http://www.pitt.edu/~kconover/ftp/ama.txt

[Guest guest]

I went ahead and copied the text from this URL here. This is probably the

absolute best description of a proper AMA that I've ever read in my life. I'd

recommend printing and posting this at your stations...

Against Medical Advice

======================

AMA needs the following documented on the chart:

1. CAPACITY: patient has the capacity (competence) to sign out

2. TOLD: attending told patient of the diagnosis

3. WHAT ELSE: What other reasonable alternatives can the patient pursue?

4. OUTCOME: What might be the outcome if the patient signs out AMA?

5. FAMILY: You have involved the family, if any, in the AMA process; have

them sign chart, if possible.

And, quoting from Emergency Department Law 1993;4(23), p. 8-7,

relating to questions I posed after a particularly difficult night,

with 2.5 inappropriate AMA discharges from our hospital:

" ...What are the attendant duties and liabilities of medical

restraint in the following not so atypical scenario? An elderly man

is brought to the Ed by his family. When asked what the problem is,

the man reveals no specific medical complaints except for 'being

sick.' The man recalls something about throwing up blood, but says

that it happened 'several days ago.'

" The patient's vital signs are unremarkable, as is his physical

exam, except for some mild epigastric tenderness. His stool is

hemetest negative and his blood pressure shows no orthostatic

instability. His answers to questions reveal no evidence of any

overt psychiatric illness, but he is disoriented as to place and

time.

" According to the family and medical records, the patient had

recently been admitted to the hospital with the diagnoses of alcohol

intoxication, pancreatitis, and an upper GI bleed. He had been

scheduled to be transferred to an alcohol detoxification center in

three days. However, he had signed out from the hospital " Against

Medical Advice " just three hours earlier.

" The patient had walked about a block from the hospital, where he had

been found collapsed in a snowdrift, confused and unable to walk. [by

his family --KC] The cause of the confusion was not clear to the

examiner, but it appeared to be alcohol withdrawal. [or the

benzodiazepines he'd been given --KC]

" During the process or re-admitting the patient to the hospital, his

family expressed great concern that the patient had been allowed to

leave the hospital, since he could have died of exposure. They

expressed willingness to sign psychiatric commitment papers, but the

emergency physician did not feel that the patient had any primary

psychiatric problems. [N.B. -- in Pennsylvania, alcohol-related

problems are specifically excluded from the reasons you can use to

involuntarily commit someone. --KC]

" Should the patient be restrained in this situation? What are the

legal risks and liabilities?

" ANALYSIS: The analysis of any patient's situation should always

begin with establishing what course of action is likely to promote

his or her good health. In this case, wandering aimlessly in

inclement weather was obviously not to the patients' advantage.

" If weather is not a factor, is the patient able to care for his

medical condition? Is he or she able to obtain and take medications

and food? IS there someone willing to assist the patient? If there

would be any doubt by a reasonable person [and those of us who work

in the ED know this is an entirely fictional legal construct --KC]

as to the patient's ability to care for him- or herself, at least

there is a proper motivation to intervene. While the analysis does

not stop here, this alone should be enough to defend against a charge

of false imprisonment.

" In fact, there may be liability if you do not act on the patient's

behalf. In an emergency condition where the patient is unconscious,

the patient has the right to presume consent to treatment. Failure

to do so would undoubtedly result in a claim of negligence.

" For example, one hospital found itself liable for the wrongful

death of an intoxicated patient who had presented to the emergency

department requesting help for this drinking problem. After making

his request, the patient left the ED with another alcoholic and was

struck by a car while attempting to cross a nearby highway. A court

later found that once the patient present asking for assistance, the

hospital had the duty to comply with that request until he regained

the capacity to protect himself.

" If it is true that a physician must have the patient's consent for

treatment, but consent is presumed when the patient is incompetent,

then the right or responsibility to restrain a patient is determined

by whether or not he or she has the ability to make an informed

decision. The test is the same whether the patient is a Jehova's

Witness who refuses life-saving blood or the fearful elderly person

who refuses life-sustaining protective measures. If they lack

capacity to make a truly informed decision, the physician is

permitted, even obligated, to presume consent to treatment that is

in the patient's best interest.

=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=

" The legal capacity to consent or refuse consent can be reasonably

determined by a four-prong test:

" - Does the patient understand the relevant information?

" - Does the patient have the ability to manipulate the information?

" - Does the patient have the ability to communicate a choice?

" - And finally, can the patient put all of these together to appreciate

the situation and its consequences?

=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=

" The first test is one of simple understanding. If the patient

cannot understand the danger, those that [sic] do have an obligation

to protect him. Asking a patient to paraphrase what has been told to

him can help assess this understanding better than asking him to

simply regurgitate information. If a person is disoriented, it is

hard to support a conclusion that they appreciate a personal danger

" To determine whether a patient can successfully manipulate

information, it is helpful to ask the patient about hypothetical

situations based on what a rational person would do. In this way a

person with normal capacity, but differing values, can demonstrate

that understanding.

" The third prong looks to whether the patient can make decisive

choices. Differing responses within short periods suggest that the

patients' capacity to organize his thoughts and choose a course of

action is confused and unstable. [see Addendum below --KC] Patients

who repeatedly change their minds should be protected until their

decision-making process is stabilized.

" The last prong entails the ability to appreciate the outcomes of

their behavior and give reasons for their choices. The goal is to

evaluate the patients' ability to do this, not to make value

judgments based upon the choices.

" The bottom line is exactly where we started. What is the best

thing for the patient's health? If restraining a patient is the best

way to ensure that outcome, then proceed with such, observing the

normal precautions.

" The advice to treat the patient as you would your own mother is a

good guideline. The legal risk of behaving in this manner is one

well worth taking. " [from Mark Plaster, M.D., J.D., FACEP]

[Addendum: on this same shift, another family brought in a woman,

against her will, who also had just signed out AMA and found by the

family in a bar drinking. She was alert, seemingly able to give a

good history, smiling, cooperative, and ready to sign out again AMA.

I was ready to let her, until I talked to the family, who said she

had been nearly dead of hepatorenal syndrome, had severe liver

failure, and had been told that if she drank again she would die.

When I went back to her, she was still alert, smiling, and a good

historian, but with a completely different history. She remembered

nothing about having liver failure, or hepatorenal syndrome. She was

a classic Korsakoff's glib confabulator. I admitted her against her

will, on the grounds that based on her poor memory she wasn't capable

of informed consent to an AMA. I called the magistrate for a

restraining order.]

[Addendum #2. A couple of hours before the end of my shift (which

by this time I thought would never end) one of our (excellent)

third-year internal medicine residents called me from the floor. He

said his internal medicine attending had told him to let his patient

sign out AMA but he had some questions and wanted to consult me

first. (Nice when even the residents on the other services consult

the emergency medicine attendings for advice.) I asked what the

patient's medical problem was. He said DTs. I asked if the patient

was hallucinating. He said yes. Only raising my voice a little (I

was very proud of this at the time) I told him that, not to mention

suing him for malpractice, I would personally strangle him if he let

the patient sign out AMA. I explained the above and he called the

magistrate. I suspect that by this time the magistrate was ready to

strangle _me_.]

Final note: when teaching residents about AMAs, I always use the

above stories to point out the following (view with nonproportional

font):

|-------------people who want to sign out AMA-------------------|

|-people to let sign out AMA-| |-people to commit-| |---*****---|

***** means there are people who want to sign AMA who don't meet the

criteria for involuntary commitment, but who still shouldn't leave.

Most are drunks who we just tell to shut up until they're sober; many

threaten to sue and we just say " see you in court, shut up and

behave. " (Most apologize when they're finally sober and able to

leave.) Ones that are more complex get " medical restraint. " And if

needed, a restraining order from a local magistrate who rules

(legally) on their competence to sign out AMA.