Too sick to leave AMA?

[Rexie]

Normally, if a pt wants to leave AMA, we'll call the doctor to come speak with them and if they still want to leave, we'll ask the pt to sign the AMA papers, and off they go. There are variations, of course. Some patients have been threatening AMA for days. Some are with us frequently and this is their pattern. Some patients have concerns or issues that we can resolve and they'll stay. But what happens if somebody is really ill and they want to leave AMA and not give us the chance to get some type of discharge plan together or if they're too sick to be discharged with any type of plan?

I had a doctor recently want to section somebody because he thought they were too sick to leave and if they wanted to leave being that sick, they much be irrational. It eventually resolved without getting to that point but we nurses were very uncomfortable with the whole scenario.

I'm curious what others experiences with this are.

[Horseshoe, BSN, RN]

I would think if the patient is competent, they have the right to refuse all treatment and/or leave AMA. That right is precious and patients who exercise that right should not be treated in a patronizing manner.

[Mandychelle79, ASN, RN]

We have had individuals kept in the hospital on a 302 (Pa's involuntary commitment) when the doctor felt necessary. I think in 5 yrs I've seen it happen once.

[LadyFree28, BSN, LPN, RN]

My understanding of AMA was to inform the doctor, witness the signature and off they go-no d/c planning, NADA, because the long is if they don't want to be there and undergo treatment, they are not adhering to a plan of care, hence the caveat that if they don't feel well, they are always welcome to come back.

No one gets discharge papers...only a copy of their AMA paper that they, the doctor, and the nurse sign.

In my experience, I witness, and then give the pt a copy; there have been times families will sign out AMA and return; either they felt the physician was inadequate and they didn't feel comfortable and would've stayed if they asked for a new physician (they wanted to stay and wouldn't tell me why they wanted to leave; then told me after the fact; so education was needed on that part) or they needed to get a family member and returned (child was sick, mom had to get special needs sibling from school).

[emtpbill, ASN, RN, EMT-P]

This is very interesting to me as I am finishing up nursing school and have been a paramedic for 20 years.

When I have a patient, in the field, who I know should go to the hospital but is refusing all treatments and transport, and I know that they will probably die if they don't allow me to help them, I will do the following. Involve family, explain that their loved one most likely will not survive without intervention. Usually this is enough especially if it is a man and his wife intervenes. If that doesn't work I call the doctor at the ER, explain everything and have the doctor talk to the patient. If that doesn't work and I know they will lose consciousness without intervention, I will usually hang around , out of patients view, and see if they go unresponsive. If they do, implied consent takes over and they don't have a choice.

Now I know that you are talking about in the hospital but some of these can apply, especially if they are that sick and may not be able to make it outside on their own without serious medical crisis.

[elkpark]

People can be held and treated against their will if it is the opinion of the attending physician that the individual lacks the mental capacity to make an informed decision to leave. In that case, there is no need (or indication) to file for an involuntary psychiatric commitment. I'm not suggesting that should be done casually or frequently, but it is legally possible.

[LongislandRN23]

In my hospital of a patient wants to leave AMA they have to be alert and oriented X4, be sound of mind and able to understand and make medical decisions. This is determined by the physician, and if the patient is deemed not competent they have to stay- this is not considered an involuntary hold.

If a patient is alert and oriented x4 they can leave Ama, we have the PA usually come and speak with them and if they are walking out in a rush we have them sign the paperwork and so long goodbye. If they sign out Ama but are not running out the door I have seen Drs and pa's give D/C paperwork and scripts out but it is well documented they left Ama.

I've had plenty of patients leave Ama who were competent, I've also had family members sign their demented parents or family members out Ama- that is allowed as well.

One patient who was a&0x4 had a stroke and the only deficit was profound dysphasia, walk my talk and speech intact and what not. He left Ama after terribly failing a modified barium bc we would not let him eat, I'm sure he went home and aspirated.

[LadyFree28, BSN, LPN, RN]

I found an article on MedScape:

Medscape: Medscape Access

It doesn't even state to give prescriptions or a d/c summary.

[Anonymous865]

In my state you do not have to be AOx4 to refuse treatment. All that is required is that the patient have the ability to understand what is being recommended and the consequences of not following the recommended treatment.

If the patient lacks decision making capacity, the state clearly specifies who can make the decision for the patient. If you can't find the POA, guardian, patient-designated surrogate, any relative, or friend, then the physician has to follow the recommendations of an ethics committee. The physician doesn't get to decide for the patient.

If a physician can decide to section someone just because they don't agree with the patient's refusal of treatment, then no one would have the right to refuse treatment.

[calivianya, BSN, RN]

I have thought about this on and off. I've had plenty of patients so sick nobody would bring them AMA papers even though they wanted to leave. If they are too weak to get out of bed, they can't even crawl, and no one will take them out of the room, it kind of becomes a moot point, I suppose.

I am thinking about one in particular - a young woman, post arrest, whose kidneys and liver were completely shot. She was bright orange, on continuous dialysis, so fluid overloaded that her skin was split open everywhere and her arms and legs were too heavy to lift, and she was on high doses of IV vasopressors. She was getting lactulose q4h to just keep her conscious and her entire backside was a giant excoriated wound from the continuous stooling and the continuous weeping out of her skin. She cried almost every night and asked to leave often. If I had turned off her IVs, she would have died in the room. Family wanted her to be a full code - said she was depressed, that she wasn't rational. Family was frequently threatening to sue us if they didn't agree with the plan. The patient was alert and oriented.

Out of curiosity, what would have happened if I had ever brought her AMA paperwork and turned her equipment off? She was definitely competent to sign. She definitely would have died in the room if I'd done it. What happens if someone signs AMA paperwork, but was a full code per family, and arrests in the room and we can't get a heartbeat back? What kind of legal implications are involved for the nurse?

[Scrubs_n_sirens, MSN, RN]

People can be held and treated against their will if it is the opinion of the attending physician that the individual lacks the mental capacity to make an informed decision to leave. In that case, there is no need (or indication) to file for an involuntary psychiatric commitment. I'm not suggesting that should be done casually or frequently, but it is legally possible.

It can indeed be done. Recently I had a female who was getting narcosis from her breathing difficulties. She was struggling and needed bipap desperately. Her ABG values were crap.

She wanted to sign out AMA and the doctor honestly felt she was a risk of dying that night.

In order to 302 for treatment, you need two separate physicians to attest that the condition is life threatening. It's a highly contested route to go and a lot of physicians won't second the medical commitment because they don't want to risk being sued for unlawful detainment.

[Scrubs_n_sirens, MSN, RN]

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Out of curiosity, what would have happened if I had ever brought her AMA paperwork and turned her equipment off? She was definitely competent to sign. She definitely would have died in the room if I'd done it. What happens if someone signs AMA paperwork, but was a full code per family, and arrests in the room and we can't get a heartbeat back? What kind of legal implications are involved for the nurse?

If they're competent they can sign out. When you d/c everything, wait until they go unresponsive and then it's considered implied consent and treat them. Actually, I don't know but I'd be curious to see other answers.

There really is no black and white answer for that. I'm not sure how the legalities of it all work if they sign out and then go unresponsive (if they're that unstable). Do they stay in their room for treatment since they're technically no longer admitted since they signed the document? Do they have to be taken to the ED? Can you simply hulk em back into their bed and reconnect all the lines?