When a patient signs out AMA...

[Lev, MSN, RN, NP]

Every so often, I have a patient who signs out AMA for the dumbest reason when they really really should stay in the hospital.

Example: We just shot your thighs with epi about 30 minutes ago for the anaphylactic reaction you're having and you want to leave??

Another example: Came in with shortness of breath. Oh your troponin is bumped...you could be having a heart attack or have a blood clot in your lungs and you want to leave??

Both true examples.

These people make me so mad.

For your typical ER patient who doesn't really need to be in the ER, is yelling at everyone and demanding things, sure sign your AMA form and get out of my face. Bye!

However, when they actually have a legit reason to be observed in the ER/stay in the hospital overnight, the nurse in me kicks in and I don't care about how nasty and demanding they've been. I just want them to be helped. And they just don't care. And that is why I get mad.

And you know what happens then? Whatever professional attitude I've had with them til that point just disappears. I told patient #1 she was being "stupid." Because she was. The doc was like "we just saved her life and she wants to leave?" I get short with them and my annoyance shows. This is after a conversation about how they can die and we won't be responsible. I know this isn't professional and I want to change this behavior.

So what do I do?

[elkpark]

Take a deep breath and remind your self that autonomy is one of the ethical principles that guide our practice. People have the right to make bad decisions for themselves, as long as they have the mental capacity to make decisions. Provide the appropriate and necessary education (or, at least, attempt to ...), document everything like mad, and watch them walk away. It's not your problem. If there is concern that the person may lack the capacity to make an informed decision, that's a different matter and needs to be investigated further.

[RiskManager]

In addition to elkpark's fine comments above, I also ask the patient to sign an AMA form, and I often put something on it about the patient falling over dead if they leave, so the heirs of the patient cannot say that the patient was not warned.

[TheCommuter, BSN, RN]

Unfortunately, we cannot keep the obtuse ignorati from harming themselves, even when the cause of the harm is totally preventable.

This is my reason for placing these types of patients in one compartment while ensuring that the people in my personal life go into the other compartment. You cannot fully help someone who doesn't want the help.

[springchick1, ADN, RN]

Remind them that in most cases, insurance won't pay the bills if they leave AMA (assuming they have insurance).

[JustBeachyNurse, LPN]

Remind them that in most cases, insurance won't pay the bills if they leave AMA (assuming they have insurance).

That is a common belief but nothing more than an urban legend. The threshold is if the care received was medically necessary and commercial insurance, Medicaid & Medicare will pay.

Will My Insurance Pay If I Leave Against Medical Advice (AMA)?

Do patients pay when they leave against medical advice? - The University of Chicago Medicine

From this study:

Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?

"No cases of payment refusal were because patient left AMA."

[coffeetalker]

I think elkpark has it --- one of the hardest things for me to learn as a nurse is that "people have the right to make bad decisions'- all we can do is educate- and tell the pt what to do if symptoms continue- ie call 911, come to ER, etc. (and on your drive home be glad that you are not the kind've person who would leave AMA )

[JustBeachyNurse, LPN]

You don't know what else is going on in their life. Not every one is an over sharer. You educate and let a competent patient make an informed decision.

[CountryMomma, ASN, RN]

I close my eyes, take a deep breath, and wish them the best while acknowledging that I probably will see them again in much worse condition, shortly.

To go along w JBN, there may be factors at play beyond your knowledge. One I can think of recently is a cousin o'mine who received a bad lac on his dominant hand while repairing a car for a client. His bipolar baby-mama was threatening to run away with their 3 m/o baby, again. He left the ER w/o stitches, tetorifice shot, X-ray, or antibiotics. Signed AMA and rushed home to make sure baby girl was safe and mama wasn't dead crazy. He didn't tell anyone because he was terrified they'd call the cops, have mama committed, and have CPS take baby girl.

[Lev, MSN, RN, NP]

Take a deep breath and remind your self that autonomy is one of the ethical principles that guide our practice. People have the right to make bad decisions for themselves, as long as they have the mental capacity to make decisions. Provide the appropriate and necessary education (or, at least, attempt to ...), document everything like mad, and watch them walk away. It's not your problem. If there is concern that the person may lack the capacity to make an informed decision, that's a different matter and needs to be investigated further.

So true! Thanks for reminding me that this is a patient right.

[Lev, MSN, RN, NP]

I guess I should just be a big person, and focus on giving them the most education possible before they do leave so they know when they should come back so if something does happen to then at least the outcome may be better if they are properly educated.

[JustBeachyNurse, LPN]

And there just may be more to the story. Did you ask why? Not that you have time but you may get an interesting response