Against Medical Advice

Aka: Against Medical Advice, Leaving AMA, Signed Out Against Medical Advice, Left Against Medical Advice, Self-discharged Patient, Informed Refusal

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II. Epidemiology

  1. Incidence of Leaving AMA
    1. Overall: 1-3%
    2. Inner city hospitals serving disadvantaged
      1. General patients: 6%
      2. HIV or AIDS: 13%

III. Risk Factors: Leaving AMA

  1. Substance Abuse
  2. Uninsured or insured on Medicaid
  3. Male
  4. Young to middle aged adults (ages 15 to 40 years old)
  5. No primary care provider
  6. Abdominal Pain

IV. Protocol: Approach to AMA Decisions (or Informed Refusal)

  1. Focus on protecting the patient from harm
    1. This will in turn be the best protection for the provider
  2. Establish trust with patient
    1. Focus on open communication and active listening (understand patient's concerns and expectations)
    2. Maintain a good rapport with the patient
    3. Allow them to feel that you respect them
    4. Use layman's terms when discussing medical condition, evaluation and treatment options
    5. Patients may refuse some or all of a providers recommendations and still remain under their care
    6. Offer alternatives to recommended treatment plan that allow the patient to make choices
  3. Negotiate for time for patient to make informed decision
    1. Apologize for patient waits and delays in care
    2. Invest time in understanding patient's viewpoint, concerns and fears
    3. "How can I better address your concerns today?"
  4. Shared Decision Making is an alternative to AMA
    1. Non-high risk patients may choose to defer part of the evaluation to future visits
    2. Often cost implications may lead a patient to prefer continuing the evaluation outpatient
    3. Shared Decision Making requires reasonable, safe alternatives
  5. Employ a family member to discuss risks and benefits further with patient
  6. Employ collaborative approach among available staff
    1. Nurses
    2. Attending medical provider
    3. Social workers

V. Protocol: Documentation of AMA Decisions (or Informed Refusal)

  1. Document adequate Decision-Making Capacity
    1. See Medical Decision-Making Capacity
    2. See CURVES Capacity Assessment Tool
    3. Adult with no Altered Level of Consciousness and Clinically Sober
    4. Intact judgment and reason consistent with the facts and their values
    5. Patient understands the condition and treatment in their own context and communicate their choices clearly
    6. Patient does not meet the criteria for an emergency hold (involuntary treatment)
      1. Patient does not pose a clear danger to themselves or others
      2. Patient is capable of caring for themself
  2. Document provider's discussion with patient (explained to the patient in lay language)
    1. Why staying in medical facility and undergoing recommended management is important
      1. Fully disclose to the patient their diagnosis and severity of illness
      2. Review the recommended management plan and benefits of treatment
    2. Why leaving presents a serious and immediate health risk
      1. Specifically describe possible consequences including death
      2. Review potential disabilities (e.g. blindness, amputation, Infertility)
      3. Avoid scare tactics or punitive statements (e.g. insurance will not pay for the visit)
    3. What reasonable options exist for evaluation and management
    4. Patient is encouraged to return at any time
    5. Confirm that the patient no longer wishes to participate in your care plan (termination of duty)
    6. Ask the patient to repeat back the potential consequences of Leaving AMA
      1. Patient explains their diagnosis
      2. Patient expresses the potential consequences of Leaving AMA
  3. Document exact wording of discussion
  4. Document which family members were present for the discussion
  5. Nurses should also document their interactions and measures
  6. AMA Form (Release of Responsibility Form)
    1. The AMA form does not replace careful documentation as described above
    2. Obtain a signature from the patient
      1. If patient refuses signature, obtain signature by witnessing family member, nurse or other witnessing staff
      2. In legal practice, AMA form signature does not truly shield a hospital or provider from law suit
    3. The AMA form does add additional evidence in support of the provider
      1. Providers attempt to communicate with the patient
      2. Nullifies the medical provider's duty to treat (established when patient sought care)
      3. Establishes affirmative defense (justification) - patient now assumes responsibility for outcome
        1. Requires that the patient understands and voluntarily accepts the risk
      4. Evidence in medical record that the patient declines care
      5. May establish contributory negligence
        1. Patient's failure to accept reasonable care that other rational people would normally accept
      6. Levy (2012) J Emerg Med 43(3): 516-20 [PubMed]
  7. Example
    1. Patient is leaving Against Medical Advice.
    2. They have Medical Decision-Making Capacity and understand the risks of leaving.
    3. Risks include permanent Disability and death in the immediate future
    4. I have answered their questions and offered them care at any time if they choose to return.
    5. I have also recommended that they pursue follow-up with their primary care provider.

VI. Protocol: Disposition

  1. Treat AMA as a discharge process
  2. Sit down and answer questions
  3. Arrange reasonable follow-up plan
  4. Medications may be offered that will benefit the patient (but that will not mask worsening or complications)
  5. Give the patient formal Discharge Instructions
  6. Welcome them to return at any time
    1. Leaving AMA does NOT bar the patient from future care

VII. Precautions: Children

  1. See Consent for Emergency Services for Children
  2. Caregivers are refusing treatment against the better interest of the child's health
    1. See Consent for Emergency Services for Children regarding Nonmaleficence
    2. In unclear cases, act in the best interests of the patient to prevent harm
    3. Emergency interventions against parental religious objections has been reviewed elsewhere
      1. Swan (2020) J Child Adolesc Trauma 13(3):343-53 +PMID: 33052253 [PubMed]
      2. Stevenson (2023) Cancer Rep 6(1):e1665 +PMID: 35792092 [PubMed]
  3. Child is being treated against their wishes
    1. Document and discuss the reasons for treatment and the risks of not treating
    2. Emancipated or mature minors may have capacity to make their own medical decisions
  4. Disposition
    1. Consider Child protective services contact if suspected abuse or neglect

VIII. Complications

  1. Poor patient outcomes
  2. Lawsuit
    1. Risk of lawsuit is increased 10-100 fold in AMA cases (rate as high as 1 lawsuit in every 300 AMA cases)
  3. Return within 30 days
    1. Often requires hospitalization in return
    2. Associated with increased morbidity and mortality
    3. Southern (2012) Am J Med 125(6): 594-602 [PubMed]
    4. Glasgow (2010) J Gen Intern Med 25(9): 926-9 [PubMed]

IX. Resources

  1. ALiEM: Proper Way to Go AMA (Matthew DeLaney, MD)
    1. http://academiclifeinem.com/proper-way-to-go-against-medical-advice/
  2. Medscape: The Importance of a Proper AMA Discharge
    1. http://www.medscape.com/viewarticle/770719_2

X. References

  1. Arredondo, Vezzetti and Allen (2020) Crit Dec Emerg Med 34(8): 15-21
  2. Bradford-Saffles and Arambasick (2013) Crit Dec Emerg Med 27(6): 11-5
  3. Lin and DeLaney in Herbert (2014) EM:Rap 14(9): 1-2
  4. Henry (2013) Avoid Being Sued, EM Bootcamp, CEME
  5. Orman, Weinstock and Rogers in Herbert (2017) EM:Rap 17(8): 7-9
  6. Weinstock and Claudius in Swadron (2023) EM:Rap 23(9)

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