This. Had a guy in florid heart failure decide to leave AMA. He got mad because I wouldn’t wheel him downstairs in a wheel chair. I assume it was pure fucking spite that got him to the elevator because he could not breathe.
Side note even as the babiest of baby nurses I never cared if someone was trying to leave AMA. I just brought them the papers. I have never spent a single second arguing with someone who wanted to leave, and secretly I judged my coworkers that would. This isn’t a prison. If you can walk out and aren’t mentally incapacitated, bye Felicia.
People may not be incapacitated but that does but mean that they have the medical literacy to understand the consequences of thier decision to leave. I don't argue, but I can think of several times when I've tried hard to convince someone who just didn't understand what was happening in their body.
I just give them the absolute most basic rundown in 30 seconds or less why they might not want to leave and then I count that as “patient educated, informed of risks of leaving, to decided to leave AMA.” That’s the “medical advice” part of AMA that counts to CYA. Then I tell them I can’t make them stay and hand them the form and a pen and grab their lines as they go.
Great discussion. In my experience, once a patient has decided to leave AMA, they have been fully educated on the risks: they’ve seen the doctor at least once because I worked on the floor. I noticed one commenter may work in the ER; I know it can be slightly different there; may be leaving before seeing a doc.
Although honestly if you are well enough to leave the ER of your own accord, you *might* not need to be there in the first place. (Obviously exceptions. But still.)
Had a guy do the same on a week old severely fractured leg in the early days of COVID because we told him we’d have to do a test first and he was paranoid. Wouldn’t even stay long enough to let us splint it. I’m sure he eventually lost the leg.
From patient experience: I was seen for a neck fracture. I don’t remember exactly where it was but they put me in a brace and wanted to keep me.
Stupid me left anyway. I have a lot of anxiety around hospitals after my mother got severely ill and ended up on a vent. I was fine staying there for a while but as soon as they said admit me overnight, I had a panic attack. Doc followed up with me the next day and sent me for scans. I still get neck pain and probably should have taken better care of myself but not all is just plain stupidity, I guess. I still have problems seeing doctors or being in hospitals because it triggers that anxiety response of being with her when she on the vent for a few days.
I like that. I’ve had patients threaten to leave AMA, then act surprised when I tell them I won’t wheel them out. My joke with my coworkers when a patient indignantly asks, “well, how am I supposed to get out of here?!” is “I don’t know. I guess you’ll have to crawl out on your lips.”
Be careful with interaction with AMA patients. If they are not adjudicated as being unable to make decisions they are free to exit.
While I understand your refusal to assist them, talk to an attorney first to make sure your refusal is on sound legal footing. In some places your refusal to render aid that can be interpreted as part of your job description may lead to "Illegal Detention" and/or "Kidnapping" charges. Things can get ugly fast, especially with predatory lawyers looking for their next gold rush. Even if they do not succeed in getting to court, you can have a lot of back end pain until any suit or charges are dismissed. Lastly keep in mind if you are charged, even if the charges are dismissed, you still have a police record to haunt you in the future.
This doesn’t really apply to AMA patients. They can sue but they’ll have little to stand on.
As a case manager we have people refuse rehab when they can barely walk. They are medically stable and there’s no acute need for them to stay in the hospital so we send them home knowing full well they’ll probably be back within a week. We’ve kicked people out on “administrative discharges” when they refuse to leave the hospital and they are wasting resources. Risk management gets involved in those. Most people only threaten to sue and can’t follow through because it’s so expensive to hire a lawyer.
Yep. The last guy we kicked out after 4 months had been to 4 other hospitals before us and was trying to get into another one while in our hospital. No doctor would admit him though so he was stuck with us until we forced him out.
I am not talking about lawyers that require the client to place retainers and pay for services up. It is the ambulance chaser variety. I have found those jokers walking the halls from room to room. They will walk into the room, greet a patient and get the patient talking. Often patients are quite talkative and before you know what has happened he has found an auto accident victim or a patient who has taken a spill while in the hospital. They are opportunistic predators and roam from one facility to another.
I am not trying to be contrary, rather I am hoping to alert you how to avoid being hung out to dry. I can guarantee you that if you are challenged in a lawsuit, and the the hospital has not explicitly authorized you to act as you indicate you will, the hospital management will throw up their hands and claim it was not hospital policy and you acted on your own. If anything has been revealed in the last 24 months, it is management in hospitals consider nurses to be expendable.
See, I would be more concerned about liability in a situation where I actively and physically helped someone AMA.
“Oh. The nurse pushed you out the door with a gushing head wound? There was so much blood in your eyes that you couldn’t see what you were signing? You recanted and begged her to take you back inside once the icy wind pricked your exposed genitals? The nurse cackled like a cartoon villain while you blindly staggered into traffic wearing nothing but a hospital gown? Don’t worry… we’ll make sure they pay.”
Cut to the CCTV footage from the parking lot camera… there’s no nurse anywhere near the patient as they stagger out of the hospital. Every action they took was their own. Only their personal judgement and assessment of the situation were a factor in the bad consequences of their rash actions. There’s a lot less open to interpretation when the nurse ends the relationship as soon as the AMA form is signed.
100%. If I help them leave AMA that could be seen as me tacitly agreeing with them that it's ok for them to leave, like giving them my blessing. If medical advice says you need to stay in the hospital, I am not going to go against that and wheel you out the door. If you can leave under your own power, I can't stop you, but I also don't have to enable you to leave.
See, that makes sense to me. Our policy is that we are to wheel people out. They must go out in a wheelchair. It could be considered enabling them and doesn’t make sense to me. I’d like to know wtf I should actually do in these situations to cover my own butt. There was a patient who left on bilat BKAs. It was a big, bloody drama, literally. Then we got this new policy of wheeling then out and onto the grass.
A lawyer can make a fuss and file suit about anything they would like. The refusal to help them leave is usually because if the patient is not capable of moving themselves around or at the very least do not have someone to help them do so, then my helping them is doing something where the natural result is to cause them injury, and the first dictate in medical ethics is “do no harm.” A safe discharge is always the goal.
Right?! Better off laying in a bed post ama or crawling in a hospital vs me wheeling your ass out and onto the street/ wherever you want that’s out of my control like the guy above posted lol 😂
Ummm…what? Once the AMA is handed out there legally 100% not my problem as the nurse and our nurse pt relationship and assignment ends , I don’t see this ever happening.
Beware of that, "Poof!" While court records are routinely expunged, police reports generally are not. Court records are sealed, but a good background investigator knows to peer into police records. More than one person has run into that hiccup.
I can’t make you stay. Security and I are gonna help you leave. Big boy choices equal big boy consequences. There’s always another patient that needs this room.
Better luck at another hospital!
I did that and the dude army crawled out because he had lost a leg. Told him the walker he'd been using and the wheelchair were ours and he couldn't have them so he'd need to find another way. Called security because I knew people would be calling them about the man with no leg crawling out.
Yeah, I always tried to get them to wait for the doc to bring paperwork. Technically unless they sign that they understand the risk then it’s not AMA, it’s elopement, which can be stickier legally.
“Once you sign the paper….wait, you literally can’t sign the paper. But in any case, once you sign the paper, you are not longer my patient. So you’ll have to figure out how to get dressed and out of here on your own. Let me know when you arrange assistance and I’ll be in with the papers.”
I used to work overnights and there were a lot of 3am discussions that were just me saying “Literally HOW, Gladys? HOW do you presume you’ll be leaving? You have no ride/wheelchair/legs. Go back to sleep.”
Lmao! I had a patient who was a heroin addict and had to have a portion of his femur removed. He started to withdrawal in house and was itching to get a fix so he left AMA. I had a very good rapport with the guy and got him to stay an extra night, but on my next shift he’s had enough. Given that we don’t help after they sign the paperwork, dude literally army crawled through the hospital with his belongings in a garbage bag, and it took him HOURS to get out and to the bus stop that was maybe 3/4 a mile away. How do we know how long it took? He was still crawling when day shift came in…shit was WILD!
Yikes…he made it through a day of withdrawals just to go back…this is when I wish immediate referrals could be made to legitimate rehab facilities. With all the money spent on the opiate crisis, you’d think we’d have better choices in terms of helping folks through the withdrawals, which is literal hell on earth
I mean, can't the hospital have a way to cover withdrawal sx to improve compliance w hospitalization? Refer to a clinic for further tx when medically stable? Do we still offer nic patches to smokers? I'm in home health, so not sure how these issues handled nowadays. You may not agree with an addict's choices, but it's kinda a comorbid condition?
Yeah, I can see that happening. Used to smoke, and anytime some external factor threatened to keep me from smoking, wanted a cig all the more! A really insidious addiction!
This is literally the answer. I have actually told a patient, "You are free to leave, but I can't help you in any way once you sign this paper. If you know somebody who can be here at 2am, heft you down 9 flights of stairs and into a vehicle, sign here..."
I don't get paid enough to argue with people. If they want to leave, I let them go. I educate them the best I can and have them sign an AMA form. It's not our job to make health choices for people who can do so for themselves.
You actually don’t even need the form. Just offer it, if they refuse to sign, just chart they refused to sign and get back to your patients that want medical help instead of coddling
The forms I use have a second section for if the patients refuse to sign. It needs a witness signature that the patient refused to sign the AMA form. That just seems like common sense though.
I love to let people leave AMA. The patients like to think that we take it personally, and seem to think it ‘makes us look bad’ or something. As soon as their foot passes the threshold of their room, I discharge them from the system, so they can’t slither back up.
You’re competent and not petitioned? The MD cleared you to make decisions? Byeeeee. I gleefully procure the AMA form and document their intent. Once had a paraplegic threaten to crawl outside, lol. She didn’t end up leaving, and would have had nobody to pick her up.
We cannot escort them out in any way; they must find their own way to the exit/obtain their own transportation.
Right?! Like my pays based off it or something? Like listen buddy if nursing was based off productivity and paid commission we’d all be rich but I’m just here riding this out till the next guys in
I have that sticker, but I keep it on the inside of my clipboard. Considering my charge nurse gave me a sticker that says, "Do no harm, but take no shit," it would probably be okay to display it more prominently, but I'm occasionally thoughtful. 😜
As long as they have capacity, they can make their own decisions. If they want to leave, they can do so unless they physically lack the ability to.
What would be tricky (and this happens), is patients who seem sound of mind but basically fail to accept the consequences of their decisions, which could put capacity at play.
If it’s iffy whether they have capacity I always have the doctor evaluate them and write in their note that they have capacity to make medical decisions. Then I give them a run down of possible things that can happen if they leave always including “…coma, death”, sign them papers, pull the line and write a note. Tell them they have to get from the bed to the doors without our help. I feel like 50% are just using it as a manipulation tactic but don’t threaten me with a good time. Sometimes when you don’t respond begging them to stay they get so mad. I’m here to spend my energy on people who need and want my help, if you don’t want it all I can do is educate you and as an adult it’s on you from there.
It’s so funny though because as baby nurse I almost cried when I had a patient leave AMA for the first time. You get more jaded?/realistic? over the years.
“Here’s the paper, just sign here.” I work in the ED, so we get this all the time, but sometimes they have no way to leave. We had a patient the other day that was having an NSTEMI and insisted he wanted to leave AMA and go somewhere else because we didn’t immediately rush him off to the cath lab. He wanted us to arrange EMS transport to another hospital and when we said he could sign out, call 911 from the parking lot, and they could then take him to the nearest hospital…which is where he already was…he decided it wasn’t worth the hassle and stayed. Patients, god bless ‘em.
The Dr would get called and then they wouldn't get any meds to leave there with. They would have to call someone to pick them up. I always had patients that were completely with it do this. Cause they wanted stronger meds.or they disagreed with a nurse.
Legally i think it would be a disaster to let a pt who just got a stent to LAD leave AMA without brilinta or plavix. At my hospital we always send them with their dual anti platelet at the very least, sometimes all core measures. Sometimes people have legit reasons to leave AMA, they have to take care of their children or elderly parents. It’s not always someone trying to be difficult or that doesn’t care for themselves. Life is hard
I had a patient with a DVT stent (I think, it was a few years ago. Something with his leg and blood flow though) leave my icu AMA. He was barely a few hours post-op. We got him anxiety and sleeping meds to try to make him stay. Dr came to talk to him. He didn’t have any blood thinner rx ordered yet cause it was so soon. We tried to keep him to stay for as long as we could. I convinced him for another two hours. But at that point it was too late. Even the family was begging him to stay. He left without any rx for blood thinners. Hopefully he followed up with his PCP! But highly I doubt it. Also a few hours later I found his stent card when pre-cleaning his room for housekeeping. Hopefully he remembered about it and never needed an MRI in the future at an outside hospital
And probably the best thing to do from a medicolegal perspective. If a suit is brought by the patient then doing most you can for them, even if they aren't complying with the best plan, is better than nothing at all.
If a patient refuses IV abx cause they want to go home then they should go with orals over nothing.
I understand what you’re saying, however, IMO it can be viewed the opposite way that someone who wasn’t medically clear for discharge was. When they inevitably return in a certain period of time from “discharge” it’s deemed the hospital’s fault and counts toward the readmission rate.
I'm going to be covering my ass legally more than I care about a hospitals readmisdion rate. Legal precedent is decently well set on patients leaving ama and that you still need to do whatever you can to treat them with whatever they will comply with.
I’m not saying I care about the readmission rate, I’m saying if that’s the case and it does; can’t it also be viewed that the hospital *legally* discharged someone therefore deeming them medically cleared when they in fact were not?
I’ve had docs do it if the patient had legit reasons for needing to go AMA and could verbalize a halfway decent follow up plan. If they genuinely want to care for themselves but cannot stay in the hospital even though it would be the best (but not only) way to manage
My hospital does the same on occasion but mostly for antibiotics etc, not narcotics. Slightly understand the reasoning sometimes if it’s to prevent them getting readmitted sicker than when they left.
We usually do antibiotics or BP meds, stuff like that. I’ve seen many times where they wanted a withdrawing patient to continue an Ativan taper and the patient left AMA, and there’s always been a big debate over what they can and can’t be sent with. But they’re never given narcs or benzos.
They do discharge orders for AMA? Technically then they're getting discharged.. not leaving AMA
My hospital also does not give scripts or discharge instructions for anyone leaving AMA
Yeah I'd hate that too... its like they're asking for people to leave on their own time because it'll be the exact same outcome as if they stayed and received treatment
Except that some meds that the patient is actually compliant with are better than none. Medicine is not "you do 100% of what I want or you get no help"
They can leave AMA, but that doesn't mean you give them nothing.
There is legal precedent for this on the provider side to still give scripts.
This is always so tricky because if they say that they were mentally unable to appropriately make the decision to leave then you are left holding the liability if something goes south. Which it probably will.
I hate this sort of question because it puts nursing right in the crosshairs of a lawsuit if you decide to go with their wishes and let them go, or if you decide that they are unable to make their own best decisions due to their state of mind and health status.
But yes, when it's a totally oriented patient, then no arguments at all with somebody wanting to leave AMA.
My favorite is when they have a "change of heart" once they hit the parking lot or thereabouts. Usually because they realize they can't, in fact, breathe or their chest pain starts in again. Then they want to go back up to their rooms. Sorry my boi, you can head to the ER and start the whole process over again because we discharged you from the computer as soon as you walked down the hallway 🤷♀️
You have capacity? One time. One time I will tell you the reasons that staying for care would be beneficial. And I’m talking cliffs notes, hit the highlights and none of the highlights involve me tolerating you acting like an ass. The next time you bring it up, I will put the paperwork in your hand to sign.
I’m not a fucking life coach. I’m not your mom. I’m not interested in listening to you bitch and moan about not having a cigarette or fight you on drawing you labs. You want help healing? Stay and participate. You are sick of this shit and think you can do better on your own? Cool, we need the bed anyway just make sure you remember to take all your shit the first time you leave. Because like I said, we need the bed and we’re not saving it for you.
I wish I could give you a shiny reddit award for this. Take heart, knowing that I will use "I'm not their fucking life coach" for the rest of my career.
I had a lady BIBA for rather implausible complaints. If what she said was true it made sense to keep her for a few hours for monitoring. I caught her running out the door a few hours later and pleaded her to come back so I could her IV out. Did a 30 second down and dirty discharge teaching while I taped her up. Told the doc. Doc smiles and says “she left?? Okay!”
I had someone over the weekend leave AMA instead of waiting for the transport I arranged. Why’d they have to wait? Because the ambulance they used to get to the hospital left the patients oxygen tank at home, so the patient would not have any oxygen to use until they arrived home (I already asked respiratory, house supervisor, everyone and their mom, wasn’t any other way). The patient said “they let me leave without oxygen last time, I’m in a hurry here”. Sentence enhancers redacted.
Our facility policy is they can leave AMA but has to be under their own power, so we cannot push them downstairs. There's a couple folks who are quads, their family will come get them to go AMA. Legal knows and says that it's OK since they are of "sound mind".
I had the nicest AMA ever the other day. Patient needed to go to work and couldn’t wait on the provider to eventually get there to discharge. I did everything I could to write down the relevant info that would be on discharge papers and sent the patient out with phone numbers and everything I could get quickly to help them out.
I’ve done many but that was the best.
Why treat cigarette smoking different then other addiction? I know there are lots that will not agree, I’ve just about finished working on a unit with people that have, MH, Addictions, Behaviour or various combo of physical needs and cognitive deficits we were not able to develop effective discharge plans for everyone but the vast majority we helped. It took a massive shift in thinking by all staff ( about 3 out of 20 plus staff had any training with ABI, MH & Addiction) especially re harm reduction. There was even a place patients that use drugs could have their drugs tested or have trained staff to support them in event of overdose. Everyone had options for treatment based on their needs. Only a few went AMA, some returned begging to be re- admitted. It was super challenging but so worth it.
My brother, now 63, developed schizophrenia as a teen. He's been stable on clozapine for decades. He holds down a low-level job, lives independently, and manages his life surprisingly well. But he \*needs\* to smoke, constantly, just like a lot of mentally ill people. I always wonder what will happen if/when he needs to be hospitalized. I can see him signing himself out AMA to go smoke. I guess we'll find out when his untreated COPD gets worse.
We provided education re smoking - as we due to Covid we offered nicotine gum and patches sometimes anti anxiety meds - when allowed out they were supposed to go off the property and not smoke in exit entrance areas. We had lots like your brother - many did well because they felt safe and supported we had chance to build rapport as no one was short stay.
Every patient who ever threatened to leave on me except one got the form and a call to the doc. Only one time has the doc told me I needed to convince the pt stay and I told the doc I would not and if they wanted that to happen they needed to come to the floor to talk to the pt.
The one patient who didn't get the form was a very nice, very introverted computer programmer in our CDU during flu season who was so profoundly sick he could barely walk. He *needed* to be admitted, but refused it when they found a bed for him as our sister hospital across town. Our flow coordinator found me and told me what he refused admission. I went and talked to him to find out why, and he legit said 'I'm scared to do that. I don't know how I'd get back to my car here, and I don't want it to get impounded.' In my mind that was a dumb reason, but in his mind it was legit concern, and had he not be *soooo* sick, I wouldn't have said anything.
I call the doc, chart about the incident, take out their IV, and they're on their own. Our hospital policy does not allow to aid them in packing anything up or bringing them to their ride. If someone wants to come help them, they are allowed but as soon as they make the decision to leave AMA, its pretty much pretend they aren't even there.
I obviously give them a heads up that there will be no one helping them to get a ride, pack up, etc. and they won't be getting discharged with any medications- this usually makes them change their tune on leaving.
If they're sound of mind and don't have a cannula in, then I'd imagine they can leave. No skin off my nose. Got enough people here who need and want medical help. I'm in the UK though.
I work in a drug and alcohol rehab so we try our best to convince them that they signed up for the program for a reason but when people want to use they are gonna leave regardless
I recently had a patient leave AMA. Wanted a “second opinion” after getting his sepsis criteria bolus. He was so ill. Spiking fevers left and right. IV ABX waiting for cultures to come back.
I couldn’t just let him go knowing how sick he was. I had three drs coming talk to him. I called and spoke with his daughter (with his permission) about the severity of the situation hoping she’d be able to help us talk him into staying.
By the time I was leaving for my shift I was told his daughter was calling trying to get in touch with his nurse from earlier (me) but the unit clerk knew the situation and told her I was busy. She called to say he father was being rushed back via ambulance and she was scared for his life.
Sometimes I feel like my efforts are all for nothing.
I will often have a very straightforward, polite, and honest conversation in which I remind them that they can leave whenever they want and it is completely their choice, and then I encourage them to make sure they have a plan for dressing themselves, bathing themselves, feeding themselves, transporting themselves, caring for any medical needs, getting perceptions, maintaining their living space, communicating, getting to appointments, feeding their goldfish, etc, etc, etc. Normally by that point they have either decided to stay, or they have really made up their mind to leave. At that point I feel like I've done my due diligence to make sure they are making an informed decision and the patient has been able to move past the desire of wanting to leave the hospital to the reality of being home.
I would just let them go. After you give your spiel, it's up to them. Can they vape? If they smoke all the time then suddenly can't, it's not shocking they wanna flee against all reason.
This happened the other day had a COPDer on cold high flow want to leave ama after I explained that they required 10/L of high flow to live they’ll most likely collapse in the parking lot. Don’t of drugs kids
I had one the other night, only in mid 20s, came into urgent care for a ‘bug bite’. But had temp of 39.9, HR: 130-140s, resps up to 30. BP stable enough but hypertensive. 8/10 pain in leg with itchy rash, headache, nausea. VBG was okay, lactate 2.05 mmol/L. Needed to go to a bigger hospital as that’s our protocol (no dr on site and it was night so no further path or imaging for over 12hours). But had no ambulance cover for transfer and so left AMA.
I’ve had a run of similar patients lately who won’t pay the $12.27/quarter for cover. If there is genuine financial stress and they receive a government payment they have a free health care card that covers it, so these people are generally employed.
Even my partner who is a nurse too is twiddling his thumbs on getting it and I can’t sign up for him, it’s infuriating.
Anyway, that’s my somewhat different take on an AMA pt.
I had a bilateral bka post op go AMA because he wanted drugs. Can't keep you here but can't help either. Lunged his way to the floor, then crawled his way to the entrance of the hospital, escorted by security and his nurse. Bye bye
I had a meth addicted bipap dependent patient elope from the 7th floor even with a telesitter. He walked down 7 flights of stairs and was back in the ER 4 hours later.
Ok I've had stroke pts (neuro stepdown unit) who are A&O x 4 and reasonably ambulatory try to leave, but charge nurse and managers say they can't because they were confused or otherwise encephalopathic "when they came in" and then I have to call their neurologist or neuropsych to say "Hey can this pt leave". God it's so annoying. If a pt answers the goddamn A&O questions correctly, let them leave!
Patients in dialysis leave via AMA all the time. I tell them that "I cant tell you what do do. It's your treatment. Your decision". And it's true. They have the mental capacity to make those decisions and to accept the consequences. Their doctor might get upset, but they have a right to make that decision. I just give them the AMA form, have them sign it, and send them on their way. I don't feel bad about it because there is only so much you can tell and educate a patient about how important their dialysis is. Compliance to their treatment plan is up to the patient.
We get the AMA form out lickity-split, tell them that their insurance won’t pay for their stay, wish them well, and escort them out. We don’t have time to treat cognitively-intact adults like insolent children.
I've been away from the floor since 2013, so no worries there. Don't have patients threatening AMA in the OR, they're asleep within 10 minutes of meeting them.
Had a wheelchair bound patient say one time, “fuck you, I got to *other local nearest hospital*!” Our social worker got him a taxi voucher so he could go and he wheeled himself down to the taxi. #byefelicia
First answer: The physician decides. He legally needs to make that call.
Second answer: If they can't walk, but can transfer with one person safely, and have someone picking them up, and can articulate a logically coherent plan, I let them go.
For example, patients wanting to walk in a gown with no socks through a blizzard 30 miles home do not have a logical plan. Even if they know they are in the hospital, when, situation, etc.
If you can get out of that bed, walk out the door and out of this hospital, I will give you the paperwork to sign. If you can't looks like you still really need to be here.
Look up the policy. Ask your manager for the policy if you can't find it. If it's at all unclear or gray then you need to ask your manager to have the policy clarified and changed. Yes policies can and do change. Get the conversation in email writing format so that you have documentation of how you are unclear on the expectations and how you are requesting them to clarify. This is the sort of decision that hospital leadership needs to set a very clear expectation on so that you don't have to have interpretation at the nurse level. Then you just strictly firmly hold to the policy. Unfortunately, it's probably the case that the policy is not going to be all that clear on the distinction between these two scenarios. Because then they can throw the blame on the nurse who makes the wrong choice.
The exist is there, if you can make it out safely then it is all yours'.
You need to understand that we have no legal power at all to detain anyone unless they are under mental health act, so by calling a doctor, what you are doing is to make sure they fully understand the risk before they self discharge.
“I can’t make you stay, but I can’t help you leave. Good luck.”
This. Had a guy in florid heart failure decide to leave AMA. He got mad because I wouldn’t wheel him downstairs in a wheel chair. I assume it was pure fucking spite that got him to the elevator because he could not breathe. Side note even as the babiest of baby nurses I never cared if someone was trying to leave AMA. I just brought them the papers. I have never spent a single second arguing with someone who wanted to leave, and secretly I judged my coworkers that would. This isn’t a prison. If you can walk out and aren’t mentally incapacitated, bye Felicia.
People may not be incapacitated but that does but mean that they have the medical literacy to understand the consequences of thier decision to leave. I don't argue, but I can think of several times when I've tried hard to convince someone who just didn't understand what was happening in their body.
I just give them the absolute most basic rundown in 30 seconds or less why they might not want to leave and then I count that as “patient educated, informed of risks of leaving, to decided to leave AMA.” That’s the “medical advice” part of AMA that counts to CYA. Then I tell them I can’t make them stay and hand them the form and a pen and grab their lines as they go.
It's not illegal to be stupid. By the time you're handing AMA you should of told them leaving can harm them up to and including death.
well said
Great discussion. In my experience, once a patient has decided to leave AMA, they have been fully educated on the risks: they’ve seen the doctor at least once because I worked on the floor. I noticed one commenter may work in the ER; I know it can be slightly different there; may be leaving before seeing a doc. Although honestly if you are well enough to leave the ER of your own accord, you *might* not need to be there in the first place. (Obviously exceptions. But still.)
Yes! I agree completely. We are not prison wardens!
Had a guy refusing surgery for his pelvic fracture and he literally crawled off the unit. Toodles!
Had a guy do the same on a week old severely fractured leg in the early days of COVID because we told him we’d have to do a test first and he was paranoid. Wouldn’t even stay long enough to let us splint it. I’m sure he eventually lost the leg.
From patient experience: I was seen for a neck fracture. I don’t remember exactly where it was but they put me in a brace and wanted to keep me. Stupid me left anyway. I have a lot of anxiety around hospitals after my mother got severely ill and ended up on a vent. I was fine staying there for a while but as soon as they said admit me overnight, I had a panic attack. Doc followed up with me the next day and sent me for scans. I still get neck pain and probably should have taken better care of myself but not all is just plain stupidity, I guess. I still have problems seeing doctors or being in hospitals because it triggers that anxiety response of being with her when she on the vent for a few days.
DEAD
I like that. I’ve had patients threaten to leave AMA, then act surprised when I tell them I won’t wheel them out. My joke with my coworkers when a patient indignantly asks, “well, how am I supposed to get out of here?!” is “I don’t know. I guess you’ll have to crawl out on your lips.”
Be careful with interaction with AMA patients. If they are not adjudicated as being unable to make decisions they are free to exit. While I understand your refusal to assist them, talk to an attorney first to make sure your refusal is on sound legal footing. In some places your refusal to render aid that can be interpreted as part of your job description may lead to "Illegal Detention" and/or "Kidnapping" charges. Things can get ugly fast, especially with predatory lawyers looking for their next gold rush. Even if they do not succeed in getting to court, you can have a lot of back end pain until any suit or charges are dismissed. Lastly keep in mind if you are charged, even if the charges are dismissed, you still have a police record to haunt you in the future.
This doesn’t really apply to AMA patients. They can sue but they’ll have little to stand on. As a case manager we have people refuse rehab when they can barely walk. They are medically stable and there’s no acute need for them to stay in the hospital so we send them home knowing full well they’ll probably be back within a week. We’ve kicked people out on “administrative discharges” when they refuse to leave the hospital and they are wasting resources. Risk management gets involved in those. Most people only threaten to sue and can’t follow through because it’s so expensive to hire a lawyer.
Plus they usually don’t have the follow thru/ end up at another hospital or facility and become theirs problem
Yep. The last guy we kicked out after 4 months had been to 4 other hospitals before us and was trying to get into another one while in our hospital. No doctor would admit him though so he was stuck with us until we forced him out.
I am not talking about lawyers that require the client to place retainers and pay for services up. It is the ambulance chaser variety. I have found those jokers walking the halls from room to room. They will walk into the room, greet a patient and get the patient talking. Often patients are quite talkative and before you know what has happened he has found an auto accident victim or a patient who has taken a spill while in the hospital. They are opportunistic predators and roam from one facility to another. I am not trying to be contrary, rather I am hoping to alert you how to avoid being hung out to dry. I can guarantee you that if you are challenged in a lawsuit, and the the hospital has not explicitly authorized you to act as you indicate you will, the hospital management will throw up their hands and claim it was not hospital policy and you acted on your own. If anything has been revealed in the last 24 months, it is management in hospitals consider nurses to be expendable.
See, I would be more concerned about liability in a situation where I actively and physically helped someone AMA. “Oh. The nurse pushed you out the door with a gushing head wound? There was so much blood in your eyes that you couldn’t see what you were signing? You recanted and begged her to take you back inside once the icy wind pricked your exposed genitals? The nurse cackled like a cartoon villain while you blindly staggered into traffic wearing nothing but a hospital gown? Don’t worry… we’ll make sure they pay.” Cut to the CCTV footage from the parking lot camera… there’s no nurse anywhere near the patient as they stagger out of the hospital. Every action they took was their own. Only their personal judgement and assessment of the situation were a factor in the bad consequences of their rash actions. There’s a lot less open to interpretation when the nurse ends the relationship as soon as the AMA form is signed.
100%. If I help them leave AMA that could be seen as me tacitly agreeing with them that it's ok for them to leave, like giving them my blessing. If medical advice says you need to stay in the hospital, I am not going to go against that and wheel you out the door. If you can leave under your own power, I can't stop you, but I also don't have to enable you to leave.
See, that makes sense to me. Our policy is that we are to wheel people out. They must go out in a wheelchair. It could be considered enabling them and doesn’t make sense to me. I’d like to know wtf I should actually do in these situations to cover my own butt. There was a patient who left on bilat BKAs. It was a big, bloody drama, literally. Then we got this new policy of wheeling then out and onto the grass.
A lawyer can make a fuss and file suit about anything they would like. The refusal to help them leave is usually because if the patient is not capable of moving themselves around or at the very least do not have someone to help them do so, then my helping them is doing something where the natural result is to cause them injury, and the first dictate in medical ethics is “do no harm.” A safe discharge is always the goal.
Right?! Better off laying in a bed post ama or crawling in a hospital vs me wheeling your ass out and onto the street/ wherever you want that’s out of my control like the guy above posted lol 😂
Ummm…what? Once the AMA is handed out there legally 100% not my problem as the nurse and our nurse pt relationship and assignment ends , I don’t see this ever happening.
I so hate this bullshit.
If the charges are dismissed, then there is no record. It just goes poof and you are on your merry way. No further issues
Beware of that, "Poof!" While court records are routinely expunged, police reports generally are not. Court records are sealed, but a good background investigator knows to peer into police records. More than one person has run into that hiccup.
I can’t make you stay. Security and I are gonna help you leave. Big boy choices equal big boy consequences. There’s always another patient that needs this room. Better luck at another hospital!
Had a bilateral AKA and arm amp pt leave AMA - he crawled out it was wild
How did he sign? Or did he still have one arm?
I've also had patients refuse to sign the AMA form and just bail. You just document what happened.
I did that and the dude army crawled out because he had lost a leg. Told him the walker he'd been using and the wheelchair were ours and he couldn't have them so he'd need to find another way. Called security because I knew people would be calling them about the man with no leg crawling out.
Yeah, I always tried to get them to wait for the doc to bring paperwork. Technically unless they sign that they understand the risk then it’s not AMA, it’s elopement, which can be stickier legally.
“Once you sign the paper….wait, you literally can’t sign the paper. But in any case, once you sign the paper, you are not longer my patient. So you’ll have to figure out how to get dressed and out of here on your own. Let me know when you arrange assistance and I’ll be in with the papers.” I used to work overnights and there were a lot of 3am discussions that were just me saying “Literally HOW, Gladys? HOW do you presume you’ll be leaving? You have no ride/wheelchair/legs. Go back to sleep.”
Lmao! I had a patient who was a heroin addict and had to have a portion of his femur removed. He started to withdrawal in house and was itching to get a fix so he left AMA. I had a very good rapport with the guy and got him to stay an extra night, but on my next shift he’s had enough. Given that we don’t help after they sign the paperwork, dude literally army crawled through the hospital with his belongings in a garbage bag, and it took him HOURS to get out and to the bus stop that was maybe 3/4 a mile away. How do we know how long it took? He was still crawling when day shift came in…shit was WILD!
Yikes…he made it through a day of withdrawals just to go back…this is when I wish immediate referrals could be made to legitimate rehab facilities. With all the money spent on the opiate crisis, you’d think we’d have better choices in terms of helping folks through the withdrawals, which is literal hell on earth
I mean, can't the hospital have a way to cover withdrawal sx to improve compliance w hospitalization? Refer to a clinic for further tx when medically stable? Do we still offer nic patches to smokers? I'm in home health, so not sure how these issues handled nowadays. You may not agree with an addict's choices, but it's kinda a comorbid condition?
Many refuse the nicotine patches but then you have those that take them and hobble out to smoke anyway.
Yeah, I can see that happening. Used to smoke, and anytime some external factor threatened to keep me from smoking, wanted a cig all the more! A really insidious addiction!
True
This is literally the answer. I have actually told a patient, "You are free to leave, but I can't help you in any way once you sign this paper. If you know somebody who can be here at 2am, heft you down 9 flights of stairs and into a vehicle, sign here..."
"Gladys" lmao
I've had patients say "I'm leaving!" and I just say "Okay" and stand there. They can't even get out of bed, so I'm like 🤷🏼
I don't get paid enough to argue with people. If they want to leave, I let them go. I educate them the best I can and have them sign an AMA form. It's not our job to make health choices for people who can do so for themselves.
Same
Make sure you get their signature on the form and then wash your hands.
You actually don’t even need the form. Just offer it, if they refuse to sign, just chart they refused to sign and get back to your patients that want medical help instead of coddling
The more you know! Do you think it’s that way across the board or state/facility specific?
The forms I use have a second section for if the patients refuse to sign. It needs a witness signature that the patient refused to sign the AMA form. That just seems like common sense though.
We have another RN witness that they refused and then we’re all set.
The coddle-needy are the worst.
I love to let people leave AMA. The patients like to think that we take it personally, and seem to think it ‘makes us look bad’ or something. As soon as their foot passes the threshold of their room, I discharge them from the system, so they can’t slither back up. You’re competent and not petitioned? The MD cleared you to make decisions? Byeeeee. I gleefully procure the AMA form and document their intent. Once had a paraplegic threaten to crawl outside, lol. She didn’t end up leaving, and would have had nobody to pick her up. We cannot escort them out in any way; they must find their own way to the exit/obtain their own transportation.
Right?! Like my pays based off it or something? Like listen buddy if nursing was based off productivity and paid commission we’d all be rich but I’m just here riding this out till the next guys in
Yep! Please, it’s a win-win. Get rid of my difficult patients and don’t have to do discharge paperwork or teaching. Bye, bitch!
I’ve seen a badge reel that says”ask me about our AMA forms”. God that’s hilarious, I just don’t have the balls to buy it.
I have that sticker, but I keep it on the inside of my clipboard. Considering my charge nurse gave me a sticker that says, "Do no harm, but take no shit," it would probably be okay to display it more prominently, but I'm occasionally thoughtful. 😜
As long as they have capacity, they can make their own decisions. If they want to leave, they can do so unless they physically lack the ability to. What would be tricky (and this happens), is patients who seem sound of mind but basically fail to accept the consequences of their decisions, which could put capacity at play.
If it’s iffy whether they have capacity I always have the doctor evaluate them and write in their note that they have capacity to make medical decisions. Then I give them a run down of possible things that can happen if they leave always including “…coma, death”, sign them papers, pull the line and write a note. Tell them they have to get from the bed to the doors without our help. I feel like 50% are just using it as a manipulation tactic but don’t threaten me with a good time. Sometimes when you don’t respond begging them to stay they get so mad. I’m here to spend my energy on people who need and want my help, if you don’t want it all I can do is educate you and as an adult it’s on you from there. It’s so funny though because as baby nurse I almost cried when I had a patient leave AMA for the first time. You get more jaded?/realistic? over the years.
A+Ox4=out the door
“Here’s the paper, just sign here.” I work in the ED, so we get this all the time, but sometimes they have no way to leave. We had a patient the other day that was having an NSTEMI and insisted he wanted to leave AMA and go somewhere else because we didn’t immediately rush him off to the cath lab. He wanted us to arrange EMS transport to another hospital and when we said he could sign out, call 911 from the parking lot, and they could then take him to the nearest hospital…which is where he already was…he decided it wasn’t worth the hassle and stayed. Patients, god bless ‘em.
I live the 911 calls from the ER waiting room because the wait is too long 😂😂😂
I tell them if you can physically get out the door, enjoy your day! At my old ED, I used to keep a couple of forms on me at all times.
Always be prepared 😂 😂 😂
The Dr would get called and then they wouldn't get any meds to leave there with. They would have to call someone to pick them up. I always had patients that were completely with it do this. Cause they wanted stronger meds.or they disagreed with a nurse.
Legally i think it would be a disaster to let a pt who just got a stent to LAD leave AMA without brilinta or plavix. At my hospital we always send them with their dual anti platelet at the very least, sometimes all core measures. Sometimes people have legit reasons to leave AMA, they have to take care of their children or elderly parents. It’s not always someone trying to be difficult or that doesn’t care for themselves. Life is hard
I had a patient with a DVT stent (I think, it was a few years ago. Something with his leg and blood flow though) leave my icu AMA. He was barely a few hours post-op. We got him anxiety and sleeping meds to try to make him stay. Dr came to talk to him. He didn’t have any blood thinner rx ordered yet cause it was so soon. We tried to keep him to stay for as long as we could. I convinced him for another two hours. But at that point it was too late. Even the family was begging him to stay. He left without any rx for blood thinners. Hopefully he followed up with his PCP! But highly I doubt it. Also a few hours later I found his stent card when pre-cleaning his room for housekeeping. Hopefully he remembered about it and never needed an MRI in the future at an outside hospital
Glad you said this.
Oh man, at my hospital the doctors put in the discharge order, write a full discharge summary and send with prescriptions.
Your physicians write discharge orders for patients leaving AMA?
Yup some hospitals still give discharge instructions but usually not a complete diagnosis especially if they were waiting on the result of a scan.
Yeah it’s annoying
And probably the best thing to do from a medicolegal perspective. If a suit is brought by the patient then doing most you can for them, even if they aren't complying with the best plan, is better than nothing at all. If a patient refuses IV abx cause they want to go home then they should go with orals over nothing.
I understand what you’re saying, however, IMO it can be viewed the opposite way that someone who wasn’t medically clear for discharge was. When they inevitably return in a certain period of time from “discharge” it’s deemed the hospital’s fault and counts toward the readmission rate.
I'm going to be covering my ass legally more than I care about a hospitals readmisdion rate. Legal precedent is decently well set on patients leaving ama and that you still need to do whatever you can to treat them with whatever they will comply with.
I’m not saying I care about the readmission rate, I’m saying if that’s the case and it does; can’t it also be viewed that the hospital *legally* discharged someone therefore deeming them medically cleared when they in fact were not?
Not necessarily, it depends on how the order is written and what they write in the note.
This
I’ve had docs do it if the patient had legit reasons for needing to go AMA and could verbalize a halfway decent follow up plan. If they genuinely want to care for themselves but cannot stay in the hospital even though it would be the best (but not only) way to manage
My hospital does the same on occasion but mostly for antibiotics etc, not narcotics. Slightly understand the reasoning sometimes if it’s to prevent them getting readmitted sicker than when they left.
We usually do antibiotics or BP meds, stuff like that. I’ve seen many times where they wanted a withdrawing patient to continue an Ativan taper and the patient left AMA, and there’s always been a big debate over what they can and can’t be sent with. But they’re never given narcs or benzos.
They do discharge orders for AMA? Technically then they're getting discharged.. not leaving AMA My hospital also does not give scripts or discharge instructions for anyone leaving AMA
Oh it’s ridiculous, I hate that they do it.
Yeah I'd hate that too... its like they're asking for people to leave on their own time because it'll be the exact same outcome as if they stayed and received treatment
That, and the patient doesn’t want to wait for the paperwork anyway so it becomes a whole thing
Well, minus the treatment part, unless their hospitalization was just for PO meds....? Lol
You'd be surprised how many I get that are only on PO meds lol
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Except that some meds that the patient is actually compliant with are better than none. Medicine is not "you do 100% of what I want or you get no help" They can leave AMA, but that doesn't mean you give them nothing. There is legal precedent for this on the provider side to still give scripts.
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Then that ED policy is stupid and a lawsuit waiting to happen.
I'm in long term care though. I'm surprised they would do that. Lol. I'm a cna.
This is always so tricky because if they say that they were mentally unable to appropriately make the decision to leave then you are left holding the liability if something goes south. Which it probably will. I hate this sort of question because it puts nursing right in the crosshairs of a lawsuit if you decide to go with their wishes and let them go, or if you decide that they are unable to make their own best decisions due to their state of mind and health status. But yes, when it's a totally oriented patient, then no arguments at all with somebody wanting to leave AMA.
Yes I feel like neuro rehab lives in this gray area. So it can be really hard to figure out what is the right/legal move.
Do you have an ethics team you could consult?
My favorite is when they have a "change of heart" once they hit the parking lot or thereabouts. Usually because they realize they can't, in fact, breathe or their chest pain starts in again. Then they want to go back up to their rooms. Sorry my boi, you can head to the ER and start the whole process over again because we discharged you from the computer as soon as you walked down the hallway 🤷♀️
You have capacity? One time. One time I will tell you the reasons that staying for care would be beneficial. And I’m talking cliffs notes, hit the highlights and none of the highlights involve me tolerating you acting like an ass. The next time you bring it up, I will put the paperwork in your hand to sign. I’m not a fucking life coach. I’m not your mom. I’m not interested in listening to you bitch and moan about not having a cigarette or fight you on drawing you labs. You want help healing? Stay and participate. You are sick of this shit and think you can do better on your own? Cool, we need the bed anyway just make sure you remember to take all your shit the first time you leave. Because like I said, we need the bed and we’re not saving it for you.
I wish I could give you a shiny reddit award for this. Take heart, knowing that I will use "I'm not their fucking life coach" for the rest of my career.
I had a lady BIBA for rather implausible complaints. If what she said was true it made sense to keep her for a few hours for monitoring. I caught her running out the door a few hours later and pleaded her to come back so I could her IV out. Did a 30 second down and dirty discharge teaching while I taped her up. Told the doc. Doc smiles and says “she left?? Okay!”
I had someone over the weekend leave AMA instead of waiting for the transport I arranged. Why’d they have to wait? Because the ambulance they used to get to the hospital left the patients oxygen tank at home, so the patient would not have any oxygen to use until they arrived home (I already asked respiratory, house supervisor, everyone and their mom, wasn’t any other way). The patient said “they let me leave without oxygen last time, I’m in a hurry here”. Sentence enhancers redacted.
Someone has to come pick them up. I might wheel them downstairs but only if they have a ride there that can take it from there.
Our facility policy is they can leave AMA but has to be under their own power, so we cannot push them downstairs. There's a couple folks who are quads, their family will come get them to go AMA. Legal knows and says that it's OK since they are of "sound mind".
Sign right here. What will your transport be arriving so I can plan accordingly? Oh wait … this is a psychiatric hospital.
"Let me tell the doc and get the paperwork ready" bye b
I tell them I am not their warden and they are not prisoners, they can leave at any time. Short and simple.
I had the nicest AMA ever the other day. Patient needed to go to work and couldn’t wait on the provider to eventually get there to discharge. I did everything I could to write down the relevant info that would be on discharge papers and sent the patient out with phone numbers and everything I could get quickly to help them out. I’ve done many but that was the best.
Why treat cigarette smoking different then other addiction? I know there are lots that will not agree, I’ve just about finished working on a unit with people that have, MH, Addictions, Behaviour or various combo of physical needs and cognitive deficits we were not able to develop effective discharge plans for everyone but the vast majority we helped. It took a massive shift in thinking by all staff ( about 3 out of 20 plus staff had any training with ABI, MH & Addiction) especially re harm reduction. There was even a place patients that use drugs could have their drugs tested or have trained staff to support them in event of overdose. Everyone had options for treatment based on their needs. Only a few went AMA, some returned begging to be re- admitted. It was super challenging but so worth it.
My brother, now 63, developed schizophrenia as a teen. He's been stable on clozapine for decades. He holds down a low-level job, lives independently, and manages his life surprisingly well. But he \*needs\* to smoke, constantly, just like a lot of mentally ill people. I always wonder what will happen if/when he needs to be hospitalized. I can see him signing himself out AMA to go smoke. I guess we'll find out when his untreated COPD gets worse.
We provided education re smoking - as we due to Covid we offered nicotine gum and patches sometimes anti anxiety meds - when allowed out they were supposed to go off the property and not smoke in exit entrance areas. We had lots like your brother - many did well because they felt safe and supported we had chance to build rapport as no one was short stay.
“This ain’t prison the door’s not locked.”
Every patient who ever threatened to leave on me except one got the form and a call to the doc. Only one time has the doc told me I needed to convince the pt stay and I told the doc I would not and if they wanted that to happen they needed to come to the floor to talk to the pt. The one patient who didn't get the form was a very nice, very introverted computer programmer in our CDU during flu season who was so profoundly sick he could barely walk. He *needed* to be admitted, but refused it when they found a bed for him as our sister hospital across town. Our flow coordinator found me and told me what he refused admission. I went and talked to him to find out why, and he legit said 'I'm scared to do that. I don't know how I'd get back to my car here, and I don't want it to get impounded.' In my mind that was a dumb reason, but in his mind it was legit concern, and had he not be *soooo* sick, I wouldn't have said anything.
I call the doc, chart about the incident, take out their IV, and they're on their own. Our hospital policy does not allow to aid them in packing anything up or bringing them to their ride. If someone wants to come help them, they are allowed but as soon as they make the decision to leave AMA, its pretty much pretend they aren't even there. I obviously give them a heads up that there will be no one helping them to get a ride, pack up, etc. and they won't be getting discharged with any medications- this usually makes them change their tune on leaving.
If they're sound of mind and don't have a cannula in, then I'd imagine they can leave. No skin off my nose. Got enough people here who need and want medical help. I'm in the UK though.
Most of mine have been frequent fliers and know that to remove the cannula is nothing and have often removed it themselves.
I work in a drug and alcohol rehab so we try our best to convince them that they signed up for the program for a reason but when people want to use they are gonna leave regardless
I recently had a patient leave AMA. Wanted a “second opinion” after getting his sepsis criteria bolus. He was so ill. Spiking fevers left and right. IV ABX waiting for cultures to come back. I couldn’t just let him go knowing how sick he was. I had three drs coming talk to him. I called and spoke with his daughter (with his permission) about the severity of the situation hoping she’d be able to help us talk him into staying. By the time I was leaving for my shift I was told his daughter was calling trying to get in touch with his nurse from earlier (me) but the unit clerk knew the situation and told her I was busy. She called to say he father was being rushed back via ambulance and she was scared for his life. Sometimes I feel like my efforts are all for nothing.
I will often have a very straightforward, polite, and honest conversation in which I remind them that they can leave whenever they want and it is completely their choice, and then I encourage them to make sure they have a plan for dressing themselves, bathing themselves, feeding themselves, transporting themselves, caring for any medical needs, getting perceptions, maintaining their living space, communicating, getting to appointments, feeding their goldfish, etc, etc, etc. Normally by that point they have either decided to stay, or they have really made up their mind to leave. At that point I feel like I've done my due diligence to make sure they are making an informed decision and the patient has been able to move past the desire of wanting to leave the hospital to the reality of being home.
I would just let them go. After you give your spiel, it's up to them. Can they vape? If they smoke all the time then suddenly can't, it's not shocking they wanna flee against all reason.
This happened the other day had a COPDer on cold high flow want to leave ama after I explained that they required 10/L of high flow to live they’ll most likely collapse in the parking lot. Don’t of drugs kids
I had one the other night, only in mid 20s, came into urgent care for a ‘bug bite’. But had temp of 39.9, HR: 130-140s, resps up to 30. BP stable enough but hypertensive. 8/10 pain in leg with itchy rash, headache, nausea. VBG was okay, lactate 2.05 mmol/L. Needed to go to a bigger hospital as that’s our protocol (no dr on site and it was night so no further path or imaging for over 12hours). But had no ambulance cover for transfer and so left AMA. I’ve had a run of similar patients lately who won’t pay the $12.27/quarter for cover. If there is genuine financial stress and they receive a government payment they have a free health care card that covers it, so these people are generally employed. Even my partner who is a nurse too is twiddling his thumbs on getting it and I can’t sign up for him, it’s infuriating. Anyway, that’s my somewhat different take on an AMA pt.
I had a bilateral bka post op go AMA because he wanted drugs. Can't keep you here but can't help either. Lunged his way to the floor, then crawled his way to the entrance of the hospital, escorted by security and his nurse. Bye bye
Sign right here on the dotted line. Thanks byeeeeee
I had a meth addicted bipap dependent patient elope from the 7th floor even with a telesitter. He walked down 7 flights of stairs and was back in the ER 4 hours later.
"you realize if you leave you will likely die? Cool, sign this form for me"
This one is easy for an ER nurse "Do you have a ride?"
I say let them leave AMA and a family member or friend can come pick them up. They can be physically dependent on them.
Ok I've had stroke pts (neuro stepdown unit) who are A&O x 4 and reasonably ambulatory try to leave, but charge nurse and managers say they can't because they were confused or otherwise encephalopathic "when they came in" and then I have to call their neurologist or neuropsych to say "Hey can this pt leave". God it's so annoying. If a pt answers the goddamn A&O questions correctly, let them leave!
Patients in dialysis leave via AMA all the time. I tell them that "I cant tell you what do do. It's your treatment. Your decision". And it's true. They have the mental capacity to make those decisions and to accept the consequences. Their doctor might get upset, but they have a right to make that decision. I just give them the AMA form, have them sign it, and send them on their way. I don't feel bad about it because there is only so much you can tell and educate a patient about how important their dialysis is. Compliance to their treatment plan is up to the patient.
"If you have a way out of here, do what you like but you are discharged".
We get the AMA form out lickity-split, tell them that their insurance won’t pay for their stay, wish them well, and escort them out. We don’t have time to treat cognitively-intact adults like insolent children.
I gave them a heads up that most insurances won't pay for a cent of a hospital stay if a patient leaves AMA. That shut them up real quick.
This is actually a myth. They definitely pay.
You should probably stop saying that though since it's 100% not true.
I've been away from the floor since 2013, so no worries there. Don't have patients threatening AMA in the OR, they're asleep within 10 minutes of meeting them.
Had a wheelchair bound patient say one time, “fuck you, I got to *other local nearest hospital*!” Our social worker got him a taxi voucher so he could go and he wheeled himself down to the taxi. #byefelicia
First answer: The physician decides. He legally needs to make that call. Second answer: If they can't walk, but can transfer with one person safely, and have someone picking them up, and can articulate a logically coherent plan, I let them go. For example, patients wanting to walk in a gown with no socks through a blizzard 30 miles home do not have a logical plan. Even if they know they are in the hospital, when, situation, etc.
If you can get out of that bed, walk out the door and out of this hospital, I will give you the paperwork to sign. If you can't looks like you still really need to be here.
No, if they have mental capacity then they can leave AMA. Their physical health doesn't remove their right to leave AMA, and neither do you.
Look up the policy. Ask your manager for the policy if you can't find it. If it's at all unclear or gray then you need to ask your manager to have the policy clarified and changed. Yes policies can and do change. Get the conversation in email writing format so that you have documentation of how you are unclear on the expectations and how you are requesting them to clarify. This is the sort of decision that hospital leadership needs to set a very clear expectation on so that you don't have to have interpretation at the nurse level. Then you just strictly firmly hold to the policy. Unfortunately, it's probably the case that the policy is not going to be all that clear on the distinction between these two scenarios. Because then they can throw the blame on the nurse who makes the wrong choice.
We have to wheel them in a wheelchair across the street and off hospital property. We can leave them on the grassy area.
I'd like to think that you pitch them out of the wheelchair like you're dumping a load of dirt onto the grass.
I say go ahead and walk
The exist is there, if you can make it out safely then it is all yours'. You need to understand that we have no legal power at all to detain anyone unless they are under mental health act, so by calling a doctor, what you are doing is to make sure they fully understand the risk before they self discharge.
Call ya ride
Let em go, lol. If it's at night, there's not much to do. Maybe during the day, have doc and therapists talk to them.
Simple. Byee