Leaving AMA

AJPV · Nov 2, 2011

Yes, it's true we shouldn't use scare tactics or sweeping generalizations about insurance not covering AMA. But I think that part of being a patient advocate includes at least including this in the discussion. Simply mentioning that insurance coverage can be questionable regarding AMA and suggesting that it may be in the pt's best financial interest to investigate the before making a final decision might be helpful. We are taught to advocate for patients on every other level (physical, psychosocial, spiritual, etc.), so why should we not advocate for them on a financial level by providing what little information we do have instead of being silent?

loriangel14, RN · Nov 2, 2011

I have had this happen and all we can really do is educate them about the risks of doing so and then get them the paper to sign, usually we don't freak out.It's their choice.

maelstrom143 · Nov 2, 2011

If my patient is A&O x3, I educate him/her as to the dx, rationale for staying, consequences of leaving (i.e. no scripts, d/c instructions, worsening condition, having to start all over again in ED, etc.), and the patient's rights to self-determination. I attempt to address any issue that may be precipitating their decision (i.e. doc told them they'd be d/c'd today, have an appt, losing apt) and then, if no resolution is reached, I make sure their IV is out, their tele is removed, and AMA is signed. And, of course, doc and charge aware.

I have had only 3 AMAs in 5 years and a couple of patients who chose to stay after being re-educated as to ED wait, loss of bed, need for procedure (one was a heart cath one a stress test).

In my experience, AMAs are never personal. Patients have issues that they had before they came to us and will have after they leave us. Nothing to do with us. All we can do is be supportive, educate and advocate and, at the end of the day, hope it all works out for the patient in the end.

anotherone, BSN, RN · Nov 2, 2011

If you have a patient who wants to leave AMA, how do you usually handle it?
I'm a nursing student who's been working as an extern at a big hospital in Philadelphia for a little over a year now. I've seen two patients sign themselves out AMA so far- they were both young (mid to late 20s) Chron's patients and they were both pretty stable- but they got totally different reactions. The first time the patient's nurse and the charge nurse were really upset and tried everything to talk them out of it, and the second time (with different nurses) they both acted like it was the patient's choice and nothing to freak out about.
I think they're all really good nurses, so I'm not asking who was wrong and who was right- I'm just curious as to how most nurses deal with this situation.

Tell the charge, nursing supervisor, page the md on call.

umcRN, BSN, RN · Nov 2, 2011

I had an interesting AMA situation a few weeks ago. 29 year old with duchenne muscular dystrophy. Trach/vent dependent but other wise cognitively intact and normal. He wanted to sign out, he really didn't need to be there so we got all the paper work etc together and his parents had been there with him the whole time so we kind of assumed he had the ride thing figured out. Oh no, as the paperwork is being signed he mentions that he needs an ambulance for transport...ha! Not at 4:30 on a Friday afternoon! He did eventually get discharged and case managers pulled a lot of strings to get him a ride by 10pm.

But no one fought him on the decision to leave or tried to convince him to stay really.

Trekfan · Nov 2, 2011

A question

What if someone will not sign the AMA paperwork ?

What happens if someone is not in there right mind ? I was in the er once and went from a sweet person to a screeming b@@ch yelling to get the he'll out of there when my sugar dropped . As I was waiting for for my close to be found I was given D50 and was fine and sweet again but I could have died if I left .

noahsmama · Nov 2, 2011

At the peds hospital where I used to work, if a parent wanted to sign their child out AMA, I would explain to them that they were allowed to do that, but that we would like for them to wait until the MD could come by and talk to them about it. I would then text page the doctor to let them know what was up, and they would generally get there fairly quickly -- this was at a large teaching hospital where each pt was assigned to a team of residents, and generally at least one doc on the team could get there within half an hour, most times they were there within 5-10 minutes. The docs would then talk to the parents, and more often than not they would convince them to stay at least another day to wait for the results of whatever tests had been done/ordered. I didn't hear the conversation, but don't think they were coercive. At lot of times it seemed the parents had decided their child wasn't so sick after all, and I think the doc just explained what the potential diagnoses were, and how the tests would help them decide if the child had one of those diagnoses.

Of course, if a child was so sick that their life might be endangered by leaving, the hospital could call CPS. I did have one case where the hospital got a court order for a life-saving treatment after the parents refused (Jehovah's Witnesses refusing a transfusion for their child with hemoglobin level of 2.3 and a platelet count that was close to zero). Thankfully the parents cooperated fully once the court order was obtained -- I'm not sure what we would have done if they had tried to leave with the child -- I guess at that point maybe the hospital would have to call the police? I'm glad I never had to experience that situation.

maelstrom143 · Nov 2, 2011

A question
What if someone will not sign the AMA paperwork ?
What happens if someone is not in there right mind ? I was in the er once and went from a sweet person to a screeming b@@ch yelling to get the he'll out of there when my sugar dropped . As I was waiting for for my close to be found I was given D50 and was fine and sweet again but I could have died if I left .

If someone leaves without signing, we make a note stating patient refused to sign and note is witnessed by charge.

I think it is common sense that if patient is not in their right mind they will be kept and restrained if necessary. AMAs are for patients that are alert, oriented, and able to make their own decisions. Therefore, it stands to reason that if you were hypoglycemic and not in your right mind you would not qualify to go AMA, JMO.

I have had patients that wanted to go AMA but we did not consider them to be able to make informed decisions, in which case doctor would order appropriately to keep patient and maintain safety, get a sitter, etc.

crb613, BSN, RN · Nov 2, 2011

As long as they A&O its their choice. I ask them to sign ama form, if they won't I chart refusal...and move on to help those that want it.

TonyaM73, ASN, RN · Nov 2, 2011

Most of the people that want to sign out AMA for me are either: #1 They feel fine now and we are not moving quick enough for them to figure out what happend or #2 The MD dc'd their dilala and they are not getting their fix anymore, so why stay. Most of the people in #1 catagory will stay when I tell them that their insurance may not cover the visit if they sign themselves out. Most of the people in #2 catagory don't care about insurance because they are on medicaid or don't plan on paying to begin with.

I let them each know what the plan of care is and why the MD feels like they should stay. If the pt decides that this is not good enough, then that is their choice and I will bring them the paper.

talaxandra · Nov 2, 2011

The difference in approach could be due to a number of factors; off my head these include:

- more experienced nurses tend to be less invested - I, for example, no longer care more about the patients than they do;

- what motivated the patients to leave may have been different, with one patient's reason easier to address than the other (or one set of nurses more willing to try to resolve it);

- I've worked harder to keep potential AMAs in if I feel like something I said or did inflammed the situation;

- though they were similar in age and diagnosis, their clinical circumstances may have been very different, with more significant consequences for the patient whose nurses tried harder;

- one may have been a frequent flier who always discharges himself.

I applaud you for noticing the difference and exploring why this might be :)

Ruby Vee, BSN · Nov 2, 2011

there are many different reasons for leaving (or wanting to leave) ama and many consequences (or potential consequences) to doing so. often i find that drugs and/or etoh are motivating factors in wanting to leave. i've had several alcoholics leave in dts over the years.

the one i still remember is the younger heart failure patient -- he had to go home to harvest his marijuana crop. following some teaching about diet, meds, etc., he signed himself out ama at the beginning of my shift. and was back in er by the end of it . . . drunk as a lord and struggling to breathe after an extra large pepperoni pizza and a case of beer. but he had his marijuana crop harvested.