AMA Without Leaving

[docB]

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Had a situation the other night and thought it would make a good learning point.

A patient who was in the ED for "severe" abdominal pain pending CT scan became angry that the nurse would not let them eat the big fried dinner brought to them by their family. Nurses always turf these issues to the doctors. I sent her back with the usual "I recommend against eating. They are an adult and can do as they wish." And the patient demanded to see me. I explained that since they came to the ER, by ambulance for a presumed life threatening condition eating could kill them outright or delay any life saving surgery. The patient told me to go have autonomous marital relations and started eating. I told the nurse to have him sign an AMA form. This is where it got interesting.

The nurse came back and said the patient had refused to leave. I said I didn't want him to leave. I just wanted him to sign an AMA form about eating and for him to get the CT scan. She told me that if he signed AMA he would have to leave. I tried to explain that this was not true but she was convinced somewhere along the line that AMA is an absolute, you sign this you're out the door proposition.

That is not correct.

A patient can refuse any aspect of treatment. That does not mean that they must refuse all treatment. In this case this patient who was a jerk but did have capacity could refuse to remain NPO but could continue with the rest of the work up. I asked that he sign the AMA form about that specific refusal to go along with my note about it.

So the take home point is a patient can refuse specific aspects of care without refusing everything and without leaving the ED or hospital. They can be asked to sign an AMA form to refuse that aspect of care and that doesn't mean their visit is over. No matter what they sign your note about their informed refusal is the most important aspect of the interaction.

 

[Birdstrike]

Had a situation the other night and thought it would make a good learning point.

A patient who was in the ED for "severe" abdominal pain pending CT scan became angry that the nurse would not let them eat the big fried dinner brought to them by their family. Nurses always turf these issues to the doctors. I sent her back with the usual "I recommend against eating. They are an adult and can do as they wish." And the patient demanded to see me. I explained that since they came to the ER, by ambulance for a presumed life threatening condition eating could kill them outright or delay any life saving surgery. The patient told me to go have autonomous marital relations and started eating. I told the nurse to have him sign an AMA form. This is where it got interesting.

The nurse came back and said the patient had refused to leave. I said I didn't want him to leave. I just wanted him to sign an AMA form about eating and for him to get the CT scan. She told me that if he signed AMA he would have to leave. I tried to explain that this was not true but she was convinced somewhere along the line that AMA is an absolute, you sign this you're out the door proposition.

That is not correct.

A patient can refuse any aspect of treatment. That does not mean that they must refuse all treatment. In this case this patient who was a jerk but did have capacity could refuse to remain NPO but could continue with the rest of the work up. I asked that he sign the AMA form about that specific refusal to go along with my note about it.

So the take home point is a patient can refuse specific aspects of care without refusing everything and without leaving the ED or hospital. They can be asked to sign an AMA form to refuse that aspect of care and that doesn't mean their visit is over. No matter what they sign your note about their informed refusal is the most important aspect of the interaction.

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.

 

[glorfindel]

I'm so glad to hear that other docs see these kinds of patients. It makes me feel.... sad for you, but happy that I'm not the only one!

Excellent point about AMA.

Too bad you had such an unpleasant patient/nurse combo.

 

[la gringa]

I'm so glad to hear that other docs see these kinds of patients. It makes me feel.... sad for you, but happy that I'm not the only one!

Excellent point about AMA.

Too bad you had such an unpleasant patient/nurse combo.

as is too often the case in these sorts of situations

my far and away worst patient complaint EVER had NOTHING to do w/ care given and was driven at least 75% by failure of the nurse to communicate the pt's family's concerns to me. then i roast...

 

[GeneralVeers]

I would probably have this patient leave.

At the point where they become verbally abusive to myself or staff, they are asked to leave, presuming that they can ambulate under their own power, and have mental capacity to understand the consequences.

I refuse to subject myself or the nurses I work with to abusive behavior in any

 

[glorfindel]

At the point where they become verbally abusive to myself or staff, they are asked to leave, presuming that they can ambulate under their own power, and have mental capacity to understand the consequences.

Ditto.

I usually offer guys like this a choice: be polite and civil, and stay for a workup. Or, be a dickhead and get out.

 

[chasingdaylight]

So, how do you guys get them to leave?

In the case of the above stated "dickhead" pt, still with incompletely evaluated abdominal pain...

Do you call security and escort these people out?

 

[southerndoc]

I would probably have this patient leave.

At the point where they become verbally abusive to myself or staff, they are asked to leave, presuming that they can ambulate under their own power, and have mental capacity to understand the consequences.

I refuse to subject myself or the nurses I work with to abusive behavior in any

Usually the armed security officers sitting outside their room as they are asked "nicely" to leave usually makes its point.

I rarely have patients sign an AMA form. I just document very well in the chart.

 

[my doc in a box]

Hm, if a patient leaves AMA or under security escort, do they still get mailed/called for a satisfaction survey?

 

[pinipig523]

Btw, how does AMA affect their bill? I've heard that in many situations, an insurance company will not pay for an AMA visit.

 

[UnderwaterDoc]

Btw, how does AMA affect their bill? I've heard that in many situations, an insurance company will not pay for an AMA visit.

According to a recent lecture we had from a lawyer/MD, this is a myth.

He also said that having someone sign an AMA affords the doc very little, if any, advantage from a liability standpoint. As Southern says, the money is in the documentation.

I can't wait to be done and be able to kick these patients out, very few of my attendings have the backbone to do it.

 

[RustedFox]

According to a recent lecture we had from a lawyer/MD, this is a myth.

He also said that having someone sign an AMA affords the doc very little, if any, advantage from a liability standpoint. As Southern says, the money is in the documentation.

I can't wait to be done and be able to kick these patients out, very few of my attendings have the backbone to do it.

Regarding: "AMA? Wont pay".... in one specific circumstance, it holds true. In my shop, we get a LOT of canucks that are wintering/vacationing here. They all know that if they sign AMA, that the gov't wont pay and they're stuck with the bill. Also.... they seem to "choose" to have their chest pain here, when they're going to be here for the next 2-3 months. Its easier to wait until winter to go to the US and get a "timely" stress/cath, than it is to wait the 6-8 months in Ottawa for their CAD eval.

Sneaky Canucks.

 

[docB]

Wow! Great discussion.

I'm so glad to hear that other docs see these kinds of patients. It makes me feel.... sad for you, but happy that I'm not the only one!

Excellent point about AMA.

Too bad you had such an unpleasant patient/nurse combo.

The nurse wasn’t being difficult. She really thought that was the “rule.” I explained it and she was cool with it. It was just 10 minutes of my day I could have used differently. Same as discussions about why it’s ok to d/c the non-toxic kid who is still febrile or the asymptomatic htn who is still htnsive.

It’s illustrative to me how much those of us in the industry, from medics to docs to nurses, are ignorant of the processes we use everyday. AMA, legal holds, capacity, EMTALA, HIPAA and so on.

I would probably have this patient leave.

At the point where they become verbally abusive to myself or staff, they are asked to leave, presuming that they can ambulate under their own power, and have mental capacity to understand the consequences.

I refuse to subject myself or the nurses I work with to abusive behavior in any

Ditto.
I usually offer guys like this a choice: be polite and civil, and stay for a workup. Or, be a dickhead and get out.

Usually the armed security officers sitting outside their room as they are asked "nicely" to leave usually makes its point.

I rarely have patients sign an AMA form. I just document very well in the chart.

I am not disagreeing here but I have a pretty high threshold for really pushing them out the door. At my shop we have really thick skins and we don’t get much understanding when complaints are levied so... From an actual medicolegal standpoint I worry that documenting “patient verbally abusive, offered option of calming down or leaving” would leave me open to allegations that I didn’t recognize whatever medical problem was causing this wonderful person to act so totally out of character. And if he leaves with any prodding from me it’s likely EMTALA will come into play.

So, how do you guys get them to leave?

In the case of the above stated "dickhead" pt, still with incompletely evaluated abdominal pain...

Do you call security and escort these people out?

Good question. I think we’ve had a thread on this before. A related question is what’s the disposition? Is it really leaving AMA if they want to stay but can’t manage their behavior? It it an elopement if they are ejected from the ED? It could be argued that if you as the treating doctor decided they were stable enough to be ejected then it was a discharge.

Hm, if a patient leaves AMA or under security escort, do they still get mailed/called for a satisfaction survey?

In my shop it would depend on what the dispo was. If it was AMA then no. It was d/c then yes. If it was eloped then maybe. They could certainly go to the poll kiosk in the lobby which we have from time to time.

According to a recent lecture we had from a lawyer/MD, this is a myth.

He also said that having someone sign an AMA affords the doc very little, if any, advantage from a liability standpoint. As Southern says, the money is in the documentation.

I can't wait to be done and be able to kick these patients out, very few of my attendings have the backbone to do it.

I agree that the AMA = insurance no pay is a myth. We’ve researched this with various risk managers, lawyers and billing specialists and they all agree (the Canadian example and likely some other specific situations excluded).


Back to the issue of us being ignorant, poorly trained or misinformed on many of these issues, we had a big policy meeting with system nursing a few years back of patients leaving AMA without being advised by the doctor. If a patient walks up to the nurse and says “I’m outtahere.” the nurse (pretty much everywhere I’ve ever been or heard of) will have them sign that AMA form that we all agree is minimally useful.

But they’re not really leaving AMA. Leaving AMA is something you do when your doctor has explained the risks and alternatives, etc., of doing so. If you haven’t been seen yet or you suddenly decide to bolt and won’t wait for the briefing on risks you are eloping.

This is important. If your nurse or clerk enters the dispo as “AMA” the patient’s lawyer will ask how this could be when you never explained the risks to the patient or his doting family. You will then have to explain this inconsistency in the chart and admit everyone made a mistake about the real dispo which was eloped.

I always write a note about elopements saying I was with another patient in the ED and they wouldn’t wait for me to give them the talk. I note that they had capacity (i.e. were A&Ox4, lucid, brilliant, etc.) to understand what they were doing. Woe be it to you if you have A&Ox1, or “slurred speech c/w intoxication” documented and then they elope. You’ve just painted a picture of someone who can’t care for themselves and you let escape. If you get stuck in that situation you need to follow your hospital’s policy and document it, e.g. “Pt with AMS eloped. Per policy we have called the patient to urge him to return. We have engaged security and police to search for the patient.”

 

[UnderwaterDoc]

Back to the issue of us being ignorant, poorly trained or misinformed on many of these issues, we had a big policy meeting with system nursing a few years back of patients leaving AMA without being advised by the doctor. If a patient walks up to the nurse and says “I’m outtahere.” the nurse (pretty much everywhere I’ve ever been or heard of) will have them sign that AMA form that we all agree is minimally useful.

But they’re not really leaving AMA. Leaving AMA is something you do when your doctor has explained the risks and alternatives, etc., of doing so. If you haven’t been seen yet or you suddenly decide to bolt and won’t wait for the briefing on risks you are eloping.

This is important. If your nurse or clerk enters the dispo as “AMA” the patient’s lawyer will ask how this could be when you never explained the risks to the patient or his doting family. You will then have to explain this inconsistency in the chart and admit everyone made a mistake about the real dispo which was eloped.

I always write a note about elopements saying I was with another patient in the ED and they wouldn’t wait for me to give them the talk. I note that they had capacity (i.e. were A&Ox4, lucid, brilliant, etc.) to understand what they were doing. Woe be it to you if you have A&Ox1, or “slurred speech c/w intoxication” documented and then they elope. You’ve just painted a picture of someone who can’t care for themselves and you let escape. If you get stuck in that situation you need to follow your hospital’s policy and document it, e.g. “Pt with AMS eloped. Per policy we have called the patient to urge him to return. We have engaged security and police to search for the patient.”

On our hospital nurses can't fill out the AMA form, and frankly I would rather have that discussion myself with the patient so that later on I can document the crap out of it. Our system also has a dispo for when they leave before being evaluated by the MD, Left Without Being Seen (LWBS), this applies even if I the resident saw the patient but they bounced before my attending had a chance to, it doesn't happen very often but when it does we make sure to write that dispo in their record.

On the issue of altered patients leaving, I had a situation recently that a patient who was obviously intoxicated was being verbally abusive towards staff, I went in the room and tried to talk him down with no success. He refused to answer questions, refused to undress, etc. The kicker was that he actually screamed out loud several times that he wanted to kill himself. Before I could get security in the room he ran out, made a bee line through our ED and exited through the ambulance bay doors. Police were called and eventually he was brought back in unharmed. Afterwards I was wondering if I should have physically restrained him myself with the help of the nurses while security got there, and just avoided that whole mess.

 

[chasingdaylight]

Just to exaggerate the senario a bit, lets say you have an EKG verified STEMI who is being a "dickhead."

Basically someone who clearly needs emergent care but has atrocious behaviour.

Would you guys still kick this guy out? Or do you just take the abuse?

I suppose you cannot intubate someone for their own good just for being a ass, it could be seen as assault... although it seems to happen sometimes in traumas.

 

[tkim]

On the issue of altered patients leaving, I had a situation recently that a patient who was obviously intoxicated was being verbally abusive towards staff, I went in the room and tried to talk him down with no success. He refused to answer questions, refused to undress, etc. The kicker was that he actually screamed out loud several times that he wanted to kill himself. Before I could get security in the room he ran out, made a bee line through our ED and exited through the ambulance bay doors. Police were called and eventually he was brought back in unharmed. Afterwards I was wondering if I should have physically restrained him myself with the help of the nurses while security got there, and just avoided that whole mess.

I would never risk myself or any of the staff being hurt in order to restrain someone from leaving. Let them leave then call the cops if you think they need to be brought back.

 

[tkim]

Just to exaggerate the senario a bit, lets say you have an EKG verified STEMI who is being a "dickhead."

Basically someone who clearly needs emergent care but has atrocious behaviour.

Would you guys still kick this guy out? Or do you just take the abuse?

I would tell them they are having a heart attack, and they need to cooperate. If they want to AMA, then I'd let them after having 'the talk'.

I mean, if they didn't actually want to leave, and were just being verbally abusive I'd suck it up. But if they were being physically abusive, but didn't want to leave, I'd sedate them. If they're infarcting and you call the cops to haul them away, when they die in a cell your ass is gone. You could always argue that the stress of being told they were infarcting caused them to flip out, requiring sedation in order to continue treatment.

 

[WilcoWorld]

Hm, if a patient leaves AMA or under security escort, do they still get mailed/called for a satisfaction survey?

Off-topic, but on-tangent:

I saw a child who was brought in by police for possible negligence today. As the social work dust settled (and I realized the kid didn't need admission, so a survey would be generated) I wondered, who is going to get this survey?

Your kid is brought to the ER by the cops for negligence and you might get a satisfaction survey - that says a lot.

 

[StevieStud]

Just to exaggerate the senario a bit, lets say you have an EKG verified STEMI who is being a "dickhead."

Basically someone who clearly needs emergent care but has atrocious behaviour.

Would you guys still kick this guy out? Or do you just take the abuse?

That is why you have double or triple coverage so when dick head starts insulting your religion/race/gender/hair-color you can pass the dick head over to your partner with special instructions on 4 point restraints and foleys.

Seriously, short of actual physical harm being inflicted on you or your staff, you need to treat the pt.

 

[GeneralVeers]

That is why you have double or triple coverage so when dick head starts insulting your religion/race/gender/hair-color you can pass the dick head over to your partner with special instructions on 4 point restraints and foleys.

Seriously, short of actual physical harm being inflicted on you or your staff, you need to treat the pt.

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.

 

[jl lin]

I would probably have this patient leave.

At the point where they become verbally abusive to myself or staff, they are asked to leave, presuming that they can ambulate under their own power, and have mental capacity to understand the consequences.

I refuse to subject myself or the nurses I work with to abusive behavior in any

Yes👍

 

[jl lin]

According to a recent lecture we had from a lawyer/MD, this is a myth.

He also said that having someone sign an AMA affords the doc very little, if any, advantage from a liability standpoint. As Southern says, the money is in the documentation.

I can't wait to be done and be able to kick these patients out, very few of my attendings have the backbone to do it.

I have had people say that BCBS states in their handbook that they don't have to cover. Having gone up against insurance companies for their refusal to cover what they already approved, at the very least it will requires months of writing and appeals. It might not be covered. You have to remember that many people are governed by their company's self-insured system, and they only use the insurance company to administrate.

Personally if working as an appeal's officer, I'd want to see some very strong rationale for the AMA from the pt's perspective....like reasonable basis for fear of type of treatment or obvious incompetence.

 

[docB]

I have had people say that BCBS states in their handbook that they don't have to cover. Having gone up against insurance companies for their refusal to cover what they already approved, at the very least it will requires months of writing and appeals. It might not be covered. You have to remember that many people are governed by their company's self-insured system, and they only use the insurance company to administrate.

Personally if working as an appeal's officer, I'd want to see some very strong rationale for the AMA from the pt's perspective....like reasonable basis for fear of type of treatment or obvious incompetence.

This is taking us off on an interesting tangent.

How do you decide what is an informed decision to decline something and what is AMA? Take the discussion about LPs in the "700 club" thread that is running right now. If you lay out the risks of LP vs. the chances of catching the white whale... er, I mean the occult SAH and they decline I'd wager no one here counts that as doing something AMA.

Some of this is going to be regional as well. In Vegas we have such poor follow up we stress all of our chest pains in house. Other places do two trops and refer for outpatient in 48 hours. If someone wants to leave after two trops in Vegas they will likely be going AMA. In other places they'd be discharged.

There's also the issue of patients who've already been admitted. We have lots of in house patients who leave "AMA" everyday because they don't want to wait on their doctor to round.

I had a very angry patient the other day who was adamant they were leaving. It was a bad situation. They called their PMD who is on staff but wasn't going to be their doctor due to their insurance having a contracted hospitalist. He said they could go home. They demanded that I d/c them. I started the AMA speech and they flipped out. They said they weren't leaving AMA because their doc said they could go. I wound up writing a BIG note and d/cing them. I even noted that they were so angry I felt pushing the AMA would cause them to explode. Tough case.

 

[glorfindel]

Just to exaggerate the senario a bit, lets say you have an EKG verified STEMI who is being a "dickhead."

Basically someone who clearly needs emergent care but has atrocious behaviour.

Would you guys still kick this guy out? Or do you just take the abuse?

I suppose you cannot intubate someone for their own good just for being a ass, it could be seen as assault... although it seems to happen sometimes in traumas.

In real life, the way this plays out for me is like this:

1) Patient arrives complaining of something, and as with most patients, I immediately put pt into one of three categories: sick, not sick, maybe sick.

2) At some point in the workup (for those who need one, e.g. abdominal pain, cp) the patient reveals himself to be a dickhead. This is, in real life, readily distinguished from the abusive/assaultive behavior that results from acute illness/intoxication/injury.

3) If the patient is behaving badly and he//she is acutely ill or injured (sick), hey, no problem. I signed up for this. I do what's best for the patient, always, and this sometimes involves sedation, verbal deescalation, restraints, whatever the clinical scenario calls for.

4) If the patient is not acutely ill or injured, he/she by definition doesn't need to be in the ER. By assessing him, I have done my required duty as an emergency physician. EMTALA is satisfied. The standard of care has been met. In most cases, I go beyond the minimum -- maybe get some tests that will help with follow-up, maybe try to diagnose the patient's non-acute, non-emergent condition, maybe counsel the patient about what to do next, maybe answer the patient's medical questions.... This is all the "customer service" stuff, and I do it for a very high percentage of the patients I see. It's just good practice -- make the patient's visit to my ED a productive one.

5) That said, all that extra customer-service stuff is OPTIONAL, and I get rid of it IMMEDIATELY in two well-defined situations:

a) the ED is overflowing with emergently sick patients that require all of my available attention and resources

b) the patient is being a dickhead.

There is nothing in the law or in the standard of emergency medical practice that requires you to put up with a patient's bulls*** (verbally or physically abusive behavior) if that patient is not acutely ill or injured. I kick those patients out immediately.

If the patient is in the "maybe sick" category, I'll still kick them out after I have a discussion about basic human civility and about my concerns about their medical condition. I'll set minimal ground rules for them ("no threatening anyone") and tell them that if they violate these rules, they're out. These patients may have something brewing, but they're still decisional, still able to control their behavior

I won't kick them out for an unpleasant personality, or for racist comments (free speech!), etc., but verbal threats or any physically abusive behavior gets them the boot.

 

[dchristismi]

I had an interesting discussion with a family about this last night.
Patient was - in their own words - a stubborn, beligerant man who would rip out his lines and storm out as soon as he got back to his normal mental status. Smoked like a chimney and drank like a fish, obtunded with a GCS around 10. They were very worried.

Well, he was *really* sick. (multiorgan failure, poss unintentional tylenol od, hypercapneic, pneumonia, acidotic, hyperammonemia, definitely an ICU player.) His PCo2 had been improving on the BIPAP, but the family basically convinced me to just go ahead and intubate him to take that off the table (I'd been on the fence anyway) - and prevent the patient from interfering in his own life-saving care. The adult children were very reasonable and one was an ICU RN, but I don't make a habit of intubating people to protect them from their own bad decisions.

This guy, well, he was a unique situtation. And it made it easier for the nurse to manage the drips without having to worry about the patient cooperating. His family was very grateful. (and one had the POA)

 

[glorfindel]

This is taking us off on an interesting tangent.

How do you decide what is an informed decision to decline something and what is AMA?

For me, AMA comes down to the very simply defined ex ante criteria of "My advice is to stay, and the patient is deciding to leave."

This excludes cases where I'm not offering strong advice one way or the other. I never strongly advise patients to stay for the white-whale chase LP. In that case, I'm simply offering up some reasonable options, and letting the patient make the decision. The key feature is, I don't give a huge rat's a** either way (because I don't think they have SAH). I think LP is reasonable, and I think going home is reasonable. Their choice.

I had a very angry patient the other day who was adamant they were leaving. It was a bad situation. They called their PMD who is on staff but wasn't going to be their doctor due to their insurance having a contracted hospitalist. He said they could go home. They demanded that I d/c them. I started the AMA speech and they flipped out. They said they weren't leaving AMA because their doc said they could go. I wound up writing a BIG note and d/cing them. I even noted that they were so angry I felt pushing the AMA would cause them to explode. Tough case.

I've had people argue with me about what AMA means, and I refuse to argue with them about it. I say "I am advising you to stay. I am your treating doctor. You are deciding to leave against my advice, for whatever reason -- your own doctor, something you read online, you just want to -- and those reasons do not matter for the designation of AMA. Your reasons are your own."

I don't care if a patient disagrees with me about my definition of AMA. I write up the chart as AMA if they leave against my advice to stay.

 

[glorfindel]

His PCo2 had been improving on the BIPAP, but the family basically convinced me to just go ahead and intubate him to take that off the table (I'd been on the fence anyway) - and prevent the patient from interfering in his own life-saving care.

Sounds like you did what you thought was best for the patient given all the available information and considering all the circumstances. Can't ever argue with that.

 

[alreadylernd]

I had an interesting discussion with a family about this last night.
Patient was - in their own words - a stubborn, beligerant man who would rip out his lines and storm out as soon as he got back to his normal mental status. Smoked like a chimney and drank like a fish, obtunded with a GCS around 10. They were very worried.

Well, he was *really* sick. (multiorgan failure, poss unintentional tylenol od, hypercapneic, pneumonia, acidotic, hyperammonemia, definitely an ICU player.) His PCo2 had been improving on the BIPAP, but the family basically convinced me to just go ahead and intubate him to take that off the table (I'd been on the fence anyway) - and prevent the patient from interfering in his own life-saving care. The adult children were very reasonable and one was an ICU RN, but I don't make a habit of intubating people to protect them from their own bad decisions.

This guy, well, he was a unique situtation. And it made it easier for the nurse to manage the drips without having to worry about the patient cooperating. His family was very grateful. (and one had the POA)

A patient with a GCS of 10 probably doesn't have capacity to leave AMA, and we certainly intubate patients to protect staff, the patient and proceed with a necessary workup- usually they're called "etoh/traumas"

 

[Birdstrike]

Try not to use the word, "AMA" with a patient. Try this,

"Do you mind signing a form that shows we had the discussion we just had?
Thank you."


"AMA" invariably causes people to overreact. It doesn't have to be confrontational. You tell them what the choices are, they decide. You don't have to beg and plead or get angry with them, or they with you. People are free to make their own ridiculously stupid decisions.

 

[glorfindel]

Why does it have to be called "AMA" which invariably causes people to over react as if it goes on their "permanent record" or something.

If they're truly leaving against my medical advice, I *want* them to think they're making a big, important decision. I want to put the screws to them in any way I can short of keeping them there against their will.

I want to shame them.
I want to make them feel guilty.
I want to make them feel selfish, impetuous, and short-sighted.
I want to make them aware that I think they are making the wrong decision, medically.

I'm nice about it, but if they're truly leaving against my advice, I want them to fear the medical consequences. And then I want to document that I did everything I could to make them fear the medical consequences.

 

[Birdstrike]

I want to shame them.
I want to make them feel guilty.
I want to make them feel selfish, impetuous, and short-sighted.
I want to make them aware that I think they are making the wrong decision, medically.

Why? What's the point, especially considering 90% of the time it's BS, isn't it?

How many times have you said, "If you leave you will die of a heart attack, you'll get septic, your arm will fall off, your head will explode, you'll go blind, you'll grow hair on your palms, etc". How many times has it actually happened?

One time in hundreds, maybe thousands, did someone I signed out AMA actually go home and have a horrendous outcome.

Plus, all the wasted energy to shame someone who obviously doesn't care enough that they are likely shameless.

Most often docs and nurses just get offended that the patient wasted their time and doesn't think their amazing advice that took umpteen years to learn is being blown off in a nanosecond because then patient has got to get to the strip club, or let their cat out, make it to dollar-pitcher night or do something else ridiculous.

 

[sluggs]

Sorry, but this is a case of patient correct, doctor wrong. A "large fried dinner" is a much better diagnostic test than CT, and it is cheaper. If you watch what the patient eats and does, it is like a CT, a HIDA, and a cholangiogram all in one. If the dinner does not exacerbate the pain you need to think testicular torsion. Otherwise, just repeat labs in 30 minutes following the fried meal, and be ready for a stool sample. Keep a strict record of Is/Os and transit time. Old school, baby!

 

[GeneralVeers]

If they're truly leaving against my medical advice, I *want* them to think they're making a big, important decision. I want to put the screws to them in any way I can short of keeping them there against their will.

I want to shame them.
I want to make them feel guilty.
I want to make them feel selfish, impetuous, and short-sighted.
I want to make them aware that I think they are making the wrong decision, medically.

I'm nice about it, but if they're truly leaving against my advice, I want them to fear the medical consequences. And then I want to document that I did everything I could to make them fear the medical consequences.

You and I think alike in many respects.

 

[GeneralVeers]

Why? What's the point, especially considering 90% of the time it's BS, isn't it?

How many times have you said, "If you leave you will die of a heart attack, you'll get septic, your arm will fall off, your head will explode, you'll go blind, you'll grow hair on your palms, etc". How many times has it actually happened?

One time in hundreds, maybe thousands, did someone I signed out AMA actually go home and have a horrendous outcome.

Plus, all the wasted energy to shame someone who obviously doesn't care enough that they are likely shameless.

Most often docs and nurses just get offended that the patient wasted their time and doesn't think their amazing advice that took umpteen years to learn is being blown off in a nanosecond because then patient has got to get to the strip club, or let their cat out, make it to dollar-pitcher night or do something else ridiculous.

I personally don't care. If they are adults, and are capable of making a decision, it doesn't harm me in any way if they leave. I give them the information and they can make whatever stupid decision they want.

I do like to have a little fun calling it "AMA" and watch them overreact.

 

[docB]

Sorry, but this is a case of patient correct, doctor wrong. A "large fried dinner" is a much better diagnostic test than CT, and it is cheaper. If you watch what the patient eats and does, it is like a CT, a HIDA, and a cholangiogram all in one. If the dinner does not exacerbate the pain you need to think testicular torsion. Otherwise, just repeat labs in 30 minutes following the fried meal, and be ready for a stool sample. Keep a strict record of Is/Os and transit time. Old school, baby!

Awesome! Maybe I could make a ranch dipping sauce with gastrograffin in it then when their pain got worse they'd already have their contrast down.

 

[glorfindel]

Why? What's the point, especially considering 90% of the time it's BS, isn't it?

I get you and agree. Usually for me, though, I'm not treating those 90% patients as "AMA." They fall into the category of "many reasonable options; going home is one of them."

For these people I'll say "your decision; here's my assessment of the medical risks, make your own decision." If they go home, I document the conversation and their choice; the dispo is "d/c."

If I feel strongly that they should stay, and they choose to leave, then they're AMA.

 

[glorfindel]

You and I think alike in many respects.

Proving the oft-repeated point that it isn't about the politics; it's about the dispositions.

 

[Apollyon]

Why? What's the point, especially considering 90% of the time it's BS, isn't it?

How many times have you said, "If you leave you will die of a heart attack, you'll get septic, your arm will fall off, your head will explode, you'll go blind, you'll grow hair on your palms, etc". How many times has it actually happened?

One time in hundreds, maybe thousands, did someone I signed out AMA actually go home and have a horrendous outcome.

Plus, all the wasted energy to shame someone who obviously doesn't care enough that they are likely shameless.

Most often docs and nurses just get offended that the patient wasted their time and doesn't think their amazing advice that took umpteen years to learn is being blown off in a nanosecond because then patient has got to get to the strip club, or let their cat out, make it to dollar-pitcher night or do something else ridiculous.

It's not "all or nothing", though - I preface it with "It is unlikely, but quite possible, that you could" then die, arm fall off, sepsis, stroke, etc.

My shaming AMA speech is tight and one minute long. "You have every right, but it is my professional opinion that what you want to do is foolish. What's worse, though, is you might not die, but live - dragging a leg, wetting the bed, can't speak, and having people point and children literally cry. It is not likely, but it is possible. However, it is your right, and, if you want to leave, we will not kidnap you - but it will be the dumbest thing you do today."

(Now, based on history, I am waiting for some ******bag resident to tell me I'm wrong, but not offer any alternative, and I would then retort "And yet, no matter how wrong YOU think, it WORKS.")

 

[gutonc]

It's not "all or nothing", though - I preface it with "It is unlikely, but quite possible, that you could" then die, arm fall off, sepsis, stroke, etc.

My shaming AMA speech is tight and one minute long. "You have every right, but it is my professional opinion that what you want to do is foolish. What's worse, though, is you might not die, but live - dragging a leg, wetting the bed, can't speak, and having people point and children literally cry. It is not likely, but it is possible. However, it is your right, and, if you want to leave, we will not kidnap you - but it will be the dumbest thing you do today."

(Now, based on history, I am waiting for some ******bag resident to tell me I'm wrong, but not offer any alternative, and I would then retort "And yet, no matter how wrong YOU think, it WORKS.")

You are wrong. But only because the people you have to give that talk to have likely done 7 or 8 dumber things (than leave AMA) prior to presenting to the ED that day.

 

[southerndoc]

I once had a patient come in with chest pain. He was having an anterior STEMI but was fully alert and appeared to have capacity to make decisions. He refused to go to the cath lab, refused to be admitted, and refused any treatment. He wouldn't even stay in the ED to allow us to monitor him.

What do you do in a situation like this? I tried my best (and the cardiologist) to get him to allow us to treat him, but he was adamant he was going home.

So when the nurse handed me the AMA form, I basically told him "I need you to sign here so that when you go home and die, your family can't sue us." I then had the wife and daughter both witness the form.

He came back about 2 hours later in cardiac arrest.

 

[Birdstrike]

I once had a patient come in with chest pain. He was having an anterior STEMI but was fully alert and appeared to have capacity to make decisions. He refused to go to the cath lab, refused to be admitted, and refused any treatment. He wouldn't even stay in the ED to allow us to monitor him.

What do you do in a situation like this?

Just what you did. What else can you do?

 

[Apollyon]

You are wrong. But only because the people you have to give that talk to have likely done 7 or 8 dumber things (than leave AMA) prior to presenting to the ED that day.

Well, YOU get a pass because you are a ******bag attending.

Just kidding!!

 

[glorfindel]

He came back about 2 hours later in cardiac arrest.

Now THIS is the sharp end of the "patient autonomy" stick.

 

[southerndoc]

Now THIS is the sharp end of the "patient autonomy" stick.

We resuscitated him, wife consented to cath, he got a cath, got extubated a few days later and then signed out AMA from the hospital before he could be discharged.

Some people are just determined to not be in the hospital. The only reason he came is because he passed out and his wife called 911 before he regained consciousness. I'm sure his previous syncopal episode was VT/VF that just happened to spontaneously resolve. He was in VF when the paramedics got to him the second time, they shocked him, got him back only for him to code again about a minute outside the hospital.

 

[glorfindel]

The only reason he came is because he passed out and his wife called 911 before he regained consciousness.

This is kind of touching -- his wife must really love him.

She has to stand around all deferential when he's conscious, and exercising his autonomy and stuff, but then as soon as he loses consciousness, BOOM! Calls 911 on his ass.

 

[24IdaFire]

Booted a pt today. I hardly ever do it, and I'm usually pretty good and talking them into staying for the work up.

Spitting in the nurses face today really made me lose my empathy.

 

[la gringa]

Try not to use the word, "AMA" with a patient. Try this,

"Do you mind signing a form that shows we had the discussion we just had?
Thank you."


"AMA" invariably causes people to overreact. It doesn't have to be confrontational. You tell them what the choices are, they decide. You don't have to beg and plead or get angry with them, or they with you. People are free to make their own ridiculously stupid decisions.

this is how i usually word it. does go over better than "AMA".

 

[jl lin]

Try not to use the word, "AMA" with a patient. Try this,

"Do you mind signing a form that shows we had the discussion we just had?
Thank you."


"AMA" invariably causes people to overreact. It doesn't have to be confrontational. You tell them what the choices are, they decide. You don't have to beg and plead or get angry with them, or they with you. People are free to make their own ridiculously stupid decisions.

LOL

What happens when the patient states, "Well, do you mind if I get my lawyer to look at it first?"

People don't have to stay if they don't want to do so. Just like people can refuse particular aspects of treatment. But they may end up having a writing and fighting contest with their insurance carrier/administrators. Having had to fight over things that the insurance company had already approved, in order to get my docs paid, I had to fight like a nut on appeal for a matter of months. Mind you, this was for surgery that they already approved for my kid. ???? They were dragging about it and wanted it to go to collections. I said, "No. The docs and all concerned are going to get paid, and I will do everything I can to keep this from going to collections." It was so blatantly wrong and unfair all the way around. In the end, I won, but it was a real b!tch! It had nothing to do with AMA; but if they can refuse to cover something they already approved, what is to stop them from not covering for AMA and non-compliance with approved treatment????

As a patient, I would think carefully before going AMA. OTOH, if there is something I feel strongly about not doing, I will exercise my right and live to fight another day, so to speak--at least hopefully. LOL

I made a decision to forego my newborn's LP--pediatrician wanted this based on her passive nursing or feeding and slightly low WBC. I knew my own history, and I honestly suspected something related to my known disorder. Yes. I took a little bit of a risk; but my thinking was strong on the benefits of the risk versus going with the LP. The child ended up with all other cultures being negative and improving. There was no infection. I made the choice, and it was a really a strong gut feeling, plus the consideration of other things she presented with--like neonatal lupus presentation. Actually, she was on the textbook side of this, and there was my autoimmune history. This pediatrician was great, nice, and very brand new. Sometimes you have to make a judgment call. It helped that I was a nurse and that I understood my own condition and how that can effect a newborn. Of course, a different situation very well may have led to a different decision.

It was not even that the LP was a huge deal. I had had several of them as a kid. Honestly, some of it was a very strong feeling coupled with her overall presentation. I mean they took blood and urine cultures and covered her anyway; but really all she needed was time to clear out some of transplacental maternal autoantibodies. She ended up being a very healthy, beautiful baby and kid--smart as a tack too. From a pediatrician's perspective, however, I could definitely see his point of view. I ended up making the right call with that kid more than once. Guess it was some combo of intuitive thinking and critical thinking, but some would view it as risky. Just so happened that it was more of a zebra-ish kind of deal with her, but that was based on my own condition.


Anyway, my point is informed consent is always something that must be in place and respected. I had already lost several pregnancies, and with the help of specialists, made it to full term with this baby. I was very protective over any potentially problematic procedures, and given the fact that she presented as transient neonatal lupus in light of my hx and the fact that she was a sluggish but not totally adversed to being nursed, I went with that. So, I don't feel bad about having a different opinion from the pediatrician.

But to be sure, coverage can be denied, regardless of what anyone says. The thing is, at least with private insurers, you can appeal and fight. When the government is the insurer, however,I am not at all convinced that the potential for real appeal is there or will be there.



Also, people have to have enough sense to know if they are going to the ED, there will be waiting. It's not an office visit, and it doesn't roll that way. You may get lucky, but there is a good chance you may not. So how serious is the issue for which the person is coming in to be seen? I know people that in fact have resisted going to the ED when they really needed to go, b/c of the wait factor. No one wants to sit for hours on end in an ED--at least not anyone with any kind of life or sense.

This brings me to another issue. I thought urgent care clinics were supposed to reduce the undue burden on EDs. In many areas, that doesn't seem to be the case.
In the inner city EDs, you better have a good reason for coming in there. But a lot of these community EDs are overrun with clinic type of patients. Why aren't these people going to urgent care centers? Why arehn't they using their community clinics? Why are they jamming up ED rooms for stuff that can be treated elsewhere?

Finally, no one in the ED should have to put up with abuse; but unfortunately it seems part of the system. Some percentage of nimrods come in and waste everyone's time and take up space and then have an attitude over treatment. If someone is abusive and they are coherent, well, AMA is a fine option. OTOH, some are abusive and they won't sign an AMA. So then you are stuck with them and their crappy attitudes.

 

[jl lin]

Booted a pt today. I hardly ever do it, and I'm usually pretty good and talking them into staying for the work up.

Spitting in the nurses face today really made me lose my empathy.

And people want to know why, as a RN, I prefer pedi/neo ICU over ED. ED would be way cool if it weren't for all the abuse down there.

 

[Birdstrike]

LOL

What happens when the patient states, "Well, do you mind if I get my lawyer to look at it first?"

.

Then you say, "OK" and they leave.

Then you document they gave verbal informed-refusal and refused to sign the form until they consulted a lawyer.

They are playing games at that point and obviously not sick. You can only do what you can do. If people want to play stupid games like consulting a lawyer while in the ED with a supposed emergency, then that tells you all you need to know.