AMA Without Leaving

[deleted109597]

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I have had people say that BCBS states in their handbook that they don't have to cover.

Well then your job should be to tell them the truth, instead of propagating an old issue that isn't true today.
http://www.ama-assn.org/amednews/m/2012/07/02/bse0705.htm
The rest of your post, while logical in a way, could be worded so that insurance doesn't ever have to pay for anything. Medication noncompliance is a huge reason people are admitted to the ED and/or hospital.

 

[jl lin]

Well then your job should be to tell them the truth, instead of propagating an old issue that isn't true today.
http://www.ama-assn.org/amednews/m/2012/07/02/bse0705.htm
The rest of your post, while logical in a way, could be worded so that insurance doesn't ever have to pay for anything. Medication noncompliance is a huge reason people are admitted to the ED and/or hospital.

Understood. Many business provide health insurance that is self-funded--the insurance companies are merely 3rd party administrators. If they fight payment over procedures that were pre-approved, they can fight payment over other issues. Sure the current climate has changed given ACA, but we will see.

I think it is reasonable to be prepared for a fight in terms of payment if you leave AMA without a good cause. It is not about what is said or even reported. It is about what is done. Again, if pre-approved surgery can be stonewalled for payment, why not other things?
My trust is based not merely on what is said, but, again, what is done.

 

[Pure Anergy]

1-This scenario just shows how ridiculous the ED environment is, and the absurdity of having to coddle a patient like this. Being forced to shoot for 5 out of 5 patient sat scores on someone like this is criminal. If someone tried to pull this abusive level of b--l s--t in any outpatient office, they'd call the cops and have the person escorted off the premises. The same thing would happen if this joker tried to pull this crap in the CEOs office.

2-To your original point, I agree AMA is not absolute. That's an important point, in fact, it's a high liability situation if you sign them out AMA but don't offer them "everything but" or the "next best" thing. AMA if not performed properly, may actually increase liability, when intending to reduce it.

For example, they refuse admission and stress test. You should still prescribe ASA, beta-blocker, arrange close follow up and outpatient stress testing.

Good post.

I have some confusion when it comes to signing out patients AMA. Specifically:

1) Is it legally better to do an AMA form w/ documentation versus just document in the chart? Most of my attendings want both. One prefers that that the patient just "elope," arguing that if you have enough time to discuss AMA with the patient and get them to sign the form, you have enough time to talk them into staying. Whereas, if they just leave, you can say that they were so intent on leaving that they wouldn't even stay long enough for you to have the discussion with them. Seems kind of disingenuous to me, and obviously it isn't possible to give them f/u instructions that way. Thoughts?

2) If someone leaves AMA, regardless of whether you have them sign or not, do you still give them written d/c instructions? Most of my attendings say yes. That same attending from question 1 says that if you have enough time to write up d/c paperwork, again, you have enough time to persuade the patient to stay, and all it shows to the lawyers is that you weren't a good enough communicator to convince the patient to stay. It's almost like AMA forms are a liability to this doc. Is that really true?

3) I know some of you have sovereign immunity and can't be sued. Does that affect how you handle AMA situations?

Thanks in advance.

 

[RustedFox]

Great thread. Thanks for the bump.

 

[The White Coat Investor]

3) I know some of you have sovereign immunity and can't be sued. Does that affect how you handle AMA situations?

Thanks in advance.

I spend very little time worrying about AMA patients. Can you imagine trying to sue someone in court for malpractice after you left AMA? That's a tough to hoe. They want to go? I make sure they understand it could make them worse, cause them permanent disability or kill them and encourage them to return if they change their mind. I document that. I ask the nurse to have them sign an AMA form. That's it. If they sign it, great. If they don't, great. I spend no further brain energy on those patients.

As far as sovereign immunity, I had that for a few years in the military. But you can still get reported to the database. So it really doesn't change anything. Malpractice isn't about your money anyway, since your insurance company will almost surely pick up the entire tab. It's about keeping those strikes off your record. You get more than average and it gets tough to find a job.

 

[Perrin]

2) If someone leaves AMA, regardless of whether you have them sign or not, do you still give them written d/c instructions? Most of my attendings say yes. That same attending from question 1 says that if you have enough time to write up d/c paperwork, again, you have enough time to persuade the patient to stay, and all it shows to the lawyers is that you weren't a good enough communicator to convince the patient to stay. It's almost like AMA forms are a liability to this doc. Is that really true.

Yes, they get their paperwork, scripts, and referrals. In most cases I view AMA as the patient's decision to pursue further testing, eval, and treatment as an outpatient. It makes it less adversarial with the patient. I just document the discussion about wanting them to stay, close follow up with PMD, or return to ED.

 

[Arcan57]

I have some confusion when it comes to signing out patients AMA. Specifically:

1) Is it legally better to do an AMA form w/ documentation versus just document in the chart? Most of my attendings want both. One prefers that that the patient just "elope," arguing that if you have enough time to discuss AMA with the patient and get them to sign the form, you have enough time to talk them into staying. Whereas, if they just leave, you can say that they were so intent on leaving that they wouldn't even stay long enough for you to have the discussion with them. Seems kind of disingenuous to me, and obviously it isn't possible to give them f/u instructions that way. Thoughts?

2) If someone leaves AMA, regardless of whether you have them sign or not, do you still give them written d/c instructions? Most of my attendings say yes. That same attending from question 1 says that if you have enough time to write up d/c paperwork, again, you have enough time to persuade the patient to stay, and all it shows to the lawyers is that you weren't a good enough communicator to convince the patient to stay. It's almost like AMA forms are a liability to this doc. Is that really true?

1) Part of it is going to depend on their mental state. Letting people that have any documentation of conditions that would impair decision making should not be a passive process. Sometimes you make a judgment call that fighting the drunk to restrain them is more dangerous than letting them go, but I wouldn't encourage the nursing staff to just let people walk out without informing you. My guess is that the attending you are mentioning doesn't feel comfortable confronting these patients and has developed some half-assed, warped rationale to justify it.

2) Everything I've read and heard about suggests that demonstrating a good faith effort (including d/c instructions, Rx if appropriate, and that the patient should return for any reason) on patients leaving AMA is far more protective legally than casting them out into the wind. If you did all these things for a patient, it's tough to argue that you were dismissive and didn't care about the patient. And that's going to be the angle the lawyer would play for the jury.

 

[dotcb]

I spend very little time worrying about AMA patients. Can you imagine trying to sue someone in court for malpractice after you left AMA? That's a tough to hoe. They want to go? I make sure they understand it could make them worse, cause them permanent disability or kill them and encourage them to return if they change their mind. I document that. I ask the nurse to have them sign an AMA form. That's it. If they sign it, great. If they don't, great. I spend no further brain energy on those patients.
.

I'm with White Coat - I spend very little mental energy on these patients. They are the group most likely to be ridiculous, petulant, abusive, and most of the time - would make terrible plaintiffs - because they are usually completely unreasonable and totally don't have their sh-t together. Although I suppose it's better to sign a form, in addition, and get it witnessed - I don't even do that. I just write a description of what happened in the medical record and include the statement - that they are sober and appropriate, verbalized understanding of risks such as death or severe disability, and declined my recommendation of _______. That's it. I let almost anyone refuse almost anything.

 

[RustedFox]

Agree with above; hate to say it, but an AMA makes it eeeassy. I have one other individual witness my discussion, document it well, and byyeee.

The verbage that I use makes it easy. I write: "The patient was asked a second time if they understood (all of the above), and made clear in both word and in gesture that they were certain in their decision to refuse any and all further care."

There's nothing dishonest about that. If they're being unreasonable, write...exactly... that.

 

[The White Coat Investor]

2) If someone leaves AMA, regardless of whether you have them sign or not, do you still give them written d/c instructions? Most of my attendings say yes. That same attending from question 1 says that if you have enough time to write up d/c paperwork, again, you have enough time to persuade the patient to stay, and all it shows to the lawyers is that you weren't a good enough communicator to convince the patient to stay. It's almost like AMA forms are a liability to this doc. Is that really true?

If they stay for instructions, I will give them written instructions. I also encourage them to return at any time both verbally and in writing. Occasionally, they do. I signed out a guy with a nasty GB once, and his wife drug him back 2 hours later to get it out once he got home and she saw his discharge paperwork.

 

[deuist]

Definitely get them to sign the form. Remember, the patient came to you for advice. If they choose to leave, that's their decision. If your mechanic recommends something for your car and you disagree, he doesn't call you an idiot, does he? Instead, tell the patient he can leave if he wants, encourage getting rapid outpatient follow up, give any necessary scripts (e.g., aspirin for chest pain patients), and get the family member to co-sign the AMA form. Next, document the entire conversation in the chart and make sure the form makes into the chart. Your attending who lets the patient elope and not sign the form is doing a real disservice to the patient and himself.

 

[deleted109597]

If your mechanic recommends something for your car and you disagree, he doesn't call you an idiot, does he?

I've had mechanics call me that. They probably like people who know about working on cars about as much as we like taking care of people with a certain degree of medical knowledge.
I've seen mechanics tell people they won't let them drive their cars home, not for a lien, which is legal, but because they say it is unsafe. Not sure the legality of that, as it's never happened to me, but it is interesting.

 

[GeneralVeers]

Definitely get them to sign the form. Remember, the patient came to you for advice. If they choose to leave, that's their decision. If your mechanic recommends something for your car and you disagree, he doesn't call you an idiot, does he? Instead, tell the patient he can leave if he wants, encourage getting rapid outpatient follow up, give any necessary scripts (e.g., aspirin for chest pain patients), and get the family member to co-sign the AMA form. Next, document the entire conversation in the chart and make sure the form makes into the chart. Your attending who lets the patient elope and not sign the form is doing a real disservice to the patient and himself.

I actually like elopement, especially for the chronic pain/soul-sucking humans. It makes my life and job easier if they simply disappear. Then I am free to document on the chart that: "When I went to reassess the patient and ask him how he was doing, we could not find him. We looked everywhere in the department and were very concerned. Unfortunately the patient could not be located, and despite our concern for his well-being we did not have the opportunity to review the results or provide follow-up."

I can't ever imagine being successfully sued in that case.

 

[deuist]

I actually like elopement, especially for the chronic pain/soul-sucking humans. It makes my life and job easier if they simply disappear. Then I am free to document on the chart that: "When I went to reassess the patient and ask him how he was doing, we could not find him. We looked everywhere in the department and were very concerned. Unfortunately the patient could not be located, and despite our concern for his well-being we did not have the opportunity to review the results or provide follow-up."

I can't ever imagine being successfully sued in that case.

That's different. You're getting rid of them because there's no medical need. They can't sue you for refusal to provide narcotics. I was referring to the potentially sick individual (such as the 50-year-old with chest pain) who decides to go AMA. For the latter, you still need to provide an appropriate amount of care. For the chronic pain patients, just writing, "I explained to the patient that I cannot find a medical cause of his pain and that I will not refill his percocet again this month," should cover it.

 

[GeneralVeers]

That's different. You're getting rid of them because there's no medical need. They can't sue you for refusal to provide narcotics. I was referring to the potentially sick individual (such as the 50-year-old with chest pain) who decides to go AMA. For the latter, you still need to provide an appropriate amount of care. For the chronic pain patients, just writing, "I explained to the patient that I cannot find a medical cause of his pain and that I will not refill his percocet again this month," should cover it.

I don't necessarily agree. If someone wants to leave badly enough that they won't talk to me about their options before they go, then it's on them. If they do decide to leave, there is nothing more I can do for them, besides document "appropriate care" up to the point where they walked out. You are referring to an AMA, which is a different animal than elopement.

 

[gman33]

I actually like elopement, especially for the chronic pain/soul-sucking humans. It makes my life and job easier if they simply disappear. Then I am free to document on the chart that: "When I went to reassess the patient and ask him how he was doing, we could not find him. We looked everywhere in the department and were very concerned. Unfortunately the patient could not be located, and despite our concern for his well-being we did not have the opportunity to review the results or provide follow-up."

I can't ever imagine being successfully sued in that case.

I love the elopement as well.
I could see how it could end in a lawsuit.
Pain or medical condition resulting in AMS.
Patient wasn't in right mind when they left.
The doctor should have reconginized this and taken appropriate action.

In most cases there would be no validity to this arguement, but I could see it being made.

 

[GeneralVeers]

I love the elopement as well.
I could see how it could end in a lawsuit.
Pain or medical condition resulting in AMS.
Patient wasn't in right mind when they left.
The doctor should have reconginized this and taken appropriate action.

In most cases there would be no validity to this arguement, but I could see it being made.

The same goes for a regular discharge or an AMA. A lawyer could argue that the patient wasn't capable of making decisions. At least with elopement, short of tying the patient to the bed, there is nothing else I could have done to stop the patient from leaving.

 

[Arcan57]

The same goes for a regular discharge or an AMA. A lawyer could argue that the patient wasn't capable of making decisions. At least with elopement, short of tying the patient to the bed, there is nothing else I could have done to stop the patient from leaving.

Whole purpose of AMA is to document that they aren't altered and they do understand the risks. Elopement doesn't allow for that assessment. I don't think this presents a huge risk but if the nursing documentation paints the picture of psychosis or severe intoxication, it's a pretty trivial argument to say that the patient should have been chemically or physically sedated to allow for further work-up.

 

[WilcoWorld]

Whole purpose of AMA is to document that they aren't altered and they do understand the risks. Elopement doesn't allow for that assessment. I don't think this presents a huge risk but if the nursing documentation paints the picture of psychosis or severe intoxication, it's a pretty trivial argument to say that the patient should have been chemically or physically sedated to allow for further work-up.

In some states (including where I work) it is illegal to restrain someone without a court order, and getting a court order requires having evidence that the person is a danger to self or others. When someone elopes, I'll usually include in my documentation a statement about not having a court order or the evidence needed to obtain one, thus making it illegal for me to restrain said person "against his will".

 

[Arcan57]

In some states (including where I work) it is illegal to restrain someone without a court order, and getting a court order requires having evidence that the person is a danger to self or others. When someone elopes, I'll usually include in my documentation a statement about not having a court order or the evidence needed to obtain one, thus making it illegal for me to restrain said person "against his will".

What do you do with agitated delirum patients?

 

[Pinner Doc]

I beg to disagree with you. We don't HAVE to treat anyone who's being disrespectful or insulting. Verbal violence is no more acceptable than physical violence. If they insult me or the nurses, I am going to have them escorted out.

I was always under the impression we DO *have* to treat these people, at least until an emergency is ruled out.

* ETA - shoulda kept reading, @glorfindel clarified quite nicely

 

[WilcoWorld]

What do you do with agitated delirum patients?

When I am actually worried about their safety? I use ativan 2mg IM. If that doesn't work I'll either follow it with more ativan or with haldol 5mg + benadryl 25mg - depending on the details of the case. In these cases I clearly document the patient's potential for harm to self and others (including staff).

When it's just a pissed off drunk guy who was brought in by the police, I document as previously described.