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Informed discharge


Alerting patients to warning symptoms and signs

Leaving against medical advice (AMA)


  • Patients who leave against medical advice are a risk to themselves and represent a potential medical-legal risk.
  • In these situations, physicians should try to educate patients on what symptoms and signs should prompt them to seek further medical attention.

Many physicians believe they are absolved of any legal duty of care when mentally capable (competent) patients discharge themselves against medical advice.

It is true a patient may be judged to have negligently caused or contributed to a clinical outcome by failing to act as might generally be expected of a reasonable patient. However, it is uncommon that a court will find the patient wholly responsible for an adverse outcome due to the contributory negligence (professional civil liability in Québec) of the patient.

Case: An older woman looking forward to seeing her granddaughter
Close up of elderly woman in hospital bed

Background

An 85-year-old woman with no significant medical history presents to the emergency department with a two-day history of fever, cough, and shortness of breath. She is assessed by a medical trainee supervised by a staff physician.

The patient functions well and lives independently. On admission to the ED, her oxygen saturation on room air is a little low. A chest X-ray shows a dense right lower lobe pneumonia. Based on the overall clinical assessment, it is recommended that she be admitted to hospital.

She is upset by the "long wait" and adamantly refuses admission because of a much anticipated upcoming visit with her only granddaughter. She appears fully cognizant of her disease and the risk of being discharged, but she remains unyielding and asks to sign an "against medical advice" (AMA) form.

Think about it

What would you do next in this situation?

Lessons learned

A physician should make reasonable attempts to confirm that the patient understands the potential consequences of refusing the recommended investigations or treatments. Consider the patient's mental competency. The patient who appears to understand the nature of the disease and the consequences of accepting or refusing treatment is likely capable.

This assessment is based on the overall clinical picture. In some situations, obtaining a consultation from another physician may be helpful in determining the patient's mental competency.

Even if a mentally capable patient refuses treatment, the physician should explain why more observation, investigation, treatment, and follow-up are recommended. This discussion may help alleviate the patient's concerns or fears.

Lessons learned continued

It may also be helpful to ask if the patient has any other personal concerns, for example, responsibility for the care of a spouse at home or a pet left unattended. There may be a way to resolve such issues.

When possible and with the patient's permission, it is generally useful to include family members in the discussion. Depending on the apparent seriousness of the clinical condition and available resources, it may be helpful to ask another physician to see the patient to reinforce the need for the recommended investigations or treatments.

The physician should advise the patient signing the AMA form of any necessary follow-up. Discharge instructions should still be provided. The patient should be made to feel welcome to return and seek re-evaluation.

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Documentation of leaving against medical advice

  • In the medical record document the discharge instructions provided.
  • A signed AMA form is acknowledgement that a discussion with the patient of the risks of discharge has occurred.

The recommendations for care, the mental capacity assessment, the patient's reasons for refusing investigation or treatment, and the follow-up and discharge instructions should be documented in the medical record.

A signed AMA form is potentially useful if issues about the assessment and informed discharge arise later. In these circumstances some physicians ask nursing staff to witness that an assessment and discussion have occurred.

If a patient refuses to take part in a discharge discussion or refuses to sign an AMA form this should also be documented.