Patient Complaints

[deleted836128]

I know that frustration - "nobody else here does that!" - when what you are doing is good medicine. Perception is reality, and everyone is the hero of their own story. Few will admit that they don't know something, and some double down on that.

YES. I’ve encountered this, too. Nurses have come up to me and said “Why are you giving them patient education and a prescription if they’re leaving AMA?” I explain that I am trying to set the patient up for success and they don’t get it. Most of the time I’ve noticed they don’t even print my patient education and the patient walks out without it.

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[Apollyon]

YES. I’ve encountered this, too. Nurses have come up to me and said “Why are you giving them patient education and a prescription if they’re leaving AMA?” I explain that I am trying to set the patient up for success and they don’t get it. Most of the time I’ve noticed they don’t even print my patient education and the patient walks out without it.

Yes, that is the point. If someone leaves AMA, I do NOT say, "sorry, dingus, go with God!" I do my best to set them up with what I can do, and give an honest estimate of how they will do without further care. The nursing idea of "they're leaving AMA, so, **** 'em" is old school, not informed, and just bad.

 

[Groove]

Taken from RMM:

Against Medical Advise (AMA)

• This is actually a legal process of "informed refusal." Getting a patient signature on a form doesn't mean a lot. Some incapacitated patients will sign anything, while other patients will refuse to sign anything. Failure to get a signature doesn't mean that you haven't properly completed the "AMA" process.
• The AMA process relates to several major issues:
  • The capacity of the patient - Is the patient old enough to make a decision, and capable of understanding the discussion?
  • What items are necessary to protect yourself from a lawsuit?
• Cardozo Doctrine - In a landmark case in 1913 (Schloendorff vs. Society of New York Hospitals), Justice Cardozo ruled that " Every human being of adult years and sound mind has a right to determine what shall be done with his own body ... a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages."
• Five items to be charted for a valid "AMA"
  • The patient is an adult or a declared emancipated minor - When a child is involved and a parent/guardian is not available, the physician acts "in loco parentis."
  • The patient is of sound mind (has capacity) - You have an obligation to act in the patient's best interests. If there is any indication that the patient's mental status is impaired (e.g., the nurse's note documents slurred speech), the patient should be held in the ED for treatment.
    • You CAN hold the patient "against his/her will" if he/she is functionally impaired.
    • You ARE REQUIRED to hold the patient if he/she is truly incapacitated.
    • You may be LIABLE if you allow an incapacitated patient to leave AMA and he or she sustains an injury....plus there is a responsibility to third parties who might be placed at risk.
    • Determination of capacity does not require a psychiatry consultation. As a physician, you can make a judgment about the patient's ability to understand your discussion and make a reasonable decision.
  • Inform the patient, in an understandable manner and language, the consequences of nontreatment. Don't use euphemisms (i.e., don't say "You have a dysrhythmia," but rather "You might drop dead"). If there is a reasonable alternative therapy, present it and why it is or isn't appropriate.
  • Involve family and friends - Often the problem of a patient wanting to leave AMA will be resolved by the patient's family, who recognize the need for treatment.
  • The signature - The AMA form should include a statement that "leaving against medical advice may result in death or grave disability." Signatures should be obtained from the patient, you (as the physician), the nurse (as your witness), and the patient's family member (if available).
• The great chart will contain documentation of all of these processes as an indication that you have "gone the extra mile" to attempt to provide the patient with proper care.
• The "smart" physician will find a way to keep the patient in the ED. Don't argue with the patient, but give the appearance that you are "on the patient's side."
  • A good phrase -- If you were a member of my family, this is what I would do for you.
• If you have done all of the above and the patient insists on discharge, you should "part as friends." Provide the patient with needed medications and invite him or her to return if necessary.
  • You might want to avoid giving pain meds to ameliorate symptoms in a patient with a potentially dangerous condition.
• Insurance companies will not refuse to pay for a visit if the patient leaves AMA. This is an oft-repeated urban myth.
• When the patient does not want to leave AMA, but refuses a needed procedure, the same documentation should take place (i.e., adult status, capacity, discussion, involvement of family members, signatures). Ask the patient what he or she is really worried about with regard to the procedure and attempt to resolve the issue (e.g., sedation for anxiety, analgesia for associated pain, etc.).
  • Assure the patient that he or she is "the boss" and provide a list of things that should be done.
• Availability of a standardized AMA form can be helpful, listing the necessary elements of "informed refusal" and containing:
  • The physician's declaration of the patient's competency based on his or her professional judgment.
  • The patient's acknowledgement (via a signature)
  • The nurse's acknowledgement
  • The family member's acknowledgement
  • The physician's acknowledgement

 

[BoardingDoc]

Taken from RMM:

Against Medical Advise (AMA)

• This is actually a legal process of "informed refusal." Getting a patient signature on a form doesn't mean a lot. Some incapacitated patients will sign anything, while other patients will refuse to sign anything. Failure to get a signature doesn't mean that you haven't properly completed the "AMA" process.
• The AMA process relates to several major issues:
  • The capacity of the patient - Is the patient old enough to make a decision, and capable of understanding the discussion?
  • What items are necessary to protect yourself from a lawsuit?
• Cardozo Doctrine - In a landmark case in 1913 (Schloendorff vs. Society of New York Hospitals), Justice Cardozo ruled that " Every human being of adult years and sound mind has a right to determine what shall be done with his own body ... a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages."
• Five items to be charted for a valid "AMA"
  • The patient is an adult or a declared emancipated minor - When a child is involved and a parent/guardian is not available, the physician acts "in loco parentis."
  • The patient is of sound mind(has capacity) - You have an obligation to act in the patient's best interests. If there is any indication that the patient's mental status is impaired (e.g., the nurse's note documents slurred speech), the patient should be held in the ED for treatment.
    • You CAN hold the patient "against his/her will" if he/she is functionally impaired.
    • You ARE REQUIRED to hold the patient if he/she is truly incapacitated.
    • You may be LIABLE if you allow an incapacitated patient to leave AMA and he or she sustains an injury....plus there is a responsibility to third parties who might be placed at risk.
    • Determination of capacity does not require a psychiatry consultation. As a physician, you can make a judgment about the patient's ability to understand your discussion and make a reasonable decision.
  • Inform the patient, in an understandable manner and language, the consequences of nontreatment. Don't use euphemisms (i.e., don't say "You have a dysrhythmia," but rather "You might drop dead"). If there is a reasonable alternative therapy, present it and why it is or isn't appropriate.
  • Involve family and friends - Often the problem of a patient wanting to leave AMA will be resolved by the patient's family, who recognize the need for treatment.
  • The signature - The AMA form should include a statement that "leaving against medical advice may result in death or grave disability." Signatures should be obtained from the patient, you (as the physician), the nurse (as your witness), and the patient's family member (if available).
• The great chart will contain documentation of all of these processes as an indication that you have "gone the extra mile" to attempt to provide the patient with proper care.
• The "smart" physician will find a way to keep the patient in the ED. Don't argue with the patient, but give the appearance that you are "on the patient's side."
  • A good phrase -- If you were a member of my family, this is what I would do for you.
• If you have done all of the above and the patient insists on discharge, you should "part as friends." Provide the patient with needed medications and invite him or her to return if necessary.
  • You might want to avoid giving pain meds to ameliorate symptoms in a patient with a potentially dangerous condition.
• Insurance companies will not refuse to pay for a visit if the patient leaves AMA. This is an oft-repeated urban myth.
• When the patient does not want to leave AMA, but refuses a needed procedure, the same documentation should take place (i.e., adult status, capacity, discussion, involvement of family members, signatures). Ask the patient what he or she is really worried about with regard to the procedure and attempt to resolve the issue (e.g., sedation for anxiety, analgesia for associated pain, etc.).
  • Assure the patient that he or she is "the boss" and provide a list of things that should be done.
• Availability of a standardized AMA formcan be helpful, listing the necessary elements of "informed refusal" and containing:
  • The physician's declaration of the patient's competency based on his or her professional judgment.
  • The patient's acknowledgement (via a signature)
  • The nurse's acknowledgement
  • The family member's acknowledgement
  • The physician's acknowledgement

Repeated references here to family member's involvement. I'm obviously in favor of doing so if they're with the patient, but if the patient presents alone, what are you doing? Obviously you can't just call a family member, even if you have their number as that's a massive HIPAA violation.

 

[Groove]

Repeated references here to family member's involvement. I'm obviously in favor of doing so if they're with the patient, but if the patient presents alone, what are you doing? Obviously you can't just call a family member, even if you have their number as that's a massive HIPAA violation.

They've brought it up in a few discussions regarding AMA in the past and it's a "best practices" approach, not a strict requirement for any and all AMA protocols. The reasons are primarily common sense... If you really don't want the pt to leave, then trying to obtain an ally in the family member/friend to help dissuade the pt from leaving is probably more effective than any further efforts by you alone. It also helps support your overall intent to do "any and everything possible" to prevent the pt from harming themselves by ill advised departure from the ER.

I agree that it's illogical to expect you to call a family member or friend unless the pt is asking you to talk to their wife, friend, etc.. about the disposition. However, if they are present in the room, I think trying to gain their support in persuading the pt to stay, documenting their name/relation, and/or obtaining their additional signature on the AMA form is prudent. It lessens any confusion and makes it more difficult for the pt and/or family member to argue that they didn't understand, or argue that you didn't try to talk them out of it, etc.. In case of a bad outcome, it's less likely that a family member would pursue litigation when they distinctly remember you having a conversation with them about attempts to dissuade their family member from leaving the ER, and also requested their signature on the AMA form, etc..

Is all of that necessary for you to successfully defend a related suit? Probably not, but it certainly makes it easier.

I always document things like "strongly recommended admission and/or further testing", "explained risks in leaving such as but not limited to death/perm disability". I document "why" the pt wanted to leave. I document the the pt verbalized understanding and demonstrated medical decision making capacity. I document that I attempted to engage family and/or friends to dissuade the pt from leaving but those efforts were unsuccessful. (I mention names and relationship.) I document that the pt was of sound mind and elected to take his chances in leaving. I obtain AMA signatures if possible. Most importantly....I make sure the nurse is in the room or I inform her immediately of the results of the discussion so she can document.

All of this sounds silly when you're faced with a homeless, belligerent, hostile, angry patient, spitting on the floor and cussing you out. Most of the times, it's not those guys you need to worry about. It's the family that comes after you for a bad outcome and/or death.

 

[turkeyjerky]

They've brought it up in a few discussions regarding AMA in the past and it's a "best practices" approach, not a strict requirement for any and all AMA protocols. The reasons are primarily common sense... If you really don't want the pt to leave, then trying to obtain an ally in the family member/friend to help dissuade the pt from leaving is probably more effective than any further efforts by you alone. It also helps support your overall intent to do "any and everything possible" to prevent the pt from harming themselves by ill advised departure from the ER.

I agree that it's illogical to expect you to call a family member or friend unless the pt is asking you to talk to their wife, friend, etc.. about the disposition. However, if they are present in the room, I think trying to gain their support in persuading the pt to stay, documenting their name/relation, and/or obtaining their additional signature on the AMA form is prudent. It lessens any confusion and makes it more difficult for the pt and/or family member to argue that they didn't understand, or argue that you didn't try to talk them out of it, etc.. In case of a bad outcome, it's less likely that a family member would pursue litigation when they distinctly remember you having a conversation with them about attempts to dissuade their family member from leaving the ER, and also requested their signature on the AMA form, etc..

Is all of that necessary for you to successfully defend a related suit? Probably not, but it certainly makes it easier.

I always document things like "strongly recommended admission and/or further testing", "explained risks in leaving such as but not limited to death/perm disability". I document "why" the pt wanted to leave. I document the the pt verbalized understanding and demonstrated medical decision making capacity. I document that I attempted to engage family and/or friends to dissuade the pt from leaving but those efforts were unsuccessful. (I mention names and relationship.) I document that the pt was of sound mind and elected to take his chances in leaving. I obtain AMA signatures if possible. Most importantly....I make sure the nurse is in the room or I inform her immediately of the results of the discussion so she can document.

All of this sounds silly when you're faced with a homeless, belligerent, hostile, angry patient, spitting on the floor and cussing you out. Most of the times, it's not those guys you need to worry about. It's the family that comes after you for a bad outcome and/or death.

But I do agree with you, I wouldn't call anyone either in the example that you mentioned.

What's with the oft-repeated trope of "signatures don't matter" followed shortly thereafter by "always get a signature".

Hopefully it's obvious that I'm being factitious, but this is one of the things I find frustrating about these type of guidelines

 

[RustedFox]

AMA?


D.G.A.F.

I will post my AMA speech on here for you all to copy.

 

[TooMuchResearch]

I ask them if I can call a family member. Most say no. One daughter convinced her father to stay a couple months ago. I think that's the only time calling family has helped.

Repeated references here to family member's involvement. I'm obviously in favor of doing so if they're with the patient, but if the patient presents alone, what are you doing? Obviously you can't just call a family member, even if you have their number as that's a massive HIPAA violation.