Discharging a Pediatric Trauma Patient Against Medical Advice (AMA)

PURPOSE:

To establish guidelines for addressing situations when minor/pediatric trauma patients depart prior to dismissal by provider (discharge against medical advice) and recognize the right of the patient’s legally recognized representative to make that determination, unless otherwise limited by law.

When any patient leaves prior to dismissal or elopes, it is the policy of Nebraska Medicine to act in accordance with the welfare of the patient and the public while respecting the patient’s rights and complying with applicable laws.

These guidelines are created specifically for the pediatric trauma patient and may not be applicable to adult trauma patients or other service lines. For more information regarding Nebraska Medicine hospital policy, please refer to LD21—Patient Departure Prior to Dismissal (AMA).

DEFINITIONS:

• Departure Prior to Dismissal (also known as departure against medical advice – AMA): departure of a patient who is admitted to the hospital as an inpatient, outpatient or observation status, or who is in a dedicated Emergency Department but has had a medical screening examination completed; patient may or may not make their intention known to staff.
• Elopement: unauthorized departure of a patient from a staffed, around the clock care setting, including the Emergency Department.
• Imminent Risk for Harm: immediate and impending threat of physical harm to self or others, as assessed by provider.
• Minor (pediatric) patient: any individual receiving care under the age of 19 (as defined by Nebraska state laws)
• Legally recognized representative: A parent, guardian, or other person with legal authority to make healthcare decisions on behalf of the minor child.

POLICY

1. The legally recognized representative (i.e. parent, legal guardian) of a minor patient has the right to terminate the care encounter and remove the patient from the premise at any time, except when prohibited by law.
   1. • Patients who are under a legal hold may not have the right to leave the premises at a time of their choose (see policy LD 12-Legal Status Holds).
      • Questions about restrictions related to specific legal holds should be referred to Legal or Risk Management.
2. If staff believe that the minor patient may be at risk for serious or imminent harm (i.e medical neglect) if removed from the care environment, it may be appropriate to consider reporting the concern an appropriate authority, such as Child Protective Services or law enforcement.
   1. • If there are questions or further discussion regarding the specific situation is warranted, providers are encouraged to call Risk Management at 402-559-0060 (24/7 hotline).
3. Nebraska Medicine will make reasonable efforts to ensure that the minor patient and the legally recognized representative for the minor is informed of the risks of leaving against the advice of the provider.
4. Nebraska Medicine respects the minor patient’s/legally recognized representative’s right to choose to accept or decline care. A patient’s or representative’s decision to leave against medical advice of the provider will not negative influence the patient’s ability to receive future care with Nebraska Medicine.

PROCEDURE

• If a minor patient or a patient’s legally recognized representative expresses the desire to leave the premises prior to dismissal against medical advice:
  1. •  AND the patient’s legally recognized representative has the capacity to make healthcare decisions AND is not under a legal hold:
       1. 1.   Staff will attempt to request that the patient and legally recognized representative stay to speak with the trauma provider.
          2.  Staff will notify the trauma provider of the plan to leave against medical advice and may initiate a care discussion, to the extent that the patient and legally recognized representative is willing to participate.
             1. • The trauma provider will subsequently notify the trauma attending immediately following notification of a minor patient/representative expressing desire to leave premises against medical advice.
          3. The trauma attending will discuss and inform patient and/or legally recognized representative of the risks and benefits of leaving against medical advice, to the extent that the patient is willing to participate.
             1. • If staff or providers believe the patient may be at imminent risk for harm if removed from the current care environment, contact Child Protective Services (CPS) or law enforcement as indicated.
                • If there are questions regarding case or presence of imminent risk for harm/medical neglect, contact Risk Management at 402-559-0060.
          4. The trauma attending/trauma providers, with appropriate assistance from staff, will provide plan for care outside the hospital and instructions appropriate to the patient’s specific needs (i.e. prescriptions, follow-up appointments, DME, etc), to the extent that the patient/representative are willing to participate.
          5. Encounter will be documented in the electronic medical record by the trauma attending or designee using the AMA note template (.AMA) and should include the following information:
             1. • Patient/representative’s intent to leave and reasons for leaving, if known.
                • Specifics of case/injuries known
                • Decision making capacity of the patient’s legally recognized representative
                • Description of attempts to inform the patient/representative of risks of leaving against medical advice and their response.
                • Parent or legal guardian sign the Informed Refusal of Healthcare Services Form. This document will be included in the patient's electronic health record (EHR) as a part of the permanent medical record. If the patient or legal guardian refuses to sign the form, ED personnel (or trauma attending if the patient is already admitted) will complete the form noting patient/legal guardian's refusal to sign. When a patient/legal guardian refuses to sing, two witnesses should sign the form. 
                • Time of departure and condition of the patient as assessed by provider.
                • If CPS report filed or law enforcement contact.
                • Mode of departure and plans for care outside the hospital and instructions given to patient/representative, as applicable.

RELATED POLICIES/PROCEDURES

• Patient Departure Prior to Dismissal (AMA) – LD21
• Legal Status Hold – LD12
  
• Patients Leaving Against Medical Advice -- OPS17 

KEY CONTRIBUTORS

• Emily Cantrell, MD | Division of Acute Care Surgery, Faculty | Principle Author
• Lora Hofstetter, MSN, RN, CCRN, C-NPT | Pediatric Trauma Program Manager | Co-Author