Leaving AMA

merlee · Nov 1, 2011

Each situation bears its own merit. Personally, after a discussion with a patient and calls to the doc and my supervisor, I would try to leave my emotions out of it.

Adults are entitled to make their own decisions.

Bruce_Wayne, ASN, RN · Nov 1, 2011

Things to remember: it's a hospital not a prison. You need to respect your patients autonomy.

2. try to talk them out of it. Use whatever rapport you've built with them to try to urge them to stay. If you can get them to agree to stay for "30 minutes" while you call the doctor, whatever emotions they had won't be running quiet as high and you can probably get them to stay.

You have to explain to them that it is dangerous to leave AMA and give specific reasons related to their care why it is dangerous.

Never coerce them into staying, and that include saying things like "your insurance won't pay if you leave AMA." Their insurance/medicare/self pay status does not factor into your job and responsibilities. Besides it's actually a rumor/lie that AMA status will affect insurance pay out. The simple fact is that you have a right to decide what medical care you receive and for how long you receive it.

canesdukegirl, BSN, RN · Nov 1, 2011

What Merlee said! I will go over the risks of leaving AMA, including any insurance information that may affect the pt's decision to leave (for example, my insurance co will not cover an ER visit if I leave AMA).

I make sure that the pt has access to every available resource we can offer, and guide them through the steps of taking advantage of said resources.

I do not beg and plead with a pt, nor do I use scare tactics that I have seen other nurses/docs use in order to persuade a pt to stay. If they don't want to stay and understand the risks of leaving AMA, then I wish them the best and hope that I don't see them again in the next hour or two!

nerdtonurse?, BSN, RN · Nov 1, 2011

Stay or don't stay, it's up to them. Most of the folks that have AMA'd out on me didn't need to be in the hospital to begin with, are in the hospital because they're non-compliant with pretty much everything, or had gotten to the point where it wasn't dangerous for them to leave. You want to leave because you don't like how you feel when your sugar's "just" 280, no problem, see ya next week when you're back in DKA again. Mad because we won't let you smoke, and you won't accept any nicotine patches or gum, you are going to light up and tell me I can't stop you? Nope, sure can't, but I can turn off the O2 you're refusing to wear so I can keep you from starting a fire, and I will hand you the AMA form. It's not personal, leave, go, don't care. Obviously, I'm not talking about psych cases, suicide attempts, those we can call the county for -- and usually when you tell them "it's us or the county jail" they decide we're a better solution. I'm not a jailer, and I'm not going to risk anybody on the shift getting hurt by trying to talk down a psych patient who's hallucinating and convinced by his voices that we're trying to kill him or activate the chip in his head. I let the deputies pick them up in the parking lot, far, far away from my vent patients.

Only had one who was really sick, but his wife was even sicker at another facility. Doc wouldn't transfer him, so he left AMA. I worried about him, got his permission to call the facility his wife was at and tell them he was coming, and had AMA'd out to go be with his dying wife. At least someone could keep an eye on him, even if he chose not to be admitted. One of those, "...and I never learned how it turned out" situations...

ChuckeRN, BSN, RN · Nov 1, 2011

Even an inmate is allowed to sign themselves out AMA.

I can't tell you how many times I've had inmates utilize resources to get sent to a hospital only to sign themselves out AMA because they didn't like something. :confused:

Things to remember: it's a hospital not a prison. You need to respect your patients autonomy.
2. try to talk them out of it. Use whatever rapport you've built with them to try to urge them to stay. If you can get them to agree to stay for "30 minutes" while you call the doctor, whatever emotions they had won't be running quiet as high and you can probably get them to stay.
You have to explain to them that it is dangerous to leave AMA and give specific reasons related to their care why it is dangerous.
Never coerce them into staying, and that include saying things like "your insurance won't pay if you leave AMA." Their insurance/medicare/self pay status does not factor into your job and responsibilities. Besides it's actually a rumor/lie that AMA status will affect insurance pay out. The simple fact is that you have a right to decide what medical care you receive and for how long you receive it.

Pepper The Cat, BSN, RN · Nov 1, 2011

I think a lot of times it depends on the reason for the pt signing themselves out.

Just recently we had a pt go AMA because we wouldn't give her a private room. We had to move her out of hers to put a dying pt in the private . She didn't have the coverage for a private. She pitched a fit. We told her she could have a private if she paid the differance between her coverage (OHIP- basic) and the cost of a private - about $250 a night. She wouldn't. We contacted MD who agreed that there was no medical reason for a private and supported us. So it was basically - sign here and don't let the door hit ya where the good Lord split ya.

I had another pt try a similar thing - he stayed when I called his bluff and started to take out the IV that took the ER nurses 5 attempts to get in.

The hospital is not a prison. People can make the choice to leave. I just have to inform them what can happen if they leave and that they may not get a bed if they come back. Considering our ER usually has at least 10 - 12 people waiting for beds, if this person leaves it just means someone else can get a bed.

Meriwhen, ASN, BSN, MSN, RN · Nov 1, 2011

Psych nursing is a little different. If a patient is being held under a temporary detention order or has been involuntary committed, they may not sign themselves out AMA. Voluntary patients may leave AMA.

However, if we feel that a patient that wants to leave AMA is a definite danger to themselves and/or others, we can call a prescreener to evaluate the patient and determine if they need to be held involuntarily. If after evaluating the patient the prescreener says Yes, they are detained and have to go to court within a day or two to determine if they need to be committed. If the prescreener says No, the patient can be discharged. Usually after hearing that we need to call a prescreener, most patients will back down from leaving in order to avoid a possible involuntary commitment.

Like a medical AMA, we explain and make sure they understand the risks of leaving AMA and that we are not liable for any negative outcome as a result. We will offer to set up follow-up appointments but most AMA patients refuse them. Depending on the circumstances and the doctor, they may or may not go home with medication prescriptions...usually they don't, and sometimes not going home with medications is enough of a deterrent to make a patient change their mind and stay.

I'll educate patients about what going AMA involves and I will encourage them to think it through before deciding...and if they decide to continue with it, I accept it and make it happen. I've learned never to take it personally. Mental health patients have the same rights as any other patient, including the right to refuse treatment.

That Guy, BSN, RN, EMT-B · Nov 1, 2011

Really depends on the person trying to leave, how bad they are doing, mental capacity at that time. You wont be able to act the same during each situation.

CapeCodMermaid, RN · Nov 2, 2011

People can make bad choices. I try to explain to them why they should stay and the risks of leaving. But if they are determined to go, I have them sign the form and wish them good luck. Our policy is not to readmit any one who has signed out AMA.

Jolie, BSN · Nov 2, 2011

I will go over the risks of leaving AMA, including any insurance information that may affect the pt's decision to leave (for example, my insurance co will not cover an ER visit if I leave AMA).

I applaud you for being familiar with the terms of your personal insurance coverage, but caution any nurse against advising a patient on his/her insurance coverage. If this is an issue in a patient's decision, please call a billing specialist to talk to the patient.

Sweeping generalizations about insurance companies refusing to pay for treatment if/when a patient leaves AMA aren't necessarily true and mis-informing a patient may come back to bite you in the butt. We aren't payment specialists. Let others do their jobs while we stick to nursing care.

Sanuk · Nov 2, 2011

People leave AMA all the time in the ER, very very rarely is it someone I am worried about. Usually it's because the doctor has just told them they can't have dilaudid just because they're allergic to all NSAIDS, tylenol, and aspirin. I will try to get them to sign the form, most refuse, and I just document that. The ones who are capable of having a rational conversation, I let them know that they can come back anytime and we will be happy to see them again for this problem, or for any new symptoms. They are usually receptive to that.