Hutzel Hospital - 3990 John R.

Road Detroit, MI 48201 (313)745-0680 Leaving the Hospital Against Medical Advice
NAME OF PERSON: Sandra White Health care service refused by person or representative: Continued Medical Services CAPABLE ADULTS I understand the doctor and others believe it is necessary for me to stay at the Hospital. I have been explained that it is important for my fetus to be monitored on labor and delivery for a prolonged period secondary to the fetal heart dropping. If I leave without the appropriate time of observation this can lead to sudden fetal death or poor outcome. The risks of leaving the hospital against medical advice have been reiterated to me which include but not limited to maternal risks including long-term and short-term morbidities and death. In addition, fetal/neonatal risks, including, but not limited to risk prematurity, preterm labor, preterm premature rupture of membranes, and preterm delivery and risks of cerebral palsy, autism, deafness, blindness, handicap, respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, IVH, and other long-term and/or short-term neonatal morbidities and mortalities. I know that no one at the Hospital is refusing to provide care to me. The doctor and others at the Hospital have explained to me the potential benefits of receiving the appropriate medical care. They have also told me that I may develop health problems, and what those problems might be if I leave the Hospital now. Even though I know I should remain at the Hospital, I intend to leave the Hospital now. I fully assume responsibility for obtaining the future health care I will need. I also release the Hospital and the people who work here, including the doctors, from responsibility for anything wrong which happens to me as a result of my leaving the Hospital at this time. PT REFUSED TO SIGN_______________________________________________________________ (Signature of Sandra White) (Date) (Time) ________________________________________ (Witness to Signature)

PHYSICIAN STATEMENT Based upon the limited information available to me, I have discussed what I believe to be the risks and benefits of the person leaving the Hospital without continuous medical treatment with the patient. In addition, I have recommended to the patient that they remain at the Hospital for continued medical care. . Patient expressed clear understanding of maternal, fetal/neonatal risks. Questions asked and answered. _________________________________________________________________ Juan Gonzalez, MD (Date) You may return to the hospital at any time. Please do so if you change your mind or if your condition gets worse. "I have read the above information and take full responsibility for my own safety."

__________ PT REFUSED TO SIGN __________________________ Sandra White

Witness