Patient refusing to leave

[anon456, BSN, RN]

We sometimes get patients who leave AMA, and since it's peds, sometimes police or CPS has to get involved if the MD feels the patient is in danger and unstable. However we had a strange situation the other day where the family refused to be discharged! The patient was recovered and the family was in agreement that the patient was well enough to go home. In this case, after social work and security was called, the patient was just told they would be paying for the room themselves after the discharge time had passed. They did leave but not until after the time had passed, so I guess they'll be getting a bill for the room. We were all trying to figure out what would happen if they decided to stay-- would it be an ugly scene? Can we make them leave if a child is involved?

We have had other cases where the family feels the patient is not okay to go home yet. Typically it's chronic patients who come in and oftentimes the MD cannot find a good reason for them to stay. They are stable and unchanged from baseline, their infection or whatever issue they had was resolved, but the family insists they are still having some issue. It's usually something that can be taken care of outpatient or managed at home or subacute care. The MDs will usually cater to the family and the patient can stay a week or two (!) past their discharge date. I suspect it's because the MD is afraid of being sued.

Have you encountered this? How does the hospital/MDs deal with it?

[KelRN215, BSN, RN]

Yes, many times working in the hospital- also peds. I've seen patients refuse to be transferred out of the ICU because they knew they were coming to a double room on the floor, patients refusing to move out of a double room as well as patients refusing to be discharged. With the ICU situation, I recall times where the family was told "Ok, but if the ICU fills up and something happens, you're the first on the list to be bumped at 2am and we won't care then if you're refusing to leave, you'll be leaving." I recall once having to call security for a patient whose family was refusing to be moved from a single room into a double room. It was either because there was a child coming in who needed a private room for precautions or an end of life patient. If necessary in that situation, the father would have been removed from the hospital and the child would have been moved to the room he needed to be moved to. It didn't come to that. Parents can come up with endless reasons why they "can't" leave the hospital too... anything from the weather to just not wanting to leave. In this customer service mentality, the MDs almost always caved. I documented if the reason they weren't being discharged was because the parents refused.

[CodeteamB]

I work in the emergency room so I probably see this once or twice a week. If a patient is refusing to leave I first try to address their concerns (answering questions, give bus fare, etc.) if they are still refusing to leave and are requesting something medical I will sometimes ask the physician to see them (if the request is for another dose of dilaudid for the road I won't generally bother with this as we all 3 of us know the answer to that one). Finally, once concerns are addressed and charted I am calling security to escort the patient off campus, but it rarely comes to that. I have had a situation where security needed to restrain a patient so I could remove the saline lock (pt was insisting that she would not leave until she received 3 different medications "pushed fast").

When I worked input I never had an experience where a discharge order had been written and the patient then wouldn't leave, but we did have patients that would try to avoid discharge by making the d/c planning a nightmare at every junction. One woman I remember managed to milk out close to 4 months inpatient stay post the time she was appropriate for discharge. Meantime she took daily "day passes" when family would come and pick her up and she would be gone all day, returning to the unit to sleep (and often to have her critical high BGL treated).

That being said, the vast majority of patients can't wait to get out of the hospital, and I'm really more likely to deal with a mysteriously empty bed than anything else.

[julz68]

We had a pt who was leaving AMA once who then decided they would not leave the floor without being escorted out by wheelchair. We tried to explain that since it was their choice to leave AMA, we could not wheel them out and they had to leave under their own power. If something happened between point A and point B while being escorted out by staff, we would be liable.

They stood at the nurse's station ranting about the situation until someone mentioned to call security. After that, they made a dash for the elevator, making threats to sue.

Some people just amaze me.

[imintrouble, BSN, RN]

I thought our little rural hospital was the only place that happened.

It mostly happens in the ER, but we get the result of the refusal to go home up on the floor....the admit.

Families who are caregivers bring granny to the ER, because they have a vacation scheduled and granny's not invited. After the workup, when there's no reason to admit, the family simply says we're leaving and granny's not going with us. ER MD then admits to the floor 23hr, and the PCP goes fishing for a reason to stay.

[KelRN215, BSN, RN]

I thought our little rural hospital was the only place that happened.

It mostly happens in the ER, but we get the result of the refusal to go home up on the floor....the admit.

Families who are caregivers bring granny to the ER, because they have a vacation scheduled and granny's not invited. After the workup, when there's no reason to admit, the family simply says we're leaving and granny's not going with us. ER MD then admits to the floor 23hr, and the PCP goes fishing for a reason to stay.

Those "social admissions" are horrible. I remember one case where the mother brought her child in for "increased seizures" or "increased crying spells" or something, child was observed in ER for several hours with no episodes, drug levels were therapeutic and child was seen by neuro and cleared for discharge. So the mother left and, whaddya know, the child mysteriously has an unwitnessed event on the way to the parking garage so she comes back in and demands to be admitted. In my experience, the MD always caves in this instance. So child is admitted, placed on continuous EEG, full work-up and everything shows no changes from her baseline and no acute seizure activity. So then mother becomes furious and starts screaming "I'M GOING TO TRANSFER HER TO ANOTHER HOSPITAL WHERE THE LISTEN TO THE PARENS!" The doctor was like, "Tell me where, I'll call the transfer in right now." Of course then she insisted on staying...