Mrs. M is a 72-year-old woman admitted with lower extremity pain and swelling. A femoral-femoral bypass was performed with consent. On the fourth day postoperatively, Mrs. M became suspicious and was noted to have auditory hallucinations (was talking with people not in the room). There was a strong odor of urine present in the room, and she complained to the nurses that men were walking into her room. She was described as demanding and struggled to leave the hospital during the night. On quick assessment, Mrs. M was neither able to explain the risks and benefits of leaving the hospital nor was she able to discuss how she would return home.
Discharges that occur against medical advice (AMA) account for up to 2% of discharges each year.1,2 AMA discharges are associated with higher morbidity, mortality, and readmissions when compared to patients discharged after the goals of care were accomplished.2 Contrary to popular belief, identifying a discharge as AMA does not protect medical providers from litigation.3,4 Early readmissions following an AMA discharge can cost more than 56% of expected expenses following the initial hospitalization.5 Hospitals may, in some cases, bear the burden of readmission expenses due to declines in Medicare reimbursement for some patient populations with chronic heart and pulmonary disorders.6,7 With these considerations in mind, AMA discharges require thorough evaluation to maximize safe and ethical patient care.
In cases where there is a question about the patient's ability to make an informed decision to refuse treatment, the nurse practitioner (NP) must quickly decide how to balance the patient's right to autonomy with protecting his or her best interest through beneficence (doing good) and nonmaleficence (inflicting no harm). He or she may consult with a physician to assess the patient's capacity in order to determine if the patient is able to make an "informed refusal." Whether or not a patient has the capacity to understand, make a decision, and take responsibility for the consequences of the decision is a clinical determination, different from legal competence.
Competence is a judicial determination made by a judge in a court of law.8 Judges often follow the recommendations of healthcare professionals regarding whether or not a patient is competent. If a patient is deemed incompetent by a court of law, the usual outcome is that a guardian is appointed to make decisions for the patient. The process for pursuing guardianship can take time and ranges from a few days for emergency situations to months for nonemergent situations. Therefore, obtaining guardianship is not an immediate solution when patients ask to leave the hospital AMA. Moreover, a patient's capacity can often be restored quickly as the medical condition improves. The clinical severity of the patient's condition can change, and leaving the hospital may not be considered AMA. Therefore, a physician may rapidly reverse a determination about whether the patient has decision-making capacity (DMC) and whether the patient needs to be detained in the hospital based on an improvement in clinical condition.
With the passage of the Patient Self-Determination Act, some patients have a durable power of attorney for healthcare (DPOAHC) that represents the patient's wishes regarding healthcare decisions when he or she lacks DMC.9 When a patient is evaluated and found to lack capacity to leave AMA, the DPOAHC should be contacted (if one exists) to discuss detaining a patient against his or her will. However, the proportion of patients with a DPOAHC is very small, and it is rarely an option.
Patients who choose to leave AMA are likely to be younger males in a low socioeconomic status, have Medicaid or no insurance, and have substance abuse problems.1,10-12 Patients who leave AMA are also not likely to have an established relationship with a primary care provider, are not satisfied with their hospital experience, have a history of leaving AMA, are experiencing financial stress, or are having concerns about the health of their family members at home.11,13-15
There are also studies addressing the therapeutic relationship and communication as a reason for leaving AMA.16,17 Patients who wish to leave AMA may have a conflicted relationship with the healthcare team and sometimes use outward anger and agitation to communicate deep, negative feelings regarding their provider. When such clues regarding dissatisfaction go unrecognized, attempts to repair and salvage the therapeutic relationship are lost, and the situation progresses to the patient wanting to leave AMA. In these cases, patients leave with inadequate understanding and treatment. Attempting to understand the patient's concerns and expectations will allow for improved communication and may avoid AMA discharge. Goals of care discussions are often helpful in determining a patient's understanding of their disease process and their approach to medical decision making.
What is DMC and how is it assessed?
Patients who lack DMC are often diagnosed with delirium, dementia, or other psychiatric disorders.8 An assessment of DMC is appropriate if the patient's capacity has been questioned by someone. The cognitive skills required and the emotional burden placed on the patient while making a decision varies based on decision at hand. Therefore, DMC should be assessed with regard to specific decisions.
Applebaum identified criteria that have been adopted by the medical community for determining DMC that are easily applied when assessing whether a patient has the capacity to make the decision to leave AMA.18 In order for one to have DMC, he or she needs to fulfill four functions (see Criteria for DMC).
The patient that lacks DMC for leaving AMA may be detained until the patient is determined to have capacity or departure no longer would result in significant impairment, injury, or potential harm or death to the patient. It is prudent, then, for the NP to assess the patient at a reasonable frequency.
|Figure. Criteria for DMC|
Who should assess DMC?
The attending physician responsible for the patient's care can evaluate the patient's DMC for leaving AMA. It is recommended at this time that the NP refer the patient with probable lack of DMC who wishes to leave AMA to an attending physician of the primary service for a determination about whether the patient does or does not have capacity. Given trends in healthcare, it is yet to be determined whether the scope of practice for NPs will include assessment of DMC.
Because the decision can be complex, oftentimes, psychiatrists or bioethicists are asked to weigh in on the assessment.19,20 The two specialties have differing ways of addressing the assessment: bioethicists address the ethical issues and philosophy of healthcare values and preferences, while psychiatrists diagnose mental illness, are skilled in identifying abnormalities of thought process and reasoning, and provide treatment for disorders of behavior and emotion. A psychiatric consultation can be sought when assessing DMC is particularly challenging. DMC should be assessed with regard to specific decisions. It is important to keep in mind that when a patient is determined to lack capacity to leave AMA, it does not automatically mean that he or she lacks capacity to make other medical decisions.
Protocol for holding patients against their will from discharging AMA
Every effort should be made by the NP to address any underlying causes for the patient's decision and to assess capacity for decision making before the patient leaves AMA. Early recognition and acknowledgement of the patient's expressions of anxiety and feelings of helplessness and anticipation of these emotions can be useful in establishing rapport between the NP and the patient in order to maintain high-quality patient care.17,21
When a patient expresses a wish to leave AMA and there is an associated, substantial physical health risk, an assessment of DMC can be quickly assessed with a few key questions (see Elements of assessment of DMC for leaving AMA). In order for a patient to have DMC, the patient has to be able to fulfill all of the four criteria. It is reasonable to hold the patient for further evaluation by an attending physician if at least one element is lacking.
The patient can be encouraged to stay with verbal redirection, use of constant supervision, distraction, or use of psychotropic medication to reduce and/or manage severe behavioral disorders. If the patient should refuse to remain in the clinical area, hospital security should be notified to assist in detaining him or her. If the patient should continue to refuse to remain in the hospital, the NP should progressively follow limiting behavioral escalation through the use of seclusion or restraint, if needed (see Restraint algorithm for managing behavorial escalation with patients lacking DMC for leaving AMA).22
When the decision is made that a patient lacks DMC and is making efforts to leave AMA, progressive force may be used to detain the patient as described. Because there is often a need to include clinical staff and sometimes hospital security to assist with detainment, a list of potential case scenarios and a list of responsibilities for training were defined (see Roles of clinical and nonclinical staff for detaining patients who lack DMC). Authorization to hold a patient involuntarily should be communicated to personnel involved in bringing the patient back to the care area. This will allay the fears of clinical staff and security personnel regarding violating patients' rights and falsely imprisoning patients.
|Table Elements of assessment of DMC for leaving AMA|
There is a trend in hospitals to wrongly use psychiatric civil commitment to detain patients who lack DMC for leaving AMA.23 Civil commitment is a legal mandate to hold patients involuntarily for a psychiatric evaluation within a limited time frame due to danger to self or others. Psychiatric civil commitment is not authorized to detain patients for medical treatment. Oftentimes, patients who lack DMC do not have a mental illness. More commonly, such patients are in the midst of a delirium episode, suffer from dementia, or traumatic brain injury. When patients lack the capacity to make the decision to leave AMA, they should be detained using a "medical hold." The term medical hold was created at the author's institution to denote the process that should be followed when patients who are deemed to lack capacity to leave AMA. The term conveys two essential ideas to clinical staff and to security personnel: The patient needs to be detained and that providing medical care is the purpose of detention. The clinical assessment of the capacity to leave AMA should be documented in the medical record while detaining the patient for medical treatment. Some patients with mental illness who lack DMC may have medical complications, which need to be addressed prior to transfer to a psychiatric hospital. Once medically stabilized, civil commitment documents may be completed to transfer to a psychiatric facility if the patient refuses a voluntary admission.
Implications for practice
AMA discharges can be anxiety provoking for the NP, clinical staff, and the patient. Due to the risk of significant adverse reactions of AMA discharges, it is important to carefully balance patient rights with beneficence and nonmaleficence. Patients may often leave AMA without proper assessment of their capacity for decision making. The NP is in a critical role to anticipate the patient's needs, feelings, and goals; determine an approach for medical decision making; educate and promote healthy communication; and to quickly make a decision about whether the patient may lack DMC. Consultation with the primary physician to make a full-capacity assessment is recommended. The patient may be detained using a "medical hold" in cases where he or she lacks DMC. When verbal redirection fails, force and restraint may be used to detain patients who lack DMC for leaving AMA.
Follow-up on case
On quick assessment, Mrs. M was unable to explain the risks of leaving the hospital, the benefits of staying in the hospital, or how she would return home. The patient's RN notified the physician in charge of her care. After speaking with the patient, the physician made a diagnosis of delirium and determined that the patient lacked the capacity to leave AMA. The patient did not have a DPOAHC. The patient was redirected by the RN under the orders of the physician. Her husband was contacted and notified of the situation. The physician discussed with the next of the kin that it was medically necessary to detain the patient and that she would benefit from medication. Her husband was in agreement that she should be detained and told the physician, "Do whatever you need to do to keep her safe, and get her better." The delirium cleared in 2 days, and she was recovering well from the surgery.
1. Yong TY, Fok JS, Hakendorf P, Ben-Tovim D, Thompson CH, Li JY. Characteristics and outcomes of discharges against medical advice among hospitalised patients. Intern Med J. 2013;43(7):798-802. [Context Link]
2. Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125(6):594-602. [Context Link]
3. Devitt PJ, Devitt AC, Dewan M. Does identifying a discharge as "against medical advice" confer legal protection. J Fam Pract. 2000;49(3):224-227. [Context Link]
4. Levy F, Mareiniss DP, Iacovelli C. The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. J Emerg Med. 2012;43(3):516-520. [Context Link]
5. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327. [Context Link]
6. Centers for Medicare & Medicaid Services. Readmissions Reduction Program. 2012. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/R. [Context Link]
7. Readmission reduction has begun and the penalties will escalate. Hosp Case Manag. 2013;21(4):45-47. [Context Link]
8. Mitty EL. Decision-making and dementia. Try This: Best Practices in Nursing Care to Older Adults with Dementia. 2012;(D9). [Context Link]
9. Pope TM. Legal briefing: the new patient self-determination act. J Clin Ethics. 2013;24(2):156-167. [Context Link]
10. Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25(9):926-929. [Context Link]
11. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929. [Context Link]
12. Tawk R, Freels S, Mullner R. Associations of mental, and medical illnesses with against medical advice discharges: The National Hospital Discharge Survey, 1988-2006. Adm Policy Ment Health. 2013;40(2):124-132. [Context Link]
13. Jeremiah J, O'Sullivan P, Stein MD. Who leaves against medical advice. J Gen Intern Med. 1995;10(7):403-405. [Context Link]
14. Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse. 2004;30(2):489-493.
15. Murante AM, Seghieri C, Brown A, Nuti S. How do hospitalization experience and institutional characteristics influence inpatient satisfaction? A multilevel approach. Int J Health Plann Manage. 2013. http://www.ncbi.nlm.nih.gov/pubmed/23818333. [Context Link]
16. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284(8):1021-1027. [Context Link]
17. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. [Context Link]
18. Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840. [Context Link]
19. Berger JT. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408. [Context Link]
20. Kontos N, Freudenreich O, Querques J. Beyond capacity: identifying ethical dilemmas underlying capacity evaluation requests. Psychosomatics. 2013;54(2):103-110. [Context Link]
21. Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med. 2013;28(12):1657-1662. http://www.ncbi.nlm.nih.gov/pubmed/23818160. [Context Link]
22. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Hospitals-Restraint/Seclusion Interpretive Guidelines & Updated State Operations Manual (SOM) Appendix A. 2008. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertific. [Context Link]
23. Mossman D. Psychiatric 'holds' for nonpsychiatric patients. Curr Psychiatry. 2013;12(3):34-37. [Context Link]