A step-by-step approach to patients leaving against medical advice (AMA) in the emergency department

Abstract

Objectives Patients leaving against medical advice (AMA) can be distressing for emergency physicians trying to navigate the medical, social, psychological, and legal ramifications of the situation in a fast-paced and chaotic environment. To guide physicians in fulfilling their obligation of care, we aimed to synthesize the best approaches to patients leaving AMA. Methods We conducted a scoping review across various fields of work, research context and methodology to synthesize the most relevant strategies for emergency physicians attending patients leaving AMA. We searched Medline, CINAHL, PSYCHO Legal Source, PsycINFO, PsycEXTRA, Psychological and Behavioural Sciences collection, SocIndex and Scopus. Search strategies included controlled vocabulary (i.e., MESH) and keywords relevant to the subject chosen by a team of four people, including two specialized librarians. Results The literature review included 34 relevant papers about approaches to patients leaving AMA: 8 case presentations, 4 ethical case analyses, 10 legal letters, 4 reviews and 8 original studies. The main identified strategies were prioritizing a patient-centered approach, proposing alternative discharge and reducing harm while properly documenting the encounter. Conclusion A systematic approach to patients leaving AMA could help improve patient care, support physicians and decrease stigmatization of this population. We advocate that emergency physicians should receive training on how to approach patients leaving AMA to limit the impact on this vulnerable population.

Approach to working with at-risk patients expressing a desire for discharge

“…This could include reviewing with the patient the purpose of the admission, associated treatment and overall goals of care, and risks associated with going home 1,2,8 ; working with Mr M. to understand what is most important to him, his reasons for wanting to go home, his concerns about ongoing support in the home, and his reluctance to modify his home for safety; and exploring ways to address his concerns and needs (eg, treating any substance use withdrawal, room change, day pass). [1][2][3][4]8,15,[22][23][24][29][30][31] This can help with navigating discharge options with the patient and inform revisions to his care plan so that having him stay during the discharge planning process is more agreeable to him (eg, incorporating goals and activities that are meaningful to the patient). 1,2,20,[22][23][24]29 Patient-centred communication strategies can assist physicians with having these sometimes challenging conversations.…”

“…The final option is to discharge Mr M. with the best possible negotiated plan using a harm reduction approach. [1][2][3][4]8,12,[15][16][17]20,22 Under Ontario's Public Hospitals Act, the attending physician (or appropriate designate) is required to discharge a patient who no longer needs care provided in hospital. 25 When there are ongoing care needs and patient safety considerations, the discharge plan should include patient and family engagement and education, follow-up instructions (eg, appointments with a family physician), medication prescriptions, and community and at-home support services.…”

“…25 When there are ongoing care needs and patient safety considerations, the discharge plan should include patient and family engagement and education, follow-up instructions (eg, appointments with a family physician), medication prescriptions, and community and at-home support services. [1][2][3][4]8,12,[15][16][17]20,[30][31][32] Exploring a home visit to determine what community and at-home support services might benefit Mr M. may be a good option, if he is agreeable. 31,33 This can help Mr M. and the team better understand his needs and how he may cope in the community (eg, he may do better than anticipated).…”