Against Medical Advice

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Stephen R. -

Great piece Mike and Rob. For patients that are intoxicated and/or influenced by other drugs, is it recommend to make mention of that? For example, "though patient is legally intoxicated, he is alert and oriented x3, answering questions appropriately, and appears to have capacity to make medical decisions."

Mike W. -

Yes this is OK if you know it to be the case (caution with "he smells of alcohol" or "the nurse knows his family and says he sells drugs...) but if you have objective evidence of intoxication but feel he has capacity, then prove it (neuro exam + verbal 'repeat back' understanding of risks) and document in the MDM!

Jason P., M.D. -

I love this segment. I was always taught to engage in shared decision-making, and document discussions well, and I like to think I am reasonably good at this. Within the last year, our hospital installed a new electronic medical record. We have downtime almost once a month, and one time the system went down for over 24 hours. At best, our EMR is inconsistent and unreliable. For the first few months, our progress notes were being deleted without our knowledge; fortunately this is now fixed. When I listen to medical legal lectures, and read medical legal papers, I am constantly haunted. I try to document well, but the platform I document on is unreliable and inconsistent in addition to being completely out of my control. Without sounding like another physician whining about electronic records, what advice can you give about medical legal documentation in an electronic era when we our ability to document medical decision making is so compromised by external factors? Please leave my name anonymous, as I do not want to bring down the wrath of hospital administration, but I know I am not the only physician who has palpitations over taking responsibility for the shortcomings of unreliable systems put in place by outside forces.

Mike W. -

Jason, thx for the comment. Yes, the EMR on the surface is fantastic (especially for physicians with illegible penmanship... like me), but when we put all of our eggs in one basket and there is downtime, it is a disaster! One 'work around' I have used is to use my voice activated program to dictate a progress note into a Word program, then to copy and paste when the downtime is resolved. This can be done without compromising HIPPA by refraining to put patient identifiers on the document then deleting when finished, but this should probably be coordinated through your hospital. Short and easy documentation can be done later, but the more extensive notes regarding SDM, can be documented while the conversation is still fresh.

Burner -

I enjoyed this segment when I first heard it this summer, and think you make some great recommendations. I recently reviewed it and have some questions. I have struggled with the decision to ask the patient to sign out AMA, because I feel that it sets us up as adversarial rather than invested in the patients interests. However, I was reviewing EMTALA for a talk I recently gave at OACEP, and was surprised to find this in EMTALA: (Interpretive Guidelines: §489.24(d)(2)(iii))
“if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual's behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual's behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual's written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. “ It further goes on to say:
"Interpretive Guidelines: §489.24(d)(3)
The medical record should reflect that screening, further examination, and or treatment were offered by the hospital prior to the individual’s refusal. In the event an individual refuses to consent to further examination or treatment, the hospital must indicate in writing the risks/benefits of the examination and/or treatment; the reasons for refusal; a description of the examination or treatment that was refused; and the steps taken to try to secure the written, informed refusal if it was not secured."
This implies to me that we are required by law to attempt to obtain a signed refusal form, as well as documenting the reasons for refusal. Any further thoughts on this?

Mike W. -

Hi Burner (I am guessing that is NOT your real name - ha ha). Thx for your comments!
A few thoughts:
1. I recommend a MDM note AND an AMA form. The most important is the MDM note, but why not do both? Takes almost no time and if it is taking a lot of time... the provider is likely having too many AMAs!
2. The way I read the EMTALA is in regard to the initial medical screening exam and not after the pt has had their screening exam and then refuses our recommendation after that fact.
Yes, offer and try as hard as you can to have the pt sign the form - but as the saying goes... you can lead a horse to water...
Thx again for your comments!

Ritter -

At my ED we are getting a lot of heat from administration to not sign people out AMA. I'm sure all they want is to improve their AMA numbers. What are your thoughts on this? They are basically telling us to never have a patient sign out AMA. They want us to document their refusal in the chart and discharge them home. Anyone else getting similar push from the higher ups?

Mike W. -

I understand the administrative push and also the physician concern. The goal should be to not have patients leave AMA, not to avoid signing the paper! It is rare to have someone leave AMA, but if this does occur, I strongly recommend documentation in the chart (the most important part) AND signing the AMA form. It would b interesting to see if your administration has asked their legal dept to weigh in...

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