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Protecting EDs & Providers When Patients Leave Against Medical Advice

Recent studies suggest that as many as 2% of discharges from acute care hospitals and EDs in the United States are done against medical advice (AMA). For disadvantaged inner-city facilities, this figure can jump to 6%. “Patients who leave AMA have higher readmission rates,” says Darren P. Mareiniss, MD, JD. “They’re also at greater risk for adverse health effects.” The risk of emergent hospitalization appears highest in the first several days after an AMA discharge. Considering the prevalence and ramifications these discharges can have, Dr. Mareiniss says that “emergency physicians must make every attempt to prevent patients from leaving AMA.” [polldaddy poll=7234675] In the Journal of Emergency Medicine, Dr. Mareiniss and colleagues and the Johns Hopkins Center for Medicine & Law at the Department of Emergency Medicine recently published an article that reviewed legal requirements of the AMA process and examined how properly executed AMA discharges can protect institutions. “In situations when AMA discharge is unavoidable, the key is to optimize legal protection,” Dr. Mareiniss says. Capacity & Disclosing Risks When patients sign out AMA, they must first be deemed as having decision-making capacity. “The assessment of decision-making capacity focuses on a patient’s ability to understand and communicate rational decisions,” explains Dr. Mareiniss. “They need to be able to express their choices and demonstrate an understanding of relevant information. They must also appreciate the significance of this information and its consequences.” Usually, determining capacity is relatively straightforward. However, if capacity is unclear and patients wish to leave AMA, emergency physicians should consult psychiatry whenever feasible. Prolonged observation may be necessary in some situations. In cases of intoxication, mental capacity...

Assessing Medical Decision-Making Capacity

Research has shown that many clinicians lack formal training in evaluating medical decision-making capacity. Typically, patients who may lack capacity are evaluated only when decisions to be made are complex and have significant risks or if patients disagree with physician recommendations. The standards for medical decision-making capacity vary, but require patients to have the ability to: 1) Understand relevant information about proposed diagnostic tests or treatment. 2) Appreciate their situation. 3) Use reason to make decisions. 4) Communicate their choice. “All licensed physicians can make a determination of incapacity, but most lack the training, experience, and confidence to do so,” says Laura L. Sessums, JD, MD. “Capacity evaluations could benefit from utilizing a standardized approach. Physicians may perform these evaluations more frequently if they have a useful instrument to guide these assessments.” Intriguing New Research on Capacity Ideally, clinical tools for evaluating capacity should be brief, reliable, and facilitate the documentation of capacity abilities. Many instruments have been developed for assessing capacity to make medical decisions, but most have not been validated in high-quality studies. In the July 27, 2011 JAMA, Dr. Sessums and colleagues conducted a study to determine the prevalence of incapacity and assess the utility of available instruments for capacity evaluation in adult medicine patients without severe mental illnesses. “Our goal was to provide a guide for clinicians to select a valid, reliable, and clinically useful tool for assessing and documenting incapacity in their own patients,” she says. The analysis showed that the overall prevalence of incapacity among healthy older adults was 2.8%, but the rate of incapacity increased substantially with higher degrees of morbidity (Table...
Patients Wary of Care from Surgical Residents

Patients Wary of Care from Surgical Residents

Most patients approve of teaching facilities and training residents. However, a new study has found that consent rates plummet when patients are given detailed information about the role a resident will play in their surgical procedures. Patient perceptions and willingness to participate in resident education were reviewed by researchers in a study published in a recent issue of Archives of Surgery. Overall, of the 300 patients who completed a questionnaire about their support of resident training, most expressed overall support: 91% felt that their care would be equal to or better than at a private hospital. 68% believed they derived benefit from participation. 85% consented to having an intern participate in their surgical procedure. 94% consented to having a resident participate in their surgical procedure. However, consent rates plunged from 94% to 18% as the level of resident participation increased: 58% consented when a junior resident would be assisting a staff surgeon. 32% gave consent when a staff surgeon would be assisting the resident. 26% consented when a staff surgeon would be observing the resident. 18% gave consent when the resident would be performing the procedure without the staff surgeon present. Although patients are not routinely informed of a resident’s role in surgical procedures, those questioned said that the information could influence their decision on whether to consent. The researchers concluded that policymakers need to consider the variation in patients’ willingness to be treated by physicians in training — but that providing detailed informed consent could adversely affect resident participation and training. Physician’s Weekly wants to know… Should patients be provided with detailed informed consent if it adversely affects...
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