Refusal of treatment in the ER?

[chasingdaylight]

I had a couple cases highlighting issues of consent for treatment and wondered what others would have done. Sorry it turned out so long.

Case 1
40 yo male patient brought in by police, involved in altercation with "nobody" and has a good sized 6-8 cm lac on forearm. Admits to having had a "few beers." He is verbally abusive, generally loud, yelling, "I ain't no chump, not gonna snitch! I'm gonna sue you, let me go!" police turn him over to the ER and he is not under arrest.

Tachycardic at 120, BP 90/70. Alert, oriented to person, place and time. Keeps repeating "I ain't no chump." Appears "buzzed" but not incapacitated.

Unable to convince him it's in his best interest to stitch him up and examine wound or even look for other injuries. One of the EMT's says the patient has successfully sued police for "unlawfully restraining him" in the past. I look him up on Google, and sure enough, he won a large settlement vs the city.

Do you forcibly restrain, sedate and treat him? let him walk out?



Case 2
Police bring 35 yo male for "medical clearance" so that they can take him to booking.
Patient refuses vitals, non-cooperative, refuses to answer questions, refuses exam, appears slightly diaphoretic (drugs? anxious? sepsis?)

Police insist that you "clear him" for them.
Our site apparently has an agreement with local PD to offer medical clearance of their prisoners for booking. Do you just send the officer away and deal with the complaints later?
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Here's what happened in my cases. A few ladies solved the problem for me.

Case 1, after much back and forth, his girlfriend finally convinced him to let us stitch up his arm and do a more thorough exam.
Case 2, one of our younger female nurses struck up a conversation with him, and he let her take his vitals, and let us then examine him, subsequently was "medically cleared"

What specific criteria do you have for restraining/forcing treatment on patients?


Thanks for your input!
Stretch

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[Birdstrike]

I had a couple cases highlighting issues of consent for treatment and wondered what others would have done. Sorry it turned out so long.

Case 1
40 yo male patient brought in by police, involved in altercation with "nobody" and has a good sized 6-8 cm lac on forearm. Admits to having had a "few beers." He is verbally abusive, generally loud, yelling, "I ain't no chump, not gonna snitch! I'm gonna sue you, let me go!" police turn him over to the ER and he is not under arrest.

Tachycardic at 120, BP 90/70. Alert, oriented to person, place and time. Keeps repeating "I ain't no chump." Appears "buzzed" but not incapacitated.

Unable to convince him it's in his best interest to stitch him up and examine wound or even look for other injuries. One of the EMT's says the patient has successfully sued police for "unlawfully restraining him" in the past. I look him up on Google, and sure enough, he won a large settlement vs the city.

Do you forcibly restrain, sedate and treat him? let him walk out?



Case 2
Police bring 35 yo male for "medical clearance" so that they can take him to booking.
Patient refuses vitals, non-cooperative, refuses to answer questions, refuses exam, appears slightly diaphoretic (drugs? anxious? sepsis?)

Police insist that you "clear him" for them.
Our site apparently has an agreement with local PD to offer medical clearance of their prisoners for booking. Do you just send the officer away and deal with the complaints later?
-
-
-
-
-
-
-
Here's what happened in my cases. A few ladies solved the problem for me.

Case 1, after much back and forth, his girlfriend finally convinced him to let us stitch up his arm and do a more thorough exam.
Case 2, one of our younger female nurses struck up a conversation with him, and he let her take his vitals, and let us then examine him, subsequently was "medically cleared"

What specific criteria do you have for restraining/forcing treatment on patients?


Thanks for your input!
Stretch

Don't make this more complicated than it has to be. The issue is whether or not the patient has the mental capacity to understand the consent/consent-refusal process, or not, and your documentation to that effect. Prior to even addressing any of this, you need to determine that, and your chart needs to reflect that proof. You don't have to prove zero ETOH level, you don't have to prove the patient is rationale. You document some basic clinical sobriety testing, A&O times three, and whether or not the patient is able to comprehend the risks of AMA. Document lack of suicidality, homicidality & lack of clinically significant alteration in mental status.

Whether the patient had a non-intoxicating amount alcohol, is an irrational jerk, or is under arrest is irrelevant.

Just make sure your chart reflects a quality neuropsych, mental status & and clinical sobriety eval, so that if they bounce back after signing out AMA, your chart proves any alteration occurred after they left and came back, and clearly wasn't present when they were on your watch. If you can't assure yourself they aren't sober enough clinically, there isn't some sort of medical mental status alteration, or suicidal/homicidal intent, then you have to restrain and treat. Similarly, if you do so, your chart must document those factors proving the patient was altered and that you acted on an emergency basis in the best interest of the patient, during a time period the patient was unable to do so for their self. That way if some bogus lawsuit attempt comes along, your chart states the alteration ("patient ataxic, slurring speech, incoherent, past pointing with cerebellum testing, and unable to give informed consent/refusal") and it will get thrown out of court at some point during the legal process. If your chart is sparse and doesn't show your proof of the patients ability to give/refuse consent, or lack thereof, then you've left yourself vulnerable.

Document

Document

Document

 

[Rendar5]

Ditto

 

[Zebra Hunter]

Question from a medical student. Is getting a patient to sign an AMA form really necessary? I was under the impression that a patient signing such a form does little in the way of protecting the provider and can come off as a bit confrontational from the patient's viewpoint. "Oh, you want to leave? Well sign these papers first."

 

[southerndoc]

Birdstrike basically said it all. They either have capacity or they don't, and your documentation should reflect that. Your nurse's documentation should also support yours. If they're acting irrational, then they probably don't have capacity to make decisions. (Irrational overall, not irrational because they don't want something to happen that we think should.)

I had a guy a few years ago who refused the cath lab for a STEMI. The cardiologist was going to have him sign out AMA. The guy had capacity to make decisions, but didn't want a cath. He didn't refuse admission, heparin, etc., so I had to explain to the cardiologist you can't have him sign out AMA because he's refusing a procedure. He's not refusing all treatment but just the procedure.

You have to be sure you document everything you can that they are refusing if they have capacity to do so, and remember, just because they are refusing admission doesn't mean they are refusing treatment. (i.e., diverticulitis refusing admission, if you have them sign out AMA, you should still write a prescription for antibiotics and pain medications) If they refuse admission and something bad happens, and if the family sues, you will be seen as more compassionate by the jury (and even the expert witness that initially reviews the case) if you at least attempted some form of treatment.

Finally, it's a lot harder to sue a physician for providing treatment against someone's will that doesn't have capacity to make decisions than it is to sue a police officer for unlawfully restraining someone. If you document they don't have capacity, and you provide treatment, most jurors will see that you are just looking out for the patient instead of just trying to do something for money. We provide treatment all the time against patient's requests. I do it at least every other shift with mental health holds for suicidal patients.

 

[Birdstrike]

I had a guy a few years ago who refused the cath lab for a STEMI. The cardiologist was going to have him sign out AMA. The guy had capacity to make decisions, but didn't want a cath. He didn't refuse admission, heparin, etc., so I had to explain to the cardiologist you can't have him sign out AMA because he's refusing a procedure. He's not refusing all treatment but just the procedure.

You have to be sure you document everything you can that they are refusing if they have capacity to do so, and remember, just because they are refusing admission doesn't mean they are refusing treatment. (i.e., diverticulitis refusing admission, if you have them sign out AMA, you should still write a prescription for antibiotics and pain medications) If they refuse admission and something bad happens, and if the family sues, you will be seen as more compassionate by the jury (and even the expert witness that initially reviews the case) if you at least attempted some form of treatment.

Yes, always offer "Next best" option(s) and document whether accepted or not. Your example was a good one. Here is a very good summary of how to do AMA right, by a physician lawyer. They have very good lawsuit avoidance CME, also.

"AMA - Doing it Right.



Attempt to understand the reason for the patient’s decision to leave AMA. Sometimes addressing the problem head on will lead to a timely resolution. Work with the patient, family, and PMD to try and alter the patient’s decision.Assuming that the EPS efforts to talk the patient into the necessary treatment have failed, certain steps should be taken. The physician must determine and document that the patient is functionally competent. If the EP deems the patient incompetent, then the refusal of care is invalid. If a life threat exists, the physician may treat the patient under the doctrine of constructive consent (also known as the “emergency doctrine”).The physician should also discuss the patient’s rationale for wanting to leave. Sometimes the patient feels that it is necessary to leave because children have been left alone, pets need to be taken care of, a check needs to be delivered, or any number of dilemmas which may be fairly easy to resolve. The ED staff should attempt to work with the patient to determine if leaving AMA is the only viable solution. Sometimes there are easy solutions that allow the patient to stay for treatment. The ED staff or social worker may be able to calm an angry patient.Prior to discharging a patient AMA, the EP should be convinced that the patient has given an informed refusal, and has had an opportunity to ask questions. Two members of the emergency department staff should witness this interchange, and both should sign the AMA note or document. Although the emergency staff is primarily patient advocates, the stark reality is that the AMA process is designed to protect the EP, and other ED staff and the hospital from inappropriate litigation. During the process of litigation, the patient will allege that the AMA discussion did not occur, and the presence of a witness is protective.Good medical care dictates a certain approach to the patient leaving against medical advice. Documentation of that approach will provide protection against liability for adverse events following the discharge. The chart should contain an AMA note that contains the elements discussed above. The emergency physician should not rely upon the hospital's pre-printed form, which states that the patient is leaving the hospital AMA and has a space for a witness to sign. This does not provide an adequate defense. Remember, AMA is a process, not a form. An AMA note may read as follows:The patient has decided to leave against medical advice. The patient has a normal mental status, and understands the risks of leaving, including permanent disability and/or death, and has had an opportunity to ask questions about his/her medical condition. The patient has been informed that he/she may return for care at any time, and follow up has been arranged.
Dubow et al, performed a retrospective review of the records of 52 consecutive AMA discharges from a level 1 hospital with a census of 42,000 patients per year. The authors found that 18 patients (36%) understood their diagnosis, 23 patients (44%) understood the proposed treatment, one patient (2%) understood the alternative therapy, and 30 (57%) understood the clinical consequences of refusal. Sixty-seven percent of the charts reflected the competence of the patient. This does not represent an adequate effort at managing the risk that accompanies patients leaving against medical advice."
https://www.thesullivangroup.com/risk_resources/against_medical_advice/against_medical_5_ama.asp"

 

[TooMuchResearch]

Question from a medical student. Is getting a patient to sign an AMA form really necessary? I was under the impression that a patient signing such a form does little in the way of protecting the provider and can come off as a bit confrontational from the patient's viewpoint. "Oh, you want to leave? Well sign these papers first."

The actual form is useless. The important part is having the conversation with the patient, setting them up as best you can for treatment within the bounds of what they will accept, and document document document.

 

[Birdstrike]

The actual form is useless. The important part is having the conversation with the patient, setting them up as best you can for treatment within the bounds of what they will accept, and document document document.

Right. Those preprinted hospital ones aren't enough. Though I don't work on T system anymore, when I did use electronic T, they had an excellent, customizable AMA note that could be used for your patient note. I'm sure some of the other EMRs do too, but I remember the electronic T system one being very good, and it would prompt you to document elements of AMA that are very easy to forget (ie, if they refused admission, were they offered transfer? Was the patients PCP and family contacted to help them make their decision, if not, did the patient decline that too? Etc). There are so many ways lawyers can combat an AMA, it's amazing. The above Sulllivan group article I linked above is excellent, as it shows several ways lawyers can get around a poorly documented AMA (the whole article, not just the section 5 I quoted).

 

[Zebra Hunter]

I realize that, but I'm wondering what the reasoning behind me being asked by my attending or resident to print out the form everytime I have a patient that wants to leave AMA. Is it just a common protocol that the administration gets pissed about if not followed? I just don't see the point in potentially alienating a patient for deciding they'd rather take the understood risk.

 

[Birdstrike]

I realize that, but I'm wondering what the reasoning behind me being asked by my attending or resident to print out the form everytime I have a patient that wants to leave AMA. Is it just a common protocol that the administration gets pissed about if not followed? I just don't see the point in potentially alienating a patient for deciding they'd rather take the understood risk.

You should do the form. The point is that it's just one element, and by itself it's not enough. Most consultants think it is, by the way, as they don't deal with AMA issues as much.

As far as alienating the patient with AMA, there is no need whatsoever.

The secret: don't be confrontational. It's NOT confrontational. Don't get angry because someone doesn't want to take your advice. There's no point, as it rarely has anything to do with you anyways.

It's all in how you do it. For example, chest pain refuses admit. You have the risk benefit discussion first, never mentioning the term "AMA." It's a buzzword that pisses some people off. Do it like this:

"Sir, it's your right to refuse admission. I don't take it personally. However, it's my job to inform you of the risks and benefits. Admitting you is the safest thing. It could prevent a heart attack, which you know could be fatal or permanent disability. You might be okay with with "X" medication and an outpatient work up but I cannot guarantee it. You can do whatever you want as long as you're aware of the risks."

Patient:

"Blah blah blah....I have to feed my cat....blah blah blah....I can't miss American idol finals....blah blah blah....."

You:

"Come back or call 911 if you get worse or change your mind."

Here's where the completely non-confrontational AMA signage comes:

"Do you mind signing a form indicating we had this discussion?"

Key: Anger, or feeling personally offended that patient won't take your brilliant advice and word "AMA" are NOT PART OF THE EQUATION WHATSOEVER.


Patient: "Sure, no problem."


If presented in a non-confrontational way, patients will almost always sign the form without further issue. If they get all weird, thinking their signature will prevent insurance from paying or whatever, it's no big deal. You can't and don't need to force them to sign the form. You just document everything you normally would and add,

"Despite treatment refusal after lengthy discussion of risks/benefits as documented above, patient refuses to sign institutional form documenting our conversation."

Then, have nurse witness discussion (as you always should have them cosign/witness the form anyways) and document that discussion was had and patients refusal to sign form.

Done.

Next patient.


(Edit: Another reason not to get too worked up over AMAs? Most of the time the patient is actually right, that nothing catastrophic will occur from them not taking your advice. It's true. Most of the time they'll be fine, and realize you're being overly cautious and are covering your ---. Respect them for seeing through your CYA lawyer fearing BS.)

 

[Zebra Hunter]

Thank you for the solid explanation.

 

[TooMuchResearch]

Right. Those preprinted hospital ones aren't enough. Though I don't work on T system anymore, when I did use electronic T, they had an excellent, customizable AMA note that could be used for your patient note. I'm sure some of the other EMRs do too, but I remember the electronic T system one being very good, and it would prompt you to document elements of AMA that are very easy to forget (ie, if they refused admission, were they offered transfer? Was the patients PCP and family contacted to help them make their decision, if not, did the patient decline that too? Etc). There are so many ways lawyers can combat an AMA, it's amazing. The above Sulllivan group article I linked above is excellent, as it shows several ways lawyers can get around a poorly documented AMA (the whole article, not just the section 5 I quoted).

That article does confuse competence and capacity many times (or at least once carried through).

I do not routinely contact family and PCP for patients leaving AMA. If it seems pertinent to help define capacity or to learn how to better work with the patient, then I will.

 

[Birdstrike]

That article does confuse competence and capacity many times (or at least once carried through).

I do not routinely contact family and PCP for patients leaving AMA. If it seems pertinent to help define capacity or to learn how to better work with the patient, then I will.

Simple: "Patient declined family/PCP contact."

You don't contact, they contact and you offer to inform. Most will not want others involved with the purpose of changing their mind. If they agree to it, you simply have the patient call them. You spend 10 seconds saying, "He's having chest pain. His ekg shows a life threatening heart attack/STEMI, but he's refusing to be admitted. I need you to help change his mind." Then hand phone to patient and walk away.

Worth documenting if you're legitimately concerned about a life/limb threat (STEMI, abnormal vital signs, ischemic extremity, etc).

 

[southerndoc]

I'm very blunt when they sign AMA forms. I educate them on diagnosis, prognosis, etc. and tell them I will try my best to treat them as an outpatient, but inpatient treatment is really indicated. I advise them they are encouraged to return to the ED immediately with any change in condition or if they change their mind regarding admission.

At the end of the discussion I bluntly tell them: "I need you to sign an AMA form so when you get home if something bad happens or if you die, we can't be sued for your decision."

 

[Hair Police]

Many excellent responses so far. Again, document there wasn't any reason to hold the person. Document that you discussed the benefits, alternatives, and detriments of the proposed treatment plan. As mentioned above, refusing an aspect of care does not mean all care is refused. The pt with PNA you wanted to admit for IV abx and monitoring? Give them orals and close follow up instead. I always mention that death or disability is a possible outcome of not following the proposed treatment plan. I try to figure out why they want to leave and document it. It shows something of the motivations of the patient and sometimes you get lucky - maybe you can make a phone call and fix the reason why they were going to leave, and resolve the situation altogether. Never make it confrontational - the AMA form is just part of your documentation to show you had the conversation and educated the patient. I also make sure they know they can come back again for this or any other complaint they may have. In my patients, there is a perception that if you don't do what the doc says, the doc will be angry, and so the patients don't come back when they develop complications.

 

[dotcb]

I take care of a high percentage of patients with substance abuse, mental illness, and the homeless. People refuse my medical recommendations right and left. The vast majority of the time, I don't make them sign any AMA form, although we have one. I just write that I recommended X, the patient understands the risks and benefits of the recommendation and declined. If their condition or diagnosis were something very severe, I would request that they sign documentation of refusal of my recommendation (ex. refusing cardiac cath, appendectomy, etc.)

I try not to discharge people who are wildly intoxicated, but sometimes it feels like I'm a jailer for drunk people. So if a patient seems like they could be reasonably or safely discharged, they don't need to stay in the ER taking up in bed. The things I pay the most attention to are their ability to walk with stable gait, speak coherently, and verbalize a plan of what they're planning on doing when they leave the ER.

I used to be much more dogmatic about having intoxicated people stay under my watch, which I don't do anymore.

I like to share this article and story with residents:

http://www.wilsonelser.com/news_and...ew_yorks_highest_court_finds_er_physician_and

Although this is from New York State, and it may not apply to where you work, the crux is that our obligation to detain intoxicated people really pertains to people who are truly an imminent severe threat to themselves. (Declining a laceration repair would not qualify.) Being intoxicated on its own and wanting to leave does not represent a definitely harmful situation, and our obligation to detain these patients is questionable at best. I like this, because it liberates me from having to wrestle all these patients.

 

[Birdstrike]

I take care of a high percentage of patients with substance abuse, mental illness, and the homeless. People refuse my medical recommendations right and left. The vast majority of the time, I don't make them sign any AMA form, although we have one. I just write that I recommended X, the patient understands the risks and benefits of the recommendation and declined. If their condition or diagnosis were something very severe, I would request that they sign documentation of refusal of my recommendation (ex. refusing cardiac cath, appendectomy, etc.)

I try not to discharge people who are wildly intoxicated, but sometimes it feels like I'm a jailer for drunk people. So if a patient seems like they could be reasonably or safely discharged, they don't need to stay in the ER taking up in bed. The things I pay the most attention to are their ability to walk with stable gait, speak coherently, and verbalize a plan of what they're planning on doing when they leave the ER.

I used to be much more dogmatic about having intoxicated people stay under my watch, which I don't do anymore.

I like to share this article and story with residents:

http://www.wilsonelser.com/news_and...ew_yorks_highest_court_finds_er_physician_and

Although this is from New York State, and it may not apply to where you work, the crux is that our obligation to detain intoxicated people really pertains to people who are truly an imminent severe threat to themselves. (Declining a laceration repair would not qualify.) Being intoxicated on its own and wanting to leave does not represent a definitely harmful situation, and our obligation to detain these patients is questionable at best. I like this, because it liberates me from having to wrestle all these patients.

I'm surprised that in NY of all places they didn't blame the doctor and side with the drunk who decided to leave and get hit by a car pithing his own cord. Maybe there's hope.

 

[chasingdaylight]

Thank you for all your insights.
Much appreciated.

-strech

 

[shookwell]

I like to share this article and story with residents:

http://www.wilsonelser.com/news_and...ew_yorks_highest_court_finds_er_physician_and

Although this is from New York State, and it may not apply to where you work, the crux is that our obligation to detain intoxicated people really pertains to people who are truly an imminent severe threat to themselves. (Declining a laceration repair would not qualify.) Being intoxicated on its own and wanting to leave does not represent a definitely harmful situation, and our obligation to detain these patients is questionable at best. I like this, because it liberates me from having to wrestle all these patients.

I print out this page and give it to the nurses when they give me **** about letting drunk people leave.

 

[Daiphon]

That article does confuse competence and capacity many times (or at least once carried through).

I'm glad this got pointed out, as while it seems nitpicky, it's actually quite important for documentation.

We determine capacity, lawyers & courts determine competence.

If you chart "competent to decline treatment," it opens up a line of questioning in pretrial discovery/depo's that one does not want to traverse.

-d