The Case

A 61-year-old woman was placed on bedrest following major surgery. Her postoperative course was complicated by urinary incontinence and a deep vein thrombosis (DVT) requiring anticoagulant therapy. An external catheter system was placed to collect her urine. During the night shift, the hospital unit was short-staffed, and her external catheter system fell off. The patient rang her call button repeatedly to request nursing assistance. Unable to get a response after 35 minutes, she hopped down the hallway on one leg to find assistance but was unsuccessful and went back to her room.

By the time the nurse came to the bedside to change the patient’s urine-soaked bed pads and sheets, the patient was angry and agitated. The nurse responded defensively and began to talk to the patient in a condescending tone, asking her if she (the patient) knew how to contact her physician. By this time, a family member was present, and another nurse on duty complained to the family member that the patient was “behaving badly.” The nursing staff was unable to de-escalate the contentious situation and the patient insisted on “leaving against medical advice,” despite having bedrest orders, citing she was extremely upset about how she was treated and spoken to. She was escorted downstairs to leave the hospital, accompanied by her family member, and was given her doctor’s name and contact information. No nurse or physician on duty was able to provide discharge education, instructions, or medications related to the DVT or urinary incontinence. The charge nurse was unaware of these events until the on-call physician contacted the unit for more information about what happened.

The patient’s family member was able to help her into her house and help her into bed. Her medications were picked up the following morning at a community pharmacy, but one of the medications was an anticoagulant requiring subcutaneous injection. Several telephone calls and a home nurse visit (one day later) were necessary before the patient was taught how to take her medications and how to follow up with her physicians on an outpatient basis.

The Commentary

By Amy Nichols, EdD, RN, CNS, CHSE, ANEF

The phenomenon of leaving the care setting against medical advice (AMA) remains inadequately understood and addressed, despite being quite common and associated with adverse quality and safety outcomes.¹ Researchers have identified certain patient characteristics as predictors of AMA discharges, such as substance abuse or other mental health disorders;² however, any patient’s underlying reasons for leaving AMA in this case were not specified. Often unexplored are patients’ reasons for leaving related to frustration or anger about how they were treated by health care providers.³ While this case has some obvious systems failures in terms of adequate nurse staffing, it is an opportunity to discuss how to take care of patients who are angry, agitated and unhappy with care provided, how to reduce the frequency of AMA discharges, and how to mitigate patient harm if AMA discharge is unavoidable.

Can AMA Discharges be Avoided?

Discharge against medical advice (AMA) occurs when a patient wants to leave the care setting before care providers have recommended discharge. In the US, each year, 1-2% of all hospital discharges (involving approximately 500,000 patients) are categorized as AMA.^4,5 While it is important to identify patients who are at risk of leaving AMA for reasons unrelated to their medical care it is even more important to understand healthcare providers’ role in contributing to AMA discharges. Preventing patients from leaving AMA is difficult and the empirical evidence on providers’ perception and experiences with AMA discharges is limited, but studies suggest that provider to patient communication has a direct influence on patient decisions to leave AMA.^6-8 It may be possible to avert an AMA discharge if providers engage in meaningful interactions with active listening, verbalize and understand the patient’s frustration, and use de-escalation techniques to address why the patient wants to leave. Reasons for leaving might be related to short staffing or other resource limitations, patients’ need related to work or family obligations, unrealistic expectations from the patient, and frustrations from either the patient, the staff, or both.

Managing Contentious Situations

Challenging patients are encountered in every setting and sometimes patients enter the health care setting already upset about their health condition. In this case, the patient was understandably distraught and encountered two nurses who did not seem very empathetic, creating a situation that escalated the patient’s frustration. Conflicts that arise in response to problematic interactions or negative experiences not only result in a breakdown of the provider-patient relationship, but also contribute to unhealthy patient care outcomes, decreased trust and satisfaction, and worsening of symptoms, leading to suboptimal patient care quality and safety. By de-escalating contentious situations, it is often possible to prevent a patient from leaving AMA.

Once a difficult situation has been identified and significantly disrupted the provider-patient relationship, the health care provider(s) involved with the patient should have an immediate conversation to discuss the situation with a nurse manager or primary provider. Eliciting staff feedback as to how this encounter evolved will enable the team to comprehend the causes and triggers that led to the conflict. This process also exposes potential staff biases and judgments regarding the patient and their family that might have negatively affected the way the patient is approached and treated. Post-event debriefing and review is also an educational opportunity to avoid potential future AMA situations.

Many communication and conflict resolution techniques have been created to help care providers manage difficult and emotionally charged clinical encounters.^9,10 These techniques highlight the importance of empathetic, patient-centered communication, focusing on rebuilding the relationship between provider and patient. Communication strategies such as reflective listening, empathetic validation, flexible negotiation, and closure with planned follow-through may help to defuse these encounters and prevent further escalation.^11,12

To ensure regular and reliable communication with the patient and family, a “point of contact” person representing the patient care team should be identified and called if needed for consultation or intervention, particularly for patients with complicated medical conditions or psychosocial circumstances. This person is assigned the responsibility of eliciting patient concerns and needs. Mixed messages can be avoided by filtering all communications through this identified person.

During the de-escalation process, patients and family members must have the opportunity to communicate all their emotions, frustrations, concerns, and questions to the team in a private setting. Because patients can become very emotional and labile during this venting process, it is imperative for health care professionals to remain open-minded and non-judgmental, and to refrain from becoming defensive. Had this process happened in the current case, the patient may have considered staying in the hospital, instead of leaving AMA. The healthcare team should recognize their own negative feelings and avoid voicing any conflicting or argumentative remarks. This is often difficult, but crucial to maintain open lines of communication and ensure conflict resolution.

Empathy and validation are equally important communication strategies that are essential for re-establishing respect and trust. Like listening, empathetic validation acknowledges a patient’s emotions and experiences, while also giving them the feeling of not being alone.¹³ An empathetic and focused apology may be appropriate. Rather than admitting guilt or taking sole responsibility for the conflict, an apology can convey a desire to provide emotional support and an acknowledgement that the team regrets the patient’s distress and seeks to learn from this experience. When a provider expresses regret and accountability for the situation with sincerity and without condescension, and resists blaming others or the system, the patient will more likely feel a sense of satisfaction or closure.¹³

Risk management strategies can help providers communicate with patients and their families during challenging circumstances, and sometimes convince the patient to stay. A patient who leaves AMA, prior to completion of evaluation and treatment is at risk for adverse outcomes. In addition to protecting the patient, convincing the patient to stay may also prevent complaints or even litigation.

Mitigating patient harm when AMA discharge is unavoidable

How can health professionals minimize the risk of harm and adverse outcomes once AMA discharge seems unavoidable? Assessment of the patient’s decision-making capability is essential; nurses should never let incompetent patients sign out AMA.In balancing patient autonomy and safety, health professionals must ensure that a patient has decision-making capability, and carefully document the basis for this conclusion, before allowing the patient to leave. One should not simply enter a conclusive statement in the medical record (e.g., “the patient is competent”), but instead document the basis for this finding, including a mental status examination, if appropriate.

Patients should always be told that they may return, and follow-up arrangements should be made whenever possible. Because patients who want to leave AMA are challenging and care providers may feel frustrated when patients refuse to follow medical advice, these patients are sometimes advised to seek subsequent treatment elsewhere. However, the health professional’s duty to provide care does not end with an AMA discharge. Discharging a patient AMA does not confer any protection against future legal action if the health care provider has not made appropriate follow-up arrangements.

Using all available resources to provide patient education prior to the patient leaving and making follow-up arrangements are of utmost importance. Alternative therapies that may be helpful should be suggested (e.g., oral therapy instead of intravenous therapy), even if they are not first choice interventions. Patients should be offered and encouraged to accept a follow-up telephone call or a home visit within the next few days if they are at risk of serious health consequences. In this case, arrangements could have been made for follow-up, especially to provide patient education on medication administration and teaching about DVTs and urinary incontinence. When a patient decides to leave AMA, communication with the healthcare team is particularly important, as the patient is likely to return later or to seek care from a different healthcare facility. Meticulous documentation is the key to averting further miscommunications and potential legal action.

In summary, this case illustrates the importance of careful attention to irate patients, including demonstrating empathy and attempting to resolve their concerns to avoid AMA discharges. If AMA discharge is unavoidable, specific risk mitigation efforts are essential, even if the patient seems uncooperative at the time. It is, of course, impossible to eliminate AMA discharges entirely, but it is often possible to de-escalate situations when the patient is angry and dissatisfied with their care.

Take Home Points

• Use communication strategies of conflict resolution, listening, empathetic validation and negotiation to mitigate the risk of the patient leaving AMA.
• Avoid defensive or argumentative behaviors that further escalates the situation.
• Involve a neutral party who can elicit patient concerns and needs.
• Always assess and document appropriately the patient’s competence to make the AMA decision.
• Document the discussion of all potential serious risks of leaving AMA; all patient education as well as alternative treatment plans that were discussed.
• Express ongoing concern for the patient and ensure timely follow-up after discharge.

Amy A Nichols, RN EdD CNS CHSE ANEF
Associate Editor, PSNet
Associate Dean of Academics, Clinical Professor
Betty Irene Moore School of Nursing
UC Davis Health
aanichols@ucdavis.edu

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