Episode 5: Leaving Against Medical Advice

Leaving against medical advice, or AMA, can be a risky decision. Let's talk about it!

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Transcript

Hello and welcome to Inside the ER. My name is Dr. Padraic Gerety and I’m a practicing, board certified emergency physician.

You’re joining us today for our fifth episode, entitled “Leaving Against Medical Advice.” This might seem like an unusual topic to devote a whole episode to, but I think it flows nicely from our last series. If you haven’t yet, I encourage you to listen to our first four episodes, which are an introduction to the podcast and the ER itself. If you already have, then I apologize for repeating this point! Though I admittedly will probably keep doing it.

Before I get into leaving against medical advice, I’m going to first discuss when patients leave without notice. Unless a patient is detained for some reason, they can of course just leave without telling anyone. If a patient registers and gets through triage, but then leaves without notice before they were evaluated by a provider, then they have left without being seen, or LWBS. If that same patient hangs around long enough to be seen by a provider, and then leaves without notice, then they have eloped. This is not getting married eloped, this is a different thing. It is of course, easier to elope without anyone knowing if you’re a patient in the Fast Track or waiting room, than if you’re in the main area. If you are a patient in the ER, I strongly urge you to not do this! Please.

When this happens it is very troubling for us because while leaving against medical advice involves a discussion and paperwork, none of that happens when a patient just bails. No conversation is had. We will attempt to call the patient if there is an abnormal test result they weren’t alerted to. But if we can’t get a hold of them and a test showed something catastrophic then we may call the police to find them. 

One time I remember a patient presented with head trauma who was otherwise well appearing. The nurse at triage ordered a CT scan and the patient remained in waiting room. The scan got done and surprisingly showed an intracranial hemorrhage, or a head bleed, which can be life threatening. When we scrambled to pull the patient out of the waiting room, we couldn’t find them. They had eloped! We couldn’t contact them and needless to say that warranted a call to the police, who managed to track them down thankfully.

We will also call the police if a patient elopes before a nurse can remove their IV. In my residency there was tale of a man who eloped with an IV in his arm but was never found…until two weeks later when he was unfortunately found dead, apparently from an overdose. What was in his arm? That same IV. So, I guess it goes without saying that we will do everything we can to find patients in these situations. Not only due to our moral duty to protect people from harm, but also to protect ourselves and the hospital from liability.

All right, so let’s get into the meat of the episode! Leaving, or being discharged, against medical advice, or AMA, is when a patient leaves the ER or hospital in opposition to the recommendation of their provider. In these cases, I can listen to their concerns and then explain my own, even beg and plead but the patient will not heed my warnings. As a provider I write a detailed noted about the conversation and make sure AMA paperwork is signed to document that the patient was informed of their condition and the risks of leaving. In the ER, we often joke about that when a patient AMAs, our lives get easier, ya know there’s one less difficult patient to deal with. But when that patient is truly sick, it can be very distressing. The disagreement here is that the patient declines to undergo a test, a treatment, or even admission. Let’s break these down, one by one. 

First, as mentioned in our previous series, almost all patients in the ER require testing to rule out emergent medical conditions. And it’ll be a lot of testing if it’s a potentially complicated case. If I have a patient that refuses a crucial test, then I’m forced to have them sign out AMA. This would be a chest pain patient refusing an EKG or someone with severe abdominal pain refusing a CT scan. There’s just no way for me to rule out an emergent condition without that step.

Next is when a patient refuses a specific treatment. The most extreme example is a patient refusing emergency surgery, such as with appendicitis or a perforated bowel. For a less dire case, I’ve had this happen when a patient with a laceration refuses sutures, also called stitches. Sure, just bandaging the wound probably isn’t going to kill them, but it will certainly lead to a ugly scar and higher chance of infection. Another example is if a patient with a fracture, or broken bone, refuses a splint or brace. Again, it’s not gonna kill them, but the bone won’t heal properly, meaning they’ll have chronic pain and poor function. So, to protect myself from liability, I would make them sign out AMA. 

Finally, a patient can AMA because they refuse to be admitted. In our last episode we had a hypothetical patient who presented with shortness of breath due to an asthma exacerbation  and despite treatments, they didn’t improve sufficiently. They were hypoxic, as in their oxygen level was low, and so they needed admission. Occasionally, a patient like this will refuse to stay, and that’s a potentially high risk AMA.

I have a vivid memory from 2020, during the height of the pandemic, of a patient with COVID who left AMA. He had all of the risk factors for having a bad outcome with COVID: he was older, obese, diabetic, smoker. He was already admitted earlier in the day by my colleague and his oxygen was so low that not even a standard nasal cannula was cutting it. He needed a high-flow nasal cannula, which, as it sounds, delivers higher flow rates of oxygen and can help overcome hypoxia in sicker patients. During my shift, the nurse calls me over and tells me this guy wants to AMA. Now, clearly, this a terrible idea. As I said, he was already admitted, but no upstairs bed was available, so he was boarding in the ER. The nurse couldn’t get in touch with the inpatient doctor and the patient was adamant to leave.

I was not thrilled to be involved, but before you call me heartless or lazy, you’ve gotta understand. These situations are quite difficult. It’s not as if this guy didn’t know how sick he was. Long before I got there, he had already been told by an ER doctor, an inpatient doctor, and a bunch of nurses several times that he was quite ill and needed to be admitted. So, I knew walking into the room that I was dealing with an obstinate patient in a high risk AMA situation. When I say high risk I mean both ways: for the patient’s health and in terms of liability. It is vital in these cases that the patient is fully informed about the risk they are incurring when they AMA.

So, the nurse was hoping I could talk some sense into him, and while this wasn’t technically my job, ya know, he was never my patient, I, of course, tried my best. As I’ve said, this is a team sport, the ER staff bands together to keep our patients safe. As you can probably tell from the title of this episode, haha, this conversation didn’t go well. There seemed to be some COVID skepticism, ya know he said something like  “I’ve been told I have COVID” implying maybe he didn’t quite believe it himself. Now, I figured, ok, so, he's on oxygen, he’s having trouble speaking to me, so he’s in no condition to walk off of oxygen, which is what he’s gonna have to do to go home, to AMA. So I told the nurse, “Let’s make him try to walk out of here and he’ll see that’s he’s gotta stay.” 

Well, this guy signed the paperwork and went for it. He huffed puffed through every step, struggling to breath, stopping every ten feet. The whole time we’re walking beside him saying, “Hey, hey, you gotta stay, you gotta stay, look at you, look at you! You can barely breathe!” But he kept refusing and made it out of the ER. I never saw him again. I hope he did all right. 

It’s time for a break, we’ll be right back after a word from our sponsor.

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Now, back to the show:

As I said, in order to do this properly, the provider has to make sure that the patient is informed. My process is to explain the medical situation I believe the patient to be in, go over their results so far, tell them what I’m worried about, and then stress the need to adhere to my treatment plan. I’ll explain the benefits of pursuing it, the risks of refusing it, and if I can, offer some alternatives. Of course, I’m listening to their concerns, why they want to AMA, and seeing if I can accommodate them somehow. If the patient is adamant to leave, then maybe I can prescribe some medication to take or suggest follow up. 

So this could be: “Ma’am, you came in with abdominal pain and you were found to have cholecystitis, which is dangerous inflammation of the gallbladder. I need to consult with a surgeon, because you may require surgery, give you IV antibiotics, and admit you to the hospital. If this goes untreated then it could lead to sepsis, a systemic infection, and even death.” Part of the AMA process is making sure the patient understands the circumstances, and so I may have them repeat back to me what’s going on. I’d listen to their concerns, answer any questions, again stress why they need to stay, and if they still refused then have them sign paperwork with this all written down. If this particular patient AMA’d, you know this one with cholecystitis that I made up, then I could put them on oral antibiotics as an alternative, stressing they are still incurring a risk of death, but perhaps this might help. Ya know like a bandaid on a bullet hole situation.

Oh, and what if the patient refuses to sign? Well if a patient demands to leave and refuses to sign any paperwork or even have a conversation with me, then I will walk beside them and just word vomit: “You are leaving against medical advice. There is a risk of untreated or undiagnosed condition, pain and suffering, permanent disability, or death.” Maybe not that fast. Something like “You are leaving against medical advice. There is a risk of untreated or undiagnosed condition, pain and suffering, permanent disability, or death.” 

That’s my standard spiel for all my AMAs, and of course I’ll add some more specific info in there depending on the situation. That way I can at least document that I explained the risks to the patient, even if they never let me draft any paperwork. I did this recently for a patient with a terrible laceration who refused treatment. I added, “infection,” “loss of function,” and  “amputation of your finger” to that AMA paperwork. Don’t worry, she came back later.

That’s an important point I might as well make now. Just telling the patient they may die if they leave is only part of it. Sure, they could die, or they could just suffer, they could fall victim to a separate disease process, or they could become permanently disabled. Some people are fine with the risk of dying but not with the risk of developing a massive stroke that leaves them disabled for life. I partly see the discussion during the signing of the AMA paperwork as the last chance to convince the patient to let me help them. I often say, “This is to show you how worried I am about you.” And then I can list all the horrible things that may happen to them, hoping that’ll change their mind. 

I recently had a patient in his 30s with no known medical history come in with abdominal pain and vomiting. Just looking at him you could tell he was jaundiced, and I suspected he was suffering from alcoholism. Sure enough he had alcoholic hepatitis and was at risk for liver failure. Despite my literal begging, he refused to be admitted, and even refused to tell me why. I was so worried about this guy that I had another doctor and one of my PAs talk to him as well. When my PA came back, she told me he said, “Dr. Gerety made it seem like I was going to die right when I leave the hospital which I don’t appreciate.” Good! That’s exactly the point I was trying to make. YES, you might suffer a horrible, slow death, so stay so I can help you!

I spent forever trying to figure out what medication I could safely prescribe him and writing an insanely detailed note. He came back the next day, agreeing to be admitted, and told another doctor that he realized he was very ill. OH, really? Ya think!? You realized now? Did my panicked pleading just take awhile to sink in?! Where was this sudden clarity yesterday? I can not believe that… Phew…I’m sorry, where was I?

Ok, so why do people LWBS, elope or AMA? There are of course a lot of reasons but let’s go through the main ones. First, long wait times. Self explanatory, the longer the wait, the more people will decide it’s just not worth it and bail. Second, family obligations! The patient has to take care of a loved one. Often patients tell me they have a disabled family member at home, or a dog. Often they need to get back to their dog. I get that. Third, drug addiction. This is unfortunately very common. Patients who abuse drugs will eventually feel withdrawal symptoms and hence leave AMA to satiate that. Fourth, disagreement with the provider about how sick they are. “No doctor, you’re wrong, I’m gonna fine!” Sure, maybe. Fifth, the patient doesn’t like the provider, or the hospital, or the nurse, or the food, whatever. Occasionally I’ll have a patient that is just unreasonable, offended by every little thing, and there’s no talking them down. And the last, and by far the most depressing, is financial hardship! Welcome to America, home of the worst health insurance system among the developed nations. With medical debt the leading cause of bankruptcy, am I really surprised an uninsured patient wants to AMA?

Now of course, in all of these cases, we will do what we can, within reason, to accommodate or convince the patient to stay and finish their workup. Maybe I can give that patient something for withdrawal, or expedite a test. Some obstacles can not be overcome, I can’t go feed their dog, and some people can not be convinced, they’re just stubborn or in an impossible home situation. Hmm, do you feel sad yet? Ok let’s move on.

The reason you as the patient have the right to leave against medical advice is that you have autonomy, of course. Patient autonomy is the right of patients to make informed decisions about their medical care, including refusing it. Again that informed part is key. When a patient is AMA’ing they are told their results so far and what else could be wrong, hence the risks. Now, for you to be able to act on your autonomy, you have to have decisional making capacity, as in have the ability in the first place to understand the risks and benefits of what you’re deciding.

If a patient does not have capacity, then they can not AMA. An easy example is an intoxicated patient with head trauma. If a patient is intoxicated, they are not of sound judgement and lack the capacity to refuse treatment. The idea being that a reasonable person would want testing and treatment done to save their life, and as this intoxicated person is acting unreasonably, they can be forced to stay until they achieve sobriety and hence capacity. Another example would be a patient with a psychiatric disturbance. If you are suicidal, or actively hallucination then you likely lack capacity to make a life threatening decision to refuse. Specific situations can have a lot of layers and nuances that will complicate the picture. Occasionally, an ER provider will enlist the help of a psychiatrist to assess a patient and deem if they indeed have capacity to refuse care.

An easy way to begin assessing capacity is to see if the patient is AandOtimes4, wait, have I explained that yet? I don’t think so. The A in AandO means alert, as in the patient is awake and responsive to the environment. The O in AandO means oriented, and then times whatever number means to what degree. A person is expected to be oriented to their name, location, time, and the situation. What’s going on. So generally when assessing a patient’s capacity, you need to make sure they can state their name, where they are, what’s the date (or at least the year), and what their situation is. 

“My name is Padraic Gerety, I’m at home, it is April 2024, and I’m slightly embarrassed by my voice as I record a podcast.” That would work.

It is common for patients with dementia or with a condition alerting their mental status (intoxication, delirium, whatever) to be alert, but not fully oriented. So they may know their name, and location, but often not the year or why they’re in the ER, so that would be AAO2. A patient with eyes open, making purposeful movements, but not speaking or writing is either AAOzero, or they have a condition that is preventing them from communicating. An unconscious patient isn’t even alert. 

There was an interesting case in residency, I think I’ll get into it more in a later episode, of a patient with an intracranial hemorrhage who wanted to AMA. Sure the patient is alert and oriented, but are they of truly sound mind, or is that brain bleed impacting their judgment? 

If a patient is off their mental baseline, they may not have the capacity to refuse, but a patient with dementia who is at their baseline is a different situation. I’ve had patients with mild dementia who are otherwise alert and oriented, and so have capacity to refuse. I’ve also had patients with severe dementia and in those cases, whoever has decision making authority over the patient can decide to AMA them. It’s always important in those situations to make sure there’s no family drama. Ya know one person claims to be power of attorney, the other close family disagree with the AMA…it’s a whole thing.

By the way all this goes out of the window if it’s a kid. Adults with capacity have autonomy over their own bodies, and so have the right to refuse care even if it’s at great risk. A child, however, innately may not have this capacity. Essentially, parents, adults, can decide to put themselves at risk, but they can not refuse life saving medical care for their child. If a child in the ER has an emergent medical condition, and the parent tries to the AMA them, then it is the moral duty of the provider to prevent them from leaving and call Child Protective Services, call CPS. The provider here wants to protect the child’s health, and must defy the parents if they do not. My pediatric colleagues tell me that most parents will back down when they realize the consequences of doing this. Now, of course, there are gray areas here. If the parent wants to leave and the provider thinks the risk of an emergent medical condition is low, then they may allow them to sign out AMA. Just depends on the situation.

The last thing I’ll say is that if you find yourself in a situation where you think you have to LWBS/elope/AMA/whatever, please remember everything I’ve said.  Consider your options and appreciate that the ER staff are trying to do their jobs. You can’t take care of your family or your dog if you become disabled or die.

On that uplifting note, that’s it for this episode, we’ll be back in two weeks!

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