Act quickly and listen a lot

What to do when a patient wants to leave against medical advice.


Hospitalizations in which a patient left against medical advice (AMA) rose 39% from 1997 to 2007, far exceeding the growth in all other hospital stays during the same period, according to the Healthcare Cost and Utilization Project.

Patients who leave AMA can be at increased risk for poor outcomes, and hospitalists are often the first line of defense in convincing patients to stay, as well as the last voice they hear on the way out.

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Although patients from all demographics leave AMA, the problem is most common among younger men in lower socioeconomic groups who have Medicaid or no insurance, or who have a history of substance abuse or of leaving AMA, said David Alfandre, ACP Member, who published a paper on the topic in Mayo Clinic Proceedings in March 2009.

A primary care physician with the Department of Veterans Affairs, New York Harbor Healthcare System and part of the VA National Center for Ethics in Health Care, Dr. Alfandre has experienced the frustration of patients leaving AMA in his own practice. He believes hospitalists can reduce AMA conflicts by talking with each patient upfront about expectations for his or her hospitalization, including the diagnosis, treatment plan and expected duration of stay.

“That brief conversation can ensure that both the patient and the provider are clear about what the course of the hospitalization will look like, and can avoid many problems,” Dr. Alfandre said.

Talking them out of it

When a hospitalist finds out a patient wants to leave—usually via a call from a nurse—seeing that patient should become a top priority, said Andrew Knoll, FACP, a former hospitalist and emergency department physician who is now an attorney in Syracuse, N.Y. “Don't give them three hours to stew,” Dr. Knoll said. “Get there while you still have a chance to change their mind.”

Be dispassionate and sympathetic as you listen to their concerns, Dr. Alfandre advised. For example, if the patient is unhappy because she did not get her pain medication on time, agree that it is unacceptable. Try to see things from the patient's perspective. “This requires time and attention, but really not a tremendous amount,” Dr. Alfandre said.

Lack of trust and poor communication are usually at the core of AMA departures, said Dilip Bearelly, ACP Member and assistant professor of medicine at the University of Missouri. “If a patient's surgeon or primary care doctor is not available, someone needs to become their advocate,” usually a nurse, Dr. Bearelly advised.

Dr. Knoll agreed that communication is a problem, sometimes one that begins very early in a hospitalization. He has encountered resistance when he arrived in the emergency room to admit patients only to find no one had told them they were being admitted.

“Any time they are dressed and angry, it is hard to talk them out of it,” he noted. “But others just feel like something is not being done right and that's when you need to really listen to their concerns.”

Dr. Knoll advised hospitalists to “make a contract” to buy time with such patients. “Ask them to give you 24 hours to try to fix the situation and try to reassure them they are being heard,” he said.

It's also important to have the entire care team on the same page. “All physicians seeing the patient need to communicate a consistent message. Hearing different things from different people is very frustrating for them,” Dr. Alfandre stressed.

Patients who are adamant

When patients can't be talked out of leaving, hospitalists need to educate them as much as possible about their condition and suggest alternate ways to get the care they need. Dr. Bearelly recommended giving patients printed materials on their condition, sharing follow-up instructions with family members, verifying the accuracy of contact information, and providing resources for further care if a condition worsens.

“Assure them that you will care for them more than ever if they decide to come back. Being welcoming is especially important with AMA patients because you don't want them to delay getting further treatment or to go elsewhere and have to start all over again with the diagnostic process,” Dr. Bearelly said.

Patients also may change their minds if you tell them that some insurance companies don't pay for care when one leaves AMA. “Letting them know this can convince them to stay long enough for you to rebuild their trust in you,” Dr. Bearelly said.

Of course, if you do not believe a patient has the capacity to make a proper health care decision, you must follow your institution's protocols to force them to stay. For example, if you believe a patient is suicidal, you can't let him or her go, said Dr. Knoll.

“You still might get sued or investigated, but a court or medical board is less likely to take action against you for trying to save someone's life,” he advised. “Always err on that side.”

Few patients receive a capacity evaluation before AMA discharge, so many of them may not be making a fully informed decision, Dr. Alfandre said. He advocated the use of a sliding scale of capacity assessment—the greater the health risk involved in the decision, the more certain the physician should be that the patient has decisional capacity.

However, “having capacity” is a very low standard, said Dr. Knoll. “Capacity means they know what they are doing. If they do, they are allowed to make their own dumb decisions,” he said.

Legal concerns

Hospitalists do, of course, face the risk of legal action after treating an AMA patient, as with any other patient. However, Dr. Knoll advises physicians not to be so afraid of future consequences that they are paralyzed from acting appropriately.

“You can't stop people from suing you; you can just be prepared to defend yourself later,” said Dr. Knoll. “Remember that if a patient wants to leave AMA, things were already not going well.”

About 10% of patients who insist on leaving AMA will listen to discharge instructions and sign informed consent paperwork. The other 90%, however, are often too angry, he said.

“You can try to get them to sign the AMA forms but it may just be a waste of your time,” Dr. Knoll said. In these cases, the notes hospitalists record in the chart are crucial. “One year from now, no one will believe what you say, but your written words will be presumed to be accurate, so don't skimp on this,” he said. Have a witness such as a nurse co-sign the notes, he advised.

For patients who sneak away without telling anyone (i.e, “eloping”), physicians should alert security and try to contact the patient by telephone, Dr. Knoll said. Document these efforts thoroughly.

Dr. Alfandre tries to avoid asking patients who insist on leaving to sign an AMA form. Instead, he works hard to come to a consensus with the patient so the discharge does not have to be officially labeled AMA.

“I try to engage in shared decision-making. If the patient explains their preferences and it may not be the best plan but it's a reasonable one, I may be talked into letting them go. Some physicians and hospitals may call it AMA for legal purposes, but I try to be more flexible by documenting their choice without stigmatizing it,” he said.

Having a patient leave AMA is never the ideal, but the application of time-tested strategies can make it go more smoothly. “These scenarios challenge what doctors are taught in medical school — to give patients the best care possible. But the real challenge for us all is in engaging them, convincing them to follow up appropriately and sharing the decision-making process with them,” said Dr. Alfandre.