Patients electing to leave against medical advice (AMA) represent a growing population in the United States and provide unique challenges to the Emergency Physician.1 Discharge AMA is defined as the patient leaving before the Emergency Physician finishes the evaluation and establishes the disposition.2 It is estimated that 1% of Emergency Department visits result in a discharge AMA.3,4 The prevalence rate of leaving AMA varies between Emergency Departments.5 Discharge AMA patients often present again within a few days, resulting in increased costs associated with repeat testing and higher acuity therapeutic interventions due to worsening of their condition.3 The AMA patient has an increased risk of repeated admission, increased admission length of stay, increased morbidity, and increased mortality.2,6-17 This chapter provides an overview of the legal obligations to treat and elements associated with the refusal of care and discusses special populations that may be encountered.
Start with the assumption that the patient can make their own decisions, unless there is suspicion otherwise.18-21 This practice is consistent with general principles of patient autonomy. Any decisions made must be in the best interest of the patient. Lack of decision-making capacity requires an assessment and documentation of how this was determined (Table 2-1). Lack of capacity requires an impairment of the patient’s brain or mind significant enough to interfere with decision-making. The determination of decision-making capacity is specific to a relative point in time and does not apply to later decisions. The CURVES mnemonic was developed to be used in an acute setting such as the Emergency Department (Table 2-1).
TABLE 2-1The U and I GLAD and CURVES Mnemonics for Determining a Patient’s Decision-Making Capacity ||Download (.pdf) TABLE 2-1 The U and I GLAD and CURVES Mnemonics for Determining a Patient’s Decision-Making Capacity
U and I GLAD
U–understanding of the procedure/discussion
G–goals and values
L–logic used to decide
D–danger or risks of decision
Communicate: Is the patient able to choose and communicate this choice?
Understand: Does the patient understand the alternatives to treatment, benefits of treatment, and risks of leaving?
Reason: Can the patient make a rational choice?
Values: Is the patient’s choice consistent with their values?
Emergency: Is there impending risk to the patient?
Surrogate: Are there patient surrogates available? Is there any documentation guiding treatment (e.g., advance directives)?
The patient has their own reasons, good or not, for leaving AMA. Not every decision by a patient is considered reasonable by the Emergency Physician.15,21 Patients often present voluntarily to the Emergency Department for evaluation and management. Leaving AMA can be considered a withdrawal of the patient’s consent signed when they initially presented for evaluation.22-24 The patient has the ...