Leaving AMA

[alreadylernd]

I was having a discussion with a colleague last night about having patients sign AMA (against medical advice) forms. I find myself rarely having the patient actually sign it, but dictating in my note that I had a discussion, explained risks of XYZ, patient refused procedure/admission, patient accepts risk and demonstrates own capacity for decision making.

My colleague seemed to think that despite that, having a signed AMA form in the chart is better protection (of course both would probably be best)

I was wondering what other people think about patients leaving AMA and using a signed form versus dictating the discussion you had. I've thought about it and I find I use the AMA form more when patients are refusing an admission, but a dictation when patients are refusing a procedure (blood draws, radiology, LPs). Patients refusing a procedure often end up getting discharged, and in their discharge instructions (which they sign), I do write "You refused XYZ today, if you change your mind please return yada yada yada"

What does everyone else do? Thanks!

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[Foster23]

I was having a discussion with a colleague last night about having patients sign AMA (against medical advice) forms. I find myself rarely having the patient actually sign it, but dictating in my note that I had a discussion, explained risks of XYZ, patient refused procedure/admission, patient accepts risk and demonstrates own capacity for decision making.

My colleague seemed to think that despite that, having a signed AMA form in the chart is better protection (of course both would probably be best)

I was wondering what other people think about patients leaving AMA and using a signed form versus dictating the discussion you had. I've thought about it and I find I use the AMA form more when patients are refusing an admission, but a dictation when patients are refusing a procedure (blood draws, radiology, LPs). Patients refusing a procedure often end up getting discharged, and in their discharge instructions (which they sign), I do write "You refused XYZ today, if you change your mind please return yada yada yada"

What does everyone else do? Thanks!

I do exactly what you stated. In addition, I also have family members (if present) sign the AMA form next to patient's signature too.

 

[GeneralVeers]

I do exactly what you stated. In addition, I also have family members (if present) sign the AMA form next to patient's signature too.

That's why "elopement" is the best outcome. You can dictate to your heart's content about how concerned you were for that patient, but when you went to check on them to give them another 4 mg of Dilaudid, they were already gone!

I try to encourage the chronic pain seekers to elope. If I don't give them any attention and they realize they aren't getting any narcs, a good number of them simply disappear without confrontation.

 

[Birdstrike]

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[Arcan57]

The more layers of protection the better. If you have the discussion, why not just hand them a form and say, "Do you mind just signing this saying we had this discussion?". It doesn't have to be angry or contentious, just one adult making a recommendation to another grown adult. The less confrontational the better.

If they refuse to sign it, then dictate that too. It's amazing how few people refuse to sign if you simply say, " It's your decision, it's just my job to inform you of the risks". You can respect and accept their RIGHT to make the decision, even if you think it's a terrible decision.

It's not your job to spend all day begging and pleading with them to make what you think might be a wiser decision. It's your job to inform. It's not your job, nor are you always able, to ensure a wise choice.

In my mind, there are two kind of AMA discussions. One revolves around the patient not wanting to do something you think is necessary, and the other revolves around you not doing something the patient thinks is necesary. The initial approach is the same, but the trajectories are very different. If the patient is refusing, discussing the risks and making sure they know to come back if they change their mind are usually easy to accomplish. I'd say 99% of these patients will sign the appropriate forms. If I am refusing, I have a nurse in the room with me and follow pretty much the same approach outlined by Veers. If they still choose to leave, it's usually them storming out of the building and the encounter is documented in non-inflammatory terms. I don't like patients eloping because I'm not convinced it's the iron-clad legal protection that Veers mentioned. In the last month, I've had to stop a 2 actively suicidal patients from walking out, both of whom the nurses were fine with letting leave.

 

[la gringa]

Arcan -

I've had to do the same w/ belligerent intoxicated patients... the nurses are fine w/ just letting them walk out. I see my name on the local news as being the doctor taking care of the patient who wandered out of the hospital into traffic and died. I'd rather fight the patient than the onslaught of medicolegal nightmares that would ensue...

 

[EM_Rebuilder]

I've wondered this and seen it debated before....

The question I have always asked... Can anyone cite any malpractice case where a patient won a suit in which they left AMA?


I agree the sticky part becomes drugs/intoxicated and at what point can we force to stay versus allow to leave and not becoming an entrapment/kidnapping issue.... If I sign out someone with alcohol or drug abuse, I make certain they can stand alone and walk without issue... I document the patient appears clincailly sober and walks without issue. I have turned down nurses wanting to sign out the guy still passed out in the bed peeing on himself... Usually if they are awake enough to hollar about leaving, they can walk without issue...


I think a patient with abdominal pain, that refuses to 'wait around for the CT' and elopes/signs a document/or simply has a chart that has a small blurb about leaving AMA... that comes back septic with a ruptured appy... I just dont see how they could have a valid case?

 

[BJJVP]

I vaguely remember hearing from someone that insurance companies may not cover complications that occur after a pt leaves AMA. It doesn't make sense to me but has anyone been told this?

 

[docB]

I've wondered this and seen it debated before....

The question I have always asked... Can anyone cite any malpractice case where a patient won a suit in which they left AMA?


I agree the sticky part becomes drugs/intoxicated and at what point can we force to stay versus allow to leave and not becoming an entrapment/kidnapping issue.... If I sign out someone with alcohol or drug abuse, I make certain they can stand alone and walk without issue... I document the patient appears clincailly sober and walks without issue. I have turned down nurses wanting to sign out the guy still passed out in the bed peeing on himself... Usually if they are awake enough to hollar about leaving, they can walk without issue...


I think a patient with abdominal pain, that refuses to 'wait around for the CT' and elopes/signs a document/or simply has a chart that has a small blurb about leaving AMA... that comes back septic with a ruptured appy... I just dont see how they could have a valid case?

I can't cite cases because few cases are publicized but the legal people I know assure me that AMA cases can and do result in lost suits. In fact the high risk EM course I took emphesized that AMA is an area fraught with problems for the doc.

The cases usually focus on accusations that the doctor didn't fully explain a specific possible complication or that the patient really didn't/couldn't understand what they were being told.

I vaguely remember hearing from someone that insurance companies may not cover complications that occur after a pt leaves AMA. It doesn't make sense to me but has anyone been told this?

We have been assured by our billing company that this is not true. They supposed that there may be some corelation of people who went to the ED for inappropriate reasons in the first place and then left AMA and that the bills were being kicked due to the former.

 

[streetdoc]

I vaguely remember hearing from someone that insurance companies may not cover complications that occur after a pt leaves AMA. It doesn't make sense to me but has anyone been told this?

every company is different (so i suppose it could exist) but for major insurance providers this is myth

 

[Birdstrike]

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[DeadCactus]

Physicians spend a lot of time documenting every asinine detail of a patient encounter. Is there any actual evidence that it provides real legal protection? I just always get the impression that legal outcomes depend more on how bad the outcome is, how much the patient likes you, and how well you come across in court/deposition than how well you document or practice medicine...

 

[Danbo1957]

2-Don't assume one needs a valid case to sue you. Once you're named, even a frivolous suit may require years and tens of thousands of dollars spent by your insurance company to get you dropped, or win.

Not in Texas; frivolous suits never make it past the pre-filing screening. And so, there are fewer attempts at frivolous suits as lawyers know that they won't get to court. Thank you tort reform.

Eloping is rarely an issue for someone in real need, but we do see drug seekers and frequent flyers leave after getting told "You're not getting anything." during the triage interview. And I make everyone sign the AMA paperwork, or note that there was a refusal to sign. Again, as you were told in med-school: document everything.

 

[GeneralVeers]

Arcan -

I've had to do the same w/ belligerent intoxicated patients... the nurses are fine w/ just letting them walk out. I see my name on the local news as being the doctor taking care of the patient who wandered out of the hospital into traffic and died. I'd rather fight the patient than the onslaught of medicolegal nightmares that would ensue...

You are talking about a different patient population. If the patient is mentally, or emotionally impaired due to psych problems, substance abuse, or other causes then we should use every reasonable method to stop them from leaving. I wouldn't however tackle or physically restrain any patient trying to leave. I'm not trained in self-defense, and wouldn't risk my life, or the lives of staff to stop someone. That's what security and/or police are for.

The eloping patients I'm referring to are the chronic pain people, secondary gainers, and malingerers. You know they're not sick, and you don't want to do what they want. The simplest way to deal with them is if they leave of their own accord.

 

[la gringa]

Veers - definitely agree there. what stinks is when they're the SAME PATIENT.. manipulative, under the influence, and with something you need to rule out. i was in that situation last week and it was a very stressful situation for myself and the staff.

 

[GeneralVeers]

Veers - definitely agree there. what stinks is when they're the SAME PATIENT.. manipulative, under the influence, and with something you need to rule out. i was in that situation last week and it was a very stressful situation for myself and the staff.

That actually is fairly simple if you don't let them emotionally hijack you. If they are impaired, and have a potentially life-threatening emergency, you are completely covered legally to do appropriate testing to rule out that emergency.

I don't accept the line: "Give me my dilaudid or I won't consent to a CT scan!"

If they are intoxicated they are not getting the dilaudid, though a little Inapsine might be called for, and they are getting the CT and labs whether or not they want it.

 

[deleted6669]

I'm less concerned about the guy who leaves ama because he doesn't get drugs than the guy who will probably be dead within 24 hrs if he refuses admission. I can think back to a handful of pts over the years who probably had poor outcomes as a result of leaving ama. I generally write something on the form which they sign in the presence of witnesses which can not be misconstrued like " leaving the hospital now without treating your infection will result in your death in the near future". I can understand the folks who leave because they need to arrange care for their kids, etc and come back later. the ones that really bug me are the ones who leave to do something stupid. I had a guy sign out a few years ago who likely had necrotizing fasciitis because he " had to help his friend move into a new apartment" the next day. I have no doubt that the guy is dead now. I had 2 other clinicians(another pa and a doc) tell this guy that he was making a big mistake that would result in his death but he left anyway.
one of my physician colleagues recently had a pt with a big stemi sign out ama because he wanted to seek care from his regular dr at a local community hospital instead of the academic medical ctr with cath lab he was at then. my friend's ama form (which the pt and his wife signed) said " you are having a major heart attack right now. if you leave the emergency dept you will be dead within the hour". he was. DOA at the other facility. within the hour.

 

[la gringa]

That actually is fairly simple if you don't let them emotionally hijack you. If they are impaired, and have a potentially life-threatening emergency, you are completely covered legally to do appropriate testing to rule out that emergency.

I don't accept the line: "Give me my dilaudid or I won't consent to a CT scan!"

If they are intoxicated they are not getting the dilaudid, though a little Inapsine might be called for, and they are getting the CT and labs whether or not they want it.

absolutely - but as mentioned above, sometimes the nurses want to pitch a fit... pretty much the only time i butt heads w/ any of the good nurses.... b/c in the end it's always more work for them than for me.

still haven't pulled out the droperidol - never used it outside of anesthesia in med school/residency, and my hospital isn't deficient in the nausea meds save for my favorite migraine med, compazine.

 

[emd123]

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[Arcan57]

After about 30,000 patient encounters, with probably 500-1000 AMA's (2-3%) I've only had one that I told, "If you leave you'll die", that did die. It was a patient with very elevated INR (and other issues) who went home, fell and came back brain dead with a subdural. It's amazing how so many seem to dodge the bullet (that we know of anyways).

It must be the God given protective effect of stupidity (and drunkenness)

That's a lot of patient encounters for a fellow. Working 150 hrs/mo x 12 mo/yr x 2.5 pt/hr = 4500 pts/yr. That's 6 2/3 yrs at that pace. Did you go back and do a fellowship after being out? I'm curious because it's something I've been thinking more about lately.

 

[Venko]

I was having a discussion with a colleague last night about having patients sign AMA (against medical advice) forms. I find myself rarely having the patient actually sign it, but dictating in my note that I had a discussion, explained risks of XYZ, patient refused procedure/admission, patient accepts risk and demonstrates own capacity for decision making.

My colleague seemed to think that despite that, having a signed AMA form in the chart is better protection (of course both would probably be best)

I was wondering what other people think about patients leaving AMA and using a signed form versus dictating the discussion you had. I've thought about it and I find I use the AMA form more when patients are refusing an admission, but a dictation when patients are refusing a procedure (blood draws, radiology, LPs). Patients refusing a procedure often end up getting discharged, and in their discharge instructions (which they sign), I do write "You refused XYZ today, if you change your mind please return yada yada yada"

What does everyone else do? Thanks!

I follow what you are describing as well. This is more of shared decision making than against medical advice, because most of what happens isn't our first line recommendation anyway.

 

[alreadylernd]

I follow what you are describing as well. This is more of shared decision making than against medical advice, because most of what happens isn't our first line recommendation anyway.

I like the "shared decision making" point. That's what I'd call it.

with regards to the poster(s) who mentioned patients leaving AMA with active MIs or nec fasc, could one make the argument that if you are in so much pain, or floridly septic, you would have difficulty making rational decisions and therefore don't have capacity to leave AMA? Just recently I psych-held a patient so psychotic/delusional who wanted to leave, but whose nasty diabetic infected leg ulcers definitely required admission.

Thanks for the discussion thus far!

 

[southerndoc]

Not only does a properly documented AMA discharge not totally protect you against liability, any AMA discharge actually INCREASES your liability. I can't site cases, but any malpractice or risk management lecture I've ever been to makes this point.

1-The types of patient who leave AMA are the most litigious (no surprise there).

2-Don't assume one needs a valid case to sue you. Once you're named, even a frivolous suit may require years and tens of thousands of dollars spent by your insurance company to get you dropped, or win.

3-Most of these cases revolve around either failure to properly inform a patient (i.e. "you told him the infection could get worse but not that he could get septic and die!") or a patient who claims they were intoxicated, confused, sedated from your meds or was otherwise not "competent" to understand the discussion.

Also, they can claim that even though they refused your treatment, you failed to inform them of options that are less than ideal but better than nothing, i.e. the chest pain that refuses admission and dies a weak later: "You should have arranged outpatient follow up with cards for a stress test within 72 hours and had him take an aspirin daily plus beta blocker"

They can claim you should've offered transfer to another hospital, that you should have called their family members to allow them a chance to change their mind, that you did NOT inform them of the risks, etc, etc, etc.

There's extensive case law in which doctors have been sued, sometimes successfully, after AMA sign outs.

We're canon fodder for these guys. Suing us is like taking candy from a baby. They don't even have win or have a case to make money off us.

Advice from an attorney:

1. Document the patient appears to have capacity to make decisions by being alert and oriented and voices back potential outcomes of signing out AMA. You can't document they understand (because how do you truly know they understand?), and don't ever use the word "competent" in the chart as that is a legal term and lawyers love to argue it until the jury loses sight of the forest for the tree.

2. Always document that the patient's questions were answered and that you encouraged the patient to return if symptoms change or if he/she changes their mind regarding treatment. Always document that you told the patient that signing the AMA form does not affect their future rights if they should ever want to be re-evaluated or seek treatment later.

3. The one that gets most people in trouble: not treating patients that AMA. Have a diverticulitis with a microperf that the patient is refusing to be admitted for IV antibiotics and possible surgery? If you don't write for antibiotics when the patient AMA's, and the patient has a bad outcome (which is likely), you will likely lose any future litigation. Just because the patient refuses admission doesn't mean he refuses outpatient treatment. Even though it's not ideal, it's still something and it shows a jury that you had compassion and tried your best to treat the patient even if it was suboptimal. I usually document something to the effect that I encouraged the preferred treatment, but I'm prescribing whatever medicine in hopes to help the patient even though he/she has refused admission.

 

[Venko]

I like the "shared decision making" point. That's what I'd call it.

with regards to the poster(s) who mentioned patients leaving AMA with active MIs or nec fasc, could one make the argument that if you are in so much pain, or floridly septic, you would have difficulty making rational decisions and therefore don't have capacity to leave AMA? Just recently I psych-held a patient so psychotic/delusional who wanted to leave, but whose nasty diabetic infected leg ulcers definitely required admission.

Thanks for the discussion thus far!

As for does a person have capacity, pain, and sepsis do not automatically negate capacity to decide. The patient should be able to provide the risks / benefits back to you in their own words, and express some rationale for their decisions (cost, time, etc), etc. If they can do this despite their pain or despite their sepsis, then they have the capacity to be make the decision to leave or not take a certain medication or to x y or z even if we recommend against it.

 

[Rendar5]

Speaking of AMA, I had a recent patient complaint from someone who left AMA, refusing an MRI to r/o carotid/vertebral artery dissection. (couldn't CT because he had just gotten a contrast load). After being called by our follow-up office who explained the reason for the call was that he left AMA the day before, he called our customer relations people. He said he never left AMA and he was upset because he thought his insurance wouldn't pay for an outpt CTA. Our customer relations saw the AMA form and thought there was just an X by the signature column.

Well, that's the reason it's nice to point out my note detailing AMA convo, the nurse's separate AMA note, and the reason for two witnesses signing the AMA form who can attest that the"X" really was his sig.