Claims Case Study: The Patient Who Left Against Medical Advice

Patients who wish to leave care settings against medical advice (AMA) create significant risks both for themselves and their providers. However, physicians and medical practices can guard against those risks by understanding them and developing a clear plan for mitigating them. A recent closed claim can help illustrate some of the relevant issues. 

Claim Overview

The patient, a 37-year-old male paraplegic, presented to the emergency department at 11:00 p.m. for complaints of vomiting, abdominal pain, diarrhea, chills, and a strong-smelling odor from his urine. (The patient self-catheterized for his urine management.)  His initial vital signs were significant for a temperature of 100.6 F, a heart rate of 154 bpm, a BP of 99/63 mmHg, and a respiratory rate of 20. He was triaged as non-urgent with a listed chief complaint of “vomiting.”

Our insured, an emergency medicine physician who was utilizing a medical scribe that night, assessed the patient and ordered lab work that included a CBC and urinalysis. The patient was diagnosed with gastroenteritis. Orders were written for IV fluids (2 liters total), IV Zofran for nausea, and IV Dilaudid for pain. The physician later testified that he re-assessed the patient after his first bag of IV fluids had infused and that the patient was “improving.” The record reflects that the patient was discharged from the ED at 03:37 a.m. Prior to discharge he was given prescriptions for Percocet and Zofran.

The following day, EMS was summoned to the patient’s home due to his worsening complaints of nausea and chest pain. He was found to be hypotensive (BP 72/44) and tachycardic (159 bpm). He was admitted to the ICU. A review of his labs from the ED visit the day before revealed a CBC with a WBC of 29.3. (Normal is 3.2-9.5.) His urinalysis was positive for the presence of WBC and bacteria. The patient’s urine was cultured and later grew out pseudomonas.

The patient was diagnosed with septic shock from his untreated urinary tract infection. He quickly progressed to multi-system organ failure and expired three days after his admission to the hospital and four days after his initial presentation to the ED.

The patient’s estate filed a lawsuit against the hospital and ED physician. During depositions, the hospital nursing staff testified that at 2:05 a.m., after receiving his first bag of IV fluids, the patient first said he wished to leave the ED AMA. Unfortunately, the patient’s ED record contained no mention of the patient’s AMA request and ultimate departure from the ED. Our insured testified that when a patient wants to leave the ED AMA, his practice is to explain to the patient the importance of staying in the ED until treatment is complete. He testified that he also documents these AMA discussions in the record. The nursing staff testified that when a patient wants to leave AMA, these discussions are also documented in the nursing notes, and patients are asked to sign a form before leaving acknowledging that they are leaving the hospital “Against Medical Advice.”

The defense of this case was further complicated by the fact that the abnormal CBC and UA were documented as being on the patient’s chart and available for review prior to his departure from the ED at 03:37 a.m. Our insured physician testified that he had re-assessed the patient after the first bag of IV fluids had infused and before the lab results had been received. He stated that he had planned on reviewing the patient’s lab results later in the patient’s ED stay and would have prescribed an antibiotic had he been aware of the abnormal lab results. He testified that when he went back to assess the patient again, he was told the patient left the hospital.

In addition to the lack of documentation of the patient’s AMA departure from the ED, the patient’s record contained multiple incorrect entries, including an active diagnosis of “abdominal pain—pregnancy” at the time of discharge, even though the patient was male. The record also included that the patient had a steady gait and that his upper and lower extremity strength and motion were strong and equal, even though he was wheelchair-bound due to his paraplegia. The record also showed that the physician signed off on all the entries of the medical scribe, noting that all documentation by the scribe had been reviewed and authenticated in accuracy.

The case was settled out of court.

Risk Management Key Takeaways

It is essential to establish a process to manage the challenges around patients who wish to leave AMA. Medical Mutual’s Risk Management department recommends doing the following:

• Perform and document an assessment of the patient’s understanding of the risks and consequences of refusal.
• Obtain a written refusal of services from patients who leave AMA or who refuse a medical screening examination, treatment, admission, or transfer.
• Document efforts to obtain the patient’s written refusal if the patient refuses to sign an Against Medical Advice form.
• Attempt to contact a patient that leaves without the opportunity to discuss their risks of not completing treatment and document those efforts in the patient’s medical record.
• Explain and justify in the patient’s medical record any deviations from clinical policies and practice parameters/guidelines utilized staff and providers.
• Utilize a standardized process in which all diagnostic reports are reviewed and addressed in a timely manner by the provider prior to disposition.
• Implement scribe documentation guidelines and conduct regular EHR audits to ensure ongoing compliance with these guidelines.
• Manage and maintain scribe documentation with the same quality assurance and compliance expectations as other patient care documentation requirements.

Additional risk management resources are available on our website to help Curi member practices implement these guidelines:

• Informed Refusal Treatment Guidance
• Against Medical Advice Template Consent – English
• Against Medical Advice Template Consent – Spanish

For further guidance, Curi members are encouraged to reach out to our Claims and Risk Management Departments at 800-328-5532.