patients who leave the floor against doctors orders

Nurses General Nursing

Published

So, we have a pt who says that she will leave the floor to go smoke, no matter what the doctor says (i'm on a med-surge floor). We can't tie her down, and we can't go with her to the smoking area downstairs. She is youngish, but she just seems unsteady. She did go out for a smoke earlier this morning with no problems. I had her nurse in there with me (i'm a supervisor), and I reiterated to her 3 or 4 times that her doctor ordered for her not to leave the floor (COPD, O2, dyspnea, anxiety), and that if she were to leave against dr's orders, we can't help her if she were downstairs. We can't monitor her or stay with her. She said she understood and took full responsibility. There has got to be a better way to handle these situations. If she were 100% steady on her feet and 100% coherent, I wouldn't have a problem with her leaving. But this one just makes me nervous. Suggestions?

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Specializes in Infusion, Med/Surg/Tele, Outpatient.

Have her sign a release of responsibility stating that she is aware of the risks (including death) and that the hospital, its employees, and her doctors are not liable if anything were to happen to her while off the unit and that treatments will not be rescheduled while she is off the unit. Be sure to offer her a nicoteine patch and chart it!

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Officially, if they leave to go smoke, they are considered leaving AMA. They have to sign out and have to come back in through the ED, incurring even more charges and it's a big hassle for everyone. When we tell smokers this, they usually opt for the nicotine patch/gum or some xanax or ativan, whatever the admitting doc is ordering.

Unofficially, I know sometimes the patients sneak out to go smoke. If we catch them, we reiterate that if they are busted again, they will be discharged the next time they are caught. For my patients, if they are sick enough to be hospitalized, they have no business going off the unit, much less going outside for a smoke. That's what we tell them, too; I don't want it to be a judgement call, like "Smoking's bad, so if you go do it, you get punished." We try to reiterate that "You are really ill and need close monitoring. If you cannot stay on the unit for this, then we cannot do our jobs. If you go into some sort of distress, we have no knowledge of this and cannot help you. Leaving the hospital for whatever reason, including smoking, is considered leaving Against Medical Advice, and to get back in, you will need to come in through the ED to be readmitted. Your insurance company may or may not pay for your hospitalization with leaving AMA and then requesting readmittance immediately. I suggest you think this through very thoroughly before you leave to go smoke again, because that might be one damn expensive cigarette, both in terms of money and your health."

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Specializes in home health, dialysis, others.

You need to get a doctor's order for her to be able to leave the floor unassisted. Or she needs to sign out or be discharged.

Make sure when you talk to the MD s/he is totally aware that no one from your unit has the time to accompany her. The order may read 'pt may leave floor for 15 min up to three times a day if accompanied by adult family/friend'. Devise some kind of sign out sheet - date, time left, pt name, sig of adult w/pt, time returned. Or whatever you need.

Please check your hosp policy manual - this really should be covered somewhere.

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Specializes in Med/Surg.

We make people sign out AMA when they leave the floor to smoke, we don't have them go through the ED to come back, though (maybe we should?). They have to sign it every time they go, and we'll do a two nurse signature if they refuse to do that. It goes on their chart, and if nothing happens while they go, we usually don't keep the form. I know there's got to be a better way, but at least it's something, should an adverse event happen if they are gone.

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If someone has signed out AMA, how can you *not* make them go through the ED for the readmission process? If a detoxer signs out AMA, goes downstairs, has a drink in the parking lot with his buddies, and then walks back upstairs, can he just climb into bed and stay a patient after all? Signing out AMA, where I work, means you are signing yourself out of the hospital. You are discharging yourself against medical advice. Once you sign that form and walk out of your room, then change your mind at the elevator, you still have to go to the ED to get readmitted.

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The patient obviously knows the risks of leaving the floor and chooses to ignore them. Give her nicotine patch (which I'm guessing she already has ordered but has been refusing---just a guess though---that's usually my experience lol), if she chooses to leave the floor again, kindly hand her the AMA paperwork, explain to her that insurance may not cover her visit if she signs out AMA, and tell her to take a detour back in through the ED doors if she wants to come back up.

I know its cynical but I feel that if you are well enough to leave the floor to smoke you are well enough to go home and free up a bed for someone who needs and WANTS it!!

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At the end of the day we are suppose to advocate for our pt. We need to respect there decision!!! That why our site has a legal document " refusal of medical treatment" have them sign it and bye bye.

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I don't have reply but a question.. I've been in the hospital going o. 2 days and one cigarette. My nurse said I was not allowed to leave my roomat all!!! Can you help????????

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Specializes in Varied.
2 hours ago, Patricia Haynes said:

I don't have reply but a question.. I've been in the hospital going o. 2 days and one cigarette. My nurse said I was not allowed to leave my roomat all!!! Can you help????????

Uhm, you can leave, but as many have already stated, at the risk of being discharged. If you do not have an order, it is likely you can't leave the floor. Without knowing your medical history (which I don't recommend including here as you've already provided your name, which is dangerous), I cannot provide further information. Perhaps you're on some type of precautions that puts other patients at risk if you leave your room. Discuss with your doctor and nurse.

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Specializes in Medical and general practice now LTC.
4 hours ago, Patricia Haynes said:

I don't have reply but a question.. I've been in the hospital going o. 2 days and one cigarette. My nurse said I was not allowed to leave my roomat all!!! Can you help????????

This is something you need to discuss with your doctors and nurses not a website. Closing thread as this is several years old

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