Discharge of Patients: Leaving against Medical Advice
By Nancy Young, Director, Risk Management, Crozer-Chester Medical Center
It is a challenge to provide quality healthcare when patients do not adhere to their physicians’ recommendations for treatment. The patient who insists on leaving the hospital Against Medical Advice (AMA) is an extreme example of non-adherence, and this situation creates high potential for serious errors.
Statistics demonstrate that patients who leave AMA account for 0.8%-2.2% of discharges from medical services at acute care hospitals in the United States. Generally, AMA discharge rates are higher in urban hospitals than suburban hospitals and higher at community hospitals than teaching hospitals. At hospitals serving disadvantaged inner-city populations, as many as 6% of general medical patients and 13% of patients with HIV/AIDS leave AMA. 
Patients with substance abuse and mental and emotional problems are at significantly higher risk for discharge AMA than the average patient. Alcohol abuse and being male are the two most significant predictors of patents leaving against medical advice. Patients without a primary care provider and those without medical insurance are also more likely to leave AMA. Patients with the most obvious risk factors should be identified early on and referred to social work and case management. 
Patients give a variety of reasons for leaving AMA: family problems or emergencies; personal or financial obligations; well enough to leave; or dissatisfaction with their treatment. Even though many patients who leave AMA have substance abuse problems, very few of them attribute their decision to drug addiction.
Patients who leave the hospital AMA may be at increased risk of adverse health outcomes. Several studies support this concern and have found that patients who leave AMA have significantly higher readmission rates than other patients.  Unfortunately, it is impossible to accurately predict which patients will leave AMA. However, what can be foretold is that many of those patients who do walk out are back in the hospital within two weeks. For psychiatric patients, readmission occurs within one week. 
Physicians should attempt to understand the reason for the patient’s decision to leave AMA. Addressing the problem head-on sometimes leads to a timely resolution. There may be times when the patient feels it is necessary to leave because pets need to be taken care of, a check needs to be delivered, they have business that requires their attention, or any number of dilemmas which may be fairly easy to resolve. The physician should discuss the patient’s rationale for wanting to leave. Sometimes there are easy solutions that allow the patient to stay for treatment.
If efforts fail to convince the patient to continue the necessary treatment, certain steps should be taken. Prior to discharging a patient AMA, the physician should be convinced that the patient has given and informed refusal, and has had an opportunity to ask questions. The physician must determine and document that the patient is functionally competent. Refusal of care is invalid for persons who have been committed to the care of the hospital by legal proceeding or who are not competent.
When a patient desires to discontinue treatment and leave the hospital without the approval of the physician in charge, the patient is required to sign a release from liability. The (AMA) release becomes a permanent part of the patient’s medical record. It is also important for the physician to document in the patient’s medical record the fact that the patient left against medical advice and also record pertinent discussion with the patient prior to his/her leaving AMA. Documentation of that approach may provide protection against liability for adverse events following the discharge.
An example of an AMA note might read as follows:
Patient has decided to leave the hospital against medical advice. The patient is competent and understands the risks of leaving, including permanent disability and/or death, and has had an opportunity to ask questions about his/her condition. The patient has been informed that he/she may return for care at any time, and follow up has been arranged.
 Discharge Against Medical Advice. Medicine May 2005. Can be found at http://www.webmm.ahrq.gov/case
Green, P., Watts, D., et al. (2003). Why patients sign out against medical advice (AMA): Factors motivating patients to sign out AMA. Am J 489.
Hwang, S.W., Li, J., et al. (2003). What happens to patients who leave against medical advice? CMAJ, 168(4), 417.
Physician’s Law Review. Against Medical Advice. Can be found at https://www.thesullivangroup.com/