Can a patient without capacity leave AMA? Was I in the wrong for asking security to help keep him in the because his guardian wanted him to stay?

[u/ferdous12345]

I’m an off-service intern rotating in the ED. Yesterday I had a patient whose wife was his legal court-appointed guardian.

He presented to the ED with his wife for fevers and worsening AMS. I picked him up and saw him. Immediately he was suspicious of my motives (claiming I was there to steal his organs) and requesting to leave. I asked him if he could tell me what would happen if he left. He said if he stayed I would steal his organs and if he left he would “avoid being detained by the government.” When I asked if there was any harm in leaving he said no. His wife talked him down and he agreed to stay for bloodwork and a UA. He was pleasant enough otherwise. I staffed him and told my attending he is suspicious of us but agrees to stay.

Then when his nurse gave him the UA cup, he stood up and said he would not be detained and that he would beat us all up. He was getting extremely angry. He walked out to the waiting room yelling profanities, and then security grabbed him.

A nurse in triage (not his nurse) said he could leave since he is not legally required to be there. I asked his wife and she said she wanted him to stay and to sedate him if needed (her words). I messaged my attending while this was happening and was going to get him from the staffing area, but security asked me what to do and they needed to know right then and there since he was wanting to leave, and I said to security “he does not have capacity, his wife is his guardian and wants him to stay, I’m going to get my attending.” The nurse got upset at me and said I was wrong, that he could leave and that I could not make him stay. She then said to get my attending because I “didn’t know what [i] was talking about.” I was already going to get my attending involved but he hadn’t seen the page. The RN’s words made me think I was missing something and that I was misunderstanding the role of a guardian and what it means if someone “has to stay” versus “can leave.”

My attending came out and convinced him back to the room, but then he threatened his nurse and me, so his wife said she would like to take him home. She understood the risks and benefits. They promptly left.

I wanted to debrief but my attending’s shift was changing and the nurse who was mad at me disappeared back to the other side of the ED. And frankly the culture here isn’t very learner-friendly lol.

Was I in the wrong for “making” him stay? As in, I asked security to help keep him in the ED since his wife is his legal guardian and wanted him to stay at the time. I said it with the intention of buying time to get my attending, not that I was going to order IM haldol and force him to be tested and treated or anything. I just felt unsure, because if I said he is okay to go when he lacked capacity and his wife as guardian wanted him to stay, then I was afraid I’d get in trouble and I’d harm the patient. But the RN with far more experience said he can leave and we cannot make him stay. And I obviously didn’t want to harm the nursing staff if he became physically threatening.

Thanks. I’m just trying to understand and be a better physician. What should I do in this situation besides get a senior/attending involved sooner? In hindsight I should’ve walked straight to the staffing area and gotten my attending instead of paging and will do that next time. But in general what is the role of a physician in this context?

[u/gottawatchquietones]

There are lots of borderline situations regarding patients refusing care and capacity to do so, but this is not one of them. If his wife was his guardian (not his healthcare proxy), then he has been found by a judge to not be capable of making his own decisions - the question of whether or not he can choose to leave the ED against his wife's wishes was literally already decided on by a judge.

[u/ferdous12345 → u/gottawatchquietones]

For my own learning, how would it change if she was his proxy/DPOA instead of guardian? I believed he lacked capacity. As his proxy if she wanted him to stay, could my response still reasonably be the same?

Scenario B, if he was picked up off the street by EMS, similarly altered and lacking capacity based on my assessment and no NOK/proxy could be contacted, could I still make him stay?

[u/gottawatchquietones → u/ferdous12345]

You are correct - you would still be right to compel the patient to stay if he lacked capacity and his healthcare proxy wanted him to stay. If there were no surrogate decision maker, you would also be right to make the patient stay. My point was just that in a situation where a person has a court-appointed guardian, you don't even need to exercise any judgement about whether or not they have capacity because that decision has already been made.

[u/swedishlightning → u/ferdous12345]

If you as the doc assess that the decision-maker (the patient, their guardian, whomever) does not have capacity to decide to leave, you’re done. You keep them.

Once the dust has settled a bit, there may be requirements/protocols for a second doc to assess and concur (eg a “second cert” in a psych patient). But in the heat of the moment, you as an ED doc have scope/authority to make that capacity assessment and hold the patient.

[u/tccrouch → u/ferdous12345]

Yes you can in both situations but you are taking the liability on yourself if he later tries to come back later and say he was falsely imprisoned/kidnapped/assaulted etc. This is where good documentation is key, including specific things he said that lead you to believe he did not have capacity.

But I agree with everyone else, at the point there is a guardian, the decision is already made and you go with the guardians decisions as long as they are within reason. Now if you had a guardian trying to AMA for a patient when they wanted care and you thought they needed it, you probably need to get legal on the line asap.

[u/SpicyMarmots → u/gottawatchquietones]

If he's altered and doesn't have capacity, surely the distinction between guardian/MPOA/health care proxy etc is moot?

[u/gottawatchquietones → u/SpicyMarmots]

You can look at it either way - I was just making the point that once a court has assigned someone a guardian, you don't need to decide whether they have decision making capacity because that decision has already been made.

[u/jljwc → u/gottawatchquietones]

The one thing to be careful of is that not all guardianships include medical decision -making. Some are financial-only. Always good to ask to see the paperwork (when they come in, not by the time things have escalated). Also, not relevant in this case but a good teaching point, withdrawal or not initiating care for people connected to your state’s department of disability may have a whole other set of rules, even if there is guardianship otherwise.

[u/SpicyMarmots → u/jljwc]

I guess my point was that this patient doesn't appear to have capacity at all whether or not someone makes their decisions. You're treating under implied consent. If this patient presents by ambulance, alone, are we letting them walk out? Seems doubtful.

[u/Ok-Raisin-6161 → u/jljwc]

Exactly. Not ALL POA includes MEDICAL POA. There is a BIG difference and you can’t always just rely on a court’s decision.

[u/-ThreeHeadedMonkey- → u/gottawatchquietones]

I think you're partly right but it surely depends on the jurisdiction/country etc. I'm theory could have a guardian but still have capacity to make medical decisions. Op was right to rule this out imo. 

The nurse was full of shit btw

[u/willsnowboard4food]

A lot of ER nurses and techs have the misconception that the only people who can “be held against their will” are those who are actively suicidal or homicidal and on some sort of involuntary commitment. They don’t understand the intricacies of decision making capacity and leaving AMA. You were correct in this situation and nurse very wrong.

[u/threeplacesatonce → u/willsnowboard4food]

I agree. I had a learning curve myself when I switched from the ambulance to the hospital. There are different criteria in the ED with a doctor and/or documents present, compared to out on the street with limited information. Even when I worked in the ambulance though, people could be too altered to refuse transport. Mental health holds are communicated better with security and staff, so everyone is already on the same page as to ability to leave. For altered patients its more murky, and not always communicated well.

[u/Purple_Opposite5464 → u/willsnowboard4food]

At my last shop, the issue was documentation and paper trail. People would want us to hold someone against their will, but also wouldn’t put in the orders and documentation of their lack of capacity, or provide the tools necessary to make it happen. 

[u/Nurseytypechick]

You were correct. Nurse was wrong. Agitated delerious grandpa is sick AF and was not demonstrating decisional capacity.

[u/ToxDoc]

Patient has been adjudicated by a court to not having decision making. That alone makes it fine for you to prevent him from leaving when his legal guardian wants him to stay.

Then he shows you he doesn't have capacity to make decisions when he starts to accuse you of wanting to steal his organs and the conspiracy stuff.

This one is a no brainer.

[u/ferdous12345 → u/ToxDoc]

I figured it was a no-brainer but when the RN disagreed with me I got scared that I was doing something harmful or illegal, and I was worried that forcing him back inside with security would cause a lot of harm. I’m an off-service intern and I haven’t been in the ED long so I was worried I was completely off base

[u/halp-im-lost]

This is the easiest case of the patient clearly not having capacity and therefore not appropriate for leaving AMA. It’s not even remotely an ethical conundrum.

[u/ferdous12345 → u/halp-im-lost]

That’s what I thought, but honestly it was the RN telling me I was wrong even after saying his guardian wants him to stay, and that I had no idea what I was talking about, made me scared I was just so off base

[u/halp-im-lost → u/ferdous12345]

You will find that there are many folks, including nurses and physicians, who hold beliefs that are completely incorrect. A good example is that insurance won’t pay if a patient leaves AMA. The RN needs education by their nursing supervisor so they don’t cause issues in the future with their misunderstanding as to who is and isn’t allowed to leave AMA.

[u/Drp1Fis]

Being febrile + altered and a person knowing them saying they’re altered is a good recipe for this person probably not actually having capacity. Capacity is also along a spectrum of course, you can have the capacity to order a coffee while you’re in the hospital, but not have capacity to deny potentially life saving treatment

[u/ferdous12345 → u/Drp1Fis]

Based on my questioning him, he had no insight into the risks of staying versus leaving, and was not able to name a single risk of leaving even with prompting (Could you get sicker? “No.” Could an infection get worse? “No”). He was also obviously not able to maintain a decision because he would switch back and forth between “I’ll stay” and “I’ll leave” when I was first interviewing him without any reasoning he could provide.

[u/keloid]

I will preface this statement by saying that ED RNs are my bros and lady bros, and I would fight a bear (and lose) for my nurses.

But very few nurses I have worked with have a good handle on capacity and competence. The nuances of leaving against medical advice and what obligations we still have to those patients despite refusal. Who we take down and who gets to walk out. It's a lot of dogma about protecting licenses and not a lot of actual malpractice/medicolegal knowledge.

In this case you have a patient without capacity _or_ competence (they have a guardian appointed) who is threatening staff and has evidence of a potentially life threatening illness (fever, altered). If the wife told me to sedate and treat him, I'm gonna do so. But that's a tough situation to be in alone as the off-service intern.

[u/Negative_Way8350]

You did the right thing here. A patient with a guardian doesn't have capacity by default. If their guardian wants to stay, they stay. His responses to your questions also show a failure to grasp the true consequences of declining care. 

Now, onto the issue with the triage RN. 

The way to respond to the RN would have been a gentle but firm "Thank you for your input" and moving on. Yes, the nurse has more experience than you. That nurse also doesn't understand the whole context of what is happening. You were right.  

I'm also going to give you a little context you might not have. 

Imagine you are stuck at a desk for 12 hours. There's no movement in the ED. No more beds to be had. All of your volume is boarding patients. You know for a fact that your 45 people in the waiting room aren't going anywhere, but there are some truly sick people there you're trying to keep alive. You've also been screamed at for 10 straight hours and nobody cares because you're just some bitch at the desk blocking them from being seen in 2.5 milliseconds. Your charge couldn't care less. Neither do your residents because those patients don't exist for them. 

Now an intern you've never seen before in your life comes into triage without their attending telling you what to do. 

Is this "not a learner friendly culture" or are you dealing with exhausted people on their last leg? 

[u/ferdous12345 → u/Negative_Way8350]

That’s a very fair point and I appreciate the perspective!

By learner-friendly culture I meant more with the attendings. The nurses are great at explaining protocols and why things get done in a specific way. The attendings at times just say “that’s how we do it” and move on, or won’t really explain their thinking to residents especially off-service ones.

[u/Negative_Way8350 → u/ferdous12345]

Now, that I can get behind as a not-learner-friendly culture.

I'm happy to help our interns learn, especially since it's still August and boy are they fresh. I want them to feel like they can come to me with questions and I will direct them to stand in the best place to observe procedures and so on.

But it's the attending who is ultimately responsible for your education, not nursing. And if they don't want to do that, an academic setting is not for them.

If this continues, I urge you to go to your medical director in confidence.

[u/FightClubLeader]

No decision-making capacity means can’t make decisions, especially to leave the hospital

[u/tk323232]

Honestly…that’s fairly bread and butter when it comes to capacity….it can be very challenging but that case does not seem to be unless I’m missing something.

[u/ileade]

Nope. Actually an incident happened at our hospital. An AMS patient with a guardian signed out AMA and was hit on the highway twice by different cars and ended up passing away. We had to have a whole education about it

[u/throwaway123454321]

My residency felt like a “nurses were in charge” location- many nurses were extremely disrespectful to the residents, wouldn’t follow thru with orders if they felt they didn’t need them (“I didn’t start your fluid-overloaded CHF patient on the nitro gtt because they said they didn’t have any chest pain.”)

Granted- an experienced nurse is worth their weight in gold, and learning to trust their intuition and acknowledge their experience will serve you well.

But it doesn’t sound like this was that time- if the person was not of sound mind and cannot explain the pros/cons of leaving the ER, and you could articulate how them leaving could pose an imminent danger to them- then they don’t have capacity. I believe you were in the right.

Plenty of cases litigated for bad things to happen to a doc who let someone leave AMA didn’t have capacity.

[u/inertiavictim → u/throwaway123454321]

Care to share any of these cases you say have been litigated

[u/InitialMajor]

You were right

[u/Crunchygranolabro]

So we have a court saying this guy is incompetent, which is technically different from, but related to capacity, and a patient completely lacking when it comes to capacity. Namely he could provide a rationale (at least one based in reality) for refusing care, and he couldn’t engage in a discussion of the risks/benefits. Bonus points for his court appointed guardian/decision maker wanting him to stay.

Now, folks can be incompetent (a decision of the courts) and still have capacity, but the onus is on you to really prove that via rationale, understanding, etc, and it tends to be few and far between.

As for the RN, as others have said this comes from a few directions. The first is that the triage RN probably doesn’t have all the information at hand. The second is that determination of capacity falls on the physician. I personally prefer to include the bedside RN in the discussion and talk through my thought process anytime I’m doing something like this, or something that is going to make a whole lot of extra work for the bedside staff. Which brings us to #3. AMA and elopes are far less work for the nursing staff. It’s one less patient (who was probably being a pain in the ass). I personally prefer a good Elopement outside of certain situations where them leaving would open me up to more liability (clinically intoxicated, high likelihood of pathology leaving before the results who I then have to call back, etc)

[u/Ineffaboble]

There are a few situations where you have to stand firm even if what you are doing seems unfair, outrageous, not patient centred, or even against the interests of your team. Almost all of those situations seem to have to do with people in acute mental health crises, intoxication, or lacking (or having) capacity. There are parts of their job and license that we will never understand, and the same goes for ours. This is one of them and it’s super awkward. Hence the need to do a great job and be a good teammate, so your colleagues will trust you even when you have to do something they dislike.

[u/socal8888]

without capacity? AMA is not appropriate. because they can't understand the risks/benefits/alternatives.

and if there is a legal question later, it's always better to be trying to defend that you did the right thing for the patient (rather than any technicality in a rule or law or policy).

[u/DadBods96]

No. It’s sort of the whole point of even caring about capacity- Can they meaningfully make an informed medical decision. Leaving AMAZ is a medical decision.

[u/Substantial-Use-1758]

Sorry that ER nurse was so rude. She was wrong 🤷‍♀️🤦‍♀️

[u/Internal_Butterfly81]

No from what I understand if you think the patient will be a harm to himself if he were to leave and/or he isn’t alert and oriented enough to understand the risks of leaving AMA then the legal guardian’s decision would stand in my opinion. Am I wrong ?

[u/Runescora]

Lots of good feedback from physicians. On the nursing side the triage nurse was wrong and wrong to insert themselves into the situation.

[u/FelineRoots21]

As a nurse - you're correct and that nurse was wrong.

I would advise against some of the advice here though about just dismissing the nurse, if as you say they've been very good about helping explain policies to you, it would benefit both you and them for it to go both ways. You absolutely could and imo should explain to that nurse why you made that decision - he lacks capacity to make his own decisions and the person that does wishes he stay, that's a slam dunk medically and legally. You demonstrated he does not have the capacity when he could not articulate the risks of leaving. That's not informed decision making.

We are a team, anybody simply saying 'im the doc I make the rules' or 'ok thanks for your opinion' adjacent comments will lose the respect and support of the nursing staff fairly quickly. Of course if it's in the moment you can say 'im confident in my approach here we can discuss why after this is settled', but definitely don't straight up dismiss your nurses.

A nurse with the experience you describe likely has her own reasons for believing that patient should be allowed to leave, so engaging in that discussion will be valuable for both sides.

[u/MaximsDecimsMeridius]

you were right. the nurse was wrong.

[u/tsupshaw]

For those of you interested in a deep dive into the subject:Physician Sued After Letting Patient Leave Against Medical Advice

Runaway Patients. Medico-legal Issues When Patients Leave AMA

Medical Incapacity Without Mental Illness: A Legal and Ethical Dilemma for Physicians

Decisions for Adult Patients Who Lack Capacity

And a podcast from Psychiatry boot camp

[u/Ananvil]

Can a patient without capacity leave AMA?

No.

This is irrespective of if they're in the ED, the floors, the ICU, wherever. If they've no capacity, they cannot make medical decisions.

Obligatory please don't consult psych for this, its within every physicians playbook to determine capacity.

[u/the_jenerator]

In California we can usually make a case for a 1799 hold in these situations.

[u/squidlessful]

You were right. He’s been febrile (context: was he febrile in the ED?), has altered mental status, is delusional, and has a court appointed guardian who at least initially wanted him to stay. At least in my state that’s certainly grounds for a PEC because he was gravely disabled. And could likewise be grounds for a (potentially successful) lawsuit if there was a bad outcome. Did your attending even examine/take history or just talk him back into a room briefly?

Also this is a tough one and not your fault / in the circumstances you did what you could do. Triage nurse certainly didn’t help to de-escalate the situation. Expect a 72-hr rearrival notification on this one if you get those.

[u/Tricky_Composer1613]

It sounds like this patient may have lacked competence if he had a legally appointed guardian. In that situation he would not legally be allowed to leave, it would be no different from a 5 year old child trying to run out of the hospital. Capacity is different and is something a healthcare provider needs to determine on a case by case basis. If you determined the patient lacks capacity then either his healthcare proxy or physician needs to help determine what is in their immediate best interest, if you think he had a possible emergent condition and needed more workup then legally you should keep him (physically if needed) if he lacked the capacity to decide for himself. Your nurse sounds like she needs some additional training, you should document what happened accurately and send it to risk management and the nursing supervisor.

[u/surpriseDRE]

Unfortunately you can’t permit a patient judged not to have capacity to leave AMA and it is appropriate to ask security to come if needed. I have slowly walked behind a patient wheel v chairing his way around the floor saying “come on man, really?”

[u/cabeao]

As a former ER nurse, the nurse was wrong. However it’s a difficult situation because the doc trying to make a patient who is becoming violent stay basically means the RN is going to get beat on her whole shift. And ED docs can be kind of frugal when giving geriatric patients sedatives. Many times there aren’t resources for a 1:1 or the sitter ends up getting beat on too. I understand why the primary RN wouldn’t be begging to get the patient to stay. But the triage RN doesn’t really have anything to do with the situation and was out of line for her comment.

[u/BathtubGinger]

You made the right call, that nurse is forgetting that in these scenarios (prior to getting psych involved) YOU are the one who makes the call on a patient's capacity. Once you've made that decision that's it, end of discussion, patient cannot AMA unless guardian says so. Good job sticking to your guns.

[u/DrCrazyPills]

you are absolutely correct in saying that this patient did not have capacity to AMA out of there. Just to add another thought, always make sure that the "guardian" is actually a guardian. Lay people often throw around that word without knowing the specific legal definition. In Texas, they should have paperwork that shows the guardianship and the terms of the guardianship.

Source: am psychiatrist, deal with this often.

[u/Ok-Raisin-6161]

I would say in this scenario, he lacks capacity to make medical decisions since you have to be able to verbalize understanding of the situation to at least SOME degree.

But, no, her being his legal guardian and POA does not override his right to refuse medical care. The bar for taking away someone’s ability to manage money, etc. (financial/legal autonomy) is MUCH lower than the bar to take away decisions regarding their own body (bodily autonomy). Medical POA on paper doesn’t even always override someone’s personal bodily autonomy. Because it generally only applies if a person is deemed incompetent (i.e. unconscious, etc.) And this is usually decided in the moment.

[u/One-Abbreviations-53]

That nurse is a moron and needs to be turned in because they're dangerous.

As already said-if someone has a healthcare guardian a court has already decided for us that they are incapable of making their own medical decisions.

Without that, every state is varied slightly so looking up your state law for medical holds will serve you well. In my state, for example, we can (and do) legally hold people against their will because they don't have, in the judgement of a provider, the capacity to handle their own affairs. My state defines "danger to self" very broadly to encompass way more than SI...including obvious "lack of healthcare insight" which the gentleman you're describing would absolutely fall in to even without a guardian present. In these cases we immediately start the ball rolling on having someone (relative or the state) applied as guardian.

[u/NoCountryForOld_Zen]

Was he A&O?

If he wasn't, would you want someone to convince you to stay if you were dying of a fever? Most people would say "yeah, keep me" hence the whole implied consent bit.

If he's A&O he's free to leave, as long as he knows he's dying.

[u/meepsicle → u/NoCountryForOld_Zen]

That's not how that works. You can be A&O and lack capacity to make a decision to leave. Example: I know my name, I know where I am, but I am profoundly psychotic and believe the doctors are devils here to steal my organs. This person (regardless of orientation) clearly demonstrated he did not understand the choice nor consequences of the decision.

[u/NoCountryForOld_Zen → u/meepsicle]

Which is why I said "as long as he knows he's dying". Obviously if he doesn't understand the risks of AMA'ing, he can't AMA.

[u/Obi-Brawn-Kenobi → u/NoCountryForOld_Zen]

I don't know where you learned that someone being A&Ox3 means they have capacity to make all decisions, but you need to unlearn it. It's nowhere near that simple. Seems to be a common misconception, though.