A 42-year-old man with a 25-year history of brittle insulin-dependent diabetes was admitted to a skilled nursing facility for intravenous antibiotic therapy. He was originally hospitalized 5 weeks earlier with cellulitis of the foot.
During that hospitalization, however, he became upset with the hospital physician, and vice versa. He was discharged from the hospital to home “against medical advice” (AMA). The hospital physician refused to provide prescriptions for medications, including antibiotics.
This discharge was not unlike those stemming from at least 15 other hospitalizations the patient had experienced over the past 10 years, primarily for diabetic ketoacidosis associated with acute infection. In almost every instance, he was discharged home from the hospital AMA.
Two weeks after his discharge home, he was readmitted to the hospital with diabetic ketoacidosis and osteomyelitis of the previously infected foot, which had received no treatment outside the hospital. Once readmitted, he received intravenous antibiotics. He developed acute renal failure (that later improved). After 2 weeks in the hospital, the patient asked to be discharged home for IV therapy there. Instead, he was transferred to a skilled nursing facility for the IV antibiotics.
Soon after arriving at the nursing facility, he told the social worker that he did not want to be in “an old folks’ home.” He asserted that he had not wanted to come to the facility at all but that the hospital sent him against his will. He insisted on going home. The attending physician at the nursing facility, contacted by phone, instructed nursing staff that the patient should “sign himself out AMA.” Several nurses and other facility staff (some of whom knew him from the community) convinced the patient to stay at the nursing facility “for a while,” but he reiterated his intention to return home soon.
On day 4 of his stay at the facility, he was transported back to the hospital for a previously scheduled appointment. The patient had not been informed of the nature of the appointment, which was neuropsychiatric testing, but agreed to go anyway. The results were normal.
Over the course of several weeks, the patient received antibiotic therapy as well as physical and occupational therapy He left the facility for hours at a time most days, between doses, to socialize with friends or to visit his home.
In the facility, he had several episodes of hypoglycemia and hyperglycemia. His dietary intake was variable. Hypoglycemia typically occurred after he declined to eat breakfast.
However, in general, he did well. Within 5 minutes of receiving his last dose of intravenous antibiotics to complete a 6-week course, he was discharged home from the facility. He was offered home health care but declined. A follow-up appointment with his primary care physician was scheduled.