When a patient signs out AMA...

Nurses Relations

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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?

Specializes in Family Nurse Practitioner.

Well one had one last night with their significant other and needed to catch a flight then next morning. The other one was hungry and family was in the waiting room. I tried to reason with them both and give them options...

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If they're well enough to walk out the door (or in one case climb out the window), I just wave goodbye. As long as they've been informed of their condition and advised medically, I'm OK with whatever decision they make.

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In many ER's with the introduction of Narcan at the first responder/field level, it has been a revolving door. With lots of very bad feelings that we wasted their money and their drugs.

And it is the fault of the ER staff that they have the potential to be thrown into acute withdrawal. Which is beyond dangerous.

Nevermind that they were blue and breathing at about 4-6 a minute.

Unfortunately, there's a dealer on every corner. Who give the AMA'ers a better deal.

Unfortunate.

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Specializes in ICU, LTACH, Internal Medicine.

Modern medicine is not able to do brain transplants just yet. And, in any case, you wouldn't give up your own brain to someone else. This someone else got his own and has right to use it as he sees fit. He already did a good gazillion of bad decisions such as eatiing badly, ignoring symptoms, etc. So just one more bad decision, even if it will be the final one.... it's ok. Take a deep breath.It is their decision, not your mistake.

P.S. i signed myself AMA within six hours after anaphylaxis twice. The thing is, i live with it for decades and pretty much know myself. If I start to get pushed to do things I know I do not need just because "it is our policy here" or I see that hospital is clearly not capable of doing what they supposed to do, I just nicely and politely, without undue fuss, run away. Sorry, but I will refuse benzos, pain killers and unnecessary tests (yeah, CT head/neck for anaphylaxis because "doctor needs to know your neck is ok in case you will need intubation" - those who push tubes down will understand, especially without any history or anyrhing else poising on possible difficult airways) unless situation is clearly requiring so, and I will get out the heck out of the place where patient brought there because allergic reaction on chocolate is given a plate of their homemade chocolate chip cookies because "it is our new hospitality policy here and iamjystdoingmyjob".

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Specializes in Allergy/ENT, Occ Health, LTC/Skilled.

Well I do not work in the hospital, I feel for you in this. In LTC, it takes everything I have to not want to scream at families who make their 90 year old mother w/ a g tube and dementia full code. I had to do CPR on a bed ridden 80 year old patient with no quality of life because her daughter wanted the works. The patient was never alert and moaned in pain no matter how much pain meds the doctor's supplied to her. It broke my heart to do that to her but I had no choice in the matter. When things like this happen, I just tell myself that I can't control other peoples selfish or harmful actions and I have to let it roll off of me for the sake of my employment.

It's very nice you care but you may just need to approach it in a very removed outlook if that makes sense. Give them the best care, educate them on what may happen, but if they sign that AMA paper once that's done, wish them a good day and send them on. It does sound quite cold but personally it's how I have had to handle these types of things in order to keep a professional demeanor.

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In many ER's with the introduction of Narcan at the first responder/field level, it has been a revolving door. With lots of very bad feelings that we wasted their money and their drugs.

And it is the fault of the ER staff that they have the potential to be thrown into acute withdrawal. Which is beyond dangerous.

Nevermind that they were blue and breathing at about 4-6 a minute.

Unfortunately, there's a dealer on every corner. Who give the AMA'ers a better deal.

Unfortunate.

Oh, yeah ... I work in the psychiatric consultation-liaison service in a small community hospital (which is part of my large academic medical center employer) and we often get called for capacity evals on people who were admitted in some kind of EtOH/drug related crisis, the immediate crisis has been stabilized, and the individual now wants to leave. The physician and nursing staff want them to stay for detox and feel it's unsafe to let them just leave because they are at risk of going into life-threatening withdrawal without appropriate medical treatment. I spend a lot of time explaining to the medical folks that they don't have to worry about this person going into withdrawal because s/he has no intention of going into withdrawal, s/he is going to use again as soon as s/he leaves the hospital, so that's not a safety concern (this particular issue never came up in the big, downtown teaching hospital, everyone there "got it," but it's a big deal in the suburban community hospital in which I'm based now).

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Specializes in Acute Care Pediatrics.

Really the only thing you can do is make sure they have all the right information. Educate and inform. And then hand them the AMA papers. I can usually scare people into staying using the "insurance won't pay the bill if you leave AMA" card.

Why do the ones I wish WOULD leave AMA stay forever?

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Specializes in ER, Med-surg.

I usually state their risks in leaving as clearly and non-technically as possible ("You could drop dead on your way in to the house, or have a stroke that leaves you unable to talk or feed yourself..." or whatever is relevant), make sure they know the symptoms that indicate they should come back ASAP, and document the crap out of their education and then get 'em to sign the AMA form and compartmentalize it mentally under "no longer my problem."

It can be frustrating, but I have patients who *do* want my help to focus on.

The only time I've been completely unable to handle it was when a not-quite-term pregnant woman who'd had no prenatal care other than a pregnancy test and dating ultrasound at our ER at the four month mark came in for "stomach pain" (labor) and then signed out rather than transfer to the womens' hospital. She made it clear she wasn't going to another hospital, but home because "it'll be fine." Not like "I have a homebirth plan and a midwife and a doula on call" kind of fine, but "I'm in denial about my pregnancy" kind of "fine."

I hope she didn't die of an undiagnosed placental abruption in her bathroom but who knows.

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Specializes in Complex pedi to LTC/SA & now a manager.
Really the only thing you can do is make sure they have all the right information. Educate and inform. And then hand them the AMA papers. I can usually scare people into staying using the "insurance won't pay the bill if you leave AMA" card.

Why do the ones I wish WOULD leave AMA stay forever?

You know the insurance won't pay if you sign out AMA is a total fallacy. Signing out AMA does not determine payment but reasonable medical necessity of treatment received prior to leaving the facility determines payment.

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

We were told we are not allowed to say this( not sure why)

Most of the time they are medicaid anyway, or have no insurance ( maybe thats why they want to leave :(

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

Unless you work for the insurance company they have coverage with you have no business telling patients this. In many cases it's just not true. My experience with AMA patients is that tend to be uninsured.

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Specializes in Complex pedi to LTC/SA & now a manager.
Unless you work for the insurance company they have coverage with you have no business telling patients this. In many cases it's just not true. My experience with AMA patients is that tend to be uninsured.

Exactly see my links above

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