Author Credentials and Financial Disclosure: James R. Roberts, MD, is the Chairman of the Department of Emergency Medicine and the Director of the Division of Toxicology at Mercy Health Systems, and a Professor of Emergency Medicine and Toxicology at the Drexel University College of Medicine, both in Philadelphia, PA. Dr. Roberts has disclosed that he has no significant relationships with or financial interests in any commercial companies that pertain to this educational activity. Wolters Kluwer Health has identified and resolved all faculty conflicts of interest regarding this educational activity.
Learning Objectives: After reading this article, the physician should be able to:
1. Discuss the issues surrounding the ultimate outcome of patients discharged AMA.
2. Explain the risk factors for AMA discharge.
3. Describe strategies to prevent premature discharge from the hospital.
Release Date: July 2005
Emergency physicians have enough to worry about when it comes to diagnosing and treating patients. But we have all been in the situation where, after spending considerable time, effort, and resources, a seemingly cooperative patient quite abruptly and quite unceremoniously decides he (usually he) does not really want to take our advice and opts to leave the hospital. This is a frustrating dilemma, one fraught with a plethora of potential and real complications for the patient and physician.
In midst of a busy ED after extending tremendous effort on the patient's behalf, it is only human nature for the physician and nursing staff to become angry, frustrated, and simply comply with the patient's wishes. We all try to discuss the issues and dangers of leaving against medical advice rationally, but once a patient makes up his mind to leave, it may be difficult to dissuade him from this poor decision. A normal reaction from an overworked and frustrated medical staff is to ask the patient simply to sign a form, and allow the patient to fend for himself, branding him as either ignorant, ungrateful, or both.
We all have certain tricks, negotiating tactics, and bargaining chips to play, but in the end, it's difficult to change the patient's mindset. Although a “good riddance” reaction may seemingly settle the issue, things are much more complicated than they initially seem.
This month's column continues a series of discussions on patients who want to leave the ED against medical advice (AMA). I have previously discussed the value, or essentially lack of value, of the standard AMA form. I offered strategies to keep patients from being their own worst enemies, and how to protect the physician against the omnipresent legal ramifications. Contrary to popular belief, the standard and hastily signed AMA form does not totally protect the hospital or physician when there is a bad outcome. Composing a poorly written AMA document is simply asking for problems. It's difficult for the family or general public (AKA jury) to believe that something more could not have been done to derail or mitigate the irrational behavior of someone who is obviously ill or in need of treatment or hospitalization.
Caveats for AMA Discharges
Create a personalized AMA form for each encounter; avoid using standard forms if they do not allow for individual scenarios.
Read and address nursing and clerk notes if they include statements about issues that would question a patient's competency, such as “confused, lethargic, has been drinking or using drugs, alcohol on breath, slurred speech.”
Specifically address involuntary commitment status. (AMA patients should not meet any criteria for involuntary commitment.)
Avoid vague and incomplete phrases to describe the mental status, such as “alert and oriented x 3.”
Provide documentation of an outpatient plan and interim treatment.
Provide and advise follow-up and specialty referral.
Enlist the aid of other physicians and relatives when appropriate.
The physician, not a nurse, should orchestrate the majority of the encounter.
Make it clear that the patient can return at any time.
Never make finances, payment, or insurance an issue.
Treat pain and anxiety, and then reassess options.
Offer food, social service, and telephone access, and expedite admission/testing.
Negotiate, negotiate, negotiate.
Try to make all encounters and decisions friendly, not hostile or punitive.
When in doubt, don't allow the patient to leave
Many patients who leave AMA have serious problems, chronic underlying medical conditions, and have a bad outcome when fending for themselves. Unfortunately, merely having them sign a piece of paper doesn't protect them or the emergency physician. Fortunately, most AMA patients seem to do OK, but everyone loses in an AMA discharge, and they should be avoided whenever possible. In the end, your best efforts can be thwarted by the system, coupled with the devices of a recalcitrant patient.
This month's discussion considers what actually happens to AMA discharged patients. It turns out that they often end up coming back to the hospital, occasionally in a worsened condition, although it may not be to the same hospital from which the egress first occurred. I don't want to overplay the poor outcome associated with an AMA discharge; the true disasters are few and far between, but these can be high-profile cases. A death after a recent hospital visit is met with great delight by the local news. The actual complication rate of AMA discharged patients is difficult to decipher, and actual mortality is probably less than one would expect. Nonetheless, this remains a thorny issue for all emergency physicians.
What Happens To Patients Who Leave Hospital Against Medical Advice? Hwang S, et al CMAJ 2003;168(4):414
Patients who leave the hospital against medical advice are at risk for bad outcomes, and occasionally they are readmitted to the ED or hospital. The purpose of this study was to examine a rate of readmission and predictors of readmissions among patients who left the hospital AMA. The authors from the University of Toronto prospectively studied 97 consecutive patients who left the general medical service of an urban teaching hospital in an AMA condition.
The authors note that the overall discharge rate from the medical service at various teaching and acute care hospitals in the U.S. is one to two percent. The percentage is higher in patients from a lower socioeconomic class, in those who lack insurance, and in patients from a disadvantaged urban area. In fact, patients from low-income urban areas have a significantly higher AMA discharge rate than one would suspect, although the exact number is difficult to obtain.
One of the biggest problems of an AMA discharge is that the patient who prematurely leaves the hospital will suffer adverse health effects. This would prompt either a worsened medical condition on readmission or even greater morbidity or mortality. It is well known that HIV-positive patients who leave AMA are readmitted with a related diagnosis on a regular basis, but there is little information available on the actual outcome after AMA discharge of general medical patients, and gaining such information was the intent of this study.
The definition of an AMA discharge in this study was either an elopement or a voiced decision to leave the hospital against the advice of the medical staff. In this study environment that had a high concentration of low-income and homeless people, the AMA discharge was six percent of the total discharges. Control patients were those who were electively discharged. Patients who had a readmission in a 90-day period following discharge were considered to be readmitted.
The most common reasons cited by patients who left AMA were family matters, feeling well enough to leave, dissatisfaction with treatment, feeling bored or fed up, a dislike of hospitals in general, and miscellaneous reasons. Interestingly, 70 percent of the patients who left AMA had a history of alcohol abuse. While patients did not cite the need to drink as the proximate cause, it likely played a role.
At 15 days, the readmission rate for the AMA group was 21 percent versus three percent for the control group. Readmission rates were higher at 15 days than they were at 90 days, although both time periods had higher readmission among the AMA patients. Although three of the patients who were discharged AMA died during the follow-up period, none of the deaths were directly related to a premature departure.
The authors highlight the high rate of AMA discharge in their patient population, and the extremely high readmission rate of 20 percent within 90 days. In addition to these factors, the longer length of stay in Canadian hospitals compared with U.S. hospitals may have influenced patients' AMA decisions.
The authors were unable to suggest ways to minimize the risk of adverse outcomes in their AMA patients. They suggested specific follow-up appointments, ensuring appropriate prescriptions, and providing a written summary of the hospital stay to other health care providers when the patients presented to a different hospital. In this study, a significant number of patients sought readmission at a different hospital.
Comment: Although this report characterizes patients leaving AMA from an inpatient medical service, it is reminiscent of ED patients who similarly discharge themselves against medical advice. In the ED, we have precious little time to make a good first impression on patients, and they are often in a distressed mental state anyway, the perfect storm for an AMA egress. As I noted in last month's column, no one wins with an AMA discharge. It does not seem fair that the risk of litigation is even an option, let alone so high. In the end, it is impossible to shield yourself completely from a lawsuit should a poor outcome ensue. You tried your level best, and usually went above and beyond reason, but essentially, you “allowed the patient to sign his life away.”
Any emergency physician reading this article would feel great empathy. The patients described in this scenario are exactly the patients who also want to leave AMA from the emergency department. They tend to be men, have drug or alcohol issues, have a poor understanding of the health care system and its inefficiencies, and come from a lower socioeconomic and disadvantaged state. We rarely get the correct reasons for patients leaving the hospital. It may be something as simple as going home to feed their cat, but many opt for the AMA route because they don't believe they need hospitalization, they fear a large hospital bill, or they need another drink or dose of heroin. All of these reasons are likely intertwined, and most physicians and nurses simply don't care once the patient decides to leave.
The truly financially destitute patient, hard-core drug addict, or homeless schizophrenic, rarely considers even opening his mail containing a hospital bill, much less paying it. As an aside, if you have to send a follow-up letter about a missed x-ray, abnormal test, etc., don't send it by certified mail — it's well known that individuals reject such hospital mailings, thinking they are some official financial bad news. Send all such letters by regular mail, and keep a record of the mailings.
Statistics of AMA Discharges
▪ The general AMA discharge rate from a medical service is one to two percent.
▪ Psychiatric services may experience AMA discharges up to 35 to 50 percent.
▪ A lower socioeconomic status/disadvantaged urban population has a higher AMA discharge rate.
▪ Lack of health insurance increases the likelihood of an AMA patient decision.
▪ Patients with HIV disease, drug or alcohol abuse, homelessness, psychiatric disease, and who are men have higher AMA discharge rates.
▪ The readmission rates for AMA discharged patients may be as high as 20 percent within 90 days.
▪ The cost of readmission of an AMA discharge is higher than for an extended first stay.
Many urban hospitals have a “no pay” rate as high as 20 percent, but many of our senior citizens on social security feel a need to pay their hospital bills. One can certainly see how they would be concerned about a $3,000-a-day admission. Weinhart et al (J Gen Intern Med 1998;13:568) reported an amazing 54 percent rate of readmission of patients discharged AMA from an urban teaching hospital, and concluded that Medicaid status was an important predictor of premature discharge. I never make an admission decision based on finances, and I don't advise anyone ever to do so. However, in borderline cases, it doesn't make a whole lot of sense to spend three months of someone's social security income because of a fear of discharging a patient with an unknown diagnosis or seemingly benign problem.
The main teaching point from this article is the profile of patients who do opt for AMA discharge and the high rate of readmission. I'm surprised that none of the 113 AMA discharged patients died outside the hospital, but I'm not surprised that many of them went to another hospital. We all get extremely frustrated when a patient comes to our ED having just spent a week at another hospital, particularly without records. Having to see a patient who just left another ED is likewise outrageous. If you are discharging someone AMA and you have paid attention to the intricacies of the properly executed AMA form, I suggest you give the leaving patient a copy of all his laboratory tests, CT scans, and ultrasounds to make life easier on your colleagues. Also include a copy of the AMA form he just signed. In a rare chance that the patient will keep these documents or present them to the next ED, it might just save an annoying phone call from a similarly overworked and frustrated colleague.
The patient's story to the next physician that explains exactly why he left your hospital is rarely the same as yours, so be prepared for an irate call from some similarly stressed-out emergency physician when he hears the patient was just in your hospital. Aliyu (Int J Clin Pract 2002;56:325) demonstrated that readmission of an AMA-discharged patient was extremely expensive. In that study, the average length of stay for the primary admission was 2.3 days, compared with the LOS on readmission of 4.7 days. The cumulative cost of a discharge-readmission was calculated to be 56 percent higher than expected for the specific problem. It makes financial sense to offer an AMA candidate free hospitalization rather than premature discharge. One interesting study would be to calculate the cost of patients going to another ED soon after they leave your ED.
EPs have tactics to stop an AMA discharge, but it can be difficult to change a patient's mindset
In some instances when an AMA discharged patient actually changes his mind and makes the ideal decision to return to the original hospital, he can be thwarted by the system again. In Philadelphia, the EMS system will only transport a patient to the nearest hospital, even though they just spent a month at another institution and had every lab test and intervention known to man. I can never figure this out, and I also can never figure out why the previous hospital gives us such a hard time in sending back a patient who just left a few days or a few hours ago. There should be some sort of law that EMS must take a patient to the hospital from which he was discharged in the past 30 days. Add this frustration to the long list.
Discharges Against Medical Advise: A Community Hospital Experience Seaborn MH, Osmun WE Canadian J Rural Med 2004;9(3):148
The authors of this report note that a community hospital experience with AMA discharges is probably less dismal than those of an inner city indigent hospital. In this study, the AMA discharge rate was only 0.6 percent. However, patients leaving this hospital milieu also were more likely to be men and have a greater frequency of substance abuse and psychiatric conditions. Interestingly, the Canadian physicians' charting habits were as poor as those of their American colleagues: only 80 percent of the charts had documentation about the AMA discharge, and only 23 percent included documentation about the competency of the patient to make that decision. These authors also demonstrate their frustrations by concluding that potential interventions to avoid AMA discharges are limited. They suggest that early identification of patients at risk may facilitate the outcome, decrease AMA discharges, and improve eventual health outcomes. Exactly how this can be determined appears to be quite elusive.
Comment: Exactly why patients sign out AMA is somewhat inscrutable. It's probably not just because they are angry or totally dissatisfied with the ED interaction. Dubow et al (J Emerg Med 1992;10:513) contacted 52 ED AMA discharged patients, and found a surprisingly high satisfaction score for the hospital/treating physician — an amazing 70 percent. However, 82 percent did not “agree” with their physician's treatment plan. Curiously, the majority of patients said they would leave AMA again under similar circumstances. The disagreement was likely centered around the concept of further observation or hospital admission, but the exact reason was not clarified. I can never figure out what is more important or pressing at home than their health.
Green et al (Am J Drug Alcohol Abuse 2004;30:489) suggest that the majority of patients leave for personal reasons, such as sickness or death in a family member, reconciliation with a spouse, girlfriend, or family member, a plethora of financial problems, and legal issues, such as a court date. I suggest that the real reason patients leave AMA is rarely clear cut, and in the long run most nurses and doctors, out of human nature, simply don't care why patients leave. In fact, doctors tend to be indignant and angry that an ungrateful patient has just decided to up and leave. It's difficult to change that mindset after you spent countless hours and tax dollars trying to rehabilitate or otherwise unravel the vagaries of the complaints of a drug abuser, alcoholic, or psychiatric patient. A “good riddance” mentality on the part of the medical staff is tough to overcome.
Leaving AMA after three or four days in the medical service is probably safer for the patient than leaving AMA after a few hours in the ED. I have not seen any studies about the outcome of patients who leave AMA from the ED. I would suspect that the adverse outcomes and revisits to other hospitals are higher in ED patients than for patients leaving the general medical ward. Following seemingly interminable waiting times and noticing all of our inefficiencies and lack of creature comforts, it's not surprising that many patients choose to leave the hospital, even though their condition has not been diagnosed or fully treated.
We should all feel very uncomfortable when a patient leaves AMA before making a specific diagnosis or if patients are still symptomatic or otherwise in need of continuing treatment. That's why it's my policy to avoid AMA discharges whenever possible. This includes bargaining with the patients, offering food, pain medication, phone use, television, and other creature comforts. Cajoling or otherwise employing the art of medicine, although difficult for most overworked physicians to conjure up, suits everyone in the long run. I sometimes wish I had a gourmet wine list to show the patient who has become quite dissatisfied with our obvious inefficient and floundering diagnostic and treatment modalities.
One particular subset of patients with a high incidence of AMA discharge and also a subgroup with a great number of medical problems is HIV patients. Anis et al (CMAJ 2002;161(6):167) noted a 13 percent AMA discharge rate of HIV patients in Vancouver. Departure on the day on which welfare checks were issued and a history of IV drug abuse were significant predictors for leaving AMA. Curiously, patients in Canadian hospitals receive less welfare money than those not in the hospital. I guess you should consider an outpatient “pass” to allow them to claim their checks if they promise to return to their beds later that day. The incidence of readmission of HIV-positive patients with associated diagnoses was high, and the authors conclude that preventing such discharges would likely benefit patients by improving their health care and benefit the health care system by reducing cost.
Other authors have noted that the AMA discharge rate for psychiatric patients, another high-risk group, can be as high as 50 percent. The next time you are at your wit's end with a bipolar patient in the ED, consider the plight of your psychiatric colleague. This topic is so important that I will devote an entire column next month to the psychiatric patient who wants to leave AMA.
The revelation that IV drug users are at greater risk for AMA discharges has been previously demonstrated. The intuitive answer for this is that the patient wants to continue to abuse drugs or may have a withdrawal state. I have never eschewed giving morphine to a patient withdrawing from heroin if I thought that would keep him in the hospital for a bout of pneumonia, or give me time to unravel or treat another significant medical problem. You won't cure their addictions and they are at risk for bad outcomes because of their immunocompromised states, but they are time bombs. Chan et al (J Acquir Immune Defic Synd 2004;35:56) recently reported that AIDS patients who are IV drug abusers have an AMA discharge rate of up to 25 percent. They found that offering inpatient methadone therapy could reduce that rate in this high-risk group.
Likewise, I never allow alcoholics to go before I am ready just because I don't want them to go into alcohol withdrawal. Getting them back on the street to avoid alcohol withdrawal is a temptation that should be resisted. This scenario is probably more vocalized than real, but overall it's a bad practice.
A truly disastrous medical outcome from an AMA discharge is likely uncommon. Data are sparse, and truly sick patients usually can be persuaded to stay for at least long enough to marshal support or begin treatment. You don't want to be on the wrong end of a high-profile problem. No one has come up with the perfect plan to prevent the AMA discharge of a sick or potentially problematic patient. In some cases, you can intuit that a patient won't stay for very long, and you can try to derail it before it happens. That's a pretty hefty mandate in the ED, but it's worth a try. Getting the family involved, treating withdrawal, and minimizing financial concerns are partial strategies, but in many cases, you just can't win.