When patients request to be discharged before receiving the full recommended evaluation and/or treatment, we often consider this a discharge against medical advice (AMA). The rate of AMA discharges is increasing with recent studies showing they account for approximately 2% of all ED discharges.
As you can imagine, leaving AMA poses significant risks to the patient and the provider. Patients who leave AMA are found to have higher rates of adverse outcomes including readmission, prolonged hospitalization, and increased mortality. Then, when an adverse event occurs, these patients are 10 times more likely to sue the providers who cared for them. Some estimates suggest that 1 in 300 AMA discharges result in a lawsuit, compared to 1 in 30,000 standard discharges.
With that being said, patients will inevitably choose to leave AMA so it’s important for us to understand how to handle this to minimize risks for both parties. One article I found suggests using the “AIMED” framework, which I personally found helpful and will outline here.
A: Assess if the patient has capacity to make an AMA decision.
Capacity requires (1) understanding all treatment options including the risks and benefits, (2) expressing a clear choice, (3) appreciating the consequences of that choice, and (4) ability to justify one’s reasoning.
I: Investigate why the patient wants to leave.
Common reasons include personal obligations (e.g., children, pets, work), financial concerns, dissatisfaction with the care, distrust of the medical system, subjective improvement of symptoms, or withdrawal symptoms.
M: Mitigate premature discharge by offering the patient comfort measures, alternatives, or compromises tailored to their specific concern.
This may include providing medication for withdrawal or involving social work to assist with their outside responsibilities.
Be careful not to make false promises because this will create distrust toward you and the healthcare system.
E: Explain & Evaluate
Explain the patient’s illness and your treatment plan in simple terms.
First review the patient’s presenting symptoms, the results of initial tests, and your working differential. Then, discuss your recommendations (further testing, observation, admission, etc) including the benefits of this plan. Next, explain the potential risks of leaving, including severe complications such as permanent disability or death.
Evaluate that the patient understands the consequences of their choice and has all the necessary information to make an informed decision.
Provide comprehensive discharge instructions, including specific follow-up appointments, referrals, and prescriptions. Emphasize that the patient can return to the emergency department at any time.
D: Document everything thoroughly.
Include an assessment of the patient’s capacity and a detailed record of your conversation about the original treatment plan, alternative options, risks of leaving, and the plan for outpatient care.
Here are two example templates I found online:
The patient expresses the desire to leave against medical advice (AMA). Their reasoning for leaving AMA is due to ***. They presented with a chief complaint of *** and I have explained my concern that based on their complaint in addition to my history, physical exam, and studies returned to date that this may represent ***. In addition, I explained that their work-up is currently incomplete and I would recommend *** to complete it. I also explained my concern that leaving at this time places them at risk for their condition worsening, critical illness, and death or permanent disability including ***. I have also offered alternative treatments options including ***. The patient explained in their own words all of my concerns including the consequences of refusing further treatment including death or permanent disability. I have also discussed my concerns with *** who was also unable to convince the patient to stay. The patient is clinically sober and has no injury that would affect their cognition. In addition, they appear to have intact insight, judgement and reason and in my opinion has the capacity to make their own healthcare decisions. Given that the patient was unwilling to stay I *** to increase the probability of a good outcome. I ensured there were no communication barriers with the patient by ***. A written informed refusal document was *** signed by the patient after our conversation. Outpatient follow-up was offered with ***. The patient was encouraged to seek care immediately if they would like to complete the work-up or if they have any new concerns. This conversation was witnessed by ***. AMA paperwork was*** completed and signed.
The patient is clinically not intoxicated, free from distracting pain or injury, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient, though the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.
According to malpractice attorneys, good documentation in the EMR is superior to an AMA form. In fact, most AMA forms offer very little medicolegal protection for providers. While it is good practice to have your patient sign the AMA form, your time is better spent writing a thorough note about your conversation with the patient rather than fighting with Taylor Health and the South Side Printers.
Finally, I want to address the misconception that leaving AMA will result in insurance coverage being denied for the visit. This is entirely false. Multiple studies have shown that leaving AMA does not place any additional financial burden on the patient, and these visits were reimbursed the same as other visits.
Sources:
https://www.emra.org/emresident/article/lit-review-ama-discharge
https://www.nuemblog.com/blog/ama
https://www.aliem.com/ama-two-high-risk-myths-misconceptions/
https://www.aliem.com/proper-way-to-go-against-medical-advice/