Against-Medical-Advice Discharges from the ED: Literature and Strategies Review

A scenario in which a patient leaves the emergency department before completing their recommended evaluation or treatment is referred to as an "Against-Medical-Advice" (AMA) discharge.

Every year in the United States, approximately 500,000 patients request to be discharged AMA and consequently suffer from significantly higher readmission and mortality rates.^1-3

When patients deny recommended care, their outcomes and predicted course change.⁴ Emergency physicians also face unique medicolegal and ethical challenges during these encounters.^5-6 As there is considerable speculation around these issues, this literature review will help provide context on AMAs and discuss best practices. Moreover, emergency physicians in training need to be equipped with the skills and training to have critical conversations with patients and families. This is a start. 

Review of Literature

Ethics Seminars: A Best-practice Approach to Navigating the Against-Medical-Advice Discharge
The authors highlight the complex medicolegal and ethical challenges presented to physicians in the case of an AMA discharge, including balancing patient autonomy and harm prevention. They advocate for a practical, systematic approach - "AIMED" (Assess, Investigate, Mitigate, Explain, and Document) - to be applied to situations in which a patient is considering leaving AMA or has already left AMA (see Table 1). In these scenarios, adherence to best-practice strategies may decrease AMA discharges and consequently readmission rates, mortality rates, and risks of legal repercussions.²²

The Importance of a Proper Against-Medical-Advice (AMA) Discharge: How Signing Out AMA May Create Significant Liability Protection for Providers
The authors of this paper discuss documentation and legal ramifications of the "AMA." This includes the requirements of a proper AMA discharge from a documentation and patient-capacity standpoint. Competence is a legal state; physicians determine capacity. 

They discuss the legal protections conferred to physicians in the event of litigation following an adverse outcome:

1. Legal precedent illustrates that a patient's decision-making capacity to refuse care is essential, as treatment without consent can be considered battery.^7-11
2. Battenfeld v. Gregory emphasizes that disclosure of risks is required for informed consent, and the legal protections of AMA documentation alone are not conferred in its absence.^12-13
3. Henson et al. suggest that documentation should be comprehensive, including capacity, disclosure of risks, decision, and signatures from both parties.¹
4. Legal precedent finds that proper AMA documentation terminates the physician's legal duty to treat, offering protection in subsequent litigation.^15-18
5. Lyons v. Walker Regional Medical Center, Inc. found that a proper AMA discharge creates an "assumption-of-risk" defense (ie, patients who leave AMA voluntarily assume the risks of adverse events).¹⁸
6. Proper documentation provides evidentiary support of the patient's refusal of care and assumption of risks in lawsuits.

The authors argue that physicians should take the precaution of properly documenting AMA discharges, both verbally and in writing, regarding the significant liability protection offered.

Patients Who Leave the Emergency Department Against-Medical-Advice
The authors conducted a cross-sectional retrospective study of general characteristics of patients who left the ED AMA in South Korea from 2010 to 2011. Of the over eight million patients in this study, 222,389 (2.78%) were discharged AMA, corroborating the estimated prevalence of 0.1% to 2.7%. Identified risk factors included: age, male gender; uninsured status; trauma; admission at a local (versus regional or specialty) emergency medical center; circulatory, endocrine, immune, neurologic, or psychiatric disease; and external sources of morbidity and mortality.¹⁹ Although ED AMA discharges account for a small proportion of discharges; they correlate with higher readmission and mortality rates. The authors argue that associated predictors and characteristics should be understood and addressed to improve outcomes and contain costs.

Financial Responsibility of Hospitalized Patients Who Left Against-Medical-Advice: Medical Urban Legend?
The authors discuss the practice of informing patients that their insurance will not reimburse their hospitalization if they leave AMA. The authors conducted a retrospective cohort study of hospitalized patients from 2001 to 2010 and a cross-sectional survey examining physician beliefs and counseling practices regarding AMA discharges. It was discovered that there were zero cases of payment refusal that could be attributed to the AMA discharge itself.⁶ The authors argue it is crucial not to deny patients the autonomy to make their own decisions.

Discharges Against-Medical-Advice from U.S. Emergency Departments
The authors conducted a retrospective cohort study of patient- and hospital-level characteristics associated with ED AMA discharges from 2006 to 2014. Over this time period, they found an increase in ED AMA discharges involving adult patients who had lower incomes, were younger, had significant comorbidities, had public insurance, and visited trauma-affiliated EDs.²⁰ These observations may be attributable to longer wait times due to increases in ED "boarding" and overcrowding.²¹ Of note, uninsured patients were disproportionately involved, constituting almost one-third of ED AMA discharges in this study.

Summary of Literature
Despite the fact that AMA discharges are a common phenomenon, accounting for approximately 500,000 discharges on an annual basis in the U.S., there is an abundance of misconceptions and knowledge gaps in the medical community.^1-4 Although patients may be partly at fault for adverse outcomes if they leave AMA, providers may still be held liable. However, if the provider determines capacity, discloses risks, and properly documents the AMA discharge, they may obtain significant liability protection in the event of litigation.⁵ Furthermore, there is a common counseling practice of informing patients that their insurance will not reimburse them if they leave AMA, which by empirical analysis appears to be a false claim. Additionally, patients who leave the ED AMA are more likely to miss follow-up appointments and not fill prescriptions and suffer from significant pathology for which they may be reluctant to return.^23-24

AMA discharges present complex professional and ethical problems that ultimately compromise patient safety and situates providers in high-risk dilemmas. In these scenarios, it may be beneficial to adhere to systematic best-practice strategies. By following AIMED frameworks, providers can uphold professional and ethical standards while reducing the risk of legal ramifications to themselves.²² To adequately address the escalating number of AMA discharges nationwide, focused efforts must identify risk factors and vulnerable populations, including those with comorbidities, psychiatric illnesses, and substance abuse disorders.

Looking Forward/What's Next
Research on AMA discharges raises awareness of misconceptions and knowledge gaps in the medical community, and frameworks are being devised to guide providers in the making more legally and ethically sound decisions with their patients. For example, Brenner et al. recently elucidated clinician-oriented factors - such as communication barriers - that influence decision to discharge AMA, laying the groundwork for future research and legislation.²⁵ Moving forward, hospital leadership, policymakers, and providers alike must further ascertain AMA discharges drivers and appropriately address them. As physicians in training, learning the dynamics of a proper AMA, and utilizing techniques to provide one are essential training components. 

Other Recommended Literature

1. Marco CA, Brenner JM, Kraus CK, McGrath NA, Derse AR; ACEP Ethics Committee. Refusal of Emergency Medical Treatment: Case Studies and Ethical Foundations. Ann Emerg Med. 2017;70(5):696-703. 
2. Tummalapalli SL, A Chang B, R Goodlev E. Physician Practices in Against Medical Advice Discharges. [published online ahead of print, 2019 Oct 24]. J Healthc Qual. 2019;10.1097/JHQ.0000000000000227. 
3. Kahn JH. Confidentiality and Capacity. Emerg Med Clin North Am. 2020;38(2):283-296. 
4. Magauran BG Jr. Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice. Emerg Med Clin North Am. 2009;27(4):605-viii. 

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References

1. Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25(9):926-929. 
2. Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125(6):594-602. doi:10.1016/j.amjmed.2011.12.017
3. Garland A, Ramsey CD, Fransoo R, et al. Rates of readmission and death associated with leaving hospital against medical advice: a population-based study. CMAJ. 2013;185(14):1207-1214. 
4. Alfandre DJ. "I'm going home": discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260. doi:10.1016/S0025-6196(11)61143-9
5. Levy F, Mareiniss DP, Iacovelli C. The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. J Emerg Med. 2012;43(3):516-520. 
6. Schaefer GR, Matus H, Schumann JH, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend?. J Gen Intern Med. 2012;27(7):825-830. 
7. Cruzan v. Missouri Department of Health, 497 U.S. 261 (1990).
8. Schloendorff v. Society of New York Hospital, 105 N.E. 92 (N.Y. 1914).
9. Kapp MB. Ethical and legal issues. In: Duthie EH, ed. Practice of geriatrics. 3rd edn. Philadelphia: Saunders; 1998:31–7.
10. Mufson M. Evaluation of competence in the medical setting. In: Samuels MA, Feske SK, eds. Office practice of neurology. 2nd edn. Oxford, UK: Churchill Livingston; 2003:998–1004.
11. Miller v. Rhode Island Hospital, 625 A.2d 778 (RI 1993).
12. Beauchamp TL, Childress JF. Principles of biomedical ethics. 4th edn. New York: Oxford University Press; 1994.
13. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
14. Henson VL, Vickery DS. Patient self discharge from the emergency department: who is at risk?. Emerg Med J. 2005;22(7):499-501. 
15. Prosser WL. Handbook of the law of torts. 4th edn. St. Paul, MN: West Publishing Co.; 1971.
16. Brumbalow v. Fritz, 358 S.E.2d 872 (Ct. App Ga. 1987).
17. Griffith v. University Hospital of Cleveland, 2004 Ohio App. LEXIS 6733 (Dec. 9, 2004 OH Ct. App.).
18. Lyons v. Walker Regional Medical Center, Inc., 868 So.2d 1071, 1087–1088 (Ala. 2003).
19. Lee CA, Cho JP, Choi SC, Kim HH, Park JO. Patients who leave the emergency department against medical advice. Clin Exp Emerg Med. 2016;3(2):88-94. Published 2016 Jun 30. 
20. Kazimi M, Niforatos JD, Yax JA, Raja AS. Discharges against medical advice from U.S. emergency departments. Am J Emerg Med. 2020;38(1):159-161. 
21. Rabin E, Kocher K, McClelland M, et al. Solutions to emergency department 'boarding' and crowding are underused and may need to be legislated. Health Aff (Millwood). 2012;31(8):1757-1766. 
22. Clark MA, Abbott JT, Adyanthaya T. Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge. Acad Emerg Med. 2014;21(9):1050-1057. 
23. Thomas EJ, Burstin HR, O'Neil AC, Orav EJ, Brennan TA. Patient noncompliance with medical advice after the emergency department visit. Ann Emerg Med. 1996;27(1):49-55. 
24. Jerrard DA, Chasm RM. Patients leaving against medical advice (AMA) from the emergency department--disease prevalence and willingness to return. J Emerg Med. 2011;41(4):412-417. 
25. Brenner J, Joslin J, Goulette A, Grant WD, Wojcik SM. Against Medical Advice: A Survey of ED Clinicians' Rationale for Use. J Emerg Nurs. 2016;42(5):408-411.