While most patients are discharged from the ED on the order of a medical provider, approximately 1 in 70 patients in the United States choose to leave the hospital against medical advice (AMA).21 In most circumstances, a patient has the right to refuse further medical care, even if that refusal may result in the patient's death. However, a patient's refusal of care must be an informed decision, since both the patient and the physician may be at risk. Patients who leave AMA are up to 7 times as likely to be readmitted in the following 30 days22-25 and also have higher 30-day mortality rates.24 Medical providers may incur liability both for treating patients against their will and for allowing patients to leave without treatment, so avoiding situations where patients wish to leave AMA can be beneficial to both patients and medical providers.
Why Do Patients Leave AMA?
Understanding the reasoning behind a patient's decision to leave AMA can be an important factor in helping to convince the patient that proceeding with proposed care is the most reasonable course of action. Certain demographics make patients more likely to leave AMA. Patients who are discharged AMA tend to be uninsured,26 be covered by Medicaid insurance,21,23 be covered by Medicare insurance,21 complain of nonspecific abdominal pain25 or chest pain,23 and have previous instances of AMA discharges.26
Patients who leave AMA commonly cite one of several reasons for leaving, including personal or family issues, financial concerns, feeling well enough to leave, dissatisfaction with the physician or treatment received, becoming “fed up,” and dislike of hospitals in general.26,27 Eighty two percent of patients leave AMA because they do not agree with a physician's treatment plan25,28 and 96% of patients who return to the hospital after leaving AMA have the same chief complaint. A smaller study of focus group interviews with patients, nurses, and physicians showed 7 themes involving AMA discharges (Box 93-2).29
Box 93-2 Seven Major Reasons that Patients Leave AMA |Favorite Table|Download (.pdf)
Box 93-2 Seven Major Reasons that Patients Leave AMA
- Drug addiction
- Pain management
- Preexisting obligations outside of hospitals
- Wait time
- Doctor's bedside manner
- Teaching hospital setting
- Poor physician-patient communication
Assessing Patient Capacity
Patients who refuse treatment must have the capacity to make a decision. Legal capacity generally requires that a patient be at least 18 years old or that the patient be an “emancipated minor.” Each practitioner should be familiar with the definition of legal capacity used in his or her state. Clinical or “decision-making” capacity generally requires that a patient be able to understand the diagnosis, the proposed medical care, and the implications of proceeding with or refusing such care. While exceptions may exist (eg, “mature minors”), in general, patients should have both legal and clinical capacity before being allowed to leave against medical advice.
Physicians seem to be quite proficient at determining when patients lack decision-making capacity. In one study, there was a 97% concordance rate between primary care physicians and psychiatric specialists in identifying patients without decision-making capacity.30 However, psychiatric specialists agreed in only 2 of 7 instances where primary physicians believed that decision-making capacity existed.
The Folstein Mini Mental State Examination has been shown to be an effective screening tool for deciding whether or not a patient has clinical decision-making capacity. A score of less than 21 of 30 on the MMSE was 100% specific and 69% sensitive in identifying patients who lacked decision-making capacity, while a score of less than 24 of 30 was 83% sensitive and 90% specific in identifying patients without decision-making capacity.30 Many factors can affect a patient's decision-making capacity including psychiatric issues, metabolic problems, head injuries, drug use, and alcohol use.
If a healthcare provider believes that a patient does not have decision-making capacity and that patient chooses a course of action that may be potentially harmful, it is usually best to proceed with treatment that is in the patient's best interests. In the context of AMA discharges, that treatment may involve preventing the patient from leaving and even restraining the patient if necessary. Consulting hospital legal counsel or a psychiatrist to determine whether a patient has capacity may also be of benefit.
A competent patient may make a decision against his or her interests, but first must be presented with information sufficient to make an informed decision. The information provided should be accurate, and in general should include that which a reasonable layperson would want to know in addition to any other information the patient reasonably requests.
Several medical malpractice case summaries illustrate that healthcare providers can be sued for failing to properly determine a patient's decision-making capacity prior to discharging a patient AMA, for failing to provide patients with sufficient information relating to their condition before allowing patients to leave AMA, and even for exaggerating the risks of leaving AMA.
An unpublished opinion in Poletti v Overlake Hospital Medical Center31 held that doctors and a hospital could be held liable for allowing a psychiatric patient who was not taking her medications to leave AMA. The patient came to the ED exhibiting signs of paranoia. She had been driving for several days trying to avoid people she believed were chasing her. She had not slept in several days and had contemplated suicide by taking an overdose. A physician evaluation the following morning recommended further inpatient observation. Several hours later, the patient stated that she felt better and was no longer having suicidal thoughts, paranoia, or hallucinations. After consulting with a mental health professional over the telephone, the nurse allowed the patient to leave the hospital AMA. The patient took a cab home, got into her car, began driving, and was killed in a car accident.
The appellate court held that there was “a reasonably foreseeable risk of very serious harm … if [the patient] was discharged and allowed to drive” and that there was a question of fact whether the patient had the mental capacity to leave the hospital AMA.
Inadequate Informed Refusal, Inadequate Patient Understanding, Lack of AMA Form
Sawyer v Comerci32 involved a patient with right-sided abdominal pain, an elevated WBC count, and blood in his stool. The emergency physician wanted to admit the patient, but the patient had a business appointment the following day and refused to be admitted. The emergency physician still believed that the patient required admission, but her notes stated that the patient and his wife “do not seem to understand the possibility of the seriousness of his condition.” After the patient's primary care physician agreed to see the patient either the next morning or the following Monday, the patient was discharged. No AMA form was signed.
Several days later, the patient returned to the hospital by ambulance with dyspnea and diaphoresis. He was admitted, but died the following day. He had never attempted to make a follow-up appointment with his primary care physician.
The lawsuit was decided in the physician's favor at trial, but was appealed. One of the issues on appeal was whether the patient had contributory negligence for leaving the hospital on the first ED visit. The Virginia Supreme Court noted that the emergency physician never noted in the patient's medical chart that the patient should have been admitted to the hospital on the first visit. In addition, the emergency physician presented no evidence that the patient “understood the severity of his condition and the consequences that might ensue if he were not admitted to the hospital.” Because the patient was not provided with sufficient information, he could not be held responsible for his decision to leave AMA.
Inadequate Informed Refusal, No AMA Form
In Taylor v Steinberg,33 a surgeon performed a cholecystectomy on a patient. Postoperatively, the patient developed a bile leak that went undiagnosed despite much diagnostic testing. The surgeon wanted to perform additional procedures, stating that he believed a bile leak was present. The patient became angry that no definitive diagnosis had been made and left the hospital. No AMA forms were signed. The discharge papers said that the principle diagnosis was “abdominal wall hematoma.” The patient was later admitted to another institution where 5 liters of bile were drained from his abdomen. He eventually died.
In the ensuing litigation, the surgeon alleged that the patient left AMA and was therefore responsible for his own injuries. A verdict of $1.2 million was entered against the surgeon. On appeal, the Ohio appellate court noted that the surgeon showed no evidence that he informed the patient of the seriousness of his condition. The absence of an AMA form “undercut [the surgeon's] claim that he recognized the seriousness of [the patient's] situation” and “created the inference that [the patient] was not informed of the seriousness of his condition such that his decisions about his own care were fully informed.” The verdict was upheld.
Exaggerated Information Regarding Danger:
Mueller v Auker34 is a 2007 Idaho Federal Court decision holding that an emergency physician may be liable for exaggerating the risks involved with refusing care. A child was brought to the ED with a 101.3°F fever. After examining the child, the emergency physician believed that a spinal tap and intravenous antibiotics were necessary. The mother refused. The physician explained the risks of refusing such treatment, but whether he cited a 5% risk of death or a 5% risk of meningitis is a disputed fact. After the mother's repeated refusal of further treatment, and based in part on the physician's assessment of risk to the child, a social worker declared the child in “imminent danger.” The State took custody of the child and the physician performed a spinal tap, which showed no signs of meningitis. The child was returned to the custody of her parents the following day.
The child's parents then sued multiple parties, including the physician whom they accused of conspiracy to deprive the family of their constitutional rights by grossly inflating the risk of refusing treatment in order to get the State to take custody of the child. While Idaho statutes provided immunity for physicians who report suspected child neglect or abuse, the Federal Court noted that if the physician “knowingly exaggerated” the risk of danger to the child, the statutory immunity would not apply and the physician could be held liable. Ultimately, the case against the physician was dismissed.
Discharging a Patient AMA
Avoid AMAs by Addressing the Patients' Issues
The best way to avoid problems related to an AMA discharge is to address the issues of concern (Box 93-2) and convince the patient not to leave AMA.
- Family issues and preexisting obligations outside the hospital have been shown to increase a patient's desire to leave AMA. Perhaps there is no one at home to care for a patient's family member or pet. Helping the patient to arrange for that care may allow the patient to remain in the hospital for treatment.
- Perhaps the patient believes that he or she will suffer adverse employment consequences for missing work. A call to the patient's employer may resolve that issue.
- Financial concerns are another factor increasing the chances of AMA discharges. Reiterate to the patient that finances are not taken into consideration for emergency medical care. A hospital financial counselor may be able to provide the patient with a discount for the services provided or may be able to establish a payment plan that meets the patient's budget.
- If the patient's symptoms have resolved, help the patient understand why allowing the proposed treatment is in his or her best interests. Consider printing out medical articles substantiating the proposed treatment, if possible. Document any attempts to mitigate the patient's circumstances.
Assuming that a patient has decision-making capacity and still wishes to leave, the physician should attempt to inform the patient of the consequences of his or her decision, including the patient's tentative diagnosis, the benefits of the proposed treatment, the major risks associated with refusing the proposed treatment, and reasonable alternatives to the proposed treatment. Discussions should be relatively specific to a patient's complaints and symptoms. Generic admonitions that “you could get worse or die” are less persuasive than warnings that a patient with chest pain “could suffer a heart attack, a blood clot in the lungs, a rupture of the main blood vessel in the chest, worsening breathing, abnormal heart rhythms, loss of consciousness, other similarly serious medical problems, permanent disability, or even death.”
Exaggerating risks involved with AMA discharge or making coercive statements in an attempt to abort the AMA process should be discouraged. As noted in the Mueller case earlier, purposely exaggerating the risk of meningitis could make a physician liable for a civil rights violation. Asserting that a patient's insurer “probably won't pay for the visit” if a patient leaves AMA would also be inappropriate given a 2010 study involving104 AMA discharges and 19 different insurance companies showing that all AMA discharges were fully reimbursed by the insurance companies.35
If patients have questions regarding their decision, the physician should also attempt to answer those questions. A “teach back” method similar to that used in normal patient discharges can help the medical providers ensure that patients understand the implications of their decisions.
Documentation and AMA Forms
Documenting that these discussions took place can literally be reduced to a shorthand notation that “Tx + R/B/A disc, AQA” signifying that treatment, risks, benefits, and alternatives were discussed and all of the patient's questions were answered.
Unfortunately, physicians frequently do a less than adequate job at documenting the AMA discharge process. Eighteen percent of charts in a rural community setting had no AMA discharge documentation.36 Documentation of a patient's clinical decision-making capacity ranges from 0%37 to 23%36 to 67%.38 Documentation of patient comprehension of their diagnosis, proposed treatment, alternative therapy, and clinical consequences of refusal occurred in 36%, 44%, 2%, and 57% of cases.38
After the patient has been informed of the consequences of his or her decision, the physician should attempt to have the patient sign a written refusal of care/AMA form. While it is not mandatory that a patient sign such a form before they may be discharged AMA, the presence of a signed AMA form creates a “rebuttable presumption” that the patient was presented with and understood the information contained on the form. Should the appropriateness of an AMA discharge later be challenged, the patient or family member would then need to present evidence to overcome the presumption that refusal of care was an informed refusal. Due to the ubiquity of AMA discharge forms, courts may view the lack of such a form on a patient's chart as evidence that informed refusal of treatment was not obtained.32 One study showed that in 42% of AMA discharges, no AMA form was signed by the patient.37 If a patient refuses to sign an AMA form, the physician should note the interaction on the chart, and may wish to add to the medical records a copy of the unsigned AMA form that was presented to the patient.
Caring Care of the AMA Patient
Finally, it is important to provide a patient leaving AMA with the same treatment that would be provided to patients who are formally discharged under similar circumstances. Patients with chronic back pain who leave AMA because they are not given narcotics need not necessarily receive a prescription for narcotic medications, especially if the physician believes that such a prescription may jeopardize the patient's health. Conversely, patients who lack essential medications such as asthma inhalers should generally be provided with prescriptions for those medications. If patients are only willing to accept alternative, but less than optimal treatments, note the treatments that were provided to the patient and why the more appropriate treatments were not given.
While physicians should make reasonable efforts to provide alternative treatments to patients who leave AMA, they should also not allow themselves to be coerced into providing inappropriate medical care to patients solely because patients threaten to leave AMA. A patient's assertion that if they do not get azithromycin for their cough, they will leave AMA should not result in a prescription for a different antibiotic, but should rather result in a discussion of why antibiotics are inappropriate medical therapy for coughs.
An outright refusal to appropriate treatment to patients who leave AMA is medically unjustified and would likely be viewed as vindictive and unprofessional by a court, jury, or licensing board. Recall that AMA decisions are often based on factors other than a patient's disagreement with the physician's medical judgment. While discussing the case of Drummond v Buckley,39 the Mississippi Supreme Court stated that “[s]urely, it cannot be suggested that supposed medical professionals would withhold proper service because a patient … exercised his prerogative not to follow medical advice.”