News & Insights

Refusing Care: When Patients Leave Against Medical Advice

September 14, 2022

By Amanda Martin-Sanchez, MEd, BSN, RN, CNOR

Refusing Care: When Patients Leave Against Medical Advice
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Patients leaving the hospital against medical advice (AMA) occurs in as many as 1%-2% of all hospital discharges – 350,000 to 700,000 AMA discharges per year! Yet, leaving AMA can increase the risk of readmission for patients, as well as worsen their morbidity and mortality. In turn, this can lead to higher healthcare utilization and possible liability claims. When medical professional liability claims involve an AMA discharge, the allegation is specific to the actual care provided. In these situations, patients may allege that the care was below the standard. But what’s often behind that allegation?

There are a wide range of reasons why a patient may decide to leave AMA. Patients may be dissatisfied with the way they were treated, feel the care wasn’t provided in a timely manner, or think no one was paying attention to them. Others may not want any care from the hospital or refuse a specific type of care. Additional concerns may include costs; fears of pain, death, or procedures; wait times; prior obligations; and communication issues.

What can physicians do to reduce their risks when a patient decides to leave against medical advice? If you are present when the patient wants to leave against your advice, consider these strategies:

  • Advocate for the patient’s health and wellbeing as much as possible. Try to ascertain why the patient wants to leave and strive to develop a mutually acceptable alternative treatment plan with the patient. Shared decision-making may be helpful, given that it can strengthen trust between clinicians and patients, as well as facilitate continuous follow-up after discharge.
  • Follow the hospital’s policy on patients leaving against medical advice. Most hospitals have a form for an AMA discharge or refusal of treatment available to accompany the policy. If the patient is competent to make the decision, have a discussion at a level the patient can understand about the risks associated with leaving based on the present clinical condition. Document the major points of the discussion and the patient’s understanding of what they were told.
  • If the patient wants to move forward with leaving AMA, continue the discharge process – as any other discharge – to the extent possible. Advise the patient that returning for care is an option.
  • Document the care provided and the patient’s response to your care in a non-judgmental, empathetic manner.
  • Patients may leave without signing the discharge AMA/refusal of treatment form. Verify that the form is complete and document the patient’s refusal to sign the form.
  • Follow up with other care providers and agencies, as needed.

If you are not available or off-site when the patient decides to leave AMA, here are a few recommendations:

  • Review the AMA discharge/refusal of treatment form in the patient’s medical record.
  • Document in the patient’s medical record that you were not present and include any additional information relevant to the discharge.

You can’t prevent a patient from leaving against medical advice, but you can engage the resources available in these situations. Although AMA discharges only account for a small percentage of all hospital discharges, they can pose liability risks when handled improperly. Consider incorporating strategies from this article into practice to minimize your liability risks and preserve the ongoing relationships with patients contemplating or choosing to leave AMA. 

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