It is a challenge to provide quality healthcare when patients do not adhere to their physicians’ recommendations for treatment. The patient who insists on leaving the hospital Against Medical Advice (AMA) is an extreme example of non-adherence, and this situation creates high potential for serious errors.  Recognition of the reasons patients leave can help negotiate these encounters. They leave for a variety of reasons including personal and financial obligations, breakdown of communication between the patient and medical staff, dissatisfaction in care, and not understanding the need for further testing or treatment. Every effort should be made to determine what is driving the patient’s decision-making process.  There may be times when the provider is at a loss to understand why a patient would walk out prior to receiving necessary care.  Even in this circumstance, treatment without consent can be deemed as battery, as patients do have the right to refuse care.

DOCUMENTATION:

Some courts have ruled that it is illegal for a hospital to require a patient to sign a waiver of liability as a “condition of their release” (Dedely V. Kings Highway Hospital Center, 617 NYS 2d 445 Supp (1994)). Therefore, the better approach consists of documenting the following eight criteria:

1. The patient’s ability to express a choice; ability to understand relevant information; ability to appreciate the significance of the information and its consequences; and, ability to manipulate information. A patient does not have to be free of mental illness or delusions
2. The signs and symptoms
3. The extent and limitation of the evaluation
4. The current treatment plan, risks, and benefits
5. The risks and benefits of forgoing treatment
6. The alternatives to suggested treatment
7. The exact statement made by the patient who left AMA, as well as the explicit documentation of what the patient was refusing
8. The follow-up care including discharge instructions

KEY POINTS:

• Practitioners should give the patient immediate attention so long as another patient is not compromised
• Do not express your frustration and anger to the patient
• Do not refuse to provide treatment – give the patient what she may be willing to accept,  such as prescriptions or future appointments, even if not the entire nor ideal treatment plan
• If unsure of capacity, call for help, which will usually entail a psychiatric consult
  • Use standard hospital and professional procedures if there is any threat the patient may harm herself or others
• Focus on medical management and not insurance issues
  • Although providers will often help whenever possible, insurance coverage is ultimately the patient’s responsibility

Learn More – Primary Sources:

Documentation proficiency of patients who leave the emergency department against medical advice

Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice

“I’m Going Home”: Discharges Against Medical Advice

Association of Hospital Discharge Against Medical Advice With Readmission and In-Hospital Mortality (JAMA Network Open)

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