Mutual Matters

Reducing your risk when patients leave against medical advice

Posted by Bill Kanich, MD on Aug 11, 2016 12:30:00 PM

Case Study

Your last patient of the day is a 23-year-old male who was added to your schedule when he calledcampaign_image.png the office that morning. It's been a long day, you're tired, you've already seen two patients today who were added onto your already full schedule. But you're not worried.  This patient has no past medical history and his chief complaint sounds relatively simple - he has a runny nose, nonproductive cough and vague chest pain. In your mind you’re already writing discharge instructions for an upper respiratory infection. Then you turn the page to read the nurses triage note and your heart drops. His vital signs are all within normal limits except for his tachycardia.  The nurse has recorded a heart rate of 155 beats per minute.

When you enter the room you meet an engaging young man who does have an upper respiratory infection but who also clinically has atrial fibrillation.  After your history and physical you inform him that he will need to be admitted to the hospital and you

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excuse yourself to make arrangements to transfer him to the inpatient care of a cardiologist for his new onset atrial fibrillation.


When you return to the room your patient’s demeanor has dramatically changed. He now appears somewhat agitated and says he cannot be admitted to the hospital because his mother is in your waiting room and needs to go home to feed her cat.  You are flabbergasted.  You've just spent the last 30 minutes arranging his transfer and now he wants to leave.  You're tired, you're ready to go home and you don't have the energy to argue.

Scenario 1

You ask him to sign an “Against Medical Advice” (AMA) form which he does.  He leaves.

Scenario 2

You remember that he mentioned his mother was in the waiting room.  You ask her to accompany you in the room.  In her presence you discuss the risks and benefits of being hospitalized for his atrial fibrillation.  You are specific and mention that he risks death or permanent, devastating neurologic disability by not being admitted for a workup.  He discusses his condition intelligently with you and his mother, demonstrates to your satisfaction he appreciates the risks of leaving, but he still declines admission.  As a final effort to treat his condition you ask if he will wait for you to re-consult the accepting cardiologist to discuss possible oral medications.  He declines and he signs the Against Medical Advice form that you have written for this encounter.  As he leaves the room you shake his hand and encourage him to call you on your mobile phone or present to the ED if he changes his mind and desires treatment for his condition.  He thanks you and leaves.

Discussion

The existence of a signed AMA by itself offers little protection against a claim of medical malpractice.  It is a helpful piece of documentation but it is not sufficient by itself to protect a provider who is accused of not providing the necessary information for patient to make an informed decision about his medical care.

To find out more about better protecting yourself and your patients when patients leave against medical advice click the button below and receive the full case study plus six simple steps for protection.

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