Cut to the case!
Emergency doctors discuss cases and how to manage tricky situations in the Emergency Department.
Cut to the case!
Discharge Against Medical Advice
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DAMA! Jana and Jonathan talk about a case where a patient wants to discharge themselves against medical advice - the reasons, the risks and a sensible approach to this all too common situation in the Emergency Department.
This happens every day, but it also comes up in the exam. It's something that we we as emergency physicians have to be able to do really well. I guess the difficulty with these cases is you have your agenda.
SPEAKER_02It's a mismatch between agendas.
SPEAKER_01And the nurse came and found me and said she she's keen to go home and doesn't want to wait for the scan. We're talking about patients who want to discharge against medical advice. Hi, it's Jana.
SPEAKER_02And this is the case. So Jana, how's things?
SPEAKER_01Yeah, good thanks.
SPEAKER_02What are we talking about today?
SPEAKER_01Um well today I thought we'd talk about a case that I had recently for a patient who wanted to Dharma, which is discharge against medical advice.
SPEAKER_02Yes, there's a lot of that going on actually.
SPEAKER_01Yeah, it's not surprising with how busy everything is.
SPEAKER_02People have other things to do. They turn up to hospital hoping for a kind of outcome, and then maybe they don't get the outcome that they thought. So they think, well, maybe I'll just leave. You know, maybe it was just a quick, I need some antibiotics to go home. Yeah. No, no, we want you to stay.
SPEAKER_01So what happened? Um, so it was a woman who was in a in quite a high-speed car accident. Um, it was over 70, 80 kilometers an hour and and didn't have many um signs of injury, serious injury. However, with that yeah, but with that mechanism, you worry about um, you know, injury in the chest, and at the very least we wanted to get a CT of her chest, um, which she was agreeable to. Um, she was also pregnant, I should add, as well. All right. Um and uh and the nurse came and found me and said, and she she's keen to go home. Um and and then we had a conversation and and she left. Um how pregnant was she, can I ask? Uh about 20 27, 28 weeks.
SPEAKER_02Yeah, so so viable pregnancy, potentially two patients. Yeah. Um so what uh so what happened? Tell me what what tell me what happened.
SPEAKER_01So what happened? So I you know, I had to go and have this conversation with her um to do my job, which is to try and advocate for for um the best care for her, which in my opinion at the time was to have was to stay and at least have some further observation and have this scan. Um, she'd also been seen by the trauma team who wanted further scans as well. Um so we were actually planning to scan her whole body. Um and you know, and I and I guess the difficulty with these cases is you have your agenda um and you really need to make it happen, uh, and you've got all these things that you need to tick off your list to sort your sort your patient out. Um, but you also have to remember that patients have, you know, commitments and lives outside of, you know.
SPEAKER_02Yeah, I mean thinking about what I think, I think it's a mismatch between agendas. And and I think this is what we see a lot. We need to impress on uh the patient, you know, what we're worried about, what our agenda is, and I guess if we don't, yeah, then that's probably our our thing. We're not doing right, I guess.
SPEAKER_01Um and it's hard because um you know that this happens every day, um, but it also comes up in the exam. Um and so it's something that we we as emergency physicians have to be able to do really well. So it happens all the time in all types of presentations and patient demographics.
SPEAKER_02So So what's your what's your step-by-step approach, Charlie? You must have one.
SPEAKER_01I do for an exam uh approach um and in real life approach. I think you need to think about the medical aspect of it and why it is you want that patient to stay, then you need to think about the patient factors as well. Um so objectively, the patient needs to stay for this test, this treatment, um, this plan for observation, whatever it is. Um, and you need to impress that onto the patient and and explain in in language they can understand why that's important. Um, a lot of people are afraid to use the word, you know, you might die. Um but sometimes you have to say that because they can't make that decision if they don't know the consequences of the decision.
SPEAKER_02And I guess people think that, well, maybe the healthcare system is so good that if I do come back, you know, I will be okay and you know, uh they'll patch me up. But actually it's not always the case, right? So so we're really worried that they might actually die or come to major harm if we don't intervene right now. Yeah. And we're worried that if you leave it for a bit longer, then it's gonna be unsalvageable. That that's what I think about. Yeah.
SPEAKER_01So so you you talk about the medical stuff, um, impress that yeah with her, and then then what what what's so you talk about the medical stuff, and then once you've you know um said your piece, as it were, um then that then it's time to have a conversation. And what you're doing in that conversation is you're exploring the reasons why they want to leave, um, and you're looking for possible solutions, and what you have to do, and this is important for the exam, is you have to think about the patient as a whole and cover all the aspects of their history. What's their social history? What's what do they do for work? Who's at home? Do they are they looking after somebody who's fully dependent on them? Um, and try and problem solve that as best you can. Um but the overarching thing that's occurring is you're assessing your patient's ability to make this decision because sometimes it sounds like capacity assessment of some part. Because sometimes, say in trauma, for example, they might be head injured, they might be drug affected, um, and maybe they don't have the ability to make that decision, and you have a responsibility to, you know, keep them in hospital to advocate and get them the care that they need. That's a rare situation, but it does happen, doesn't it?
SPEAKER_02So we we impress our reasons for needing to stay, we explore their side of things if you like. What is it that they need to go home for? What you know, what's the big what is the issue? Yeah, and hopefully come to some ground. If you are making that capacity assessment, what are the key points in that capacity?
SPEAKER_01So the key points is that they have to be able to understand what you're telling them. Um so that's number one. They need to be able to understand the consequences of their decision to go home and they have to be able to repeat that back to you. Um and and those are the main components, I think, of capacity assessment.
SPEAKER_02Why is it why is repeating back so important?
SPEAKER_01Because it shows retention and that they understand they remember it. They remember it and they can understand the impact of that decision. Yeah.
SPEAKER_02Yeah, it's kind of gone in there, locked in. They've actually maybe processed it. They haven't just gone, no, no, no, whatever you say, uh, I I just want to go. It's kind of not good enough, is it? Yeah. You really have to retain it. Yes, I understand what you said to me. Repeat it back, I guess. Uh, and here are the reasons why. Um anything else to it?
SPEAKER_01Um I think you have to also figure out what their reasons are for leaving and see if those are reasons that are, you know, because sometimes you could have patients who have mental health problems, who have a psychosis, and those reasons might actually be a part of that illness. Um so it's really important to really explore with the patient why it is they need to leave and not cut that short.
SPEAKER_02Yeah, that's the problem-solving part, isn't it? Because we we're in this situation every day, but the patient might only be in this situation once or twice in their life. So we're in the situation where actually there are ways around all these things that we we find for other people every day, you know, like someone can go and feed the dog, or someone can go and do this thing for you, or actually you know, you can well, you know, we can get you back tomorrow. It is possible, we understand the system. Uh I'm the agent for you, and I can tell you how the system works. Or the reason you need to stay is because the system works this way. If you go home, you can't come back for the operation tomorrow because you'll lose your spot in the list, right? So people don't necessarily know that.
SPEAKER_01It's hard, and it doesn't, it's not always true, right? Because sometimes we can send people home and they can come back and have the plastic surgery the next day and they don't have to stay in that. So it's so it is variable. Variable is the thing, obviously. And so then so you've done your capacity assessment, you've explored the reasons why they want to leave, and you're trying to problem solve it, and you've delivered all the information you need to, and they still want to leave, then what do we do?
SPEAKER_02Well, do you go and cry on the corner like you're a failure? It feels like a fail.
SPEAKER_01It feels like you failed. Because actually what has happened is we have failed in a in a sense, especially with how busy everything is. We failed to deliver that care in a time that is, you know, appropriate for them or what they would deem appropriate for their life, you know, or you know, their their needs. Um so it in a way they feel like we failed them, and so you kind of have to acknowledge that as well. Um, and then my next step is okay, I've tried everything in my arsenal to get you to stay. Um, how can I make this situation as safe as possible? So that's like facilitating as safe as possible. So it's a harm minimization as well. Yes.
SPEAKER_02So you're gonna go, but uh okay, got it. Yeah, we're we're not changing that, you're going. Yeah. But here's how I can help it so that you'll have less harm when you leave. Yes, yes.
SPEAKER_01So that could come, that could look like um, okay, um, let's get you, I'll book you a rapid access clinic appointment next week.
SPEAKER_00Yeah.
SPEAKER_01Um, or make an appointment with your GP in the next two days. I'm gonna write a plan out for them to repeat this blood test or you know, to organize this, you know, this investigation, or why don't you come back tomorrow, we'll do the ultrasound tomorrow as an outpatient and we'll think about it.
SPEAKER_02Do you ever get resentful doing that? I mean, it's more work.
SPEAKER_01It's it is more work. It is more work. But then I think about my life at the moment with small kids, and I think, gosh, it would be so frustrating waiting for something that like you know, if you're waiting, how long do you have to wait for a scan? That's what I'm saying. And if you're not urgent, you just get bump, bump, bump, bump, bump. And you know it's gonna be normal because you feel well in yourself, and they often are like fine, aren't they? But we're becoming.
SPEAKER_02So I've been in a minute hospital twice. Both times I'd done it. Both times I did. Because you know what? I felt okay. What I did was done. They wanted to keep me for a reason, and I thought, well, I don't need it.
SPEAKER_01Yeah. And I left. Yeah.
SPEAKER_02I'm the worst patient ever.
SPEAKER_01So there you go. But we all we all have lives and we all have things to do, and nobody wants to sit in an ED if you're feeling not too bad and you don't want to be there. Um, what w what is the problem? It's we're we're actually it's we're worried about um, you know, uh bad outcomes and what that would mean for us, I think, as well. So I think it's uh yeah, and I think that's part of it. Um we want to give the best care, but also I would be worried if someone left without a scan and I've missed something and then something bad happens to them. Yeah, yeah, yeah.
SPEAKER_02What I mean by the the outcome for the system, if if someone has to then come back again the next day, then that's a whole lot more work that's now generated on the system. So because they get worked up again, the history happens again, all that you won't be using them again, and then there's this whole repetition thing that uh people don't necessarily realise either. So so there's a another chunk of work, which means another person has to wait, which just compounds the problem of people waiting. Yeah, you know, so it's a tricky thing. It's really hard. But I think you've nailed it, Jana. So so let's let's wrap it up. So summary, what are we doing?
SPEAKER_01So what we're doing is we're talking about patients who want to discharge against medical advice, so like halfway through their care in the ED. Yep. Um, and so a a good approach is you know would be good for your exam as well, is to think about um, you know, a capacity assessment. So are they able to make that decision? Um, conveying to them the medical reasons why you want them to stay and the potential complications or harm that could come to them if they leave before you complete their care. Um, make sure they can repeat that back to you and and understand the weight of that decision. Yeah. Um and then um if all else fails, well, actually you you're gonna do the problem solving bit while you're doing that. It's actually problematic. Why do you want to leave? Is it childcare? Is it feeding a dog? Is it, you know, is it work? Um and if all else fails, then do everything you can to facilitate. Don't just throw in the towel and go, well, that's your decision, but I think we still have a responsibility to make it as safe as possible.
SPEAKER_02Minimize harm, yeah, because we know that that's the whole reason why we wanted them to stay, so they didn't have any harm. And I guess finally it's it's documented, isn't it? Document everything. So that people understand.
SPEAKER_01The next person down the check understands what it's good for your for your um you know, for to protect yourself, but also it's invaluable to the person who will then look after that patient if they do represent. And they know what's been discussed, they know where you were got up to in your treatment or your investigation plan, um, and it makes it easier for everybody.
SPEAKER_02They can just pick up where you left off. Yeah, yeah. Okay. Well thanks, Shana. That was great. That's that's karma. Discharge against medical advice. A pregnant lady. And that's a bit of a segue about something that's coming, isn't it? Yeah, yeah.
SPEAKER_01So we're doing um a course on obstetric trauma soon. Um and so a good I thought a good thing we could discuss is how we um talk to our pregnant patients about radiation in the emergency department. Because that's something that's a lot of people. So let's make that for next time.
SPEAKER_02All right, see you everyone. See ya. Bye.
unknownYou can take a break.