When a patient signs out AMA...

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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 Pediatric Hematology/Oncology.
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).

Hmmm...I've never thought of it that way. Truly they have no intention of going home and trying to weather the detox storm themselves. Sad but it's common sense and I'll have to remember that in the future.

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it is not "what you do not know, but what you know ,that is not so " telling someone that their insurance will not pay if they leave AMA is telling them to NOT beleave a word that comes out of your mouth, when they know for a fact you are wrong.

my mother was a nurse and one time when going to the doctor, the nurse taking her vitals had left her watch at home and stared at her wrist as she took my mothers pulse. when the doctor came in, my mom hit him hard with the information the nurse wrote down was fraudulant and left immediately.

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would you want your automobile repair person to "scare" you into getting a complete engine overhaul when your problem is a blown head gasket? or how about the local police scaring your 17 year old son or daughter into making a confession to a crime that they had no evidence to even charge them with?

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It's been used as a scare tactic & coercion for years towards patients making an informed decision to sign out AMA.
and used by cops to gain confessions by claiming "your buddy is in the other room telling us it was all your doing, if he signs before you do, your going to prison"
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What about pts that sign out AMA but need EMS transport? Is the hospital supposed to arrange that?

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Specializes in Complex pedi to LTC/SA & now a manager.
What about pts that sign out AMA but need EMS transport? Is the hospital supposed to arrange that?

Why would one need EMS/911? Or do you mean invalid coach/mobility assistance vans? If bed bound would they not meet the criteria for stretcher or wheelchair transport upon discharge whether self initiated discharge vs physician/provider initiated discharge? If medically necessary Medicare/Medicaid/insurance will pay for a mobility assistance vehicle team to transport the patient home

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Specializes in PCCN.
What about pts that sign out AMA but need EMS transport? Is the hospital supposed to arrange that?

we usually have social work handle this part.They usually arrange a cab or medicab.

I dont have time to judge anymore. It is what it is

Gaming (or not gaming) the system has been going on for a long time. It isnt about to stop.

Some people do get emergencies - one gal couldnt get a hold of her 15 year old kid who was by himself. I understand why she left AMA ( she was stable)

Also, I'd rather the etoh/drugs person just go back to what they were doing. I really hate detoxing people who have no intention of staying that way- no matter what help theyve been offered or how many rehab sessions theyve had. Nothing personal- i just hope they dont drive( and they usually dont)

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Specializes in Palliative.
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.

Yep we had one that went ama because we took all the isogel away from him, and promptly died a few blocks from the hospital. Sure enough the family called the police and claimed we discharged him while he was still sick. The signed ama papers of course said otherwise.

While you don't mince words with such people, you can't make them do what they don't want to. It IS their life to risk.

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Last summer I had a patient come in for high blood sugar. She had run out of her diabetes meds because she couldn't afford them (though she could afford her cigarettes) and now she was in DKA. She was all set to be admitted to the icu when she told me she wanted to go home. She said she needed to be with her kid. I explained to her how important it was for her to stay (she was super acidotic and her sugars were in the 800s) and asked if there was anyone else to watch her child. It took some convincing but she ended up deciding to stay. I got her up to the icu so impressed with myself for explaining effectively to her the importance of her remaining in the hospital to continue her treatment.

Four hours later, we had a 7 year old boy come in for a drowning. They were at a pool party and everyone just assumed he could swim. Turns out, that was her kid. The boyfriend was her option for childcare and he didn't know the boy couldn't swim and just stopped watching him. We lost that little boy.

I will never again question a patient's reason for leaving AMA. You never know what their reasons for leaving really are.

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Specializes in PCCN.

Four hours later, we had a 7 year old boy come in for a drowning. They were at a pool party and everyone just assumed he could swim. Turns out, that was her kid. The boyfriend was her option for childcare and he didn't know the boy couldn't swim and just stopped watching him. We lost that little boy.

I will never again question a patient's reason for leaving AMA. You never know what their reasons for leaving really are.

omg that is just absolutely horrrible!!!!:(

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Specializes in Critical Care (ICU/CVICU).

who has time to convince aalert and oriented person to not leave AMA? I personally LOVE when patients decide to go AMA. These patients are usually the more difficult ones to deal with. Want to leave?? Sure! AMA papers will be printed before they even finish asking the question.

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Last summer I had a patient come in for high blood sugar. She had run out of her diabetes meds because she couldn't afford them (though she could afford her cigarettes) and now she was in DKA. She was all set to be admitted to the icu when she told me she wanted to go home. She said she needed to be with her kid. I explained to her how important it was for her to stay (she was super acidotic and her sugars were in the 800s) and asked if there was anyone else to watch her child. It took some convincing but she ended up deciding to stay. I got her up to the icu so impressed with myself for explaining effectively to her the importance of her remaining in the hospital to continue her treatment.

Four hours later, we had a 7 year old boy come in for a drowning. They were at a pool party and everyone just assumed he could swim. Turns out, that was her kid. The boyfriend was her option for childcare and he didn't know the boy couldn't swim and just stopped watching him. We lost that little boy.

I will never again question a patient's reason for leaving AMA. You never know what their reasons for leaving really are.

Terrible turn of events. But I don't thinks a patient in DKA would be well enough to save a drowning child. Or even really be present enough to focus. I don't want to sound cold hearted, but if she had taken care of her self in the first place then maybe that awful situation would have never happened.

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