When a patient wants to leave the hospital and the hospital says they shouldn’t, what’s a patient or family member to do? When patients leave against medical advice (AMA) staff is not happy. The physicians’ recommendations are ignored (and who likes to be defied?) and to avoid legal entanglements patients are pressured to sign a form acknowledging that they are behaving in a way counter to medical advice and that they are assuming the risk and consequences of their actions (although the forms do not necessarily preclude liability claims or ward off lawsuits). Medical professionals discourage patients taking matters into their own hands because they may require further monitoring or services, and research supports the notion that leaving AMA results in higher mortality and hospital readmission. A recent study in the Journal of the American Geriatrics Society describes some of the issues involved in this complicated situation (“Discharge Against Medical Advice among Elderly Inpatients in the US.” Carlijn Lelieveld, Rosanne Leipzig, Licia Gaber-Bayliss, Madhu Mazumdar, Stavros G. Memtsoudis, Nicole Zubizarreta, and Jashvant Poeran. Journal of the American Geriatrics Society; Published Online: June 19, 2017 (DOI: 10.1111/jgs.14985). The study found that the proportion of patients who left AMA increased significantly over the past decade, in patients over 65.
Why would patients literally take their lives into their own hands by leaving when the medical establishment puts pressure on them to stay put? And how much pressure should the physicians put on their patients? When are patients’ rights and decision making powers violated? When should doctors override a patient’s wish to leave without treatment? What are the medical, psychological and legal ramifications of these decisions?
Complicated, right? The cynical view is that hospitals like patients to stay because it increases the money they make. Also in the cynical camp is that with the Affordable Care Act, hospitals are penalized for readmissions. Less cynically, physicians may be invested in the good care they deliver and may think they are working solely for the patient’s well-being. When patients leave AMA they often do not follow-up with medical appointments and medication regimes.
Some patients leave the hospital for financial reasons. They simply can’t afford to stay if, for example, they have a high deductible on their insurance plan. Or patients believe that hospitals are not safe places, that there are infections that are hospital acquired, and they want to get out as soon as possible. Hospital safety has been notoriously criticized as very poor.
But we are supposed to be living in a time that stresses patient-centered care. A mentally competent patient should be able to make a decision and have it honored by the hospital staff. Shared decision-making bucks the traditional paternalistic culture of most healthcare organizations. Reasonable people, both doctors and patients, can disagree about plans. Encouraging a real partnership and enhancing communication may help patients decide with their physician what is best for them.