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July 13, 2017

Why patients leave 'against medical advice'—and how providers can prevent it

Daily Briefing

A patient's decision to leave a hospital against medical advice can be "contentious," and as the health care industry moves toward patient-centered care, providers are seeking new ways to engage patients in finding alternatives to A.M.A. discharges, Paula Span writes for the New York Times' "The New Old Age."

While Span writes that leaving against medical advice is "uncommon," research shows the percentage of patients over age 65 who have signed an A.M.A. discharge form rose from 0.37 percent, or 45,535 discharge forms, in 2003 to 0.42 percent, or 50,650 discharge forms, in 2013.

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And Jashvant Poeran, an epidemiologist at the Icahn School of Medicine at Mount Sinai who led the study, said those findings are "very conservative" numbers because they do not include all of the outpatients who left EDs or those who simply walk out without signing a form.

Why do people leave A.M.A.?

There could be any number of reasons why patients opt to leave against medical advice, Span writes. Some patients may feel their symptoms have lessened, while others may be afraid of the recommended treatment or feel they need to take care of pressing needs at home, Span writes.

Some research also has shown costs are a factor. For instance, Poeran's study found that older patients who were discharged A.M.A. were more likely to have lower incomes.

Another factor may be that hospitalization can be risky for older patients, as multiple days in a hospital bed can cause reductions in mobility, trigger delirium, and even expose them to infections or falls, all of which could result in nursing home care, Span writes.

Eileen Callahan, a geriatrician at Mount Sinai Hospital in New York, said that for many older patients a hospital stay is "often a life-changing event."

A contentious moment

Arthur Derse, director of the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin, said A.M.A. discharges have "always been one of the most difficult ethical dilemmas," adding, "Patients come and seem to be in need of help, and then they say, 'Sorry, I've got to leave.'"

Derse said hospital risk managers may encourage providers to have patients sign A.M.A. discharge forms to avoid liability, though Derse said that such forms do not always "preclude liability claims."

According to Span, some physicians feel patients who sign A.M.A. discharge forms are taking a major risk. Span cites research that has shown patients who have signed an A.M.A. discharge form to leave have higher rates of mortality and hospital readmissions, are less likely to receive needed follow-up care and medications, and may be disinclined to return to the hospital if complications persist.

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In other cases, physicians may struggle when a patient questions or refuses their medical advice. David Alfandre, a bioethicist at the N.Y.U. School of Medicine, said, "Some physicians don't like being questioned," adding, "It's not uncommon for the physician to get angry and frustrated, and those feelings are transmitted to the patient."

Alfandre believes the forms undermine the decision-making process that goes on between doctors and patients. As Span writes, "A mentally competent patient, after all, can accept or decline any treatment."

How can A.M.A. discharges be avoided?

Span writes that providers and patients need to engage in meaningful conversation about why the patient wants to leave in order to reach "less contentious solutions, including outpatient treatment, home visits, or drugs taken orally at home instead of being administered intravenously." Providers may even make exceptional accommodations to convince a patient to stay, as in one instance where a patient's pet parrot was brought to his hospital room.

"Let's see if we can come up with an alternative plan," said Cordelia Stearns, a hospitalist. "A lot of the time, we can. We're doctors, not jailers" (Span, "New Old Age," New York Times, 7/7).

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