Gerbasi Joan B, Simon Robert I
Department of Psychiatry and Division of Forensic Psychiatry, University of California, Davis, Sacramento, CA 95817.
Harv Rev Psychiatry. 2003 Nov-Dec;11(6):333-43.
Every psychiatrist who treats voluntary inpatients has had or will have patients who leave the hospital against medical advice (AMA). Studies reveal that between 6 and 35 percent of voluntary psychiatric inpatients are discharged AMA. These patients often are acutely ill and have severe symptoms at discharge. They also, as a group, have high rehospitalization rates and worse outcomes than patients who do not leave AMA. When a mentally ill patient demands to leave the hospital AMA, a tension arises between the patient's rights and the psychiatrist's duties. These duties include those to the patient and, in many cases, to third parties. Patients discharged AMA may remain dangerous and can expose health care providers to a heightened liability risk. More importantly, because of such factors, decisions about handling the AMA discharge are more difficult than decisions about admission. This article analyzes the sources of increased liability risk posed by AMA discharges. It includes discussions of patients' rights, including the different types of voluntary admissions, and psychiatrists' duties. Malpractice litigation in this area is reviewed. The article concludes by suggesting risk-management techniques that can aid in protecting the psychiatrist while also respecting patients' rights and delivering good clinical care.
每位治疗自愿住院患者的精神科医生都曾有过或将会遇到违背医嘱（AMA）出院的患者。研究表明，6%至35%的自愿住院精神科患者会违背医嘱出院。这些患者出院时往往病情严重且症状明显。与未违背医嘱出院的患者相比，他们作为一个群体，再次住院率较高，预后也较差。当一名精神病患者要求违背医嘱出院时，患者权利与精神科医生职责之间就会产生矛盾。这些职责包括对患者的职责，在许多情况下还包括对第三方的职责。违背医嘱出院的患者可能仍然具有危险性，会使医疗服务提供者面临更高的责任风险。更重要的是，由于这些因素，处理违背医嘱出院的决策比入院决策更加困难。本文分析了违背医嘱出院带来的责任风险增加的根源。其中包括对患者权利的讨论，包括不同类型的自愿入院，以及精神科医生的职责。还回顾了该领域的医疗事故诉讼。文章最后提出了风险管理技巧，有助于在保护精神科医生的同时，尊重患者权利并提供良好的临床护理。
