Archives for July 20, 2006

Leaving AMA: A Patient’s Perspective

In the mailbag, a very well-written exposition from a patient about leaving AMA:

I was in for a [surgery] and had jumped through all the hoops (completed basic physical therapy, and my bowels and urine system were up and running).

[Surgery] was ready to release me but noticed and elevated resting pulse. It cost me two days in the hospital and testing found nothing except when my body is stressed, my resting pulse is high.

Here’s the issue. I was miserable for those two days. I wanted to be home. I like the scale that hospitals use to describe pain 1 to 10 and don’t let it get much over 3 because it will set you back. Let’s substitute mental emotional pain for physical pain. Anger, depression, fear, panic, clostrophobia… Confinement to a hospital room, hospital gowns, and drugs exacerbate the problem. It’s hard to stay ‘grounded’. On a misery scale I was a 7 or 8.

Consider this; pain passes, misery leaves indelible marks. We see this with rape victims and returning soldiers. When the misery scale gets too high it becomes a long term issue.Here’s the problem. Someone like me who’s had a miserable indelible experience in the hospital is going to be much more difficult to get back in the hospital the next time hospitalization is needed. You can say “Quit whining and be logical” and I’m going to agree that it is not logical to avoid needed medical care, but humans don’t make decisions based on logic, at the core, decisions are usually based on emotive factors.

When you are faced with a request to leave AMA, ask about the misery scale level. Can you do anything to relieve the stressors? Will hospital privileges help? Is what we are doing really that urgent? Can I contract with the patient for outpatient followup? Remember it’s not just the short term medical issues, and they may override the patient’s misery level, it’s also the long term ability to have your patient believe that a doctor is truly their advocate for health.

That’s an excellent presentation of just some of the stressors that induce patients to leave AMA.

When notified someone wants to leave AMA, we ‘offer all services of the hospital’, but often that’s not well understood (by either side in the conversation). And generally all offers fall on deaf ears, as when someone has mustered the courage to ask to leave AMA, they’re decided on leaving. The patient wants to go, but wants, usually, to be grown-up about it, announce their intentions and exit. It would be ever so much easier for them to simply walk out (I’m using my ED as an example), so I respect those who announce their intentions, though overall we tend to be very patronizing to them.

Thanks for the letter. I hope you’re not scared-off for life.