Normally, if a pt wants to leave AMA, we'll call the doctor to come speak with them and if they still want to leave, we'll ask the pt to sign the AMA papers, and off they go. There are variations, of course. Some patients have been threatening AMA for days. Some are with us frequently and this is their pattern. Some patients have concerns or issues that we can resolve and they'll stay. But what happens if somebody is really ill and they want to leave AMA and not give us the chance to get some type of discharge plan together or if they're too sick to be discharged with any type of plan?
I had a doctor recently want to section somebody because he thought they were too sick to leave and if they wanted to leave being that sick, they much be irrational. It eventually resolved without getting to that point but we nurses were very uncomfortable with the whole scenario.
I'm curious what others experiences with this are.
I have thought about this on and off. I've had plenty of patients so sick nobody would bring them AMA papers even though they wanted to leave. If they are too weak to get out of bed, they can't even crawl, and no one will take them out of the room, it kind of becomes a moot point, I suppose.
I am thinking about one in particular - a young woman, post arrest, whose kidneys and liver were completely shot. She was bright orange, on continuous dialysis, so fluid overloaded that her skin was split open everywhere and her arms and legs were too heavy to lift, and she was on high doses of IV vasopressors. She was getting lactulose q4h to just keep her conscious and her entire backside was a giant excoriated wound from the continuous stooling and the continuous weeping out of her skin. She cried almost every night and asked to leave often. If I had turned off her IVs, she would have died in the room. Family wanted her to be a full code - said she was depressed, that she wasn't rational. Family was frequently threatening to sue us if they didn't agree with the plan. The patient was alert and oriented.
Out of curiosity, what would have happened if I had ever brought her AMA paperwork and turned her equipment off? She was definitely competent to sign. She definitely would have died in the room if I'd done it. What happens if someone signs AMA paperwork, but was a full code per family, and arrests in the room and we can't get a heartbeat back? What kind of legal implications are involved for the nurse?
Who said she was "definitely competent to sign"? Was that the opinion of the entire treatment team, or was that just your own opinion? In the first place, we don't deal with "competency" in the medical setting; "competency" is a legal status which is determined by the courts. Everyone is "competent," regardless of circumstances, until a court says that s/he isn't. In healthcare settings, we deal with (mental) "capacity," which is a specific and fluid construct and can vary from day to day, or even hour to hour.
There is a lot more involved in whether someone has the capacity to make her/his own decisions about treatment than whether the individual is alert and oriented. If someone needs "lactulose q4h to just keep her conscious," that sounds like she was being treated for encephalopathy (delirium), which can often render people (temporarily) incapable of making reasonable decisions for themselves (despite their knowing where they are and what the date is).
As for the consequences, I would hope that no nurse in that situation would do something like discontinue treatment independently, without conferring with the physician(s) involved. An action like that, with such severe and final consequences, should be the decision of the entire treatment team. In the scenario you describe, if the young woman's treatment were discontinued and she were allowed to die, I would assume it would be likely that the family would sue the hospital and physician(s) involved; it's possible that one or more individual nurses could be named in the suit, also. If an individual nurse chose to "go rogue" and independently discontinue treatment, disregarding the physician's orders, I would expect the family to sue that nurse and possibly even attempt to pursue criminal charges (and, in that scenario, the independent action of the nurse would pretty much let the hospital and physician(s) off the hook; I'm sure the family would try to sue them, but the fact that the nurse acted independently and counter to the physician's orders would be a strong defense).
It can indeed be done. Recently I had a female who was getting narcosis from her breathing difficulties. She was struggling and needed bipap desperately. Her ABG values were crap.
She wanted to sign out AMA and the doctor honestly felt she was a risk of dying that night.
In order to 302 for treatment, you need two separate physicians to attest that the condition is life threatening. It's a highly contested route to go and a lot of physicians won't second the medical commitment because they don't want to risk being sued for unlawful detainment.
I've been in PA for several years now, and I've never heard of a "medical commitment." A 302 petition is to detain people with psychiatric conditions for psychiatric evaluation in a psychiatric facility. Is there somewhere in the state that you can use a 302 to hold people for medical treatment against their will? That would never fly in my county. No wonder physicians in your area are reluctant to get involved; that's likely to get someone in serious trouble at some point.
ETA: And even the 302 petition and 303 commitment don't allow for involuntary treatment of the individual against her/his will; the individual can be detained against her/his will, but can still refuse treatment.
Everybody was consulted. A million (or so) different specialties, the intensivists, the hospitalists. Psych was consulted and the ethics committee was consulted. The ethics committee recommended withdrawing care because her current state was incompatible with life and she was not a candidate for organ transplant. The family refused. In my hospital, the ethics committee can only make recommendations - it means nothing if it's not what the family wants.
When she'd been getting her lactulose as ordered, it was beyond just knowing who and where she was - she could have perfect conversations, passed her CAM-ICU with flying colors, etc. No evidence of delirium that myself or anyone else could find. The physicians were even charting that she had full capacity to make decisions. Her liver failure was irreversible. They were more preventing encephalopathy from coming back in than treating it - she would need lactulose continually the rest of her life.
Psych also thought she had capacity to make decisions and gave us some extra things for depression and anxiety because she was miserable. Family promptly said she didn't need anything messing with her head. They often refused to let her have anything for pain, either, so if I wanted her not to hurt before doing a dressing change, I had to wait until a family member went to the bathroom to give her the pain medicine she was asking for unless I wanted to start a fight.
She stayed with us for three months in ICU before she got accepted by another hospital (because we were doing such a horrible job with her, obviously). She lasted less than a week at the other hospital before she died. It was a terrible situation, but looking back on it, I really do wish she'd been allowed to die like she wanted to, and we hadn't catered to her family so much and continually tortured her for the last three months of her life. This was one case where I can say that I felt like we did no good at all, and we actually did lots of harm to someone who didn't want it.
Everybody was consulted. A million (or so) different specialties, the intensivists, the hospitalists. Psych was consulted and the ethics committee was consulted. The ethics committee recommended withdrawing care because her current state was incompatible with life and she was not a candidate for organ transplant. The family refused. In my hospital, the ethics committee can only make recommendations - it means nothing if it's not what the family wants.
When she'd been getting her lactulose as ordered, it was beyond just knowing who and where she was - she could have perfect conversations, passed her CAM-ICU with flying colors, etc. No evidence of delirium that myself or anyone else could find. The physicians were even charting that she had full capacity to make decisions. Her liver failure was irreversible. They were more preventing encephalopathy from coming back in than treating it - she would need lactulose continually the rest of her life.
Psych also thought she had capacity to make decisions and gave us some extra things for depression and anxiety because she was miserable. Family promptly said she didn't need anything messing with her head. They often refused to let her have anything for pain, either, so if I wanted her not to hurt before doing a dressing change, I had to wait until a family member went to the bathroom to give her the pain medicine she was asking for unless I wanted to start a fight.
She stayed with us for three months in ICU before she got accepted by another hospital (because we were doing such a horrible job with her, obviously). She lasted less than a week at the other hospital before she died. It was a terrible situation, but looking back on it, I really do wish she'd been allowed to die like she wanted to, and we hadn't catered to her family so much and continually tortured her for the last three months of her life. This was one case where I can say that I felt like we did no good at all, and we actually did lots of harm to someone who didn't want it.
In my experience, these situations are the most gut-wrenching for all the professionals involved. I remember vividly one case in which I was involved, almost 20 years ago, when I was a member of the psychiatric consultation-liaison service of a large academic medical center (as I am now, at a different medical center). There was a woman on one of our units who had been fighting cancer for a number of years, and it had now metastasized throughout her body. She said that she was tired of fighting, she recognized there was no chance she was going to survive, she was tired of being sick and in pain all the time, and she wanted to discontinue all aggressive treatment and just be allowed to pass comfortably. Her two grown daughters were at the bedside and insisting that they wanted everything possible (i.e., active treatment of the cancer) done for Mom. My service was consulted to evaluate her capacity to refuse treatment, and I was the clinician who caught the case (although, in capacity cases, the final opinion had to come from our attending psychiatrist). We found that she had the capacity to make the decision and her wishes should be respected. The medical center ethics committee found that her wishes should be respected. The hospital caved and went with the daughters, which led to a prolonged period of her lying in the bed, awake and alert, and saying, "No, stop that, I don't want that, please don't do that" while the nurses were putting stuff in her IV. It was v. hard for the nursing staff involved. Of course, she did eventually die, but it was much more difficult and painful, for a much longer span of time.
In my experience, hospitals (and most physicians) will always side with the family, even when there are established Advanced Directives in place, because, as any hospital attorney will tell you, there's almost no chance someone will sue a hospital for keeping her/him alive, but families sue hospitals all the time for letting their family members die. It's a v. simple calculation, as far as they're concerned ...
In my experience, these situations are the most gut-wrenching for all the professionals involved. I remember vividly one case in which I was involved, almost 20 years ago, when I was a member of the psychiatric consultation-liaison service of a large academic medical center (as I am now, at a different medical center). There was a woman on one of our units who had been fighting cancer for a number of years, and it had now metastasized throughout her body. She said that she was tired of fighting, she recognized there was no chance she was going to survive, she was tired of being sick and in pain all the time, and she wanted to discontinue all aggressive treatment and just be allowed to pass comfortably. Her two grown daughters were at the bedside and insisting that they wanted everything possible (i.e., active treatment of the cancer) done for Mom. My service was consulted to evaluate her capacity to refuse treatment, and I was the clinician who caught the case (although, in capacity cases, the final opinion had to come from our attending psychiatrist). We found that she had the capacity to make the decision and her wishes should be respected. The medical center ethics committee found that her wishes should be respected. The hospital caved and went with the daughters, which led to a prolonged period of her lying in the bed, awake and alert, and saying, "No, stop that, I don't want that, please don't do that" while the nurses were putting stuff in her IV. It was v. hard for the nursing staff involved. Of course, she did eventually die, but it was much more difficult and painful, for a much longer span of time.
In my experience, hospitals (and most physicians) will always side with the family, even when there are established Advanced Directives in place, because, as any hospital attorney will tell you, there's almost no chance someone will sue a hospital for keeping her/him alive, but families sue hospitals all the time for letting their family members die. It's a v. simple calculation, as far as they're concerned ...
Why do you abbreviate the word 'very'? I don't mean to be inflammatory, I've just seen that a lot on this forum and it's not something I've seen elsewhere on the Internet.
In my experience, these situations are the most gut-wrenching for all the professionals involved. I remember vividly one case in which I was involved, almost 20 years ago, when I was a member of the psychiatric consultation-liaison service of a large academic medical center (as I am now, at a different medical center). There was a woman on one of our units who had been fighting cancer for a number of years, and it had now metastasized throughout her body. She said that she was tired of fighting, she recognized there was no chance she was going to survive, she was tired of being sick and in pain all the time, and she wanted to discontinue all aggressive treatment and just be allowed to pass comfortably. Her two grown daughters were at the bedside and insisting that they wanted everything possible (i.e., active treatment of the cancer) done for Mom. My service was consulted to evaluate her capacity to refuse treatment, and I was the clinician who caught the case (although, in capacity cases, the final opinion had to come from our attending psychiatrist). We found that she had the capacity to make the decision and her wishes should be respected. The medical center ethics committee found that her wishes should be respected. The hospital caved and went with the daughters, which led to a prolonged period of her lying in the bed, awake and alert, and saying, "No, stop that, I don't want that, please don't do that" while the nurses were putting stuff in her IV. It was v. hard for the nursing staff involved. Of course, she did eventually die, but it was much more difficult and painful, for a much longer span of time.
In my experience, hospitals (and most physicians) will always side with the family, even when there are established Advanced Directives in place, because, as any hospital attorney will tell you, there's almost no chance someone will sue a hospital for keeping her/him alive, but families sue hospitals all the time for letting their family members die. It's a v. simple calculation, as far as they're concerned ...
Specializes in Psych, Addictions, SOL (Student of Life).
Out of curiosity, what would have happened if I had ever brought her AMA paperwork and turned her equipment off? She was definitely competent to sign. She definitely would have died in the room if I'd done it. What happens if someone signs AMA paperwork, but was a full code per family, and arrests in the room and we can't get a heartbeat back? What kind of legal implications are involved for the nurse?
Even if she signed AMA I would be reluctant to turn every thing off. What I would have done in this particular case with an alert and oriented patient who was clearly dying would be to contact the physician to order a psych consult to determine if she was competent to make her own decisions. Once competency was established. The Physician can order a hospice consult if the patient so desires. The patient has the right to discontinue burdensome measures and change over to comfort measures only. In that case she could go home and pass in her own bed. If the family disagrees or refuses to take her home. She can receive comfortable end life care in the hospital or more likely be transferred to a skilled nursing facility to finish her journey. In this way the patient does not leave AMA but rather receives continuous care according to her wishes. I suspect that once comfort measures were put in place she would have passed prior to a transport being arranged.
As a side note this is exactly why each and every one of us and our loved ones should execute an advanced directive so there is no question what out wishes are with regard to end of life care. I executed one at the age of 50 when I had colon surgery because even though I was relatively young and strong one never knows what can happen when they are under anesthesia. I also told my husband that if he ever tried to keep me alive on machines when meaningful quality of life was impossible I would haunt him to his grave and not in a nice way.
Hppy
PS - I apologize for any grammatical of spelling errors - my keyboard has issues.
Why in the **** is family given so much power over people over age 18 and clearly expressing wishes?? Even simple wishes like refusing the med in the RN's hand? Competent people have the right to autonomy. Why is it difficult to say, "this pain med is ordered, she needs it, and she's getting it?" Or "She is a&o, she just refused her med. Legally I can't give it; it's a form of battery."
Why in the **** is family given so much power over people over age 18 and clearly expressing wishes?? Even simple wishes like refusing the med in the RN's hand? Competent people have the right to autonomy. Why is it difficult to say, "this pain med is ordered, she needs it, and she's getting it?" Or "She is a&o, she just refused her med. Legally I can't give it; it's a form of battery."
I really don't understand.
I also don't understand medical personnel who try to force patients to have treatments they refuse. If the patient has decision making capacity and they want to leave, let them leave. If they don't want the life-saving treatment and they understand what they are refusing, let them refuse.
It seems medical personnel and families only respect autonomy when they agree with the patient's decision.
I've had a few people leave AMA and it was usually about pain meds or alcohol. It is becoming more of a problem now that Dr's are being told to give less narcotics and so the patient that was used to being catered to with lots of high dose narcotics is now admitted and offered much less for chronic pain. Then becomes irate and leaves when he cannot blackmail the Dr and staff into increasing his narcs. I expect more people will leave AMA for this reason. Had an alcoholic leave AMA in withdrawal and I blame the prior nurse in part for not giving enough ativan to control his withdrawal, also a change away from scheduled and prn ativan that waited for patients to go into withdrawal. Another stupid change from TPTB! He left to go to the nearest bar and refused my effort to give him some ativan. Usually only the confused patients are not allowed to leave AMA.
I've been in PA for several years now, and I've never heard of a "medical commitment." A 302 petition is to detain people with psychiatric conditions for psychiatric evaluation in a psychiatric facility. Is there somewhere in the state that you can use a 302 to hold people for medical treatment against their will? That would never fly in my county. No wonder physicians in your area are reluctant to get involved; that's likely to get someone in serious trouble at some point.
There might be a little used mechanism for that in PA. I know from experience that Virginia has a medical Temporary Detention Order (TDO) process that is similar to the psychiatric TDO process in that a magistrate gets involved to issue the order, but I have only seen it used one time. I remember that the magistrate asked our ED physician if the patient would die in the next 24 hours if he/she went home. The doc said yes, and the patient was medically detained. Rarely used in my experience, but there it is.
There might be a little used mechanism for that in PA. I know from experience that Virginia has a medical Temporary Detention Order (TDO) process that is similar to the psychiatric TDO process in that a magistrate gets involved to issue the order, but I have only seen it used one time. I remember that the magistrate asked our ED physician if the patient would die in the next 24 hours if he/she went home. The doc said yes, and the patient was medically detained. Rarely used in my experience, but there it is.
The TDO in Virginia may only be used if the person is not able to provide informed consent because of their illness and injury and if they will suffer death, disability, or serious irreversable injury within the next 24 hours because of that illness or injury.
elkpark
14,633 Posts
Who said she was "definitely competent to sign"? Was that the opinion of the entire treatment team, or was that just your own opinion? In the first place, we don't deal with "competency" in the medical setting; "competency" is a legal status which is determined by the courts. Everyone is "competent," regardless of circumstances, until a court says that s/he isn't. In healthcare settings, we deal with (mental) "capacity," which is a specific and fluid construct and can vary from day to day, or even hour to hour.
There is a lot more involved in whether someone has the capacity to make her/his own decisions about treatment than whether the individual is alert and oriented. If someone needs "lactulose q4h to just keep her conscious," that sounds like she was being treated for encephalopathy (delirium), which can often render people (temporarily) incapable of making reasonable decisions for themselves (despite their knowing where they are and what the date is).
As for the consequences, I would hope that no nurse in that situation would do something like discontinue treatment independently, without conferring with the physician(s) involved. An action like that, with such severe and final consequences, should be the decision of the entire treatment team. In the scenario you describe, if the young woman's treatment were discontinued and she were allowed to die, I would assume it would be likely that the family would sue the hospital and physician(s) involved; it's possible that one or more individual nurses could be named in the suit, also. If an individual nurse chose to "go rogue" and independently discontinue treatment, disregarding the physician's orders, I would expect the family to sue that nurse and possibly even attempt to pursue criminal charges (and, in that scenario, the independent action of the nurse would pretty much let the hospital and physician(s) off the hook; I'm sure the family would try to sue them, but the fact that the nurse acted independently and counter to the physician's orders would be a strong defense).
Was psychiatry consulted on this case? I hope so.