PubMed13. David Alfandre, MD, MSPH, VA National Center for Ethics in Health Care, Assistant Professor of Medicine and Population Health, NYU School of Medicine, 423 East 23rd St (10E1E), New York, NY 10010; Telephone: 212-951-3306; Fax: 212-951-3353; E-mail: [email protected], The “Things We Do for No Reason” (TWDFNR) series reviews practices which have become common parts of hospital care but which may provide little value to our patients. 2001;10(2):189-195. Increased risk of mortality and readmission among patients discharged against medical advice. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/downloads/MMSHospital-WideAll-ConditionReadmissionRate.pdf. 2011;41(4):412-417. A population-based analysis of leaving the hospital against medical advice: incidence and associated variables. Evidence-based and widely accepted examples of harm reduction strategies include nicotine replacement therapy and needle exchange programs.19, SDM in discharge planning provides a range of discharge and transitional care options that are within prevailing medical standards, not simply a single recommendation that prioritizes health promotion to the exclusion of other identified patient goals. PubMed6. She has a primary medical doctor at the hospital and follows up with her regularly. Stratton K, Shetty P, Wallace R, Bondurant S. Clearing the smoke: the science base for tobacco harm reduction--executive summary. Further research is needed to better understand current practice patterns and to identify evidence-based strategies for safe discharge planning in the AMA population. A.M.A. Insurance companies refusing payment for patients who leave the emergency department against medical advice is a myth. Devitt PJ, Devitt AC, Dewan M. Does identifying a discharge as “against medical advice” confer legal protection? Clearly, patients have a diversity of reasons for requesting to be discharged AMA, and further research is necessary to define clear and potentially modifiable risk factors. Discharges against medical advice: are race/ethnicity predictors? Schaefer GR, Matus H, Schumann JH, et al. We invite you to propose ideas for other “Things We Do for No Reason” topics by emailing [email protected], 1. After hearing the risks and benefits of surgery from the … $15 per month. AMA patients are clinically, demographically, and psychosocially heterogeneous. Compared with standard discharges, AMA discharges are associated with an increased adjusted relative risk of 30-day mortality as high as 10% and 30-day readmission rates that are 20%-40% higher than readmission rates following standard discharges.2 AMA discharges are more likely among patients with substance use disorders, psychiatric illness, and HIV.3. 2006;3:35. One of a resident’s options is the right to refuse medical care and sign out of a nursing home, at any time, against medical advice. Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend? Epub 2012 Apr 17. Discharges against medical advice (AMA) account for approximately 1% of discharges for general medical patients. While leaving before a medically specified endpoint may not promote the patient's health above their other values, there is widespread ethical and legal consensus that competent patients (or their authorized surrogates… The hospital physician refused to provide prescriptions for medications, including antibiotics. A recent closed claim can help … 3 Lastly, though only 0.5% of patients who have undergone a … In Case No. We suggest that an individualized approach be taken for each patient, with attention to both clinical and psychosocial risk. Against medical advice (AMA) discharges, which account for up to 2% of all inpatient discharges, are associated with worse health and health services outcomes and disproportionately affect vulnerable patient populations. If you choose to designate a discharge as AMA, approach the discharge planning process consistently and with patient-centered principles by optimizing SDM and harm reduction. The term leaving against medical advice smacks of paternalism and the fear of liability. 2012;27(7):825-830. 2004;30(2):489-493. 1991). The physician then expanded the range of potential treatment options, including evaluation for medication-assisted treatment for the patient’s opioid use disorder (OUD) and harm reduction measures such as safer injection practices, needle exchange, housing assistance, and overdose prevention and treatment education.23 An alternative harm-reducing option included discharge with oral antibiotics and follow-up with his primary physician in 48-72 hours. Of course, because an AMA discharge is “against” the provider’s preferred advice, some may think it illogical to offer “second-best” advice. A 44-year-old member asked: Can pharmacists dispense medical … Can J Rural Med. One of the recurring questions I have been asked during my years of practicing as a nurse attorney is whether a nurse would be held liable for a patient who leaves a health care facility against medical advice. The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. Instead, clinicians should maintain a single discharge process with clear, objective documentation including providing appropriate prescriptions and follow-up appointments regardless of whether the patient’s choice is consistent with a physician’s recommendation. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice, “I’m going home”: discharges against medical advice, Reasons for discharges against medical advice: a qualitative study, Discharge against medical advice: ethical considerations and professional obligations, Defining Patient Experience: 'Everything We Say and Do', Among asymptomatic, 2% may harbor 90% of community’s viral load: Study, CDC: Vaccinated? Healthcare Cost … She becomes visibly upset and insists that she must return home. A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. . It’s worth noting that the majority of these patients had government-funded health … Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. At present, the decision to classify a discharge as AMA falls solely on the treating provider, and we suspect that there is great variability in practice patterns, particularly as there are few established professional society practice guidelines regarding this difficult issue. Windish DM, Ratanawongsa N. Providers’ perceptions of relationships and professional roles when caring for patients who leave the hospital against medical advice. What is Wrong with Discharges Against Medical Advice (and How to Fix Them) You can imagine my enthusiasm when I read the title of this month’s “Viewpoint” article published in an upcoming December 2013 issue of the Journal of the American Medical Association (JAMA), in which authors David Alfondre, MD … The patient was treated with benzodiazepines for his alcohol withdrawal and remained medically stable. Quality discharge planning should provide the “right care for the right patient at the right time”20 that moves beyond the false choice of either remaining in the hospital under the conditions specified by the physician or leaving AMA. 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. However, physicians and medical practices can guard against those risks by understanding them and developing a clear plan for mitigating them. 2012;43(3):516-520. PubMed19. Patients leaving against medical advice are considered high risk. 1994;154(12):1365-1370. Although there are little empirical data to inform how and why physicians choose to designate a discharge as AMA when patients decline recommended care, the existing evidence suggests that fears of legal liability are strongly driving the practice.4 Physicians may believe that they must discharge patients AMA in order to fulfill their legal and ethical responsibilities, or to demonstrate in writing the physician’s concern and the significant risk of leaving.5,6 Clinicians may have been acculturated during training to believe that an AMA discharge may also be seen as a way of formally distancing themselves from the patient’s request for a nonstandard or unsafe discharge plan, thus deflecting any potential blame for worse patient outcomes. PubMed16. 2011;26(5):518-523. O’Hara D, Hart W, McDonald I. Click here for the latest news from SHM Converge. The patient wanted treatment for his cellulitis, but he was experiencing pain and opioid withdrawal. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. Although state laws vary from state to state, the following case illustrates how the Dakota Supreme Court … From a healthcare quality perspective, the designation of a discharge as AMA is low-value care in that it is a routine hospital practice without demonstrated benefit and is not supported by a strong evidence base. Providing Prescriptions to the Patient Who Is Leaving Against Medical Advice. Treat all discharges similarly. Choosing Wisely: Things We Do For No Reason. All rights reserved. Brenner J, Joslin J, Goulette A, Grant WD, Wojcik SM. Failure to respond with calm and reason can spell medical tragedy and … You don’t need a mask indoors, CDC recommends use of Pfizer’s COVID vaccine in 12- to 15-year-olds, Reassuring data on impact of mild COVID-19 on the heart, Dr. Fauci: Feds may ease indoor mask mandates soon, Percentage of doctors who are Black barely changed in 120 years, Critical care and COVID-19: Dr. Matt Aldrich, Treatment options for COVID-19: Dr. Annie Luetkemeyer, Managing the COVID-19 isolation floor at UCSF Medical Center, Copyright by Society of Hospital Medicine. 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. Jerrard DA, Chasm RM. This can lead to poor outcomes for the patient, ethical turmoil for the physician, and liability for the health care system. The treatment team informed the patient that an additional 2-3 days of IV antibiotics would produce a more reliable cure and reduce the risk of readmission. A 54-year-old man with active intravenous (IV) drug use and hepatitis C was admitted with lower extremity cellulitis. 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. Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA. All rights reserved. Agency for Healthcare Research and Quality, Rockville, MD. Avoid designating an inpatient discharge as AMA. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. Hospitalizations in which patients leave the hospital against medical advice (AMA), 2007. “Leaving against medical advice” The CMPA advises physicians to inform patients of symptoms and signs alerting them to seek further medical care and provide advice tailored to their specific clinical situation. Hence, this patient can be properly said to be leaving “against medical advice.” PubMed2. Free. The patient’s physician – The physician or the medical practitioner who handled the patient during his arrival and who supplied prescriptions as well as have suggested surgeries or medical procedures to the patient will have to affix his signature on the against medical advice form fulfilled by the patient. J Gen Intern Med. Wigder HN, Propp DA, Leslie K, Mathew A. Harm reduction practices seek to reduce the adverse health consequences that may come from unhealthy behaviors while assuming that patients will likely continue such behaviors. Tob Control. Barriers to the dissemination of four harm reduction strategies: a survey of addiction treatment providers in Ontario. Ct. App. https://archive.ahrq.gov/news/speech/test031809.html21. J Gen Intern Med. J Gen Intern Med. — Against Medical Advice. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. In clinically low-risk cases (e.g., Case No. A discharge against medical advice (AMA) is one that 1) is patient-initiated, and 2) occurs prior to work-up or treatment or discharge planning has been completed, and 3) the work-up, treatment, or discharge planning cannot safely be performed on an outpatient basis, and 4) the patient has decision-making capacity. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission. New York Public Health Law provides that “[e]very patient shall have the right . A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai. These patients risk morbidity and mortality when being discharged AMA. Patients who leave the hospital AMA chal-lenge the healthcare … This discharge was not unlike those stemming from at least 15 other hospitalizations the patient had experienced over the past 10 years, primarily … Ensure there is objective documentation of the patient’s informed choice to leave the hospital. BMC Health Serv Res. Against medical advice (AMA) discharges, which account for up to 2% of all inpatient discharges, are associated with worse health and health services outcomes and dispropor-tionately affect vulnerable patient populations. A survey of nearly 50,000 patient medical records from the University of Chicago Medicine found that, of 453 patients who had left against medical advice, not a single patient was denied insurance coverage for their care due to their discharge decision. Even in such clinically high-risk cases, however, we argue that a collaborative strategy aimed at identifying and addressing the patient’s psychosocial concerns is appropriate, as such an approach promotes shared decision making, builds trust between the patient and the care team, and therefore may facilitate improved follow-up at the time of discharge. Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. PubMed10. Against medical advice (AMA) discharges, which account for up to 2% of all inpatient discharges, are associated with worse health and health services outcomes and disproportionately affect vulnerable patient populations. In another 2-year retrospective review of patients discharged AMA from a general medical service of a university-affiliated tertiary care hospital, prescriptions and follow-up plans were only documented in 24.4% and 31.3% of medical records, respectively. To persuade patients to remain hospitalized, 85% of trainees and 67% of attending physicians in one study incorrectly informed their patients that insurance will not reimburse a hospitalization if they leave AMA.13 Because this study demonstrated that there is no empirical evidence that payment after AMA discharges is denied by private or government payers, physicians sharing this misinformation can breed distrust and coercively undermine patients’ ability to make a voluntary choice. My pager vibrated against my waist. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Capacity. Div. PubMed18. A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the medical service with mild alcohol withdrawal. Kraut A, Fransoo R, Olafson K, Ramsey CD, Yogendran M, Garland A. J Emerg Med. The solution to improve quality is straightforward—avoid designating discharges as AMA. The AMA designation is used in part to help legally shield the doctor and hospital from liability if a patient gets ill or dies as a result of the premature … He has no known physical address or telephone number and has no known outpatient healthcare providers. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. 2016;27(1):21-27. Against Medical Advice (AMA) Take Home Points Patients are going to continue to leave AMA. Discharges against medical advice … PubMed5. to refuse medication and treatment after being fully informed of and understanding the consequences of … 2016;31(9):1011-1018. J Clin Ethics. The AMA discharge is a routine hospital practice without demonstrated patient benefit and which disproportionately affects vulnerable populations. These examples demonstrate extremes on the clinical and psychosocial spectrum of patients requesting an “early” discharge and suggest that no two patients at risk of AMA discharge are the same. Talk to a doctor. PubMed22. In its place, the physician should use shared decision-making (SDM) and harm reduction principles to enhance the patient’s well-being within the identified constraints. He was also found to have a proximal humeral fracture, and the orthopedic consult recommended surgical repair. For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.3,4,5, Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. A prospective trial of a new policy eliminating signed consent for do not resuscitate orders. Most children who were taken from the hospital left within the first two days of hospitalization. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Should the team inform the patient that he will be discharged against medical advice (AMA) if he chooses to leave the hospital prematurely? The patient should also be informed about who is the most responsible health-care professional for follow … J Gen Intern Med. A year prior, she had an episode of endocarditis due to different pathogens, and left against medical advice (AMA) after 4.5 weeks of therapy. Saab D, Nisenbaum R, Dhalla I, Hwang SW. Hospital Readmissions in a Community-based Sample of Homeless Adults: a Matched-cohort Study. 2008;23(10):1698-1707. 2000;49(3):224-227. Lessons from plaintiff depositions. Health, NYU School of Medicine, New York, New York. SDM involves physicians and patients making healthcare decisions together by combining the patients’ values and preferences for care with the physicians’ expertise and knowledge of medical evidence. When declining any treatment, even life-sustaining treatment, the request for a patient signature to decline such treatment has not been demonstrated to improve risk communication and is not considered a best practice for informed consent.18 When the physician’s motives for this behavior are punitive or directed primarily at reducing liability, it may distract the physician from their fiduciary duty to put patients first. A survey of general internal medicine doctors at the University of Chicago Medicine found that two-thirds of residents and almost half of attending physicians believe that when a patient leaves the hospital against medical advice, insurance companies will not pay for the patient's hospitalization, leaving the patient liable … March 2009. This paper will review the background data on AMA discharges as well as the reasons physicians may choose to discharge patients AMA. Hospital-Wide (All-Condition) 30-Day Risk-Standardized Readmission Measure.