When a patient decides they are leaving against medical advice (AMA) what responsibility does the physician have in their discharge process? When I was a resident in training, I would often receive a page from the nurse stating that Mrs Smith was demanding to leave the hospital immediately. I would tell the nurse, "Fine. Let her go. I am not her father." I would tell the nurse to discharge Mrs Smith with no medications and leave it up to the patient to make appropriate follow up arrangements. I was wrong, but I was not alone.
After a decade of hospitalist experience, I still run into situations where nurses and physicians feel this is an appropriate discharge plan. I've seen it over and over again. Many doctors and nurses continue to feel leaving AMA requires no discharge plan. Patients have a right to leave on their own free will. Doctors and nurses have an obligation to provide an appropriate discharge plan. Even if the patient makes a poor decision to leave the hospital, that decision will not prevent the medical team from losing a bad outcome lawsuit if they fail to provide an appropriate discharge plan. Here's a case report and a great clinical discussion on the ramifications for physicians who fail to provide appropriate discharge plans in these types of situations. Good clinical care and careful documentation are of paramount importance.
After a decade of hospitalist experience, I still run into situations where nurses and physicians feel this is an appropriate discharge plan. I've seen it over and over again. Many doctors and nurses continue to feel leaving AMA requires no discharge plan. Patients have a right to leave on their own free will. Doctors and nurses have an obligation to provide an appropriate discharge plan. Even if the patient makes a poor decision to leave the hospital, that decision will not prevent the medical team from losing a bad outcome lawsuit if they fail to provide an appropriate discharge plan. Here's a case report and a great clinical discussion on the ramifications for physicians who fail to provide appropriate discharge plans in these types of situations. Good clinical care and careful documentation are of paramount importance.
Will leaving against medical advice negate insurance coverage for the patient? While I can't speak for your private policy, Medicare will not deny payment if you leave AMA. Patient's have a right to refuse any and all therapies recommended by their physician. If a patient wished to be discharged, physicians can't hold them against their will if they have the capacity to make their own medical decisions. Physically preventing patients from exiting a hospital would be kidnapping. I can't imagine Blue Cross would deny payment for a patient's services already provided if they wished to leave the hospital against the advice of their physician. It just doesn't pass the common sense sniff test. Stop telling your patients their insurance won't pay!
What about the outcomes of patients who leave against medical advice? Are they at an increased risk of readmission, adverse events or death? One study reports a significantly increased likelihood of readmission within 15 days for patients who leave against medical advice with males who drink alcohol leading the way.
As a resident, I rarely got any legal education on patient care issues when I discharged patients leaving against medical advice. After a little research, my whole attitude about my responsibility as a physician in these situations changed. I used to just tell the nurse to have the patient sign out AMA and let them go. Now I will take the time to discuss Mrs Smith's concerns about continued voluntary hospitalization. Patients can often be convinced to stay when presented with the facts of their care and care plan. If Mrs Smith still chooses to leave after our discussion and I can document that I believe she has the capacity to make her own medical decisions, however poor, and that she understands the risks and benefits of leaving against medical advice, then I formally discharge her with all appropriate discharge medications, instructions, supplies and necessary follow up care.
Physicians should bill a routine inpatient hospital discharge, CPT® 99238 or 99239, or the appropriate outpatient discharge codes for observation patients leaving against medical advice. Again, patient's who wish to leave AMA should be formally discharged after informed consent is provided about the risks and benefits of leaving AMA.
If the patient needs an antibiotic prescription for pneumonia, write her a prescription for her medication. If she needs a heart pill, write her a prescription for her heart pill. Physicians have an obligation and a responsibility to provide a normal discharge process for patients leaving AMA.
Many physicians falsely believe that by formally discharging Mrs Smith, they are approving of the discharge plans. That couldn't be farther from the truth. Documentation should indicate that you disagree with her decision to be discharged but that you implemented safe discharge practices to minimize potential harm after she leaves the hospital. By discharging Mrs Smith, you are providing her with a standard of care that is expected in your community. Many subspecialists may refuse to see Mrs Smith on follow up after she leaves against medical advice believing that seeing her would increase their liability for practicing medicine on a patient who's actions increase the likelihood of a bad outcome. Again, that couldn't be farther from the truth. Patients in the hospital have the opportunity to refuse therapies and evaluations at anytime, including continued hospitalization.
Many physicians falsely believe that by formally discharging Mrs Smith, they are approving of the discharge plans. That couldn't be farther from the truth. Documentation should indicate that you disagree with her decision to be discharged but that you implemented safe discharge practices to minimize potential harm after she leaves the hospital. By discharging Mrs Smith, you are providing her with a standard of care that is expected in your community. Many subspecialists may refuse to see Mrs Smith on follow up after she leaves against medical advice believing that seeing her would increase their liability for practicing medicine on a patient who's actions increase the likelihood of a bad outcome. Again, that couldn't be farther from the truth. Patients in the hospital have the opportunity to refuse therapies and evaluations at anytime, including continued hospitalization.
What if I don't think a patient has the capacity to make their own medical decisions and they still feel like leaving against medical advice? I have been told by my experts in my community that because the patient was admitted to a medical wing and because they came in voluntarily I have no legal grounds to force them to stay, even if I believe they lack the capacity to make their own medical decisions. I have no legal basis to prevent them from leaving and in fact I could be charged with some sort of unlawful imprisonment charge if I tried to keep someone in the medical wing against their will, unless an emergency protective custody (EPC) order can be obtained before the patient leaves the hospital. This is rarely possible.
If I believe a patient leaving against medical advice lacks the capacity to make their own medical decisions, I let them leave the confines of the hospital, but I ask the floor to contact the police department to pick the patient up the moment they step foot outside the hospital doors. The police then make a determination as to whether the patient needs an emergency protective custody order to be evaluated in a psychiatric setting to prevent harm to themselves or to others around them.
If your patient is leaving against medical advice, take my advice and formally discharge them. You will save yourself a lot of potential legal trouble in our world where every bad outcome is someone else's fault and our legal system encourages an incredible lack of personal responsibility.
