Against Medical Advice Discharges: Pediatric Considerations

  • Armand H. Matheny AntommariaEmail author


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.


Against medical advice Discharge Pediatrics Principled negotiation Medical neglect 


  1. 1.
    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.CrossRefPubMedGoogle Scholar
  2. 2.
    Defillippis EM. When patients leave ‘against medical advice.’ The New York Times. Jan 12, 2017.Google Scholar
  3. 3.
    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.CrossRefPubMedGoogle Scholar
  4. 4.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Dubow D, Propp D, Narasimhan K. Emergency department discharges against medical advice. J Emerg Med. 1992;10(4):513–6.CrossRefPubMedGoogle Scholar
  6. 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.CrossRefPubMedGoogle Scholar
  7. 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.CrossRefGoogle Scholar
  8. 8.
    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.PubMedPubMedCentralGoogle Scholar
  9. 9.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    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.Google Scholar
  12. 12.
    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.CrossRefPubMedGoogle Scholar
  13. 13.
    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.CrossRefPubMedGoogle Scholar
  14. 14.
    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.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Intern Med. 1995;10(7):403–5.CrossRefPubMedGoogle Scholar
  16. 16.
    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.CrossRefPubMedGoogle Scholar
  17. 17.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    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.CrossRefPubMedGoogle Scholar
  19. 19.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Fiscella K, Meldrum S, Barnett S. Hospital discharge against advice after myocardial infarction: deaths and readmissions. Am J Med. 2007;120(12):1047–53.CrossRefPubMedGoogle Scholar
  22. 22.
    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.PubMedGoogle Scholar
  23. 23.
    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.PubMedPubMedCentralGoogle Scholar
  24. 24.
    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.Google Scholar
  25. 25.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Alfandre D, Schumann JH. What is wrong with discharges against medical advice (and how to fix them). JAMA. 2013;310(22):2393–4.CrossRefPubMedGoogle Scholar
  27. 27.
    Kettle KL, Haubl G. The signature effect: signing influences consumption-related behavior by priming self-identity. J Constr Res. 2011;38:474–89.CrossRefGoogle Scholar
  28. 28.
    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.CrossRefPubMedGoogle Scholar
  29. 29.
    Battenfeld v. Gregory, 589 A2d 1059 (N.J. Super. Ct. App. Div. 1991).Google Scholar
  30. 30.
    Henson VL, Vickery DS. Patient self discharge from the emergency department: who is at risk? Emerg Med J. 2005;22(7):499–501.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Saitz R. Discharges against medical advice: time to address the causes. CMAJ. 2002;167(6):647–8.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Janz NK, Becker MH, Hartman PE. Contingency contracting to enhance patient compliance: a review. Patient Educ Couns. 1984;5(4):165–78.CrossRefPubMedGoogle Scholar
  33. 33.
    Fisher R, Ury W, Bruce P. Getting to YES: negotiating agreement without giving in. 2nd ed. New York: Houghton Mifflin; 1991.Google Scholar
  34. 34.
    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.CrossRefGoogle Scholar
  35. 35.
    Watt K, Waddle E, Jhaveri R. Changing epidemiology of serious bacterial infections in febrile infants without localizing signs. PLoS One. 2010;5(8):e12448.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    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.CrossRefPubMedGoogle Scholar
  37. 37.
    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.CrossRefPubMedGoogle Scholar
  38. 38.
    Katz AL, Webb SA, Committee On Bioethics. Informed consent in decision-making in pediatric practice. Pediatrics. 2016;138(2):e20161485.CrossRefPubMedGoogle Scholar
  39. 39.
    Testa M, West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010;7(10):30–40.Google Scholar
  40. 40.
    Jenny C. Committee on child abuse and neglect. Recognizing and responding to medical neglect. Pediatrics. 2007;120(6):1385–9.CrossRefGoogle Scholar
  41. 41.
    Committee on Bioethics. Conflicts between religious or spiritual beliefs and pediatric care: informed refusal, exemptions, and public funding. Pediatrics. 2013;132(5):962–5.CrossRefGoogle Scholar
  42. 42.
    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.Google Scholar
  43. 43.
    Diekema DS. Parental refusals of medical treatment: the harm principle as threshold for state intervention. Theor Med Bioeth. 2004;25(4):243–64.CrossRefPubMedGoogle Scholar
  44. 44.
    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.CrossRefPubMedGoogle Scholar
  45. 45.
    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.CrossRefPubMedGoogle Scholar
  46. 46.
    Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision making. Cambridge: Cambridge University Press; 1990.CrossRefGoogle Scholar
  47. 47.
    Kopelman LM. The best-interests standard as threshold, ideal, and standard of reasonableness. J Med Philos. 1997;22(3):271–89.CrossRefPubMedGoogle Scholar
  48. 48.
    Rhodes R, Holzman IR. The not unreasonable standard for assessment of surrogates and surrogate decisions. Theor Med Bioeth. 2004;25(4):367–85.CrossRefPubMedGoogle Scholar
  49. 49.
    Swota AH. Changing policy to reflect a concern for patients who sign out against medical advice. Am J Bioeth. 2007;7(3):32–4.CrossRefPubMedGoogle Scholar
  50. 50.
    Berger JT. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403–8.CrossRefPubMedGoogle Scholar
  51. 51.
    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.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PediatricsCincinnati Children’s Hospital Medical CenterCincinnatiUSA

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