AAOS Now

Published 11/1/2012
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Thomas B. Fleeter, MD

When a Patient Leaves Against Medical Advice

The patient with a comminuted impacted distal radius fracture arrived at the emergency department (ED) inebriated, hostile, and angry. The ED physician hastily splints the wrist and sends the patient for radiographs.

As the on-call orthopaedic surgeon, you are in the operating room, and it’s more than an hour before you can see the wrist-fracture patient. Despite your apology about the delay, the patient becomes more upset. The flustered nurse offers him a “Discharge Against Medical Advice (AMA)” form, which he grabs, signs, and then staggers from the ED.

Are you protected from a medical liability lawsuit if the wrist fracture results in a malunion and subsequent deformity?

A difficult choice
Surprisingly, there is a paucity of literature available describing the consequences of patients who leave against medical advice (AMA). Although logically patients who leave AMA should be held responsible for any future consequences, a signed AMA form is not an absolute defense of medical liability. In fact, if the patient left AMA after a dispute with the physician, courts may view the premature discharge as a retaliatory move by the physician and then view the physician as liable.

A review of various sources finds that the percentage of AMA discharges from general hospitals ranges from 0.8 percent to 2.0 percent. The average patient who leaves AMA is young, male, living alone, and has additional medical issues. Psychosocial issues include anger, fear, and psychosis. Patients who leave AMA have a 4-times higher rate of readmission within 30 days than other patients. Although a Medline search of cases found few in which an AMA discharge was related to a liability suit, unhappy patients do sue more often and patients who leave AMA are certainly dissatisfied. When physicians and hospitals have been sued following AMA discharges, the plaintiff has often been successful.

If a patient wishes to leave, should you, as the treating physician, try to persuade him or her to remain for treatment? The goal should be to provide the best possible care under difficult circumstances. However, leaving AMA does have legal consequences as the following cases show.

Lyons v. Walker Regional Medical Center
In this case, which was decided by the Alabama Supreme Court, an incarcerated patient was transferred to the ED with abdominal pain. The patient refused treatment and left AMA. He died several days later of diabetic ketoacidosis. The hospital cited contributory negligence, but the court sided with the defendant because the patient was not informed of his condition or the danger in leaving without treatment.

Battenfeld v. Gregory
In this New Jersey case, a patient who was 5 months pregnant was admitted to the maternity ward with abdominal pain. After a miscarriage, she felt well enough and wanted to go home for a family holiday. Her treating physician was aware that she still had a fever and elevated white blood count but did not inform her of the lab results or their implications. The physician offered her the option of going home if she signed an AMA form.

A few days later, the patient was readmitted to the hospital for a laparotomy and appendectomy. She sued successfully, saying that she would have stayed in the hospital if she had understood the serious nature of her condition.

Rivera v. Queen of the Valley Hospital
In this California case, the patient came to the ED complaining of pain between the shoulder blades. Due to the atypical pain, the patient was not immediately brought to the treating area but remained in the waiting area and was checked by the triage nurse. When the patient became frustrated by the wait and wanted to go home, the nurse had him sign an AMA form. Later that evening, the patient died at home of a heart attack. The case was decided in favor of the patient; the court found that the nurse was negligent in not fully informing the patient of the consequences of the decision to leave without a full evaluation.

What’s a doc to do?
The lesson to be learned from these cases is that it is always best to avoid an AMA decision. Before giving the patient an AMA form, try to determine why he or she insists on leaving. The patient may be afraid of being hospitalized or worried about the financial implications, in which case you may be able to offer treatment options that may not require hospitalization.

Identifying family members or friends who might be persuasive can help eliminate the need for an AMA discharge. Even bargaining for time—such as by offering a meal—can be helpful in avoiding an AMA discharge. The added wait may allow the patient to reconsider the decision.

If you, as the treating physician, and the hospital staff are still unable to make the patient reconsider, you may need to determine whether the patient has the capacity to make the decision to leave AMA. Patients who are under the influence of drugs or alcohol should probably not be allowed to leave. It may be necessary to obtain a psychiatric evaluation to determine mental competency.

Simply noting that the patient is inebriated may not provide protection against liability. A detailed description of the patient’s mental status and overall appearance, including inappropriate actions the patient has taken, should be included in the chart. However, be cautious about restraining patients against their wishes, because this can expose you and your hospital to a suit for unlawful imprisonment.

If all efforts to persuade the patient to stay fail, it is important to ask the patient to sign the AMA form. If family members are present, they should also be asked to sign the form. Having another medical staff member witness the form can also be helpful. It is not permissible to require the patient to sign a form releasing the hospital or physician from liability for malpractice claims.

In the event that an AMA discharge cannot be avoided, make sure to document that the patient understands the nature of the illness and the consequences of leaving against medical advice. Also document that the patient possesses the mental capability in making this decision. Finally, ascertain that the patient does not meet the state standard for involuntary psychiatric hospitalization.

Thomas B. Fleeter, MD, chairs the AAOS Medical Liability Committee. He can be reached at bonedock@comcast.net

Editor’s Note: Articles labeled Orthopaedic Risk Manager (ORM) are presented by the Medical Liability Committee under the direction of David H. Sohn, JD, MD, ORM editor.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

Email your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

Steps to remember
Before a patient leaves AMA, the treating physician and/or hospital staff should take the following steps:

  1. Assess the patient’s decision-making ability:
    • Assess the decision-making ability
    • Document the capacity in the chart
    • Document the discussion held with the patient
  2. Attend to follow-up arrangements:
    • Discuss possible treatment scenarios
    • Arrange for phone, home, or outpatient follow-up
    • Provide needed prescriptions
    • Document efforts in the chart
  3. Communicate:
    • Provide the patient with a summary of diagnosis and treatments and follow-up plans
    • Communicate with the patient’s primary care physician if possible
    • Communicate with next of kin (with the patient’s permission)
    • Document communication efforts in the chart

Additional References

  1. Devitt PJ, DevittAC, Deswan M: Does identifying a discharge as “against medical advice” confer legal protection? J Fam Pract 2000;49(3):224-227.
  2. Sullivan W: Patients leaving against medical advice: Avoiding legal Pitfalls. Emergency Physician’s Monthly Magazine, March 2001.
  3. Alfandre D: “I’m going home”: Discharges against medical advice. Mayo Clin Proc 2009;84(3):255-260. Review.
  4. Hwang S: Discharge against medical advice. Web M&M, May 2005.