12.6 Crm Leaving Against Medical Advice Em Dunn 212

Front 1

The patient who leaves against medical advice (LAMA, also = discharge against MA - DAMA) creates a tension between failing to reasonably restrain the patient (negligence) and unreasonably restraining the patient (assault/false imprisonment). This is an ethical conflict - autonomy vs. beneficence/nonmaleficence.

What questions should be asked (of the patient, and of the circumstances) to determine the course of action?

(NB LAMA, DAMA and refusal of specific/general treatment are considered in the same way in terms of management)

Back 1

1. Is there a duty of care? Patient must be engaged in process of treatment e.g registered as pt, must be incompetent, must be facing a risk

2. Why do they want to leave? Is there a lack of understanding of the risks of leaving, benefits of Rx? Are there fears associated with hospitalisation (e.g. substance withdrawal), or breakdown in communication/trust with hospital staff?

3. Can someone else legally determine consent? e.g. minor, detention under mental health act, enduring Power of Attorney (medical treatment), guardianship board

4. What is the risk to the patient of DAMA? Clinical assessment of medical and psychiatric state. Likely compliance with alternative treatments

5. What is the risk to the patient of restraint (not usually a significant factor in decision)? How much force/medication will be required? Comorbidities.

6. Is the patient capable of refusing consent? See next slide

Front 2

Consent - what are the features of competence required

Back 2

Age

Cognitive capacity to understand (diagnosis/condition, options, recommendations, potential adverse outcomes)

MMSE >20

Accept information as reality, retain, paraphrase, explain consequences, indicate the factors in their decisions and importance assigned to them

Front 3

What are the outcomes associated with LAMA?

Back 3

4.4% unscheduled readmission (Cf. 0.1% patients routine discharge)

Delay diagnosis/treatment

Rarely adverse outcomes unless in HIGH RISK patient groups (chest pain, head injury, headache, fever/abnormal vital signs, paeds, elderly, pregnancy, GP concern, impaired patient judgement, ETOH/drug intoxication, psychosis - list from Dunn 211 DNW)

Front 4

How would you manage someone who wanted to LAMA/refuse medical treatment? In order of escalation...

Back 4

Maintain nonjudgemental approach (pt more likely to return for care if needed)

If CONSENT ALREADY LEGALLY DETERMINED (minor - parents, detained, recommended, guardianship, refusal of treatment order) treat as per statutory authority, or parent/guardian wishes

OTHERWISE
Address reasons for treatment refusal
Recruit others to assist - family, pt GP, another ED Dr
Attempt compromise
Provide alternative care - e.g. SSU Cf ward, part of management rather than whole
Last resort - stall e.g. if waiting arrival of relative on your side
Use police - if public safety compromised e.g. driving whilst intoxicated

RESTRAIN if high risk and urgent treatment required to prevent morbidity/mortality e.g. suicidality, abnormal mental state, significant physiological derangement, D&A influence, behaviour inconsistent with personality as per family/friends/GP/notes

If INAPPROPRIATE TO RESTRAIN
Arrange follow up GP/other
Encourage to sek care if worsens
Discharge at own risk form to be signed - if refuses, 2nd staff member who has witnessed interaction to make/sign statement
Document in medical record - pt mental status, findings supportive of competency, information given to patient, alternative mx options provided, involvement family members

Front 5

What is the Medical Treatment Act of Victoria?

Back 5

GIves a direct statutory right to competent adults to refuse medical treatment, whether terminally ill or otherwise. Does NOT apply to palliative care. A certificate should be completed to formalise the process.

At least one witness on the refusal of medical treatment certificate must be a registered medical practitioner and may also be the treating doctor. They should be satisfied that the person understands risks involved with the proposed procedure or treatment and any alternatives.

Once the treating doctor is aware that a certificate exists, it is an offence for that doctor to continue or undertake any medical treatment covered by the certificate.

The Act protects all registered medical practitioners or people acting under their direction who refuse to perform or continue a procedure or a medical treatment in accordance with a refusal of medical treatment certificate. A medical practitioner is not guilty of misconduct, any offence or liability in any civil proceeding for failing to perform or continue the relevant treatment.


The refusal of treatment certificate applies only to a current condition and not to a condition that may or may not occur in the future.

For this reason, the refusal of treatment certificate does not function as an "advance directive" except where the treatment is anticipated for a current condition.