Cases & Commentaries

Discharge Against Medical Advice

Commentary By Stephen W. Hwang, MD, MPH

The Case

A 50-year-old man with a history of alcohol abuse
and alcohol-induced dementia was admitted to the medical service
with mild alcohol withdrawal. He was also found to have a proximal
humeral fracture, and the orthopedic consult recommended surgical
repair. The patient was treated with benzodiazepines for his
alcohol withdrawal and remained medically stable. After hearing the
risks and benefits of surgery from the physicians, the patient
refused.

In light of the patient’s chronic dementia
and acute delirium due to alcohol withdrawal, formal mental status
testing was performed, which indicated that the patient lacked the
capacity to make medical decisions. A psychiatry consultation
supported this determination.

On hospital day 4, at approximately midnight, the
patient stated to his nurse that he wished to leave the hospital.
Neither the floor nurse nor the charge nurse was aware the patient
had been found to lack decision-making capacity. They contacted the
nightfloat covering resident and informed her that the patient
wished to leave. The resident glanced at the chart, asked the
patient a few questions, and allowed him to leave against medical
advice (AMA).

The primary medical team was informed the
following morning about the discharge. They had no contact
information for the patient, and he could not be located. What
happened to him is unknown.

The Commentary

Providing high-quality health care is a challenge
when patients do not adhere to their physicians’
recommendations. The patient who insists on leaving the hospital
AMA is an extreme example of non-adherence, and this situation
creates high potential for serious errors.

Epidemiology of Discharges
AMA

Patients who leave AMA account for 0.8%-2.2% of
discharges from medical services at acute care hospitals in the
United States.(1-4) In
general, AMA discharge rates tend to be higher at urban hospitals
than suburban hospitals and higher at community hospitals than
teaching hospitals.(1) At hospitals
serving disadvantaged inner-city populations, as many as 6% of
general medical patients (5) and 13% of
patients with HIV/AIDS leave AMA.(6)

It is not clear why the patient in this case
wanted to leave AMA, but he had a number of risk factors.
Characteristics associated with an increased likelihood of leaving
AMA include male sex, Medicaid coverage or lack of health
insurance, lack of a primary care physician, admission through the
emergency department, admission with a substance
abuse–related diagnosis, and previous AMA
discharge.(1-3) In a study
of HIV-positive patients, injection drug users were more than four
times more likely than non-users to leave AMA, and AMA discharges
were three times more likely to occur on days when welfare checks
were issued.(6)
Unfortunately, there is no prediction rule that can accurately
identify in advance which patients will leave AMA.

Patients leave AMA for a variety of reasons. When
asked, they most commonly cite family problems or emergencies;
personal or financial obligations; feeling bored, fed up, or well
enough to leave; or dissatisfaction with their treatment.(5,7) Although
many patients who discharge themselves AMA have substance abuse
problems, few of them attribute their decision to leave to their
addiction.

Patient Outcomes in Discharges
AMA

It seems likely that discharge AMA puts patients
at increased risk of adverse health outcomes. This concern is
supported by several studies that found that patients who leave AMA
have significantly higher readmission rates than other
patients.(3,5,6) In a
study of general medical patients, the readmission rate within the
first 15 days after discharge was 21% in patients leaving AMA,
compared with 3% in matched controls; the rate of readmission over
the subsequent 75-day period was similar in the two
groups.(5) No specific
factors have been found to strongly predict readmission among
patients discharged AMA.

It is uncertain whether patients leaving the
hospital AMA face an increased risk of death, as no study has
compared mortality rates among patients leaving AMA to those
formally discharged. Among patients leaving AMA from an Australian
hospital, the mortality rate was 3% within 28 days (8). In patients
leaving AMA from a general medical service at a Canadian hospital,
the mortality rate was 3% within 90 days.(5)
Although a causal link is difficult to demonstrate, many physicians
can recall anecdotal but sobering cases of patients who left AMA
and died shortly thereafter. In an example from my own experience,
a homeless man with schizophrenia was admitted with abdominal pain
believed to be due to a volvulus. He was allowed to leave AMA in
the middle of the night, only to be found a few hours later
collapsed on the sidewalk within one block of the hospital. All
efforts to resuscitate him were unsuccessful.

Reducing Errors and Adverse Outcomes
Associated with Discharges AMA

How can health care professionals minimize the
risk of errors and/or adverse outcomes in patients leaving AMA?
Obviously, the prevention of AMA discharges would be ideal,
although difficult to achieve in practice.(9)
In a study of HIV-positive patients, 61% of whom were active
injection drug users, in-hospital prescription of methadone reduced
the odds of discharge AMA by 50%.(10)
Interventions to enhance social supports in marginalized
populations may also be useful.(10) In some
cases, a patient who plans to leave AMA may have a specific concern
(e.g., a pet at home), and he or she may be persuaded to remain in
hospital if the concern is addressed.

When a patient insists on leaving AMA, the goal
should be to provide the best possible care under clearly
suboptimal circumstances. Although existing research does not
provide much guidance in this area, a number of recommendations
seem reasonable. Hospitals should consider establishing a
standardized AMA discharge protocol to ensure that important steps
are carried out (Table). As
illustrated by this case, nurses are usually the first to become
aware of an impending AMA discharge. Their active involvement in
the AMA discharge protocol is vital and can help promote better
communication between nurses and physicians around the time of the
discharge. Such protocols become particularly important when the
patient leaves at night or on a weekend, increasing the risk that
critical safeguards will be neglected.

Assessment of the patient’s decision-making
capability is essential; practical algorithms are available to help
guide this process.(11) In an
effort to balance patient autonomy and patient safety, physicians
should ensure that a patient with a severe life-threatening illness
has a very high level of decision-making capability before allowing
him or her to leave AMA. Less stringent criteria may be applied to
patients with conditions that are not immediately life
threatening.

Follow-up arrangements are of paramount
importance. In general, physicians should offer outpatient
therapies that may be helpful, even if they are suboptimal (e.g.,
oral antibiotics to treat an infection for which intravenous
antibiotics are the standard of care). Patients who leave AMA
sometimes do not fill the prescriptions that are given to them.
Thus, if critical new medications are prescribed, they would
ideally be dispensed by the pharmacy and given to the patient
before he or she leaves. If the patient is at very high risk of
serious health consequences, the physician can seek the
patient’s permission to follow up by phone call or home visit
within the next few days. However, patients who leave AMA are often
difficult to locate after discharge, as this case vividly
demonstrates.

When a patient decides to leave AMA, good
communication with other members of the health care team is
especially important. Even in the middle of the night, it would not
be unreasonable for a covering physician to immediately inform the
patient’s primary physician of the impending discharge. In
this case, such action may have averted the AMA discharge, since
the covering physician would have learned of the patient’s
diminished decision-making capacity. In addition, the physician
should provide the patient with a brief written summary of the
hospital stay. Such a summary may be particularly helpful if the
patient subsequently seeks care from a different health care
facility.

Physicians may be under the mistaken impression
that discharging a patient AMA (with the patient presumably
“consented” regarding the consequences of leaving)
confers full protection against future legal action. In rare cases,
physicians have been sued for medical malpractice after their
patient left AMA. The successful defense of these physicians was
based not on the fact that the patient left AMA, but on the grounds
that there was no proof of negligence.(12) Thus,
assessment and documentation of the patient’s decision-making
capacity is crucial.

In summary, this case illustrates numerous points
at which preventable errors can occur when a patient is discharged
AMA. The covering resident did not adequately assess the
patient’s decision-making capacity, and the
provider-to-provider communication that would have identified the
patient’s lack of capacity did not occur. Better attention to
obtaining the patient’s contact information and making
follow-up arrangements might have allowed the medical team to
reduce the risk of a poor outcome. As is so often the case, the
discharge AMA took place at an inconvenient time, highlighting the
need for a pre-established protocol to ensure that critical
safeguards are not neglected.

Take-Home Points

  • Approximately 1%-2% of hospital
    discharges occur AMA. Patients who leave AMA have significantly
    higher readmission rates and may be at increased risk of serious
    adverse health consequences when compared with normally discharged
    patients.
  • The use of a standardized protocol to
    address issues of decision-making capacity, follow-up arrangements,
    and communication may help reduce the risk of errors when patients
    are discharged AMA.
  • Discharge AMA does not absolve the
    physician of responsibility for poor outcomes; as always, good
    clinical care and careful documentation are of paramount
    importance.

Stephen W. Hwang, MD,
MPH
Assistant Professor, University of Toronto
Research Scientist, Centre for Research on Inner City Health, St.
Michael’s Hospital

References

1. Smith DB, Telles JL. Discharges against
medical advice at regional acute care hospitals. Am J Public
Health. 1991;81:212-215.
[ go to PubMed ]

2. Jeremiah J, O'Sullivan P, Stein MD. Who leaves
against medical advice? J Gen Intern Med. 1995;10:403-405.
[ go to PubMed ]

3. Weingart SN, Davis RB, Phillips RS. Patients
discharged against medical advice from a general medicine service.
J Gen Intern Med. 1998;13:568-571.
[ go to PubMed ]

4. Saitz R, Ghali WA, Moskowitz MA.
Characteristics of patients with pneumonia who are discharged from
hospitals against medical advice. Am J Med. 1999;107:507-509.
[ go to PubMed ]

5. Hwang SW, Li J, Gupta R, Chien V, Martin RE.
What happens to patients who leave hospital against medical advice?
CMAJ. 2003;168:417-420.
[ go to PubMed ]

6. Anis AH, Sun H, Guh DP, Palepu A, Schechter
MT, O'Shaughnessy MV. Leaving hospital against medical advice among
HIV-positive patients. CMAJ. 2002;167:633-637.
[ go to PubMed ]

7. Green P, Watts D, Poole S, Dhopesh V. Why
patients sign out against medical advice (AMA): factors motivating
patients to sign out AMA. Am J Drug Alcohol Abuse.
2004;30:489-493.
[ go to PubMed ]

8. O'Hara D, Hart W, McDonald I. Leaving hospital
against medical advice. J Qual Clin Pract. 1996;16:157-164.
[ go to PubMed ]

9. Saitz R. Discharges against medical advice:
time to address the causes. CMAJ. 2002;167:647-648.
[ go to PubMed ]

10. Chan AC, Palepu A, Guh DP, et al.
HIV-positive injection drug users who leave the hospital against
medical advice: the mitigating role of methadone and social
support. J Acquir Immune Defic Syndr. 2004;35:56-59.
[ go to PubMed ]

11. Jones RC, Holden T. A guide to assessing
decision-making capacity. Cleve Clin J Med. 2004;71:971-975.
[ go to PubMed ]

12. Devitt PJ, Devitt AC, Dewan M. An examination
of whether discharging patients against medical advice protects
physicians from malpractice charges. Psychiatr Serv.
2000;51:899-902.
[ go to PubMed ]

Table

Table. Important Steps When a Patient
Is Leaving Against Medical Advice

Issues

Specific Actions

Decision-making capacity

  • Assess the patient’s
    decision-making capacity
  • Document the capacity assessment in the
    chart
  • Document the discussion with the patient
    regarding the severity of the patient’s illness and the
    potential consequences of leaving AMA

Follow-up arrangements

  • Discuss specific scenarios with the
    patient that should prompt an immediate return to the emergency
    department
  • Arrange for telephone follow-up, if
    indicated
  • Arrange for home care, if indicated
  • Arrange for an outpatient follow-up
    appointment (preferably within the next 7 days)
  • Provide prescriptions for any new
    medications (arrange for dispensing of medications to the patient,
    if possible)
  • Document the above in the chart

Communication

  • Provide the patient with a brief written
    summary of his or her diagnoses, treatments, medications, and
    follow-up plans
  • Immediately inform the patient’s
    primary medical team regarding discharge AMA and follow-up
    plans
  • Communicate with the patient’s
    primary care provider (if different from the inpatient medical
    team) regarding discharge AMA and follow-up plans
  • With the patient’s consent,
    communicate with the patient’s next-of-kin regarding
    discharge AMA and follow-up plans
  • Document the above in the chart