“Despite my advising the patient of the potential risks, he still left against medical advice.”
I dictated these exact words in two consecutive discharge summaries last week…on two consecutive days.
On Wednesday my words described a patient who, from the moment I met him in the ER, never wanted to be admitted, but he nonetheless stayed for an additional three days. Every morning and every afternoon during my rounds as an intern on a general medicine floor, this patient asked when he could go home. I felt as if I was begging him to stay, initially “just until you can be seen by an infectious disease specialist,” then “just a little bit longer for IV antibiotics,” and then “just until your CT has been read.” Finally, he had had enough, and wary at the impending cost of every minute spent in the hospital, and knowing full well the risks of his decision, he left against medical advice. Yes, that’s right, he went rogue, took off, went AWOL. He committed the ultimate of patient transgressions…”he left AMA.” However, in addition to making sure he “signed out AMA,” I did everything possible to provide him with a formal discharge, completing his discharge instructions, reconciling his discharge medications, providing him with signed prescriptions for oral antibiotics. and even establishing follow-up with his primary care physician. Despite my follow-your-gut-instincts to do what I could to care for my patient, I still wondered if I had followed the appropriate procedure. Should I have given him formal discharge instructions and a prescription for an oral antibiotic knowing that this treatment would be suboptimal to the IV antibiotics I recommended he receive in the hospital? Would these efforts be seen by a malpractice judge as my providing what I knew to be suboptimal care inasmuch as I knew the prescription for oral antibiotics might not provide appropriate coverage for his infection?
On Thursday, and with a different attending physician, I dictated the same statement, though my earlier doubts invoked a much different, minimalistic and embarrassing lack-of-effort on my part. Thursday’s patient, with his history of polysubstance drug abuse, was admitted for an overdose, and was receiving close monitoring, though he had exhibited no signs of withdrawal. Given his overdose, we were not providing him with the prescription medications to which he had grown accustomed “on the street” and he requested to leave. Once again, just as before, I explained to him the risks of his decision and made him “sign out AMA,” but I didn’t make nearly the same effort to provide him with a formal discharge or provide him prescriptions for his medications. In light of his overdose, I did, however, make a personal phone call to his internist, to inform him of this patient’s hospital admission and of my concern for possible medication abuse, and to suggest close follow-up in the coming weeks. My dictation included the same words, but the effort on my part was drastically different.
Later I began to wonder if I had done the right thing. Had I followed the hospital protocol correctly? IS there a hospital protocol? Does a patient leaving AMA require a formal discharge? If I sign the discharge instructions/order does that negate the patient’s having left AMA and appear as though I formally discharged him with suboptimal care? Should I reconcile his/her medications or should it appear as though the patient just left all-of-a-sudden? Does an AMA discharge even require a dictation?”
Beyond these procedural-based questions, I too wondered, “What are the legal implications of this patient’s leaving AMA? Why do I feel so adversarial when a competent patient makes a reasonable, well-thought-out decision to leave against medical advice? If I were in his position, knowing that each hospital day meant thousands of dollars for me and my family, would I make a similar decision to leave against medical advice? Am I actually a closet rogue-AMA patient-in-waiting merely disguised temporarily as a physician?”
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 and John H. Schumann, MD provide an in-depth analysis of what is wrong with against medical advice discharges. Here are a few of the highlights, along with some of my own editorial commentary:
- “Readmission rates for patients discharged against medical advice are 20-40% higher and their 30-day adjusted relative risk of mortality is 10% or higher.” Clearly, the harmful risks of patients leaving AMA are significant. But what about the harm that these discharges create on physicians and staff? The article continues, “Physicians…and other staff…report feeling distressed and powerless when patients choose suboptimal care, and disagreement over discharge against medical advice can cause patient-physician and intrateam conflict.” So true! I definitely felt distressed and powerless knowing I was delivering suboptimal care, and I felt pulled in different directions by various attending physicians/nurses/staff on the correct do’s and don’ts of AMA discharges.
- “85% of residents and 67% of attending physicians reported that they informed patients about denial of insurance payment so that patients would reconsider remaining in the hospital.” While I don’t fall within the incorrect 85% in this case, I have heard this “denial of insurance payment” claim used when encouraging patients to remain in the hospital. I’m relieved that the JAMA article states that this claim is NOT accurate. However, the principle underlying this claim is that physicians frequently use similar if-you-don’t-stay-you’re-gonna-get-it statements to coerce patients to remain in the hospital. Such coercion, as the article describes, is not consistent with the “shared-decision-making” model being applied to many patient-physician communications in today’s model of health care delivery. Physicians need to get their facts straight before propagating similar “if-you-don’t-stay-you’re-gonna-get-it” myths.
- “Although health professionals use discharge against medical advice forms because they believe it is required to protect themselves and their institutions from legal liability, these presumptions are not valid.” This argument is based on a Journal of Family Practice (2000) article in which authors searched legal databases for cases involving discharges against medical advice. The article states, “In the case of Dedely vs. Kings Highway Hospital Center, a mother requesting the release of her infant son was required to sign a form by which she assumed ‘all risks, responsibilities and liabilities, whatsoever; and released the hospital, ‘physicians, surgeons, authorities, and employees from all risks, claims, responsibilities whatsoever.’ The court found this type of form to be contrary to public policy and therefore worthless. It also observed that a hospital’s refusing a patient be allowed to leave ‘unless it sought judicial relief, would undoubtedly subject the hospital to an actionable tort.'” Despite this legal precedent, the only consistent counsel I have received from every attending when discharging a patient AMA is that I “be sure to have the patient sign the AMA form.” Clearly, we must educate physicians, hospital administrators, and staff on the lack of necessity and potential for malpractice of similar all-encompassing, cover-your-own-you-know-what AMA forms.
- “Accepting a patient’s preferences for care, even when such preferences deviate from the physician’s own judgments, can still be acceptable, if not ideal.” In today’s culture of shared-decision-making, physicians must recognize that empowering patients is the key to compliance. It is through empowering informed decision making that patients will be eager to comply with a prescribed treatment plan. Accepting alternative “preferences for care” is the first step to empowering future patient compliance.
I hope you agree with me that it is time for physicians and hospital administrators to develop standards for discharges against medical advice. What qualifies a discharge as AMA? What is the physician’s role in discharging a patient AMA? What healthcare-wide policies should exist to provide appropriate follow-up for such patients? These are just a few of the questions that must be addressed.
While I alone cannot start the much-needed revolution for improvements in against medical advice discharges, I will strive to empower my patients by recognizing their “preferences for care” may not be mine, but that I still can do everything within my power to ensure optimal post-discharge care.
If you agree with the need for improvement in “AMA hospital discharges,” please share this article or the cited JAMA article with your friends and colleagues.
Alone we can do very little, but together we can start a revolution.