Reconsidering Against Medical Advice Discharges: Embracing Patient-Centeredness to Promote High Quality Care and a Renewed Research Agenda

Abstract

Hospital discharges against medical advice (AMA) are common, costly, stigmatizing to patients, and are associated with excess morbidity and mortality. Achieving better quality care for patients discharged AMA has been limited both by the sparse research illuminating how best to care for this challenging patient population, as well as a lack of standards regarding this clinical practice. This paper will review elements of the AMA literature and highlight the gaps, including the predictors of AMA discharge, challenges to high quality informed consent in AMA discharges, problematic aspects of AMA discharge forms, and the stigma associated with patients discharged AMA. These gaps in the evidence base collectively limit the ability to adequately and completely address AMA discharges and improve health care quality. This paper will recommend future directions to answer remaining questions for the field, and offer guidance for providing ethically sound and high quality care for the affected population. Applying the widely accepted principles of patientcentered care and shared decision making to AMA discharges offers the opportunity to improve quality of care and promote ethical health care practice.KEY WORDS: against medical advice; shared decision making; patientcentered care.

Discharges Against Medical Advice at a County Hospital: Provider Perceptions and Practice

“…31 This discrepancy highlights an urgent need for the education and involvement of nurses as stakeholders in the challenging AMA discharge process. Although the percentage of physicians who thought they were not obligated to provide medications and arrange follow-up for AMA patients was lower than the percentage of nurses, these beliefs contradict best practice guidelines for AMA discharges, 22,23 and this finding calls attention to the need for interventions to improve adherence to professional and ethical guidelines in this aspect of clinical practice.…”

Improving Quality in Against Medical Advice Discharges—More Empirical Evidence, Enhanced Professional Education, and Directed Systems Changes

“…9 Furthermore, given that these forms may be written using institution-centered legalistic language or at an inappropriate reading level, this common hospital practice should be evaluated to assess whether patients comprehend and benefit from the forms, and how the forms influence healthcare decision making. 10 Finally, the authors' finding that 38% of nurses, 22% of physician trainees, and 6% of attendings believe patients discharged AMA lose the "right" to follow-up is noteworthy. The practice would suggest a significant lapse in understanding the professional obligation to acknowledge and communicate that the informed consent process is voluntary and patients have the right to decline recommended treatment without forfeiting future access to care.…”

Discharge against Medical Advice in Surgical Patients with Posttraumatic Stress Disorder: A Case Report Series Illustrating Unique Challenges

“…Patients leaving AMA have higher mortality and hospital readmission rate, increased risk of suicide, and higher overall healthcare costs [1, 3, 16]. Moreover, DAMA is likely to impair the doctor-patient relationship and reduce patient adherence to medical treatments [1, 2].…”