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Leave Against
Medical Advice
Ahmad Thanin
Definitions
• The patient/patient's representative requests discharge from the hospital and the attending
clinician considers that discharge may result in serious patient risk resulting in an adverse
health outcome.
Leave Against Medical Advice (LAMA):
• The patient/patient's representative refuses to undergo diagnostic or therapeutic procedures
or refuses to follow the treatment plan as recommended by the attending clinician.
Against Medical Advice (AMA):
• is responsible for the care of the patient.
Primary / Attending Clinician:
• include but are not limited to victims of assault, injury to a child caused by either
or both parents or any party known to them, or serious notifiable conditions or
communicable diseases that could pose a threat to the community.
Special circumstances / suspicious situations:
• when signed, releases the attending clinician, the hospital from liability for
problems and complications resulting from the patient’s decision to be
discharged or to refuse care against medical advice.
Against Medical Advice (AMA) Form:
• refers to the individual who gives consent on behalf of the patient when the
patient is unable to do so by him or herself.
Patient’s representative”
“Patient’s
representative”
• According to the Saudi legal system,
the order of kinship hierarchy is as
follows:
• spouse (husband or wife)
• an adult son or daughter.
• Parent.
• adult brothers or sisters,
• other adult relatives.
Left Without Being Seen
In this scenario, the
patient has not yet
interacted with a
physician.
There is not much to do
here as long as the
provider never met the
patient, if so, they would
be in a different category.
There are no known cases
where the ED, or ED
Providers, have been sued
and found to be at fault or
responsible for an
outcome.
People have the right to
walk in and walk out as
they choose.
The Eloped Patient
If the provider has met the patient and they leave the department before completion of their work-
up or before having had the AMA discharge conversation, they are considered to have eloped.
Most departments have their own policy for this situation, it is recommended to follow your own
departmental policy. If not, here are a few things to do:
• Look for the patient a few times (once every 20 minutes for an hour)
• If witnessed by RN, have them document the time the patient left as well as the status of their IV.
• If an IV is still in place, first try to contact the patient and then their emergency contact.
• If no success, contact the police non-emergently to aid in locating the patient.
• Review sent labs, if there are any critical values contact the patient or their emergency contact and advise to return to this or
the closest ED.
• If there are any life-threatening findings and the patient is unable to be contacted, contact the police non-emergently.
• Document the time you were made aware the patient left as well as your attempts to contact them.
• If prior to desertion the patient was awake and alert and appeared to have capacity, document this.
• If the patient is at risk and you are truly uncertain of capacity, notify the police and document as such.
Understanding Patient
Motivation to AMA
Financial/Employment Caring for Dependents
Undermanaged Drug
Withdrawal, Pain, or Other
Symptoms
Perception of
Stigmatization/Discrimination
by Healthcare Provider
Unclear Expectations (e.g.,
timing of procedures, NPO
status, overall care plan)
Disagreements with Discharge
Planning
How to
Navigate an
AMA Discharge
in the
Emergency
Department
The capacity of a patient to make the decision to
leave the hospital against medical advice is the
most important feature of the AMA discharge
process. There are four basic elements to capacity:
The ability to communicate with the
provider
The understanding of treatment options
including the option of refusal
The ability to reason and explain ‘why’ he
or she is making the choice
The understanding of consequences of
choices
LAMA Process
1- Investigate
Investigate barriers to
communication (and
resolve them if able)
Investigate patient’s
rational for wanting to
leave AMA
Investigate if anyone else
can help convince the
patient (family, friend,
PCP).
2- Discuss
Discuss working or actual
diagnosis and findings
Discuss recommended
course of treatment
including alternatives and
comfort measures you can
provide
Discuss risks of refusing
treatment, including
disability/death
3- Evaluate Understanding
Have the patient explain
their diagnosis/findings in
their own words. “I
understand” is not enough
Have the patient explain
the consequences of them
leaving AMA.
4- Allow the AMA
Go over discharge
instructions including
reasons to return
Ensure the patient
understands that they can
return at any time
Have the patient sign the
AMA form. For a witness,
use a family member if
possible, or an RN
CURVES”
MNEUMONI
C FOR
ASSESSMENT
OF CAPACITY
THE “AIMED”
APPROACH
Patients that Lack Capacity
Patients have a fundamental right to refuse care, however those that lack
decision-making capacity or are at risk for harm to self or others cannot refuse
treatment, and therefore cannot leave AMA.
The ED provider has an obligation to try and restore decision-making capacity as
soon as possible. Some steps to do this include:
• Locating a surrogate decision maker
• If there is no designated healthcare POA, in most states the hierarchy is: Adult Spouse > Adult
Children > Parents of Patient
• Locating an Advance Directive
• Reassessments of Capacity over time (sober reassessments)
Documentation
A well written addendum for an AMA discharge will include the following:
• Discussion of the treatment(s) offered
• Discussion of the risks/benefits of further treatment and for no treatment
• Reasons for refusal
• Efforts taken at negotiating with the patient including possible alternative treatments,
risks/benefits of alternative courses as well as comfort measures offered
• Steps taken to secure a written informed refusal
• An assessment that the patient has capacity to make the decision, and if there are concerns or
gray areas involving capacity note what they were and why it was resolved in the manner
chosen
Do’s and Don’ts:
Do’s Don’ts
determine the decision-making capacity of the patient. Do they
comprehend the information and consequences and understand the
risks and benefits of the options, and can they communicate these back
to you?
ignore the patient who wants to leave AMA. If at all possible,
stop what you are doing and prepare to address the issue.
apologize if the patient has been waiting or if there have been delays in
the patient care process. Apologies are free. Lawsuits cost millions.
blame or berate the patient or anyone else for their desire to
leave.
enlist the patient’s family and friends in your attempt to convince the
patient to stay.
just ask the nurse to have the patient sign a generic AMA
form and leave. This course of action provides little
protection for the practitioner.
ocument the patient’s “informed refusal” of crucial diagnostic testing
(e.g., blood work or X-rays), procedures (e.g., LP to rule out meningitis
or subarachnoid hemorrhage), or treatments (e.g., medications or
transfusions) in the same detail as you would an AMA.
express your frustration and anger to the patient. Instead,
earnestly convince them that your overriding interest is their
well-being. Make sure they know that you are on their side
against a potential threat to their health.
Do’s and Don’ts:
Do’s Don’ts
document the details of the AMA patient encounter in
the patient’s chart (see samples below). Include
documentation of the patient’s decision-making capacity,
the specific benefits of your proposed treatment and risk
of leaving AMA, what you did to get the patient to stay,
and your compassionate interest in having the patient
return for any reason. Have the patient sign an AMA
form that addresses these details, witnessed by a family
member and/or staff member.
refuse to provide treatment; this could be
considered abandoning the patient. Provide
whatever treatment, prescriptions, follow-up
appointments, and specific discharge
instructions the patient will accept.
worry about whether or not the patient’s insurance
will deny payment if they sign out AMA. Their
insurance is not your problem, but a malpractice
suit will definitely be your problem.
Medico-legal Considerations
providers need to be aware that the simple signing of an AMA
form does not confer absolute medico-legal protection.
Furthermore, not giving discharge instructions, follow-up or
medications could be construed as coercion, negligence or
unwillingness to consider alternative options for the patient.
Moreover, advising a patient that their insurance will not
cover their visit if they leave AMA is not only incorrect but
could also be considered coercion.
Leave against medical advice

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Leave against medical advice

  • 2. Definitions • The patient/patient's representative requests discharge from the hospital and the attending clinician considers that discharge may result in serious patient risk resulting in an adverse health outcome. Leave Against Medical Advice (LAMA): • The patient/patient's representative refuses to undergo diagnostic or therapeutic procedures or refuses to follow the treatment plan as recommended by the attending clinician. Against Medical Advice (AMA): • is responsible for the care of the patient. Primary / Attending Clinician:
  • 3. • include but are not limited to victims of assault, injury to a child caused by either or both parents or any party known to them, or serious notifiable conditions or communicable diseases that could pose a threat to the community. Special circumstances / suspicious situations: • when signed, releases the attending clinician, the hospital from liability for problems and complications resulting from the patient’s decision to be discharged or to refuse care against medical advice. Against Medical Advice (AMA) Form: • refers to the individual who gives consent on behalf of the patient when the patient is unable to do so by him or herself. Patient’s representative”
  • 4. “Patient’s representative” • According to the Saudi legal system, the order of kinship hierarchy is as follows: • spouse (husband or wife) • an adult son or daughter. • Parent. • adult brothers or sisters, • other adult relatives.
  • 5. Left Without Being Seen In this scenario, the patient has not yet interacted with a physician. There is not much to do here as long as the provider never met the patient, if so, they would be in a different category. There are no known cases where the ED, or ED Providers, have been sued and found to be at fault or responsible for an outcome. People have the right to walk in and walk out as they choose.
  • 6. The Eloped Patient If the provider has met the patient and they leave the department before completion of their work- up or before having had the AMA discharge conversation, they are considered to have eloped. Most departments have their own policy for this situation, it is recommended to follow your own departmental policy. If not, here are a few things to do: • Look for the patient a few times (once every 20 minutes for an hour) • If witnessed by RN, have them document the time the patient left as well as the status of their IV. • If an IV is still in place, first try to contact the patient and then their emergency contact. • If no success, contact the police non-emergently to aid in locating the patient. • Review sent labs, if there are any critical values contact the patient or their emergency contact and advise to return to this or the closest ED. • If there are any life-threatening findings and the patient is unable to be contacted, contact the police non-emergently. • Document the time you were made aware the patient left as well as your attempts to contact them. • If prior to desertion the patient was awake and alert and appeared to have capacity, document this. • If the patient is at risk and you are truly uncertain of capacity, notify the police and document as such.
  • 7. Understanding Patient Motivation to AMA Financial/Employment Caring for Dependents Undermanaged Drug Withdrawal, Pain, or Other Symptoms Perception of Stigmatization/Discrimination by Healthcare Provider Unclear Expectations (e.g., timing of procedures, NPO status, overall care plan) Disagreements with Discharge Planning
  • 8. How to Navigate an AMA Discharge in the Emergency Department The capacity of a patient to make the decision to leave the hospital against medical advice is the most important feature of the AMA discharge process. There are four basic elements to capacity: The ability to communicate with the provider The understanding of treatment options including the option of refusal The ability to reason and explain ‘why’ he or she is making the choice The understanding of consequences of choices
  • 9. LAMA Process 1- Investigate Investigate barriers to communication (and resolve them if able) Investigate patient’s rational for wanting to leave AMA Investigate if anyone else can help convince the patient (family, friend, PCP). 2- Discuss Discuss working or actual diagnosis and findings Discuss recommended course of treatment including alternatives and comfort measures you can provide Discuss risks of refusing treatment, including disability/death 3- Evaluate Understanding Have the patient explain their diagnosis/findings in their own words. “I understand” is not enough Have the patient explain the consequences of them leaving AMA. 4- Allow the AMA Go over discharge instructions including reasons to return Ensure the patient understands that they can return at any time Have the patient sign the AMA form. For a witness, use a family member if possible, or an RN
  • 12. Patients that Lack Capacity Patients have a fundamental right to refuse care, however those that lack decision-making capacity or are at risk for harm to self or others cannot refuse treatment, and therefore cannot leave AMA. The ED provider has an obligation to try and restore decision-making capacity as soon as possible. Some steps to do this include: • Locating a surrogate decision maker • If there is no designated healthcare POA, in most states the hierarchy is: Adult Spouse > Adult Children > Parents of Patient • Locating an Advance Directive • Reassessments of Capacity over time (sober reassessments)
  • 13. Documentation A well written addendum for an AMA discharge will include the following: • Discussion of the treatment(s) offered • Discussion of the risks/benefits of further treatment and for no treatment • Reasons for refusal • Efforts taken at negotiating with the patient including possible alternative treatments, risks/benefits of alternative courses as well as comfort measures offered • Steps taken to secure a written informed refusal • An assessment that the patient has capacity to make the decision, and if there are concerns or gray areas involving capacity note what they were and why it was resolved in the manner chosen
  • 14.
  • 15. Do’s and Don’ts: Do’s Don’ts determine the decision-making capacity of the patient. Do they comprehend the information and consequences and understand the risks and benefits of the options, and can they communicate these back to you? ignore the patient who wants to leave AMA. If at all possible, stop what you are doing and prepare to address the issue. apologize if the patient has been waiting or if there have been delays in the patient care process. Apologies are free. Lawsuits cost millions. blame or berate the patient or anyone else for their desire to leave. enlist the patient’s family and friends in your attempt to convince the patient to stay. just ask the nurse to have the patient sign a generic AMA form and leave. This course of action provides little protection for the practitioner. ocument the patient’s “informed refusal” of crucial diagnostic testing (e.g., blood work or X-rays), procedures (e.g., LP to rule out meningitis or subarachnoid hemorrhage), or treatments (e.g., medications or transfusions) in the same detail as you would an AMA. express your frustration and anger to the patient. Instead, earnestly convince them that your overriding interest is their well-being. Make sure they know that you are on their side against a potential threat to their health.
  • 16. Do’s and Don’ts: Do’s Don’ts document the details of the AMA patient encounter in the patient’s chart (see samples below). Include documentation of the patient’s decision-making capacity, the specific benefits of your proposed treatment and risk of leaving AMA, what you did to get the patient to stay, and your compassionate interest in having the patient return for any reason. Have the patient sign an AMA form that addresses these details, witnessed by a family member and/or staff member. refuse to provide treatment; this could be considered abandoning the patient. Provide whatever treatment, prescriptions, follow-up appointments, and specific discharge instructions the patient will accept. worry about whether or not the patient’s insurance will deny payment if they sign out AMA. Their insurance is not your problem, but a malpractice suit will definitely be your problem.
  • 17. Medico-legal Considerations providers need to be aware that the simple signing of an AMA form does not confer absolute medico-legal protection. Furthermore, not giving discharge instructions, follow-up or medications could be construed as coercion, negligence or unwillingness to consider alternative options for the patient. Moreover, advising a patient that their insurance will not cover their visit if they leave AMA is not only incorrect but could also be considered coercion.