Leaving Against Medical Advice (AMA): A Clinician’s Dilemma

“You’ll have to sign out against medical advice (AMA) . Your blood pressure is high.” The ER physician stood in the doorway of my room.

“What difference would it make now?” I asked.

The doctor fiddled with the cuffs of his white coat, then glanced at his cell phone.

I picked up my car keys.

“High blood pressure is dangerous,” he added.

I looked down at the floor, watching puddles form around my feet as the snow melted on my UGGs. A cold wind blew snow against the window, causing the blinds to rattle.

“I don’t know the cause of death,” I said.

The doctor tapped his foot on the floor; “You could have a stroke. And your insurance might not cover this visit, if you leave AMA.”

I leaned forward in my chair, holding my head in my hands. It was then that I saw the photograph tucked in the top of my purse. Perhaps this would help?

I reached into my purse and offered the picture to the doc – that grainy ultrasound image of my son.

“Do you want to see his picture?” The doctor shook his head. I crumpled in my seat. Tears gathered.

“High blood pressure might damage your kidneys or your heart,” he said, crossing his arms over his chest.

Damage my heart?

I bit down on my bottom lip, then formed my hands into a temple. My obstetrician had insisted I come to the ER.  I hadn’t wanted to come. The experience had been awful from the beginning.

I looked at the doctor through the arches of my fingers.

“Do you own a dictionary.” I asked.

“Yes – why?”

“You should look up the word empathy,” I replied in a quiet voice.

I got up then and walked out. I did not look back. Not once.

I had never left a hospital AMA before. And I have not left AMA since. Even now, years on, I know I made the right choice. It changed everything.

The AMA Dilemma

Certainly, patients discharged against medical advice are both a concern and a challenge for healthcare providers due to the increased risk of both litigation and adverse medical events. Furthermore, these patients are  more likely to be readmitted for the same or a related condition. Additionally, they frequently suffer from serious underlying pathology.

What does leaving against medical advice (AMA) mean?

When a patient leaves AMA, the patient is leaving before their treating physician recommends discharge or despite medical advice to the contrary.

This definition implies the patient received and understood the medical advice given. In practice, the term AMA is often used regardless of whether medical advice was given or not. Additionally, patients are frequently required to sign an AMA form. Unfortunately, these attestation forms are often confusing, coercive, and written in language beyond the reading level of the patient.

This creates two important questions:

• If a patient does not have sufficient information or understanding to make informed decisions, are they in fact leaving against medical advice?
• Shouldn’t health literacy be a consideration in AMA discharges?

Who leaves AMA?

Identifying those patients most at risk for leaving AMA is important if we are to design interventions to prevent it. Variables include:

• Alcohol or substance abuse
• Male sex
• HIV/AIDS
• Low socioeconomic status
• History of leaving AMA
• Black race
• Psychiatric disorders
• Absence of health insurance
• Homeless

AMA Healthcare Disparities

Certainly, the choice to leave a medical facility lies with the competent patient, but the choice to designate the discharge as AMA lies with the medical provider. Despite this, there is a lack of data about providers who discharge patients AMA. To fully understand AMA predictors, we need to know more about clinicians.

It is well known that clinician attitudes vary based on patient characteristics. Such variability may shape the quality of care given. Stigma may result in lower quality care resulting in poorer outcomes. Furthermore, if you consider the groups most at risk for AMA discharge, there’s clear intersectionality between them. For instance, a black sexual minority male is more likely to be homeless, less likely to have insurance, and at higher risk of depression or other mental illness. Consequently, a disproportionate number of patients leaving AMA come from stigmatized or marginalized minority groups.

Why do patients leave AMA?

Recognition of the reasons patients leave can help us negotiate these encounters. They may include:

• Personal and financial obligations
• Breakdown of communication between the patient and medical staff
• Dissatisfaction with care
• Lack of trust in the healthcare provider
• Not understanding the need for further testing or treatment

Medico-legal Considerations

Above all, providers need to be aware that the simple signing of an AMA form does not confer absolute medico-legal protection. Furthermore, not giving discharge instructions, follow-up or medications could be construed as coercion, negligence or unwillingness to consider alternative options for the patient. Moreover, advising a patient that their insurance will not cover their visit if they leave AMA is not only incorrect but could also be considered coercion.

This article provides an excellent review of medico-legal standards.

In Conclusion

For me, leaving the ER AMA gave me precious time alone with my son. Moreover, it removed me from a hostile and unpleasant situation. I returned to the hospital the next day to deliver my son. He had died suddenly in the second trimester. No amount of ER medicine would have changed that outcome. My experience that night precipitated my return to education and pursuit of a career as an emergency medicine PA.

Certainly, the onus is on all providers to carefully examine the role that their bias, language, and behavior might play in triggering an AMA discharge. Furthermore, patients must understand the medical advice given and the potential sequelae of their decisions if we are to document AMA. Providers should take time to explore their patient’s thinking and engage them in shared decision making. Repairing the patient-clinician alliance may help facilitate communication and rebuild trust. And of course, you don’t get told to read the dictionary…