We don’t seem to get many folks wanting to leave against medical advice. Many times the floor nurse can somehow pacify them enough to allow us to care for them. It’s something I don’t understand. You get yourself admitted to the hospital, but absolutely refuse to participate in your care. What? It’s not like we came down to your house, picked you up for no reason and then proceeded to admit you and perform ungodly amounts of tests and whatnot in order to just torture you. And this is in folks who are lucid, non-demented and fully cognizant of their situation. With some you can talk until you’re blue in the face, laying out the horrible things that could happen to them if they left. It doesn’t faze them. They want out. Now.
Then there are those that use the threat of leaving AMA as a lever to get their way. Like petulant little children who didn’t get a lollipop, they throw a tantrum in the guise of leaving AMA, somehow hoping to get what they wanted: smoking privileges, more narcotics or a private room. Many times it works. I’ve lost count of how many the residents have talked out of leaving. And then they give them what they wanted. Most of the time I’m of the nature to say, “OK, don’t let the door hit your ass on the way out. Oh, can you sign this (AMA) form right here?” But sometimes, when the reason for admission is very grave, I don’t want them walking out the door; mostly for the fear they’ll just bounce back in worse shape, but more because I like my license.
This weekend one nurse had 2 patients demand to leave. Evidently, this had happened earlier in the month as well. So she got a new nickname: the AMA Queen. This weekend she had one of each: one we wanted to stay, they other was welcome to leave.
The first woke up screaming after her stent placement. Screaming in pain, cursing the nurses, the doctor, threatening to sue anyone who crossed her path. After some Fentanyl and Ativan, she calmed down (…was gorked out of her mind!). She woke up again, and the cycle was repeated. Then night shift arrived. By now she wasn’t feeling so happy anymore as the effects of the meds had pretty much worn off. For awhile she was compliant. Yes, inspecting your insertion site into the femoral artery in the groin is not a pleasant thing, especially when it happens every hour because you’re on Integrillin and had gotten 600mg of Plavix. But we need to check for bleeding, hematomas and a variety of other unpleasnt things that could go wrong from the opening of a large hole in you artery. Finally she had enough. “I’m leaving.” she proclaimed, “Get this IV out of me and take your stupid box!” as she tore off her telemetry box.
This was one where I was leery about letting her go. Besides the evident cardiac instability, there was the fact she had a large bore hole in her femoral artery, albeit closed and was on a large does of anti-platelet medications. The Queen put in a call to the cardiologist, the residents and after some time, with her patient see-sawing back and forth of her promising to stay, then threatenting to leave, a solution was reached: more drugs, more frequently, no more groin checks with vitals and assessments Q8 instead of Q4. The Queen was beside herself, as I would have been, as she had a patient on Integrillin and she nothing to go on but faith that the site was free from bleeding, hematoma formation and that the patient still had distal blood flow. Not good. Faith is good, but fixing a pseudo-aneurysm from a hematoma or vascular surgery to save a leg isn’t pretty. The patient however was near ecstatic as she had won. And me? As charge I was furious, at the residents, at the cardiologist and at the patient. She had played us and the docs gave in. We had lost any chance to deal rationally with her now or in the future as she had learned that if you scream loud enough and long enough, you get what you want. Just like a child in the supermarket.
The second one was just the opposite. About an hour into the shift he announced to the Queen, “I’m ready to go now.” Baffled at the apparent rewind of events she did what we do and called the on-call resident. Only this time, the resident had been the patient’s primary doc for the last 3 days. Up to the floor she came, explained the risks of leaving, did the whole informed consent thing and let him go. We knew that this wold have been better than fighting with him all night. Before the consensus fo rhim to leave was reached, he put on his light. As I answered it he said, “Oh, I don’t want trouble. I just want to leave.”
“OK,” I said, “we’re talking with your doc right now. Give us 5 minutes, OK?”
“Sure” he mumbled. And good to my word, his doc with there in about 5 and he was out the door 30 minutes later.
Now that’s the way it should go.