Documentation for Patients Leaving Against Medical Advice with Thrombocytopenia
When a patient with thrombocytopenia wishes to leave against medical advice, they should be informed that hospital admission is strongly recommended for newly diagnosed thrombocytopenia with platelet counts <20 × 10^9/L due to significant risks of bleeding complications and the need for further diagnostic evaluation. 1, 2
Risks of Leaving Against Medical Advice
- Patients with platelet counts <20 × 10^9/L have moderate to high risk of serious bleeding complications, including potential life-threatening hemorrhage 1, 3
- Patients with platelet counts between 20-50 × 10^9/L still have risk of mild bleeding manifestations such as petechiae, purpura, or ecchymosis 3
- Delayed diagnosis of the underlying cause of thrombocytopenia, which could lead to worsening of the condition and poorer outcomes 2, 3
- Inability to monitor platelet count trends and response to initial therapy 1
- Missed opportunity for prompt management if serious bleeding were to ensue 1
- Potential for thrombotic complications in certain types of thrombocytopenia (e.g., heparin-induced thrombocytopenia, antiphospholipid syndrome) 3
Further Studies Needed for Thrombocytopenia Evaluation
- Complete blood count with peripheral blood smear review to confirm true thrombocytopenia and identify potential alternative diagnoses 1, 3, 4
- Coagulation studies including D-dimer measurement and Clauss fibrinogen assay 1, 3
- Diagnostic tests to determine the cause of thrombocytopenia, which may include: 3, 4
- Tests for immune thrombocytopenia (ITP)
- Drug-induced thrombocytopenia evaluation
- Infection workup
- Liver function tests
- Tests for disseminated intravascular coagulation
- Bone marrow examination in selected cases
- Imaging studies based on clinical presentation to identify potential sites of bleeding or thrombosis 1, 2
Documentation Recommendations
- Clearly document that you have informed the patient about the risks of leaving against medical advice, including: 5
- Specific bleeding risks based on their platelet count
- Potential for rapid clinical deterioration
- Importance of diagnostic evaluation to determine the cause
- Document the patient's decision-making capacity and understanding of the risks 5
- Record any attempts to address the patient's concerns about hospitalization 5
- Document the follow-up plan, including: 2, 6
- Urgent follow-up with a hematologist within 24-72 hours
- Instructions on when to return to the emergency department
- Warning signs of bleeding that require immediate medical attention
- Provide written discharge instructions that include all the above information 2, 6
Critical Follow-up Requirements
- Ensure the patient has an appointment with a hematologist within 24-72 hours of leaving 1, 2, 6
- Provide clear instructions about activity restrictions to minimize bleeding risk (avoid trauma, contact sports, NSAIDs) 3
- Educate about signs and symptoms that should prompt immediate return to the hospital: 2, 3
- New or worsening bruising
- Petechiae
- Mucosal bleeding (gums, nose)
- Blood in urine or stool
- Severe headache
- Visual changes
- Altered mental status
Communication Approach
- Acknowledge the patient's concerns about hospitalization while emphasizing the medical necessity 5
- Use clear, non-technical language to explain the risks of thrombocytopenia 5
- Explore alternatives that might address the patient's reasons for wanting to leave 5
- Document that you have attempted to establish trust and address conflicts that may be contributing to the patient's decision 5
Remember that patients with newly diagnosed thrombocytopenia with platelet counts <20 × 10^9/L, significant mucosal bleeding, uncertainty about diagnosis, or significant comorbidities with risk of bleeding should be strongly encouraged to remain hospitalized for proper evaluation and management 1, 2.