Patients often make a decision to act against medical advice (AMA) despite being potentially detrimental to their health. Approximately 1.5% of discharges from hospital facilities are categorized as AMA. These patients are at a clearly heightened risk for further illness. When medical providers encounter patients who insist on being discharged, it is essential that informed consent is obtained and proper documentation is made. The patient should be made aware of the consequences and alternatives through a documented consultation and their actions must be voluntary (without coercion).
AMA Patient Characteristics
Some of the most likely characteristics that exist among these patients include:
- They are most likely to be younger males that live alone
- Often they have psychiatric conditions and/or problems with drug or alcohol abuse
- They are most likely to have low income and may be homeless
- These individuals are commonly hospitalized, yet may have limited health literacy
- Many AMA patients cite family or financial problems as influencing their decision
- They often are dissatisfied with their treatment and are subjected to long wait times
Understanding Informed Consent
Physicians are required to obtain informed consent from patients based on ethical obligations. The principle is that patients should comprehend and freely enter the treatment process. Prior to receiving care, the patient should be made aware of all relevant information so an educated decision may be made. Informed consent is essentially an agreement that is reached allowing for a particular treatment to be performed. The patient should always ultimately decide what happens to their body.
Required Disclosures of Informed Consent
The following disclosures should be formally made according to the case of Canterbury v. Spence (1972):
- The type of condition that requires treatment or care
- Characteristics and nature of the treatment or procedure
- The likely results of the treatment (and of not having treatment)
- Potential alternatives that may be considered
- Disclosure of the potential risks, consequences, and benefits that will result
Importance of Proper Documentation
Having proper documentation is critical in the defense of claims of medical malpractice involving AMA patients. Patients may be asked to sign an “AMA form”; however, completion of this form alone does not guarantee that the provider will be shielded from negligence. Physicians should conduct an assessment to determine the patient’s decision-making capabilities. This may be done with assistance from a psychiatrist. Data suggests that medical providers typically do discuss these decisions with AMA patients, yet they rarely document them sufficiently. Specialists in these situations should inform the patient’s primary care physician of the event.
Patients who discharge themselves AMA have a much greater likelihood of returning to the hospital and being readmitted within a two week period. Physicians are challenged with finding a medium (balance) between maintaining patient autonomy and ensuring their safety. The overall goal is to proactively address AMA situations to lower the number of occurrences. Doctors often find themselves in contentious situations with patients seeking discharge. When these situations arise the best course of action for the physician is to make sure that the proper assessment and documentation is completed.
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