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What To Do When Your Patient Wants To Leave The Hospital Against Your Better Judgment?

When a patient decides they are leaving against medical advice what responsibility does the physician have to their care?  When I was a resident in training, and even early on in my position as a hospitalist, I would get a call from the nurse that  Mrs Smith was demanding to leave the hospital against medical advice.  I would tell the nurse “Fine. Let her go. I’m not her father.”  I would tell the nurse to discharge Mrs Smith with no medications and leave it up to them to find follow up.

I would suspect this is a prevalent attitude for many hospital and emergency based physicians.   I’ve seen it over and over again.  And I still see it today.  Many doctors and nurses feel obliged to let grown men and women make poor decisions.    However, being a grown man or woman able to make poor decisions is apparently not enough to keep a doctor for being sued and losing that lawsuit because a patient chose to make poor decisions.  Here’s a case report on leaving against medical advice and their bullet points at the end

Discharge AMA does not absolve the physician of responsibility for poor outcomes; as always, good clinical care and careful documentation are of paramount importance.

Will leaving against medical advice negate insurance coverage for the patient?  Dr Gott chimes in by scolding a physician for telling an elderly lady just that.

DEAR READER: The social worker who saw you in the hospital was absolutely correct. The doctor does know better than to behave that way. He should also know that Medicare and other insurance will cover hospital care even if the patient leaves against medical advice (AMA).

But what about the outcomes of patients who leave against medical advice?

The significantly increased risk of readmission among general medicine patients who leave hospital AMA is concentrated in the first 2 weeks after discharge. However, it is difficult to identify which patients will likely be readmitted.

As a resident, I rarely got any legal education on patient care issues.  I know for a fact I never got any education on the legal ramifications when I discharge a patient leaving against medical advice.  A few years back I did a little research on what is expected of physicians when patients are leaving against medical advice.

That research changed my attitude about how to deal with patients choosing to leave against medical advice.  I used to let them go and leave it at that.  But now, I will take the time to discuss Mrs Smith’s concerns about continued voluntary hospitalization.  Often patients can be convinced to stay when presented with the facts of their care and care plan, as I did the other day with an old man who was out of control.  If Mrs Smith still chooses to leave after discussion,  I document that Mrs Smith has the capacity to make poor medical decisions for herself and that she understands the risks and benefits of leaving against medical advice including the high probability of death or disability.

Once I am convinced that Mrs Smith has the capacity to make poor medical decisions and understands the consequences of those choices, including long term death and disability, I discharge her just like I do any other patient.  And I bill her as a discharge code (CPT 99238 or 99239) just like I would if she was leaving with my blessing.

If she needs a prescription for pneumonia, she gets a prescription for pneumonia.  If she needs a heart pill, she gets a script for a heart pill.  She gets the same care as if I was discharging her with my blessing.    Many physicians falsely believe that by formally discharging Mrs Smith, they are approving of the discharge plans.  That couldn’t be farther from the truth.  By formally discharging Mrs Smith in her leaving against medical advice manner, you are protecting yourself against charges of abandonment and failing to provide standard of care upon discharge.  Many subspecialists will refuse to see Mrs Smith on follow up after she leaves against medical advice believing that seeing her would increase their liability for practicing medicine on a patient who’s actions increase the likelihood of a bad outcome.  Again, that couldn’t be farther from the truth.

I will discharge Mrs Smith just as if she was leaving with my blessing and I will clearly document that I oppose her decisions but recognize her right for leaving against medical advice.  Patients in the hospital have the opportunity to refuse therapies and evaluations at anytime.   Leaving the hospital is no different.

But what if I don’t think a patient has the capacity to make their own medical decisions and they still feel like leaving against medical advice?  I have been told by my psychiatry service several years ago that because the patient was admitted to a medical wing and because they came in voluntarily I have no legal grounds to force them to stay, even if I believe they lack the capacity to make their own medical decisions.   I have no legal basis to prevent them from leaving and in fact I could be charged with some sort of unlawful imprisonment charge if I tried to keep someone in the medical wing against their will.

My duty at this point, if I believe the patient leaving against medical advice lacks the capacity to make their own medical decisions, is to let them leave the confines of the hospital, but to contact the police department to pick the patient up the moment they step foot outside the hospital doors.

Today’s Hospitalist had a great review earlier this year.  Who tends to leave against medical advice?

And a body of research has identified several characteristics common in AMA discharges. These individuals are often young, male, have Medicaid or no insurance, come from a low socioeconomic class, or have a history of substance abuse.

Thankfully the against medical advice crowd is not a large one.  AMedNews reports that only about 2% of hospitalized patients end up leaving against medical advice.

About one in 50 patients leaves the hospital early, disregarding the doctor’s orders. These patients are three times more likely to be re-hospitalized within a month, according to a recent review of more than two dozen studies since 1970 that examined the phenomenon of “self-discharge.”

As a medical physician, I have been told I have no authority in Happy’s state to hold someone in the medical floor against their will, regardless of their mental capacity to make sound decisions.  They have to be picked up by local authorities and transferred to a psychiatric hospital for a medical hold, or the police department must place an emergency protective custody  (EPC) on the patient which allows a physician/hospital to hold the patient for up to 48 hours  in Happy’s state before  a judge  declares intentions for further court ordered confinement or not.

If your patient is leaving against medical advice, take my advice and formally discharge them.  You will save yourself a lot of potential trouble in our world where every bad outcome is someone else’s fault and our legal system encourages an incredible lack of personal responsibility.

*This blog post was originally published at A Happy Hospitalist*

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