If a parent wishes to sign out a child against medical advice (AMA), emergency physicians (EPs) may become offended, annoyed, hostile, or appear unconcerned. These reactions increase the risk of a malpractice suit being filed in the event of a bad outcome, warns Laura Pimentel, MD, vice president/chief medical officer at Maryland Emergency Medicine Network in Baltimore, MD.
“In the past, there was a tendency to leave patients/parents to their own devices, since they refused further care in the hospital,” says Pimentel. “Failure to continue to try to care for the patient by providing the best possible outpatient care or follow up is very risky.” She offers these practices that can reduce legal risks of pediatric AMA discharges in the emergency department (ED):
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Learn the reason why the parents or guardian is signing the child out.
ED staff might learn of a logistical problem, such as the need to go home and care for other children or pick someone up from school. “Sometimes, interventions by social workers can mitigate this situation and prevent the AMA,” says Pimentel.
Pimentel says a more concerning scenario is when parents are leaving the ED because they are dissatisfied. “This can be for many reasons,” she says. “It is very much in the ED physician’s interest to try to rectify the situation, if possible.”
Parents may be upset over a long waiting time, difficulty drawing blood from the child, or a poor interaction with the ED physician, the ED nurse, or other ED staff member. Apologizing for a long wait and expediting the remainder of the visit may be effective, says Pimentel. “Asking a different staff member to work with the child, or even another physician to take over the care, may be in the best interest of the patient and the clinician,” she advises.
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Take reasonable steps to keep the parents from leaving until the visit is complete.
This may entail enlisting the help of other family members or the patients’ pediatrician. “Physicians should document these efforts and discussions with other influential people,” advises Pimentel. She gives this example: “The case was reviewed with the patient’s primary care pediatrician. She has encouraged admission to the hospitalist service. The child’s mother spoke directly to the pediatrician over the phone. After consideration, she has still decided to leave AMA. Follow up with the primary care pediatrician was arranged for tomorrow morning at 10 a.m.”
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If the parent is going to leave despite the ED’s efforts, the EP should provide the best outpatient care possible.
“Doing and documenting everything possible to arrange excellent outpatient care is essential,” says Pimentel. “This is especially true in case of dissatisfaction with ED care.” EPs can prescribe appropriate medications, such as antibiotics in the case of infection, steroids and inhalers or nebulizers in the case of asthma, and pain medications in the case of orthopedic injuries. EPs can arrange expedited follow up with the primary care pediatrician or appropriate specialist.
“If expeditious follow up cannot be arranged from the ED, one can always instruct the parent to bring the child back to the ED for re-evaluation in 24 or 48 hours,” says Pimentel.
Pimentel says particularly concerning scenarios involve AMAs for pediatric patients with respiratory illnesses such as croup, bronchiolitis, or asthma. “Aggressive outpatient treatment, documented precautions, and next-day follow up are the best the EP can do to mitigate potential disaster for the child and the physician,” she says.
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Tell the parents that they may return at any time if circumstances change, the child deteriorates, or they change their mind.
“Try to part company in a friendly and professional manner,” says Pimentel. “Do not manifest irritation or hostility toward the patient or family.”
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Have the parent sign an AMA form.
“Nothing is completely legally protective in the event that a child suffers death or disability. But a well-constructed AMA form that is signed and witnessed is helpful toward the defense of the EP,” says Pimentel. This will document the information and risks explained to the parents and their insistence upon discharge. “At University of Maryland, we have transitioned from AMA to the concept of informed refusal,” she reports. “Our emergency medicine risk forum committee has designed a form including several key points.” These are as follows:
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Risks that might be anticipated, including permanent disability and death;
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The parent assumes responsibility for the decision;
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Release of the clinicians and hospital from responsibility;
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Specific language stating that the patient may return at any time;
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Evaluation of the lucidity or capacity of the decision maker to understand the risks that were explained.
Pimentel says that under these two circumstances, the EP should refuse to allow a pediatric patient to be signed out AMA:
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If there is concern for non-accidental trauma. If the EP suspects abuse or neglect, nearly all states require that the child be held for evaluation by child protective services. “The EP should notify hospital administrators and lawyers in this circumstance,” says Pimentel.
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If the child is critically ill or has a clearly diagnosed life-threatening diagnosis, such as meningitis, sepsis, appendicitis, or diabetic ketoacidosis. In such cases, the EP should hold the child and have hospital personnel work on obtaining a court order for treatment, says Pimentel.
Edward Monico, MD, JD, assistant professor in the section of emergency medicine at Yale University School of Medicine in New Haven, CT, says that generally, an EP has the legal authority to take temporary protective custody of a child without the consent of the parents or caretaker if the following conditions exist:
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If there is reasonable suspicion of child endangerment and the belief that sending the child home would present an imminent danger threatening the child’s life or health;
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If the parent refuses treatment in a life-threatening situation;
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If there is insufficient time to apply for a court order under local child protection laws for temporary custody of the child.
Risk-reducing Practices
Patients who leave the ED AMA frequently suffer from serious underlying medical pathology, warns Monico, and tend to represent a higher-than-average source of medical-legal liability than other ED patients.1 “In fact, these patients sue the emergency physician and hospital nearly 10 times as often as the typical ED patient — about one in 300 AMA cases result in litigation, vs the usual rate of one in 20,000 to 30,000 ED visits,” says Monico.2
Legal risks that flow from pediatric AMA encounters are two-fold, says Monico. First, patients who terminate diagnostic studies and treatment prematurely may have undiagnosed and/or inadequately treated pathology that can lead to bad outcomes.
“Second, without proper documentation of the encounter, physicians leave themselves open for claims that patients left without the requisite information to make an informed decision to do so,” he says. Monico recommends these strategies for EPs to reduce risks of pediatric AMA encounters:
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Understand institutional expectations regarding docu-mentation of AMA encounters;
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Have a thorough under-standing of the current standard of care for documentation within a given jurisdiction;
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Document any discussion of foreseeable risks particular to the given scenario, as well as the results and limitations of testing already conducted.
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Provide an opportunity for the patient to ask questions.
Monico says that often, hospital AMA forms are constructed with an expectation that healthcare providers will document the process of providing patients with sufficient information to enable them to make an informed decision to act against medical advice. “Many times, these forms are merely signed without further documentation,” he says. “This leaves healthcare workers open for claims arising from lack of providing requisite information and possibly breach of hospital policy.”
Many EPs lack knowledge as to what information to share with patients contemplating leaving AMA, or how to document that information. In a 2009 study performed at Yale-New Haven (CT) Hospital, only 4.8 % of providers documented that patients leaving AMA were informed of the risks of terminating their emergency evaluation; only 5.7% documented alternatives to treatment.1 “About 50% documented they actually informed patients they were leaving AMA,” says Monico, the study’s lead author.
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Monico EP, Schwartz I. Leaving against medical advice: Facing the issue in the emergency department. J Healthcare Risk Management 2009; 29(2):6-15.
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Bitterman RA. Against medical advice: When should you take “no” for an answer? Lecture presented at the ACEP Scientific Assembly, Chicago, IL. Oct. 30, 2008.
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Edward Monico, MD, JD, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT. Phone: (203) 785-4710. E-mail: [email protected].
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Laura Pimentel, MD, Vice President/Chief Medical Officer, Maryland Emergency Medicine Network. E-mail: [email protected].
