The AMA decision is essentially a refusal of medical care. The competent adult patient has the right to refuse care. In Cruzan v. Director, Missouri Department of Health, the United States Supreme Court determined that a competent person has a constitutionally protected liberty interest to refuse medical treatment. The court concluded that the U.S. Constitution would grant a competent person a constitutionally protected right to refuse life saving medical treatment including nutrition and hydration.

State courts have increasingly allowed competent adult patients to refuse treatment. With the Supreme Court's decision in Cruzan, and the increased use of advance directives, the courts are allowing individuals to decline medical intervention. However this is not an unlimited right to refuse life saving care. In certain situations courts will determine that the right to refuse care is not absolute and will consider countervailing interests. Countervailing interests include preservation of life, prevention of suicide, maintenance of the ethical integrity of the medical profession and protection of innocent third parties. Decision making in this arena is complex, and emergency physicians should seek advice from hospital counsel and the hospital risk manager.

Emergency physicians face a dilemma when a parent wants to sign a child out AMA. Generally, state and federal courts support parental control over the basic matters affecting their children. However, when parental actions have resulted in inadequate medical care, courts in the United States have stepped in to decide between parent wishes and physician concerns. Under the doctrine of "parens patriae" (the state's paternalistic interest in children) the state will not allow a child's health to be seriously jeopardized because of the parent's limitations or convictions. A parent does not have the authority to forbid saving their child's life. Courts invariably rule in favor of a physician who claims that a parent is denying standard medical care to a child. One judge asserted that "The right to practice religion freely does not include the liberty to expose... a child... to ill health or death. Parents may be free to become martyrs themselves. But it does not follow that they are free ... to make martyrs of their children..."

The emergency physician is empowered by understanding the law. If parents want to sign a child out AMA, and there is serious threat to the child’s well-being, the emergency physician may consider taking temporary protective custody based on the state child abuse laws. If you take that course, it helps to explain to the parents that this is a medical obligation under the law, and you will immediately report to the hospital administrator, hospital attorney and the local child protection agency. The parents will typically stand down and allow you to proceed with your mission.

If there is no life threat, and no potential for serious impairment, the parent’s AMA request should be respected. The refusal should be "informed" and well documented. In this context, "informed" means that one or both parents have a normal mental status, understand the risks of refusal, have had an opportunity to ask questions and have decided to leave against your advice.

Remember that you are protected from civil and criminal liability under the child abuse and neglect statutes. You may be hesitant to take custody, but it should not be for fear of liability.


Case # 1 Drug Overdose, AMA - Cardiac Arrest

The patient was a seventeen year old female who was brought to the emergency department of Mission Hospital after she overdosed on medication prescribed by her psychiatrist. Following the emergency treatment, the plaintiffs took the patient home against medical advice. The next day the patient suffered a cardiac arrest, allegedly as an aftereffect of the drugs she had ingested, and she remained in a coma until her death four days later.

The plaintiffs contended that the treatment by the defendant hospital's emergency department staff was inadequate and incomplete with regard to the particular overdose the patient took. The plaintiffs contended that they did not understand the nature of the "against medical advice" form which they signed, and that the defendant improperly discharged the patient as a result of the plaintiffs lack of funds and/or medical insurance.

The defendant contended that the emergency department physician properly stabilized the decedent after the overdose and arranged for transfer to Los Angeles County hospital for further observation and treatment, that the emergency physician advised the plaintiffs that the decedent needed this care but they chose to have her discharged against medical advice, and the defendant did not have legal authority to place the decedent under a 72 hour psychiatric code, while the county hospital could hold her for observation.

The jury returned a defense verdict.

Case Commentary

This case presents several important issues. First, the parents alleged that they did not understand the AMA procedure. The jury did not believe them. Also, the defendant contended that he did not have the legal authority to place the decedent under a 72 hour psychiatric code. In this jurisdiction, by state law, the physician could not initiate a psychiatric hold. In most jurisdictions if a patient is suicidal that usually means he or she is not competent to consent to or refuse care. In the case of a potentially dangerous overdose, when the patient is medically at high risk and functionally incompetent, the patient should be treated against his or her will and admitted involuntarily, or steps taken to assure the patient is admitted to a psychiatric institution.

This situation is complicated when the patient is a minor and the parents want to take the child home against medical advice. Generally speaking, the parents have the right to consent to or refuse medical care for their children as they could for themselves. However, the parents may not do so, if their decision puts a child at risk. Many American jurisdictions have dealt with these issues, and all have upheld the importance of maintaining the health of the child over supporting the wishes of the parents.

In this case, the physician could justifiably have taken protective custody under the state child abuse laws and admit the child for further medical management. Although the parents may sue for assault and battery, false imprisonment and sometimes defamation, the emergency physician is immunized in such litigation. The emergency physician has broad discretion when it comes to protecting children in this type of circumstance.