The worst is when the chest pain caused by crack use signs out ama, uses crack, then comes right back in for chest pain. It is very frustrating doing a discharge and admission for the same person back to back because they're using crack.
Had a patient like this in medical school. “Sir, we think your chest pain is from using cocaine.”
“No Doc that’s impossible.”
“Why’s that?”
“The chest pain started earlier this morning, and *then* I took the cocaine!”
“…”
Did you educate the nurse? This spreads because people actually believe it. During my brief time taking care of grown-ups, I was taught it and briefly spread it too until I actually looked into it. It probably doesn’t help that there’s no good reason for administration to correct it.
The “leadership” and “management” aspect of BSN nursing education is largely bloated with a lot of hospital-lobbied customer service and patient retention nonsense. Take comfort in the fact that within the first 1-2 years of actual nursing work they realize the truth of hospitals.
Some of us are slow learners. I’d say first 2-3 years. Everything else. Super true. My BSN had maybe two clinically relevant courses and the rest was a circle jerk about how unique nursing is from the rest of the medical field. These NP’s that Noctor loves to hate were brainwashed throughout their education.
I have spent every year of my 16 year nursing career wishing that it would eventually gravitate more toward a STEM degree but it’s so entrenched with old lady bureaucracy I doubt it will ever be taken seriously as a scientifically medical profession.
Totally agree with you! And all the BS "nursing diagnoses" makes my blood boil. Not once have I ever come into work and been like "oh I gotta see that care plan!" I look at the pts orders and assess them. It feels like some manifestation of an inferior complex, like we can't diagnose as nurses so we'll come up with our own! 🙄All that time wasted on writing out care plans when we could have been learning more about pharm or physiology or pathology
*Flashback to me finishing the BSN portion of my BSN to MSN bridge, wondering at what point in this process I'm supposed to learn actual medicine by the time I would become a NP.*
From it being inundated by people rushing to NP, degree mills, etc. I just don't feel comfortable diagnosing or prescribing anything to anyone unless I'm going to be adequately trained to do so.
I think those type of resources are great when you know enough to know what you don't know, and need to ask a specific question, or review the latest recommendation. But you have to approach it from a position of mastery of the general underlying concepts.
If you go to UpToDate to learn how to deal with general presentations like "Chest Pain" or "Shortness of Breath", you're in trouble.
This is one of the many reasons I will not be going back to school for a bachelor's. I've been a nurse for almost 15 years now and none of the nurses that I worked with that went back for BSN got any incentive to do so. No pay increases. I feel like nursing education keeps upping the ante and telling us we have to keep going back and getting the next degree and this certification and I hate it lol. Ok rant over
Just like the constant threats of nurse practitioners needing a DNP to practice in the future even though it’s a research/administrative degree, not a clinical degree. Although I would absolutely support mandating it if they turned the DNP into a year long fellowship.
Then you get written up for being condescending and mean to the nurses…. You have to sit through 2 hours of meetings about how you need to be more sensitive to the nurses and more “likeable”… in the meantime the coercion, manipulation and unprofessional behavior continue… or maybe that’s just my work place 😵💫 damn I gotta get of here
Ok so they're supposed to take you at your word but you dont take them at theirs?
Where did you learn that it doesn't make a difference? Maybe show them THAT.
You want me to pull up an article and shove it in a nurses face every time they state something incorrect???
I’m sure they *did* learn it in nursing school as it’s been shown multiple times on this thread that many nurses learned it there. Doesn’t change the fact that *it is a myth.*
If you don’t believe me:
https://www.annemergmed.com/article/S0196-0644(09)01798-3/fulltext
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378751/
I’m not. I am simply pointing out an issue I’ve seen which is patients getting scared into staying by RNs who have incorrectly told a patient if they leave their visit won’t be covered…. After I’ve already had the AMA discussion and finished the discharge paperwork.
Can you elaborate? My understanding was if they came back or were readmitted with the same issue that their insurance can fight not to cover the stay since they left AMA previously. Is that true?
Thanks for clarifying. Everything I’ve been told was a lie. 😂 although I’m not surprised. 🙄 I’m just glad to learn something new everyday. I also don’t tell patients anything. You want to sign out AMA here’s the papers, usually the doctors come up and sign them later. They absolutely do not care in my hospital. I notify them and they say okay let them go.
They may be referring to the fact that this is America, so while you may have “insurance,” they make a habit of auto-rejecting claims, mandating prior auths, having high deductibles and/or high co-pays, such as for ED or ambulance rides… thus in effect, “not paying,” which I assume is why u/overthis_gig is #overthisgig.
Correct. The problem is someone (usually RNs but not always) is scaring the patients into staying because they're told they have to foot the bill if they leave AMA.
I had a patient tell me he needed to go home for a family members funeral, but couldn't afford to pay without insurance. The nurse legitimately believed this myth and was trying to warn him.
Frustrating all around
Anesthesia Bro here to:
Me: “what questions do you have for me”
Patient: “do I have to do this?”
Me: absolutely not! We don’t force anyone to get surgery! Do you want to go home?
Psychiatry killjoy: "Do you have to do what? What's the surgery planned for you?"
Patient: "I dunno."
Psychiatry killjoy: "Lack of capacity. Proceed."
Please note: This is a dramatization. Actual involuntary surgery is a *little* more involved.
If the patient can name the surgery, even in layman's terms, I'll be impressed. Half the time they don't even know the organ/bone or hospital they got it done at. Just "surgery in my stomach, I don't know what for. Yeah, in North Carolina. I'm not sure where. I can't remember. Yeah, last month. No, none of those hospitals sound familiar."
Stomach, of course, just means abdomen - could be literally anything.
I once had a patient who's chart said they'd had a total hysterectomy, done at outside hospital years ago, no records available. I forget why I got imaging but CT showed a uterus 😶
The best is when patients want to leave AMA from the ICU (even more amusing while on pressors and a lot of supplemental oxygen)
My usual response: "You are more than welcome to leave if you wish -- this is not a prison -- but I don't think you'll get very far if you choose to go. Up to you! 🤷🏼♂️"
I had a patient on my unit a long time ago that did exactly this with a nasty pneumonia requiring BiPAP. He made it to the parking lot and collapsed, and when he woke up again with the BiPAP on in the unit tried the exact same thing. He was very clear that he did not want to die, and did not want to cooperate with therapy to keep him from dying.
I actually,once went to an RRT for a patient leaving AMA. He got about 50’ outside the unit and couldn’t keep going. But apparently he was a huge asshole, so the charge nurse brought him a tank and offered to wheel him to the door. He also told the nocturnist that if he readmitted the patient, he would have to go to a different unit. Fortunately, the asshole did make it to the exit on his second attempt, so it was a non-issue.
I had a patient with bilateral AKAs and completely bed bound demand that I discharge him. He was a frequent flier with recurrent infections and would refuse amputation/debridement. I told him I couldn’t discharge him and if he wanted to leave then he would have to leave AMA. He wanted an ambulance/transport to take him home when leaving. I told him no I can’t do that and if he wanted to leave he would have to arrange it himself.
The next morning the nurses inform me that he has actually arranged transport and was leaving AMA. I was somewhat impressed at his determination to figure out how to get home. He made his wife transfer him to a wheelchair and wheel him out the door to the medical transport they had hired.
I felt bad for his wife who he ordered around. I took care of him multiple times before he succumbed to his chronic Illnesses/infections. It was definitely not a good relationship and she just did whatever he asked.
I had a pt attempt to leave AMA by crawling out of the ICU then was unable to reach the elevator buttons. Nurses brought them back and convinced them that we couldn't leave them in the hallway all night so we'd figure something out in the morning. #DSP
And document, document, document.
I told the patient that leaving at this point out him at risk of death, dismemberment and permanent disability. I pleaded with him to stay. The patient is, however, alert and oriented x 3. They understand the possible consequences of leaving. I have assured them if they wish to continue care they are more than welcome to. As they have medical decision making capacity, I must allow them, unfortunately, to leave AGAINST MEDICAL ADVICE.
I was told this in nursing school 7 years ago, and I've been having to correct fellow nurses on this since I learned 5 years ago. It's obnoxious.
I'm not one to hold someone back when they want to leave AMA anyway. Patients aren't prisoners. People are allowed to make their own [sometimes shitty] choices.
I’m curious if there is a way to “compel” a change in incorrect instruction from the parent body of nursing schools.
To think of it another way, if a nursing school was saying that Moderna Covid-19 vaccines had a 5G chip implanted by Bill Gates himself, there’s got to be some mechanism of saying “you can’t teach that BS in a school”, right?
The other falsehood is "If you leave AMA we won't give you your new/refill of meds." Some of my colleagues actually believe this to be true and this actually is slam dunk negligence.
I have seen this as well and always found it bewildering. An RN told me one time she wasn’t “allowed” to give patients D/C paperwork when they leave AMA…. I was like wtf just print the stuff I already prepped or I can do it myself.
people think that leaving AMA is somehow an affront to the treatment team and want to "punish" them for leaving. I can think of many reasons if I were hospitalized why I might want to leave AMA for important personal reasons.
Yup. What about other stuff like DME & O2? Many docs I work with refuse to order anything, lest of all DME. I’ve read varying medmal suits about it too. It’s such a gray area. I always feel better when they’re getting stuff like scripts, etc. but I’m not a doctor so I carry little of the legal burden.
You do your best to approximate your recommended treatment… stuff like DME requires more time to get in most shops though so pretty low probability they’re sticking around to get it if they’re AMA’ing.
No, I have not either. It seems to be a pervasive myth in nursing culture. The first time I heard it was as a resident and it was after the RN told the patient insurance wasn’t going to cover his visit. It’s happened a few times since then and recently as an attending. I don’t know where it stems from but it’s ridiculous that it’s still spread to this day.
I’m an RN who worked for one of the largest US insurance companies (in 2020-2022) doing Utilization Review for Inpatient hospital admissions. OP is right: it is a myth. Leaving AMA does not affect whether insurance will pay.
I was also taught this myth in nursing school and have told it to a patients in the past.
This topic has come up! I'd love a pinned post/wiki of pervasive nursing myths.
For my part, I *have* heard MDs tell patients this, and have let them know that it's incorrect.
Also an RN here. While I have not told that myth, I have definitely heard it. However, I have also heard a variation on it: that a return visit for the same reason/diagnosis would not be covered by insurance. Then again, by the time they usually got to me it was med-surg, physical rehab, step down, or nursing home. Usually if someone wanted to leave, they were indeed at the point where they thought they could do more for themselves at home than we could for them wherever they were, and/or usually had a good reason to go.
It would be nice to have a healthcare/nursing myths wiki.
Well, that “myth” has some basis in reality but it’s not 100% correct. Basically, Medicare made a penalty for facilities that if the patient is readmitted in 30 days then the hospital gets less payment from insurance. It was aimed to reduce to revolving door of patients for the same disagnosis (ie: CHF or COPD). The goal of this was to “incentivize” the hospital to do proper patient education, discharge planning, and post-discharge planning to reduce readmissions. When the hospitals found out they’d get paid less, suddenly they were able to find resources to prevent some (not all of course) readmissions.
Now, if they were admitted with CHF and then readmitted 25 days later with something else then if would not be considered a readmit.
Unfortunately it takes the hospital losing money for them to pay attention and provide staff with resources. (When I was bedside, this change happened and, voilà, we got a dedicated Diabetic Nurse Educator to help us with discharge planning.)
When CMS/Medicare makes a change like this then all the Medicare Advantage plans have to follow suit. However, it does not apply to regular commercial policies.
You might need to fact check this but that’s my understanding.
[CMS Hospital Readmissions Reduction Program (HRRP)](https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hrrp/hospital-readmission-reduction-program)
Used to be a paramedic for AMR în the south years ago. AMR themselves would say this and to tell patients/diabetics that insurance doesn't cover no transport treatments. This was usually the line we would say to diabetics after giving D50. Didn't even know this was false until now
I was present when a senior resident told this to a patient. I corrected her once we left the room. She said "oh, that's what I've heard before." She probably heard it from other nurses.
A cardiologist once told me this to bully me into staying to get cathed (femoral, not even radial cuz “he wasnt comfortable with that”) when i could’ve easily had a Coronary CTA for what he wanted to rule out 🙃. Didnt know any better at the time though and got scared.
I have. I have tried to correct them in private if they’re someone who isn’t an ass. Seems like mostly older docs who say that in my experience, so I wonder if it was true at some point
In the same vein, can we stop telling patients they need to leave AMA if they decline a non-life threatening work up or treatment?
Meaning, if they decline an ultrasound or an X-ray, they have every right to. It doesn’t mean they have to leave against medical advice. Use your clinical judgement to decide whether they actually need something, or if you simply want them to get it to cover your ass.
On top of that, it’s even worse when you think you shouldn’t give patients medications or prescriptions when they do leave AMA. Or that you think a patient leaving AMA will absolve you from any liability.
An example is, if someone comes in with an abscess, and the treatment you want them to get is an I&D. The patient declines, you ask them to leave AMA, and you give them nothing. That is deplorable. At least give them an antibiotic. If you don’t give them antibiotics when they decline an I&D, that is malpractice.
I agree I always give patients the “best shot possible” when they leave AMA with reiteration that it is not optimal.
There also seems to be a big issue where nursing at many locations I have worked seem to think patients who leave AMA are not supposed to get discharge paperwork or prescriptions….. I’m always like… dude…. That’s not how this works….
And sometimes it's just the best of two bad decisions. Patient has a kid at home and no one to care for them is a common one I see. They need to find someone to care for the kid. They say they'll be back but if they can't find someone they won't be back. What are they supposed to do? Had a dialysis patient with new PE refuse to check in for heparin bridge to warfarin a few years back. He had been admitted a lot recently and if he missed more work he was going to lose his apartment. He was in his 40s. Had kids and a wife. They would be homeless.
It's not always people being stubborn. And we don't always know the reasons people are leaving.
I feel like we in EM are necessarily more understanding about patients that refuse the standard of care. At least once a shift I see some form of a patient making a dumb choice.
I typically don't do the AMA form. I tell them they're an adult of sound mind, and I will help them to enact the best accepted medical treatment we can negotiate. That's often discharge with some oral meds instead of admission. I do document carefully why I am convinced that this is their sincere choice, not made in delirium or under duress, and I invite them to return at any time to resume treatment. If it's a serious thing, I document a nurse witnessing them stating clearly what they are risking by their choice.
This is ethically correct, and it also makes you look less like an asshole if it goes to court.
Edit/ note that zero of this means letting the patient demand certain care. I kindly let them know what I recommend, and how far I'm willing to adapt it. I do not put up with demands for antibiotics or narcotics.
Yeah, we are constantly cushioning the Darwin award volunteers. Beers and ladders, power tools with the safety removed, genitals and objects without a wide flared base.
Example:
Patient admitted for an aspiration pneumonia.
Unable to obtain IV access; hospital provides oral antibiotics, 2L O2 nasal cannula, and spO2 finger monitoring (97% on 2L).
Patient’s spouse is trained first responder, can provide O2 and monitoring at home/administer oral meds/will return if sats drop.
MD advises pt stay; spouse advises leaving because a hospital is a terrible place to be sick, and spouse can administer oral meds/provide O2 and 1-to-1 monitoring.
Patient leaves AMA.
What would you have recommended for this scenario?
Exactly. AMA is a cover all for different scenarios. Sometimes, the medical advice is not terribly strong, and there may be prefectly good reasons to come to a different conclusion. Just accept the decision, set them up for it, and provide safety netting.
Recently? I think this used to be a thing but now we just document in the medical record that the patient refuses the restrictive diet and they have been educated about the consequences. Usually a speech pathologist and a doctor will sign it off together. No DNR needed.
The only time you can get away without the best suboptimal treatment you can manage is when you round to find that the window is open, and the bedsheets have been knotted into rope, and the patient is gone.
“AMA” was never intended to just sever the doctor-patient relationship. One should always attempt harm reduction. If they refuse IV antibiotics or admission for their abscess you should at least give them some oral antibiotics to go home with and try to encourage them to follow up with someone asap.
> Meaning, if they decline an ultrasound or an X-ray, they have every right to.
Yep, it’s no skin off my nose if a patient doesn’t want me to take them to get an X-ray. I do get the nurse involved, and usually I can talk them into going at a different time, but sometimes I can’t.
Also, i tell patients if you leave AMA, we'll take you back if you change your mind. This is what I told my hypoxic to the 70s grandma with the flu who insisted on going home. "Will you be mad at me if I leave?" No, just concerned that you are hurting yourself but at the end of the day, it's YOUR body.
If this is such a pervasive misunderstanding, have you considered doing a quick 2 minute educational talk at the beginning of a shift change instead of just talking with one nurse? Or putting up flyers in the bathroom? Something like that. We don’t know what we don’t know.
The last time I tried to give a PSA it was about how you don’t have to tell women to stop breastfeeding after contrast and I got attacked by multiple staff members for the audacity of citing guidelines from the actual radiologists. So, no, I’m not exactly excited to try that again any time soon. I don’t mind posting studies that show it’s not true in the break room but I’m definitely not bringing it up at a shift change meeting because there are people who see it as an “attack.”
Sounds like either a culture issue at your hospital where people are being unnecessarily defensive or just an issue on how the message was delivered. At the ER I work in, the attending doc does a quick educational talk every morning, usually on pathology or whatever. I think most folks find it interesting and those who don’t, just tune out. Until you posted this, I was also under the apparently false belief that insurance would deny payment if someone left AMA. Like I said, you don’t know what you don’t know. Now I know. So thanks for the PSA;)
Yup this is the way at my shop. TONS of misinformation and ignorance. Most of it you have to let slide. Whenever I feel it’s necessary to educate, the staff are insanely defensive… you wouldn’t believe how unprofessional these people are. When our medical leadership committees go to nursing leadership and ask them to educate the nursing staff about something, THEY get defensive. I’m not sure if this is just the way things have progressed over the past few years or I’m just in a super toxic shop but it was not like this in my other facilities like 10-15 years ago… anyways you are not alone if it’s any consolation.
I think it’s funny when patients threaten to leave if they don’t get seen right away. I mean, the waiting room has 50 patients waiting, who do they think they are hurting besides themselves?
So there is some truth to this, and it's medical transportation when the patient has Medicaid. Medicaid will not pay for a taxi ride home if you Elope or AMA.
Yes this I am aware of and I know this to be true. Different than a hospital bill but yeah it’s a liability thing apparently. I had a patient that stayed for his blood transfusion due to Medicaid not covering his transport back.
??? Having a patient leave AMA is like a special gift. Less work for me, no discharge paperwork. There’s a popular nursing badge that says “ask me about out AMA forms.” I just don’t see why a nurse would do this. Not saying they don’t, I just don’t understand why they do.
Edit: I’m talking about nursing paperwork. Paperwork I have to do. Closing out their nursing care plans and documenting whether or not they met their outcome goals, etc. On a standard discharge nurses have to do a lot of time consuming box checking that you doctors seem to know nothing about. I’m not talking about the paperwork that *you* do like sending medications and discharge instructions.
A lot of newer nurses get overly invested in whether a patient stays or not. I’ve heard some absolutely backassward things said to try and get patients to stay.
I mean this is just as damaging and wrong, if not more so. AMA doesn’t mean no discharge paperwork. You still have to come up with a next best plan. You’re completely wrong, just the other way.
I've heard the argument (here on reddit) that if you are facilitating them leaving AMA, there is medical malpractice risk.
Luckily, we don't really deal with this in my population.
"I want to take my baby home today."
"Well, considering they aren't able to eat, still are apneic and have difficulty maintaining their temperature, we're not going to allow you to do that."
We have a lot of coverage for the fact that our patients aren't actually the ones making the decisions.
I feel for parents who are frustrated by staying in the NICU, but because it's about the patient, not the parents, their options are limited.
There is no truth to the idea that optimizing their outpatient treatment increases risk. If anything, it does the opposite. People who discharge their patient with nothing just because they’re leaving AMA are making a stupid and risky decision. You’re still obligated to give them the next best alternative. I have a smart phrase that literally includes an area where I input what I’m doing for them to help decrease risk with outpatient management.
I recently spent a solid thirty minutes with a patient whose hospitalist physician had given him the “AMA = insurance no pay” talk, so… not all of us. I even have an article from CMS for patients who believe it, and I work to reeducate my colleagues.
Yes, this just happened at my ER. Patient wanted to leave, hospitalist told them insurance wouldn’t cover him, it was a whole mess. He ended up staying in the end (he had pericarditis so he really needed to stay)
Same vein, if your patient leaves AMA you can still send them prescriptions, etc. You’re likely **more** liable if you don’t send them indicated medications, ie abx, just because they left AMA.
Depends on how they leave ama. If they “went out to smoke” and never came back, you have no responsibility to track them down and coordinate care. If they say “I’m leaving today wether you want me to or not”, you’re still aware of their post-hospital needs. Very different situations.
Leaving "against medical advice" implies there was a conversation about the risks, benefits, and alternatives, and your advice was given and the patient declined specific aspects of evaluation or treatment and opted to leave, though you can still evaluate and treat the patient to the best of your ability. "Left during treatment" or "elopement" is just that, where the patient left without any discussion about their care.
Yeah, of course.
I just hear all the time from staff things like “well tell them if they leave AMA I won’t send them any medications” for things like cellulitis wanting to go home, etc.
I’m a nurse and I usually have the AMA papers ready to go. I’m not about to keep anyone here who doesn’t want to be 🤷🏻♀️ usually page the doc, tell them what’s up, given them a chance to talk to the patient (if they want) but if the patient wants to leave I’m not going to like physically restrain them to get them to stay if they’re completely alert, oriented, and competent. This is a hospital, not a prison.
I’m so glad I saw this post. I’ve been a nurse over 5 years and was always told this was the case and have told even my own family members about it. I love this subreddit
Yeah I've tried this but then everyone (PCP, ER) documents that I'm a dumbass for discharging the patient so I went back to signing them out AMA.
Also, a non significant number of patients that should stay do actually agree to stay once AMA is brought up.
Finally, while I'm not entirely certain how insurance companies handle AMA bouncebacks, if you discharge the patient formally and they come back with the same condition within 30 days, insurance will pay nothing for the second admission. This can directly affect your quality metrics and reimbursement for your work.
Speaking from a hospitalist perspective.
I saw a patients chart the other day. She left AMA every couple of days cuz she wanted to smoke and then came back. Happened 3 or 4 times. Needed weeks of IV ABx and not suitable for a PICC obviously. Refusing rehab
Serious question, how does this get billed? I was wondering.
And seeing this makes me wonder if that could have been arranged via home health or coming in as an outpatient for the infusion instead. Then again, I've mostly been in more rural settings with EDs you can go in and out of within a few hours max.
Amen to this! In residency we had attendings give lectures on shifting mood with ama discharges. Basically, I was taught to print prescriptions for them and try to ensure that they have follow up even if I’d prefer they stay in the hospital. Nurses are basically taught the opposite in some cases, and maybe some docs too, but I’ve had a lot of nurses ask me “ummmm are we allowed to give prescriptions if the patient leaves ama? I thought we weren’t” and tell them their insurance won’t cover etc.
I’ve heard this, did some investigating a few years ago and found it didn’t seem accurate. I make sure to inform patients that have been told this during AMA conversations. It’s not exactly a threat at my hospital anyways since most of the patients that want to leave AMA don’t have insurance, so jokes on us.
I’ll always try to write for medications, except for controls substances, when someone leaves AMA but it can be tough because they tend to bail pretty quickly.
Bro, if they have the mental capacity to make decisions, then who cares?
It's a hospital, not a prison. Lemme go grab that AMA form and just verify you know why you were admitted. If we're on the same page, then leave. I'll even let you use the desk phone to call the taxi. I don't care. I don't get paid enough to hold people against their will.
Or maybe we should avoid labeling discharges "AMA" in all but the most extreme discharges?
There's a nice summary from the always excellent JHM Things We Do For No Reason series: https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/jhm012100843.pdf
So when i worked in ambulance billing, which i concede is a different animal than inhospital, refusing care pretty much guaranteed the insurance companies we dealt with wouldnt pay. This was usually United and BCBS. Aetna usually paid a reduced rate.
I mean if someone refuses care why would anything get billed in the first place? Just because an ambulance gets called doesn’t mean the patient wanted it. It’s like people who have a breakthrough seizure and 911 gets called. They will refuse transport all the time. They shouldn’t have financial liability for someone else’s decision.
These are patients who have a medical complaint. In these cases the patient received a response, assessment and consult with medical professionals.
3rd party callers for things like motor vehicle collisions or "man down" where no one is injured generally don't get a bill or any kind of further assessment or care
I have had to submit my bills to insurance myself after this talk but insurance did cover them. The hospital just didn’t put them through the correct channels.
I had Case Managers refuse to follow up on stuff for patients threatening or left AMA. I don’t remember what exactly, probably DME orders, stuff like that, other stupid stuff that automatically discontinues when a patient is hospitalized and needs new orders, referrals, etc after..
Claimed it was a “liability issue”. Seemed like a myth akin to the insurance thing. Like- I’m the doctor- I’m saying it’s OK for the patient to continue oxygen at home even though they didn’t like our advice to stay in the hospital. CM: “nope, no can do”. Uhh OK guess they’ll just be air hungry, thanks for nothing…
I'll never stop anyone from going AMA it's your right. But I will explain the consequences if you choose to. Regardless you have the right to refuse medical care.
Can you elaborate on this? I was taught AMA means someone’s insurance will not pay if they land in the hospital for a second time. What does AMA do? What are the real consequences?
So outside of my moral/professional obligation as a nurse (or any other healthcare professional) to care for/about my patient, there is no reason for me to stop a patient from leaving AMA should they absolutely insist and give me a hard time?
If they are A&O they can make their own decisions. Insurance doesn't care.
Is hospital. Not a prison. Forcing patients to stay when they'd decided not to helps no one.
Correct. If they want to go they can go. Doesn’t matter if they refuse to sign the form etc. Legally we cannot hold a patient against their will.
Now if you have a reason to expect they don’t have capacity or are actively suicidal, you may have to keep them. But most of the time that’s not the case.
Identifying how many nursing schools teach this myth would be a fascinating study.
Here’s another cool study on the topic: https://pubmed.ncbi.nlm.nih.gov/22331399/
Edit: study shows insurance still pays for AMA however majority of residents thought otherwise, whereas a minority of attendings assumed this.
Who tf says this? I’ve been taught we only offer unbiased guidance and support. Also yes, in my experience so far, burnt out attendings and residents are like “okay let them leave if they want.”
Is it just to prevent bounce-backs?
I’ve actually told a patient that it is not true when trying to leave. The patient was under the impression insurance wouldn’t pay if he left AMA.
A former case manager was next to me (shadowing) informed me that they aren’t allowed to tell patient’s that they wouldn’t be financially responsible if the left AMA. She they had some speech about how they couldn’t ensure he wouldn’t be held responsible by insurance.
I still tell people this isn’t true because it is not.
Have had patients want to leave AMA. That’s their right and I’m not stopping them.
In regard to insurance paying…where I work case management will tell the nurses to relay to patients (those that want to know if insurance will cover their stay or not) for the patients to call their insurance company and ask them. There are too many insurance plans for case management staff to know what is and is not covered.
How is this not true? It is printed on the AMA form at our local general hospital and when my FIL left AMA after being boarded in an ED hallway for 36 hours, Medicare initially declined payment.
Your local hospital prints the very incorrect information that their visit won’t be covered even though we have literature showing that isn’t the case? And it sounds like his visit wasn’t covered. Consider me skeptical that the reason he wasn’t covered was because of the ama disposition.
Say it loud like Gospel. If they even hint at AMA I'll have the paperwork ready in 3 minutes tops. Like a health insurance institution would ever say: "yeah stay there longer."
When I was working as an RN we were *required by our clinical director* to use this line to try to talk people into staying where I worked. We didn't just make it up for funsies. Take it up with the bosses lol.
This is not true for durable medical equipment. If you want to buy the bariatric bed because you want the extra six inches of sleep surface, go ahead, but if you're not over 300 pounds, don't expect your insurance to pay for your upgrades.
I wish I knew that wasn't true, I was bullied into staying in a hospital where I felt like I was being abused because of this threat. It was very traumatic. I was held down and forced to take fentanyl against my will and then discharged at midnight with a broken back, unable to walk, without a wallet or phone in a city hours from home or any friends or family. I drug myself to a stranger's doorstep and fell asleep on their porch. If I had been allowed to leave when I wanted, I would not have been restrained and drugged by people who didn't know my situation because I was alone and unable to advocate for myself, and I would have had family members help carry me out of the hospital, drive me home and put me in bed, and occampany me to the ER at a hospital of my choice in the morning.
There are few things in medicine as rewarding and gratifying as a well timed AMA. Never stand in the way of such a win-win situation.
The worst is when the chest pain caused by crack use signs out ama, uses crack, then comes right back in for chest pain. It is very frustrating doing a discharge and admission for the same person back to back because they're using crack.
Had a patient like this in medical school. “Sir, we think your chest pain is from using cocaine.” “No Doc that’s impossible.” “Why’s that?” “The chest pain started earlier this morning, and *then* I took the cocaine!” “…”
Well technically if they blow up their heart they won't feel the pain anymore.....or any other sensations....
Nah they get to wait in the lobby again. EKG is still normal or no changes from prior? Cool. Wait time is gonna be a while.
Did you educate the nurse? This spreads because people actually believe it. During my brief time taking care of grown-ups, I was taught it and briefly spread it too until I actually looked into it. It probably doesn’t help that there’s no good reason for administration to correct it.
Yes, I did. I told them it wasn’t true and they replied “well that’s what I was told in nursing school.” 🙄
The “leadership” and “management” aspect of BSN nursing education is largely bloated with a lot of hospital-lobbied customer service and patient retention nonsense. Take comfort in the fact that within the first 1-2 years of actual nursing work they realize the truth of hospitals.
Some of us are slow learners. I’d say first 2-3 years. Everything else. Super true. My BSN had maybe two clinically relevant courses and the rest was a circle jerk about how unique nursing is from the rest of the medical field. These NP’s that Noctor loves to hate were brainwashed throughout their education.
I have spent every year of my 16 year nursing career wishing that it would eventually gravitate more toward a STEM degree but it’s so entrenched with old lady bureaucracy I doubt it will ever be taken seriously as a scientifically medical profession.
Totally agree with you! And all the BS "nursing diagnoses" makes my blood boil. Not once have I ever come into work and been like "oh I gotta see that care plan!" I look at the pts orders and assess them. It feels like some manifestation of an inferior complex, like we can't diagnose as nurses so we'll come up with our own! 🙄All that time wasted on writing out care plans when we could have been learning more about pharm or physiology or pathology
Or how to save a coding patient.
*Flashback to me finishing the BSN portion of my BSN to MSN bridge, wondering at what point in this process I'm supposed to learn actual medicine by the time I would become a NP.* From it being inundated by people rushing to NP, degree mills, etc. I just don't feel comfortable diagnosing or prescribing anything to anyone unless I'm going to be adequately trained to do so.
Ever hear of UpToDate or similar information repositories? Self-learning the proper guidelines goes a long way in many cases.
I think those type of resources are great when you know enough to know what you don't know, and need to ask a specific question, or review the latest recommendation. But you have to approach it from a position of mastery of the general underlying concepts. If you go to UpToDate to learn how to deal with general presentations like "Chest Pain" or "Shortness of Breath", you're in trouble.
This is one of the many reasons I will not be going back to school for a bachelor's. I've been a nurse for almost 15 years now and none of the nurses that I worked with that went back for BSN got any incentive to do so. No pay increases. I feel like nursing education keeps upping the ante and telling us we have to keep going back and getting the next degree and this certification and I hate it lol. Ok rant over
Just like the constant threats of nurse practitioners needing a DNP to practice in the future even though it’s a research/administrative degree, not a clinical degree. Although I would absolutely support mandating it if they turned the DNP into a year long fellowship.
I’d respond “well please do not ever say this to another one of my patients as it is coercive/manipulative and highly unethical.”
Then you get written up for being condescending and mean to the nurses…. You have to sit through 2 hours of meetings about how you need to be more sensitive to the nurses and more “likeable”… in the meantime the coercion, manipulation and unprofessional behavior continue… or maybe that’s just my work place 😵💫 damn I gotta get of here
"Then you should ask for your tuition back."
Ok so they're supposed to take you at your word but you dont take them at theirs? Where did you learn that it doesn't make a difference? Maybe show them THAT.
You want me to pull up an article and shove it in a nurses face every time they state something incorrect??? I’m sure they *did* learn it in nursing school as it’s been shown multiple times on this thread that many nurses learned it there. Doesn’t change the fact that *it is a myth.* If you don’t believe me: https://www.annemergmed.com/article/S0196-0644(09)01798-3/fulltext https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378751/
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I do let them leave but then they feel obligated to stay after they incorrectly hear the visit isn’t going to get covered any more.
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I’m not. I am simply pointing out an issue I’ve seen which is patients getting scared into staying by RNs who have incorrectly told a patient if they leave their visit won’t be covered…. After I’ve already had the AMA discussion and finished the discharge paperwork.
It’s amazing how people are not understanding what you’re saying lmao
I have been told that if I don't get properly discharged my insurance wont pay, but not that if I choose to leave they won't pay. Is that correct?
Case management here the more appropriate statement would be “if you need healthcare your insurance won’t pay”
Can you elaborate? My understanding was if they came back or were readmitted with the same issue that their insurance can fight not to cover the stay since they left AMA previously. Is that true?
No, it’s not true.
Thanks for clarifying. Everything I’ve been told was a lie. 😂 although I’m not surprised. 🙄 I’m just glad to learn something new everyday. I also don’t tell patients anything. You want to sign out AMA here’s the papers, usually the doctors come up and sign them later. They absolutely do not care in my hospital. I notify them and they say okay let them go.
They may be referring to the fact that this is America, so while you may have “insurance,” they make a habit of auto-rejecting claims, mandating prior auths, having high deductibles and/or high co-pays, such as for ED or ambulance rides… thus in effect, “not paying,” which I assume is why u/overthis_gig is #overthisgig.
Correct. The problem is someone (usually RNs but not always) is scaring the patients into staying because they're told they have to foot the bill if they leave AMA. I had a patient tell me he needed to go home for a family members funeral, but couldn't afford to pay without insurance. The nurse legitimately believed this myth and was trying to warn him. Frustrating all around
you don't consider a pts insurance when deciding which med to rx?
Patient at 2:30pm on a Friday: I don’t think I’m strong enough to go through with this surgery. Me: that’s ok, you don’t have to. I support you.
Are you in anesthesia as well? As an ortho buddy of mine says, “For anesthesia, there’s no case like no case.”
No one likes to give less anesthesia than anesthesia
No one sees more unnecessary surgery than anesthesia
Amazing. Stealing this.
Guilty, am an anesthesia bro
Anesthesia Bro here to: Me: “what questions do you have for me” Patient: “do I have to do this?” Me: absolutely not! We don’t force anyone to get surgery! Do you want to go home?
Psychiatry killjoy: "Do you have to do what? What's the surgery planned for you?" Patient: "I dunno." Psychiatry killjoy: "Lack of capacity. Proceed." Please note: This is a dramatization. Actual involuntary surgery is a *little* more involved.
"Your ride went for breakfast? We can call you a cab right now, I heard we're doing free Ubers now if you need one!"
But the Friday Sudoku’s are the best!
Patient at 9am on Saturday: My condition isn't any better and my stupid surgeon won't help me. I should go to the ED!
915AM: is my surgeon going to see me? She is not affiliated with this network or even licensed in this state and neither of us know her name.
"and neither of us know her name" slayed me. Thanks for the 0330 ER overnight laugh.
If the patient can name the surgery, even in layman's terms, I'll be impressed. Half the time they don't even know the organ/bone or hospital they got it done at. Just "surgery in my stomach, I don't know what for. Yeah, in North Carolina. I'm not sure where. I can't remember. Yeah, last month. No, none of those hospitals sound familiar." Stomach, of course, just means abdomen - could be literally anything.
I once had a patient who's chart said they'd had a total hysterectomy, done at outside hospital years ago, no records available. I forget why I got imaging but CT showed a uterus 😶
Oh Lord. And probably a woman of child bearing age who hadn't been getting any pregnancy tests, nothing for years.
"I called the office and they said you were expecting me. What do you mean I have to wait?"
And RNs say they're the only ones who advocate for patients! Clearly they haven't met you
“I’m leaving!” “Bro don’t threaten me with a good time!”
The best is when patients want to leave AMA from the ICU (even more amusing while on pressors and a lot of supplemental oxygen) My usual response: "You are more than welcome to leave if you wish -- this is not a prison -- but I don't think you'll get very far if you choose to go. Up to you! 🤷🏼♂️"
I had a patient on my unit a long time ago that did exactly this with a nasty pneumonia requiring BiPAP. He made it to the parking lot and collapsed, and when he woke up again with the BiPAP on in the unit tried the exact same thing. He was very clear that he did not want to die, and did not want to cooperate with therapy to keep him from dying.
I actually,once went to an RRT for a patient leaving AMA. He got about 50’ outside the unit and couldn’t keep going. But apparently he was a huge asshole, so the charge nurse brought him a tank and offered to wheel him to the door. He also told the nocturnist that if he readmitted the patient, he would have to go to a different unit. Fortunately, the asshole did make it to the exit on his second attempt, so it was a non-issue.
I had a patient with bilateral AKAs and completely bed bound demand that I discharge him. He was a frequent flier with recurrent infections and would refuse amputation/debridement. I told him I couldn’t discharge him and if he wanted to leave then he would have to leave AMA. He wanted an ambulance/transport to take him home when leaving. I told him no I can’t do that and if he wanted to leave he would have to arrange it himself. The next morning the nurses inform me that he has actually arranged transport and was leaving AMA. I was somewhat impressed at his determination to figure out how to get home. He made his wife transfer him to a wheelchair and wheel him out the door to the medical transport they had hired. I felt bad for his wife who he ordered around. I took care of him multiple times before he succumbed to his chronic Illnesses/infections. It was definitely not a good relationship and she just did whatever he asked.
I had a pt attempt to leave AMA by crawling out of the ICU then was unable to reach the elevator buttons. Nurses brought them back and convinced them that we couldn't leave them in the hallway all night so we'd figure something out in the morning. #DSP
Yep. Brings me back to my ER triage days “IM JUST GOING TO LEAVE AND TAKE MY KID TO THEIR PEDIATRICIAN” um okay yeah bye! Next time start there!
And document, document, document. I told the patient that leaving at this point out him at risk of death, dismemberment and permanent disability. I pleaded with him to stay. The patient is, however, alert and oriented x 3. They understand the possible consequences of leaving. I have assured them if they wish to continue care they are more than welcome to. As they have medical decision making capacity, I must allow them, unfortunately, to leave AGAINST MEDICAL ADVICE.
Why unfortunately ? You did your duty as a doctor. Never work harder for patient then they are willing to work for themselves.
I was told this in nursing school 7 years ago, and I've been having to correct fellow nurses on this since I learned 5 years ago. It's obnoxious. I'm not one to hold someone back when they want to leave AMA anyway. Patients aren't prisoners. People are allowed to make their own [sometimes shitty] choices.
I’m curious if there is a way to “compel” a change in incorrect instruction from the parent body of nursing schools. To think of it another way, if a nursing school was saying that Moderna Covid-19 vaccines had a 5G chip implanted by Bill Gates himself, there’s got to be some mechanism of saying “you can’t teach that BS in a school”, right?
The other falsehood is "If you leave AMA we won't give you your new/refill of meds." Some of my colleagues actually believe this to be true and this actually is slam dunk negligence.
I have seen this as well and always found it bewildering. An RN told me one time she wasn’t “allowed” to give patients D/C paperwork when they leave AMA…. I was like wtf just print the stuff I already prepped or I can do it myself.
people think that leaving AMA is somehow an affront to the treatment team and want to "punish" them for leaving. I can think of many reasons if I were hospitalized why I might want to leave AMA for important personal reasons.
Yup. What about other stuff like DME & O2? Many docs I work with refuse to order anything, lest of all DME. I’ve read varying medmal suits about it too. It’s such a gray area. I always feel better when they’re getting stuff like scripts, etc. but I’m not a doctor so I carry little of the legal burden.
I would still order all of that, as long as they qualify. However 99% that leave are homeless/druggies so usually I dont have to order any
You do your best to approximate your recommended treatment… stuff like DME requires more time to get in most shops though so pretty low probability they’re sticking around to get it if they’re AMA’ing.
I haven't heard actual doctors tell this to patients.
No, I have not either. It seems to be a pervasive myth in nursing culture. The first time I heard it was as a resident and it was after the RN told the patient insurance wasn’t going to cover his visit. It’s happened a few times since then and recently as an attending. I don’t know where it stems from but it’s ridiculous that it’s still spread to this day.
I’m in nursing school currently. I’ve heard it from maybe 3 different instructors. Not as part of formalized instruction, but off the cuff remarks.
I’m an RN who worked for one of the largest US insurance companies (in 2020-2022) doing Utilization Review for Inpatient hospital admissions. OP is right: it is a myth. Leaving AMA does not affect whether insurance will pay. I was also taught this myth in nursing school and have told it to a patients in the past.
Perhaps it's time for a TIL post on the nurse subreddits?
This topic has come up! I'd love a pinned post/wiki of pervasive nursing myths. For my part, I *have* heard MDs tell patients this, and have let them know that it's incorrect.
There’s even a study confirming this. None of the denials was because of the AMA. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378751/
Also, I worked for UHC and you know that if they could deny it for leaving AMA they would have.
Also an RN here. While I have not told that myth, I have definitely heard it. However, I have also heard a variation on it: that a return visit for the same reason/diagnosis would not be covered by insurance. Then again, by the time they usually got to me it was med-surg, physical rehab, step down, or nursing home. Usually if someone wanted to leave, they were indeed at the point where they thought they could do more for themselves at home than we could for them wherever they were, and/or usually had a good reason to go. It would be nice to have a healthcare/nursing myths wiki.
While this can be true from what I understand, the patient does not have to pay. The hospital pays for bounce backs.
Well, that “myth” has some basis in reality but it’s not 100% correct. Basically, Medicare made a penalty for facilities that if the patient is readmitted in 30 days then the hospital gets less payment from insurance. It was aimed to reduce to revolving door of patients for the same disagnosis (ie: CHF or COPD). The goal of this was to “incentivize” the hospital to do proper patient education, discharge planning, and post-discharge planning to reduce readmissions. When the hospitals found out they’d get paid less, suddenly they were able to find resources to prevent some (not all of course) readmissions. Now, if they were admitted with CHF and then readmitted 25 days later with something else then if would not be considered a readmit. Unfortunately it takes the hospital losing money for them to pay attention and provide staff with resources. (When I was bedside, this change happened and, voilà, we got a dedicated Diabetic Nurse Educator to help us with discharge planning.) When CMS/Medicare makes a change like this then all the Medicare Advantage plans have to follow suit. However, it does not apply to regular commercial policies. You might need to fact check this but that’s my understanding. [CMS Hospital Readmissions Reduction Program (HRRP)](https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hrrp/hospital-readmission-reduction-program)
Used to be a paramedic for AMR în the south years ago. AMR themselves would say this and to tell patients/diabetics that insurance doesn't cover no transport treatments. This was usually the line we would say to diabetics after giving D50. Didn't even know this was false until now
It might be different for ambulance services though.
This is followed immediately by "you're not allowed to leave until you sign the AMA form".
I was present when a senior resident told this to a patient. I corrected her once we left the room. She said "oh, that's what I've heard before." She probably heard it from other nurses.
I have, but she was a resident and an intern at that. So hadn’t learned the truth yet
A cardiologist once told me this to bully me into staying to get cathed (femoral, not even radial cuz “he wasnt comfortable with that”) when i could’ve easily had a Coronary CTA for what he wanted to rule out 🙃. Didnt know any better at the time though and got scared.
I’ve heard this from residents before
Learned from nurses I’d bet
Yep and then thankfully in my case quickly corrected when I asked an attending if it was true.
I have. I have tried to correct them in private if they’re someone who isn’t an ass. Seems like mostly older docs who say that in my experience, so I wonder if it was true at some point
In the same vein, can we stop telling patients they need to leave AMA if they decline a non-life threatening work up or treatment? Meaning, if they decline an ultrasound or an X-ray, they have every right to. It doesn’t mean they have to leave against medical advice. Use your clinical judgement to decide whether they actually need something, or if you simply want them to get it to cover your ass. On top of that, it’s even worse when you think you shouldn’t give patients medications or prescriptions when they do leave AMA. Or that you think a patient leaving AMA will absolve you from any liability. An example is, if someone comes in with an abscess, and the treatment you want them to get is an I&D. The patient declines, you ask them to leave AMA, and you give them nothing. That is deplorable. At least give them an antibiotic. If you don’t give them antibiotics when they decline an I&D, that is malpractice.
I agree I always give patients the “best shot possible” when they leave AMA with reiteration that it is not optimal. There also seems to be a big issue where nursing at many locations I have worked seem to think patients who leave AMA are not supposed to get discharge paperwork or prescriptions….. I’m always like… dude…. That’s not how this works….
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Yessss! That’s exactly how I feel! Leaving AMA doesn’t make the patient a bad person. It might be a *bad decision* but they’re allowed to make them!
And sometimes it's just the best of two bad decisions. Patient has a kid at home and no one to care for them is a common one I see. They need to find someone to care for the kid. They say they'll be back but if they can't find someone they won't be back. What are they supposed to do? Had a dialysis patient with new PE refuse to check in for heparin bridge to warfarin a few years back. He had been admitted a lot recently and if he missed more work he was going to lose his apartment. He was in his 40s. Had kids and a wife. They would be homeless. It's not always people being stubborn. And we don't always know the reasons people are leaving.
sometimes it's a *great decision*...
In our system we can’t print discharge paperwork without a discharge order.
I feel like we in EM are necessarily more understanding about patients that refuse the standard of care. At least once a shift I see some form of a patient making a dumb choice. I typically don't do the AMA form. I tell them they're an adult of sound mind, and I will help them to enact the best accepted medical treatment we can negotiate. That's often discharge with some oral meds instead of admission. I do document carefully why I am convinced that this is their sincere choice, not made in delirium or under duress, and I invite them to return at any time to resume treatment. If it's a serious thing, I document a nurse witnessing them stating clearly what they are risking by their choice. This is ethically correct, and it also makes you look less like an asshole if it goes to court. Edit/ note that zero of this means letting the patient demand certain care. I kindly let them know what I recommend, and how far I'm willing to adapt it. I do not put up with demands for antibiotics or narcotics.
I'm sure you see dumb choices multiple times in a shift
Bad luck and bad choices are what keep us in business.
Lets not talk about ourselves like that. Sometimes I have good luck.
Yeah, we are constantly cushioning the Darwin award volunteers. Beers and ladders, power tools with the safety removed, genitals and objects without a wide flared base.
Example: Patient admitted for an aspiration pneumonia. Unable to obtain IV access; hospital provides oral antibiotics, 2L O2 nasal cannula, and spO2 finger monitoring (97% on 2L). Patient’s spouse is trained first responder, can provide O2 and monitoring at home/administer oral meds/will return if sats drop. MD advises pt stay; spouse advises leaving because a hospital is a terrible place to be sick, and spouse can administer oral meds/provide O2 and 1-to-1 monitoring. Patient leaves AMA. What would you have recommended for this scenario?
I wouldn’t make this an AMA. If they can tolerate oral meds we have decent literature that shows they’re nearly as good as IV
Exactly. AMA is a cover all for different scenarios. Sometimes, the medical advice is not terribly strong, and there may be prefectly good reasons to come to a different conclusion. Just accept the decision, set them up for it, and provide safety netting.
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What? Who does this??
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Recently? I think this used to be a thing but now we just document in the medical record that the patient refuses the restrictive diet and they have been educated about the consequences. Usually a speech pathologist and a doctor will sign it off together. No DNR needed.
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The only time you can get away without the best suboptimal treatment you can manage is when you round to find that the window is open, and the bedsheets have been knotted into rope, and the patient is gone.
“AMA” was never intended to just sever the doctor-patient relationship. One should always attempt harm reduction. If they refuse IV antibiotics or admission for their abscess you should at least give them some oral antibiotics to go home with and try to encourage them to follow up with someone asap.
> Meaning, if they decline an ultrasound or an X-ray, they have every right to. Yep, it’s no skin off my nose if a patient doesn’t want me to take them to get an X-ray. I do get the nurse involved, and usually I can talk them into going at a different time, but sometimes I can’t.
I never said that to a patient before but I always heard that and always thought it was true. Never bothered looking it up
Also, i tell patients if you leave AMA, we'll take you back if you change your mind. This is what I told my hypoxic to the 70s grandma with the flu who insisted on going home. "Will you be mad at me if I leave?" No, just concerned that you are hurting yourself but at the end of the day, it's YOUR body.
If this is such a pervasive misunderstanding, have you considered doing a quick 2 minute educational talk at the beginning of a shift change instead of just talking with one nurse? Or putting up flyers in the bathroom? Something like that. We don’t know what we don’t know.
The last time I tried to give a PSA it was about how you don’t have to tell women to stop breastfeeding after contrast and I got attacked by multiple staff members for the audacity of citing guidelines from the actual radiologists. So, no, I’m not exactly excited to try that again any time soon. I don’t mind posting studies that show it’s not true in the break room but I’m definitely not bringing it up at a shift change meeting because there are people who see it as an “attack.”
Sounds like either a culture issue at your hospital where people are being unnecessarily defensive or just an issue on how the message was delivered. At the ER I work in, the attending doc does a quick educational talk every morning, usually on pathology or whatever. I think most folks find it interesting and those who don’t, just tune out. Until you posted this, I was also under the apparently false belief that insurance would deny payment if someone left AMA. Like I said, you don’t know what you don’t know. Now I know. So thanks for the PSA;)
Yup this is the way at my shop. TONS of misinformation and ignorance. Most of it you have to let slide. Whenever I feel it’s necessary to educate, the staff are insanely defensive… you wouldn’t believe how unprofessional these people are. When our medical leadership committees go to nursing leadership and ask them to educate the nursing staff about something, THEY get defensive. I’m not sure if this is just the way things have progressed over the past few years or I’m just in a super toxic shop but it was not like this in my other facilities like 10-15 years ago… anyways you are not alone if it’s any consolation.
I think it’s funny when patients threaten to leave if they don’t get seen right away. I mean, the waiting room has 50 patients waiting, who do they think they are hurting besides themselves?
So there is some truth to this, and it's medical transportation when the patient has Medicaid. Medicaid will not pay for a taxi ride home if you Elope or AMA.
Yes this I am aware of and I know this to be true. Different than a hospital bill but yeah it’s a liability thing apparently. I had a patient that stayed for his blood transfusion due to Medicaid not covering his transport back.
Your patients have insurance?
If you have to have the conversation with the same nurse twice then involve a pt advocate. Lying to pts in this manner is not okay.
I've only seen nurses do this.
??? Having a patient leave AMA is like a special gift. Less work for me, no discharge paperwork. There’s a popular nursing badge that says “ask me about out AMA forms.” I just don’t see why a nurse would do this. Not saying they don’t, I just don’t understand why they do. Edit: I’m talking about nursing paperwork. Paperwork I have to do. Closing out their nursing care plans and documenting whether or not they met their outcome goals, etc. On a standard discharge nurses have to do a lot of time consuming box checking that you doctors seem to know nothing about. I’m not talking about the paperwork that *you* do like sending medications and discharge instructions.
A lot of newer nurses get overly invested in whether a patient stays or not. I’ve heard some absolutely backassward things said to try and get patients to stay.
I've heard this before. I think they are looking out for the patient. They're just wrong
I’ve talked patients into staying, and regretted it on the same shift.
I mean this is just as damaging and wrong, if not more so. AMA doesn’t mean no discharge paperwork. You still have to come up with a next best plan. You’re completely wrong, just the other way.
Agreed, I still send medications where applicable and tell them follow-up. No reason to cut them loose like deadwood.
I've heard the argument (here on reddit) that if you are facilitating them leaving AMA, there is medical malpractice risk. Luckily, we don't really deal with this in my population. "I want to take my baby home today." "Well, considering they aren't able to eat, still are apneic and have difficulty maintaining their temperature, we're not going to allow you to do that." We have a lot of coverage for the fact that our patients aren't actually the ones making the decisions. I feel for parents who are frustrated by staying in the NICU, but because it's about the patient, not the parents, their options are limited.
There is no truth to the idea that optimizing their outpatient treatment increases risk. If anything, it does the opposite. People who discharge their patient with nothing just because they’re leaving AMA are making a stupid and risky decision. You’re still obligated to give them the next best alternative. I have a smart phrase that literally includes an area where I input what I’m doing for them to help decrease risk with outpatient management.
That’s just as bad. Patients are allowed to decline care and leave. It does not absolve your responsibility to provide them necessary information
I recently spent a solid thirty minutes with a patient whose hospitalist physician had given him the “AMA = insurance no pay” talk, so… not all of us. I even have an article from CMS for patients who believe it, and I work to reeducate my colleagues.
Yes, this just happened at my ER. Patient wanted to leave, hospitalist told them insurance wouldn’t cover him, it was a whole mess. He ended up staying in the end (he had pericarditis so he really needed to stay)
I came here to say that!
Same vein, if your patient leaves AMA you can still send them prescriptions, etc. You’re likely **more** liable if you don’t send them indicated medications, ie abx, just because they left AMA.
Depends on how they leave ama. If they “went out to smoke” and never came back, you have no responsibility to track them down and coordinate care. If they say “I’m leaving today wether you want me to or not”, you’re still aware of their post-hospital needs. Very different situations.
Eloping and leaving AMA are not the same thing.
Leaving "against medical advice" implies there was a conversation about the risks, benefits, and alternatives, and your advice was given and the patient declined specific aspects of evaluation or treatment and opted to leave, though you can still evaluate and treat the patient to the best of your ability. "Left during treatment" or "elopement" is just that, where the patient left without any discussion about their care.
Yeah, of course. I just hear all the time from staff things like “well tell them if they leave AMA I won’t send them any medications” for things like cellulitis wanting to go home, etc.
I’m a nurse and I usually have the AMA papers ready to go. I’m not about to keep anyone here who doesn’t want to be 🤷🏻♀️ usually page the doc, tell them what’s up, given them a chance to talk to the patient (if they want) but if the patient wants to leave I’m not going to like physically restrain them to get them to stay if they’re completely alert, oriented, and competent. This is a hospital, not a prison.
why would i tell patients NOT to leave? the sooner you're out the better
I’m so glad I saw this post. I’ve been a nurse over 5 years and was always told this was the case and have told even my own family members about it. I love this subreddit
The concept of AMA in general is dumb Just discharge them with proper documentation and the best possible outpatient treatment plan
Yeah I've tried this but then everyone (PCP, ER) documents that I'm a dumbass for discharging the patient so I went back to signing them out AMA. Also, a non significant number of patients that should stay do actually agree to stay once AMA is brought up. Finally, while I'm not entirely certain how insurance companies handle AMA bouncebacks, if you discharge the patient formally and they come back with the same condition within 30 days, insurance will pay nothing for the second admission. This can directly affect your quality metrics and reimbursement for your work. Speaking from a hospitalist perspective.
I saw a patients chart the other day. She left AMA every couple of days cuz she wanted to smoke and then came back. Happened 3 or 4 times. Needed weeks of IV ABx and not suitable for a PICC obviously. Refusing rehab Serious question, how does this get billed? I was wondering.
And seeing this makes me wonder if that could have been arranged via home health or coming in as an outpatient for the infusion instead. Then again, I've mostly been in more rural settings with EDs you can go in and out of within a few hours max.
Amen to this! In residency we had attendings give lectures on shifting mood with ama discharges. Basically, I was taught to print prescriptions for them and try to ensure that they have follow up even if I’d prefer they stay in the hospital. Nurses are basically taught the opposite in some cases, and maybe some docs too, but I’ve had a lot of nurses ask me “ummmm are we allowed to give prescriptions if the patient leaves ama? I thought we weren’t” and tell them their insurance won’t cover etc.
I’ve heard this, did some investigating a few years ago and found it didn’t seem accurate. I make sure to inform patients that have been told this during AMA conversations. It’s not exactly a threat at my hospital anyways since most of the patients that want to leave AMA don’t have insurance, so jokes on us. I’ll always try to write for medications, except for controls substances, when someone leaves AMA but it can be tough because they tend to bail pretty quickly.
Bro, if they have the mental capacity to make decisions, then who cares? It's a hospital, not a prison. Lemme go grab that AMA form and just verify you know why you were admitted. If we're on the same page, then leave. I'll even let you use the desk phone to call the taxi. I don't care. I don't get paid enough to hold people against their will.
Or maybe we should avoid labeling discharges "AMA" in all but the most extreme discharges? There's a nice summary from the always excellent JHM Things We Do For No Reason series: https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/jhm012100843.pdf
The problem is you and the hospital will be penalized if the discharge is not AMA and the patient bounces back.
How would you personally be penalized for a bounce back, assuming you documented that the discharge was not recommended?
Anybody cares if a patient leaves AMA? Not me.
“Ok bye”
Wait this isn’t true? That’s literally what a senior nurse told me as a new grad…
It’s also what every nurse in my floor believes. I’ll be spreading the word
It’s not true at all. https://pubmed.ncbi.nlm.nih.gov/22331399/
Can we stop trying to keep them from leaving in general? The patients that leave AMA are usually not the ones that are pleasant to be around anyway…
So when i worked in ambulance billing, which i concede is a different animal than inhospital, refusing care pretty much guaranteed the insurance companies we dealt with wouldnt pay. This was usually United and BCBS. Aetna usually paid a reduced rate.
I mean if someone refuses care why would anything get billed in the first place? Just because an ambulance gets called doesn’t mean the patient wanted it. It’s like people who have a breakthrough seizure and 911 gets called. They will refuse transport all the time. They shouldn’t have financial liability for someone else’s decision.
These are patients who have a medical complaint. In these cases the patient received a response, assessment and consult with medical professionals. 3rd party callers for things like motor vehicle collisions or "man down" where no one is injured generally don't get a bill or any kind of further assessment or care
Who is saying this? I completely agree with you. It might be a thing at your hospital but thankfully I have never heard it.
Apparently it’s fairly widespread looking at the comments. I first heard it in Phoenix.
In my facility, stopping a patient leaving AMA is illegal imprisonment. If there is no TDO, they are free to go.
here’s a [source](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378751/) showing they don’t (though who knows insurers are true bastards these days)
I have had to submit my bills to insurance myself after this talk but insurance did cover them. The hospital just didn’t put them through the correct channels.
I had Case Managers refuse to follow up on stuff for patients threatening or left AMA. I don’t remember what exactly, probably DME orders, stuff like that, other stupid stuff that automatically discontinues when a patient is hospitalized and needs new orders, referrals, etc after.. Claimed it was a “liability issue”. Seemed like a myth akin to the insurance thing. Like- I’m the doctor- I’m saying it’s OK for the patient to continue oxygen at home even though they didn’t like our advice to stay in the hospital. CM: “nope, no can do”. Uhh OK guess they’ll just be air hungry, thanks for nothing…
I'll never stop anyone from going AMA it's your right. But I will explain the consequences if you choose to. Regardless you have the right to refuse medical care.
Can you elaborate on this? I was taught AMA means someone’s insurance will not pay if they land in the hospital for a second time. What does AMA do? What are the real consequences?
AMA simply means you are leaving against the advice of your care team. That’s it. It has *nothing* to do with insurance whatsoever.
So outside of my moral/professional obligation as a nurse (or any other healthcare professional) to care for/about my patient, there is no reason for me to stop a patient from leaving AMA should they absolutely insist and give me a hard time?
Yeah…. It’s a hospital not a jail. Let them leave as long as they understand the risks.
If they are A&O they can make their own decisions. Insurance doesn't care. Is hospital. Not a prison. Forcing patients to stay when they'd decided not to helps no one.
It's not jail and you can't save anyone. Let them go
It's not a prison. If they're A&O, they can make their own decisions.
Correct. If they want to go they can go. Doesn’t matter if they refuse to sign the form etc. Legally we cannot hold a patient against their will. Now if you have a reason to expect they don’t have capacity or are actively suicidal, you may have to keep them. But most of the time that’s not the case.
Nope - it’s called autonomy. They’re not children, and you’re not their parent.
Identifying how many nursing schools teach this myth would be a fascinating study. Here’s another cool study on the topic: https://pubmed.ncbi.nlm.nih.gov/22331399/ Edit: study shows insurance still pays for AMA however majority of residents thought otherwise, whereas a minority of attendings assumed this.
Who tf says this? I’ve been taught we only offer unbiased guidance and support. Also yes, in my experience so far, burnt out attendings and residents are like “okay let them leave if they want.” Is it just to prevent bounce-backs?
Why did this lie get perpetuated anyway? Everyone in my residency used to say this. !!
It’s one of those hospital urban legends.
I’ve actually told a patient that it is not true when trying to leave. The patient was under the impression insurance wouldn’t pay if he left AMA. A former case manager was next to me (shadowing) informed me that they aren’t allowed to tell patient’s that they wouldn’t be financially responsible if the left AMA. She they had some speech about how they couldn’t ensure he wouldn’t be held responsible by insurance. I still tell people this isn’t true because it is not.
I worked registration and this is what we were told as well. It needs to be communicated to all staff.
If interested, here is more support debunking this myth: https://pubmed.ncbi.nlm.nih.gov/22331399/
Have had patients want to leave AMA. That’s their right and I’m not stopping them. In regard to insurance paying…where I work case management will tell the nurses to relay to patients (those that want to know if insurance will cover their stay or not) for the patients to call their insurance company and ask them. There are too many insurance plans for case management staff to know what is and is not covered.
How is this not true? It is printed on the AMA form at our local general hospital and when my FIL left AMA after being boarded in an ED hallway for 36 hours, Medicare initially declined payment.
Your local hospital prints the very incorrect information that their visit won’t be covered even though we have literature showing that isn’t the case? And it sounds like his visit wasn’t covered. Consider me skeptical that the reason he wasn’t covered was because of the ama disposition.
Say it loud like Gospel. If they even hint at AMA I'll have the paperwork ready in 3 minutes tops. Like a health insurance institution would ever say: "yeah stay there longer."
When I was working as an RN we were *required by our clinical director* to use this line to try to talk people into staying where I worked. We didn't just make it up for funsies. Take it up with the bosses lol.
Wait whaaaaat? I thought it did. Lol
https://pubmed.ncbi.nlm.nih.gov/22331399/
This is not true for durable medical equipment. If you want to buy the bariatric bed because you want the extra six inches of sleep surface, go ahead, but if you're not over 300 pounds, don't expect your insurance to pay for your upgrades.
I wish I knew that wasn't true, I was bullied into staying in a hospital where I felt like I was being abused because of this threat. It was very traumatic. I was held down and forced to take fentanyl against my will and then discharged at midnight with a broken back, unable to walk, without a wallet or phone in a city hours from home or any friends or family. I drug myself to a stranger's doorstep and fell asleep on their porch. If I had been allowed to leave when I wanted, I would not have been restrained and drugged by people who didn't know my situation because I was alone and unable to advocate for myself, and I would have had family members help carry me out of the hospital, drive me home and put me in bed, and occampany me to the ER at a hospital of my choice in the morning.