Need real world guidance - Refusing treatment and discharge (ethics paper)

[bitter_betsy, BSN]

Can a terminal patient refuse a particular treatment and still be discharged (possibly with similar suggested treatment provided by home health) so that insurance still pays for their home health care?

I'm working on an ethics project and in this case study as the patient is being discharged, he begins coughing up blood. The patient begs his nurse not to tell anyone... states he knows he can leave AMA but then his insurance won't pay for the remainder of his home health care.

The case study is written so that it leads you to believe that reporting = no discharge = AMA = no insurance payments.

In the real world is this a potential real scenario?

1) if a terminal patient refused a treatment could/would a physician still discharge them?

2) is this a thing where insurance doesn't pay if you leave AMA?

The actual paper is a series of 6 questions leading you through the ethics of the case. You write your initial responses (which I've done), then a colleague writes a rebuttal (this is where I am) and then your group collectively re-answers all the questions together providing all the evidence through provisions. I'm just trying to understand how much of this occurs in the real world so that I can develop my thoughts and most importantly if this is possibly a misunderstanding of how home health insurance works and I need to provide patient education in the process. I feel like there are other options here but I don't know how much of the AMA / discharge / no insurance is true. Looking for facts and hoping someone can explain if this case study would happen in real life and if so what it would look like. I'm not looking to address the ethics just "facts".

Thank you so much!!

[Music in My Heart]

16 hours ago, bitter_betsy said:

In the real world is this a potential real scenario?

1) if a terminal patient refused a treatment could/would a physician still discharge them?

On occasion, yes... in fact, oftentimes so... either with a referral to hospice or with a palliative care consult... or, if the patient refused those, simply with medications and strategies for symptom management, though the refusal of hospice/palliative care might trigger the AMA from the doc.

The key is that the patient must have capacity to make their own decisions and have the means to care for themselves and follow through with the referrals and plan of home care.

16 hours ago, bitter_betsy said:

2) is this a thing where insurance doesn't pay if you leave AMA?

I have been told so but by anybody who I have seen to have the experience or expertise to definitely make such a statement. I'd actually be surprised if this were "a thing" but... I'm a nurse not an insurance expert.

[bitter_betsy, BSN]

@Music in My Heart

Thank you so much! This is exactly what I needed to know.

I wonder what would happen if I called my insurance company to ask?? I'd probably have a giant black mark on my record forever. Now - to just actually write the responses!!

[JKL33]

Have you done a search regarding the AMA/insurance issue? I think you should.

On 1/28/2020 at 11:16 PM, bitter_betsy said:

1) if a terminal patient refused a treatment could/would a physician still discharge them?

2) is this a thing where insurance doesn't pay if you leave AMA?

1. Absolutely. In fact I have heard it credibly argued that the worst thing a provider can do (from both a liability and ethics perspective) is throw up their hands and essentially say, "If you don't want to follow my recommendation you're on your own." That is neither ethical nor wise. It is unnecessary, to boot. The best way to handle the situation is to take reasonable steps to evaluate the patient's capacity for making the particular decision in question and go from there (I also recommend you quickly google to understand the difference between capacity and competency). If they truly do not demonstrate capacity for the decision in question, then the provider has additional obligations. If they do have the capacity then it is in everyone's best interest to reasonably help the patient come up with a plan based upon the choices they are entitled to due to the right of autonomy. If the patient has the capacity to decide to leave, is in everyone's interest to formulate a reasonable discharge plan centered around the patient's health and safety based on the choice they have made. This can be done in a way that the patient made this choice after presented with other options from the care team.

2. I'm suspicious your instructor wants you to investigate this. Both whether or not it is true, and the ethics of using that tact to influence a patient's decision-making. ?

[MunoRN, RN]

The idea that insurance generally won't cover something because you leave AMA is a common, but untrue myth.

A patient is free to refuse any recommended or prescribed treatments and not be punished for that choice, physicians and other caregivers must still adjust the plan of care to meet the patient's goals and wishes, and still have to make reasonable attempts to provide for a safe discharge, including post-discharge care needs, even in a patient who chooses to leave AMA.

If the patient refuses the care or services that home health would be providing, then no, insurance would not cover home health since there would be no covered care provided. Otherwise, so long as the home health care is indicated and included in the patient's coverage, then no, leaving AMA wouldn't affect that. If the patient left the hospital still requiring care that can't be provided by home health, then obviously the services he could receive would be limited.