Against Medical Advice (AMA): Clinical Pearls Blog

Gerard Kiernan, MD, FAAFP, FHMClinical Pearls, Emergency Medicine, Family Medicine, Internal Medicine, Nurse Practitioner, Pediatric Medicine, Urgent Care

against medical advice AMA discharge

Against Medical Advice (AMA)

Clinical Pearls of Wisdom Q&A Case

When a patient leaves against medical advice - or AMA, the patient is leaving before their treating physician recommends discharge or despite medical advice to the contrary. This definition implies the patient received and understood the medical advice given. In practice, the term "AMA" is often used regardless of whether medical advice was given or not.  Patients may lack the capacity to fully understand such decisions and their risks. Add in the fact that AMA attestation forms are often written beyond the literacy level of patients and patients, it can be difficult to prevent a patient from leaving the care center against medical advice.  Let's take a look at a case and discuss how to handle a patient who wants to leave your facility against medical advice.

Against Medical Advice (AMA) Case:

A 32-year-old man has been hospitalized for a day, due to sepsis.

The source of infection was an abscess and cellulitis on the right forearm, where he had injected drugs.

His initial blood cultures, obtained in the emergency department, were positive for gram positive cocci eighteen hours after being drawn.

He was initially hypotensive, tachycardic and febrile, but his vital signs normalized with fluid administration, acetaminophen and antibiotics.

His comorbidities include ADHD, depression, and hepatitis C which has not yet been treated.

The patient’s nurse calls, saying that the patient is angry at being restricted to the hospital and was planning to leave, since ‘he had lots of things that he needed to do’.

Question:

What is the most appropriate next step in this situation where the patient is contemplating acting against medical advice?

Answer Options:

Explain to the nurse that the patient is likely withdrawing from street drugs and that they can’t be allowed to leave, since they will likely inject drugs and then not return for ongoing treatment.

Ask the nurse to remind the patient that if they leave AMA, their insurance will not pay for their stay.

Ask the nurse to have the patient sign the hospital’s AMA form and have them leave after that.

Evaluate the patient in person and determine whether they have the capacity to make the decision to stay or to leave. Explain and document the rationale for staying. If they still wish to leave, work with the patient to reduce harm by planning the best possible follow-up and prescriptions.

See the Answer:


About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

About Clinical Pearl of the Month:

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Against Medical Advice Discharge AMA

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