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3. When parents sign their child out against medical advice (AMA)

What should I do if a parent wants to sign a child out AMA from the hospital?

If a child’s life or limb is not in immediate jeopardy, we cannot legally hold a child in the hospital against a legal guardian’s wishes. 

• Talk to the guardian to identify why the guardian wishes to sign the child out AMA.
• Identify concrete barriers to guardian and child staying, like lack of transportation, other children at home, guardian has a work issue, guardian is afraid etc. 
• Work with the guardian to develop a mutually agreed upon plan toward overcoming concrete barriers to the child staying in the hospital.
• Make sure the clinician is clear with the guardian as to why you feel the child needs to stay, the consequences of the child not staying, and what the plan of care for the child will be while they are here.

If you cannot reach an agreement and the guardian still wishes to leave with the child or attempts to physically remove the child from the hospital, the attending needs to decide if that child’s life or limb is in immediate jeopardy.

1. If the attending physician decides that a child’s life or limb is in immediate jeopardy, the following should happen:

• Call security to help you keep the child on the hospital premises and to help de-escalate the situation.
• Initiate filing a 51A
• Call the hospital general counsel on call 31-1523 to advise you on your legal responsibilities and rights.  If you choose to hold a child in the hospital against a guardian’s will, general counsel will contact an on-call judge to seek emergency custody of the child.  You will be required to appear in front of a judge to explain your reasons for detaining a child in the hospital against a guardian’s will.
• Call your unit’s social worker, if available, or the child protection team (pager #7336) for assistance.

2. If the attending physician decides that a child’s life or limb is NOT in immediate  

   jeopardy, the following should happen:

• Call your unit’s social worker, if available, or the child protection team (pager #7336) for assistance.
• Consider other treatment options that allow for the guardian to leave with the child but provide for adequate medical follow up/treatment outside the hospital.  For example, a child with significant cellulitis could perhaps get one iv dose of antibiotics, a prescription for oral antibiotics, and 24 hour follow up instead of admission.
• Be clear with parents about:
• the importance of following through with alternate plan,
• the fact that you are extremely concerned about their child’s health,
• exactly when and where you want the child to be seen,
• how they are going to get medications and transportation to follow the plan, and
• what the concrete consequences are of not following through (eg. you will file a 51A, you will send police out to the home)