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Dying after leaving AMA

Somehow, patients are convinced we're lying

September 2021

THE NURSE CALLED: “The patient wants to leave AMA.”

These calls come, fortunately, not often. Typically, these patients are not terribly ill, but they really miss their cigarettes or alcohol. While spending another day or two in the hospital would be wise, leaving against medical advice is not actually jeopardizing their life.

Adamant about leaving
This patient was different. He was very ill but competent to make his own decisions. He had covid, and this was day No. 10 in the hospital. The patient was stable but required high-flow oxygen, 100% at 60 liters per minute. He was in his own room on our covid floor, which after 10 days he probably viewed as a 12-by-12-foot prison cell. We don’t even let patients who are on this floor in the hallway.

I sat down and said that I heard he wanted to leave. The patient was calm and collected—and he pointed out that what we were doing was not working. Which, I must admit, is partially true. We don’t have great treatments for covid and, while I was pleased he was not in our ICU, he really did not feel any better than when he was admitted. He had a valid point.

Had this patient stayed or gotten vaccinated before contracting covid, he very likely would still be alive.

I asked about his plan. He said he would call his doctor. I made that call instead and his PCP called him, but the patient was resolute: He was going home.

We took his high flow oxygen off to see how he did. The pulse ox dropped to 60% within a minute. No difference; he was leaving. He indicated that he would not want CPR or intubation, so we executed a written DNR. He remained on an oxygen tank at 5 liters until he was in his wife’s car, headed home.

He died the next day. When he became unresponsive at home, his wife called 911. Paramedics performed CPR and gave epinephrine. He was breathing, but in PEA. When the spouse told the ED team that the patient did not want CPR or intubation, they stopped.

What do we do about it?
This one hurt. Yes, patients die, and I really don’t believe any of our doctors or nurses bear any responsibility for this death. But this patient should not have died. He was in his 60’s and was taking only blood pressure meds and a PPI.

This was not glioblastoma or a major trauma where everything we do really does not matter; sometimes, the patient is going to die regardless. Respiratory therapists, nurses and doctors all told this patient that he would die if he left. He just did not believe us. Had this patient stayed or gotten vaccinated before contracting covid, he very likely would still be alive.

How did we get here? How did we get to the point that severely ill patients, competent to make their own medical decisions, believe that all the RTs, nurses and doctors are wrong about covid? How do intelligent people (you may not agree with them, but that does not mean they lack mental capacity) believe that this virus does not kill people? That we are all in some vast conspiracy to get them to take a vaccine that is really going to hurt them, not save their lives?

And what do we do about it? I’m a hospitalist, and I care for several covid patients every day that I work. That’s been the case since early 2020, and it’s not improving. We round on these patients for days or weeks, and they usually improve, but it’s very slow. I’m tired of it, and they make up only about 25% of my patients. It’s closer to 100% for the nurses and RTs on the covid floors and in the ICUs, and I can only imagine their exhaustion.

This is where we are: hospitalizations rising, new variants that are more infectious, and many people believing that this is all a hoax or that millions of people have conspired together to make injections that harm people, not help them. Patients leaving AMA and dying because there’s no trust anymore.

This is where we should be: people recognizing that we don’t like wearing masks or getting shots, but maybe we should to get things under control. People trusting that health care workers are really working in the best interest of everyone, and health care workers optimistic because we see progress.

How do we get from here to there?

Steve Burgess, MD, is a practicing hospitalist who teaches CME through Hospital Medicine Seminars. This column originally appeared on the Hospital Medicine Seminars site.



Published in the September/October 2021 issue of Today’s Hospitalist

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Dr Guenin
Dr Guenin
September 2021 7:01 am

Unfortunately same story happened to my patient and I was devastated for days … it could of been prevented. Two kids were left without a mother. I share your pain..

Cynthia D. Owens, D.O., FACOI, FACP
Cynthia D. Owens, D.O., FACOI, FACP
September 2021 11:00 pm

I am also a hospitalist and had a similar experience with a 35-year-old patient with COVID associated pneumonia complicated with early ARDS who required high flow oxygen alternating with Bipap. She had no co-morbidities. She did not get vaccinated. She presented in moderate severe respiratory distress. From the first day of her admission she repeatedly stated her belief that she did not have COVID and wanted to be discharged home. When asked what she believed her diagnosis was, she didn’t respond. She only admitted to “feeling ill” as her reason for coming to the hospital for help. She was advised… Read more »