“I Don’t Care What You Say. I’m Out of Here Doc…”

You take a big breath and walk out of the SRU.  After having just spent the last hour and a half caring for a hypotensive, actively vomiting variceal bleeder, a patient in full arrest that you had to pronounce, and a patient with a GSW to the chest that went quickly to the OR, you are dreading to see the state of your Pod.  As you are just about to sneak into your workstation to get your bearings, you’re flagged down by Mr. Finch, the patient in bed 2.

The brief history you took from him prior to going into the SRU flashes through your mind: 

End stage renal disease from glomerulonephritis at the age of 25…M/W/F dialysis last dialyzed 5 days ago… previous failed renal transplant

“Why did he miss dialysis?” you think, before quickly remembering he wasn’t able to arrange transportation.

“What was his chief complaint again?” Ah, yes, elevated potassium on labs drawn at his PCPs office yesterday.

<you> “What can I help you with sir?”

<Mr. Finch> “What do you mean, what can you help me with?  Man just get my paperwork and let me get out of here.  I’ve had it with this place.  I’m tired of being a pin cushion and I’m not going to take this crap anymore.”

By the looks of the many bandaids stuck to the patient’s arms, the past 90 minutes of Mr. Finch’s ED stay has been taken up by several nurses and phlebotomists trying to get a blood sample to confirm the abnormal labs from his primary care provider. You check quickly with the nurse and find that all attempts to obtain blood have failed to this point.

You prepare yourself to return to Mr. Finch’s bedside and a couple of questions run through your mind.

What are you going to say to de-escalate the increasingly upset Mr. Finch?

Are you going to “let him sign out against medical advice”?

What if you can’t convince him to let you try to get the blood sample, are there other reasonable options for the patient’s care?

We'd love to hear your thoughts and comments on these questions!  Comment below and join in on the conversation!


Who leaves Against Medical Advice (AMA)?

Patients that leave AMA are more often male, young, underinsured, more commonly lack social support systems and primary care providers, are more likely to have a large number of medical comorbidities including psychiatric illness, as well as higher rates of homelessness and substance abuse. (3)

Why do patient’s sign out AMA?

  • Pressing personal needs
  • Financial obligations
  • Mental health problems
  • Disagreements with staff
  • Need to have self-control over their medical care

AMA Myths

These patients are well and there’s nothing wrong with them.

  • Not quite. Patient’s that leave AMA are 7x more likely to be readmitted in 15 days.  They have higher resource utilization when readmitted and have increased morbidity and mortality. (3)

I can’t get sued if a patient leaves AMA

  • Patient’s that sign out AMA may be more likely to initiate lawsuits (1)
  • EM physicians can be given significant leeway with regards to determination of capacity if the patient wishes to sign out AMA.  If there is question as to the patient’s capacity to sign out AMA, it may be better to act in the patient’s interest as opposed to let the patient leave (depending on the severity of illness and the risk of a poor outcome). (2)

Your Responsibilities to the Patient Leaving AMA (1)

  1. Determination of decision making capacity
  2. Balancing protection of patient autonomy with prevention of harm
  3. Providing alternative acceptable care
  4. Negotiating to encourage patient’s to stay
  5. Planning for subsequent care
  6. Documenting what transpired

Determination of Capacity

  1. Ability to communicate with the provider
  2. Understanding of treatment options (including refusal of treatment)
  3. Understanding of the consequences of leaving
  4. Ability to reason and explain why they are making their choice

“CURVES” Mneumonic for Assessment of Capacity (2)

Adapted from Herbet, M, et al Decision Making Capacity. EM:RAP Emergency Medicine: Reviews and Perspectives. 14 (11)

Adapted from Herbet, M, et al Decision Making Capacity. EM:RAP Emergency Medicine: Reviews and Perspectives. 14 (11)

The “AIMED” Approach (1)

Adapted from Clark, M., Abbott, J., & Adyanthaya, T. (2014) Ethics Seminars: A Best-Practice Approach to Navigating the Against-Medical-Advice Discharge. Academic Emergency Medicine. 21, 1050-1057

Adapted from Clark, M., Abbott, J., & Adyanthaya, T. (2014) Ethics Seminars: A Best-Practice Approach to Navigating the Against-Medical-Advice Discharge. Academic Emergency Medicine. 21, 1050-1057

Preventing AMA Discharges (3)

  • Addressing Substance Abuse - maintain an empathetic attitude, avoid being accusatory and adversarial in your discussion about substance abuse.
  • Recognizing Psychological Factors - some patients may use the threat of an AMA discharge to express feelings of anxiety, anger, or depression.  Physicians and nurses need to acknowledge these feelings when they arise and they need to be aware of their own feelings of anger when they arise during these patient interactions.
  • Motivational Interviewing - using empathetic questioning to identify the underlying motivations behind a patients behavior.  Once the underlying motivations have been discovered, negotiations can focus on those issues as opposed to strictly medical concerns. It “broadens the terms of engagement”
…when physicians recognize that the vision of a completely adherent patient is idealized, it is easier to accept other options for the patient’s care. Accepting a patient’s preferences for care, even when such preferences deviate from the physician’s own judgments, can still be acceptable, if not ideal.” - David Alfandre (4)

References

  1. Clark, M., Abbott, J., & Adyanthaya, T. (2014) Ethics Seminars: A Best-Practice Approach to Navigating the Against-Medical-Advice Discharge. Academic Emergency Medicine. 21, 1050-1057
  2. Herbert, M., Henry, G., Arambasick, J., Orman, R., & Orman, R. (2014) Decision Making Capacity. EM:RAP Emergency Medicine: Reviews and Perspectives. 14 (11).
  3. Alfandre, D. (2009) “I’m Going Home”: Discharges Against Medical Advice. Mayo Clinic Proceedings. 84 (3), 255-260.
  4. Alfandre, D. (2013) What is Wrong with Discharges Against Medical Advice (and How to Fix Them). JAMA. 310 (22) 2393-2394.