Dying after leaving AMA

The nurse called: “The patient wants to leave AMA.”

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

This was different. This patient was very ill, but competent to make his own decisions. He had COVID, and this was day 10 in the hospital. He was stable, but requiring high flow oxygen, 100% at 60 liters per minute. He was in his own room on our Covid floor, which he probably viewed as a 12 by 12-foot cell after 10 days. We don’t even let them in the hallway.

I sat down, and said that I was told he wanted to leave. He was calm and collected, and said 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.

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. 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 physician that he did not want CPR or intubation, they stopped.

This one hurt. Yes, patients die, and I really don’t believe any of our doctors or nurses share in responsibility for this death. But this patient should not have died – he was in his 60’s, and was only on blood pressure meds and a PPI. Respiratory therapists, nurses and doctors all told him that he would die if he left. He just did not believe us. This was not glioblastoma or a major trauma where everything we do really does not matter - sometimes the patient is going to die regardless. No, had this patient stayed, or gotten vaccinated before contracting Covid, he very likely would have lived.

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 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 it’s only about 25% of my patients. It’s closer to 100% for the nurses and RTs on the Covid floors and in the ICUs – 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 rather than helping 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 in order to get things under control, people trusting that healthcare workers are really working toward the best interest of everyone, healthcare workers optimistic because they see progress.

How do we get from here to there?