Henry is a 55-year-old male who presents to the ER with crushing chest pain radiating to his jaw, and shortness of breath. He appears pale, sweaty, and on top of everything, has a history full of risk factors for heart attack.
A half-hour after arrival, while testing and treatments are in progress, Henry suddenly announces that he wants to go home. He seems resolute in his decision and asks to sign AMA (against medical advice) papers.
What would you do if you were part of Henry’s healthcare team?
A) Get the AMA forms. Don’t waste your time arguing with him
B) Let him know he is waiving the right to litigate for any damages that may occur from leaving AMA
C) Withhold a prescription for nitroglycerin as punishment for leaving AMA
D) Tell him that his insurance won’t pay for his ER visit if he leaves
E) Make sure he knows that he isn’t welcome back once AMA papers are signed
F) None of the above
Hopefully, you chose F, none of the above. An excellent article published in the Academic Emergency Medicine Journal discusses the importance of approaching AMA patients with a careful plan and process, rather than grabbing the AMA form and feeling like due diligence was performed.
The article proposed using the acronym “AIMED” in these situations: Assess, Investigate, Mitigate, Explain, and Document.
Let’s look at Henry’s case.
Assess: does he have capacity to make his own decisions? Are there any language barriers? What is the severity of his condition? Does he need treatment urgently?
Investigate: try to identify Henry’s reasons for leaving and address his individual concerns. Is he anxious about a pet he needs to take care of? Is he worried about medical bills? Consider calling family members to help persuade him to stay.
Mitigate: provide Henry with all the needed treatment he will accept. Send a prescription for nitro with him. Try convincing him to take an aspirin before he walks out the door. Provide him with detailed discharge and follow-up instructions.
Explain: tell Henry plainly that he may die without emergent treatment. Talk about risks, benefits, and alternatives as they apply to his situation. Assure him that he can come back and be treated at any time.
Document: every effort made to convince Henry to stay and be treated should be documented. An AMA form does not insulate against litigation. Henry can sue and win if a process such as AIMED is not honored.
Ideally, by meticulously working with Henry through possible issues and barriers, he will change his mind and receive the treatment he desperately needs.