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Preventing patients from leaving AMA, legally covered?

Specializes in Long term care; med-surg; critical care.

We have recently had a few patients in our unit that have been evaluated by the psychiatrist and the psychiatric consult note states something like "Patient is not allowed to leave against medical advice because he lacks insight into his current condition. Patient has been cleared for suicidal or homicidal ideation and does not require a 1:1 sitter." These patients have generally been detoxing from alcohol, either because they presented to the ED asking for help with detox resources (rarely), or people they were admitted for acute pancreatitis (usually). My concern is when a current patient became belligerent and agitated we had to put him in four point restraints and use medications like geodon to keep him and our staff safe. At the time he appeared alert and oriented to person, place, time and situation. He was demanding to leave AMA and threatening both physical violence to staff and legal actions to sue us for unlawful detention. He has a relative who is a lawyer that called into the unit and threatened similar action. Now, as a nurse I have a progress note from a consulting physician with a line in it that says patient can't leave AMA. I don't have an order, and as it has been explained to me, a PEC is not valid for patients receiving medical treatment, only patients that have been medically cleared and are receiving inpatient psychiatric treatment. I don't feel like a line in a progress note is sufficient to protect my license if one of these patients sues us. If a hospitalist writes "patient needs lasix administration" in a progress note, I don't administer lasix, I followed the prescribed orders in the chart. When I questioned the psychiatrist about this I was dismissed with a condescending statement that "I don't know how your nursing license works, sorry, but if you read my progress note you can see he can't leave". I was told there is no order associated with that note, but system wide that is sufficient to keep a patient against their will. I've tried numerous Google searches and checked scope of practice guidelines, but I don't see anything that appears to cover this issue. Does anyone have any insight? Thanks for any feedback.

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

There are laws in your state that speak to this.  If the patient is to be held against his will on mental health grounds, there should be a certification process that the doctor has to follow.  There will also be an appeals process in favour of the patient's wishes.

I do not believe there are any jurisdictions where a doctor's order will suffice on its own to detain someone against his will.

Please discuss this situation with your manager ASAP.  If need be, run this by your hospital's risk manager.  You could be named in a habeas corpus suit if you go along with this.

These doctors need to be hauled up short.  Please research the applicable laws in your state and get your protocols updated.

Contact your facility's risk management department and tell them legally you can't hold a patient against AMA orders unless they're a hazard to themselves or others, or they were pink-slipped. Also, as you said, doctor's notes aren't orders.

JBMmom, MSN

Specializes in Long term care; med-surg; critical care.

2 hours ago, TriciaJ said:

There are laws in your state that speak to this.  If the patient is to be held against his will on mental health grounds, there should be a certification process that the doctor has to follow.  There will also be an appeals process in favour of the patient's wishes.

I do not believe there are any jurisdictions where a doctor's order will suffice on its own to detain someone against his will.

Please discuss this situation with your manager ASAP.  If need be, run this by your hospital's risk manager.  You could be named in a habeas corpus suit if you go along with this.

These doctors need to be hauled up short.  Please research the applicable laws in your state and get your protocols updated.

Thank you, on an upcoming day off I will try to do more specific research related to my state's laws in this area. It just hasn't been a straight forward search to this point.

2 hours ago, NurseBlaq said:

Contact your facility's risk management department and tell them legally you can't hold a patient against AMA orders unless they're a hazard to themselves or others, or they were pink-slipped. Also, as you said, doctor's notes aren't orders.

Thank you, I had not thought of following up with risk management, I will do so.

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, Elder Care, L&D.

In California a patient must meet certain criteria to be kept in the hospital against their will. They must present as a danger to themselves (suicidal), a danger to other's (homicidal toward a specific intended victim or victims) or gravely disabled due to mental defect or disease.

I did two assessments today. In both cases the physician clearly felt the patients would benefit from further treatment yet neither met criteria to be held. In the case you cited of a detoxing patient who according to the doctor lacks insight the assessment is simple. Does the patient verbalize SI or HI. Does the patient have a safe place to go? Does the patient understand the recommendations of the physician? Does the patients have sufficient funds to pay for overnight lodging? If the patient answers yes to all the above questions They can leave the hospital. Even in the case of an AMA the hospital is required to provide a written relapse prevention plans and prescriptions for non-scheduled medications.

You physician is setting a dangerous precedent and can lose their license for false imprisonment. In this case I would as my patient's advocate suggest they call Patient's Right's and request a judicial release.

Hppy    

In my state, you have to get a TDO (Temporary Detainment Order) approved by the magistrate or the patient is allowed to walk out the door.

No physician can override that process. 

verene, MSN

Specializes in mental health / psychiatic nursing.

This is going to be state dependent. In my state a psychiatrist (or other mental health professional) may place a "hold" on a patient if concerned for their mental health. A patient on a "hold" (of which there are several types) may NOT discharge AMA.  Depending on Clinician credential/Setting a hold ranges from 12-72 hours. In all instances designating a patient as under a hold for mental health evaluation triggers a legal process which MUST be followed - including documentation requirements and notification of various parties (e.g. court investigators) and starts a count down towards either release of hold or court hearing.

 

6 hours ago, JBMmom said:

We have recently had a few patients in our unit that have been evaluated by the psychiatrist and the psychiatric consult note states something like "Patient is not allowed to leave against medical advice because he lacks insight into his current condition. Patient has been cleared for suicidal or homicidal ideation and does not require a 1:1 sitter." These patients have generally been detoxing from alcohol, either because they presented to the ED asking for help with detox resources (rarely), or people they were admitted for acute pancreatitis (usually). My concern is when a current patient became belligerent and agitated we had to put him in four point restraints and use medications like geodon to keep him and our staff safe. At the time he appeared alert and oriented to person, place, time and situation. He was demanding to leave AMA and threatening both physical violence to staff and legal actions to sue us for unlawful detention. He has a relative who is a lawyer that called into the unit and threatened similar action. Now, as a nurse I have a progress note from a consulting physician with a line in it that says patient can't leave AMA. I don't have an order, and as it has been explained to me, a PEC is not valid for patients receiving medical treatment, only patients that have been medically cleared and are receiving inpatient psychiatric treatment. I don't feel like a line in a progress note is sufficient to protect my license if one of these patients sues us. If a hospitalist writes "patient needs lasix administration" in a progress note, I don't administer lasix, I followed the prescribed orders in the chart. When I questioned the psychiatrist about this I was dismissed with a condescending statement that "I don't know how your nursing license works, sorry, but if you read my progress note you can see he can't leave". I was told there is no order associated with that note, but system wide that is sufficient to keep a patient against their will. I've tried numerous Google searches and checked scope of practice guidelines, but I don't see anything that appears to cover this issue. Does anyone have any insight? Thanks for any feedback.

My 2 cents: no , you don't have a clear order to keep the patient in. But you also don't have a discharge order either. 

Someone suggested risk management, do get in touch with them and go from there. If the whole mess ends up in a law suit, at least you can prove that you reported it and sought guidence from higher up. 

6 hours ago, JBMmom said:

We have recently had a few patients in our unit that have been evaluated by the psychiatrist and the psychiatric consult note states something like "Patient is not allowed to leave against medical advice because he lacks insight into his current condition. Patient has been cleared for suicidal or homicidal ideation and does not require a 1:1 sitter." These patients have generally been detoxing from alcohol, either because they presented to the ED asking for help with detox resources (rarely), or people they were admitted for acute pancreatitis (usually). My concern is when a current patient became belligerent and agitated we had to put him in four point restraints and use medications like geodon to keep him and our staff safe. At the time he appeared alert and oriented to person, place, time and situation. He was demanding to leave AMA and threatening both physical violence to staff and legal actions to sue us for unlawful detention. He has a relative who is a lawyer that called into the unit and threatened similar action. Now, as a nurse I have a progress note from a consulting physician with a line in it that says patient can't leave AMA. I don't have an order, and as it has been explained to me, a PEC is not valid for patients receiving medical treatment, only patients that have been medically cleared and are receiving inpatient psychiatric treatment. I don't feel like a line in a progress note is sufficient to protect my license if one of these patients sues us. If a hospitalist writes "patient needs lasix administration" in a progress note, I don't administer lasix, I followed the prescribed orders in the chart. When I questioned the psychiatrist about this I was dismissed with a condescending statement that "I don't know how your nursing license works, sorry, but if you read my progress note you can see he can't leave". I was told there is no order associated with that note, but system wide that is sufficient to keep a patient against their will. I've tried numerous Google searches and checked scope of practice guidelines, but I don't see anything that appears to cover this issue. Does anyone have any insight? Thanks for any feedback.

My 2 cents: no , you don't have a clear order to keep the patient in. But you also don't have a discharge order either. 

Someone suggested risk management, do get in touch with them and go from there. If the whole mess ends up in a law suit, at least you can prove that you reported it and sought guidence from higher up. 

BeenThere2012, ASN, RN

Specializes in PICU, Pediatrics, Trauma.

In CA, most of our patients come in on a 5150 hold (72 hours).  If within that time frame( down to the minute) the physician can document them unsafe for discharge, they can be placed on a 5250 (14 days) hold.  After that, 5270 (30 days). At the time they are placed on those holds, they are offered a hearing on site.  They don’t have to attend.  They have a lawyer assigned to their case. They can attend though and argue their side and the judge determines if they prevail or not.  If the patient prevails, they have to be discharged within a certain time frame.  If they do not prevail, they must stay for the remainder of the hold.  Of course, the doctor must document certain criteria to maintain the hold.  

The rare case where a patient is admitted voluntarily, or converts to voluntary status  after their 5150 is expired and they decide to leave, and the doctor does not feel they are safe to leave, they can be placed on a hold (5250) or leave AMA.  There is a lot of documentation that must be done for the AMA.  

For clarification, for any hold, the time periods are “up to” 72 hours, 14 days or 30 days respectively.  They may be stable enough before the holds expire and then the doctor can write the order for discharge.  

Hope this is helpful!

JBMmom, MSN

Specializes in Long term care; med-surg; critical care.

Thank you to everyone that took the time to get back to me. I'm definitely going to follow up by learning more about my state's laws in this area. I have a feeling that what some of these patients are experiencing is not within the legal scope. We are seeing more notes about patient being held because they "lack insight into their condition". In some of these situations it feels like they may not truly meet criteria to be held. I would say many of the people we deal with that are admitted for problems related to substance abuse lack insight into their condition. We have patients that medically detox all the time, even though they have no intention of stopping their behaviors. We can't force people to make healthy decisions. I appreciate the responses, to keep my license safe, and to do what's best for patients.

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

3 hours ago, JBMmom said:

Thank you to everyone that took the time to get back to me. I'm definitely going to follow up by learning more about my state's laws in this area. I have a feeling that what some of these patients are experiencing is not within the legal scope. We are seeing more notes about patient being held because they "lack insight into their condition". In some of these situations it feels like they may not truly meet criteria to be held. I would say many of the people we deal with that are admitted for problems related to substance abuse lack insight into their condition. We have patients that medically detox all the time, even though they have no intention of stopping their behaviors. We can't force people to make healthy decisions. I appreciate the responses, to keep my license safe, and to do what's best for patients.

"Lacking insight" generally is not considered adequate criteria for a hold.  A doctor's order is certainly not adequate to involuntarily detain someone.  If the "hold" process isn't appropriately followed, you need to open the door and let the patient walk.

On 7/15/2020 at 12:22 AM, NewRN'16 said:

My 2 cents: no , you don't have a clear order to keep the patient in. But you also don't have a discharge order either. 

Someone suggested risk management, do get in touch with them and go from there. If the whole mess ends up in a law suit, at least you can prove that you reported it and sought guidence from higher up. 

My 2 cents: no , you don't have a clear order to keep the patient in. But you also don't have a discharge order either. 

Someone suggested risk management, do get in touch with them and go from there. If the whole mess ends up in a law suit, at least you can prove that you reported it and sought guidence from higher up. 

Nobody needs a discharge order to leave AMA.  If the patient wants to leave, they can leave.  

I would call risk management if I were the OP and get clarification immediately on the legal process in their state.  You would be hard pressed to find a state that would allow a physician to make that decision unilaterally without any legal process. Those days are gone.

mmc51264, ADN, BSN, MSN, RN

Specializes in orthopedic; Informatics, diabetes.

I would think that if a person is deemed unfit to make the decision to leave AMA, they should be on a medical hold and require a 1:1 attendant. 

It sounds like a financial thing. If we have someone on a medical hold, we have an attendant. If they are not, they can leave AMA-it is STRONGLY discouraged and all help is given to avoid. 

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