Written by Monisha Dilip
Edited by Wesley Chan
On 10/6/20, the Admin Mini-Fellowship convened to discuss Against Medical Advice (AMA) discharges.
Discharges against medical advice (AMA) are often contentious and have unclear legal implications for the provider in the instance of a bad outcome. Using EMRA’s Administration and Operations committee’s literature review on AMAs as a basis [1], we discussed the potential legal ramifications of negative outcomes for patients who leave AMA as well as some strategies to ensure that our patients have appropriate follow-up if they choose to leave. As expected, patients who leave AMA were found to have higher mortality and readmission rates [2].
Patients leave AMA for a variety of reasons, including social issues at home, transportation issues, unclear medical instructions, or a lack of understanding of the consequences of leaving the hospitals, among other reasons [1]. Male gender, trauma, and uninsured status are all factors that increase the chance of a patient leaving AMA [3,4]. It is important to understand the patient’s reasoning for leaving AMA as it can help the provider tailor his/her care to the patient’s needs. For example, if a patient has concerns regarding child care, a provider can help the patient make phone calls or perhaps arrange for close, outpatient follow-up once the patient is able to arrange child care.
Once a patient has decided to leave AMA, some suggest a systematic approach, using the acronym AIMED: Assess, Investigate, Mitigate, Explain, Document [5].
Assessment: The initial assessment is illness severity – can the patient consent to leaving? Do they have the capacity to refuse care? Do they understand the severity of their illness?
Investigate: It is important for the provider to investigate why the patient wishes to leave AMA and see if it is something that he/she can rectify.
Mitigate: Once the provider understands why the patient wishes to leave, they should offer as much therapy as possible while the patient is still in the ED and then arrange appropriate follow-up.
Explain: Ensure that the patient truly does understand all the risks of leaving AMA and can explain them back to you. Construct an alternative plan together that the patient can then follow to receive care when they can. Explain that the patient is welcome back at any time.
Document: Make sure that a medical screening exam is properly documented, along with an assessment of decision-making capacity and a summary of the above information. You can document what was discussed with the patient and that they understand all the risks as you’ve outlined them, as well as the alternate plan that you have made together and the discharge instructions they were given.
The concept of leaving AMA absolving the physician of legal culpability was up for debate [6]. A few papers cited legal precedents that support a physician’s documentation of the above as sufficient to release the physician from legal responsibility [7]. For example, Lyons v. Walker Regional Medical Center noted that patients who leave AMA are assuming the risks of leaving as long as they are explained the risks and it is documented that they understand. As explained in Devitt et al [7], cases found in favor of the physician were those in which the documentation reflected a clear differential diagnosis and medically sound decision-making. Those in which the plaintiff, or the patient, won were those in which the physician was found to be medically negligent in their care, held to the same standard as if a patient had not left AMA. Stearns et al [3] found that despite providers’ comfort in assessing capacity to make medical decisions, many physicians did not document this discussion adequately, leaving them open for legal action.
It is important for us as physicians to explain to the patient all of the risks of leaving AMA and set them up for success in future medical encounters [8]. We can mitigate our own risks as well by discussing our reasoning and medical decision-making with the patient, documenting that and attempting to address the reasons why patients leave AMA. Using these strategies, hopefully, we, as emergency medicine physicians, can reduce the number of people leaving AMA and decrease our morbidity and readmission rates.
The Admin Mini-Fellowship gathered virtually to discuss AMAs and discharges on 10/6/2020
References
- 1. Lam C, Ditkowsky J, Sharma VK, Stark N. EMRA Admin&Ops Literature and Strategies Review: Against-Medical-Advice Discharges from the ED. Published online September 21, 2020.
- 2. Spooner KK, Saunders JJ, Chima CC, Zoorob RJ, Salemi JL. Increased risk of 30-day hospital readmission among patients discharged against medical advice: a nationwide analysis [published online ahead of print, 2020 Aug 6]. Ann Epidemiol. 2020;S1047-2797(20)30281-7. doi:10.1016/j.annepidem.2020.07.021
- 3. Stearns CR, Bakamjian A, Sattar S, Weintraub MR. Discharges Against Medical Advice at a County Hospital: Provider Perceptions and Practice. J Hosp Med. 2017;12(1):11-17. doi:10.1002/jhm.2672
- 4. Marco CA, Brenner JM, Kraus CK, McGrath NA, Derse AR; ACEP Ethics Committee. Refusal of Emergency Medical Treatment: Case Studies and Ethical Foundations. Ann Emerg Med. 2017;70(5):696-703. doi:10.1016/j.annemergmed.2017.04.015
- 5. Clark MA, Abbott JT, Adyanthaya T. Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge. Acad Emerg Med. 2014;21(9):1050-1057. doi:10.1111/acem.12461
- 6. Magauran BG Jr. Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice. Emerg Med Clin North Am. 2009;27(4):605-viii. doi:10.1016/j.emc.2009.08.001
- 7. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51(7):899-902. doi:10.1176/appi.ps.51.7.899
- 8. Tummalapalli SL, Chang BA, Goodlev ER. Physician Practices in Against Medical Advice Discharges. J Healthc Qual. 2020;42(5):269-277. doi:10.1097/JHQ.0000000000000227
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