The request to leave AMA is a signal for an honest conversation

His nurse paged me at 9pm: Mr. L wants to leave against medical advice (AMA). As the covering doctor, I dreaded the impending standoff even more than usual.

I emerged from the elevator minutes later to find that the gaunt octogenarian had advanced from his isolation room, passed the nurse’s station and the unit doors, and arrived at the elevator bay to greet me. Security guards hovered at a cautious distance as I met his eyes.

“Hi sir. I understand you’d like to leave?”

He spat his response like chewing tobacco from his blood-crusted lips: “They changed my room. I’m tired of this place. I just gotta do something at home.”

Mr. L had come to the hospital after months of coughing, weight loss, and difficulty swallowing. The list of possible diagnoses was long, with cancer and tuberculosis in the lead. But he was not at all interested in staying to sort it out.

The term leaving against medical advice smacks of paternalism and the fear of liability. Even when the designation is warranted (that is, at odds with clear medical need, not physician convenience), it generates an inherently lopsided power struggle that is uncomfortable for all parties (at the very least) and potentially dangerous. It is a concept badly in need of a patient-centered update, according to a recent article from the Journal of the American Medical Association.

As many as two percent of hospital discharges are labeled as AMA. More often than not, they are carried out by young men, patients covered by Medicaid or without insurance, and those struggling with substance abuse. According to a review of nearly two million stays at a Veteran’s Affairs (VA) hospital, such discharges carry a 35 percent higher risk of readmission and 10 percent higher death rates after 30 days, even when accounting for differences in underlying health.

Patients who leave AMA likely differ from those who do not in important ways that weren’t captured by the VA study: in how they view their medical problems and the role of the health care system in addressing them, for example.

I wonder also about the role that doctors play.

Too often, the AMA label gives us a license to stop caring about what happens to a patient. Once the battle is lost, we shift the burden of the discharge entirely onto the patient instead of seeking compromise and mitigating risk (by setting up follow-up appointments, writing prescriptions, and the like). Perpetuating this short-sighted view is the policy from the Centers for Medicare & Medicaid Services that does not extend readmissions penalties to hospitals for patients who return after leaving AMA.

Doctors’ behavior is also fueled in part by the lack of a formal definition of leaving AMA. The designation is not a legal necessity nor does it force the patient to pay for the hospital stay out-of-pocket, despite what most doctors believe (or at least what they tell patients).

Then there is our discomfort with incorporating patient preference into any decision and the difficulty, when we so frequently pass off responsibility between doctors, of developing relationships with patients in the hospital. And it is simply easier to avoid patients we view as difficult than to engage with them.

Mr. L’s request, by the light of day, would hardly have been outrageous. But I was meeting him for the first time and I had other patients to see. I told him why I thought he’d benefit from staying and asked him to get some rest and reconsider in the morning, but he held his ground.

The nurses and I finally coaxed him back into his room with the promise of offering the AMA form — itself an item of questionable purpose. His ambitions were stymied by the relative who would not come to fetch him at the late hour, so the topic was tabled. My shift ended soon after, and I regret that I never had the chance to better understand why he wanted to leave so badly. I wonder if he even had the capacity to make that decision (which would preclude him leaving AMA) and whether I could have done anything more to ease his mind.

The hospital is not always a pleasant setting, nor is that its purpose. To some extent, patients must cede control of their lives in the hopes of saving them. So whether or not you believe that health care is a right, declining this care altogether (for a sound-minded patient) is most certainly one.

As doctors, we should take a patient’s petition to leave AMA as a signal for an honest conversation. If, in the end, his decision is to walk away, we cannot abandon him in return.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared. 

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  • uDRAKSh2L5

    A frightening discussion. A resident – presumably a physician at the high point of his career in terms of altruism and optimism – who voices the concerns shared by nearly every physician about the trade offs between responsibility, autonomy, self determination and paternalism, and who then, in effect, abandons the patient.

    “My shift ended soon after, and I regret that I never had the chance to better understand why he wanted to leave so badly.”
    He had the chance, but he didn’t take it.

    • FEDUP MD

      How could he, with current work hour restrictions? Once your shift is over, you leave, or there are serious consequences, and any issues become someon else’s issue. If you are worried about abandonment, the current rules pretty much demand it to some degree.

  • Amy Tai

    as an intern in Baltimore, a young man with a MRSA infection requiring iv antibiotics was requesting to leave AMA, after he was already tucked into a warm, solo room for the night. As the night float on call, I went to see him when he requested to leave AMA. I asked him. Calmly, he explained his sister had been sexually assaulted and he was going to seek out the man who had done this. While I don’t support vigilante justice, in the cultural context he came from, I believe he was doing what he thought was right for his sister and his family. So I gave him a prescription for oral antibiotics and asked him to come back as soon as he could. I don’t know if he did get justice he was seeking that night, but I know I never saw him again.
    I don’t think leaving AMA is really as simple as the patient being dissatisfied with their care. Most people come to the hospital really because they need help, the ED is the last place someone wants to go.

  • ninguem

    And please don’t perpetuate the myth that insurance will not pay for a hospital stay if the patient leaves AMA.

    • Suzi Q 38

      My friend, who is a physician, told me this was true.
      That if the patient leaves AMA, the insurance refuses to pay and so the hospital sues the patient.
      Is this true?

      • ninguem

        This is a bad memory for me. Thirty years ago as an intern, I got bullied by nurses to alter a medical record to indicate I’d discharged a patient leaving AMA because “insurance would not pay” if the patient left AMA, but would if the patient was “discharged”.

        “You’re just an intern, we nurses know more than you”.

        Actually, they didn’t. There’s really nothing worse than arrogant ignorance.

        This was published in 2012.

        http://www.ncbi.nlm.nih.gov/pubmed/22331399

        http://www.uchospitals.edu/news/2012/20120203-billing.html

        You know what’s sad about this? There was bullying of junior house staff, medical records were distorted, and patients were misinformed thirty years ago, and who knows how long before that. But the sad part is, the alterations, distortions, misinformation, and bullying continued for decades afterward. Not for nothing did these docs feel a need to publish such an article.

        So no, it’s a myth, and it’s ALWAYS been a myth.

  • Suzi Q 38

    I almost took my BIL out of the hospital he was in AMA.

    We had felt his condition was terminal, we tried to get him into a cancer hospital, but the local hospital was reticent to ameliorate the transfer.
    Also, he was tired of the chemo and radiation, and was ready to give up.

    The cancer hospital could not accept him because there was no cure and the first hospital had used up 75% of his lifetime insurance.
    A transfer was finally granted so that the cancer hospital could manage his pain before he died.

    When someone you care for is so sick it is difficult not to blame all the medical personnel around you.

    This is sad and wrong, but more should be done to figure out how to best serve the patient given their illness and prognosis.

    They should be told the truth to spare them all the pain of drug therapies, blood work, and countless tests to no avail.

    Such a waste of insurance and more so the time that is left that could have been better spent away from the hospital and with family and friends.

  • Ed

    Patients don’t need permission, nor do we need to sign any documentation, prior to simply walking out. This is still a free country, and we don’t surrender any of the rights millions have fought and died for, simply because they were admitted to a hospital.

  • PoliticallyIncorrectMD

    Why should physicians be held responsible for competent adults making unwise choices? There are plenty of those who want my help! Why should I waste my efforts on those who do not?

    • Arby

      What is your speciality, if you don’t mind my asking? If you do, then never mind.

    • rbthe4th2

      You are implying that the doctor knows all the reasons why the patient wants to leave, and has the same morals and values they do. If you only think that you are wasting your efforts on only those who do what you dictate, then cherry pick your patients, let them know the stance before hand. Not everyone looks to make “unwise” choices, just because a doctor makes them doesn’t make them all knowing and all seeing. It basically says that competent adults won’t make wise choices. In my case I made a very wise choice when I didn’t get appropriate medical care and was misdiagnosed. However, I was “non compliant”. Going another route saved me.
      Why should we waste all our money on doctors who delay or mis diagnosis us? We don’t get our money back for decisions that were incorrect. We can get blacklisted, etc.
      Good luck.
      Randy

      • PoliticallyIncorrectMD

        I don’t think doctors are infallible. I also believe patients have the right to do what they think is right for them. Having said that, I find it inconsistent when people come to me for advice, choose to ignore it and still hold me responsible for the outcome.

        • rbthe4th2

          Me either, but then again, I don’t hold docs responsible for outcomes when I do my own thing. I just ask them to pick me up and patch me up and send me back out. The only trouble I’ve had is the fallout from a doctor who gave me recommends that couldn’t be medically proven or wouldn’t explain why something was important, etc. In other words, do as I say without me owing an explanation to you and if you disobey me in something that is opinion and not fact, I’ll drop you for it.
          I can live with not being infallible, to a point. If I present medical research, I’d expect a doc to look at it and know that I made a reasoned approach to it. When that doesn’t happen, I’m blown off, its not really right to call someone non compliant when they are doing that.

  • T H

    I have plenty of patients leave the ED after receiving partial or no treatment but before I can either complete treatment or get them admitted into the hospital. Some are drug seekers. Some have obligations that they deem more important (“my kids/ dogs/ horses/ work/ etc.”). Most of them do have what seem to be good reasons, some do not. My job is to ensure they have the information they need to make an informed choice.

    That being said, there is certainly a subset within that group where the phrase “You’re an adult and that gives you the right to make stupid decisions” certainly applies.

  • Kim

    Suzi Q 38,
    This is absolutely NOT TRUE. If you leave the hospital AMA your insurance will still cover your expenses. This is a huge lie told by hospital staff to get patients to stay in the hospital. And sometimes patients leave for all of the RIGHT reasons even if they are not obvious to medical staff.

    As this is still a FREE country you can leave and/or refuse treatment anytime you wish.

    • ninguem

      In my reply to SuzieQ, there’s a link to a medical journal article on the subject. You are absolutely right. It’s not true, was never true, and now there’s documentation.

      And maybe there was malicious motivation, but in my experience with that, it’s more easily explained by plain old ignorance and stupidity. As the saying goes, the most common elements in the universe are hydrogen and stupidity.

      And my internship was about 30 years ago, so the myth existed then, and who known how long before that, and it persisted decades later, to where some docs at another hospital felt the need to publish an article on the myth, in 2012.

      It’s sad and disturbing to know the myth persisted as long as it did.

  • rbthe4th2

    I would be abandoned ( and have been ) in a New York second, and have been by a doctor for something that happened 10 months previously.
    Only a few understand you making a choice and then if you need them, call. Otherwise they dump you like a flash. You truly have no autonomy and patients “rights” are nothing compared to paternalistic medicine.

  • PoliticallyIncorrectMD

    Sure I would treat them… and they don’t even have to admit they made a mistake… just agree to follow my recommendations while under my care.

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