[4 MIN READ]

As practitioners, we like to think our charm and skills are so valuable that no patient would possibly consider leaving the ED or hospital against our sage medical advice!

However, no matter how hard we try or how fast we work, a few patients will always choose to leave before an evaluation is complete—and against medical advice (AMA). Available data shows that about 1.2% of ED patients leave AMA.

Patients leave AMA for a variety of reasons:

• the wait is too long
• their expectations are not met
• they feel better
• they changed their mind
• and more.

It can also be a sign of ED throughput problems or legitimate patient dissatisfaction. 

No matter what the reason, AMA patients are high-risk.

Practitioners are wise to take a calm and reasoned approach to the AMA patient. Failure to do so can spell medical tragedy for the patient and malpractice disaster for the practitioner. Should a case come to litigation, the outcome will hinge on what was said, done, and documented when the patient left the ED or hospital, especially AMA.

As a guide to the AMA process, consider the following list of Do’s and Don’ts:

• Don’t ignore the patient who wants to leave AMA. If at all possible, stop what you are doing and prepare to address the issue.
• Do determine the decision-making capacity of the patient. Do they comprehend the information and consequences and understand the risks and benefits of the options, and can they communicate these back to you?
• Don’t blame or berate the patient or anyone else for their desire to leave.
• Do apologize if the patient has been waiting or if there have been delays in the patient care process. Apologies are free. Lawsuits cost millions.
• Don’t just ask the nurse to have the patient sign a generic AMA form and leave. This course of action provides little protection for the practitioner.
• Do enlist the patient’s family and friends in your attempt to convince the patient to stay.
• Don’t express your frustration and anger to the patient. Instead, earnestly convince them that your overriding interest is their well-being. Make sure they know that you are on their side against a potential threat to their health.
• Do document the patient’s “informed refusal” of crucial diagnostic testing (e.g., blood work or X-rays), procedures (e.g., LP to rule out meningitis or subarachnoid hemorrhage), or treatments (e.g., medications or transfusions) in the same detail as you would an AMA.
• Don’t refuse to provide treatment; this could be considered abandoning the patient. Provide whatever treatment, prescriptions, follow-up appointments, and specific discharge instructions the patient will accept.
• Do document the details of the AMA patient encounter in the patient’s chart (see samples below). Include documentation of the patient’s decision-making capacity, the specific benefits of your proposed treatment and risk of leaving AMA, what you did to get the patient to stay, and your compassionate interest in having the patient return for any reason. Have the patient sign an AMA form that addresses these details, witnessed by a family member and/or staff member.
• Don’t worry about whether or not the patient’s insurance will deny payment if they sign out AMA. Their insurance is not your problem, but a malpractice suit will definitely be your problem.

Are your physicians prepared to react appropriately in high-risk situations? Compare how 3 different organizations approach Physician Integration.

Sample “Leaving AMA” Chart Documentation

1. The patient has decided to leave against medical advice because ______.
2. They have normal mental status and adequate capacity to make medical decisions.
3. The patient refuses hospital admission and wants to be discharged.
4. The risks have been explained to the patient, including _________, worsening illness, chronic pain, permanent disability and death.
5. The benefits of admission have also been explained, including the availability and proximity of nurses, physicians, monitoring, diagnostic testing, treatment and ___________.
6. The patient was able to understand and state the risks and benefits of hospital admission. This was witnessed by nurse _________ and me.
7. They had the opportunity to ask questions about their medical condition.
8. The patient was treated to the extent that they would allow and knows that they may return for care at any time.
9. Follow-up has been discussed and arranged with Dr. ___________.

Sample Informed Refusal Documentation

(Lumbar Puncture, for example)

1. The patient has decided to refuse the procedure of lumbar puncture because ______.
2. They have normal mental status and adequate capacity to make medical decisions.
3. The risks of refusing the procedure have been explained to the patient, including the inability to detect meningitis or subarachnoid hemorrhage, worsening illness, brain damage, chronic pain, permanent disability and death.
4. The benefits of the procedure have also been explained, including the ability to test the spinal fluid for meningitis and subarachnoid hemorrhage and to determine the best treatment based on these results.
5. The patient was able to understand and state the risks and benefits of the lumbar puncture. This discussion was witnessed by nurse _______ and me.
6. They had the opportunity to ask questions about their medical condition.
7. The patient was treated to the extent that they would allow and knows that they may change their mind and have the lumbar puncture any time.

The Bottom Line

Take the AMA process seriously. The ultimate goal is to have the patient stay and complete the recommended treatment. If they still want to leave AMA, your best ally is thorough chart documentation AND a signed AMA form. Without these, the only defense you will have in a suit will be your word against that of everyone else.

Interested in other ways to lower your medical-legal risk? Check out our Patient Safety Fundamentals Program.

You might also enjoy:

• 10 Medical-Legal Basics Every Provider Must Know
• Case Examples of EMTALA Violations
• Principles of Informed Consent in Healthcare