Emergency physicians have a lot to consider when diagnosing and treating complex ED patients. But we have all been in the situation where we spent considerable time, effort, and resources, and a seemingly cooperative patient quite abruptly and certainly 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 that is fraught with potential and real complications for the patient and physician.
No universal standard of care exists for ED AMA discharges. Last month I discussed the lack of value of the standard AMA form. Contrary to common physician belief, the hastily signed vague and incomplete AMA form we all have used for decades does little to protect the hospital or physician when a patient has a bad outcome. Good charting generally equates to good medicine, and a poorly written AMA document is literally asking for medical — and legal — problems.
Merely having a noncompliant patient sign a piece of paper, often because you are happy to be rid of him, does not give blanket immunity to caregivers. A fully informed and competent individual has the right to refuse any medical intervention for himself and his children, but everyone loses in an AMA discharge. No law prohibits a patient from being in denial, stubborn, or simply ignorant. Patients must be reasonably informed and deemed competent, however, to leave your ED, and the chart should clearly confirm these caveats.
We don't know much about eventual outcomes, but it turns out that AMA patients often return for an extended and very expensive hospital stay, occasionally in a worsened condition, but not necessarily to the same hospital from which the egress occurred. True disasters are few and far between, but these can be high-profile cases. A death after a recent ED visit is met with great delight by the always-critical 6 o'clock local news. This remains a thorny issue for all EPs.
What Happens to Patients who Leave Hospital Against Medical Advice?
Hwang SW, Li J, et al.
Patients who leave AMA are at risk for bad outcomes and subsequent readmission, often with eventually longer and more expensive hospital stays. The purpose of this study was to examine the rate and predictors of readmission of patients who had left the hospital AMA. The authors, from an urban hospital treating many indigent and homeless patients in Toronto, studied the records of and conducted personal interviews with 97 consecutive patients who left AMA from the general medical service.
The overall AMA discharge rate is one to two percent for inpatients at various hospitals in the United States. The percentage is higher for the lower socioeconomic class, those who lack insurance, and patients from disadvantaged urban areas. Patients from low-income urban hospitals have significantly higher AMA discharges than one would suspect, although the exact number is difficult to obtain. A primary issue of an AMA discharge is a subsequent adverse medical outcome, including a worsened condition on readmission or 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. Little information is available on the actual outcome after AMA discharge of general medical inpatients, however.
The definition of an AMA discharge is an elopement or a voiced decision to leave the hospital prematurely. The AMA discharge rate in this study environment — with a high percentage of low-income and homeless individuals — was a high six percent. Control patients were those who were electively discharged. Patients who had a readmission within 90 days were considered to be readmitted.
Patient interviews gleaned that reasons for leaving were varied, including pressing family matters, feeling well enough to go home, dissatisfaction with treatment, feeling bored or fed up, and a general dislike of hospitals. Interestingly, 70 percent had a history of alcohol and drug abuse. Patients did not cite withdrawal or the need to drink or obtain drugs as the proximate cause, but it likely played a role.
The readmission rate for the AMA group at 15 days was impressive: 21 percent vs. three percent for the control group. Readmission rates were higher at 15 days than at 90 days, although both time periods had high readmission rates. Three of the patients who were discharged AMA died during the follow-up period, but none of the deaths was considered directly related to premature departure. Homeless patients left more often than domiciled individuals. Most left within two to five days, but some exited after more than six days of hospitalization. The overall longer length of stay in Canadian hospitals compared with U.S. hospitals may have influenced patients' AMA decisions.
The authors were unable to define specific disease patterns associated with AMA discharge, suggest ways to stop AMA discharge, or proffer ideas to minimize the risk of adverse outcomes. They suggested specific follow-up appointments, providing appropriate prescriptions, and giving a written summary of the hospital stay for other health care providers. A significant number of patients will seek readmission at a different hospital.
Comment: This report characterizes patients leaving AMA from an inpatient medical service, but it is reminiscent of ED patients who similarly discharge themselves. We have precious little time to make a good first impression in the ED or provide personal attention to the warm and fuzzies, such as meals and other expected comfort measures. Our clients are often in a distressed mental state already. No one wins with an AMA discharge, though. It does not seem fair that litigation is even an option if informed consent is appropriate and the patient is otherwise competent. My experience is that charting issues (great doctoring but omnipresent poor documentation) are the plaintiff's best ammunition against the EP. Most of us spend hours with the patient, yet only a few seconds on the paperwork that proves it. You did your best and usually went above and beyond reason, but essentially you were charged with “allowing the patient to sign his life away.” Whatever happened to the patient's duties and responsibilities?
A Typical Profile
Any EP reading this article would feel great empathy. Patients described in this scenario generally fit the profile of those who leave the ED. (Acad Emerg Med 2007;14:870.) They are usually young men, have drug and alcohol issues, and a poor understanding of and little patience with our inefficient health care system. Theirs is a fast-food mentality: They want it their way, and they want it now. Many are frequent denizens of the ED, don't have a family physician or social support, and look to the hospital for the lack of personal attention they crave for their impenetrable medical and social problems.
Coming from a lower socioeconomic and disadvantaged home or homeless environment makes it difficult for physicians to get across extant issues with our lumbering system. Waiting 10 hours for an inpatient bed, or for a tardy then rude consultant, frustrates clinicians also. We rarely ascertain the correct reasons for patients leaving the hospital, but it may be something as simple as going home to feed the cat. Many opt for the AMA route by denying their condition, having to take care of a child or ailing family member, being afraid of a large hospital bill, or needing another drink or a dose of heroin. Interminable waits and delays for non-life-threatening problems define many ED elopements.
Weinhart, et al., reported an amazing 54 percent readmission rate for patients discharged AMA from an urban teaching hospital, concluding that Medicaid status was an important predictor of premature discharge. (J Gen Intern Med 1998;13:568.) Fixed income senior citizens often feel an honest responsibility to pay their bill. One can certainly see how they would be concerned about the ubiquitous $20,000-a-day admission. Never make admission decisions based on finances, but it also doesn't make sense in borderline cases to spend someone's three-month Social Security income because you are afraid to discharge a patient with an unknown diagnosis or merely because of defensive medicine. If true financial issues sway a borderline admission and it's essentially a joint decision to go home, my advice is to construct a formal, albeit amicable, AMA discharge paragraph. Make it is crystal clear that your recommendation was admission or further testing. You want the patient to remember that it was his decision to leave; you did not obstruct admission because he did not have insurance.
This study could not predict which patients would be readmitted or offer ways to decrease incidence. I am not surprised that many went to another hospital. We all get frustrated when patients come to our ED having just spent a week at another hospital, particularly without records. Seeing a patient who just left another ED is likewise outrageous. If you discharge someone AMA and you have paid attention to the intricacies of the properly executed AMA form, give the patient a copy of pertinent laboratory tests, CT scans, and ultrasounds to make life easier on your colleagues. Also include a copy of the AMA form he just signed. You might save yourself an annoying phone call from a similarly overworked and frustrated colleague on the rare chance that the patient keeps these documents. The patient's version of the story to the next physician, detailing 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 his complex and unhappy patient was just in your hospital.
AMA discharge of an indigent patient does not help the hospital's financial bottom line. Readmission of an AMA discharged patient is extremely expensive. (Int J Clin Pract 2002;56:325.) The average LOS for the primary admission was 2.3 days in one study, 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.
Discharges Against Medical Advice: A Community Hospital Experience
Seaborn Moyse H, Osmun WE
Can J Rural Med
These authors note that a Canadian community hospital experience with AMA discharges is probably less dismal than those of an inner city indigent hospital. Their AMA discharge rate was only 0.6 percent. Patients leaving this hospital, however, were also more likely to be male and have a greater frequency of substance abuse and psychiatric conditions. Canadian physicians' charting habits were dismal, worse than their American colleagues. Only 80 percent of the charts had AMA documentation, and only 23 percent included evaluation of patient competency. These authors also frustratingly conclude that potential interventions to deter AMA discharge 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 or implemented is 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., contacted 52 ED AMA discharged patients and found a surprisingly high satisfaction score for the hospital and treating physician (70%). (J Emerg Med 1992;10:513.) Eighty-two percent of patients, however, did not “agree” with their physician's treatment plan. Curiously, the majority of patients said they would leave AMA again under similar circumstances. I can never understand what is more important or pressing at home than their health. Go figure.
Green, et al., suggest the majority of patients leave for personal reasons, such as sickness or disability of a family member, a plethora of financial problems, and legal issues, such as a court date. (Am J Drug Alcohol Abuse 2004;30:489.) I suggest that the real reason patients leave AMA is rarely clear-cut or forthcoming. We never get the true answer, and most nurses and physicians simply don't care; it's human nature. Physicians, in fact, tend to be indignant and angry that an ungrateful patient precipitously decides to up and leave. It's difficult to ameliorate that mindset after you spent countless hours and tax dollars trying to unravel the vagaries and complaints of a drug abuser, alcoholic, or psychiatric patient.
Berger emphasizes that noncompliance to more urgent ED medical advice parallels noncompliance to multiple, less urgent outpatient medical interventions. (J Hosp Med 2008;3:403.) Noncompliance is posited to be related to treatment side effects, costs, inconvenience, child care or pressing family member needs, psychosocial burden, and patient-physician relationships. If office advice for chronic conditions is heeded 20 percent of the time, that's considered “good.”
The data specifically about ED AMA discharges are sparse. Fernandes, et al., concluded that ED AMA patients have a low acuity and often leave because of waiting times, but I have not seen any good data about the outcome of ED patients who leave or strategies to decrease incidence. (Ann Emerg Med 1994;24:1092.) Lee, et al., reported the seriousness of cardiac disease in ED AMA discharges for chest pain had a varying prognosis, and it was not always benign. (J Gen Intern Med 1988;3:21.) Leaving AMA after three or four days in the medical service is probably safer than leaving after a few hours in the ED. Contrary to my intuition, it has not been proven that adverse outcomes and revisits to other hospitals is higher in ED patients than for patients leaving the general medical ward.
Patients with HIV have a high incidence of AMA discharge. Anis, et al., noted a 13 percent AMA discharge rate of HIV patients in Vancouver. (CMAJ 2002;167:633.) Chan, et al., reported that AIDS patients who are IV drug abusers have an AMA discharge rate of up to 25 percent. (J Acquir Immune Defic Syndr 2004;35:56.) Offering inpatient methadone therapy reduced that rate in this high-risk group.
A truly disastrous medical outcome from an AMA discharge is likely uncommon; nonetheless, you don't want to be on the wrong end of a high-profile problem. No one has come up with an insightful plan to prevent the AMA discharge of a bona fide sick or potentially problematic patient. You can intuit that a patient won't stay for very long in some cases and skillfully try to derail the AMA before it happens, using all of our common tactics. That's a pretty hefty mandate in the ED but worth a try. Getting the family involved, apologizing for inconvenience, treating withdrawal, expediting tests and admission, and minimizing financial concerns are partial strategies, but in many cases, you just can't win.
Multiple authors have noted the high AMA discharge rate for psychiatric patients is 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.
Profile of AMA Discharges
- The overall AMA discharge rate from a medical service and ED is one to three percent but up to six to seven percent in those fitting a high-risk profile.
- 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.
- Other AMA variables include feeling better, lack of a primary care physician, lack of insurance, patient-physician friction, a child or impaired relative at home, denial, and feeling bored and frustrated.
- Patients with HIV disease, drug or alcohol abuse, homelessness, and young 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 significantly higher than an extended first stay.
- The best way to thwart an AMA discharge is unknown.
- The outcome of ED AMA discharges has not been clarified, but ED patients may have a lower acuity and leave because of long waiting times.
- No specific medical diagnoses, conditions, or initial complaints have been identified as high risk for ED AMA discharge.
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