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Paper written by Professor Omar Hasan Kasule Sr.
DNR
DISCHARGE AMA AND DEATH
Case1
: Elderly put on DNR because of multiple pathology ( Acute on chronic
respiratory failure, Acute exacerbation of Chronic Obstructive Airways
Disease, Recurrent aspiration and aspiration pneumonia, Diabetes Mellitus
type II, Hypertension, Dementia, Chronic bed-bound status, Degenerative
arthritis, Advanced osteoporosis, Osteoporosis induced right arm fracture,
status-post cast placement, Status post PEG tube feeding insertion). He
was managed on antibiotic, noninvasive ventilation and oxygen, short of
intubation and mechanical ventilation. The family asked for discharge against
medical advice and the patient died in the hospital he was referred to. The
family demanded compensation from the first hospital.
Response:
In cases of normal or AMA discharge you must have clear procedures for transfer
of responsibility. Your staff will be responsible as long as the patient is in
the hospital. They are discharged from responsibility at the door of the
hospital or when another ambulance crew takes over. If your ambulance transfers
him to the next hospital you are responsible until the other hospital takes
over the patient. After you hand over the patient you are not responsible for
any expenses because of the discharge AMA. However ARAMCO may have a
compassionate policy and help the employee on humanitarian grounds. You have to
make sure that the DNR decision was right (i.e. was the patient in an
established and irreversible death process?). I think that irrespective of the
DNR status the respiratory support given short of intubation and ventilation
was satisfactory. I am however not sure if all the supportive treatment was
provided because this is not recorded.