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Posted: 10/24/2016 9:04:45 AM

Nursing Tips: When a Patient Leaves Against Medical Advice

“You can’t make me stay.” Although providers may seem shocked when a patient decides to leave the hospital Against Medical Advice (AMA), the patient is exercising his or her right to refuse recommended care or treatment. In an article for Mayo Clinic Proceedings, David J. Alfandre, MD, reports that about 2% of all medical admits result in an AMA discharge. When a patient leaves AMA, the risk of readmission for the same diagnosis increases, as well as establishing a precedent for future AMA discharges.

Who is most at risk for leaving AMA?

- Medicaid or no insurance
- Males
- Young adults
- Lives alone
- Alcoholism or substance abuse
- Psychiatric history
- Additional medical issues
- Family or financial obligations

The consequences of an AMA discharge vary by circumstance. Some patients are ready to leave, while others are quite vulnerable. In Dr. Alfandre’s article, retrospective analysis showed:

- Asthmatics had four times more ER visits and three times more hospital re-admits within 30 days.

- General medicine patients who were hospitalized had an almost seven times the likelihood of being readmitted within 15 days.

- Patients who had myocardial infarctions had a 40% higher chance of death or readmission for another MI within two years.

Nurses are likely to be the first healthcare professional that hears when a patient is considering an AMA discharge. Communication with the patient and the physician can be adequate in preventing an untimely discharge. Asking a patient to wait thirty minutes while you phone the physician or prepare the discharge plan may be enough time to calm an angry patient and allow for an honest conversation. The court has ruled in favor of a hospital using “a reasonable amount of time” to permit routine paperwork and procedure. (Bailie vs. Miami Valley Hospital)

Here are five tips for nurses who may encounter AMA situations:

1. Never threaten a patient by saying that if he or she leaves AMA that insurance will not cover the stay. Insurance will pay for care given up to the time of discharge.

2. Whenever possible, take time to talk with the patient to understand more about the reasons for seeking discharge. Patients sometimes have compelling reasons to leave and alternate care resources can be arranged. Document the conversation.

3. Using your facility’s AMA form, provide an informed consent regarding an AMA discharge. Elements of an informed consent include the patient’s acknowledgement that he or she is leaving AMA; that the risks have been explained and the patient understands; and that the patient knows he or she may return at any time. The patient’s signature indicates refusal of recommended treatment. If the patient refuses, the nurse can sign as the witness and document the refusal.

4. His or her rights to receive full discharge instructions and materials remain the same as other patients. Review the instructions with the patient. If the patient agrees, provide wheelchair or escort service from the unit. Document the events.

5. Psychiatric or violent patients may be retained if they are a threat to themselves or others. In these cases, the hospital may use legal means to keep the patient. Accurate documentation by the nurse is key in the process.

When a patient decides to leave AMA, the nurse can help provide as safe and responsible discharge process as possible. Respecting the patient’s autonomy while providing ethical and compassionate care are important nursing responsibilities.