One patient will always haunt Dr
Stephen Hwang. The homeless schizophrenic man was admitted
with abdominal cramps due to volvulus. In the middle
of the night, he discharged himself from hospital against
medical advice. He collapsed and died a block away.
"It sticks in your mind if you've
experienced it yourself," says Dr Hwang, an internist
at St Michael's Hospital in downtown Toronto, which
treats a lot of homeless patients. And many of you have
experienced it — each year, 20,000 Canadians discharge
against medical advice (AMA), often to readmit within
weeks. But there are ways to predict and prevent these
cases, or at least reduce harm when they happen.
PREDICT
Discharge AMA is hard to anticipate, but some patients
are more likely than others to try it.
Male AMA discharges are
often single, young adult males, with a history of repeated
events and numerous hospitalizations.
Addiction Substance abuse
is very common among those who check themselves out
of hospitals. In one study, Dr Hwang found that 70%
of AMA discharges in the general medical setting involved
alcohol abusers, although few of them cited this as
their reason for leaving.
Homelessness Homeless patients
tend to have higher AMA rates. Dr Hwang says that these
patients sometimes just don't mesh with the hospital
atmosphere, and feel mistrustful of orders they're given.
They also tend to have a lot of other risk factors.
Mental illness Psychiatric issues,
like personality disorders and antisocial behaviour,
are also more common. "A person might be unstable,"
says Dr Karl Looper, a psychiatrist at Montreal's Jewish
General Hospital. Patients who try to bail must usually
speak with him first. "First seeking help, they'll turn
around and refuse it, for no apparent reason. There's
often a fundamental lack of insight at play."
PREVENT
The ideal way to address AMA discharge is through preventive
measures. There are several things you can do.
Inform "Tell patients everything
that's going to happen during their stay," advises Dr
Sriram Ramaswamy, an Omaha, NE, psychiatrist who recently
published an outline on handling psychiatric AMA discharge
in Current Psychiatry. "For instance, they should
know in advance if they won't be allowed to smoke, especially
in the psychiatric setting." Dr Looper agrees. "There
should be as few surprises as possible," he says.
Explain Some patients need
everything explained to them. Misunderstandings between
patient and doctor often lead to non-compliance. "We
need to clarify the goals of treatment," says Dr Looper.
"Listen to what patients ask for and give updates if
plans change. They'll be more cooperative."
Team effort Patients who
discharge AMA are often difficult to get along with.
If another member of the medical team seems to have
a good rapport with such a patient, you shouldn't hesitate
to get them involved.
Family matters Some patients
may want to leave for very practical reasons, such as
young kids back at home, rent to pay or a fear of missing
work. The needs of homeless patients may sound odd to
you, notes Dr Hwang, but if you and your staff make
an effort to contact the patient's family members, friends
or social worker and get things sorted, you'll increase
the odds they'll stay.
Night watch Patients are
often tempted to sneak off during the night, when their
doc's not around. Night staff should be informed if
a patient has a known history or risk of AMA discharge.
They shouldn't hesitate to call the daytime physician
should there be a late-night AMA discharge request.
Stall Stalling tactics may
allow enough time for an aggressive or unruly patient
to calm down, or be convinced to stay. Dr Ramaswamy,
who works in a locked facility, notes that an AMA discharge
form must always be completed before a patient leaves.
A classic stalling tactic is to take a long time processing
this paperwork.
Gauge competence "It's critical
to assess whether a patient is capable of making decisions
before allowing them to go," says Dr Hwang. Discuss
the gravity of the medical problem with patients. Make
sure they know where you stand, and document your discussion.
Consider a Form 1 "If a
patient fails to appreciate the risks posed," says Dr
Looper, "there are grounds for keeping them in hospital
against their will." Holding a patient against their
will, which is more common in the psychiatric setting,
is typically justifiable if there are big foreseeable
risks, like suicidal tendencies, says Dr Looper. "But
not infrequently people make decisions we think are
inadvisable, and we have to let them go. Think of smokers,
for example."
DAMAGE
CONTROL
Dr Hwang stresses that, as frustrating as it is for
a patient to short circuit your care, their decision
doesn't absolve you of all responsibility. So what can
you do if they insist on leaving, despite your preventive
efforts?
Write up scripts Write the
patient prescriptions, even if for sub-optimal treatments
— after examining them as well as you can. Since
their spotty self-care may continue outside of the hospital,
just give them meds instead of a script if you're worried
they won't get them filled.
Arrange follow-up Make follow-up
care a priority. Chances are high they'll need to come
back. Schedule an appointment.
Written instructions Provide
them with a written summary of their diagnosis. They
might not care what's happening now, but it could help
them when the analgesics start to wear off.
Stay in touch Get as much
patient contact information as possible. If your patient
is homeless get their caseworker's name and number,
if possible. Give the patient phone numbers and contact
info in case they're in a jam.
Leave the door open Dr Looper
cautions against getting overly upset with them, even
if you feel like you're being second-guessed. "Don't
discourage patients from coming back," adds Dr Ramaswamy.
Take notes Dr Hwang stresses
the importance of documenting the whole process, if
possible. Doctors sued for malpractice in AMA discharge
cases have successfully defended themselves by demonstrating
a lack of evidence of negligence. Do what you can for
the patient, and keep a record of your efforts.
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