My pager vibrated against my waist as I was making afternoon rounds. I called the nursing station, and they told me my cardiac patient, who needed a valve replacement, was going to leave “AMA”—against medical advice—and I would need to convince her to stay. As I walked into her room, I saw a woman in her mid-50s crying in her hospital bed with her walker propped beside the table. She was admitted for heart failure due to a failed heart valve that needed to be repaired. 

 

 

A patient who promised to return

 

This patient’s heart valve failed early on in life due to a childhood episode of rheumatic fever following a case of untreated strep throat. Her mother was in and out of rehab for drug addiction and was not around to provide her with medical care.

She had previous hospital admissions, understood her disease, and knew it would worsen without proper treatment. During those past admissions, she always had a family member by her side, but unfortunately, nobody could come during her current stay. The idea of staying in the hospital room alone terrified her, as she was haunted and traumatized by feelings of abandonment from her childhood. I tried to barter and plead with her to change her mind, but after a while, I realized she had made her decision. 

I knew it was not my job to force her to stay against her will. I realized that I was causing more suffering by keeping her in the hospital.

After discussing her case with the medical team, I told her she could leave after I booked her an appointment in the clinic for follow-up within 3 days. Tears of joy rolled down her face, and she thanked me. After her clinic follow-up appointment, she returned to the hospital and had her elective valve replacement. 

 

When we forget our patients are real people

 

Any patient who understands the risks and benefits of forgoing medical care is able to leave AMA at any time. Nevertheless, healthcare professionals often stigmatize such patients, labeling them as noncompliant, ungrateful, or unwilling to accept appropriate medical care. 

Patients leaving AMA occurs more often than we would like. As physicians, we do everything in our power to educate on the risks of leaving the hospital before having a full workup and treatment plan. When our patients leave AMA, we often become frustrated and risk ruining our relationship with them. No wonder these patients are “noncompliant” and do not follow up in our clinics. Many patients avoid seeking ongoing medical care,

Alfandre D, Schumann JH. What is wrong with discharges against medical advice (and how to fix them). JAMA. 2013 Dec 11;310(22):2393-4.

due in part to their circumstances and the resistance they meet from doctors.

Querques J, Kontos N, Freudenreich O. Discharges against medical advice. JAMA. 2014 May 7;311(17):1807-8.

 

I have seen my fair share of attending physicians threaten never to see these patients again if they leave AMA, telling them things like, “Your insurance will not cover this hospital stay.”

 

This is difficult to watch from the sidelines, but I like to believe that we, as physicians, are wired to treat our patients, but we often forget that they have a life outside of the hospital walls. We sometimes isolate our patient’s medical illnesses without having any regard for what is going on in their personal lives or circumstances outside of their physical health. 

 

AMA patients are traditionally of the underserved patient population

 

Approximately 1 to 2 percent of all hospital discharges are against medical advice.

Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010 Sep;25(9):926-9.

Many patients who leave AMA are young males who struggle with underlying substance abuse and mental health disorders and tend to be poor. 

 

When our patients leave AMA, physicians know it results in a higher likelihood of increased morbidity and mortality and they are more likely to be readmitted to the hospital, usually within the first 2 weeks.

 

The bigger picture

 

As physicians, we must take a step back, consider each case on its merits, and explore the underlying reasons our patients want to be discharged from the hospital. This often requires putting our egos aside and having an open, honest, and empathetic conversation with each patient. We often assume that keeping our patients in the hospital is better for their health. Still, we often forget that our patients’ mental and emotional health is just as important as their physical health. 

Medicine is often a tricky balancing act between shared decision-making among the physician and patient, knowing we cannot ultimately control our patients regardless of how much we try. What happens if a patient wants to be discharged from the emergency room with an evolving myocardial infarction? Unless we have evidence that the patient is homicidal or suicidal, we cannot keep them against their will, even if they are at risk of mortality after leaving the hospital. 

If they still wish to leave against our medical advice, we have no other option but to document the conversation and the risks involved, and document the departure as AMA. Even in these cases, we should do our due diligence and work with the patient to form a follow-up plan, prescribe medications, and assure the patient they are welcome in our care at any time. 

What we do not want to do is make this an adversarial transaction to worsen the doctor-patient relationship, which can lead to further noncompliance.