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CMECNE

What to Do When Your Patient Leaves the Hospital Against Medical Advice?

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Restate that medical treatment requires patient consent
2. Summarize key elements that should be included when documenting refusal of care

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

It is a challenge to provide quality healthcare when patients do not adhere to their physicians’ recommendations for treatment. The patient who insists on leaving the hospital Against Medical Advice (AMA) is an extreme example of non-adherence, and this situation creates high potential for serious errors.  Recognition of the reasons patients leave can help negotiate these encounters. They leave for a variety of reasons including personal and financial obligations, breakdown of communication between the patient and medical staff, dissatisfaction in care, and not understanding the need for further testing or treatment. Every effort should be made to determine what is driving the patient’s decision-making process.  There may be times when the provider is at a loss to understand why a patient would walk out prior to receiving necessary care.  Even in this circumstance, treatment without consent can be deemed as battery, as patients do have the right to refuse care.

DOCUMENTATION:

Some courts have ruled that it is illegal for a hospital to require a patient to sign a waiver of liability as a “condition of their release” (Dedely V. Kings Highway Hospital Center, 617 NYS 2d 445 Supp (1994)). Therefore, the better approach consists of documenting the following eight criteria:

  1. The patient’s ability to express a choice; ability to understand relevant information; ability to appreciate the significance of the information and its consequences; and, ability to manipulate information. A patient does not have to be free of mental illness or delusions
  2. The signs and symptoms
  3. The extent and limitation of the evaluation
  4. The current treatment plan, risks, and benefits
  5. The risks and benefits of forgoing treatment
  6. The alternatives to suggested treatment
  7. The exact statement made by the patient who left AMA, as well as the explicit documentation of what the patient was refusing
  8. The follow-up care including discharge instructions

KEY POINTS:

  • Practitioners should give the patient immediate attention so long as another patient is not compromised
  • Do not express your frustration and anger to the patient
  • Do not refuse to provide treatment – give the patient what she may be willing to accept,  such as prescriptions or future appointments, even if not the entire nor ideal treatment plan
  • If unsure of capacity, call for help, which will usually entail a psychiatric consult
    • Use standard hospital and professional procedures if there is any threat the patient may harm herself or others
  • Focus on medical management and not insurance issues
    • Although providers will often help whenever possible, insurance coverage is ultimately the patient’s responsibility

Learn More – Primary Sources:

Documentation proficiency of patients who leave the emergency department against medical advice

Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice

“I’m Going Home”: Discharges Against Medical Advice

Association of Hospital Discharge Against Medical Advice With Readmission and In-Hospital Mortality (JAMA Network Open)

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This website (the “Website”) is a service made available by The ObG Project LLC, its partners, affiliates or subsidiaries (“Provider”). This Website provides general information related to the law and is designed to help users safely cope with their own legal needs. This website does not provide legal advice and Provider is not a law firm. None of our customer service representatives are lawyers and they also do not provide legal advice. Although we go to great lengths to make sure our information is accurate and useful, we recommend you consult a lawyer if you want legal advice. No attorney-client or confidential relationship exists or will be formed between you and Provider or any of our representatives.
This website is not intended to be a source for legal advice, and thus the reader should not rely on any information provided in this website as such. Readers should not consider the information provided to be an invitation for an attorney-client relationship, and should always seek the advice of competent counsel in the reader’s home jurisdiction. Provider may provide links to third party websites. These links are provided only as a convenience. Linked websites are not reviewed, controlled or examined by Provider and Provider is not responsible for the information, advertising, products, resources or other materials, of any linked site or any link contained in a linked site. The inclusion of any link does not imply endorsement by Provider. In addition, please be aware that your use of any linked site is subject to the terms and conditions applicable to that site. Please direct any questions regarding linked sites to the webmaster of that site.

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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