AMA discharges: What you may not know

You are called to the emergency room to consult on a 57-year-old woman who, as a pedestrian, was struck by a car in a crosswalk. She has polytrauma, the most serious of which is a stage IV right renal laceration. She is admitted to urology for conservative management, serial hemoglobin and hematocrit, and repeat CT scan. Bedrest is ordered and the patient is compliant and hemodynamically stable for the first 48 hours.

At the close of hospital day two, she is feeling well and wants to go home. As the attending urologist, you advise against this as she is still having some hematuria, her hemoglobin and hematocrit have not fully rebounded, and you are planning to get a repeat CT scan at 72 hours. The patient is adamant about leaving the hospital, and does so against medical advice (AMA).

The patient is found down at home by her daughter later that evening and brought back to the emergency room by ambulance. She is found to have a delayed renal hemorrhage requiring activation of the hospital’s massive transfusion protocol, and is admitted to the intensive care unit. She is discharged 9 days later and subsequently sues you for medical malpractice under a claim for lack of informed consent.

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You are legally protected, right? She made a decision against your medical advice and must accept the consequences. The answer is maybe, and it depends on a few key factors.

Somewhere between 1% and 2% of all hospital discharges are AMA discharges (Mayo Clin Proc 2009; 84:255-60). As a population, those who are discharged AMA are at higher risk for morbidity and mortality. Literature shows that those most likely to leave AMA are younger, male, more frequently hospitalized, live alone, and have more severe symptoms at discharge (J Fam Pract 2000; 49:224-7). While clinical providers are bound to act with beneficence, a conflict can arise when a patient’s right to self-determination and autonomy comes into direct opposition with what is best for the patient.

Informed consent and leaving AMA

In dealing with patients who want to be discharged AMA, informed consent is at the crux of any potential future legal issues. In deciding to leave AMA, the patient is effectively revoking his consent to a voluntary hospital admission. Informed consent in deciding to leave AMA means that the patient has come to the decision after consultation with his or her physician, without coercion, and with a full understanding of the risks, benefits, and alternatives of the decision. Assessment of a patient’s ability to make decisions is essential, and a formal evaluation of this, by way of a psychiatry consult, may be required (bit.ly/dischargeAMA). How this process and decision is documented in the medical record is the evidence a trier of fact will look to.

Next:Specifics to address in medical recordsSuccessfully defending a claim of medical malpractice for the patient who left AMA and was subsequently harmed will hinge on the clinical assessment and associated documentation. Having a patient sign an “AMA form” in and of itself, is not enough, as it does not prove an absence of negligence. Specifics to address in the medical records might include:

• an assessment of the patient’s understanding of his or her illness and prognosis

• the risks, benefits, and alternatives to leaving the hospital AMA

• the patient’s level of health literacy

• whether an attempt was made, if permission given, to engage the patient’s family or friends in the decision-making process

•  the patient’s ability to make and communicate a choice clearly

• if and how the patient’s choice aligns with his or her values

• whether the patient’s decision was communicated to the patient’s primary care physician, to ensure close outpatient follow-up

• what information the patient was given at discharge about how and where to follow up, reasons to return to the emergency department, and instructions on medications.

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In an attempt to balance patient autonomy and patient safety, some institutions follow a “sliding scale” for capacity assessments that require the physician to have a higher certainty of the patient’s decisional capacity for higher risk AMA discharges (Mayo Clin Proc 2009; 84:255-60). If there is incongruence in the level of risk the patient is willing to accept and the physician’s certainty of decision-making capacity, it is prudent to invoke whatever additional resources are available to aid in this, such as additional mental status screening exams, a psychiatry consult, or involvement of an ethics committee.

Patients’ decisions to leave AMA are multifactorial, ranging from dissatisfaction with care, to extended wait times for interventions, to financial or insurance fears. Proactive development of strategies to reduce the number of AMA discharges is a first step organizations can take to lower their rate. When these strategies do not work, and an AMA discharge is inevitable, a thorough assessment and documentation of that assessment is a physician’s best tool should any litigation arise out of injuries a patient sustains connected with that discharge.