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CC: AMA
 
(Instructions: click on the checkbox to expand the decision tree and suggested options below. Click on the submit button a chart will be generated below in the text box). *Has yet to be sufficiently peer reviewed for clinical purposes and is only appropriate for educational purposes with attending supervision for teaching. 
 
Citation: Against Medical Advice by Dr Matthew Delaney published on Academic Life in Emergency Medicine (https://www.aliem.com/2014/02/ama-two-high-risk-myths-misconceptions/)
 
  • Documentation of AMA.
    • The patient insisted to leave AMA (against medical advice). The patient exhibits:
    • Capacity.
      • The patient was clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has demonstrated capacity to make this medical decision to leave AMA. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's condition given that a full evaluation and treatment had not occurred.
    • Articulates understanding of symptoms and signs and my concerns as the provider.
      • The patient and I have discussed the need for further evaluation to determine if their symptoms and signs are caused by a condition that would cause permanent disability, long term pain/suffering, development of morbidity which could in addition could require advanced medical care, hospitalization, and procedures that could be very costly and possibly averted by full evaluation and treatment at this time. I explained that these could cause problems which would prevent them from being able to work or care for themselves independently, and even lead to death. The patient demonstrated understanding of these risks to me.
    • Exhibits understanding of limitations of evaluation.
      • I explained that the limited evaluation performed was not conclusive nor sufficiently able to exclude pathological processes and that by being partially evaluated, this could lead to a false reassurance of well-being when in fact serious pathology had not yet been elucidated.
    • Exhibits understanding of advised treatment plan
      • which includes remaining in the ED for additional evaluation, diagnostics, and treatment.
    • Exhibits understanding of foregoing additional evaluation/treatment.
      • The risks of leaving that I explained and the patient verbalized back (I included a broad set of complications given that the work up was incomplete and definitive diagnosis was not know) including: immediate deterioration of health, long term disability (both neurological and physical), infection with sepsis, loss of limb or ability, loss of ability work, organ failure leading to death, and death without preceding symptoms to allow patient to get back to an Emergency Department quickly enough to treat
    • Was offered alternatives to advised plan.
      • Treatments to mitigate risk for patient (given with uncertainty from incomplete work up):
        • Empiric treatment based upon presumptive suspicion of etiology though this was balanced with risk of causing harm from treating the incorrect etiology of the patient's s/s given diagnostic uncertainty at that point in the work up.
        • I attempted to offer alternative treatments even with the patient leaving (while being very clear that the treatment would be suboptimal care and thereby place the patient at risk for the same morbidity/mortality as described (I used non-medical words to describe these concepts). This was my hope that the patient may be amenable to partial or empiric treatment contingent upon it being safe and less likely to cause harm that help patient even if they insisted against our strongest medical advice to stay.
        • Additionally, I tried offering alternative options or options for patient comfort (sandwich, water,warm blanket, turning off alarms in pt's room, offer for SW to come and assist with any psychosocial issues or financial concerns, and also offered analgesia or other symptomatic relief), in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient.
      • AMA form:
        • pt signed, placed in chart.
        • pt refused to sign secondary, had ability to sign but was unfortunately unwilling
      • Questions. I addressed all questions, implored importance of follow up, and re-iterated return precautions.
        • Unfortunately despite all attempts, the patient declined and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation/treatment regardless of how they feel but especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation and we would welcome their return to continue their evaluation at any time. I strongly encouraged the patient to return to this or any Emergency Department at any time if they are not willing to do so, at least to contact their PMD in hopes that the patient may at least have as much care to reduce risk to the extent that they are willing to do so.
      • Witness to this interaction and patient's departure against my medical advice:
      • It is my dear hope that the patient will return to my care, the care of one of my colleagues, or to the care of another physician to order to ensure the safety of the patient.

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