The proper way to go Against Medical Advice (AMA): 8 Elements to Address

The proper way to go Against Medical Advice (AMA): 8 Elements to Address

2016-11-11T19:18:09+00:00

ExitSignCase Example: 42 y/o male presents with right lower quadrant abdominal pain and has significant tenderness at McBurney’s point on exam. While waiting for a CT scan to evaluate for possible appendicitis the patient rips out his IV and tells the nurse “I’m leaving, I don’t want to sit here all night, and you can’t make me stay.” The nurse pulls you out of another room and hands you the standard against medical advice (AMA) paperwork.

Leaving AMA

In 1992, about 0.1% of patients seen in the Emergency Department (ED) left AMA. In the years since, this number has increased significantly with recent studies showing that up to 2% of ED patients leave AMA. These patients pose a particular challenge for ED providers from both a diagnostic and risk management standpoint.

Risks to the Patient

From a medical standpoint, patients who leave AMA tend to have an increased risk of having an adverse outcome. Baptist et al. found that asthma patients who left AMA had an increased risk of both relapse and subsequent ICU admissions [1]. Similarly patients with chest pain who left AMA had a higher risk of myocardial infarction than other patients with similar characteristics who stayed in the ED to complete their workup [2].

Risks to the Provider

Patients who leave against medical advice are up to 10x more likely to sue the emergency physician when compared to other ED patients. Some estimate that 1 in 300 AMA cases results in a lawsuit compared to 1 in 30,000 standard ED visits [3].

While posing a particular challenge to providers, there are several basic steps that can be taken when dealing with a patient leaving AMA that can help improve patient outcomes while providing significant medicolegal protection to the providers.

How to do it properly

“The patient looks sober. I told them if they leave that they could die.”

While seen on charts in ED’s across the country, documentation like this offers essentially no legal protection and should not be used. When patients insist on leaving AMA there are eight commonly held standards that should be discussed and documented with all patients.

Basically the provider needs to establish that the patient is able to make reasonable decisions and in this particular instance was given all the information that would be necessary to make an informed decision.

Eight Parts of the AMA Process

1. Capacity

This term refers to the patient’s medical ability to make a decision. Documenting that the patient “understood” offers little protection, while documenting a patient’s ability to carry on a conversation and demonstrate reason provides a much more compelling example of their capacity to make decisions. Additionally patients should be noted to be clinically sober as a way to support their capacity. Example: “The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason and in my opinion has the capacity to make decisions.”

2. Signs and Symptoms

The patient and provider need to agree on both the patient’s symptoms and also the providers concerns. Example: “The patient presents with abdominal pain. I have explained that I am concerned that this may represent appendicitis; they have verbalized an understanding of my concerns.”

3. Extent and Limitation of the Exam

Document what has been done as well as the limitations that still exist. Example: “I have told the patient that while their labs were normal, they could still have appendicitis.”

4. Current Treatment Plan

Example: “I have discussed the need for a CT scan to get more information about potential causes of the patient’s pain.”

5. Risks of Foregoing Treatment

Simply documenting “you could die if you leave” is inadequate. Patient should be informed of reasonably foreseeable complications including disability and death. Specific threats such as loss of fertility for testicular/ovarian pathology or loss of vision for ocular complaints should be included when appropriate. Example: “I have told the patient that if they leave and have appendicitis, they could get much worse, could become critically ill, and could possibly become disabled or die.”

6. Alternatives to Suggested Treatment

Providers should clearly document the efforts they have made to prevent the patient from leaving AMA. In addition to alternative diagnostics and treatments, discussions with family and friends can be included. Example: “I have offered to give the patient more pain medication. I have asked them to stay in the hospital for serial abdominal exams. I have offered to have an ultrasound performed instead of a CT scan. I have discussed these concerns with the patient’s wife who is at the bedside and she is unable to convince them to stay for further evaluation.”

7. Explicit Statement of AMA and About What the Patient Refused

Example: “The patient is not willing to undergo a CT scan. He is unwilling to stay overnight for monitoring. He is refusing any further care and is leaving against medical advice.”

8. Questions, Follow-up, Medicines, Instructions

When patients leave AMA, providers should do whatever is possible to limit bad medical outcomes. A commonly held misconception is that providing a patient with prescriptions or paperwork somehow negates their AMA status and places the provider at risk. In reality, refusing to provide any discharge medication or instructions only increases the chance that the patient will have a bad outcome, which significantly increases the provider’s risk. For instance, if a patient with pneumonia is leaving AMA, they should be given appropriate antibiotics, and the provider should offer to set up outpatient follow-up. All questions should be answered. Example: “I am unable to convince the patient to stay, I have asked them to return as soon as possible to complete their evaluation. I have spoken with coverage for their primary care doctor in regards to their abdominal pain. I have answered all their questions.”

Bottom Line

Patients are going to continue to leave AMA. Providers should recognize these situations as high risk to both the patient and provider. When patients insist on leaving careful discussion with the patient and specific documentation can hopefully improve outcomes.

 

References

  1. Baptist AP, Warrier I, Arora R, et al. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J. Allergy Clin. Immunol. 2007;119 (4): 924-9. PMID 17239431
  2. Lee TH, Short LW, Brand DA, et al. Patients with acute chest pain who leave emergency departments against medical advice: prevalence, clinical characteristics, and natural history. J Gen Intern Med. 3 (1): 21-4. PMID 3339484
  3. Bitterman RA. Against medical advice: When should you take “no” for an answer? Lecture presented at ACEP Scientific Assembly. Chicago, Oct. 30, 2008.
  4. Monico EP, Schwartz I. Leaving against medical advice: facing the issue in the emergency department. J Healthc Risk Manag. 2009;29 (2): 6-9, 13, 15. PMID 19908647
  5. Miller S. Obtaining a valid AMA (Against Medical Advice). JEMS. 1996;21 (2): 54-5. PMID 10154651

This post belong’s to Dr. Matthew DeLaney’s series on Everyday Risk in Emergency Medicine (EREM).                  

Matthew DeLaney, MD

Matthew DeLaney, MD

Assistant Professor of Emergency Medicine
Assistant Medical Director
University of Alabama at Birmingham
  • Agree wholeheartedly, but especially with number 8. I frequently have to remind the nurses and residents that if the patient refuses to stay, he or she isn’t refusing treatment per se, and you should give them the best chance for their trial of outpatient therapy.

    In the end, the ED isn’t jail, and we can’t force people to stay. If you need to keep someone in the ED for capacity issues (psychiatric or substance), then that’s a job for security or the police, not for the doctors and nurses.

    • Michelle

      Great point. There was a Q from @ClinicalEMed on Twitter about whether you give pain meds to these patients.

  • Michelle

    Excellent post, Matthew. I also end my AMA’s with a final statement along the lines of “No hard feelings on our end. We just want what’s best for you. Feel free to come back if you are feeling worse.”

    Sometimes our attempts to thoroughly address all the key elements that you summarize can make a feel patient feel like you never want to see them again – no matter what.

    • Matthew

      Great line Michelle. Ultimately these patients are very high risk from a risk management standpoint, if they are leaving the worst thing we do is make it a contentious situation. Patients who feel insulted or leave the ED angry are much less likely to tolerate a bad outcome, and are much more likely to consider taking legal action.
      I tell folks “This form doesn’t mean that we don’t care, it doesn’t mean that you can’t sue me, it just proves to the hospital that you and I talked about your options and that you chose to leave.”

  • Thomas Dalton

    Great post.

    I would echo that even despite the patient not agreeing with, or wanting to stay for a recommended work-up that you do what you can to treat the patient appropriately. Let them know that you understand that they need to leave, given them prescriptions for antibiotics or other necessary medications and encourage them that they can come back without any repercussions if the want to be seen for their complaints again.

    Sometimes being understandable of each particular patient’s situation can lead to them staying or getting a little more data or an intervention (another trop, EKG, a dose of IV antibiotics, etc) than can lessen them having a bad outcome. It builds rapport, shows that you care, and hopefully can lead to better compliance and treatment..

    I also wanted to share a dotphrase (for those EPIC users out there) that I use when I sign-out patient’s AMA. It might be useful to the community. I’ve compiled it from different resources such as this one over the years. Feel free to use it as you see fit but I need to add the disclaimer that this is not legal advice and I am not a lawyer. It is an example and everyone should do, and document, what they think is medically and legally appropriate and that this sample if used in no way will prevent you from getting sued, or if so, will prevent a lawsuit from being successful. As you know that it more dependent on other factors such as patient rapport, communication, proper medical care, etc.

    ——–

    The patient requested to leave. I considered this to be leaving against medical advice. I personally discussed that following with them.

    That they currently had a medical condition of: *** and I am concerned that they have *** or other serious pathology ***even despite ***.
    My proposed course of evaluation and treatment and that of any consultants is: *** Benefits would include: possible diagnosis or excluding of *** or an alternative serious condition such as ***, which if identified early would lead to appropriate intervention in a timely manner lessing the burden of disability and death
    Risks of leaving before this had been completed include: misdiagnosis, worsening illness leading up to and including prolonged or permanent disability or death. Specific risks pertinent, but not all inclusive, of their current medical condition include but are not limited to: ** I also discussed alternatives including: ***
    Despite this they stated they wanted to leave due to *** and refused further evaluation, treatment, or admission at this time.
    They appear clinically sober, to be mentating appropriately, free from distracting injury, have controlled pain, appear to have intact insight, judgement, and reason and in my opinion have the capacity to make this decision.
    Specifically, they were able to verbally state back in a coherent manner their current medical condition/current diagnosis, the proposes course of treatment, and the risks, benefits, and alternatives of treatment versus leaving against medical advice.
    They understand that they may return to seek medical attention here at whatever time they want. I highly advised them to return to the Emergency Department immediately if they experienced any: ***, reconsidered treatment a/o admission, or had any other concerns. This would be without any repercussions.

    I recommended they follow-up with *** within 24 hours for further evaluation and treatment. I also called their primary provider to inform them of the patients ED visit and course***.

    They were discharged against medical advice.

    • Matthew

      One of the few things that I like about our EHR is that it makes it fairly easy to set up a macro/autotext/dotpharse to expedite documentation in a lot of high risk situations (AMA, pt declines LP for SAH, low risk chest pain…)

  • Allie

    Had a case the other week (I’m an ED RN at a small community hospital): STEMI with Hx of the same, patient lived local, drove to the ED, upon finding out about the STEMI requested transfer to hospital >90 minutes away by ground, “because that’s where my cardiologist did my stent after the last heart attack.” Agreeable to everything else (meds, interventions, & transfer), but not the transfer to the closest Cath Lab (30 min away by ground). Ended up flying the patient out, so in retrospect, ED door to Cath Lab time was probably about the same. However, my questions is, what legal aspects should I have considered when documenting this situation?

  • MDfor911

    #6 is also important. I try my best to involve any family members, SO’s, etc., in on the discussion. I’ve found that sometimes, they are better at convincing! And in reality, who will sue you if the pt dies or has a bad outcome? The family, etc.

  • EMDOC

    is it reasonable to discharge a patient rather than have them sign AMA in certain circumstances? For example low risk chest pain who wants to go home or elderly patient who doesn’t want to spend the night in the hospital. I often do this if I’ve had a discussion with the patient addressing the points above (and documented it). In these cases, where the patient is reasonable, understands the risks and wants to leave, am I making myself any more medico-legally vulnerable? My thought is that it’s the discussion of the potential risks and that documentation,rather than having the patient formally “sign out AMA,” that’s essential.

    • Matthew DeLaney

      Really great point. The most important thing to do whether you have the sign out AMA or whether you discharge them using some shared decision making is to be very clear in the chart about how what conversation occurred before they left.
      A lot of folks are discharging folks using this idea of shared decision making, however from a risk management standpoint I think it can be a little bit riskier than having them leave AMA. What I will do is have the shared decision making discussion and then explain to the patient that my medical opinion is that they should stay, but that I understand if they reach a different conclusion and want to leave. I document that they are leaving against medical advice, with the thought that if they were to have a bad outcome I would receive some legal protection from previous rulings in cases with patients who leave AMA. My only issue with shared decision making and formal discharge is that there doesn’t seem to be nearly as much data on how these situations play out when a bad outcome occurs. For me calling it against medical advice, puts it in a language that other folks who look at the chart will recognize and hopefully gives me a little medicolegal protection while still respecting the patients right to make a decision.

  • simon

    This is filled with idiotic biased claims! Patients many times should leave AMA because hospitals purposely keep them their and make them go through unnecessary treatments to make money. And many times doctors are incompetent and make mistakes which cause further health problems and even death!

    Why does this article not talk about how patients have died or suffered because of bad hospital treatment? How patients have gotten diseases from other patients? or How patients are very uncomfortable in hospitals and high stress in these settings. How is someone supposed to cover in such a stressful environment. Why not talk about how you have to wait very long just to see the doctor.

    Doctors act like they know everything but reality is doctors make mistakes and a person knows more about their body than any doctor does! Control your egos doctors and realize hospitals only care about money and so do many of you!

  • simon

    A Hospital is a business end of story.

  • doc2

    Thanks Matthew. That’s good info to add to my canned charting.
    But how ridiculously pathetic has our profession become that we have to do this? If my mechanic/ broker/ lawyer/ grocery store clerk tells me I shouldn’t do something because it’ll hurt me, they don’t have to spend 10 minutes writing it down. They just watch me leave and laugh their a$$es off that I’m acting like such a moron. Instead, the morons we see enter a lottery where they’re likely to win a lifetime supply of cheez-whiz, cable tv, and pal mals…..

  • Greg Meyers

    If a patient goes back to work early after being told to take off 3 months on a back surgery issue and he goes back to work early who is liable if he re-injures his back? Greg M.