Patient Care

What Are Best Practices for Patients Discharged against Medical Advice?

We propose that a high-quality AMA discharge be defined as a discharge in which the patient is informed of the clinical team’s determination that further hospitalization is required but elects to leave the hospital, and it includes a clear discussion of the risks of outpatient treatment, a determination of capacity, and an exploration of safe alternative care plans that could satisfy both the patient’s medical and social needs. This definition places the burden on hospitalists and other providers to fully explore the motivations behind a patient’s request to leave the hospital and treats psychosocial motivators for premature discharge as variables in the complex risk-benefit analysis that underlies the informed consent discussion prior to AMA discharge.

Furthermore, AMA discharge does not obviate a physician’s responsibility to advocate for a patient’s well-being, and therefore an AMA discharge should be accompanied by reasonable efforts to coordinate a patient’s ongoing outpatient care. Of note, this approach is consistent with previous reviews and attempts to balance the physician’s duty to honor a patient’s autonomy with the responsibility to protect the patient from harm.2,16

Conclusion

Patients discharged AMA are a diverse population at markedly increased risk of morbidity, readmissions, and subsequent healthcare cost. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Such an approach allows the provider to identify and address the patient’s concerns regarding further inpatient care, to explore possible safe outpatient treatment options, to document patient capacity, and to provide appropriate harm-reduction measures such as prescriptions.

Further research into the current practice patterns of hospitalists and other providers is necessary to allow for the formulation and adoption of best practices and implementation of appropriate harm-reduction strategies. TH

Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai.

Key Points

  • Patients discharged against medical advice are a vulnerable patient population and suffer increased morbidity and mortality, healthcare costs, and rates of readmission.
  • AMA patients are clinically, demographically, and psychosocially heterogeneous.
  • Shared decision making between patients and providers may allow for harm reduction in discharge planning and may obviate the need to discharge certain patients AMA.
  • Further research is needed to better understand current practice patterns and to identify evidence-based strategies for safe discharge planning in the AMA population.

References

    1. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327.
    2. Kahle CH, Rubio ML, Santos RA. Discharges against medical advice: considerations for the hospitalist and the patient. Hospital Medicine Clinics. 2015;4(3):421-429.
    3. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929.
    4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.
    5. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Int Med. 2010;25(9):926-929.
    6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.
    7. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Int Med. 1995; 10(7);403-405.
    8. O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract.1996;16(3):157-164.
    9. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12): 2204-2208.
    10. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.
    11. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955-960.
    12. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999;107(5):507-509.
    13. Alfandre, DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.
    14. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. doi: 10.1136/qshc.2009.036269.
    15. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
    16. Berger J. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408.
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