When leaving your care, patients must be informed of certain facts to help them monitor their situation at home. These include:
- The clinical situation and the diagnosis (or differential diagnoses if there is uncertainty)
- Instructions for activities of daily living throughout the recovery period
- The symptoms and signs alerting them to seek further medical care (i.e. clues that the condition is worsening or that the diagnosis may not be correct)
- When and who to contact and where to go if they experience complications
- Knowing they are welcome (made to feel comfortable) to return for re-evaluation
The information should be tailored to each patient and each clinical situation. This advice would include discussion of the potential side effects and monitoring requirements of any prescribed medications.
Just as when obtaining informed consent, it is important to describe the symptoms and signs of common complications and also of rare complications with a potential for serious harm. It is a good practice to confirm the patient’s understanding of the issues and address any questions. The discussion with the patient should be documented in the medical record.
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Handouts support the informed discharge discussion but do not replace the personal interaction.
It can be very helpful to give the patient (or the person taking the patient home) written instructions. These are supplements to the personal interaction, but cannot replace it. Because handouts may be fairly general, consider deleting any parts that don't apply to the particular patient or specific clinical situation and consider adding any absent points that may be pertinent to the patient. Keeping a copy of your handout in the medical record will help others understand what advice was provided and may serve to support your care.
Surgical teams that have adopted ERAS (Enhanced Recovery After Surgery) protocols have found that streamlining standard patient care pathways contributes to optimized outcomes. This includes pre-operative discussions about what to expect after the surgery, reinforced by key post-operative messages.
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Consider the safety of the post operative patients and provide appropriate advice to those who will be with them.
Patients may be discharged from an emergency department or a day-surgical facility while still not fully capable due to medications such as anaesthetics or sedatives that were provided while under medical care.
In these circumstances the patient should generally be accompanied by a relative or friend who is willing and able to help, including with travel arrangements upon discharge. With the patient's consent, that individual should be part of the discharge discussion. Courts have confirmed that physicians have a legal duty to advise patients who may continue to be impaired from sedation or for other reasons about the risks of leaving the hospital or clinic alone.
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When discharging a patient after an episode of care, inform the patient of any need for follow-up, and identify the most responsible health professional who will be providing the follow-up and how the arrangements will be made (e.g. appointments, etc.).
- To facilitate continuity of care, the health professional responsible for following the patient after discharge should generally receive information about any outstanding investigations or any required follow-up care.
- Long delays may occur between a patient’s visit to an emergency department or a consultant’s clinic and the time when their primary care physician receives a letter. It is important not to presuppose that another health professional will be willing and/or able to assume the follow-up for care you provide.
- Courts have determined that it is the ordering physician’s responsibility to ensure follow-up on pending investigations. While this responsibility can be delegated to another provider, they should be notified and agree to take on that responsibility.
- The discharge information should be sufficient to enable ongoing care. In particular, the information should indicate the provider most responsible for following the patient and for arranging recommended investigations.
- If the patient has been given responsibility for making a follow-up appointment with another physician or healthcare provider, that healthcare provider should have been notified so that appropriate follow-up can be arranged.
- If follow-up is perceived to be urgent, it is often helpful to contact the subsequent provider to verbally explain the clinical situation. Document your efforts in the medical record.
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Patients who leave against medical advice may put themselves at risk of harm and create potential medico-legal risk. Nevertheless, the capable patient is free to make informed choices about their care.
Many physicians believe they are absolved of any legal duty of care when capable patients discharge themselves against medical advice. While it is true a patient may be judged to have negligently caused or contributed to a clinical outcome by failing to act as might generally be expected of a reasonable patient, it is uncommon that a court will find the patient wholly responsible for an adverse outcome due to their contributory negligence (contributory responsibility in Québec).
When a patient wants to leave AMA, a physician should make reasonable attempts to confirm that the patient understands the potential consequences of refusing the recommended investigations or treatments. The patient who appears to understand the nature of the disease and the consequences of accepting or refusing treatment is likely capable.
This capacity assessment is based on the overall clinical picture. Use care in your questioning such that the answers help you determine whether the patient truly appreciates their situation. Exploring the reasons for the patient’s wish to leave may be helpful (e.g. asking if the patient has any other personal concerns like a responsibility for the care of a spouse at home or a pet left unattended). Being aware of such concerns may help identify ways to resolve such issues.
Relying on questions such as “Do you understand?” might be misleading and provide false reassurance that a patient understands more than they actually do. Asking the patient to explain what might happen if they leave against medical advice might be a more effective strategy to ascertain their understanding.
Patients have a right to refuse treatment. While important to avoid coercing a patient, it may be helpful, depending on the apparent seriousness of the clinical condition and available resources, to ask another physician to assess the patient’s competency or to reinforce the need for the recommended investigations or treatments.
Even if a capable patient refuses treatment, the physician should explain why more observation, investigation, treatment, and follow-up are recommended. This discussion may help alleviate the patient's concerns or fears. When possible and with the patient's permission, it is generally useful to include family members in the discussion.
Just as with informed consent, a signed “AMA form” does not necessarily constitute evidence of an informed discharge. A clinical note outlining the recommendations for care, the capacity assessment, the patient's reasons for refusing investigation or treatment, and the follow-up and discharge instructions will serve that purpose more effectively. If a patient refuses to take part in a discharge discussion or refuses to sign an AMA form this should also be documented.
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