So in my state, if a voluntary psychiatric patient wishes to "sign out" of treatment, they can sign a "72 hour notice" that they would like to withdrawal from treatment, but the form states they can be held up to 72 hours in the hospital for further observation. At your facility ,if a patient who has signed a 72 hour notice gets discharged, do you have them also sign a separate "AMA" paper that states they understand they are leaving AMA and that this and the risks of doing do have been explained to them? Basically, are signing a 72 hour notice and signing out AMA the same thing? Or can a patient sign a 72 hour notice to withdrawal from treatment, and then the psychiatrist says ok, you can be discharged and lets them go without it being considered AMA?
There is confusion on this at my facility....practice has been that if a patient signs a 72 hour notice, the MD will specify whether they want the patient to also sign an AMA form. Other times, patients sign a 72 hour intent to withdrawal from treatment form and are NOT required to sign a separate AMA form. I was always under the impression from working at a previous facility that if a patient signs a 72 hour notice and then gets discharged, the discharge would be considered against medical advise, but that doesnt seem to be the thought where I am working now...
to my knowledge, if they sign to withdrawl from treatment, make sure they understand that them signing AMA wouldn't be a regular discharge and the MD will not be giving them script. Most patients retract the form after knowing the will not have prescription.
Now, if a voluntary pt still persist about leaving (before MD discharge) and they do not seem to be a threat to self or others, they have 72 hours before the MD allows the discharge to happen, in my hospital, AMA and 4 hour notice is the same paper.
Ethically, any discharge, including AMA, needs to be approved by a doctor. The doc needs to conduct another evaluation to determine if the patient is safe enough to discharge. If you think about it, if we discharge any patient that isn't safe and they go home and kill themselves or someone else, ultimately we are liable for letting them walk out that door. Destroys the sole purpose of any inpatient stay (I.e. higher level of care). 24 hours is allotted for us because docs are not always on site to do this evaluation...so if I get an AMA request at 2330, which I have, they unfortunately will have to wait until morning for the doc to come in. All of our AMAs are pretty understanding about this.
Normally a client with this severe of an intent is put on a 72hr hold initially to prevent circumstances like wanting to leave AMA from happening...but I have seen cases where a client comes in voluntary and an intent develops during hospitalization to hurt oneself or another person.
Also, leaving AMA means insurance won't cover their hospitalization, which can change people's minds sometimes.
AMA by definition means the patient doesn't need to be approved by the doctor, that why it's Against Medical Advice. The only time they can't leave AMA is when they are on a legal hold, which why I don't understand how you're legally able to hold someone for that long without a legal hold on the patient. If all voluntary patients were essentially on a legal hold by default, which is what you need to only discharge with the physicians approval, then why do we pursue legal holds?
Here in NC, our patients that are admitted voluntarily cannot just change their minds and leave whenever they'd like. They must be evaluated by an MD and discharge orders given. Unfortunately, patients are not told this in the EDs prior to signing in voluntarily and often become quite frustrated when we tell them. If they request discharge, they are given a 72 Hour Request for Discharge form. At that point, the clock starts which gives the doctor 72 hours to discharge the patient or IVC them through the courts. At my particular facility, we do not use an AMA form.
Here in NC, our patients that are admitted voluntarily cannot just change their minds and leave whenever they'd like. They must be evaluated by an MD and discharge orders given. Unfortunately, patients are not told this in the EDs prior to signing in voluntarily and often become quite frustrated when we tell them.
This is a shame as well as being unethical. I have seen it with select social workers in the EDs over the years and it is something that should be addressed with management.
Every once in a while I will see a patient in the ED and admit them to my unit and if I'm discussing the voluntary form with them I always make it very clear they are able to place a 72 hour notice not request to leave at any time simply because the signed a voluntary. It is unfair to both the patient and staff who have to deal with the fall-out if a patient is admitted under these circumstances.
I completely agree Jules A. It's very difficult being on the receiving end of a frustrated patient who has received misinformation, not to mention how the patient must feel.
We always inform them of the 72 hour form on admit to our unit but that really should be explained prior to their arrival. We've educated and re-educated the ED staff but to no avail.
And here I thought it was only our ED that does this with the 72 hour silly me.[/quote']
I have worked at 4 hospitals where it has been a problem at times. My threshold is pretty low for it and I will mention it to management. Although they attempt to hide behind "you know the patient's lie" it is believable when you hear the same comment from more than one patient when certain social workers are working.
It is similar to self-disclosure in psych, imo, something that is often done by inexperienced staff in an effort to make things easier but with poor results. I'm willing to chance the fight up front and the bottom line is in most cases if I'm offering a voluntary I have enough to commit the patient anyway so there really isn't a need to be deceptive. If you can't cert them and they refuse a voluntary when presented in an honest, ethical manner you simply have to discharge them.
I completely agree Jules A. It's very difficult being on the receiving end of a frustrated patient who has received misinformation, not to mention how the patient must feel.
We always inform them of the 72 hour form on admit to our unit but that really should be explained prior to their arrival. We've educated and re-educated the ED staff but to no avail.
If the patient can't express that they are aware they agreed to a 72 hour hold then they didn't agree to a 72 hour hold. Everywhere that I've worked requires a patient's signature for this agreement, but also two licensed staff to sign saying that they confirmed with the patient they are agreeing to the contract.
If a facility hasn't used some sort of process to document a confirmation of the patient's understanding of the agreement, and then holds a patient to such an agreement that they deny being aware of, attempting to hold the patient to that agreement is pretty clear violation of their rights and our basic ethical obligations to the patient.
If the patient can't express that they are aware they agreed to a 72 hour hold then they didn't agree to a 72 hour hold. Everywhere that I've worked requires a patient's signature for this agreement, but also two licensed staff to sign saying that they confirmed with the patient they are agreeing to the contract.
If a facility hasn't used some sort of process to document a confirmation of the patient's understanding of the agreement, and then holds a patient to such an agreement that they deny being aware of, attempting to hold the patient to that agreement is pretty clear violation of their rights and our basic ethical obligations to the patient.
It sounds like my state's voluntary admission process is different to what you use in your state. The application for voluntary admission that I am referring to is not a 72h hold agreement. It states that the patient meets criteria of having a mental condition, would likely benefit from treatment and they are agreeing to come in for treatment. There is no time frame hence the need for staff to explain that if they decide they want to leave they have the right to submit a statement giving their 72h notice of intent to leave. At some point during the next 72h the patient will be evaluated by a provider and either discharged, asked to rescind their 72 or certified.
It sounds like my state's voluntary admission process is different to what you use in your state. The application for voluntary admission that I am referring to is not a 72h hold agreement. It states that the patient meets criteria of having a mental condition, would likely benefit from treatment and they are agreeing to come in for treatment. There is no time frame hence the need for staff to explain that if they decide they want to leave they have the right to submit a statement giving their 72h notice of intent to leave. At some point during the next 72h the patient will be evaluated by a provider and either discharged, asked to rescind their 72 or certified.
There are various types of holds, but anytime a patient cannot leave by choice they are on a hold. You seem to be describing a system where not even voluntary admits can choose to leave, how is that not just putting every patient on an automatic hold? Are they aware they will not be allowed to leave upon request?
Specializes in psych, addictions, hospice, education.
In my state a voluntary patient can request to leave at any time. If the doctor decides they shouldn't leave but are not in danger and not dangerous, then they are discharged. If the doctor thinks they could benefit by staying and really shouldnt go, they sigh a request to leave AMA. The doctor then chooses if they can leave or not. If he says they cant leave, he starts the 72 hour hold legal, court-involved procedure.
There are various types of holds, but anytime a patient cannot leave by choice they are on a hold. You seem to be describing a system where not even voluntary admits can choose to leave, how is that not just putting every patient on an automatic hold? Are they aware they will not be allowed to leave upon request?
Yeah that is what I have been talking about. Maybe it is considered an automatic hold? I haven't heard it referred to any type of hold so it might just be a different terminology. They are not free to leave at any time they have to put in a 72h notice with intent to leave during which time they are seen by a provider. As noted above they absolutely do need to be informed of this prior to admission but there are times when I do not believe staff does an appropriate job of getting this point across to the patient.
MyPrnPleaseBSN
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to my knowledge, if they sign to withdrawl from treatment, make sure they understand that them signing AMA wouldn't be a regular discharge and the MD will not be giving them script. Most patients retract the form after knowing the will not have prescription.
Now, if a voluntary pt still persist about leaving (before MD discharge) and they do not seem to be a threat to self or others, they have 72 hours before the MD allows the discharge to happen, in my hospital, AMA and 4 hour notice is the same paper.