Patients
Leaving AMA
- Another Legal Pitfall
In a busy emergency department, a patient
who threatens to sign out against medical advice (AMA) does not
always seem like a bad idea. Unfortunately, while this may seem
like a short-term solution to a chaotic day, the data shows that
patients who leave AMA continue to cause problems for the physicians
and hospitals despite a signed AMA form. The courts often view
an AMA disposition as physician laziness or retaliation against
a difficult patient, and, in case after case, the courts side
with the patient.
Documentation is our strongest weapon.
Sadly, most AMA forms are lacking in the information needed for
our protection.
Despite our frustration and typical lack
of time, a face-to-face discussion with the patient about his
or her specific concerns is warranted. Sometimes fear and confusion
are easily resolved by explaining delays and interpreting tests.
Involve family if they seem supportive; separate them if they
are not. Offer a meal, bargain for more time, or give alternative
routes of medication if appropriate.
If all efforts fail, we must document that the patient is capable
to make the decision to leave. Mental status must be documented.
The patient must understand: 1) condition/diagnosis, 2) extent
of proposed treatment, 3) risks and benefits of proposed treatment,
4) risks of treatment refusal.
In addition to the above, there are several
ways to minimize liability when patients want to leave AMA.
- Establish a quality physician-patient relationship from the
moment of the initial interview.
- Give the patient details about condition
and treatment options and document responses in quotes.
- Do not be vindictive; let the patient
know you are not angry and offer them alternatives.
- Give the patient prescriptions and follow
up instructions, even though they are signing out AMA (to withhold
care is medical negligence and viewed as retaliation).
- Refusal of signature is a special circumstance
because it is more difficult to demonstrate patient competence
and understanding. If the patient refuses to sign your properly
prepared AMA form, documentation becomes even more critical
and witnesses must be involved. Have the nurse document supporting
information.
AMA patients are a special case and must
be treated as such. If handled improperly, they can become a prolonged
nightmare in court.
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