I’m not implying every nurse or doctor does this, but couldn’t come up with a better title.
A cognizant patient is above all a free person. A free person is free to accept and to deny care, whatever may come. It’s his life, let him live his life as he sees fit. Explain, educate, inform and then ask: do you understand that if we don’t do this you may die / lose a limb / lose your liver / fall down and have a stroke and end up bed bound if we’re lucky enough to save your life?
I don’t understand the logic playing mental gymnastics to make a patient stay at a unit because the nurse or doctor in charge are convinced it’s in the patient’s best interest to do so, even when after education he wants to leave. I’m the odd one at my unit, as most of my coworkers do vehemently disagree with me, as they expect me to provide care AND to care. They feel they lost if a patient leaves against medical advice.
To me it looks like they don’t understand individual freedom and forget that a patient is still a free person. I wouldn’t want to be my coworkers’ patient.
You cannot stop grown ups from making stupid choices. The cognizant patient gets to decide his answer. Not a nurse or doctor convinced they get to decide for the patient.
Another problem I see: say you force a cognizant patient to stay at your unit because you are convinced you are doing the right thing. Why do you think he’s going to be a pleasant patient to work with? People lash out when they feel trapped and they insult and punch personnel. What’s the point?
Punched coworkers will call in sick and start looking for jobs elsewhere, some insulted ones too.
Wouldn’t it be better to inform, document, let him leave, move on?
US Physician here. The efforts I place into keeping a patient with capacity in the hospital vary directly to the concern I have about their pathology. There is a very real subset of people who have capacity, i.e. have the mental faculties about them that I cannot legally or ethically place them under a medical hold for treatment, who clearly do not comprehend the gravity of their situation or the likelihood they will die if they leave. I have unfortunately seen a number of patients who require significant amounts of supplemental oxygen, IV medications to support their blood pressure, life-threatening infections requiring IV antibiotics, etc, who for whatever reason decide they don’t want to be in the hospital anymore. Discontinuation of this life support puts their life at near-immediate risk, but the folks that are usually trying to leave in these situations are angry, distrusting of the medical system, and very goal-oriented on what they want to leave the hospital for (food because they’re NPO, illicit substance use, smoking, care for their dog, etc) to the point that they’re capable of saying “yeah yeah I can die whatever fucker, unhook me and let me leave.” These patients deserve for me to sit down with them and try and have a conversation about what we can do to keep them in the hospital because I’m worried they physically won’t make it through the hospital doors before they lose consciousness.
There are also people who have capacity, want to leave for whatever reason, and aren’t literally gonna die in 5 minutes. They get papers and a pat on the back as they walk out the door.
All of this hinges on a patient’s decision making capacity, and the reason every single time you want to leave the hospital against medical advice (AMA) you have to talk to one of the treating doctors is they have to determine if you have capacity at the time you’re making that decision. To be allowed to leave the hospital AMA you have to be able to demonstrate that you can understand why you’re in the hospital, the risks of leaving the hospital AMA, and hold consistent and logical (not necessarily rational) positions on decisions/priorities. If you can’t do any one of those things, you by definition don’t have medical decision making capacity, and I am not only legally allowed to, but I’m ethically obligated to keep you in the hospital to be treated until either a surrogate decision maker with capacity can be identified OR you have return of your capacity after your illness improves and we have this conversation again.