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Discharging Patients "Against Medical Advice"
Anthony Rudine -- I often have discussions with my attendings on issues outside of specific patients' problems, and more generalized philosophical conversations on medical care. The most recent discussion was perhaps the most interesting.
I spoke with two different physicians, both board certified in psychiatry. The discussion centered around the relevance and the usage of the "against medical advice" discharge. To be honest, I had never thought about the relevance of this particular discharge.
The first physician, who brought up the conversation to begin with, claimed that an AMA discharge should never be used in clinical practice because it is essentially meaningless. His thinking was that the patient is in control of their own treatment and that physicians must be careful in separating what is best for the patient from what is best for the patient medically. He claimed that it was their right not to follow the treatment and advice of the treating physician, and that if it was essential that the patient stay, they should be held under an operation of protective custody, or something similar. He also stated that in his thirty years of clinical practice, he has rarely used a discharge of AMA.
The other physician I spoke with, however, felt much differently. She stated that a discharge of AMA is vitally important to the medical community, and not for the reasons that I would have thought. Her reasoning was that, although a patient may not be suicidal, homicidal, or hallucinating (the generally accepted reasons for holding a patient on an emergency detention), they still could present a clear psychiatric danger, yet it might not be possible to keep them for treatment against their will. Thus, a discharge of against medical advice must be used. She also stated that patients often fall through the cracks of the system in not meeting criteria for emergency detention, while the physician still feels that there is a danger in releasing the patient.
I had never really thought of the arguments of the situation, and am personally convinced that the AMA discharge is useful. What do you think?
October 10, 2006 | Permalink
Comments
I think the other "perk" to discharging patients because they do not want to be treated and go against the doctor's advice is a legal matter. If the physician truly feels the patient must stay but the patient checks themself out anyway and then goes and does something terrible or stupid, the physician has some sort of backing that they were against the patient checking themselves out....
Posted by: momo | Oct 17, 2006 7:24:33 AM
This issue of AMA in the context mentioned is a tough one. I think there is a bigger issue here and you hit on it quite well.Too many people are falling through the cracks. The legal seems at times to tie the hands of the doctors trying to help.By the time the patient does become a harm to themselves or others it is often too late. Having said that I would have the patient the sign the AMA paperwork just to cover my own butt if I am sued. God I never thought I would get to a point I would say something like that.It seems that coming and going you have to watch your backside when it comes to malpractice. :o( These conscience issues can be tough.
Posted by: Sarah Hobbs | Oct 17, 2006 3:20:39 PM
AMA is definatly a CYA discharge. You have a severe hypertension situation and the patient insists on leaving. The MI or Stroke that hits them on the way home or in the next day or even month could find its way back to you. My thoughts are that AMA is a way to say "You arent following steps in what is thought to be critical in your care. I can not hold you against your will for your condition but I advise you not to go." Its that simple and a very critical step for the physician to take in the world of lawsuit happy people. Should your patient die you better believe that the bereaved will come looking for answers. Extra steps may also be warranted such as calling a local ER with the patient in the room with you and telling them that the patient may be there later. It seems overly dramatic but will cover your bases in case something does happen. It may help to impress upon the patient the seriousness of what is going on while showing tat you care about their health.
Posted by: ChefMo | Oct 17, 2006 5:29:48 PM
I am an intern in Internal medicine. Interestingly, while on Cardiology rotation we had a 40-something year old patient with multivessel CAD which required CABG. The patient was admitted to the hospital by another attending to our service with the hopes that we could convince him to go through with the surgery. The next day the patient wanted to leave. When we entered the room on rounds he was fully dressed and demanding that his IV sites be removed. Since this was expected, we discharged him with the explicit instruction that it was AMA and that he should take the prescribed list of medications. The attending said that the patient could go since he had the right to choose to not have surgery.
To make this long story short, this man presented the following week to the ED with a large AMI and in CHF. He coded in the ED and died that day.
We must remember that patients have the right to choose to be unhealthy and go against our advice. Our job is to ensure that the patient makes an informed and educated decision.
Posted by: cuanzo | Oct 21, 2006 6:54:39 AM
I think an AMA is very useful. It states that what the patient will do is his personal opinion after having heard the professional opinion of his doctor's. It's human nature to want to blame ur mistakes on anyone else. In this case, the patient can't. I know this sounds dry but at the end of the day, do u really want a patient's family to assume (even if wrongfully) that u didn't do ur job properly? I wouldn't :)
Posted by: | Oct 21, 2006 7:30:03 AM
I don’t know if the problem of discharging patient is the same everywhere. In Côte d’Ivoire, there’re 2 reasons which lead to discharging, either patients are poor or they estimate not to be very well treated. But in two cases, it’s a great problem. In my country, there’s not French national health and pensions organization like in developed countries. Medical units have no drugs for patients. So if patients don’t pay drugs for their health, doctor can’t work. In this context, I think that it’s necessary for authorities or world health organization passing a law on “Against Medical Advice” discharge. Because doctors are not monsters, and it’s very difficult to take alone such responsibility; above all, when discharging concerns neonates
Posted by: nassirou faïssal | Oct 24, 2006 3:34:42 AM
