Drunk & Combative Patient in Low-to-Medium Risk MVC

[Birdstrike]

I think boarding docs argument falls into the spectrum of how I feel.

There is pretty good anecdotal evidence that unless a (capacitated) person makes a completely indefensible medical decision, that AMA discharge raises your risk of loss in court not lowers*. This is compared to taking thst same patient and doing a thoroughly written shared decision making commentary. You're allowed to discharge someone and say that you disagree with them, as long as you can document that they understood your reasoning and declined everything you offered.**

* I believe Greg Henry referred to AMA documents as the fastest way to turn a bad outcome into your lawyer settling. It basically makes you seem like a doctor who didn't care to listen to the patient or work with the patient to find a middle ground. Medicine doesnt always *have* a middle ground, but thats irrelevant when this appearance colors a court case against you in those subjective ways that make your lawyer want to settle.

** there are people who will then argue that your informed consent is just an AMA without the negative stigma - but that your hospital will freak out because they feel the provisions they want in the AMA for their defense aren't in there. My residency would yell at us for every single AMA regardless of reason as AMA was an administrative metric, but they yell even louder if they found out that we educated and discharged someone where we openly acknowledged they refused necessary treatment because we didn't use the legal forms they liked. They begged us to find some third way, which obviously didn't exist. Point being - I never AMA someone unless they're making a completely terrible decision or the rare "I want to be admittred but I have to drive my family home first/walk the dog first" since that guy is my problem if he doesn't come back. But shared decision making is just a different way of doing it that is better for the doctor unless your admin makes it worse for you

AMA situations do carry high risk of liability. Any time a person refuses to listen to their doctor, when told, "If you don't stay and get treated you'll die or end up disabled" they're at high risk of having a bad outcome, and at high risk of being a vindictive and litigious person who will blame everyone and anyone other than their self for their misfortune, and potentially sue. Once that type of person shows up in your ED sick, your risk of liability is high. Not documenting properly, does NOT decrease that liability. Implying that a fear of the letters "AMA" and refusal to document you did what you could and informed the patients of their risks, will somehow protect you, is just plain wrong.

"You're allowed to discharge someone and say that you disagree with them, as long as you can document that they understood your reasoning and declined everything you offered.**"
Yep. And you know what that process is referred to?
It's called "AMA" documentation.
Sure, if it makes you feel better, document everything that's smart to document without ever using the term "AMA" in your words to the patient, and leave the term 'AMA' out of your documentation. But to imply that because the term "AMA" is an emotionally charged term for some patients and lawyers that you should somehow not protect yourself with documentation is not smart. Also, to assume that a lawyer will reward you for leaving out effective AMA documentation, by not suing you for a bad outcome, because you were word-smithy enough to dance around the term 'AMA,' is setting yourself up for disappointment.

Go back and reread your post. What you're basically saying is, "Don't sign anyone out 'AMA.' Instead, "Sign people out 'AMA' just call it 'discharging someone while saying you disagree with them, while documenting they understood treatments offered and your reasoning," but just don't use the term 'AMA' because lawyers will be too stupid to realize you signed someone out AMA without using the term and therefore won't sue you for a bad outcome.

The main problem surrounding the "AMA" documentation process, in my opinion, has always been less about the semantics around it, but the anger and resentment surrounding the discussion, often from the patient AND the doctor, which can incite the patient and family. It can also come out in your documentation, if your wording come off as angry and condescending.

You should never let such a discussion get confrontational, or take it personally. People will ignore your advise daily. Just give the patients your advice, explain the options and your reasoning once, document your thinking and be done with it. Don't every argue with patients. Don't get angry, offended or insulted. Just do the deed, clinically and systematically and move on. Don't beg, plead, argue and act all exasperated in disbelief that someone would ignore your amazing, brilliant advice, well crafted by years of study and toil. Just make your recommendations, leave a highly defensible chart, and move on. If it makes you feel better, leave out the term "AMA," but sure as hell document everything legally recommended by lawyers when it comes to the AMA process.

You will get sued. And when you do, you're going to hate yourself, if your chart sucks. You'll be much more confident defending yourself with a detailed chart.

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[DocEspana]

AMA situations do carry high risk of liability. Any time a person is too stupid to listen to their doctor, when told, "If you don't stay and get treated you'll die or end up disabled" they're at high risk of having a bad outcome, and at high risk of being a vindictive and litigious person who will blame everyone and anyone other than their self for their misfortune, and potentially sue. Once that type of person shows up in your ED sick, your risk of liability is high. Not documenting properly, does NOT decrease that liability. Implying that a fear of the letters "AMA" and refusal to document you did what you could and informed the patients of their risks, will somehow protect you, is just plain wrong.

"You're allowed to discharge someone and say that you disagree with them, as long as you can document that they understood your reasoning and declined everything you offered.**"
Yep. And you know what that process is referred to?
It's called "AMA" documentation.
Sure, if it makes you feel better, document everything that's smart to document without ever using the term "AMA" in your words to the patient, and leave the term out of your documentation. But to imply that because the term "AMA" is an emotionally charged term for some patients and lawyers that you should somehow not protect yourself with documentation is not smart. Also, to assume that a lawyer will reward you for leaving out effective AMA documentation, by not suing you for a bad outcome, because you were word-smithy enough to dance around the term 'AMA,' is setting yourself up for disappointment.

Go back and reread your post. What you're basically saying is, "Don't sign anyone out 'AMA.' Instead, "Sign people out 'AMA' just call it 'discharging someone while saying you disagree with them, while documenting they understood treatments offered and your reasoning," but just don't use the term 'AMA' because lawyers will be too stupid to realize you signed someone out AMA without using the term and therefore won't sue you for a bad outcome.

The main problem surrounding the "AMA" documentation process, in my opinion, has always been less about the semantics around it, but the anger and resentment surrounding the discussion, often from the patient AND the doctor, which can incite the patient and family. It can also come out in your documentation, if your wording come off as angry and condescending.

You should never let such a discussion get confrontational, or take it personally. People will ignore your advise daily. Just give the patients your advice, explain the options and your reasoning once, document your thinking and be done with it. Don't every argue with patients. Don't get angry, offended or insulted. Just do the deed, clinically and systematically and move on. Don't beg, plead, argue and act all exasperated in disbelief that someone would ignore your amazing, brilliant advice, well crafted by years of study and toil. Just make your recommendations, leave a highly defensible chart, and move on. If it makes you feel better, leave out the term "AMA," but sure as hell document everything legally recommended by lawyers when it comes to the AMA process.

You will get sued. And when you due, you're going to hate yourself, if your chart sucks. You'll be much more confident defending yourself with a detailed chart.

The thing you're mocking and saying I'm accidentally suggesting is what I am suggesting.

So let me spell out what a few medical defense groups implied and greg Henry flat out says.

If you have the ability to avoid an AMA discharge, even if simply only avoiding the term, do everything in your power to avoid using that term.

What you wrote off as unlikely is what the attorneys all say is totally the truth. The AMA form has horrible optics in a case. By literally doing everything but that form you move from appearing as an uncaring doctor to a deeply caring doctor. Why? Because people in the jury will know the AMA form and carry absolutely biased memories of their experience with it.

It turns a case the prosecution narrowly won't take into one they will roll the dice on. And turns one your attorneys will fight into one they will settle. Greg Henry is explicit in say8ng he's seen multiple nearly identical cases go dramatically differently just because the negative stigma of that AMA form. That it has such a sway when a good prosecutor leverages it. And thst visceral response just doesn't exist with informed consent because it is the AMA itself that's the trigger for the juries.

Of note - he gave this lecture at NY ACEP about trashing the AMA form. So we then had him come talk at our hospital along with a senior partner at a medical defense firm and one of the premiere medmal attorneys in the city. They all were in complete agreement that the AMA form is s horrible thing that should just be trashed and never used. The prosecutor called it "a gift".

 

[Vandalia]

Why? Because people in the jury will know the AMA form and carry absolutely biased memories of their experience with it.

Your source for this? I have hardly come across anyone who didn't work in the ED who has ever heard of an "AMA form", and those few who did thought it stood for the American Medical Association.

(What rate do you have for people leaving AMA? I vaguely remember nationally it is around 1% of visits and most of these are the same patients, so the number of distinct individuals is far less. For us it is at most 1-2/week. For what you are saying, you must be having every other patient leave AMA.)

And if they do have experience with "AMA" they should be struck for cause by your attorney. That is the whole point of voir dire. If by some chance they slip through and make it to being jurors, you then sue your attorney for malpractice.

 

[TooMuchResearch]

AMA situations do carry high risk of liability. Any time a person is too stupid to listen to their doctor, when told, "If you don't stay and get treated you'll die or end up disabled" they're at high risk of having a bad outcome, and at high risk of being a vindictive and litigious person who will blame everyone and anyone other than their self for their misfortune, and potentially sue. Once that type of person shows up in your ED sick, your risk of liability is high. Not documenting properly, does NOT decrease that liability. Implying that a fear of the letters "AMA" and refusal to document you did what you could and informed the patients of their risks, will somehow protect you, is just plain wrong.

"You're allowed to discharge someone and say that you disagree with them, as long as you can document that they understood your reasoning and declined everything you offered.**"
Yep. And you know what that process is referred to?
It's called "AMA" documentation.
Sure, if it makes you feel better, document everything that's smart to document without ever using the term "AMA" in your words to the patient, and leave the term 'AMA' out of your documentation. But to imply that because the term "AMA" is an emotionally charged term for some patients and lawyers that you should somehow not protect yourself with documentation is not smart. Also, to assume that a lawyer will reward you for leaving out effective AMA documentation, by not suing you for a bad outcome, because you were word-smithy enough to dance around the term 'AMA,' is setting yourself up for disappointment.

Go back and reread your post. What you're basically saying is, "Don't sign anyone out 'AMA.' Instead, "Sign people out 'AMA' just call it 'discharging someone while saying you disagree with them, while documenting they understood treatments offered and your reasoning," but just don't use the term 'AMA' because lawyers will be too stupid to realize you signed someone out AMA without using the term and therefore won't sue you for a bad outcome.

The main problem surrounding the "AMA" documentation process, in my opinion, has always been less about the semantics around it, but the anger and resentment surrounding the discussion, often from the patient AND the doctor, which can incite the patient and family. It can also come out in your documentation, if your wording come off as angry and condescending.

You should never let such a discussion get confrontational, or take it personally. People will ignore your advise daily. Just give the patients your advice, explain the options and your reasoning once, document your thinking and be done with it. Don't every argue with patients. Don't get angry, offended or insulted. Just do the deed, clinically and systematically and move on. Don't beg, plead, argue and act all exasperated in disbelief that someone would ignore your amazing, brilliant advice, well crafted by years of study and toil. Just make your recommendations, leave a highly defensible chart, and move on. If it makes you feel better, leave out the term "AMA," but sure as hell document everything legally recommended by lawyers when it comes to the AMA process.

You will get sued. And when you do, you're going to hate yourself, if your chart sucks. You'll be much more confident defending yourself with a detailed chart.

I call it AMA and click the AMA disposition in the chart but don't fill out the paper AMA form.

 

[Birdstrike]

Although it's tempting to get distracted by the shiny red ball that is the term "AMA," what's ultimately important is that you properly understand, perform and document informed refusal. Informed refusal is as important as informed consent. The term "AMA" is simply a slang term, and by itself isn't specific enough to be helpful in a medical-legal sense.

Where I think some of the confusion comes from, is people that think 'informed refusal' equals 'Just give this guy the standard form, get a quick signature and that all you have to due and you have legal immunity.' That is not correct. The two things are not, the same.

At the same time, because the signage of a pre-printed form without any meaningful discussion or documentation of informed refusal isn't good enough, does not mean that properly performing and documenting informed refusal isn't important. Informed refusal, and the proper documentation of it, is important.

When one obtains and documents informed consent for an elective procedure, you don't just slap a form in a patient's face, get a quick signature with no discussion of risk, benefits or alternatives, and expect that to provide meaningful medical-legal defense. The same applies to informed refusal. A patient-signed boiler plate form, by itself, with no corresponding documentation of the specifics of the discussion in your medical records, isn't very helpful. What is helpful, is to document in your chart you explained the ideal treatment and plan and its benefits, that you explained the risks of refusal, and explained other reasonable alternatives. It's also helpful to document normal mental status and the ability to give informed refusal. It helps to document that you've also discussed these issues with present family members or any family or friends you've discussed with over the phone. Document if the patient refused to allow you to discuss the situation with his/her friends or family members. It's helpful to document that the patient was encouraged to come back for treatment if they changed their mind or symptoms worsened, and that it's okay for them to do so. Give them the relevant follow up instructions regarding there diagnosis in case they worsen. It's important not to put any pejoratives in the chart that would make it appear that you kicked the patient out and refused to treat them, as opposed to them refusing you. Also, document that the patient indicated understanding, and that you answered any pertinent questions they may have had.

Finally, getting the patient signature with a witness signature (usually the nurse), is critical. Anyone that says not to get a patient signature, in some form, is not trustworthy or credible, in my opinion. A signature is the only way you have to document you didn't just make it all up, and as such is the underpinning of nearly all legal documents and contract in existence, now, and going back thousands of years.

Those are all basic, tried and true concepts regarding medical-legal informed refusal. They've served me very well. I have been sued before, but out of about 45,000 patient interactions and counting, in my career, I've never once (knock on wood) had anyone even try to sue me on an AMA case, let alone win. And at least 35,000 or more of those patient interactions are >3 years ago, in other words past the statute of limitations, and of no use to any attorney looking for a hot AMA suit.

Now, in regards to the above poster's anecdotal experience about Greg Henry's anecdotal experience, I can't say that I've followed him in recent years, but I do think he's a smart guy. Whether or not he's truly advising people to forego informed refusal documentation, and completely give up your ability to place the patient at the discussion you've documented by getting a signature in some form, I'm not sure (although I seriously doubt it). But if so, that's a fringe, fringe, opinion, that goes against the standard thinking in this area and against standard medical-legal advice on this subject. I'd consider it legal advice worth about what I paid for it.

 

[Birdstrike]

I call it AMA and click the AMA disposition in the chart but don't fill out the paper AMA form.

Do you document the details of your informed refusal discussion with the patient?
If so, what verifiable proof do you obtain, that you can point to later, that places the patient physically present at that discussion?
What evidence are you creating, that you can point to, when you patient or his lawyer claims at a later date, "He never even talked to me. He never told me any of that. It never happened"?
Are you just relying on the trust and good-heartedness of the patient and his lawyer to take you word for it, years later, that this informed refusal discussion you claim you had with the patient, ever happened?

 

[GTP]

Do you document the details of your informed refusal discussion with the patient?
If so, what verifiable proof do you obtain, that you can point to later, that places the patient physically present at that discussion?
What evidence are you creating, that you can point to, when you patient or his lawyer claims at a later date, "He never even talked to me. He never told me any of that. It never happened"?
Are you just relying on the trust and good-heartedness of the patient and his lawyer to take you word for it, years later, that this informed refusal discussion you claim you had with the patient, ever happened?

If this is true, then why do we bother writing in our charts "patient told to take all antibiotics until they are completely finished and to return immediately at any time if cellulitis worsens despite oral antibiotics". Patients don't sign everything and we give lots of advice, but yet I'm told by my attendings to write stuff like this in my chart. Just trying to learn. I'm pgy3 going out in the real world soon.

 

[BoardingDoc]

If this is true, then why do we bother writing in our charts "patient told to take all antibiotics until they are completely finished and to return immediately at any time if cellulitis worsens despite oral antibiotics". Patients don't sign everything and we give lots of advice, but yet I'm told by my attendings to write stuff like this in my chart. Just trying to learn. I'm pgy3 going out in the real world soon.

Because the RN who discharges the patient should be reading them their DC instructions where you've written all of that. You now have a paper document that the patient received as well as the RN note saying that they read it to the patient. There is a preponderance of evidence in your favor. I think Birdstrike is saying you shouldn't DC patients where they're leaving AMA and simply write in your chart that they left AMA. At the very least your DC paperwork should say that you recommended that they stay, talk about the risks of them leaving and that they are always welcome to come back. A better answer is to do the same thing and have them sign it.

 

[gamerEMdoc]

I personally you have them leave AMA because after all, that's what it is, but you still do your best to give them the best followup discharge plan. They are both discharged, and leave AMA. If someone has a STEMI and absolutely refuses to get care in the ED, they should still go home on aspirin, be given a number for a cardiologist to followup with, etc. I agree with the sentiment the forms are worthless, its all about you taking the time to try to convince the person to do the right thing, documenting the conversation and attempts made to convince them otherwise, and developing an alternative plan to the best of your ability.

 

[Birdstrike]

I personally you have them leave AMA because after all, that's what it is, but you still do your best to give them the best followup discharge plan. They are both discharged, and leave AMA. If someone has a STEMI and absolutely refuses to get care in the ED, they should still go home on aspirin, be given a number for a cardiologist to followup with, etc. I agree with the sentiment the forms are worthless, its all about you taking the time to try to convince the person to do the right thing, documenting the conversation and attempts made to convince them otherwise, and developing an alternative plan to the best of your ability.

The forms by themselves, are worthless. But combined with all the other important factors related to informed refusal, they indicate the patient's acknowledgement that 1) The conversation occurred, and 2) The signature places them at the conversation and involved enough to put there signature on a piece of paper. The signature is necessary, but by itself, not sufficient to properly document informed refusal.

 

[TooMuchResearch]

Do you document the details of your informed refusal discussion with the patient?
If so, what verifiable proof do you obtain, that you can point to later, that places the patient physically present at that discussion?
What evidence are you creating, that you can point to, when you patient or his lawyer claims at a later date, "He never even talked to me. He never told me any of that. It never happened"?
Are you just relying on the trust and good-heartedness of the patient and his lawyer to take you word for it, years later, that this informed refusal discussion you claim you had with the patient, ever happened?

Yes, I thoroughly document informed refusal.
I guess I only have the same evidence of any discharge discussion I have: my signed note, the printed discharge instructions (which are stored in the EMR), and the patient's signature on discharge paperwork per usual (unless they refuse to sign it). That and the patient probably secretly recording me.

 

[TooMuchResearch]

I personally you have them leave AMA because after all, that's what it is, but you still do your best to give them the best followup discharge plan. They are both discharged, and leave AMA. If someone has a STEMI and absolutely refuses to get care in the ED, they should still go home on aspirin, be given a number for a cardiologist to followup with, etc. I agree with the sentiment the forms are worthless, its all about you taking the time to try to convince the person to do the right thing, documenting the conversation and attempts made to convince them otherwise, and developing an alternative plan to the best of your ability.

In residency I managed to get an attending consultant to come down to discuss a best possible discharge med and clinic follow up plan for a patient with a limb and possibly life threatening illness leaving AMA.

 

[Birdstrike]

If this is true, then why do we bother writing in our charts "patient told to take all antibiotics until they are completely finished and to return immediately at any time if cellulitis worsens despite oral antibiotics". Patients don't sign everything and we give lots of advice, but yet I'm told by my attendings to write stuff like this in my chart. Just trying to learn. I'm pgy3 going out in the real world soon.

You absolutely can have patients sign your written discharge instructions, and scan it back into the EMR, if you want to. Many people do. But the reason that's not emphasized as much as it is for informed refusal, is because its not as high a risk of a situation as when a patient is making a point to refuse care. The guy who is going to take your antibiotics for cellulitis, is much less likely to have a bad outcome to try to sue you over, than the febrile, diabetic alcoholic who refuses all antibiotics until he's scooped up off the street unresponsive with a gangrenous leg. The 'routine' is generally lower risk, than a high acuity situation where a patient is taking on enough risk that you're worried enough to pull out all the stops to cover your butt.

But here's what it comes down to. Pretty soon you'll be on your own. There's nothing set in stone. You'll have to decide how many layers of protection you want, for yourself. The name of the game is to protect yourself, not to please me or any other know-it-all on SDN. Do you want to block as many common plaintiff's lawyer's strategies as possible, beforehand? Or do you want to cover only one or two, to save 15 seconds, and tee up some low hanging fruit for an attorney?

Do you want to ride with the guy that says, "Do the minimum and you'll probably be fine, because a guy, who knows a guy, who was an expert, said that's all you need"? Or do you want to formulate a system that's as fool proof as possible, one that's easy, systematic and routine, that you can do while tired, without much thought, that can cover most of the medical-legal weak spots attorney's will try to exploit?

It's your life; your career. There are no absolutes. Your system. Your consequences.

I'm sure you've heard of Sullivan Group. If not, they do excellent CME specifically from the standpoint of, "What low hanging fruit do attorney's look for in reviewing med mal charts? And what efficient and targeted steps can I take, to block as many of those angles of attack, as possible?" The group was started by a guy who's an Emergency Physician and a lawyer. The lessons are good enough, that some medical malpractice insurance companies will give you a discount on your premiums, if you do their CME. It's pretty high yield, from a risk management standpoint. I'm sure there are other similar courses.

Here's what they say about informed refusal, and how best to protect yourself:

Do's & Don'ts of AMA: Patients Who Leave Against Medical Advice

On the other hand, if you want to go based on what some lecturer says, who has a different opinion, then go ahead. Follow what advice you think makes most sense, because it's going to be you defending it under cross examination, some day, not me.

Or maybe you won't have to defend much of anything, if your documentation is so damn iron clad, attorney's read it, and say to their prospective plaintiff's, "Sorry, I can't take this case. I just don't think I can win this one."

 

[Birdstrike]

Here's an example of where people go wrong with AMA's and where an attorney can get easily some money out of a case where the doc thinks he's got himself covered, with no risk at all:

A patient comes in with chest pain. He's 60, the story is atypical, but he's got enough risk factors you decide it at least needs an EKG, labs, CXR, enzymes, and to be worked up. You tell the patient, "It's probably not your heart, but it's best if we do some tests and rule it out." The patient seems agreeable. You walk away, put in your orders, and dive into your busy shift.

Some time later the nurse comes back to you, and says, "The patient in room 10, with chest pain, wants to go home. We haven't even drawn blood yet, and when we went to do the EKG, he said he wants to 'sign out.'"

Since the time you saw him, you've picked up several critical patients, a few other complex work-ups and the waiting room just blew up with countless impatient non-urgents. "Ok, fine. Sign him out AMA," you say.

The nurse grabs the generic 'AMA form' and takes it to the patient to sign. You go and intubate one of your other patients, thinking, that patient had BS chest pain, anyways. He'll probably be fine, but I sure as heck am going to (here it comes....) 'cover myself with an AMA form.'

2 years and 11 months later an officer of the court wearing a badge finds you at work and hands you a subpoena. Only now do you find out the patient went home and died.

Although you seemingly 'covered yourself' by having the patient sign an AMA waiver, why is the lawyer confident he can squeeze a few bucks out of your insurance company?

(If you're thinking that somehow the AMA form sabotaged you, that AMA forms are bad luck, toxic and if you had skipped it, you wouldn't have gotten sued, read on.)

The lawyer is confident, because when he deposed the patient's wife, who was there in the ED with him, she said, you never came in the room and even talked to them. Other than a token signed, off-the-shelf AMA form, there was no actual discussion with the patient, no discussion of risks, benefits, alternatives or any of the other necessary elements of an actual informed refusal process documented. Also, the wife said, "The last thing I remember was, the doctor came in and said, 'It's probably not your heart...' then walked out of the room and the next thing I know, the nurse said, 'All you have to do, is signed this form and the doctor says you can go.'"

The lawyer views it from the patient's standpoint and is thinking he can easily get a jury to believe you left the impression there wasn't much to worry about, and didn't properly inform the patient of the risks of walking out, untreated and untested. Then the lawyer goes down the very easy, and very routine list of necessary elements of informed refusal and sees none of them in your chart (other than the signed form). Although you covered one of the necessary elements, alone it's not sufficient to convince the jury you actually explained to the guy that death by heart attack could actually happen, as opposed to the non-cardiac chest pain you were signaling that you thought he likely had.

Then, when the wife says the "nurse seemed irritated, seemed like she was mad at us and just wanted to get rid of us," all of a sudden what you thought was an iron clad case of 'patient took matters into his own hands, screwed up and I have no liability,' has turned into as sympathetic case of a 'sad and aging women, left widowed, by a rude, overworked ED crew who doesn't care enough about their patients to even spend 30 seconds convincing them they shouldn't make the worst mistake of their life. "I NEVER would have let him leave, if they told me he would die," she says, choking back tears.

This kind of scenario is actually incredibly common. Once a provider hears the words, "Patient ____ wants to sign out AMA" often the response is not, "Okay, I need to go through an important informed refusal process and document it well." Often, the response is, "Good. Get him out of here. If he doesn't want to take my advice then ____ and _____. Sign him out. I'm done," drenching in a good dose of anger, irritation and righteous indignation.

So, it's not the fact that the patient was given an AMA form and signed it, that's the problem. It's not that there's anything wrong with the form itself. It's that no valid, or even minimal, informed refusal discussion was had, let alone documented.

So, the lawyers are looking at it from the perspective that there's, 1) A very bad outcome, i.e., damages, 2) A sympathetic witness who's either dead or severely disabled, 3) Very thin documentation involving nothing more than a signature on a piece of paper and nothing specific at all about the actual risk/benefit conversation that occurred, or even better for them, no signed form at all to even indicate any informed refusal discussion happened at all, and 4) Elements that allow him to paint either the doctor, the nurse, hospital or all of the above as cold, uncaring, overworked, and/or understaffed.

Combine that with a doctor with righteous indignation who (wrongly) thinks there's no chance a jury of the patient's peers will side with the dead patient, and you've got the perfect way to shake out a small, but worthwhile settlement from the insurance company, who wants to avoid a seven figure sympathy/lottery-ticket judgement by putting the incensed doctor on the stand, who may not be skilled at either persuasion or projecting compassion in an environment where he feels like a fish out of water.

It's not the form, it's the process.

 

[deleted859535]

I do both. I am quick to utilize AMA disposition in Epic, "left against medical advice" under Clinical Impressions, and an AMA form itself. Discharge instructions refer to further testing / come back if you change your mind. It's clear from all angles I didn't want them to leave.

HOWEVER.

This all comes with a very long/detailed MDM in the chart of our conversation. No "hard feelings." Nobody is mad. We want you to come back if you change your mind. Here's what I said in the room in general in the note. Here's why I wanted to do what I wanted to do. If applicable, meds are still prescribed. Here's why the patient didn't want to stay. They had the capacity to make that decision, autonomy, etc.

I literally document the chart to the point of not being able to think of anything else useful to add. Can't imagine there's any better way.

 

[Janders]

Agree with the last couple posters. I do use the disposition "AMA". I sometimes use the boilerplate form from the hospital. But I ALWAYS have a lengthy MDM detailing precisely the conversation I had with patient about SPECIFIC risks, SPECIFIC alternatives, and their OBVIOUS CAPACITY to make their own independent and personal medical decisions. As well, it is stated clearly that I invited the patient to please return anytime that is good for them so we can do XYZ.

I put the exact same information into their discharge instruction free text area. Thus they get a copy. And they get to sign it to (our hospital keeps these).


Story time-- my first year out I go an absolute craptastic signout bomb. Eventually this guy demands to leave AMA. He has multiple reasons to stay in the hospital. Good reasons. But absolutely will not. The RN really tried to connect with him, and failed. Me too. So I give him the best options I can-- oral antibiotics for his infection, instructions to have plenty of water, our phone number he can call anytime, instructions to return ASAP so we can finish our treatment. I also specifically wrote "We want you to stay in the hospital because of life-threatening XYZ, but you prefer to leave to deal with ABC. We are afraid your condition could worsen and you could die. PLEASE come back as soon as possible. If you won't come back PLEASE take these prescriptions and see your PCP tomorrow" As the header to his d/c instructions.

Turns out he took these home, put them on the coffee table, and died on his couch sometime in the next 48 hours. The Rx was unfilled.

I heard about it because the family called the ED to tell us he died, and to thank us for doing everything we could to help him. They said he was a hard headed dingus, and he relished living in a free country, and they could tell from our paperwork we really tried to help him. And that we shouldn't feel bad, he went out on his own terms...

I felt this was a sign from above to always take AMAs seriously, to truly try and connect with the patient if you think it matters, and to document the hell out of your and your staff's attempts.

 

[Birdstrike]

I do both. I am quick to utilize AMA disposition in Epic, "left against medical advice" under Clinical Impressions, and an AMA form itself. Discharge instructions refer to further testing / come back if you change your mind. It's clear from all angles I didn't want them to leave.

HOWEVER.

This all comes with a very long/detailed MDM in the chart of our conversation. No "hard feelings." Nobody is mad. We want you to come back if you change your mind. Here's what I said in the room in general in the note. Here's why I wanted to do what I wanted to do. If applicable, meds are still prescribed. Here's why the patient didn't want to stay. They had the capacity to make that decision, autonomy, etc.

I literally document the chart to the point of not being able to think of anything else useful to add. Can't imagine there's any better way.

What you described, is exactly how to do it. But always have them at least sign something. Even if you print your note, have them sign that and scan it into the chart, so they can't try to claim you lied, and made it all up just to cover your butt.

 

[Birdstrike]

Agree with the last couple posters. I do use the disposition "AMA". I sometimes use the boilerplate form from the hospital. But I ALWAYS have a lengthy MDM detailing precisely the conversation I had with patient about SPECIFIC risks, SPECIFIC alternatives, and their OBVIOUS CAPACITY to make their own independent and personal medical decisions. As well, it is stated clearly that I invited the patient to please return anytime that is good for them so we can do XYZ.

I put the exact same information into their discharge instruction free text area. Thus they get a copy. And they get to sign it to (our hospital keeps these).


Story time-- my first year out I go an absolute craptastic signout bomb. Eventually this guy demands to leave AMA. He has multiple reasons to stay in the hospital. Good reasons. But absolutely will not. The RN really tried to connect with him, and failed. Me too. So I give him the best options I can-- oral antibiotics for his infection, instructions to have plenty of water, our phone number he can call anytime, instructions to return ASAP so we can finish our treatment. I also specifically wrote "We want you to stay in the hospital because of life-threatening XYZ, but you prefer to leave to deal with ABC. We are afraid your condition could worsen and you could die. PLEASE come back as soon as possible. If you won't come back PLEASE take these prescriptions and see your PCP tomorrow" As the header to his d/c instructions.

Turns out he took these home, put them on the coffee table, and died on his couch sometime in the next 48 hours. The Rx was unfilled.

I heard about it because the family called the ED to tell us he died, and to thank us for doing everything we could to help him. They said he was a hard headed dingus, and he relished living in a free country, and they could tell from our paperwork we really tried to help him. And that we shouldn't feel bad, he went out on his own terms...

I felt this was a sign from above to always take AMAs seriously, to truly try and connect with the patient if you think it matters, and to document the hell out of your and your staff's attempts.

Well done.

 

[GTP]

I do both. I am quick to utilize AMA disposition in Epic, "left against medical advice" under Clinical Impressions, and an AMA form itself. Discharge instructions refer to further testing / come back if you change your mind. It's clear from all angles I didn't want them to leave.

HOWEVER.

This all comes with a very long/detailed MDM in the chart of our conversation. No "hard feelings." Nobody is mad. We want you to come back if you change your mind. Here's what I said in the room in general in the note. Here's why I wanted to do what I wanted to do. If applicable, meds are still prescribed. Here's why the patient didn't want to stay. They had the capacity to make that decision, autonomy, etc.

I literally document the chart to the point of not being able to think of anything else useful to add. Can't imagine there's any better way.

This is exactly how I do my AMAs. Except I also include being disabled or having lost wages

 

[GTP]

Because the RN who discharges the patient should be reading them their DC instructions where you've written all of that. You now have a paper document that the patient received as well as the RN note saying that they read it to the patient. There is a preponderance of evidence in your favor. I think Birdstrike is saying you shouldn't DC patients where they're leaving AMA and simply write in your chart that they left AMA. At the very least your DC paperwork should say that you recommended that they stay, talk about the risks of them leaving and that they are always welcome to come back. A better answer is to do the same thing and have them sign it.

30% of our RNs don't do this and think we are stupid. That's why I always see each patient at least 3 times. At the beginning for h&p, in the middle to update and see if symptoms improved and right before I discharge them.

 

[deleted109597]

I've never worked anywhere that didn't require patients to sign that they received discharge instructions. This leads me to believe that it's either a TJC rule or something deeply embedded in the hospital culture. Either way, putting things in the D/C instructions is very important. Don't refuse antibiotics or other lifesaving meds simply due to AMA status.
I'm actually a little scared about refusing pain meds for these people. Yes, pain meds don't save lives. But the simple act of not doing it puts a conflict in the system. And they're less likely to take other meds as well.
Basically, the vast majority of AMA patients just suck.

 

[GTP]

These lazy nurses I'm referring to just say here is your discharge, sign here. They don't rehash my discharge instructions. I go through everything myself right before discharge. I ambulate my own patients...etc