Pt refuses labs, wants to be admitted

[Interpolfanclub]

Another resident picked up a patient last night with a CC of CP who had been worked up in the recent past for same complaint. Patient refused to have any labs drawn and wanted to be admitted without them. Other resident thought she was probably competent tried to sign her out AMA but she refused to sign the papers. Our uber-conservative attending told him to admit her without labs for "observation" but the hospitalist refused to admit.

Later that night her MS started to change and my colleague worked her up and admitted her anyway.

This is the first time I have encountered this situation where a patient is competent but refuses a work up and won't sign AMA. What do you guys do in this situation? The fact her MS changed solved the problem but what if it hadn't? Do you remove them from the ER? Do you try and admit without labs? Should you?

Very interested in what you guys think about this. Thanks.

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[defibme]

my own personal opinion is this:

we do not have time to deal with patients who do not want our help. If she refuses medically necessary care, offer her AMA. If she refuses AMA, chart her competence, her refusal, and have the staff doc and patient's RN corroborate on their own charts. Then tell the patient to leave. If she refuses, call security and have her removed.

Just my two cents.

 

[GeneralVeers]

my own personal opinion is this:

we do not have time to deal with patients who do not want our help. If she refuses medically necessary care, offer her AMA. If she refuses AMA, chart her competence, her refusal, and have the staff doc and patient's RN corroborate on their own charts. Then tell the patient to leave. If she refuses, call security and have her removed.

Just my two cents.

I agree and have done this a couple of times. It is not Burger King and you can't have it "your way". If your chest pain is bad enough that you came to the hospital, then you get labs, meds, admission if necessary. Within reason you can refuse certain medications or invasive procedures, but if your refusal prevents a proper workup and is irrational, then we will show you to the door.

 

[DeLaughterDO]

I agree and have done this a couple of times. It is not Burger King and you can't have it "your way". If your chest pain is bad enough that you came to the hospital, then you get labs, meds, admission if necessary. Within reason you can refuse certain medications or invasive procedures, but if your refusal prevents a proper workup and is irrational, then we will show you to the door.

 

[southerndoc]

I agree and have done this a couple of times. It is not Burger King and you can't have it "your way". If your chest pain is bad enough that you came to the hospital, then you get labs, meds, admission if necessary. Within reason you can refuse certain medications or invasive procedures, but if your refusal prevents a proper workup and is irrational, then we will show you to the door.

I agree as well. What if her troponin was 30 when you admitted her? If she signs an AMA form stating she refused the labs, then I would be ok admitting her for observation if I was worried about her. I would have a long discussion about the importance of labs, but a long discussion is always a painful discussion in a busy ED.

 

[GeneralVeers]

I agree as well. What if her troponin was 30 when you admitted her? If she signs an AMA form stating she refused the labs, then I would be ok admitting her for observation if I was worried about her. I would have a long discussion about the importance of labs, but a long discussion is always a painful discussion in a busy ED.

I don't think anyone would discharge a patient with a troponin of 30, however if you have the troponin back, doesn't that mean you got labs from her?

Usually the ones I see are chronic pain patients who like to be admitted for secondary gain and actively refuse any other test/intervention except narcotics.

 

[WilcoWorld]

A bit off topic, but I recently had one of the conversations southerndoc alluded to, and surprised myself at how easy it has become for me to tell people, "You could die" very matter-of-factly. When I started residency I would dance around the topic for a while, and only say it as a last resort. Now, I explain the plan, explain the alternatives, explain the risks & benefits, and if the patient is still refusing I cut right to the chase, "Do you understand that you could die from this?"

People who are being stubborn and / or unreasobale need the plain truth, not a bunch of euphemisms.

From a legal standpoint, I usually throw in "permanent disability" as well, and put that in my documentation of the conversation. There are a few reasons for this: I think I'd rather die than llinger with anoxic brain injury, if the patient doesn't die, but becomes disabled he could claim you didn't warn him about that, and if you get sued, permanent disability is worth a lot more than death.

 

[EctopicFetus]

my own personal opinion is this:

we do not have time to deal with patients who do not want our help. If she refuses medically necessary care, offer her AMA. If she refuses AMA, chart her competence, her refusal, and have the staff doc and patient's RN corroborate on their own charts. Then tell the patient to leave. If she refuses, call security and have her removed.

Just my two cents.

Agreed as well. Patients dont tell me what tests to order, what meds to give em or if they get admitted or not. Thats why I went to med school. I had one of these yesterday. I just tell people there is no reason for that. Some other people will give the I want to be admitted, i just say there has to be a reason and if there isnt then you will have to go home. Plain and simple.

 

[EctopicFetus]

My AMA shpeil (sp?) is something like (here is what could happen specifically to your condition), then I almost always throw in stroke, heart attack, death etc. I think the etc after death means other badness. I do like permanent disability. Ill use that one next time!

 

[southerndoc]

I don't think anyone would discharge a patient with a troponin of 30, however if you have the troponin back, doesn't that mean you got labs from her?

Usually the ones I see are chronic pain patients who like to be admitted for secondary gain and actively refuse any other test/intervention except narcotics.

My point was the legality of admitting someone without labs, not about you knowing what the troponin was. I'm saying what if the patient refuses labs, gets admitted, and then somebody talks the patient into labs an hour later... her troponin comes back at 30. There is a lot of liability on the emergency physician for not detecting it earlier and initiating treatment.

In essense, I was agreeing with you.

 

[southerndoc]

A bit off topic, but I recently had one of the conversations southerndoc alluded to, and surprised myself at how easy it has become for me to tell people, "You could die" very matter-of-factly. When I started residency I would dance around the topic for a while, and only say it as a last resort. Now, I explain the plan, explain the alternatives, explain the risks & benefits, and if the patient is still refusing I cut right to the chase, "Do you understand that you could die from this?"

People who are being stubborn and / or unreasobale need the plain truth, not a bunch of euphemisms.

From a legal standpoint, I usually throw in "permanent disability" as well, and put that in my documentation of the conversation. There are a few reasons for this: I think I'd rather die than llinger with anoxic brain injury, if the patient doesn't die, but becomes disabled he could claim you didn't warn him about that, and if you get sued, permanent disability is worth a lot more than death.

I had a patient complain on me once after she refused hospital admission, refused surgical consult, and insisted that she go home and follow up with her own primary care physician. The complaint? Because I told her she could become septic and die from her acute cholecystitis. (I mentioned it wasn't that common with treatment, but it's a possibility without getting treatment soon.)

I called her PMD, who of course was a cross-covering on-call doc. The patient insisted on going home, so I signed her out AMA.

 

[Apollyon]

My AMA shpeil (sp?) is something like (here is what could happen specifically to your condition), then I almost always throw in stroke, heart attack, death etc. I think the etc after death means other badness. I do like permanent disability. Ill use that one next time!

As an attending, I don't sanitize it by saying "permanent disability". I come right out and say, "If you die, you're dead. You're done. What you don't want to do is (stroke/have an MI/whatever) and live. Do you want to poop your pants, have a tube in your whizzer, and not be able to even keep food in your mouth for the next 40 years?"

 

[southerndoc]

As an attending, I don't sanitize it by saying "permanent disability". I come right out and say, "If you die, you're dead. You're done. What you don't want to do is (stroke/have an MI/whatever) and live. Do you want to poop your pants, have a tube in your whizzer, and not be able to even keep food in your mouth for the next 40 years?"

I'm quote candid when they sign the form. "This is a form that states that when you go home, you're doing so against my advice, and if something bad happens to you, including you dying, then you nor your family can sue me or the hospital for your decision."

It's amazing how many people will change their mind when you give them that spill.

 

[Apollyon]

I'm quote candid when they sign the form. "This is a form that states that when you go home, you're doing so against my advice, and if something bad happens to you, including you dying, then you nor your family can sue me or the hospital for your decision."

It's amazing how many people will change their mind when you give them that spill.

And I still can't believe it when they don't change their minds. I thought getting the grandchildren to cry would work, but, boy howdy, that guy wanted to go.

 

[DeLaughterDO]

I'm quote candid when they sign the form. "This is a form that states that when you go home, you're doing so against my advice, and if something bad happens to you, including you dying, then you nor your family can sue me or the hospital for your decision."

It's amazing how many people will change their mind when you give them that spill.

Does anyone know if one of these "AMA" forms has been held up in court, or do they, like most of the medical forms we have patients sign, go under the bus?

Just interested in how watertight an AMA or Informed refusal of care form is for defense when the patient eventually sues for whatever it is they think you should have found despite their throwing a fit and not wanting you to look...

 

[matt_mt19]

Only as water tight as the judge and/or jury enforcing the ink on the paper... emotions tend to over ride legalities, especially when "that mean doctor made me sign this form so he wouldn't get in trouble when he hurt me." I love the law

 

[group_theory]

Does anyone know if one of these "AMA" forms has been held up in court, or do they, like most of the medical forms we have patients sign, go under the bus?

Just interested in how watertight an AMA or Informed refusal of care form is for defense when the patient eventually sues for whatever it is they think you should have found despite their throwing a fit and not wanting you to look...

Psychiatr Serv 51:899-902, July 2000
An Examination of Whether Discharging Patients Against Medical Advice Protects Physicians From Malpractice Charges
http://psychservices.psychiatryonline.org/cgi/reprint/51/7/899
OBJECTIVE: Many physicians believe that documenting a discharge as "against medical advice" protects them from legal actions for adverse consequences related to the discharge. The authors examined case law for evidence of such protection
RESULTS: Four relevant cases were found in which medical authorities and physicians were sued for medical malpractice even though they discharged a patient against medical advice. In all cases the defendants prevailed. However, their success was not due to the fact that they used the procedure of discharging patients against medical advice. Rather, it was based on the plaintiffs' failure to prove negligence. The authors offer guidelines for physicians faced with the decision to discharge against medical advice. Physicians should perform a careful and well-documented examination. They should assess the severity of illness and the severity of the risk if the patient is discharged. They should engage in a constructive dialogue with the patient about grievances. They should ensure that the patient's withholding of consent for further hospitalization is informed with respect to risks, benefits, and alternatives. If the patient meets criteria for involuntary hospitalization, the patient should be committed

Against Medical Advice: When Should the Doctor Say No?​

Catherine A. Marco, MD, FACEP
October 10, 2007
ACEP meeting in Seattle, Washington

http://meetings.acep.org/NR/rdonlyres/3389C314-2395-4FCE-BD9A-FAABFFC0DFB6/0/WE184.pdf​

"It has been estimated that 1 in 300 AMA discharge patients will file related lawsuits. Generally, these suits fail as courts and juries are unsympathetic to patients who refuse medically recommended treatment and later claim that they were not made aware of the consequences of the refusal. Appropriate documentation of against medical advice has offered partial or complete protection for plaintiff physicians and institutions, but not complete legal protection in all cases.

​

In some cases, leaving against medical advice has been considered a reasonable action in certain circumstances. Institutions may not require patients to sign a document prior to leaving against medical advice. Courts have found forms releasing institutions and health care providers from liability to be against public policy and worthless. Nonetheless, provision of the best clinical care and appropriate documentation provide the best legal protection."​

 

[emergiQ]

And I still can't believe it when they don't change their minds. I thought getting the grandchildren to cry would work, but, boy howdy, that guy wanted to go.

Sometimes I get patients who refuse even to sign the damn AMA form. I document something like the following:

1) that they refuse further care
2) that I think they need further work up
3) that their vitals and all other findings are essentially normal

e.g.,

"Patient is adamantly against any further investigation or tests including laboratory work-up, ECG or imaging. In my opinion, this patient, given their [insert chief complaint here] requires further work up, but refuses all interventions as noted above. In addition, patient refuses to sign AMA form despite discussion that patient's chief complaint may be consistent with a condition that may cause further pain, permanent disability, or even death.

Patient's vitals are stable. Able to ambulate, converse and take oral nutrition without difficulty. Alert and oriented x 3 with clear sensorium and at this time does not appear to have an impaired ability to reason, nor does he/she have any other sign or symptom to suggest lack of competence with regard to medical decision making.

Patient is discharged against medical advice without signed AMA form"



I've often wondered how relevant/air tight this sort of thing is. I know there is probably some question as to whether or not I should be using the word "competence"... or even, quite frankly, if I'm even using it in the appropriate context.

Any others have another style, or any specific problems you see with my text?

 

[southerndoc]

Does anyone know if one of these "AMA" forms has been held up in court, or do they, like most of the medical forms we have patients sign, go under the bus?

Just interested in how watertight an AMA or Informed refusal of care form is for defense when the patient eventually sues for whatever it is they think you should have found despite their throwing a fit and not wanting you to look...

One of my residency attendings is also a lawyer. He has a lot of knowledge about AMA's, and basically his advice:

1. It's your documentation, not the AMA form, that will offer the most protection from a bad outcome secondary to an AMA discharge.

2. Patients must still be given discharge instructions even if they sign out AMA. Failure to do so will increase your liability. The family could argue that had the patient been given discharge instructions (for chest pain, MI, whatever), he might have changed his mind, known what to look for that would indicate more serious disease, etc..

3. Document that the patient has capacity to make decision (NEVER use the word competent, which is a legal term determined by a judge). The patient should have capacity to make decision as judged by answers to your questions. Of course documenting the patient to be alert and orientated to person, place, and time is mandatory here.

4. Never document that the patient understood the risks. You should document that risks were clearly explained to the patient in both medical and layman's terms, and the patient was able to voice back those risks. If you document the patient understood the risks, it could open more doors for lawsuits given a lawyer can argue how you knew the patient understood the risks.

5. Finally, you should document that the patient was afforded the opportunity to ask questions, all questions were answered, and the patient was told that if at any time he changes his mind about treatment or if his condition changes, he is welcome and encouraged to return to the ED as soon as possible.

It's a lot of work to properly document an AMA, but this is his recommendation. (Hopefully I didn't leave anything out.)

 

[MadMack]

Get a witness to sign the AMA in the even that the patient refuses to sign it; family members will sometimes sign even if the patient refuses to. Most ERs where I live, Florida, have at least one police officer on duty in it who we generally have sign the form as a witness if the patient and family refuse to sign the AMA discharge; we also have a separate set of lines to fill out if the patient refuses to sign the form.

We have similar refusal forms in all of our rescues and engines in Fire Rescue, generally PD or SO responds to calls with us; so if a patient refuses treatment/transport we try to get a family member to sign as a witness, failing that we have the police do it.

But, for what its worth, document document document, a comprehensive and complete report is going to be worth a lot more in court then a refusal or care or AMA discharge form is going to be.

 

[docB]

I heartily second everything Southerndoc said here.

I also do a seperate AMA instruction on the discharge paperwork noting that they may die or be severely injured and that they can come back at any time. That's in addition to my note in the chart saying they were advised of same. I think it's really important to be able to prove that they were handed a paper with those instructions in writing.

Another thing I do that many don't is that I write prescriptions for the AMA patients. If I have to go to court on one of these I want to be able to say I did everything I could for the patient even though they wouldn't stay. I write for antibiotics for anything that might be infectious. For the AMA chest pains I write for ASA, sublingual NTG and Lortab. That's as close to MONA as I can get outside. I also document on the discharge instructions that "You have been given prescriptions to try to help your condition. These are NOT a substitute for a complete work up. You can come back to the ER at any time."

Finally let me point out that there are some really difficult AMA situations. I'll cite two personal experiences:

Paraplegic homeless patient patient gets brought in by ambulance for something. Find some minor pathology (I think it was a pyelo or something like that) but he's totally A&Ox4. He suddenly decides he wants to leave AMA. His wheelchair was stolen prior to EMS finding the guy and he has no clothes (they were covered in poop). Nurse calls me over to the hall where the naked, poop covered fully oriented patient is dragging himself toward the door. He could not be reasoned with. This was a tough spot. He was totally lucid. We called in risk management, social services and adult protective services (which after hours in the police). We ultimately all agreed to place him on a hold that the cops initiated, I certified and the nurses agreed with in their documentation. The hold was placed on the basis of the patient being unable to care for himself. I know it was the right thing to do but it's very difficult basically arresting someone and forcing them to stay in the hospital when they're not clearly crazy.

The other example was a patient with tearing chest pain and was found to have a thoracic dissection. The EP (I wound up involved in this one from the admin side) went and told the patient he needed to go to the OR. The patient had been given all the appropriate stuff including narcotics. The patient refused and wanted to go back to LA for his surgery. So now he's refusing surgery and wants to leave but he's been given narcs so does he have capacity? The same cast of characters, risk, admin, etc. swarm this guy and he still refuses. By the time the dust is settling it's been ~4hrs since his last dose and he is A&Ox4 so we let him go. I don't know how he did.

 

[enfuegoEP]

One of my residency attendings is also a lawyer. He has a lot of knowledge about AMA's, and basically his advice:

1. It's your documentation, not the AMA form, that will offer the most protection from a bad outcome secondary to an AMA discharge.

2. Patients must still be given discharge instructions even if they sign out AMA. Failure to do so will increase your liability. The family could argue that had the patient been given discharge instructions (for chest pain, MI, whatever), he might have changed his mind, known what to look for that would indicate more serious disease, etc..

3. Document that the patient has capacity to make decision (NEVER use the word competent, which is a legal term determined by a judge). The patient should have capacity to make decision as judged by answers to your questions. Of course documenting the patient to be alert and orientated to person, place, and time is mandatory here.

4. Never document that the patient understood the risks. You should document that risks were clearly explained to the patient in both medical and layman's terms, and the patient was able to voice back those risks. If you document the patient understood the risks, it could open more doors for lawsuits given a lawyer can argue how you knew the patient understood the risks.

5. Finally, you should document that the patient was afforded the opportunity to ask questions, all questions were answered, and the patient was told that if at any time he changes his mind about treatment or if his condition changes, he is welcome and encouraged to return to the ED as soon as possible.

It's a lot of work to properly document an AMA, but this is his recommendation. (Hopefully I didn't leave anything out.)

I'm going to print this and keep it in my back pocket.

 

[southerndoc]

I also agree with giving prescriptions for AMA patients. If the patient has diverticular abscess and is refusing admission, at least give him a script for ciprofloxacin and metronidazole. If the patient goes home, gets septic, and dies, it's hard to say that you didn't care about the patient.

One case comes to mind where a physician wrote on the discharge paperwork in all capital letters "you are being given antibiotics in hopes that this will help. However, it is unlikely they will help and you are encouraged to come back to the ER immediately if you change your mind about your decision not to be treated properly or if your condition changes in any way. Your leaving against medical advice does not affect your future rights to treatment in any way."

 

[Greenbbs]

we have T-Sheets in the emergency dpt. i'm in, and the AMA form they use requires patient signature and initialed understanding of all the consequences including disability....it's pretty handy, and if the patient initials on the lines next to those, they ain't nobody gonna side for them in a court of law.

 

[docB]

Back to the OP's actual question of what to do with a patient who is refusing parts of their care yet still wants to be in the hospital that is a tough spot. I occasionally have had to admit people who have no IV access because they refuse a central line (everyone wants a PICC which I can't get at night). So it falls to me to decide if it's worth putting them in. I usually do think that they can get some benefit out of being admitted despite having no IV access because they can get PO and IM meds and monitoring. If someone refuses all their labs I probably would not admit them because then there's no way to really know what's wrong with them.