What is the best way to handle a patient leaving AMA?
Leaving AMA is not a benign action, both to the patient and the provider. Patients who leave AMA have higher rates of adverse outcomes compared to patients who have completed their medical workup and treatment, and are up to 10% more likely to sue their providers. It is estimated that 1 in 300 AMAs result in a lawsuit. Leaving AMA is a problem that continues to increase in frequency as the years go by; in 1992, 0.1% of ED patients left AMA, and now that number is close to 2% of all discharged ED patients.
Who is more at risk for leaving the ED AMA?
According to Kazimi et al, our most vulnerable patients are the ones leaving AMA. This includes patients with lower incomes, are African American, male, young patients, those with multiple significant comorbidities such as psychiatirc, substance abuse, and HIV in particular, those on public insurance, patients with no PMD, patients with poor social support, and unfortunately unsurprisingly, the uninsured patient comprised almost 1/3 of all AMA discharges documented in the study.
Why do patients leave AMA?
Often cited reasons include personal obligations (children at home, feeding cats, need to go to work), financial concerns, dissatisfaction with care and customer service, distrust of the medical system, wait times, and disagreements with staff.
What is the best way to handle someone leaving AMA?
The most important step is to first try to prevent the AMA discharge. Like the illnesses we treat medically as providers, prevention is key. First step is talking to the patient and figuring out what their reasoning for leaving is. Try to meet the patient where they are- their concerns and priorities may not always match ours. Oftentimes the patient (and the provider) do not realize what options are available that may fix their problem. We have an excellent team of social workers, case managers, substance abuse specialists, and patient reps that can help tackle specific reasons why the patient wants to leave AMA. Additionally, patients may not fully understand the extent of their illness. It is our responsibility as providers to present our reasoning for wanting the patient to stay, and try to find middle ground between our and the patient's goals of care.
But unfortunately, many AMA discharges are inevitable. What should we do when there's seemingly nothing else we can do?
ALIEM has a great article written about AMA discharges: there are 8 components of any AMA that in addition to discussing with the patient, must be documented. Here's a quick summary:
Assess the patient's capacity. Assess sobriety, the patient's ability to communicate a choice, understanding, appreciation, and ability to reason.
Signs and Symptoms: Patient and provider need to agree with their concerns: patient should acknowledge, for example, that their RLQ abdominal pain may be signs of appendicitis.
Extent and Limitation of the Exam: Basically detailing that the workup thus far may be incomplete and not representative of the patient's potential illness; labs may be OK, but imaging may still be warranted to rule out appendicitis
Current Treatment Plan: Discussed what the patient still needs in their workup/reasons for observation/admission, what medications they need, etc.
Risks of Foregoing Treatment: patients should be informed of specific complications they may face, including death, infertility, loss of limb, vision, etc.
Alternatives to Suggested Treatment: discuss with the patient alternatives to their current and most effective treatment plan.
Explicit Statement of AMA and Why the Patient Refused
Questions, Follow-up, Medicines, Instructions: Do what we can to limit bad outcomes for our patients. Even if the alternative treatment plan is sub-optimal, we are still doing all we can possibly do for the good of the patient. Help arrange follow up as soon as possible and coordinate with their existing doctors if they don't want to stay. Provide oral antibiotics if they do not want to stay for IV antibiotics.
Here's an example I found of AMA discharge documentation:
The patient is clinically not intoxicated, free from distracting pain, 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.
Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909809/
https://www.wikem.org/wiki/Against_medical_advice
https://www.uptodate.com/contents/hospital-discharge-and-readmission#H14129862
https://www.aliem.com/proper-way-to-go-against-medical-advice/
https://www.emra.org/emresident/article/lit-review-ama-discharge/
https://www.nuemblog.com/blog/ama
https://www.emra.org/emresident/article/lit-review-ama-discharge/