II. Epidemiology

  1. Incidence of Leaving AMA
    1. Overall: 1-2%
    2. Inner city hospitals serving disadvantaged
      1. General patients: 6%
      2. HIV or AIDS: 13%

III. Risk Factors: Leaving AMA

  1. Substance Abuse
  2. Uninsured or insured on Medicaid
  3. Male
  4. Young adults

IV. Protocol: Approach to AMA Decisions (or Informed Refusal)

  1. Focus on protecting the patient from harm (and this will in turn be the best protection for the provider)
  2. Establish trust with patient (focus on open communication)
    1. Maintain a good rapport with the patient
    2. Allow them to feel that you respect them
    3. Patients may refuse some or all of a providers recommendations and still remain under their care
    4. Offer alternatives to recommended treatment plan that allow the patient to make choices
  3. Negotiate for time for patient to make informed decision
  4. Shared decision making is an alternative to AMA
    1. Non-high risk patients may choose to defer part of the evaluation to future visits
    2. Often cost implications may lead a patient to prefer continuing the evaluation outpatient
    3. Shared decision making requires reasonable, safe alternatives
  5. Employ a family member to discuss risks and benefits further with patient

V. Protocol: Documentation of AMA Decisions (or Informed Refusal)

  1. Document adequate Decision-Making Capacity
    1. See Medical Decision-Making Capacity
    2. See CURVES Capacity Assessment Tool
    3. Adult with no Altered Level of Consciousness and clinically sober
    4. Intact judgment and reason consistent with the facts and their values
    5. Patient understands the condition and treatment in their own context and communicate their choices clearly
  2. Document provider's discussion with patient (explained to the patient in lay language)
    1. Why staying in medical facility and undergoing recommended management is important
    2. Why leaving presents a serious and immediate health risk
      1. Specifically describe possible consequences including death
      2. Review potential disabilities (e.g. blindness, amputation, Infertility)
    3. What reasonable options exist for evaluation and management
    4. Patient may return at any time
    5. Consider asking the patient to repeat back the potential consequences of Leaving AMA
    6. Confirm that the patient no longer wishes to participate in your care plan (termination of duty)
  3. Document exact wording of discussion
  4. Document which family members were present for the discussion
  5. Nurses should also document their interactions and measures
  6. Obtain a signature from the patient
    1. If patient refuses signature, obtain signature by witnessing family member, nurse or other witnessing staff
    2. In legal practice, AMA form signature does not truly shield a hospital or provider from law suit
    3. The AMA form does not replace careful documentation as described above
    4. The form does add additional documentation of a providers attempt to communicate with the patient
  7. Example
    1. Patient is leaving Against Medical Advice.
    2. They have Medical Decision-Making Capacity and understand the risks of leaving.
    3. Risks include permanent Disability and death in the immediate future
    4. I have answered their questions and offered them care at any time if they choose to return.
    5. I have also recommended that they pursue follow-up with their primary care provider.

VI. Protocol: Disposition

  1. Treat AMA as a discharge process
  2. Sit down and answer questions
  3. Arrange reasonable follow-up plan
  4. Medications may be offered that will benefit the patient (but that will not mask worsening or complications)
  5. Give the patient formal Discharge Instructions
  6. Welcome them to return at any time

VII. Complications

  1. Poor patient outcomes
  2. Lawsuit
    1. Risk of lawsuit is increased 10-100 fold in AMA cases (rate as high as 1 lawsuit in every 300 AMA cases)

VIII. Resources

  1. ALiEM: Proper Way to Go AMA (Matthew DeLaney, MD)
    1. http://academiclifeinem.com/proper-way-to-go-against-medical-advice/
  2. Medscape: The Importance of a Proper AMA Discharge
    1. http://www.medscape.com/viewarticle/770719_2

IX. References

  1. Bradford-Saffles and Arambasick (2013) Crit Dec Emerg Med 27(6): 11-5
  2. Lin and DeLaney in Herbert (2014) EM:Rap 14(9): 1-2
  3. Henry (2013) Avoid Being Sued, EM Bootcamp, CEME
  4. Orman, Weinstock and Rogers in Herbert (2017) EM:Rap 17(8): 7-9

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Ontology: Left Against Medical Advice (C2919670)

Definition (NCI) A designation that a patient has chosen not to heed the directions that medical staff has advised, and has chosen to leave the facility.
Definition (NCI_CDISC) The patient vacated the medical center or ceased medical care contrary to the recommendation of a trained healthcare provider.
Concepts Finding (T033)
SnomedCT 445060000
HL7 07
English Left against medical advice (finding), Left against medical advice, Left AMA, Left Against Medical Advice, Left Against Medical Advice or Discontinued Care, Left against medical advice or discontinued care
Spanish se fue en contra del consejo médico, se fue en contra del consejo médico (hallazgo)