prior to laboratory results/xray/etc . explained rationale for remaining in ED and encouraged pt to do so. md notified of pt's desire to leave ED."

[Bethy-lynn]

I happpen to be good friends with one of our hospital's family docs, and once he had a pt that was very , very ill, and had absolutely NO business leaving ama. He had the nurse put, in very bold letters at the bottom of the sign out sheet " YOU MAY DIE". The patient still left, but since then, I have told this to patients threatening to leave, and have managed, in doing so , to actually keep a few that really needed to be in pt. Go figure.