Patients with capacity refusing treatment/care

[larpleston]

Hypothetical patient with fever, tachycardia and leukocytosis is is very tender on belly exam. They have full capacity but adamantly refuse CT because of tik tok induced radiation concerns/cluster B enjoyment of watching their doc squirm. Patient doesn’t want to leave ama and agrees to abx but is steadfast in refusal to get CT, US or KUB. Hospitalist won’t admit what is likely a surgical problem without surgery consult, surgeon says I need to figure out a way to get CT. I tell patient and they still refuse.

I’ve had two patients like this recently, the other with pneumonia and hypoxia refusing abx but wanting to be hospitalized. Hospitalist says no point in admitting if theyre not going to agree to treatment. What do you do?

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[Groove]

You just document carefully. It also helps to mention that you brought in a family member to try to change their mind and were unsuccessful. Document medical decision making capacity. Pt informed of benefits and risks with risks including but not limited to deterioration of condition, delay in diagnosis, permanent disability and/or death. Pt verbalized understanding of said risks and benefits and elected to leave AGAINST MEDICAL ADVICE. Ask nursing to also place a nursing note confirmation that you had this discussion. At the end of the day, you can't cure stupid and you can't commit these people either. I've had 2 patients like this that needed admission. One died within 24 hours. It doesn't mean you did anything wrong but you want to have all your T's crossed and I's dotted and the chart completed before the end of your shift because chances are you're not going to be able to open it back up again. Medicolegally, I've read that it always looks good when you ask family and/or additional healthcare staff to try to talk reason into the patient because a jury will view that as you going above and beyond in efforts to convince the pt to agree to proper treatment. Neither of my cases ended up in a suit btw, I just read that one time.

 

[BoardingDoc]

You just document carefully. It also helps to mention that you brought in a family member to try to change their mind and were unsuccessful. Document medical decision making capacity. Pt informed of benefits and risks with risks including but not limited to deterioration of condition, delay in diagnosis, permanent disability and/or death. Pt verbalized understanding of said risks and benefits and elected to leave AGAINST MEDICAL ADVICE. Ask nursing to also place a nursing note confirmation that you had this discussion. At the end of the day, you can't cure stupid and you can't commit these people either. I've had 2 patients like this that needed admission. One died within 24 hours. It doesn't mean you did anything wrong but you want to have all your T's crossed and I's dotted and the chart completed before the end of your shift because chances are you're not going to be able to open it back up again. Medicolegally, I've read that it always looks good when you ask family and/or additional healthcare staff to try to talk reason into the patient because a jury will view that as you going above and beyond in efforts to convince the pt to agree to proper treatment. Neither of my cases ended up in a suit btw, I just read that one time.

Are you escorting these patients out? OP said they don't want to leave, they're just refusing tests.

In the scenario where they appear peritoneal, want to be admitted but are refusing CT, I would contact family to explain in very clear terms that the patient is choosing to likely die or be permanently disabled/disfigured and that you are hopeful that they can change this person's mind.

If family has no luck (or no family available) I would document how I explained that if the patient continued to refuse the CT that they were extremely likely to die or be permanently disabled/disfigured etc. I would then push to admit to medicine for the ABX that OP said they would agree to and get hospital risk management involved immediately. There should always be an admin on call. Call them. This is their problem as it's a legal risk issue more than a medical one.

 

[Mount Asclepius]

You shouldn’t make people leave the hospital against medical advice if they have a condition that requires admission, but aren’t agreeable with typical recommendations. You should still do everything you can to help the patient. These are high risk patients.

 

[ScepticSkeksis]

Have them sign AMA as far as the CT scan goes, then admit to medicine with surgical consult. If medicine refuses, call whatever administrator is on-call and have them sort it out. I move on to other tasks while admin/medicine are battling it out.

 

[xaelia]

I would then push to admit to medicine for the ABX that OP said they would agree to and get hospital risk management involved immediately. There should always be an admin on call. Call them. This is their problem as it's a legal risk issue more than a medical one.

Yeh, it's not as though you can kick out someone with legitimate acute medical illness who wants to stay.

One of those times where you're forced to be heavy-handed and formally consult an admitting service to evaluate the patient and determine disposition under the oversight of hospital administration/risk-management. Not good enough for them to tell you want they will and won't do over the phone; they gotta put their name in the chart as refusing to accept the admission.

 

[Splenda88]

Have them sign AMA as far as the CT scan goes, then admit to medicine with surgical consult. If medicine refuses, call whatever administrator is on-call and have them sort it out. I move on to other tasks while admin/medicine are battling it out.

The surgeon said: "figure out a way to get CT." Why should the hospitalist agree to admit a patient who is already refusing CT for what most likely is a surgical issue?

I have never given any pushbacks to ED docs, but I probably would have done the same thing that hospitalist did.

I think the CMO or the hospitalist medical director should admit a patient like that. This case has lawsuit written all over it.

 

[Groove]

Are you escorting these patients out? OP said they don't want to leave, they're just refusing tests.

In the scenario where they appear peritoneal, want to be admitted but are refusing CT, I would contact family to explain in very clear terms that the patient is choosing to likely die or be permanently disabled/disfigured and that you are hopeful that they can change this person's mind.

If family has no luck (or no family available) I would document how I explained that if the patient continued to refuse the CT that they were extremely likely to die or be permanently disabled/disfigured etc. I would then push to admit to medicine for the ABX that OP said they would agree to and get hospital risk management involved immediately. There should always be an admin on call. Call them. This is their problem as it's a legal risk issue more than a medical one.

I don't think I've ever had someone refusing a specific type of test but allowing me to do everything else. Usually if it's an extremely rare circumstance where they don't want ionizing radiation, etc.. I can convince them to obtain an MRI/US, etc.. So, it's a bit weird that the OP's pt seems to decline multimodal diagnostic studies. I don't know if I've ever seen something quite like that. In my case, the diagnosis was made and I pleaded for admission and did everything I could think of and the pt just didn't want to stay in the hospital. I told them point blank that they would die if they left the hospital. Included family, etc.. Why would I escort them out? Escorting them out would seem to infer that I'm condoning their decision to leave AMA. I don't ever escort AMAs out the door. I'm certainly not kicking them out, they are leaving of their own volition against my advice.

The involving risk and hospital admin, etc.. all sounds great in theory but the reality is that these are extremely rare cases, and the pt is usually very anxious to leave. They aren't going to wait for me to phone up a hospital admin who is going to phone up hospital legal and risk management and everyone pow wow about what to do and meanwhile the pt leaves anyway. I totally agree that these are high risk cases but what's someone going to successfully sue me for? That I correctly diagnosed a life threatening condition and against overwhelming effort to convince the pt into life saving medical management, point blank telling them they are going to die if they leave the hospital....they choose to leave anyway? Like I said, you just can't cure stupid sometimes. But yeah, if the pt is willing to stay long enough to bring in c-suite that probably looks better on paper but I doubt they'd be able to assist in any meaningful way.

I have no idea what I'd do with a pt who refuses all testing but obviously needs to come into the hospital and is willing. I don't think I've ever been unsuccessful in at least convincing them to allow me to complete enough testing to warrant an admission. In OPs case, I might try asking the surgeon to evaluate the pt in the ED to assist me in convincing them they might have a surgical process and are in need of further diagnostic testing. I can't blame the hospitalist for not wanting to admit a pt without a diagnosis. Am I admitting perforated viscus or diverticulitis, etc..? I wouldn't discharge them in either case. I'd probably have to use my ace and tell both surgery and medicine that they are formally consulted in the ED and per hospital bylaw I need their bedside evaluation and consult note. But damn...I can't remember the last time I had to do something like that.

 

[Groove]

The thing people need to keep in mind is that hospital risk management is 100% concerned about protecting the hospital from lawsuit and 0% concerned with protecting an independent contractor ED doc from lawsuit. Don't ever forget that. If you find yourself in a sticky case, be on your guard when talking to these people. They are NOT your friends.

 

[BoardingDoc]

I don't think I've ever had someone refusing a specific type of test but allowing me to do everything else. Usually if it's an extremely rare circumstance where they don't want ionizing radiation, etc.. I can convince them to obtain an MRI/US, etc.. So, it's a bit weird that the OP's pt seems to decline multimodal diagnostic studies. I don't know if I've ever seen something quite like that. In my case, the diagnosis was made and I pleaded for admission and did everything I could think of and the pt just didn't want to stay in the hospital. I told them point blank that they would die if they left the hospital. Included family, etc.. Why would I escort them out? Escorting them out would seem to infer that I'm condoning their decision to leave AMA. I don't ever escort AMAs out the door. I'm certainly not kicking them out, they are leaving of their own volition against my advice.

The involving risk and hospital admin, etc.. all sounds great in theory but the reality is that these are extremely rare cases, and the pt is usually very anxious to leave. They aren't going to wait for me to phone up a hospital admin who is going to phone up hospital legal and risk management and everyone pow wow about what to do and meanwhile the pt leaves anyway. I totally agree that these are high risk cases but what's someone going to successfully sue me for? That I correctly diagnosed a life threatening condition and against overwhelming effort to convince the pt into life saving medical management, point blank telling them they are going to die if they leave the hospital....they choose to leave anyway? Like I said, you just can't cure stupid sometimes. But yeah, if the pt is willing to stay long enough to bring in c-suite that probably looks better on paper but I doubt they'd be able to assist in any meaningful way.

I have no idea what I'd do with a pt who refuses all testing but obviously needs to come into the hospital and is willing. I don't think I've ever been unsuccessful in at least convincing them to allow me to complete enough testing to warrant an admission. In OPs case, I might try asking the surgeon to evaluate the pt in the ED to assist me in convincing them they might have a surgical process and are in need of further diagnostic testing. I can't blame the hospitalist for not wanting to admit a pt without a diagnosis. Am I admitting perforated viscus or diverticulitis, etc..? I wouldn't discharge them in either case. I'd probably have to use my ace and tell both surgery and medicine that they are formally consulted in the ED and per hospital bylaw I need their bedside evaluation and consult note. But damn...I can't remember the last time I had to do something like that.

We are talking about 2 entirely different scenarios. OP asked about the example of the patient wanting to be admitted but refusing certain tests. I agree this is much, MUCH less common than the patient who simply wants to leave AMA. I don't think there's anything terribly complicated about the latter, and I wasn't suggesting you get admin involved in that scenario, even if the patient is about to drop dead when they AMA. I was only discussing the scenario that OP presented where the patient DOES NOT WANT TO LEAVE, but is also refusing likely lifesaving tests. In that scenario, I 100% feel like you get the admin on call involved as you have plenty of time and that scenario is a clusterf***.

 

[Groove]

We are talking about 2 entirely different scenarios. OP asked about the example of the patient wanting to be admitted but refusing certain tests. I agree this is much, MUCH less common than the patient who simply wants to leave AMA. I don't think there's anything terribly complicated about the latter, and I wasn't suggesting you get admin involved in that scenario, even if the patient is about to drop dead when they AMA. I was only discussing the scenario that OP presented where the patient DOES NOT WANT TO LEAVE, but is also refusing likely lifesaving tests. In that scenario, I 100% feel like you get the admin on call involved as you have plenty of time and that scenario is a clusterf***.

Yeah, you're probably right and as a plus it pretty much forces medicine/surgery/etc. to come in and see the pt in the event that they refuse to come in.

 

[Rendar5]

Hypothetical patient with fever, tachycardia and leukocytosis is is very tender on belly exam. They have full capacity but adamantly refuse CT because of tik tok induced radiation concerns/cluster B enjoyment of watching their doc squirm. Patient doesn’t want to leave ama and agrees to abx but is steadfast in refusal to get CT, US or KUB. Hospitalist won’t admit what is likely a surgical problem without surgery consult, surgeon says I need to figure out a way to get CT. I tell patient and they still refuse.

I’ve had two patients like this recently, the other with pneumonia and hypoxia refusing abx but wanting to be hospitalized. Hospitalist says no point in admitting if theyre not going to agree to treatment. What do you do?

The first case the surgeon needs to treat them within the parameters that the patient sets. So sucks to be the surgeon but they’re going to have to make a decision to perform exploratory surgery or not. I mean like surgeons did before ct scans were routine.

The second case they can still get oxygen and iv fluids on admission. It’s not like they’ll do nothing on admission. Though I would likely actually get a psych consult in the guy for this one. I can see some sorta rational thought process (rational, not smart) on the former but not the latter.

 

[TooMuchResearch]

Hypothetical patient with fever, tachycardia and leukocytosis is is very tender on belly exam. They have full capacity but adamantly refuse CT because of tik tok induced radiation concerns/cluster B enjoyment of watching their doc squirm. Patient doesn’t want to leave ama and agrees to abx but is steadfast in refusal to get CT, US or KUB. Hospitalist won’t admit what is likely a surgical problem without surgery consult, surgeon says I need to figure out a way to get CT. I tell patient and they still refuse.

I’ve had two patients like this recently, the other with pneumonia and hypoxia refusing abx but wanting to be hospitalized. Hospitalist says no point in admitting if theyre not going to agree to treatment. What do you do?

If your hospitalist and surgeon won't get involved in a patient that clearly needs their involvement, you involve an admin on call.

 

[TooMuchResearch]

You just document carefully. It also helps to mention that you brought in a family member to try to change their mind and were unsuccessful. Document medical decision making capacity. Pt informed of benefits and risks with risks including but not limited to deterioration of condition, delay in diagnosis, permanent disability and/or death. Pt verbalized understanding of said risks and benefits and elected to leave AGAINST MEDICAL ADVICE. Ask nursing to also place a nursing note confirmation that you had this discussion. At the end of the day, you can't cure stupid and you can't commit these people either. I've had 2 patients like this that needed admission. One died within 24 hours. It doesn't mean you did anything wrong but you want to have all your T's crossed and I's dotted and the chart completed before the end of your shift because chances are you're not going to be able to open it back up again. Medicolegally, I've read that it always looks good when you ask family and/or additional healthcare staff to try to talk reason into the patient because a jury will view that as you going above and beyond in efforts to convince the pt to agree to proper treatment. Neither of my cases ended up in a suit btw, I just read that one time.

Read the question stem again. Patient wants to stay and has evidence of a condition appropriate for admit.

 

[CliveStaples]

It seems unlikely that a patient who is refusing CT scan will consent to an exploratory surgery - I think the ED physician can have that conversation with the patient. In the bizarre circumstance where a patient could articulate why they won’t consent to a CT scan but would consent to an operation, then you get your surgeon to examine the patient and determine if they’re willing to offer an operation or not. If your surgeon won’t come examine the patient, then you talk to your administrator to explain how you’re going to be transferring the patient with the dreaded “consultant refused” box checked off unless they get their surgeon in line.

 

[The Knife & Gun Club]

This is a tough case and I’ve had a couple of these in the past.

In the cases I’ve had I’ve never had someone refuse CT but also refuse MRI but want admission unless they’re malingering or doing it for secondary gain.

Outside of secondary gain and incredible stupidity I think it’s reasonable from a physician standpoint to say they have an infection in their abdomen and need IV antibiotics. We’ve all had old or otherwise chronically ill people opt for non-op management of what is likely a surgical diagnosis and get admitted to medicine for IV Abx.

 

[The Knife & Gun Club]

My imaginary note would say:

Pt is a 35F TikTok SuperUser who presents with a CC of abdominal pain. On exam she has frank peritonitis, fever, hypotension, and labs concerning for septic shock. She is AO3, GCS15 and has demonstrated full capacity to make medical decisions based on a detailed and extensive discussion with the patient regarding all potential diagnostic and treatment modalities for this highly concerning presentation.

At this time the patient adamantly refuses advanced imaging including CT, MRI, US, XR. The patient understands that without advanced imaging we can not determine the etiology of the patients presenting disease process and proper treatment. This will likely result in death or permanent disability. Collateral information was obtained from the patient family member, who also urged the patient to proceed with definitive workup for this life threatening condition, however the patient continues to have full capacity and understanding but declines. They have no SI/HI/psychiatric confounders.

A consultation was placed to Dr ____, general surgery given concern for peritonitis. Per Dr ___ he will not offer further consideration for the patient as a surgical candidate without advanced imaging.

A consultation was placed to Dr ____, Hospitalist for admission for IV antibiotics given the patient likely has an infectious etiology and has been deemed a non-operative candidate at this time by Dr. ___, surgeon. Hospitalist declines the admission citing disagreement with the surgeon about the patients operative candidacy.

Consult was placed to Dr ____, CMO, for assistance with adjudication of this issue. The patient will remain in the EDs care until a decision can be reached by the consulted physicians.

Maybe with some time stamps too for extra pizzaz.

TLDR; you can consult a surgeon without a CT, and they are welcome to deem the patient non-operative in the absence of advanced imaging. You can consult a hospitalists for admission and they are welcome to say they, an IM physician, disagree with the surgeons determination of operative candidacy. Both of them will probably be hung out to dry by a hungry malpractice attorney for making those decisions though.

 

[JacobMcCandles]

A lot of other specialties don’t deal with AMA as much as we do in the ED. My experience is that many people don’t understand that AMA doesn’t mean they’re refusing all treatment, just usually something specific like admission, etc. Chest pains that don’t want to be admitted? They get a discussion and many will still stay for a second troponin to further risk stratify them. Patient doesn’t want to be admitted for whatever infection? Ok, we still need to prescribe whatever antibiotics and other meds they need. You just need to document it appropriately.

 

[emergentmd]

Pt capable of making his own decision. Pt wants to be admitted but doesn't want testing/treatment. Whats the point of making them sign out AMA. I have always thought having them sign this is just to make the hospital/docs more comfortable.

I just document pt is coherent, understands the risks including death. I will stand by this all day b/c sometimes pts will refuse to sign AMA anyhow so seems like a waste of time to push it.

Anyhow, I am calling the hospitalist and consult for admission. If they refuse, I document and pt can stay in the ER for days until they want to leave, becomes incoherent to refuse treatment, or agrees to treatment. Let the hospital admin deal with this. I am leaving in a few hours anyhow, and I refuse to waste much more time than about 10 minutes dealing with this.

 

[JacobMcCandles]

Anyhow, I am calling the hospitalist and consult for admission. If they refuse, I document and pt can stay in the ER for days until they want to leave, becomes incoherent to refuse treatment, or agrees to treatment. Let the hospital admin deal with this. I am leaving in a few hours anyhow, and I refuse to waste much more time than about 10 minutes dealing with this.

That seems like a bad way to treat your partners. I agree about getting admin involved but staying in the ER isn’t a good plan. This just brings your partners into this mess.

 

[Ubba]

Vanco + mero + Flagyl, NPO, vitals q2H, consult Surgery for +/- ex lap. Keep pt in ER until he agrees, goes to surgery, or dies.

 

[Janders]

This isn’t very difficult. Perhaps convincing the patient to get a CT is difficult, but the rest is easy.

Consult surgery.
“Surgery won’t come until you have a CT”.
Explain politely you understand its unusual, but the patient refuses but is clearly ill and you really need a bedside consultation. Remind them of their obligation under EMTALA and per hospital bylaws, if they continue to refuse. Explain you have explored every other option you could think of (MRI, US), but you’re optimistic the second opinion of an attending surgery might convince the patient.
If they STILL continue to refuse? Page chief of surgery. Page AOD. Page CMO. Remove all emotions from your being and then politely repeat the facts and ask for their help with this unusual but ILL patient. Do NOT discharge the patient.

Consult hospitalist for admission. Same dance routine as above, if they refuse to see the patient.
Now, I fully admit I’ve had some entertaining conversations over the years, usually with sub specialists, about a patient refusing their recommended XYZ and thus them telling the patient they must leave AMA and sign the form. Malarkey. If the patient refuses XYZ (MRI/MRA + heparin drip) but still wants to be in the hospital and be treated, you offer them suboptimal option ABC and chart the hell out of it (Repeat CT in 48hr and oral Plavix).

Similarly, I’ve had patients demand discharge from the hospital AMA on, say, IV abx for a pelvic abscess and have had services sign them AMA out without medication. Horse Manure. You explain your reasoning to them, and explain oral antibiotics are a poor but better option than NOTHING and then you Rx them 14 days of augmentin and let them sign out AMA.

I find that 80% of the time if you remain calm, and let the patient hear the repeated message of our recommendations (from me, from the RN staff, from the consultants) in a non-confrontational manner, they eventually realize people do care about them and go along with the flow.

 

[Janders]

A tangentially related personal anecdote—

I once had a patient signed out to me that the overnight doc sat on for their entire shift without doing much, then decided needed an LP but hey its 0700AM look that new grad just wanted in, he’s been out of training a couple months now I’ll sign this pile of unexplained leukocytosis, AKI, hyperkalemia in a ornery patient with a ongoing substance problem to him!

I did said LP (normal), and in the end discovered this was an alcoholic with moderate rhabdo and AKI likely from being down some hours on a floor intoxicated, with a minimal troponin leak and probably a UTI. He demanded to leave. He wasn’t intoxicated or withdrawing at that point I’d made enough of a therapeutic bond with him doing the LP that me and the rusty battle axe resource nurse talked him into staying for a couple liters of NS and some ceftriaxone. But prior to actually getting admitted, he demanded to leave again. We asked why, and he gave a complicated story about his personal property, someone stealing something, yadda yadda yadda. We explained that he had kidney failure and an infection and he could very very well die at home. He promised he needed a few hours to return, but he’d come back late afternoon and get admitted. I doubted he’d actuall come back back. So, I wrote him an Rx for some oral abx and signed him AMA.

About 4 days later my director emailed me (I was on vacation, my first post-residency) that this guy I’d discharged had been found dead on his couch by his family and he’d talk to me when I got back [don’t do this, directors].

The full story was that his nearby family had found him dead, next to a stack of ER discharge papers he’d carried home, and his Rx’d meds. They looked at said papers, and read them. They then send the ER flowers and food, and a note saying that they’d read our discharge instructions to their relative, and they appreciated all of the love and caring that we showed for him. They acknowledged he’d been a difficult man all his life, and that we shouldn’t be sad that he refused to stay, and shouldn’t feel any guilt. Instead, they found peace in the fact he was shown love in his last interactions.

The nurse and I had typed non-confrontational, easy to read instructions for him. Basically saying he had kidney failure and an infection, and he could die from it. That we wanted him to stay in the hospital, but we respected his decision to leave. That he could take the pills and drink a lot of water, but the BEST thing was to come back to the hospital ASAP like he promised us. The nurse had left a little hand-written comment that she was working the next day and would be waiting for him.

 

[wareagle726]

The biggest part which sets the OPs case apart is the ridiculousness of the demands. There are difficult patients that will have certain concerns or demands which I feel like I can usually get past. I don't agree with it but I can totally see why someone would refuse a CT if they saw some TikTok about radiation causing ridiculous problems. Easy, US and MRIs don't have radiation. Beyond that they are being irrational at which point I would call house sup to intervene and ask that they put a note in. I'm a doctor, not a negotiator. I'm also not going to delay care of other patients waiting to be seen due to the underlying supratentorial issues of another patient.

I guess what I'm trying to say is when I've come across the difficult patient one of two paths occur: 1.) There is a reasonable alternative which may be stupid in our minds, but is plausible and will get the job done and as long as they are taken care of it is worth the extra effort OR 2.) Nothing you do will appease the personality disorder and they will, in all likelihood, be fine...but still get other higher-ups involved.

 

[thegenius]

You just document carefully. It also helps to mention that you brought in a family member to try to change their mind and were unsuccessful. Document medical decision making capacity. Pt informed of benefits and risks with risks including but not limited to deterioration of condition, delay in diagnosis, permanent disability and/or death. Pt verbalized understanding of said risks and benefits and elected to leave AGAINST MEDICAL ADVICE. Ask nursing to also place a nursing note confirmation that you had this discussion. At the end of the day, you can't cure stupid and you can't commit these people either. I've had 2 patients like this that needed admission. One died within 24 hours. It doesn't mean you did anything wrong but you want to have all your T's crossed and I's dotted and the chart completed before the end of your shift because chances are you're not going to be able to open it back up again. Medicolegally, I've read that it always looks good when you ask family and/or additional healthcare staff to try to talk reason into the patient because a jury will view that as you going above and beyond in efforts to convince the pt to agree to proper treatment. Neither of my cases ended up in a suit btw, I just read that one time.

Good advice
I don't think I've had one like this recently. I did have a STEMI once and the guy was terribly afraid of having a cath for some reason. He refused it. I watched him for 20 minutes or so and pleaded with him, and he eventually wanted to leave. So I let him leave. What are you going to do?

It's worse when pts dont want certain things but want to remain in the hospital. I can kind of understand not wanting a CT, yet still wanting to stay. But there are some dinguses who say "I don't feel good, leave me alone" and refuse vitals, a physical exam, etc. For those I simply discharge and ask security to remove them if they don't remove voluntarily.

Document well. Make sure the nurses document well too. And yea friends and family are very helpful when they are at your side.

 

[Mount Asclepius]

I did have a STEMI once and the guy was terribly afraid of having a cath for some reason. He refused it. I watched him for 20 minutes or so and pleaded with him, and he eventually wanted to leave. So I let him leave. What are you going to do?

Offer/treat with TNKase.

 

[emergentmd]

That seems like a bad way to treat your partners. I agree about getting admin involved but staying in the ER isn’t a good plan. This just brings your partners into this mess.

Pt wants to be admitted but doesn't want to get necessary testing/treatment + Specialists doesn't want to consult unless CT obtained + Hospitalist doesn't want to admit. Please explain my choices?

Kick pt out - Big nope
Fight with hospitalist/Surgeon to admit essentially getting them involved in a potential bomb? - Big nope
Take it like a man and deal with said pt b/c I am involved anyhow - Yes, I will jump on the grenade.

Every other option is time consuming, so best to let the pt stay in Er until they become too sick to refuse and I can get my scan. Sometimes you have to pick the best solution. I would have no issue if my partner passed this pt on to me b/c I realize this is the best although not optimal option.

 

[emergentmd]

This isn’t very difficult. Perhaps convincing the patient to get a CT is difficult, but the rest is easy.

Consult surgery.
“Surgery won’t come until you have a CT”.
Explain politely you understand its unusual, but the patient refuses but is clearly ill and you really need a bedside consultation. Remind them of their obligation under EMTALA and per hospital bylaws, if they continue to refuse. Explain you have explored every other option you could think of (MRI, US), but you’re optimistic the second opinion of an attending surgery might convince the patient.
If they STILL continue to refuse? Page chief of surgery. Page AOD. Page CMO. Remove all emotions from your being and then politely repeat the facts and ask for their help with this unusual but ILL patient. Do NOT discharge the patient.

Consult hospitalist for admission. Same dance routine as above, if they refuse to see the patient.
Now, I fully admit I’ve had some entertaining conversations over the years, usually with sub specialists, about a patient refusing their recommended XYZ and thus them telling the patient they must leave AMA and sign the form. Malarkey. If the patient refuses XYZ (MRI/MRA + heparin drip) but still wants to be in the hospital and be treated, you offer them suboptimal option ABC and chart the hell out of it (Repeat CT in 48hr and oral Plavix).

Similarly, I’ve had patients demand discharge from the hospital AMA on, say, IV abx for a pelvic abscess and have had services sign them AMA out without medication. Horse Manure. You explain your reasoning to them, and explain oral antibiotics are a poor but better option than NOTHING and then you Rx them 14 days of augmentin and let them sign out AMA.

I find that 80% of the time if you remain calm, and let the patient hear the repeated message of our recommendations (from me, from the RN staff, from the consultants) in a non-confrontational manner, they eventually realize people do care about them and go along with the flow.

If you are going this route and going above the on call specialists head, then at best you have pissed of a fellow doc and at worse opened them up to a bad lawsuit. Imagine if you forced the surgeon to admit, pt refused treatment, and died resulting in a lawsuit for the hospitalist/surgeon/hospital; You would be a marked man.

I have practiced 25 years and have NEVER went over a specialists head. I have begged, explained that there is no other option BUT never had the thought of going over the specialists head.

Plus your phone merry go round costs me lots of time which is much more valuable than pleasing an unreasonable pt.

 

[thegenius]

Pt wants to be admitted but doesn't want to get necessary testing/treatment + Specialists doesn't want to consult unless CT obtained + Hospitalist doesn't want to admit. Please explain my choices?

Kick pt out - Big nope
Fight with hospitalist/Surgeon to admit essentially getting them involved in a potential bomb? - Big nope
Take it like a man and deal with said pt b/c I am involved anyhow - Yes, I will jump on the grenade.

Every other option is time consuming, so best to let the pt stay in Er until they become too sick to refuse and I can get my scan. Sometimes you have to pick the best solution. I would have no issue if my partner passed this pt on to me b/c I realize this is the best although not optimal option.

The hospitalists and consultants have to be involved. There is no jumping on the grenade for these loser patients. Like others have said...you wouldn't keep them in the ER it the CT machine was being repaired and out of commission for a day; surgeons have done surgery in the past without CTs, etc.

 

[BoardingDoc]

If you are going this route and going above the on call specialists head, then at best you have pissed of a fellow doc and at worse opened them up to a bad lawsuit. Imagine if you forced the surgeon to admit, pt refused treatment, and died resulting in a lawsuit for the hospitalist/surgeon/hospital; You would be a marked man.

I have practiced 25 years and have NEVER went over a specialists head. I have begged, explained that there is no other option BUT never had the thought of going over the specialists head.

Plus your phone merry go round costs me lots of time which is much more valuable than pleasing an unreasonable pt.

Man, I know that the whole "I'd keep them in the ER indefinitely" ... "I'd fall on that grenade" thing sound noble, but you're literally choosing suboptimal care for a patient because you don't want to force the issue and have your colleagues do their (admittedly s***ty) job.

That isn't noble, that's bad medicine.

Also

Every other option is time consuming, so best to let the pt stay in Er until they become too sick to refuse and I can get my scan. Sometimes you have to pick the best solution

This sounds like something I would say when I'm particularly salty, but never actually do because ... you know ... I'm not actually in favor of letting patients decompensate in order to avoid awkward or time consuming phone calls.

 

[Rendar5]

.

Every other option is time consuming, so best to let the pt stay in Er until they become too sick to refuse and I can get my scan. Sometimes you have to pick the best solution. I would have no issue if my partner passed this pt on to me b/c I realize this is the best although not optimal option.

you could do that but could still be in legal trouble if the patient survived and found out what you did.

The only reason we can do things when the patient is too ill to make decisions is through implied consent. Not because we have free reign. Implied consent assumes that the patient would want you to make decisions for them to save their life in the event they were unable to make an informed decision. This patient already told you, when they were able, what their decision was. This voids implied consent.

 

[JacobMcCandles]

Pt wants to be admitted but doesn't want to get necessary testing/treatment + Specialists doesn't want to consult unless CT obtained + Hospitalist doesn't want to admit. Please explain my choices?

Kick pt out - Big nope
Fight with hospitalist/Surgeon to admit essentially getting them involved in a potential bomb? - Big nope
Take it like a man and deal with said pt b/c I am involved anyhow - Yes, I will jump on the grenade.

Every other option is time consuming, so best to let the pt stay in Er until they become too sick to refuse and I can get my scan. Sometimes you have to pick the best solution. I would have no issue if my partner passed this pt on to me b/c I realize this is the best although not optimal option.

So you can get your scan? The chance the patient decompensates enough for you to get your scan while you are on shift will be low. This’ll end up being your partner’s problem. A good relationship with the hospitalists will go a long way here. Although the patient is refusing certain aspects of their care, the floor is where they belong.

 

[Janders]

If you are going this route and going above the on call specialists head, then at best you have pissed of a fellow doc and at worse opened them up to a bad lawsuit. Imagine if you forced the surgeon to admit, pt refused treatment, and died resulting in a lawsuit for the hospitalist/surgeon/hospital; You would be a marked man.

I have practiced 25 years and have NEVER went over a specialists head. I have begged, explained that there is no other option BUT never had the thought of going over the specialists head.

Plus your phone merry go round costs me lots of time which is much more valuable than pleasing an unreasonable pt.

If I ask for an in person consult from Surgery and medicine, and they refuse to come and see the patient… I just say OK?

That’s what we are talking about here, surgery refused to come down until CT done, and hospitalist refused to see patient without surgery consult.

I can’t make anyone operate; I can’t make anyone admit. I CAN may them come see a patient and write a damned note with a formal plan.

There is a zero percent chance I drop this patient into ED observation and kick the can down the road to my partners like a game of borderline Russian Roulette.

I can’t count the times I’ve admitted patients who refuse certain aspects of their care. Its common. Its fine. We all chart that the patient has capacity, is refusing recommended XYZ and we’re gonna do our next best ABC. My surgeons don’t refuse to see these patients, and it would be a rare hospitalist to refuse to admit them. We’d bellyache to each other sure…

So I don’t need a time consuming phone merry go round because it doesn’t come up, but it IS the utility of our secure texting app. I can just secure text Rn supervisor, CMO, chief of surgery that I have an odd patient who does need a surgical consult, and surgery who isn’t willing to do one, and we need a friendly resolution to prevent bad optics. Don’t even throw the consulting surgeon under the bus… play friendly and just ask for the best way to care for this patient in the hospital without getting everyone sued. 100% the solution won’t be holding them in the ED for 32hr of ED care.

 

[Tenk]

One thing I’ve found to sometimes be effective in cases like these is to start asking them specific questions.

Why don’t you want a ct?
How does a ct scanner work?
What specific antibiotics do you want?
How do antibiotics work?
Etc…

Just flood them with questions. The constant I don’t know, I’m not a doctor response will sometimes make them realize they really have no idea what they are doing. This scares some people because while they like being difficult, they really don’t want to actually take the helm and steer their own ship. So let them. They will usually fold. This doesn’t work all the time and sometimes they just get pissed off and walk out (which in cases like this is also a win).

 

[TooMuchResearch]

Pt wants to be admitted but doesn't want to get necessary testing/treatment + Specialists doesn't want to consult unless CT obtained + Hospitalist doesn't want to admit. Please explain my choices?

Kick pt out - Big nope
Fight with hospitalist/Surgeon to admit essentially getting them involved in a potential bomb? - Big nope
Take it like a man and deal with said pt b/c I am involved anyhow - Yes, I will jump on the grenade.

Every other option is time consuming, so best to let the pt stay in Er until they become too sick to refuse and I can get my scan. Sometimes you have to pick the best solution. I would have no issue if my partner passed this pt on to me b/c I realize this is the best although not optimal option.

Patient refused your scan potentially many times while alert. Don't scan them if they are no longer alert.

 

[TooMuchResearch]

If you are going this route and going above the on call specialists head, then at best you have pissed of a fellow doc and at worse opened them up to a bad lawsuit. Imagine if you forced the surgeon to admit, pt refused treatment, and died resulting in a lawsuit for the hospitalist/surgeon/hospital; You would be a marked man.

I have practiced 25 years and have NEVER went over a specialists head. I have begged, explained that there is no other option BUT never had the thought of going over the specialists head.

Plus your phone merry go round costs me lots of time which is much more valuable than pleasing an unreasonable pt.

Yeah, this isn't 25 years ago though. If another specialty refuses to do their job and refuses to see the patient if I insist they see the patient, I'm calling an administrator to take care of it.

 

[ScepticSkeksis]

Patient refused your scan potentially many times while alert. Don't scan them if they are no longer alert.

Or what? They will sue?

 

[lymphocyte]

If you are going this route and going above the on call specialists head, then at best you have pissed of a fellow doc and at worse opened them up to a bad lawsuit. Imagine if you forced the surgeon to admit, pt refused treatment, and died resulting in a lawsuit for the hospitalist/surgeon/hospital; You would be a marked man.

I have practiced 25 years and have NEVER went over a specialists head. I have begged, explained that there is no other option BUT never had the thought of going over the specialists head.

Plus your phone merry go round costs me lots of time which is much more valuable than pleasing an unreasonable pt.

Yeah nah.

I had a surgeon refuse even a diagnostic cut down for a nec fasc with free gas on the X-ray and multiple vasopressors. Patient was a medical student too. I went over his head to anyone and everyone that would listen. **** that prick.

 

[Goro]

Yeah nah.

I had a surgeon refuse even a diagnostic cut down for a nec fasc with free gas on the X-ray and multiple vasopressors. Patient was a medical student too. I went over his head to anyone and everyone that would listen. **** that prick.

What was the end result of your efforts?

 

[Rendar5]

Or what? They will sue?

They can and they would likely be successful if they chose to do so. Remember, this person is irrational to begin with. They are just the sort to sue you if you save their life in a manner not of their choosing.

 

[pkwraith]

Patient refused your scan potentially many times while alert. Don't scan them if they are no longer alert.

Just curious what you would do once they're obtunded. Admit them to hospice? Presumably they're still Full Code.

 

[lymphocyte]

What was the end result of your efforts?

Patient didn't permanently lose a body part.
Surgeon permanently lost his job.
Happy days.

 

[WildEMDoc]

This thread is confusing to me, maybe I'm just not getting it or have been doing it wrong. I also live in a good state in terms of malpractice.

If I really felt like a patient needed a CT or whatever study is needed to admit etc, and they have capacity and refused then our care in the ER is over. AMA and get out of my ER.

If a patient with capacity refuses whatever thing is needed to get them appropriately treated especially if that is a necessary test to admit, they don't want care, get out.

 

[Janders]

This thread is confusing to me, maybe I'm just not getting it or have been doing it wrong. I also live in a good state in terms of malpractice.

If I really felt like a patient needed a CT or whatever study is needed to admit etc, and they have capacity and refused then our care in the ER is over. AMA and get out of my ER.

If a patient with capacity refuses whatever thing is needed to get them appropriately treated especially if that is a necessary test to admit, they don't want care, get out.

I think a lot of us find most of these cases are nuanced and not binary.

E.G. "Sir you have appendicitis, we recommend surgery as does are surgical consultant"
Patient-- "No way, no one is cutting ME!"

Do you (A) Have them sign out AMA and leave or (B) say ok, listen, that's a bad choice. But lets at least admit you on IV abx and see how you do...

There are a million versions of these across a spectrum, and it's rare I'm going to want to kick out / force AMA someone if any other option for some form of care exists.

 

[JacobMcCandles]

This thread is confusing to me, maybe I'm just not getting it or have been doing it wrong. I also live in a good state in terms of malpractice.

If I really felt like a patient needed a CT or whatever study is needed to admit etc, and they have capacity and refused then our care in the ER is over. AMA and get out of my ER.

If a patient with capacity refuses whatever thing is needed to get them appropriately treated especially if that is a necessary test to admit, they don't want care, get out.

Personally, I think this is a bad and flawed approach. If they're only refusing a certain test and not admission to the hospital for treatment of what you presume to be the issue then making them leave completely is probably not the leg I would want to be standing on in court. I understand this would be a very specific example but I think you're throwing the baby out with the bath water.

 

[Rendar5]

This thread is confusing to me, maybe I'm just not getting it or have been doing it wrong. I also live in a good state in terms of malpractice.

If I really felt like a patient needed a CT or whatever study is needed to admit etc, and they have capacity and refused then our care in the ER is over. AMA and get out of my ER.

If a patient with capacity refuses whatever thing is needed to get them appropriately treated especially if that is a necessary test to admit, they don't want care, get out.

leaving the hospital against medical advice is different than refusing a test against medical advice. Patients have autonomy and unless you terminate the patient doctor relationship, you are stuck treating them within the parameters they set for you.

Assuming they have capacity.

I believe there are actual rules or guidelines on how to terminate a doctor patient relationship, ask your outpatient colleagues. But it’s not as straightforward as just walking away.

 

[thegenius]

Personally, I think this is a bad and flawed approach. If they're only refusing a certain test and not admission to the hospital for treatment of what you presume to be the issue then making them leave completely is probably not the leg I would want to be standing on in court. I understand this would be a very specific example but I think you're throwing the baby out with the bath water.

I only kick people out if they refuse everything. You can't take up a bed and refuse a complaint (or make one up) and refuse vitals, a physical exam, etc.

I've had people refuse particular tests, or interventions (like CT or antibiotics, or an I&D) and they don't refuse other things. You do your best...it isn't that complicated.

Occasionally you get the intoxicated and obnoxious folks who have head trauma and are refusing everything. I think if you are putting up an uproar and yelling and fighting everyone, you probably don't have a head injury. These are the most trying patients.

 

[WildEMDoc]

Personally, I think this is a bad and flawed approach. If they're only refusing a certain test and not admission to the hospital for treatment of what you presume to be the issue then making them leave completely is probably not the leg I would want to be standing on in court. I understand this would be a very specific example but I think you're throwing the baby out with the bath water.

They are refusing reasonable care. In someone who is presently stable, we'll say with SIRS and abdominal pain, older. The refuse a CT, there is no way for us to appropriately care for that person. We don't know the cause of the abdominal pain and haven't ruled out surgery. There is no way that should be admitted as a bomb on the floor with supportive care and antibiotics when the etiology is not clear and a test would help clarify significantly.

Working in the confines of someone's WebMD/TikTok opinions is not any sort of care I think I would follow. At the end of the day we are the "expert" and if we let this go undiagnosed then the failure could be on us for not presenting the information to the patient to make a good decision. Working within religious constraints is different and also much easier to hang in court.

There is a difference between someone refusing one test that may be able to be changed or "shared decision making" vs refusing a test that completely dictates what appropriate care may be.

 

[thegenius]

They are refusing reasonable care. In someone who is presently stable, we'll say with SIRS and abdominal pain, older. The refuse a CT, there is no way for us to appropriately care for that person. We don't know the cause of the abdominal pain and haven't ruled out surgery. There is no way that should be admitted as a bomb on the floor with supportive care and antibiotics when the etiology is not clear and a test would help clarify significantly.

Working in the confines of someone's WebMD/TikTok opinions is not any sort of care I think I would follow. There is a difference between someone refusing one test that may be able to be changed or "shared decision making" vs refusing a test that completely dictates what appropriate care may be.

So a bomb in the ED is OK?

Why do people think that the ED docs are "special" and that we can handle undifferentiated patients, and no-one else can? There is nothing special about the ED. Hospitalists are board certified (I hope) and can do physical exams (I hope), and can reason with patients (I presume), and are knowledgeable about pathology (jeez...now I'm stretching).

If this situation were to ever actually exist...like having a really sick patient who refused part of their care...they get admitted. It's like patients refusing blood transfusions who have a clear indication for them. They can just refuse it, or they can refuse it due to be a Jehovah's Witness. There is no difference between the two. Even if their hemoglobin is 5 with melena, you do your best. "Oh I'm MR Dr GI and I'm MRS Dr Hematology and we BOTH cannot care for this patient. KTHXBYE."

 

[WildEMDoc]

So a bomb in the ED is OK?

Why do people think that the ED docs are "special" and that we can handle undifferentiated patients, and no-one else can? There is nothing special about the ED. Hospitalists are board certified (I hope) and can do physical exams (I hope), and can reason with patients (I presume), and are knowledgeable about pathology (jeez...now I'm stretching).

If this situation were to ever actually exist...like having a really sick patient who refused part of their care...they get admitted. It's like patients refusing blood transfusions who have a clear indication for them. They can just refuse it, or they can refuse it due to be a Jehovah's Witness. There is no difference between the two. Even if their hemoglobin is 5 with melena, you do your best. "Oh I'm MR Dr GI and I'm MRS Dr Hematology and we BOTH cannot care for this patient. KTHXBYE."

I'm not saying this person stays in the ER either. They should just go, can come back when they change their mind.

There is not an equivalency to religious preferences in my mind easier to separate from a patient refusing standards of care based on whatever poor source the patient chooses to use that they trust over the doc.

Working within the confines of these demands based on the current trend on TikTok are in my mind closer to a patient demanding they will only get "dilaudid and benadryl IV for my pain".

I would probably have the hospitalist come down and see the patient as well, if only to add another doctor who has told the patient this is what they need. This is case by case though, and not uniform. The CT patient I would have AMA. The PNA patient refusing antibiotics would be an easy admit still.