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Nursing Tips: When a Patient Leaves Against Medical Advice
“You can’t make me stay.” Although providers may seem shocked when a patient decides to leave the hospital Against Medical Advice (AMA), the patient is exercising his or her right to refuse recommended care or treatment. In an article for Mayo Clinic Proceedings, David J. Alfandre, MD, reports that about 2% of all medical admits result in an AMA discharge. When a patient leaves AMA, the risk of readmission for the same diagnosis increases, as well as establishing a precedent for future AMA discharges.
Who is most at risk for leaving AMA?
- Medicaid or no insurance
- Young adults
- Lives alone
- Alcoholism or substance abuse
- Psychiatric history
- Additional medical issues
- Family or financial obligations
The consequences of an AMA discharge vary by circumstance. Some patients are ready to leave, while others are quite vulnerable. In Dr. Alfandre’s article, retrospective analysis showed:
- Asthmatics had four times more ER visits and three times more hospital re-admits within 30 days.
- General medicine patients who were hospitalized had an almost seven times the likelihood of being readmitted within 15 days.
- Patients who had myocardial infarctions had a 40% higher chance of death or readmission for another MI within two years.
Nurses are likely to be the first healthcare professional that hears when a patient is considering an AMA discharge. Communication with the patient and the physician can be adequate in preventing an untimely discharge. Asking a patient to wait thirty minutes while you phone the physician or prepare the discharge plan may be enough time to calm an angry patient and allow for an honest conversation. The court has ruled in favor of a hospital using “a reasonable amount of time” to permit routine paperwork and procedure. (Bailie vs. Miami Valley Hospital)
Here are five tips for nurses who may encounter AMA situations:
1. Never threaten a patient by saying that if he or she leaves AMA that insurance will not cover the stay. Insurance will pay for care given up to the time of discharge.
2. Whenever possible, take time to talk with the patient to understand more about the reasons for seeking discharge. Patients sometimes have compelling reasons to leave and alternate care resources can be arranged. Document the conversation.
3. Using your facility’s AMA form, provide an informed consent regarding an AMA discharge. Elements of an informed consent include the patient’s acknowledgement that he or she is leaving AMA; that the risks have been explained and the patient understands; and that the patient knows he or she may return at any time. The patient’s signature indicates refusal of recommended treatment. If the patient refuses, the nurse can sign as the witness and document the refusal.
4. His or her rights to receive full discharge instructions and materials remain the same as other patients. Review the instructions with the patient. If the patient agrees, provide wheelchair or escort service from the unit. Document the events.
5. Psychiatric or violent patients may be retained if they are a threat to themselves or others. In these cases, the hospital may use legal means to keep the patient. Accurate documentation by the nurse is key in the process.
When a patient decides to leave AMA, the nurse can help provide as safe and responsible discharge process as possible. Respecting the patient’s autonomy while providing ethical and compassionate care are important nursing responsibilities.
Posted: 6/23/2016 1:00:30 PM
Is It Time to Start Your BSN?
When you wrote your New Year’s resolutions for this year, didl you include starting your BSN? Maybe you’ve been intending to do it for a while, but something always seems to interfere. Family, money, or other commitments push aside your plans…and suddenly another year has flown by.
Why should you get a BSN?
• You’ll get a leg up in your nursing career. The BSN curriculum can include courses in leadership, critical thinking, and communication. These “non-clinical” courses will be necessary for advancement beyond a bedside nurse.
• You’ll earn more money! Salaries vary by region of the country, but a 2013 Rasmussen College article reported that an Associate Degree median salary was $66,620, while a BSN median salary was $75,484. In just five years, a BSN will earn $44,320 more!
• You’ll be on your way to graduate school and advanced clinical practice. Nurse practitioners, nurse anesthetists, nurse midwives…if you’re interested in any of these, or becoming an administrator, you will need a Master’s Degree or Doctorate.
• More hospitals are requiring a BSN for entry-level positions. While ADN graduates will be able to find jobs, the best paying jobs increasingly demand a BSN.
The good news is that there are more options than ever to help you reach your goal. And depending how long you’ve been out of nursing school, some of your credits can be applied to your BSN. Here are three ways to get your RN-to-BSN:
1. Accelerated BSN Programs. Many universities offer programs that can get you to a BSN degree in as little as 12-16 months. The curriculum varies by school; it can be online, campus, or a combination, along with clinical practicums. These programs are for motivated, focused students who are able to study full-time.
2. Online BSN Programs. If flexibility is a priority, you may prefer to take classes online from an accredited school. You can study on your own schedule, although assignments have strict deadlines and some schools require “attendance” at certain times for student interactions. The timeline for BSN completion can be similar to accelerated programs, but the cost is often less. The key to online success is discipline, because no one is going to remind you that a project is due.
3. Community College Partnerships. Colleges and universities in many states are making it easy for ADN graduates to continue on to get a BSN or MSN degree. Called a “Nursing Partnership” or “Nursing Pathway,” the programs offer discounted tuition and easy transfer of credits to encourage community college students to continue their nursing education. Another benefit is that the programs recognize that the nurses are employed, so students can take a term off, and then return without reapplying.
The Institute of Medicine’s 2010 “Future of Nursing” report recommended that 80% of all hospital RNs have a BSN by 2020. If you are considering pursuing your BSN, there is no better time than now.
Posted: 5/6/2016 10:32:06 AM
Medical Tourism: How Much Do You Know?
As a Registered Nurse, you know that people assume you know everything! They can ask you to diagnose a rash or to predict the next flu outbreak. You may even be asked about the growing trend of medical tourism, which is defined as “travel to another country to seek and receive medical care.” According to the Centers for Disease Control and Prevention (CDC), the most common procedures are cosmetic surgery, dental care, and heart surgery. Almost seven million patients from all over the world will travel to another country each year to seek affordable treatments.
Medical tourism, also called “health tourism,” is not really new. Ancient Greeks traveled to the sanctuary of the healing god, Asklepios. Europeans have always visited hot mineral springs and spas known for their reputations for treating ailments from arthritis to gout to respiratory diseases.
Why do people look abroad for health care? Cost and availability seem to motivate patients to look beyond their own providers. Here are some examples:
• Heart bypass in the U.S. costs about $123,000. The same procedure is $27,000 in Costa Rica; $14,800 in Columbia; or $7,900 in India.
• Face lift in the U.S. costs about $11,000. Go to Costa Rica for $4,500; $4,900 in Mexico; or $3,950 in Thailand.
• In-Vitro Fertilization will cost $12,400 in the U.S. Fly to Jordan or Mexico and pay $5,000; Columbia is slightly more at $5,400; or pay just $2,500 in India.
Of course, you are wondering if the quality and care are the same. In 1999, the Joint Commission launched its Joint Commission International branch. The standards and accreditation processes are the same as in the United States. More than 600 international hospitals are JCI-accredited, with an annual growth rate of 20%. Patients seeking treatment at a JCI facility can be assured of safe and high-quality care. Also, many physicians have studied and trained in the U.S. and other developed countries.
Countries that are actively building and promoting health tourism facilities often include a “health vacation” that allows patients (and whoever travels with them) to explore the country while healing, before post-op appointments.
All may seem good, but as in any medical procedure, patients should always be knowledgeable about their care, as well as be aware of possible risks:
• Facilities provide procedures and services without liability. The standard of care is high, but patients assume all risk.
• Long-distance travel is not for everyone. Going to an unfamiliar country, arranging for an interpreter, and the journey back home can be stressful.
• Should complications develop after returning home, patients may need to visit their local providers. This will require insurance coverage or the ability to pay for treatment.
With the ability for people to travel around the world, medical tourism is likely here to stay. International treatment is estimated to be worth $40 billion a year, with an annual growth rate of 25%.
What can you tell people who ask you about medical tourism? It’s not for everyone, but you can offer them some information and encourage them to do their own research before making any decisions.
Posted: 4/4/2016 10:42:16 AM
April Is Donate Life Month: Transplantation Update
Every April, the health care community celebrates Donate Life Month, a reminder of the need for organ donation and life-saving transplants. Nurses are often asked about donation, or may be involved in the donation process as part of their job. Take a few minutes to read about what’s new in transplantation and to review some facts about the need for organ donors.
Organ donation and transplantation is a relatively new branch of medicine, started in 1954 when the first successful kidney transplant was done with identical twins. Following this landmark procedure, transplant entered an experimental era, including the famous 1967 heart transplant by Dr. Christian Barnard. However initially successful the operation, organs were rejected by the recipient’s immune system. It wasn’t until 1983, when the first immunosuppressive drug (Cyclosporine) was available, that transplantation could be considered as a realistic treatment for organ failure.
Over sixty years later, transplantation is now routine for end-stage organ failure. Most rejection can be avoided or delayed with sophisticated drugs and constant medical management. New areas of transplantation continue to expand the boundaries of what is possible:
• Vascularized Composite Allografts, such as hand and face, are complicated transplant procedures involving blood vessels, nerves, bones, and tendons. They can dramatically change and improve the recipient’s life by allowing them to return to society.
• Uterine transplants offer hope for women with Uterine Factor Infertility (UFI) whose only option has been surrogate pregnancies. While the first U.S. uterine transplant was not successful, nine other transplants around the world have resulted in five pregnancies and four healthy babies. The interesting thing about uterine transplants is that they are “temporary,” with anti-rejection drug therapy for 1 or 2 pregnancies before removing the uterus.
• Stanford University has developed a regime for kidney transplant patients that eliminates the need for immunosuppression. This is a major breakthrough, since long-term immunosuppression can lead to complications, including osteoporosis and some types of cancer.
• 3-D printers show exciting promise in producing functional body parts. Although early in development, researchers have “grown” ears for mice that are able to form cartilage and blood vessels. The implications for providing precise individual structures to replace living tissue or organs could impact the future of transplantation.
Meanwhile, the list of patients waiting for an organ transplant grows every day. Over 125,000 children and adults need a transplant to stay alive. A name is added to the waiting list every 10 minutes…and someone who is waiting will die every hour. Even with awareness campaigns, there are not enough organ donors. In 2014, there were 14, 414 donors who gave the “gift of life” to 29, 532 recipients. Clearly the need for donation is great.
As a nurse, you may find these talking points useful during Donate Life Month:
• Anyone can be an organ donor! Criteria is constantly expanding; your medical condition will be evaluated at the time of death.
• Even if you are on your state’s Donor Registry, tell your family so they know your wishes.
• Organ donation is consistent with the beliefs of most major religions.
• There is no cost to the family or the donor’s estate for donating organs.
• An open-casket funeral is possible for organ, tissue, and eye donors.
• All races and ethnic groups are encouraged to be donors. Transplant success is better when these groups can be matched.
• Organs and tissues that can be donated are heart, kidneys, lungs, pancreas, liver, intestines, corneas, skin, tendons, bone, and heart valves.
Posted: 3/8/2016 9:58:36 AM
What’s GOOD About Being a Nurse?
Every day we read how nurses are burnt out. Exhausted, over-worked, under-paid. Unappreciated and unacknowledged. Why would anyone want that job?
Because for every negative, there is a bigger and better positive. For each nurse, there is a unique reason why he or she loves the work and why he or she doesn’t regret the career choice. Studies show that 74% of nurses report being satisfied with their jobs. Compare this to doctors: Only 63% of dermatologists are satisfied, the highest of all physician specialties.
What are some of those reasons nurses are satisfied?
1. Altruism: Of course, this is at the top of the list. “Unselfish concern for the welfare of others” says the dictionary. Few nurses enter the field for reasons other than the need or desire to make a difference in someone’s life by giving the best possible care. The emotional reward of helping others is unsurpassed.
2. Job Security: There has, and always will be, a need for nurses. A nurse can find employment during every economic situation or at any location. Most nursing jobs offer a good salary and benefits, as well as additional pay for shifts, holidays, and overtime.
3. Flexibility: Nursing is one of the few careers that offer options for when and how long to work. Twelve-hours shifts, three days a week? Part-time? Weekends only? Evenings? There’s something for every lifestyle. As hospitals look to recruit and retain nurses, scheduling can get creative and enticing.
4. Range of Specialties: There is probably not another field or career path that allows for changes in specialty. A nurse can work in one area, such as pediatrics, then switch to another, perhaps surgery, rehabilitation, or orthopedics. There are no boundaries! A nurse can also choose to get certified in a specialty, as well as pursue an advanced degree as a Nurse Practitioner.
5. Respect: Year after year, nursing tops the Gallup Poll as the “most trusted” profession. Over 85% of the public sees nurses as honest and ethical. (Pharmacists are second, with 68%.) Family and friends seek the advice of a nurse, and are likely to listen when the nurse provides education or encourages them to see a provider.
The Bureau of Labor Statistics projects a need of almost 440,000 more nurses by 2024. The job growth rate is 16%, well ahead of the average rate of 7%. For people considering becoming a nurse, the outlook is bright.
Donna Wilk Cardillo expresses her feelings about being a nurse in an inspirational way:
“When I think about all the patients and their loved ones that I have worked with over the years, I know most of them don’t remember me nor I them, but I do know that I gave a little piece of myself to each of them and they to me and those threads make up the beautiful tapestry in my mind that is my career in nursing.”