What Is Wrong With Discharges Against Medical Advice (and How to Fix Them)

Alfandre, David; Schumann, John H.

doi:10.1001/jama.2013.280887

Cited by 35 publications

(20 citation statements)

References 5 publications

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“…Moreover, DAMA is likely to impair the doctor-patient relationship and reduce patient adherence to medical treatments [1, 2]. Known predictors of DAMA include male gender, younger age, lower socioeconomic class, history of substance abuse, lack of health insurance, and previous history of leaving AMA [1, 3, 10, 11, 17, 18]. …”

Section: Discussionmentioning

confidence: 99%

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

Brzeziński

Gregersen

Schuch

et al. 2017

Case Reports in Anesthesiology

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Discharge against medical advice (DAMA) can have detrimental effects on patient outcomes. Recently, the diagnosis of posttraumatic stress disorder (PTSD) has been linked with DAMA in the mental health setting. However, PTSD as a risk factor for DAMA in surgical patients has not received much consideration, although such patients may be at risk for triggering or amplification of PTSD symptoms perioperatively. We present the first case report series of three surgical patients with PTSD who left the hospital AMA. These cases differ markedly from DAMA in non-PTSD patients. In all three subjects, the stress of feeling misunderstood by clinicians and the distress of public detainment by hospital security in the setting of chronic PTSD led to aggressive and risky behavior. All three subjects represented a risk to themselves and to others at the time of DAMA. Finally, all three subjects were difficult to contact for follow-up or medical care and missed appointments.

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Section: Discussionmentioning

confidence: 99%

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

Brzeziński

Gregersen

Schuch

et al. 2017

Case Reports in Anesthesiology

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“…Here, flexibility is important as one may then arrange for medically-sanctioned discharges home, where the patient care is facilitated. Notably, shared decision making has a role in achieving more patient-centred care in decisions related to discharge against medical advice [37]. Hastily arranged medicallysanctioned discharges home that accept the realities of inevitable compromises in patient care are facilitated, often with home hospice care input, in order to preserve the therapeutic relationship.…”

Section: Discussionmentioning

confidence: 99%

The Ramifications of At-Own-Risk Discharges in the Palliative Care Setting

Loh¹

2015

J Palliat Care Med

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Objective: The Principle of Respect for Autonomy is integral to the patient-physician relationship, yet within a society that prizes the value of life and remains defined by Confucian-inspired concepts of Beneficence, limits to respect for patient choice are increasingly apparent. This is particularly evident in the end-of-life setting and specifically in situations where terminally ill palliative care patients choose to leave health care institutions against medical advice potentially to the detriment of their health. Focusing on "discharges against medical advice" (DAMA), also known as "at own risk" (AOR) discharges within the palliative care inpatients setting, we highlight growing concerns on the AOR discharge process as it is practiced presently. Methods:We used 3 patient case studies to highlight the various aspects of concern surrounding AOR discharges and its compromise of patient welfare, ostensibly as a result of compliance with the central tenets of the Principle of Autonomy and patient choice. To preserve the interests of the patient we propose the employment of Krishna, Lee and Watkinson's Welfare Model (WM) which offers a more clinically relevant and ethically sensitive means to decision-making at the end of life within societies still inspired by Confucian beliefs and the Principle of Beneficence.Results: Based on the WM, AOR discharges in palliative care may be viable if decisions to respect them adopt: (1) a humanistic and holistic approach, (2) patient specific decision-making method, (3) a multidisciplinary medical team approach, (4) clear documentation of the deliberation process, and (5) an evidence-based decision making process that is consistent with regnant professional, social, institutional, and legal standards. Conclusion:Greater efforts need to be taken to pre-empt AOR discharges where possible among inpatients of palliative care or other medical disciplines. If an AOR discharge is unavoidable, a decision-making process defined by the WM provides the best means of protecting patient welfare and being consistent with prevailing socio-cultural beliefs and values.

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“…Physicians are often reluctant to provide drugs to addicted persons. However, this is often the most practical way to alleviate drug craving and withdrawal symptoms and to assure successful completion of necessary acute medical treatment …”

Section: Balancing Ethical Obligations and Managing Legal Risk Througmentioning

confidence: 99%

“…The ED team assures the patient that he or she is welcome to return at any time if circumstances change. The literature has reported a reluctance to return by patients who sign out AMA because of embarrassment and the fear of a negative reaction by hospital staff . The tone of the conversation is as important as the content, since it best demonstrates a persistent respectful interest in the patient's welfare.…”

Section: Balancing Ethical Obligations and Managing Legal Risk Througmentioning

confidence: 99%

Ethics Seminars: A Best‐practice Approach to Navigating the Against‐Medical‐Advice Discharge

Clark

Abbott

Adyanthaya³

2014

Academic Emergency Medicine

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Patients who sign out or choose to leave the emergency department (ED) against medical advice (AMA) present important challenges. The current approach to the complex legal, ethical, and medical challenges that arise when adult patients decline medical care in the ED would benefit from a systematic bestpractice strategy to maximize patient care outcomes, minimize legal risk, and reach the optimal ethical standard for this at-risk population. Professional responsibilities generated during an AMA encounter include determination of patient decision-making capacity, balancing protection of patient autonomy with prevention of harm, providing the best alternatives for patients who decline some or all of the proposed plan, negotiating to encourage patients to stay, planning for subsequent care, and documenting what transpired.We present two cases that illustrate key insights into a best-practice approach for emergency physicians (EPs) to address problems arising when patients want or need to leave the ED prior to completion of their care. We propose a practical, systematic framework, "AIMED" (assess, investigate, mitigate, explain, and document), that can be consistently applied in situations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. Our goal is to maximize patient outcomes, minimize legal risk, and encourage a consistent and ethical approach to these vulnerable patients.

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What Is Wrong With Discharges Against Medical Advice (and How to Fix Them)

Cited by 35 publications

References 5 publications

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

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

The Ramifications of At-Own-Risk Discharges in the Palliative Care Setting

Ethics Seminars: A Best‐practice Approach to Navigating the Against‐Medical‐Advice Discharge

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