Abstract
Discharges against medical advice are a common phenomenon accounting for 1–2% of discharges of general medical inpatients in the United States and Canada. They are more common in certain patient populations, but targeted interventions have been limited. Many institutional policies focus on conveying the potential risks of discharge and documenting that patients understand them. Focusing on the medical risks unfortunately ignores the varied reasons patients have for requesting discharge, including family obligations and financial concerns. Principled negotiation is a potential strategy to address requests for discharge that providers consider premature. This negotiation method seeks to develop wise outcomes efficiently by explicitly addressing the relationship, focusing on the underlying interests, considering a wide range of options, and seeking objective criteria. Providers of adult patients have an obligation to assure that patients discharged against medical advice possess medical decision-making capacity and do not fulfill the criteria for civil commitment. In addition, providers of pediatric patients should assure that discharge does not constitute medical neglect, i.e., patients are not at imminent risk of serious, preventable harm. If an agreement cannot be reached, providers should still assure that an adequate discharge plan is in place. Having patients sign the discharge plan may encourage their adherence.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Clark MA, Abbott JT, Adyanthaya T. Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge. Acad Emerg Med. 2014;21(9):1050–7.
Defillippis EM. When patients leave ‘against medical advice.’ The New York Times. Jan 12, 2017.
Yong TY, Fok JS, Hakendorf P, Ben-Tovim D, Thompson CH, Li JY. Characteristics and outcomes of discharges against medical advice among hospitalised patients. Intern Med J. 2013;43(7):798–802.
Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med. 2013;28(12):1657–62.
Dubow D, Propp D, Narasimhan K. Emergency department discharges against medical advice. J Emerg Med. 1992;10(4):513–6.
Jerrard DA, Chasm RM. Patients leaving against medical advice (AMA) from the emergency department – disease prevalence and willingness to return. J Emerg Med. 2011;41(4):412–7.
Reinke DA, Walker M, Boslaugh S, Hodge D 3rd. Predictors of pediatric emergency patients discharged against medical advice. Clin Pediatr (Phila). 2009;48(3):263–70.
Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417–20.
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;25(9):926–9.
Kraut A, Fransoo R, Olafson K, Ramsey CD, Yogendran M, Garland A. A population-based analysis of leaving the hospital against medical advice: incidence and associated variables. BMC Health Serv Res. 2013;13:415.
Stranges E, Wier L, Merrill CT, Steiner C. Hospitalizations in which patients leave the hospital against medical advice (AMA), 2007: statistical brief #78. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD; 2006.
Brook M, Hilty DM, Liu W, Hu R, Frye MA. Discharge against medical advice from inpatient psychiatric treatment: a literature review. Psychiatr Serv. 2006;57(8):1192–8.
Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse. 2004;30(2):489–93.
Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633–7.
Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Intern Med. 1995;10(7):403–5.
Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924–9.
Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568–71.
Targum SD, Capodanno AE, Hoffman HA, Foudraine C. An intervention to reduce the rate of hospital discharges against medical advice. Am J Psychiatry. 1982;139(5):657–9.
Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125(6):594–602.
Choi M, Kim H, Qian H, Palepu A. Readmission rates of patients discharged against medical advice: a matched cohort study. PLoS One. 2011;6(9):e24459.
Fiscella K, Meldrum S, Barnett S. Hospital discharge against advice after myocardial infarction: deaths and readmissions. Am J Med. 2007;120(12):1047–53.
Devpura B, Bhadesia P, Nimbalkar S, Desai S, Phatak A. Discharge against medical advice at neonatal intensive care unit in Gujarat. India Int J Pediatr. 2016;2016:1897039.
Mohseni M, Alikhani M, Tourani S, Azami-Aghdash S, Royani S, Moradi-Joo M. Rate and causes of discharge against medical advice in Iranian hospitals: a systematic review and meta-analysis. Iran J Public Health. 2015;44(7):902–12.
Jimoh BM, Anthonia OC, Chinwe I, Oluwafemi A, Ganiyu A, Haroun A, et al. Prospective evaluation of cases of discharge against medical advice in Abuja. Nigeria Sci World J. 2015;2015:314817.
Schaefer GR, Matus H, Schumann JH, Sauter K, Vekhter B, Meltzer DO, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med. 2012;27(7):825–30.
Alfandre D, Schumann JH. What is wrong with discharges against medical advice (and how to fix them). JAMA. 2013;310(22):2393–4.
Kettle KL, Haubl G. The signature effect: signing influences consumption-related behavior by priming self-identity. J Constr Res. 2011;38:474–89.
Levy F, Mareiniss DP, Iacovelli C. The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. J Emerg Med. 2012;43(3):516–20.
Battenfeld v. Gregory, 589 A2d 1059 (N.J. Super. Ct. App. Div. 1991).
Henson VL, Vickery DS. Patient self discharge from the emergency department: who is at risk? Emerg Med J. 2005;22(7):499–501.
Saitz R. Discharges against medical advice: time to address the causes. CMAJ. 2002;167(6):647–8.
Janz NK, Becker MH, Hartman PE. Contingency contracting to enhance patient compliance: a review. Patient Educ Couns. 1984;5(4):165–78.
Fisher R, Ury W, Bruce P. Getting to YES: negotiating agreement without giving in. 2nd ed. New York: Houghton Mifflin; 1991.
Arora R, Mahajan P. Evaluation of child with fever without source: review of literature and update. Pediatr Clin N Am. 2013;60(5):1049–62.
Watt K, Waddle E, Jhaveri R. Changing epidemiology of serious bacterial infections in febrile infants without localizing signs. PLoS One. 2010;5(8):e12448.
Biondi EA, Mischler M, Jerardi KE, Statile AM, French J, Evans R, et al. Blood culture time to positivity in febrile infants with bacteremia. JAMA Pediatr. 2014;168(9):844–9.
Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51(7):899–902.
Katz AL, Webb SA, Committee On Bioethics. Informed consent in decision-making in pediatric practice. Pediatrics. 2016;138(2):e20161485.
Testa M, West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010;7(10):30–40.
Jenny C. Committee on child abuse and neglect. Recognizing and responding to medical neglect. Pediatrics. 2007;120(6):1385–9.
Committee on Bioethics. Conflicts between religious or spiritual beliefs and pediatric care: informed refusal, exemptions, and public funding. Pediatrics. 2013;132(5):962–5.
Areen J. Intervention between parent and child: a reappraisal of the state’s role in child neglect and abuse cases. Geo L J. 1975;63:887–937.
Diekema DS. Parental refusals of medical treatment: the harm principle as threshold for state intervention. Theor Med Bioeth. 2004;25(4):243–64.
Hickey KS, Lyckholm L. Child welfare versus parental autonomy: medical ethics, the law, and faith-based healing. Theor Med Bioeth. 2004;25(4):265–76.
McDougall RJ, Notini L. Overriding parents’ medical decisions for their children: a systematic review of normative literature. J Med Ethics. 2014;40(7):448–52.
Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision making. Cambridge: Cambridge University Press; 1990.
Kopelman LM. The best-interests standard as threshold, ideal, and standard of reasonableness. J Med Philos. 1997;22(3):271–89.
Rhodes R, Holzman IR. The not unreasonable standard for assessment of surrogates and surrogate decisions. Theor Med Bioeth. 2004;25(4):367–85.
Swota AH. Changing policy to reflect a concern for patients who sign out against medical advice. Am J Bioeth. 2007;7(3):32–4.
Berger JT. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403–8.
Williams BR, Bezner J, Chesbro SB, Leavitt R. The effect of a walking program on perceived benefits and barriers to exercise in postmenopausal African American women. J Geriatr Phys Ther. 2006;29(2):43–9.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG, part of Springer Nature
About this chapter
Cite this chapter
Antommaria, A.H.M. (2018). Against Medical Advice Discharges: Pediatric Considerations. In: Alfandre, D. (eds) Against‐Medical‐Advice Discharges from the Hospital. Springer, Cham. https://doi.org/10.1007/978-3-319-75130-6_10
Download citation
DOI: https://doi.org/10.1007/978-3-319-75130-6_10
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-75129-0
Online ISBN: 978-3-319-75130-6
eBook Packages: MedicineMedicine (R0)