Against medical advice

Background

• AMA discharges account for approximately 1-2% of all ED discharges
• Patients who leave AMA have higher rates of readmission, morbidity, and mortality
• AMA does not waive the physician's duty of care — the standard of care still applies
• Signing an AMA form alone is insufficient
  • The quality of the documented conversation is what matters medicolegally
• A patient does not lose insurance coverage by leaving AMA (this is a common myth)
• Patients may still receive discharge medications, follow-up instructions, and prescriptions even when leaving AMA

Key Documentation Points

• Mental status at time of conversation
• Who was present during the AMA conversation (nurse, family members, interpreter, etc.)
  • Have nurses write a brief note about the AMA conversation if present
• Specific risks discussed for leaving against medical advice, including the possibility of death or serious disability
  • Patient understood risks and was able to verbalize them back
• Return precautions including that they may return at any time
• Provide written discharge instructions as documentation that precautions were reviewed
• Alternative treatments offered that the patient declined
• Prescriptions provided and follow-up recommended despite AMA departure

Determining Capacity

• Four components must be present for decision-making capacity. The patient must be able to:
  • Understand the relevant information
  • Appreciate the situation and its consequences
  • Reason through treatment options
  • Communicate a choice
• Capacity is task-specific and can fluctuate
  • Intoxication alone does not necessarily eliminate capacity, but must be assessed
• If the patient lacks capacity and wishes to leave, use the least restrictive measures to ensure safety
• Psychiatric holds (e.g., 5150) may be appropriate if the patient is a danger to self and lacks capacity
• See also Informed consent documentation

Sample Documentation

The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital.

In this scenario, it would be battery to subject a patient to treatment against his/her will.

I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed.

I discussed the specific benefits of additional treatment, as well as tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient. However, the patient declined my options and insisted on leaving.

Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.

Common Pitfalls

• Refusing to provide prescriptions or discharge instructions to AMA patients (this is not appropriate — always treat what you can)
• Failing to document specific risks discussed (do not rely solely on a signed AMA form)
• Not offering alternatives (e.g., "if you won't stay for the CT, would you at least let us check labs?")
• Assuming intoxicated patients automatically lack capacity
• Not documenting who was present during the AMA discussion

See Also

Documentation Pages

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations

External Links

• ALIEM - The Proper Way to Go Against Medical Advice