When is AMA appropriate?

[wookie]

Heyoo,

I'm now into my 5th month in emergency medicine fresh out of school and there's one thing (among many) that my brain's not quite clicking on. 

When is it appropriate to have a patient sign out AMA versus just documenting the pros and cons of certain testing/treatments and discharging them to home. 

If you have a patient on coumadin sustain minor head injury and they refuse a CT scan, would you sign this patient out AMA or just document that you had a discussion at length regarding the importance of imaging and potential consequences of not getting a CT (disability/death)?? What about an elderly patient with multiple comorbidities with classic presentation of MI who's refusing all testing? 

Thanks for any clarification

[LT_Oneal_PAC]

If they refused any evaluation, testing, treatment, then AMA.  If they, for instance, just wanted me to do a neuro exam and avoid radiation from a CT if exam normal though I think they need one anyway, then we have a risk benefit discussion and they make their choice through shared decision making and patient autonomy.

[SERENITY NOW]

If there is a clear indication to do something and not doing it would be a breach in the standard of care, and the patient refuses it, they should get AMA form.  That being said, the AMA form alone does not in any way protect you from liability.  In fact, patients discharged AMA have much much higher rates of litigation, and successful litigation at that.  So, you still need to document extensively the conversation you had with the patient, which is more important than the form for your protection.  Remember that there are several components you have to address... their reasons (validity), competency AND capacity, specific risks of leaving, benefits of staying, involvement of family members as applicable, and most importantly, trying to facilitate the best alternative plan including max outpatient therapy and close follow up window, or return if they ever change their mind.  The old school paradigm of "well you don't want to listen to me, so get out of here!" is definitely out, since it really helps the lawyers case against you!

[DizzyJ]

My street smarts understanding....documentation is perhaps most important then a signature on an AMA form.  If a patient signs out AMA, but you didn't document that a clear conversation took place with an individual with capacity to make an informed decision, there is still potential liability.  When an AMA form is used, it should spell out exactly what you want to do, pros/cons, why you want to do it, and the risks/potential death that could come if it isn't done. 

Important to note your opinion about capacity and NOT competency.  Only a judge can declare competency. 

[gbrothers98]

While I won't disagree with our colleagues here, best to do 2 things.

Meet with your ED director and your primary supervising physician (if different) about this. That way you are on the same page with each and you have support for your actions.

Next, the ED is a minefield for well meaning new grads and not everyone is going to be your proponent in these sticky situations. So determine what is going to drive your practice in addition to direction from your Director and SP. Use some professional development funds to subscribe to the following podcast:

https://www.ccme.org/riskMgmt/default.aspx

Henry & Bukata are well known in the field and advice/direction from them is difficult to argue against or discount. At $150 / year with 24 cat 1 CME credits available, this is a great use of $, calculated to $6.25 per cat I credit.

Good luck.

George