Makindo Medical Notes.com

Those who discharge themselves are still entitled to their medication and a discharge letter which they may have to return for if you can't reasonably produce it quick enough. The GP needs to know. If concerned inform consultant and GP

About: If unsure or concerned escalate it to Registrar or Consultant

• Patients are within their right to refuse treatment if they have the capacity. In some cases, patients have been absolutely right to do so as they had been given poor advice. You have a duty of care and a patient's refusal of one management option e.g. staying in hospital for observation does not mean a patient loses the rights to others.
• If a patient for example with chest pain chooses to discharge themselves before troponin one should explain the risks (much greater acutely if ST elevation) and the importance of doing ongoing tests. Explain that a 3-hour troponin will be useful and strike a deal to see if they would stay for that. As long as you fully inform the patient and document it and you are happy the patient is competent then you have done your best. You would advise and document advice for the patient to return if any more symptoms or if they have a "change of mind". It would be reasonable in this case for example to give antiplatelet and beta-blocker and organise outpatient follow up.
• You should not prejudice patient for not accepting your care but work around them at all times being reasonable. You must make the patient your first concern. if they discharge against advice they have the same entitlement to hospital transport, discharge pathways and support that another patient would get. The patient may have what they feel are other reasons to leave that they may not wish to share with you.
• If there is a pressing concern and GP follow up would help t would be good practice to inform the GP by fax or email or phone call to the duty GP if urgent when reasonable possible same day or next in case they get called to see patient later. The patient should be given medications and a GP letter. if not ready at that point offer them to be collected later. Offer cardiology follows up or advises them to see their GP at the earliest opportunity. I always document that I tell them to return if any further symptoms and we will be happy to see them. In this case, if you think there has been an MI then driving advice as per DVLA in UK or state guidelines should be offered. Most importantly all document everything fully there and then. Nurses should do likewise
• The one case where this would be more concerning is that a patient with suicidal intent comes in with an overdose and decides to leave. They should be seen by a duty psychiatrist or the psychiatric team. Call them and discuss if the patient is about to leave. Discuss risks and your options. It is not your duty to physically restrain but delay and procrastinate and get advice. if the patient leaves inform the police, psychiatric team and family and GP and your boss as soon as possible. Do all that is reasonably possible. You might have to defend your actions in a coroner's court if the patient then follows through.