Against Medical Advice
Click on the image above for another great blog post on https://www.nuemblog.com/ Written by: Brett Cohen, MD (NUEM PGY-3) Edited by: Will Ford, MD, MBA (NUEM ‘19) Expert commentary by: Larry Weiss, MD
Also known as AMA…I have to admit I was undereducated or nieve to the true meaning of “signing out AMA.” At first, AMA seemed like a sweet "get out of jail free" card, that absolved me of any responsibility and made for one less patient to be seen. Unfortunately, this was cruel, dumb, and short-sighted. Instead, I recommend you avoid my idiocracy.
Truly, the best choice is to avoid any patient leaving against medical advice. As it turns out, if documented properly a patient who leaves AMA should require much more documentation than a passing statement that the patient “refused care.” Instead, I suggest you consider the following points:
Just because a patient refuses your treatment plan does not mean that you must terminate the relationship. Welcome to the 21st century. Patient have a voice and a choice in their medical care. Doctors (and PAs) don't have all-knowing god-like status anymore. Patients are more educated (even if they are ill-informed by their Googling). Therefore, we have a responsibility to negotiate with patients. It is not unreasonable to modify your treatment plan based on your patient's preferences (i.e. get over yourself). Most of the time, after a little education patients just might agree with your plan. Try sitting down and talking about it.
After talking to the patient, offer an alternative treatment plan. For example, if a patient refuses to be admitted for chest pain or undergo a CT scan for abdominal pain, ask if they would be willing to follow up with their doctor in the morning or stay a few more hours for serial EKGs or abdominal exams. It might not be the best (most expedient) plan, but it is better than nothing (i.e. AMA and out the door).
Patients must have the capacity to decide to refuse care. This means that patients must understand the plan, alternatives, and consequences of their choice. In practice, I document that the patient "understands and can repeat back to me the risks of leaving" AMA.
You must communicate and document relevant risks. This means more than just telling the patient that "if you leave the ER you might die." I always include death in the risks of leaving AMA but also include adverse outcomes relevant to the reason the patient came to the ED. For example, a ruptured appendix for the abdominal pain or infertility for the pelvic complaint. I also include the risk that might be "worse than death" depending on the patient's outlook, like permanent disfigurement, loss of income, and disability.
The reason for a patient leaving AMA does not always need to be included in your documentation. Many times patients ask to leave to take care of a loved one (including their dogs and cats). This might sound ridiculous to you (and probably a jury), therefore it's probably not a great idea to include this in your documentation. You also probably don't need to include all the profanities that might be thrown your way with a particularly ornery patient might have explicated on their way out of the department. Pro tip - you will sound kinda petty if you include, "The patient called me a piece of $#@!"
Document and have the patient (and hopefully family) sign the AMA form. I like to have a nurse, the patient, myself, and hopefully, another witness like a family member sign an AMA form that includes all my specific risks of leaving.
In every case, try to make AMA the last resort. It is much better to document all the ways you tried to help your patient rather than simple refusal of care. Almost everyone
“Four specific abilities should be assessed: the ability to understand information about treatment; the ability to appreciate how that information applies to their situation; the ability to reason with that information; and the ability to make a choice and express it.”
In any event that the AMA form does become the final pathway, be sure to include the above aspects of your patient care. While your hospital may have specific templates for this, here is one that you might modify and use in your charting.
“The patient has decided to sign out against my medical advice of ***. The patient was able to express this decision and the reason that they wanted to leave including ***. I explained in plain terms my concern that leaving against medical advice could result in death, disability, loss of income, suffering, and ***. The patient was able to repeat back to me their choice after acknowledging an understanding of my concern and being given time to ask questions. I encouraged the patient to ***.”
I’d be happy to hear your suggestions for improvement and further references by email or in the comments below.
