Spotlight Case

1. Spotlight Case Standard Deviations

2. Source and Credits • This presentation is based on the December 2009 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by:James E. Sabin, MDHarvard Medical School; Harvard Pilgrim Health Care • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Niraj Sehgal, MD, MPH • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand the safety risks associated with patients being discharged against medical advice (AMA) • Recognize safety risks associated with being part of a stigmatized group • Explain how the concept of “cultural competence” should extend to include the homeless intravenous drug user population • Appreciate the role of ethics and psychiatric consultations in patients whose refusal to cooperate with treatment is perplexing

4. Case: Standard Deviations (1) A 45-year-old man with an active history of intravenous drug use (IVDU) was admitted to the medical service with fevers and low back pain. He was noted to have a leukocytosis and an elevated erythrocyte sedimentation rate (ESR). A subsequent MRI showed an epidural abscess with surrounding osteomyelitis. After having the abscess successfully drained, the patient required a 6-week course of intravenous antibiotics for methicillin-resistant staphylococcus aureus (MRSA).

5. Case: Standard Deviations (2) Because the patient was homeless, uninsured, and actively abusing IV drugs, there was no appropriate care setting where he could complete his required therapy. Therefore, he remained hospitalized while awaiting Medicaid enrollment. After the first 2 weeks, he became increasingly abusive to nursing staff, was found smoking on the unit, and twice threatened to leave against medical advice (AMA). In efforts to make the best of the situation, physicians caring for the patient elected to discharge him on an oral antibiotic regimen with follow-up in a free health clinic.

6. Challenging Patient Situations • Patients who are homeless and uninsured and who also have substance abuse problems, mental health conditions, or both may pose challenges to carrying out treatment plans • Uninsured status is an additional societal concern with 45,000 deaths annually attributed to lack of insurance See Notes for reference.

7. Defining “Standard of Care” • Clinical standard is complex • Negligence associated with standard of “customary practice”—how others practice • Legal standard has shifted from actual practice patterns to “reasonable” ones to allow for possibility of slow adoption of evidence-based guidelines • American Medical Association advocates “competent care”—to avoid judgment distinction between competence and excellence See Notes for references.

8. Against Medical Advice (AMA) • Discharges AMA not uncommon; 1.44% rate • For patients with mental illness and/or substance abuse, the rate is 51% • Discharges AMA confer poor prognosis • 7 times more likely to be readmitted within 2 weeks • AMA events require a “systems” prevention approach as patients at high risk can be identified See Notes for references.

9. Provider Competencies • Caring for patients from stigmatized groups, such as homeless IV drug users, requires competencies and sensitivities similar to those needed in dealing with culturally distinct patients and groups • Abusive patients can erode the provider–patient relationship and pose specific patient safety risks • Providers’ loss of empathy for and rapport with such patients adds obstacles to determining ethical standards and decision-making capacity See Notes for references.

10. Ethical Standard of Care • Refers to treatment that should be provided • Over time, this has come to mean that “informed consent” determines what should be provided • Informed consent contingent upon adequate assessment of patient’s decision-making capacity

11. Assessing Decision-Making Capacity Defined by four criteria: • Ability to communicate a choice • Ability to understand relevant information • Ability to appreciate the situation and its consequences • Ability to reason about treatment options • Capacity particularly important to assess in homeless patients because they have higher risk of mental health disorders and subtle cognitive deficits See Notes for references.

12. Homeless Patients and Decision-Making • Homeless patients reject services because of: • A desire to be independent • A lack of active participation in services • Poor therapeutic relationships • Lack of provider cultural competence • Side effects from medications • Clinical pearl: in such situations, consider collaborating with a shelter worker, priest, or a homeless person that patient looks up to See Notes for references.

13. Case: Standard Deviations (3) The patient was readmitted to the same hospital 3 weeks later with a recurrent epidural abscess and worsened osteomyelitis. He reported taking “most of his antibiotics” but never made it to a clinic for scheduled follow-up care. He required a more extensive surgical debridement and he also developed MRSA endocarditis. The patient became quite deconditioned postoperatively.

14. Case: Standard Deviations (4) After nearly 3 weeks of inpatient care, the patient threatened to leave AMA once again. Although he was ambulating at that point, he still required additional IV antibiotics and still lacked any viable option for institutional non-hospital care. The providers “negotiated” with the patient to remain hospitalized, but he ultimately left AMA after an additional week. He was subsequently lost to follow-up.

15. Lost Opportunity? • Treat AMA departures as “sentinel events” to learn about prevention strategies (system and patient-specific approaches) • Ethics and/or psychiatric consultations can be helpful to provider teams and patients in optimizing desired outcome

16. Toll on Providers • Physicians, nurses, and other health care providers may be confused and deeply troubled when clinical, ethical, and legal standards point in different directions • Hospital teams are required to provide safe care, but patients are not obliged to treat themselves in safe manner if decision-making capacity present • Even with comprehensive efforts, AMA discharges will occur and should serve as learning opportunities for providers and hospitals

17. Take-Home Points • Patients from stigmatized groups, like homeless IV drug users, require culturally competent care as much as patients from foreign cultures do • Homeless IV drug users are predictably at high risk for leaving the hospital AMA, and hospitals should plan in advance how to deal with that risk • Patients who sign out AMA are at risk for worse outcomes • Patients whom staff find difficult to like, or care for, are vulnerable to safety risks created by reduced empathy and rapport • Ethics consultation, psychiatric consultation, or both can be useful for patients with whom it is difficult to establish a therapeutic alliance