When a patient signs out AMA...

[Lev]

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?

[JustBeachyNurse, LPN]

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

Because it's simply not true whether Medicaid, Medicare or commercial insurance.

[Susie2310]

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

From reading on the internet, my guess is that this could be because of the facility's need to act in accordance with the law in regard to the subject of payment for medical care, right to receive care, etc.

[sharkdiver]

1 2:10 pm by jrwest

Quote from springchick1

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

Because:

A. It is false

B. By lying to the patient you are engaging in an act of coercion, which invalidates any subsequent consent - exposing both you and the facility to possible legal repercussions

This kind of stuff drives risk management folks nuts!

Please, Please, Please - just play it straight and do your job!

[elkpark]

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.

That sounds like the kind of situation in which a deeper evaluation of her capacity to make the decision to leave might have been in order, and the kind of situation for which my service often gets consulted for capacity.

[springchick1, ADN, RN]

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."

Thanks for the info. I had no idea. I actually had more than one clinical instructor in school tell our groups that. Guess I should have done some research myself.

[JustBeachyNurse, LPN]

Thanks for the info. I had no idea. I actually had more than one clinical instructor in school tell our groups that. Guess I should have done some research myself.

It's been used as a scare tactic & coercion for years towards patients making an informed decision to sign out AMA.

[emmy27]

That sounds like the kind of situation in which a deeper evaluation of her capacity to make the decision to leave might have been in order, and the kind of situation for which my service often gets consulted for capacity.

Eh, denial was perhaps the wrong term. She was fully aware she was pregnant, she already had a child (with her), she was certainly fully alert and oriented. Her mother came (to bring a car seat, because she had been dropped off and wanted to leave with a ride who didn't have a car seat- and would have if no one had intervened) had exactly the same attitude- that we were crazy to suggest that she should go to another hospital for a higher level of care. She (the mother) even got angry at us for being "not positive-thinking." Her explanation for why she didn't get any prenatal care other than the one earlier visit to us was that she hadn't had any for her first child and "he turned out fine."

Neither of them was on the shortlist for a MacArthur genius grant, but they weren't incapacitated. Unless we can redefine incapacitated as "making poor decisions based on magical thinking" in which case nearly all of my patients are incapacitated.

[BuckyBadgerRN, ASN, RN]

How did you come up with that one? If they received treatment in the ER and insurance is billed, they'd have no reason NOT to pay it. Insurance "will" pay 2 days for a lady partsl delivery, if Mom wants to leave 4 hours after delivery and the MD thinks it would be a good idea if she stayed, but Mom insists, you really think that insurance isn't going to pay?!

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

[springchick1, ADN, RN]

How did you come up with that one?

I had two different clinicals instructors tell me that in school. Like I told JustBeachy, I should have looked into myself.

[RiskManager]

This kind of stuff drives risk management folks nuts!

I thought I felt a disturbance in the Force...

[Anna Flaxis, BSN, RN]

Aside from explaining the risks in layman's terms, ascertaining their reason for not wanting to stay is a good idea. It could be something you or a social worker (if your facility has one available) can help with.

Example: Elderly lady who was really sick and needed to stay wanted to go home because she had nobody to feed her cats. The social worker was able to make arrangements for someone to feed the cats, so the lady stayed.

Another time, the patient was an elderly man who was the caretaker for his wife with dementia. He didn't want to stay, because he didn't want to have to ask anyone to help care for his wife. The social worker spoke with the pastor of the man's church (with his permission, of course), and was able to arrange for the church congregation to help out until family members could arrive from out of town.

If you have social workers available, use them! Sometimes people have really valid reasons for wanting to leave, but if those reasons can be addressed, then they will choose to stay.

[imintrouble, BSN, RN]

I shouldn't admit this, as a nurse posting on a nursing forum, but I was one who visited an ER and left AMA.

I was one who believed the whole insurance thing, but my private pay insurance paid that claim.

It was a stupid thing to do. I was every stupid patient I ever took care of. My reasons were valid. At least they were to me.

I think, and again I hate to admit it, I didn't trust the health care people taking care of me. I didn't trust that they were telling me the truth about why I needed to be admitted. I absolutely know that a few of my AMAs felt the same about me.

In my case at least, my psych issues trumped my intelligence.