RMA vs AMA: Refusing vs Against medical advice?

[FutureDNP2021, ASN, RN]

Ive seen partial refusals of tx during a pts continued admit, but sometimes pts are discharged AMA if they are refusing or non-compliant with tx. Please help me to understand the difference here in accordance with hospital policies regarding these two and how this affects their treatment plan.

It seems that a pt would be discharged for major non-compliance (refusal) to tx because the facility can no longer be responsible for a pts outcome? (This would be different than discharge AMA where the pt wants to abruptly leave the facility, which is discharge AMA).

So, my question is where exactly is the line drawn for such situations? How do we determine minor refusals (eg. pt doesn't want their multivitamin today, or too tired to do PT) and they're still able to continue with their admitted stay, versus major non-compliance/refusal of tx so that they would be discharged?

I hope I am explaining this question well, sorry I am very unclear on this issue. Thank you

[YoutubeTheNP]

AMA is when the pt wants to go home, but the attending physician is not ready to discharge the patient.

Refusing care in the hospital is not grounds for a AMA (PT, meds, food, whatever). We can't kick people out for not cooperating fully if they aren't safe to be discharged. A simple 'patient refused' next to whatever s/he didn't want will suffice and the attending should discuss the problems with the patient.

[AliNajaCat]

We don't use the word "compliant" anymore. In the military you must comply with an order; as taxpayers, we must comply with IRS regulations; as drivers, we must comply with rules of the road. Patients ALWAYS have the ability to choose not to adhere to any part of a medical or nursing or physical therapy or dietary plan of care, if they have not been declared incompetent by a court of law; in that case, the person with health care proxy or power of attorney or legal guardian has that right on the patient's behalf. Ignoring that and proceeding with unwanted treatment can make you liable for assault and battery.

Any physician or hospital that feels vulnerable to reprisals or lawsuit of malpractice can ask a patient to sign a release acknowledging possible results of nonadherence to (the prescribed plan of care). A physician can refuse to treat a patient and "fire" the patient from the practice who does not adhere to plan of care; you don't have to treat someone who doesn't want treatment. Again, a pt-signed treatment contract and acknowledgment from the patient protects the physician.

Your role as a nurse is to explain the consequences of nonadherence to your documented NURSING plan of care, e.g., "We want to turn you every two hours because if we don't you could suffer skin breakdown, and these wounds would be painful and a source of infection." "Your physician has prescribed XYZ; this is what it's for, and if you don't choose to take it/do it, your condition will not get better/could get worse/ whatever." When you document, you say, "I told the patient 'We want to turn you every two hours because if we don't you could suffer skin breakdown, and these wounds would be painful and a source of infection.' He refused, saying, "I don't care, leave me alone, I want to lie still." If you have to document this q2hrs, do it; your position will be much, much stronger when the records are reviewed in a malpractice action. I have seen charts of refusals over time, such as dates and times that food, respiratory treatments, meds, and the like were refused, on a graph with relevant outcomes, like weight, wound diameter, labs, or whatever. That downward curve is an impressive piece of evidence when it ends in death or serious other consequence. It only works with consistent documentation all the way along the line.

In answer to your specific question, there is no bright line or list that says, "The patient can refuse a multivit but not surgery," or anything remotely like it. Your hospital has an ethics committee; the nursing staff should contact a member as soon as this sort of thing becomes an issue, so they can help the patient and the staff discover the best, ethical course of action.