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At Miami Children's (FL) we don't have a pediatric AMA form because we
believe that if we cannot come up with an alternative plan/compromise that
satisfies both our medical judgment ("adequate" vs "optimal" evaluation and
treatment) and the family's needs or concerns, we should take the proper
legal steps to retain temporary custody of the child if we feel he/she is in
potential immediate danger. If we feel the patient is not in danger there's
no basis for an AMA. An AMA form should not be a substitute for working with
the family to reach a mutually agreed upon plan. Sometimes that means
lowering our standards a bit; it can be very difficult for us to agree to do
"less" than we usually do but, IMHO, a compromise is usually better than
letting the family walk out the door. Parents have the right to disagree
with our recommendations as long as their decisions don't place the child at
potential significant risk. We try to enlist the assistance of the patient's
primary care physician (usually by phone) whenever possible. We can also
offer to get a second opinion from another on-duty physician. (Note that
this strategy is what we use in the ED. I'm not sure what they use for
inpatients but I believe it's probably the same approach.)

An example of an alternative plan would be when a parent refuses an LP for a
child with very clear-cut indications. In that case, the alternative to the
LP may be admitting the child without the LP and treating them as if we knew
the child had bacterial meningitis. When it's made clear to the parents that
this probably means 10 days in the hospital on IV antibiotics, they usually
think again, especially if there's a chance we might send the child home if
the LP's negative. 

It's amazing how many parents change their minds about leaving or refusing a
procedure or treatment when you bring up the fact that we have the power and
obligation to take temporary legal custody of their child if we feel their
decision puts him/her at significant risk. I do everything I can before I
pull that trump card out of my pocket though, because the parent's usual
immediate reaction is obviously pretty hostile. It does, however,
demonstrate how far we will go as advocates for the child and how serious we
are about what we think needs to be done. In a 20 year career I can't recall
ever having to carry through on the threat. 

In my experience, refusals are often due to parental fears based on
misinformation. Taking the time to identify and validate their concerns and
to educate the family is a very successful strategy, at least in my
experience in a busy suburban hospital. Patience and an investment of time
are much more fruitful and protective of both patient and care providers
than a sheet of paper that means very little. 

If you are going to use an AMA form, the part that probably means more than
anything else legally is your written documentation of exactly what you told
the family about potential risks and consequences and what they should look
for as possible danger signs. The parent should be able to read what you
write before they sign; their signature attests that they have both read and
heard your advice and understand to the best of their ability. I would also
give them a copy of the document because it will give them a instructions to
refer to if they start getting nervous after they leave. As always, your
documentation can either hang you or save you!

Lou

Lou Romig MD, FAAP, FACEP
Miami Children's Hospital Pediatric Emergency Medicine
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>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Date:    Mon, 13 Jul 2009 09:30:45 -0500
From:    Jason Foland <[log in to unmask]>
Subject: AMA from the ER

Dear all=2C

=20

We have had an issue with our hospital's current policy for Pediatric AMA w=
hich is just a piece of paper for the guardian/ parent to sign stating they=
 are leaving against physician advice. Understanding that there are state l=
aw issues=2C how have other hospitals in Florida as well as those in other =
states dealt with this issue?

=20

Jason

Jason A. Foland=2C MD
Pediatric Critical Care Physician
Nemours Children's Clinic
www.nemours.org
Medical Director=2C Pediatric Respiratory Therapy
Sacred Heart Women & Children's Hospital
www.sacred-heart.org
Pensacola=2C Florida
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