Request for AMA in middle of night

[TerraceHouse]

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When providing on-call coverage during the evening for an inpatient unit, if you get calls from the house supervisor for voluntary patients and/or an adolescent’s parent to request to leave AMA, how do you all navigate that?

There have been times where an adult psychotic patient’s parent have called the police to try and get them discharged and thankfully there was good documentation on the day’s progress note & STC where it was obvious the patient was not ready to be discharged but even then I had to explain to the police officer the protocol that typically the judge would hear both sides and make a decision.

However, with voluntary patients/adolescents that I personally don’t know who request to leave AMA when I’m on call, it’s been difficult navigating this because on one hand, it’s clear they’re still having very poor distress tolerance but are not an imminent threat and we’ve allowed them to leave AMA. One situation was when an adolescent didn’t want to return with the parent but the parent was demanding to take them home and given the instability of patient and still endorsing intent to self-harm, was put on a 72 hour hold and the parent was very unhappy.

I’m still a resident and learning when would be appropriate to allow to leave AMA vs when to initiate a hold based on their inability to keep themselves safe if they were already voluntary. Thx for feedback in advance!

 

[calvnandhobbs68]

This is 100% a "call the attending every time this happens" type issue if they're trying to leave AMA from a psych unit. We would also usually have to call legal too to let them know this was happening, just in case something ever came of it. If an attending gives you crap about it, they're a ***** because it's their butt on the line at the end of the day for this (something goes wrong and the patient goes and kills themselves that night, their name is going to be on the lawsuit).

This is also extremely state dependent in terms of threshold for involuntary hold procedures, which is even more why this needs to be a discussion with the attending. For instance, in my current state, if the adolescent was 14yo+, it doesn't matter if the parent wants to take them home, they can consent to their own voluntary admission, so there would be no need to do a hold. For voluntary adult patients, it's a bit different because unless the documentation supports the fact that they would meet involuntary criteria, they may have to be discharged (again, depending on state law), but my discussion would usually be with the patient that it's probably not a good idea to leave in the middle of the night without a plan setup for followup/discharge and if they can just wait until the next morning, the day team and day social worker can help them get a good discharge plan setup to leave the next day.

You guys should also go over this kind of stuff in the residency program (again since it's state dependent) and the protocols for this on your units. If you don't already go over this, ask the program director if you all can get some more info on how you should go about this.

 

[michaelrack]

Agree that this is very state dependent

 

[Bartelby]

Seconded that you should contact your attending, especially if you are a resident practicing child psychiatry (often child call is left to fellows).

You should also clarify what local law allows you to do. If they signed in voluntary, can you then legally place a hold? Probably. What if they came in on a hold, it was dropped, and now you are considering placing a new one? Quite possibly not, especially if it has been a long time since they came in to the unit. You want to know exactly what you are legally allowed to do.

For voluntary psychiatric patients asking to leave AMA, though, in general you need to assess for imminent risk meeting hold criteria. If that is not present you would need to let them leave AMA. (A gross lack of decision making capacity could change this determination again based on local law and hospital policy, but it is rare that a psychiatric patient would fully lack decision making capacity while also clearly not meeting imminent risk criteria including grave disability). I tend to approach this like I would in an emergency room setting, reviewing any collateral information (which includes, of course, the intake note and all recent progress notes). Because you have more data, you may be better positioned to make a more informed call about risk. You want to take these decisions seriously though, as patients leaving AMA from an inpatient unit are at higher risk for a subsequent suicide attempt or completion then your average outpatient population.

 

[TerraceHouse]

This is what makes phone call coverage hard as we are not on-site, I don’t know the patient/often times neither does the attending on call, paper charts can be difficult to read handwriting and often I’m relying on nursing to give me the data, and need to make a decision in a given timeframe.

I’ve read the probability of malpractice occurring from an adverse event after discharging AMA is higher vs false imprisonment and holding a patient longer.

I’ve seen most attendings err on the side of caution in these situations.

 

[Jules A]

In my state if admitted on a voluntary basis the patient/parent are able to put in a 72h notice of their intent to leave which would be the recommended action particularly in the middle of the night.

 

[calvnandhobbs68]

This is what makes phone call coverage hard as we are not on-site, I don’t know the patient/often times neither does the attending on call, paper charts can be difficult to read handwriting and often I’m relying on nursing to give me the data, and need to make a decision in a given timeframe.

I’ve read the probability of malpractice occurring from an adverse event after discharging AMA is higher vs false imprisonment and holding a patient longer.

I’ve seen most attendings err on the side of caution in these situations.

Yeah honestly if nobody is helpful in this situation, I'd just tell them sorry bud you're staying tonight until the day team gets here tomorrow unless there's a specific state statute that indicates a person has to be released immediately from a voluntary admission. As I used to like to say, not a night team kind of issue. Of course, you need to tell the day team on signout that this problem is incoming though.

You could always argue that since the day team did not indicate that the patient was appropriate for discharge, no appropriate discharge planning had been put into place and they had been admitted for psychiatric reasons which would already put them at elevated risk if d/c'd inappropriately, it would be unsafe to d/c them without their primary team arranging for discharge and there is very little harm one would be able to argue could have been sustained from an "involuntary" deprivation of liberty for 12 more hours.

For child this is a bit more tricky and why you should be talking to the child attending, because in these cases you can be technically charged with "kidnapping" (however ridiculous that sounds) if a patient doesn't meet involuntary criteria, the parents are the consenting party and you are holding the child there against parent consent. Which is why age of consent really matters here. However, good thing for you is that liability ends up being way lower because the parents are assumed to be competent and thus assume a lot of the risk if they are requesting a d/c AMA. You also document up the butt that you informed the parents of the risk of early d/c, up to and including the risk of DEATH and they acknowledged this and wished to d/c.

 

[whopper]

It happens. Doesn't happen often.

There's such a thing as something happening a lot and frequently. So when it happens everyone knows how to deal with it.

Then there's the type of thing that never happens so people don't worry about it and their ignorance doesn't hurt them.

And here's the real-kicker, the problem happens and when it happens everyone freaks out, and it doesn't happen often enough to a degree where when it happens again people (edit: forgot incorrectly wrote learned) from the prior experience and everyone freaks out again.

AMAs in the middle of the night were that for me and several others and this is across several institutions. They didn't happen often enough for attendings, residents, nurses and other staff members to be incorporated into their usual schemas of normal.

I will say this, and echoing above. It will likely depend on the local laws but if a person wants to leave AMA in the middle of the night, if you tell them to stay for the night to sort it out tomorrow and they still want to go, you may HAVE TO LET THEM GO AND DO ALL THE PAPERWORK AND OTHER STUFF THAT GOES ALONG WITH IT. Otherwise it could be considered an illegal seizure/detainment, whatever it's called in the local laws.

(Another it happens but not enough and everyone freaks out when it does, when you need the anesthesiologist to knock out the agitated patient because Thorazine 100 mg IM, Haldol 20 mg IM, Lorazepam 3 mg IM Hydroxyzine 100 mg IM hasn't done ANYTHING! The anesthesiologist gets mad at you for calling them and says you're not supposed to call them, then you contact your department chair who calls the anesthesiologist chair who then forces the anesthesiologist on duty to help you after 3 hours of screaming at your nurses and you. Patient is finally knocked out. Next time it happens it's years later and a different idiot anesthesiologist is on duty and the same exact thing happens all over again while the patient is punching people for 3 hours. You tell both departments "this can't happen again. I got some injured staff members." The chairs of both departments promise it won't happen again but a few months later, to quote President Zelenskyy....."NEVER AGAIN AND YET HERE WE ARE." )

 

[TerraceHouse]

You guys are awesome. Love the brain trust on here.

 

[TerraceHouse]

I actually want to post again about how appreciative I am for everyone’s posts on here. SDN has been awesome for me throughout my entire career. Sometimes I wish there were these type of discussions at my residency but unfortunately the truth is the other residents are just as clueless as me. The attendings often just share their opinions as dogma and now we have been told four different truths and/or we get taught defensive medicine to protect the attendings or sometimes whatever is less work for them.

 

[whopper]

If your own department doesn't have it in order I recommend the following.
1) Talk to your department on what the local laws are. This may force you to talk to your institution's lawyers. Don't worry. If you're part of a university hospital they'll have one that'll guide you through this process. Seriously one of the biggest things I miss with working with a hospital is being able to ask the hospital lawyer what the laws are concerning something when I encounter something where I'm not sure. Now I got to pay a lawyer about $200 and hour.

2) Someone in the department make this a policy in print so next time this happens everyone knows the policy and people won't have to freak out.

 

[mistafab]

If your own department doesn't have it in order I recommend the following.
1) Talk to your department on what the local laws are. This may force you to talk to your institution's lawyers. Don't worry. If you're part of a university hospital they'll have one that'll guide you through this process. Seriously one of the biggest things I miss with working with a hospital is being able to ask the hospital lawyer what the laws are concerning something when I encounter something where I'm not sure. Now I got to pay a lawyer about $200 and hour.

2) Someone in the department make this a policy in print so next time this happens everyone knows the policy and people won't have to freak out.

This a million times. The situation is not unique enough that you should be forced to reinvent the wheel at midnight.

 

[hamstergang]

This is what makes phone call coverage hard as we are not on-site

I would never discharge a patient AMA over the phone unless state law mandated it. There's too much risk and too little ability to make an accurate evaluation through that format.

 

[nexus73]

I think you either have to go in, or if you have enough information to have a hold placed that's an option. Our state laws require the hospital supervisor to place holds once a patient is admitted to a psych unit, which is nice for the psychiatrists because the RN House Supervisor has to come down and place the hold, and not the on call doctor. I would not feel comfortable discharging a patient in the middle of the night without seeing them face to face, otherwise you can't do a legit risk assessment or discuss AMA in the right way where you can determine the patient is capable of deciding to leave AMA.

 

[Celexa]

I'm in one of those states where consenting to voluntary admission means consenting to having to give advance notice if you want to leave, so this is a non issue that we don't even get called about. The nurse gives them a piece of paper to sign and it's a day team problem.

Agree with everyone saying this is something your institution really needs to have a clear policy on that is accurately grounded in local mental health law.

 

[Mass Effect]

For voluntary psychiatric patients asking to leave AMA, though, in general you need to assess for imminent risk meeting hold criteria. If that is not present you would need to let them leave AMA.

Just want to repeat this is all state dependent. Where I trained, we had to let them go after calling attending and legal.

Where I am now if they signed in voluntarily and are on the unit, I cannot let them leave AMA overnight. This is state law. Once they're on a locked psych unit, discharges cannot be done by the on-call person. The team in the morning has to discharge them if there's no imminent threat.

In some states, they have to give the team 24H or 48H to discharge if they want to leave AMA. This is to allow the team time to not only do a safe discharge but also to fully evaluate the patient.

So definitely state dependent. And as a resident, always call your attending for these high liability cases.

 

[J ROD]

I let them know I will take their request under advisement and in my state have the right to hold them for 3 days not including weekends or holidays. IF at that time I feel they need IVC I put them on papers, if not I let them go with an appointment for outpatient follow up and medications. They are advised on this when they sign the voluntary form. The specific law is quoted on the bottom of the form.

 

[Candidate2017]

The attendings often just share their opinions as dogma and now we have been told four different truths and/or we get taught defensive medicine to protect the attendings or sometimes whatever is less work for them.

Yes, I doubt faculty have read their state's mental health statutes cover to cover, despite the fact psychiatrists have significant regulations imposed upon them that do not pertain to other physicians. Each state should have an online resource about psychiatric patient rights and in/voluntary forms, which is a good overview prior to reading your state's statutes. Also talk to the specialist: find out when the mental health lawyer makes their rounds and have a chat.

It's also possible staff is poorly trained. For example, I don't know why the police showed up, requiring you to speak to them. Where I trained, patients often called 911 for all perceived manner of wrongs, and nurses would document and speak with the police if needed.

In any event, you have no chance of convincing 12 random people in a jury box, let alone your malpractice carrier, that it's a good idea to let (1) a psychiatric patient (2) with poor distress tolerance (3) that you've never examined (4) leave AMA (5) from a locked psych ward (6) in the middle of the night.

Again, chat with the lawyer and find out available options to keep patients overnight. As pointed out above, voluntary in some states doesn't mean patients get to leave this instant. In which case, you need to train staff that this is not an overnight pager issue and patients need to be redirected. Alas, staff will probably keep paging for the rest of your residency about this, but being a broken record and saying no to staff/patients/families in 20 different ways is a big part of being a psychiatrist.

 

[deleted1100659]

It would be an extremely rare circumstance that I would let a patient go in the middle of the night.

The best discharge plans happen during the day/morning. During the middle of the night whats the chance that someone responsible is going to be there to pick the patient up and ensure they get what they need? Also if appropriate f/us arent made, everything will be closed. If they need to go to an outside pharmacy (for some reason) then it will be closed. Everything is closed. People are asleep. Usually my train of thought is, they have made it this long, why not just get a night of sleep then they can be assessed when everyone is refreshed and thinking clearly?

If someone is demanding to leave, then it becomes a little different, sure, and it depends on why they're there and what the situation is that they want to leave all the sudden. That's another question to ask, why were they ok to stay until randomly the middle of the night? Sure people change their mind, but people make impulsive choices too.

 

[comp1]

It would be nice to know what state the OP is in so they could actually be given the specific advice that their attendings already should have given them. If it is possible to discharge someone AMA who is voluntary overnight (in their state), this seems like an excellent situation in which a robust telehealth system needs to be in place for such an assessment to take place during home call. The above commentaries on kidnapping or illegal detainment are...interesting, but definitely not something I have ever seen, even with extremely lazy attendings. The OP should learn and follow the state law because they genuinely want to respect human rights, not because of some external consequence.

 

[Candidate2017]

Dr. Google says an M-8 cert can be filed, on a previously voluntary Colorado patient, for a 90-day hold.

But it's filed by the professional who "participated in the evaluation" of the patient. Presumably you did not eval the patient because you are the pager grunt for the evening. So either you have to see the patient to sign the M-8, or the attending or resident who H&P'ed the patient needs to be awakened to sign the M-8 cert.

27-65-107. Certification for short-term treatment - procedure.​

"The notice of certification must be signed by a professional person on the staff of the evaluation facility who participated in the evaluation and must state facts sufficient to establish reasonable grounds to believe that the person has a mental health disorder and, as a result of the mental health disorder, is a danger to others or to himself or herself or is gravely disabled."

Provider resources for involuntary mental health services | Behavioral Health Administration

Find forms, training, and requirements for providing involuntary mental health services

cdhs.colorado.gov

Colorado Mental Health M-1 Holds – The Power To Arrest And To Detain – 27-65-102 C.R.S.

By H. Michael Steinberg Colorado Criminal Defense Lawyer Colorado Mental Health M-1 Holds - The Power To Arrest And To Detain -27-65-102 C.R.S. - On December 31, 2017, Douglas County Sheriff Zack ...

www.colorado-criminal-lawyer-online.com

 

[calvnandhobbs68]

It would be nice to know what state the OP is in so they could actually be given the specific advice that their attendings already should have given them. If it is possible to discharge someone AMA who is voluntary overnight (in their state), this seems like an excellent situation in which a robust telehealth system needs to be in place for such an assessment to take place during home call. The above commentaries on kidnapping or illegal detainment are...interesting, but definitely not something I have ever seen, even with extremely lazy attendings. The OP should learn and follow the state law because they genuinely want to respect human rights, not because of some external consequence.

Large amounts of inpatient psychiatry are driven by external consequence. It's not a stretch to say that a large percentage of people admitted for "SI" on an inpatient unit are there because of perceived liability reasons if they're discharged. From an epidemiological perspective, we could probably skip the assessment, flip a coin to d/c or not people from the psych ED and see no difference in rates of suicide in the patient population presenting to the ED.

The people who don't acknowledge this aren't being truthful about our actual ability to predict short term suicide risk. So yes, it's all driven by liability concerns.

I also don't know what you mean by "The above commentaries on kidnapping or illegal detainment are...interesting, but definitely not something I have ever seen, even with extremely lazy attendings." Are you doubting these laws exist or are enforced or something?

 

[comp1]

I am indeed a little doubtful that psychiatrists are being charged with kidnapping or illegal detainment with any frequency. I'd be interested in reading of any published examples. My whole point was that that should not be the motivation in this case.

 

[Stagg737]

One of our hospitals legally requires us to discharge voluntary patients overnight if they demand to leave and cannot be held if they don't meet criteria for involuntary. I've only been on overnight call when a patient had to be discharged once around 11pm, but that was after I went in and evaluated them and ensured they had a safety plan. Situation where a guy was transferring from a medical hospital and told our unit was a rehab unit (it is not). We had accepted him because of statements of SI, which turned out to be vague passive statements made while high before he was detoxed at the medical hospital. He demanded to leave as soon as he got there, no reason to hold him and turned out safety planning was easy since he basically lived across the street from the unit with his sibling.

I've gotten that request 2 or 3 other times, but the patients clearly met criteria for an involuntary hold, so I just told the staff they could not leave and to file and involuntary if they demanded to. The above was pretty straightforward and an easy discharge, even so I went in and would not discharge anyone demanding to leave without going in for a face-to-face eval. That being said, most patients are reasonable enough that they'll wait until the morning to talk to the primary team, and when patients can't be convinced it's usually due to the condition that gives us reason to hold them.

 

[Stagg737]

I am indeed a little doubtful that psychiatrists are being charged with kidnapping or illegal detainment with any frequency. I'd be interested in reading of any published examples. My whole point was that that should not be the motivation in this case.

The above commentaries on kidnapping or illegal detainment are...interesting, but definitely not something I have ever seen, even with extremely lazy attendings.

This actually happened to me during my intern year while I was on medicine at a smaller hospital we rotated through. We weren't held liable, but it was a pretty big deal at that hospital and with several of our academic center's programs that rotated there.

Patient was on an unlocked medical floor being seen by medicine with psych consulted for meth-induced "psychosis" and HI (he was not psychotic, just high, but the HI was real). Was told by the psych attending one Friday that they were filing the paperwork to hold a guy d/t substance induced HI and the IM attending was also part of the petition. I worked that weekend with the same IM attending and he asked several times if he could leave and was told no. Monday rolls around with a new attending and during rounds I say he's there involuntarily, at which time SW spoke up and informed us there was no paperwork on file. Turns out the attending(s) from Friday never faxed the paperwork and we had technically held him against his will all weekend despite having full capacity. New IM attending got in touch with another psychiatrist who actually new what they were doing, and I ended up having a 3-way phone call with the psychiatrist and the county DA who told us to file the paperwork ASAP as he was planning on pressing other charges related to a local warrant or something. This psych attending knew the laws, we informed the patient he was not on a hold at the time, and that he could leave if he wanted. Patient was annoyed, but actually pretty pleasant about it and just glad to leave. His gf picked him up a couple hours later, and 30ish minutes after that the DA called us saying the forms were done and to hold him. DA was pretty pissed to find out he had been discharged despite our psychiatrist telling him we couldn't hold him.

So after that cluster of a day, there was no immediate fallout because we had not physically kept the patient from leaving at any point. But we were informed by the hospital's legal team that if we had physically touched him in a way to restrain him from leaving at all we could have faced charges for basically kidnapping. Not surprisingly this ended up being a pretty big deal for the hospital and there were several meetings and RCAs about it. I found out the first two attendings actually tried to throw me and another resident who was on over the weekend under the bus and that the second IM attending completely went off at a meeting defending us. The other resident's PD also got involved and basically threatened to pull all their residents from the hospital because of it. In the end, we (residents) didn't get blamed, the DA ended up not pressing charges because the patient lived in another state and crossed state lines, and the first IM attending involved no longer works at that hospital.

Definitely one of the most stressful days of residency for me, but probably learned more in those 14 hours about the legal/forensic side than a lot of people do their intern year, lol.

 

[FlowRate]

I'll just note that the apparent plain language of state statues and hold forms is not always how things play out in terms of implementation and hospital policy. Where I trained the letter of the forms made little sense (in at least some places) when compared to the way things played out "IRL."

This is another reminder, along with a patient I was very close to hospitalizing last week, that I really need to learn how things actually play out in this new state. (We have a crisis team that helps us out/manages a lot of this, so there hasn't been a super pressing need.)

 

[whopper]

I'd be interested in reading of any published examples. My whole point was that that should not be the motivation in this case.

In a Forensic Psych program part of the curriculum is going over cases where people were detained inappropriately against their will.

Seriously, if you know your hospital isn't letting people out in a timely manner that is in compliance with the local laws, you can have someone admitted, want to get out AMA and if told to stay till the next day against their will, that person can adamantly refused, and if not allowed to leave that person can sue everyone involved. Holding people illegally is a big deal and a constitutional violation. It's a legal equivalent of someone c/o chest pain. Courts have to take it seriously.

If I were a lawyer I'd scope all of the local hospitals and have people willing to work with me to "test the waters." Anyone not being allowed to leave in compliance with the law then I'd sue them. As bad as that sounds the law doesn't see it that way. Legal experts will argue that this is the mechanism to make institutions compliant with laws meant to uphold the most basic Constitutional freedoms.

In NJ the state has on several occasions paid actors to play this role. IF the person is being held illegally they're told to contact specific people in the state that will get the person out and then the institution is in MAJOR TROUBLE.

Giving a quick example in NJ it's illegal for people with firearms to go into an involuntary psych unit. A case happened right before residency where police officers had to go into the unit because the security was inadequate and nurses didn't feel safe injecting the patient who was smashing a chair against the window. The police brought in an attack dog "Chompers" who ran up to the patient about to attack him. To the police dog's credit once the patient saw this he curled into a ball, the police immediately ordered Chompers to come back, the dog complied (followed every command very well) and sat there in a friendly manner. From there the nurses injected the patient.

Wow, and after this happened the hospital was ripped apart for the event. Inadequate security leading to the police having to be called, police officers entered the unit while armed with guns, an attack dog had to be used......This occurred before I started residency in that same hospital and it led to the hospital having very good security as a result of that event.

 

[Mass Effect]

In a Forensic Psych program part of the curriculum is going over cases where people were detained inappropriately against their will.

Seriously, if you know your hospital isn't letting people out in a timely manner that is in compliance with the local laws, you can have someone admitted, want to get out AMA and if told to stay till the next day against their will, that person can adamantly refused, and if not allowed to leave that person can sue everyone involved. Holding people illegally is a big deal and a constitutional violation. It's a legal equivalent of someone c/o chest pain. Courts have to take it seriously.

If I were a lawyer I'd scope all of the local hospitals and have people willing to work with me to "test the waters." Anyone not being allowed to leave in compliance with the law then I'd sue them. As bad as that sounds the law doesn't see it that way. Legal experts will argue that this is the mechanism to make institutions compliant with laws meant to uphold the most basic Constitutional freedoms.

In NJ the state has on several occasions paid actors to play this role. IF the person is being held illegally they're told to contact specific people in the state that will get the person out and then the institution is in MAJOR TROUBLE.

Giving a quick example in NJ it's illegal for people with firearms to go into an involuntary psych unit. A case happened right before residency where police officers had to go into the unit because the security was inadequate and nurses didn't feel safe injecting the patient who was smashing a chair against the window. The police brought in an attack dog "Chompers" who ran up to the patient about to attack him. To the police dog's credit once the patient saw this he curled into a ball, the police immediately ordered Chompers to come back, the dog complied (followed every command very well) and sat there in a friendly manner. From there the nurses injected the patient.

Wow, and after this happened the hospital was ripped apart for the event. Inadequate security leading to the police having to be called, police officers entered the unit while armed with guns, an attack dog had to be used......This occurred before I started residency in that same hospital and it led to the hospital having very good security as a result of that event.

Well there is a case to be made for not letting patients on a psych unit leave at 3 am. But overall, I agree. I saw all of these happen right next door in New York (cops with K-9, cops with guns, people held after they wanted to go).

 

[UTsksk]

I guess now I feel kind of fortunate that in my state if someone is on a voluntary legal status and they want to leave AMA then they will sign an objection to formal voluntary that still allows 72 hours for the team to assess.

 

[whopper]

Piece of advice. Always interact with others as if you're on camera. Same goes with this issue. Follow the laws. Do your job the way you're supposed to do it. Getting called up in the middle of the night because of someone who wants out AMA is the exact type of thing to make you want to hold that guy against their will when it may be illegal. Don't fall into that emotional trap.

Watch the youtube channel "Audit the Audit." Some of the people being caught red-handed breaking the law are caught on camera including police officers by self-declared first-amendment auditors with a camera. You could be on it yourself.

If you don't know what to do, now that you know this is one of those traps you can fall into ask your attendings up to the department chair. If they don't know what to do ask the hospital lawyer and tell your department what that lawyer said, and/or look up the laws yourself.

If you move to a different state look up all the laws in the new state cause they may differ. E.g. I'm in Missouri. In this state there's a 96 hour hold, not a 72 hour hold.

 

[himitsuda]

I'm curious what the voluntary admission forms look like at your institution/in your state. Where I'm a resident, when a patient signs the paperwork for voluntary admission, there's a section (that they need to separately sign acknowledgment of) that states if they wish to leave AMA, they must file a request to withdraw treatment and allow the team up to 72 hours in order to set up appropriate follow-up and ensure a safe dispo. This means that when a patient requests to leave in the middle of the night, we direct them to sign the paperwork and then tell them the day team will set up discharge (if appropriate) within 72 hours.

 

[Merovinge]

I'm curious what the voluntary admission forms look like at your institution/in your state. Where I'm a resident, when a patient signs the paperwork for voluntary admission, there's a section (that they need to separately sign acknowledgment of) that states if they wish to leave AMA, they must file a request to withdraw treatment and allow the team up to 72 hours in order to set up appropriate follow-up and ensure a safe dispo. This means that when a patient requests to leave in the middle of the night, we direct them to sign the paperwork and then tell them the day team will set up discharge (if appropriate) within 72 hours.

I hear you. I've been in two states and both have as part of voluntary a time period required for discharge such that AMA at 0300h does not exist. I'm be dumbfounded to practice somewhere that this is a thing and part of cross-cover.

 

[Mad Jack]

Just want to repeat this is all state dependent. Where I trained, we had to let them go after calling attending and legal.

Where I am now if they signed in voluntarily and are on the unit, I cannot let them leave AMA overnight. This is state law. Once they're on a locked psych unit, discharges cannot be done by the on-call person. The team in the morning has to discharge them if there's no imminent threat.

In some states, they have to give the team 24H or 48H to discharge if they want to leave AMA. This is to allow the team time to not only do a safe discharge but also to fully evaluate the patient.

So definitely state dependent. And as a resident, always call your attending for these high liability cases.

Yeah, every state I've practiced in it is between one and three days notice for a psych unit discharge. For medical floors things can be more complicated but in that case you can always leave it to the discretion of the primary team and re-evaluate of they want a second opinion on the morning.