Retiring the “Against Medical Advice” Discharge

[DrMetal]

https://www.acpjournals.org/doi/10.7326/M22-2964

Anybody else see this article in Annals ? It really pissed me off. It's a great example of physicians 'beating up' on each other for things outside of their control (mostly). It also ignores the futility of medicine (yes, some medicine is futile). How on earth would changing AMA to BMA ('before medical advice') affect anything?

Did make me wonder though: how do you all deal with AMA discharges? Do you write a DC summary, order meds? Or do you refrain from doing such things, because in so doing, you may be condoning the patient's ill decision? Does your institution give you crap for AMA discharges? [Mine doesn't, we're way too busy.]

And what are we supposed to do, how much time and effort are we supposed to devote to these patients, when there are plenty of other sick people that do want our help???

What a load of crap . . .

Retiring the “Against Medical Advice” Discharge​

Robert A. Kleinman, MD
,
Thomas D. Brothers, MD
, and
Nathaniel P. Morris, MD
Author, Article, and Disclosure Information
https://doi.org/10.7326/M22-2964

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Most clinicians are familiar with the following scenario: A patient hospitalized with a serious illness asks to leave. The patient's illness would likely improve with further treatment, but despite entreaties from the clinical team, the patient wishes to go. Following hospital policy, a clinician asks the patient to sign a form describing the risks of leaving, and the patient scribbles a signature. The team completes discharge paperwork and indicates that the discharge was “against medical advice,” or “AMA.” We believe it is time to retire the “AMA” designation.
Against medical advice discharges are common, particularly among patients facing socioeconomic disadvantages. ...

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[gutonc]

I saw a new one the other day, PDD or "Patient Directed Discharge". Same BS, different phrase.

 

[DrMetal]

I saw a new one the other day, PDD or "Patient Directed Discharge". Same BS, different phrase.

Yeah, the authors of this article make mention of "Patient Direct Discharge" and argue that it's still 'offensive' and 'antagonistic', so they suggest using 'before medical advice' (BMA) as a better alternative.

Absurd.

My guess is these authors aren't working in a busy hospital environment, where the physician has 20 patients on her list, each one sicker than the next, plus 6 holdover admissions pending. In that context, I'd love to see how they deal with the 1 patient threatening to leave AMA or 'BMA'.

 

[chessknt]

My guess is that they work directly with patients quite rarely to be able to conjure up this garbage. Just ignore it and keep using AMA.

And to answer your other question absolutely document a discharge summary. If someone elopes just put that on there including meds you Rx and left a Vm telling them where to pick it up etc. No way you would ever get successfully sued plus the people AMAing/eloping dont have the resources to sue.

 

[DrMetal]

My guess is that they work directly with patients quite rarely to be able to conjure up this garbage. Just ignore it and keep using AMA.

And to answer your other question absolutely document a discharge summary. If someone elopes just put that on there including meds you Rx and left a Vm telling them where to pick it up etc. No way you would ever get successfully sued plus the people AMAing/eloping dont have the resources to sue.

I can see how that's a smart thing to do from a CYA perspective.

Have you guys ever head of a physician being disciplined for not doing this? (not writing a DC summary or rxing meds for a patient that left AMA). I would think there's no grounds for any disciplinary or legal action because the patient assumed the liability when he decided to leave AMA.

 

[InternistDO]

We had a lecture about this in residency and the consensus from the lawyers running it was that you were at much higher risk of being sued for NOT prescribing meds then if you did, so if someone AMAed with pneumonia it was best to send them with a script for oral abx or what have you.

They also said AMAing is an area where physicians/the hospital are extremely vulnerable to lawsuits despite the patient not listening to you. Apparently there is still significant liability since a malpractice lawyer can easily bring up concerns about capacity in the moment of the AMA. On the other hand, I doubt you remove that liability by blasting all your AMAs with benzos whenever they want to leave so you're kind of screwed either way.

We always have to do DC summaries at my hospital regardless of dispo (AMA, DC, celestial, etc) so AMAing doesn't change that.

 

[TooMuchResearch]

Yeah, the authors of this article make mention of "Patient Direct Discharge" and argue that it's still 'offensive' and 'antagonistic', so they suggest using 'before medical advice' (BMA) as a better alternative.

Absurd.

My guess is these authors aren't working in a busy hospital environment, where the physician has 20 patients on her list, each one sicker than the next, plus 6 holdover admissions pending. In that context, I'd love to see how they deal with the 1 patient threatening to leave AMA or 'BMA'.

Hey, I give them advice and they still leave, that's not before medical advice.

 

[DrMetal]

We had a lecture about this in residency

I must've ignored those lectures. I tend to ignore the absurd. Ours must be the only profession so vested in helping people that don't want our help. I certainly try to address the patient's concerns. If it's something easy I can do to help them (advance their diet, mild pain meds, provide more teaching/explanation), I do it. And 90% of the time, that keeps them in house. But at some point . . . I do lose my patience (no pun intended).

We always have to do DC summaries at my hospital regardless of dispo (AMA, DC, celestial, etc) so AMAing doesn't change that.

So too will I from now on. Makes sense from a CYA perspective. With our glorious EMRs, it takes 30 seconds to write a templated DC summary and put it in some doxy, that you know he's not going to pickup.

 

[Drrrrrr. Celty]

It's easier to do something performative than to address the central causes of the issues within the workplace environment. Nothing regarding the probably 50% of AMAs leave because they'll either not have childcare or lose their job or lose their home. Nothing about the violent AMAers who are physically and emotionally disruptive. Etc.

Easier to just change some words and claim that it actually helps people.

 

[DrMetal]

Hey, I give them advice and they still leave, that's not before medical advice.

Of course you did. Hell, by the time you've seen the patient, at least a half dozen staff members (other doctors, nurses) have rendered some form of medical advice.

That's what makes the suggestion posed by these authors so absurd and non-sensical.

This really is an offensive article. I'm surprised Annals published it, especially with no counter point opinion. (maybe they were going for the shock factor).

It's a great example of 'ivory-tower' physicians lecturing from their soap boxes, in a way, insulting those of us who are on the 'front lines' (as if we don't know how hard it is to deal with patients leaving AMA, in the first place).

 

[chessknt]

It's easier to do something performative than to address the central causes of the issues within the workplace environment. Nothing regarding the probably 50% of AMAs leave because they'll either not have childcare or lose their job or lose their home. Nothing about the violent AMAers who are physically and emotionally disruptive. Etc.

Easier to just change some words and claim that it actually helps people.

Probably 50% eh? Probably 90% want to go do drugs or drink is my experience but cool for you if yours has been different. And last time I checked solving society's problems wasn't part of the job of a physician.

It isn't performative to write a document defending yourself from lawyers in this country and I pity you on the day you discover that if you aren't doing such 'performative' work yourself.

 

[end stage fibro]

this is such horse manure. NEJM had a recent article about a similar topic. Fortunately, the audience poll was in favor 88% of using the term AMA.

I am not sure what is the impetus for these articles/research.
1) Are the authors so high in their ivory tower that they don't realize how divorced from reality this sentiment is?
2) Has the publish or perish mentality fomented a type of academic avant garde that produces this drivel?
3) I think all this "patient directed" rhetoric is further eroding trust in physicians and has equated patient care with customer service. Perhaps a covert push from the hospital admin/NP/naturopath cabal!?

 

[DrMetal]

this is such horse manure. NEJM had a recent article about a similar topic. Fortunately, the audience poll was in favor 88% of using the term AMA.

I am not sure what is the impetus for these articles/research.
1) Are the authors so high in their ivory tower that they don't realize how divorced from reality this sentiment is?
2) Has the publish or perish mentality fomented a type of academic avant garde that produces this drivel?
3) I think all this "patient directed" rhetoric is further eroding trust in physicians and has equated patient care with customer service. Perhaps a covert push from the hospital admin/NP/naturopath cabal!?

Likely all of the above.

We (physicians) are our own worst enemy.

 

[Drrrrrr. Celty]

Probably 50% eh? Probably 90% want to go do drugs or drink is my experience but cool for you if yours has been different. And last time I checked solving society's problems wasn't part of the job of a physician.

It isn't performative to write a document defending yourself from always in this country and I pity you on the day you discover that if you aren't doing such 'performative' work yourself.

Making a change to AMA is performative.

Yes, but part of our job is to advocate that healthcare and healing can actually be achieved.

 

[DrMetal]

Making a change to AMA is performative.

Yes, but part of our job is to advocate that healthcare and healing can actually be achieved.

Please don't tell me you're in agreement with any of this non-sense

You advocate plenty, when you've rounded on this patient, explained the diagnosis, provided education, and proposed a good treatment plan.

You advocate again, when he threatens to leave AMA, you circle back and try to address his concerns.

You advocate again, when you circle back a second, or third time, again, trying to appease him.

There is no fourth time: you then move on to someone who needs and actually wants your help.

 

[chessknt]

Making a change to AMA is performative.

Yes, but part of our job is to advocate that healthcare and healing can actually be achieved.

Advocate how? I am supposed to go lobby congress on my days off? What mythical Bernie rainbow system should I be advocating for precisely? Free childcare and rent whenever you are hospitalized paid for by the taxpayers with no limit? Are the nurses, janitors, EMTs, MAs, phlebotomists, and healthcare admins also expected to do this or just doctors?

 

[Drrrrrr. Celty]

Please don't tell me you're in agreement with any of this non-sense

You advocate plenty, when you've rounded on this patient, explained the diagnosis, provided education, and proposed a good treatment plan.

You advocate again, when he threatens to leave AMA, you circle back and try to address his concerns.

You advocate again, when you circle back a second, or third time, again, trying to appease him.

There is no fourth time: you then move on to someone who needs and actually wants your help.

Yes. These happened.

For me I had far more folks telling me if they miss work they'll get fired or if they aren't at their apartment to pick up or drop off a check they'll lose their home.

It can be both.

 

[Drrrrrr. Celty]

Advocate how? I am supposed to go lobby congress on my days off? What mythical Bernie rainbow system should I be advocating for precisely? Free childcare and rent whenever you are hospitalized paid for by the taxpayers with no limit? Are the nurses, janitors, EMTs, MAs, phlebotomists, and healthcare admins also expected to do this or just doctors?

Take it down a peg pip-squeak, this isn't 4chan.

I am simply saying that **** happens. What am I going to tell a mom who has left her 8 year old alone for 2 days for a heart failure AE? Oh, sucks for the kid? Or the person who just got clean finally got a house and still has tricuspid issues and goes into heart failure and now needs to go be at an appointment to sign for that house?

 

[chessknt]

Take it down a peg pip-squeak, this isn't 4chan.

I am simply saying that **** happens. What am I going to tell a mom who has left her 8 year old alone for 2 days for a heart failure AE? Oh, sucks for the kid? Or the person who just got clean finally got a house and still has tricuspid issues and goes into heart failure and now needs to go be at an appointment to sign for that house?

Do they not have social workers at your hospital to get CPS and legal forms filled out?

How poor would your insight have to be to think that leaving the hospital with an untreated life threatening condition was a good choice for either of those reasons? That 8 year old is going to be a lot worse off with no mom forever than no mom for a week and being dead seems worse than having to go through a housing search. I've yet to see any scenario a SW can't forestall when there is a legitimate medical concern.

 

[SXMMD]

People make bad choices under duress when there's no "safe" option all the time. It is what it is, I don't get mad if I can't break through to those people.

Brother who misses dialysis on the regular so he can smoke and drink with the boys, get his emergency dialysis once in a while while taking a crap on the staff before walking out ama can get wrekt though

For people polite enough to wait for courtesy dc orders/rx I'll help out. For the jerks, I let them walk then write " patient was advised of risk blah blah blah, still patient refused to wait for courtesy orders/follow up referrals, he should probably see his PCP or return to the ER if he feels like it" on the DC summary and call it a day.

 

[VA Hopeful Dr]

Take it down a peg pip-squeak, this isn't 4chan.

I am simply saying that **** happens. What am I going to tell a mom who has left her 8 year old alone for 2 days for a heart failure AE? Oh, sucks for the kid? Or the person who just got clean finally got a house and still has tricuspid issues and goes into heart failure and now needs to go be at an appointment to sign for that house?

That doesn't require a change in the terminology for when a patient leaves the hospital before their physician thinks they are safe to do so.

 

[Drrrrrr. Celty]

That doesn't require a change in the terminology for when a patient leaves the hospital before their physician thinks they are safe to do so.

I literally just said that changing the term is performative and dumb...

 

[DrSnips]

What am I going to tell a mom who has left her 8 year old alone for 2 days for a heart failure AE?

Tell them that by leaving prior to being stabilized, they may be leaving their child alone for their entire lifetime rather than a few days.

 

[dozitgetchahi]

Please don't tell me you're in agreement with any of this non-sense

You advocate plenty, when you've rounded on this patient, explained the diagnosis, provided education, and proposed a good treatment plan.

You advocate again, when he threatens to leave AMA, you circle back and try to address his concerns.

You advocate again, when you circle back a second, or third time, again, trying to appease him.

There is no fourth time: you then move on to someone who needs and actually wants your help.

Look, as they told us in residency, “it’s not a jail and we can’t keep people here if they don’t want to be here” (aside from very limited situations like psych holds).

I’m so sorry if the socioeconomic realities of America cause trouble for people who are in the hospital, but those can’t and won’t be solved by me as a doctor. If you need medical care and leaving the hospital is literally a life threatening situation for you, I’m not sure how I’m supposed to water down that message for someone (and if I do, the lawyers will eat me alive for it). You can’t take care of your kid or work your job if you’re dead.

When patients have bitched at me over the cost of things in healthcare, or how much Medicare/insurance/whatever sucks, or some other system related issue that I have no control over whatsoever as a doctor, lately I’ve been telling people “call your congressman”. My last job in Alabama featured a TON of miserable patients just whining and bitching about everything in their lives, and dear god did I ever burn out on dealing with it after a while. Go whine at your congressman, Joe Biden, a counselor, family members, clergy, or literally anyone else that cares, but holy god stop whining at me about everything I have no control over and can’t really change, either.

 

[dozitgetchahi]

Yes. These happened.

For me I had far more folks telling me if they miss work they'll get fired or if they aren't at their apartment to pick up or drop off a check they'll lose their home.

It can be both.

In my experience, most of these situations are overblown and can easily be forestalled by an effective social worker.

 

[LoudBark]

I can see how that's a smart thing to do from a CYA perspective.

Have you guys ever head of a physician being disciplined for not doing this? (not writing a DC summary or rxing meds for a patient that left AMA). I would think there's no grounds for any disciplinary or legal action because the patient assumed the liability when he decided to leave AMA.

Every hospital I have ever been at has bylaws that the attending physician has to do a discharge summary on every patient who leaves that hospital more than 24 hours after admission........whether that be a legitimate discharge, death, or AMA.

 

[DrMetal]

Every hospital I have ever been at has bylaws that the attending physician has to do a discharge summary on every patient who leaves that hospital more than 24 hours after admission........whether that be a legitimate discharge, death, or AMA.

Not mine, and I had never done it. Doesn't make sense. Why should I document something (discharge) that I didn't do? (I didn't actually discharge the patient). It'd be like writing a note on a patient I never saw.

It doesn't make any logical sense, but I do see how it makes sense from a CYA perspective. So I will do it from now on . . .

 

[chessknt]

Not mine, and I had never done it. Doesn't make sense. Why should I document something (discharge) that I didn't do? (I didn't actually discharge the patient). It'd be like writing a note on a patient I never saw.

It doesn't make any logical sense, but I do see how it makes sense from a CYA perspective. So I will do it from now on . . .

I have worked in probably a dozen different hospitals by this point--every single one required it, perhaps it is regional. I agree with the idea too--if someone comes back and has to be admitted again it is much better for care if somebody summarized what happened rather than having to go hunt down individual notes.

 

[anonperson]

Not mine, and I had never done it. Doesn't make sense. Why should I document something (discharge) that I didn't do? (I didn't actually discharge the patient). It'd be like writing a note on a patient I never saw.

It doesn't make any logical sense, but I do see how it makes sense from a CYA perspective. So I will do it from now on . . .

I do a discharge summary regardless if patient was discharged or left AMA.

I just consider it a overview of the hospital stay for future information. Our hospital EMR has the option to select if patient left AMA, was discharged etc.

I don't think doing a discharge summary on a left AMA patient implies anything on the physicians end.

I still drop notes etc on patients who refuse treatments etc.

 

[gutonc]

Not mine, and I had never done it. Doesn't make sense. Why should I document something (discharge) that I didn't do? (I didn't actually discharge the patient). It'd be like writing a note on a patient I never saw.

It doesn't make any logical sense, but I do see how it makes sense from a CYA perspective. So I will do it from now on . . .

Aren't you in MilMed? If so, that might explain why you can get away with doing whatever you want while the rest of us have to do stuff which is ostensibly (but only really peripherally) for patient care and safety, but really just for billing purposes.

 

[DrMetal]

Aren't you in MilMed? If so, that might explain why you can get away with doing whatever you want while the rest of us have to do stuff which is ostensibly (but only really peripherally) for patient care and safety, but really just for billing purposes.

No, I was referring to a civilian hospital where I moonlight. The place is so busy and crazy, clerical errors have even occurred where patients drop off our lists and aren't seen for 1-2 days. No one seems to care too much about those who leave AMA (which I still document in a note, of course, just wasn't doing formal discharge summaries).

The MilMed is far less busy, and thus more 'babying' of its patients. When a patient threatens to leave AMA from a military hospital, you're expected to utilize every last resource, explore every social dilemma, ad nauseum. You have the time do that, when you have a census of 6-8 patients.

 

[Splenda88]

I stop begging people to stay in the hospital... If I do that at the rate I was doing it during residency, a quick burnout will be down the road waiting for me.

80%+ of these people have no legitimate reasons to leave AMA

 

[TooMuchResearch]

Not mine, and I had never done it. Doesn't make sense. Why should I document something (discharge) that I didn't do? (I didn't actually discharge the patient). It'd be like writing a note on a patient I never saw.

It doesn't make any logical sense, but I do see how it makes sense from a CYA perspective. So I will do it from now on . . .

It makes sense to me when they bounce back to the ED two days after leaving AMA and I'm trying to figure out what happened while hospitalized.

 

[NITRAS]

Not mine, and I had never done it. Doesn't make sense. Why should I document something (discharge) that I didn't do? (I didn't actually discharge the patient). It'd be like writing a note on a patient I never saw.

It doesn't make any logical sense, but I do see how it makes sense from a CYA perspective. So I will do it from now on . . .

People leave AMA for lots of reasons. I’m happy to discuss the risks and benefits of them leaving AMA. I have no problem Rx the medications that will leave the highest chance of success of the patient leaving. A DC summary isn’t hard, but it really shouldn’t be templated , especially in this circumstance. Your risk of a bad outcome is high.

Sounds like the civilian place you moonlight is a ****-show. We have had people drop off lists, too. It usually is because some idiot resident adjusts the patient’s teams and didn’t know better. Our admissions RN’s have screwed with it too, but they should know better. This is a big deal and we have literally dozens of physicians trying to figure out practical solutions.

 

[Gastrapathy]

I have a great car mechanic. He knows my job. He recommended some stuff that I declined for a car I was thinking about selling. The funny ****er hand wrote an AMA form (against mechanical advice) and made me sign it.

 

[dgdg]

Wish the journal article were not paywalled. Can't read it except for the excerpt.

During a malpractice CME talk given by an attorney for our carrier he simply noted that we needed to always document informed refusal (including detailing the discussed specific risks of their action/inaction) and their capacity to make medical decisions in the chart note. An AMA contract never came up and no one asked about it.
Like routine care, it comes down providing your best care to the patient, and documenting it in the medical record.

As far as AMA 'contracts' for more serious situations, you'd need a malpractice attorney to weigh in on their value.

 

[DrMetal]

Wish the journal article were not paywalled. Can't read it except for the excerpt.

During a malpractice CME talk given by an attorney for our carrier he simply noted that we needed to always document informed refusal (including detailing the discussed specific risks of their action/inaction) and their capacity to make medical decisions in the chart note. An AMA contract never came up and no one asked about it.
Like routine care, it comes down providing your best care to the patient, and documenting it in the medical record.

As far as AMA 'contracts' for more serious situations, you'd need a malpractice attorney to weigh in on their value.

I certainly document, just wasn't always doing a formal DC summary and putting in outpatient meds.

I'm not too worried about it from a legal standpoint. Most of these POS patients are unreasonable. In the same way that they don't comply with medical advice, they're hardly likely to follow good legal advice and participate in a lawsuit. (and if they are reasonable, I'm usually able to negotiate with them and prevent the AMA in the first place).

 

[dgdg]

I certainly document, just wasn't always doing a formal DC summary and putting in outpatient meds.

Good that you document.
These patients will have a higher readmission rate than their peers with similar problems. Having a full blown detailed formal discharge summary is going to help your colleague re-admitting them at 2am some day.
Even if they do not follow our best advice, we should still put in the recommended DC meds even if they disagree with some of the meds listed. What we expect they will not take can be notated inline if possible, or in the hospital summary in the informed refusal paragraph. As an outpatient internist for decades seeing many older sick patients, this information will be incredibly valuable to me and the patient. They may eventually decide to take your advice, if I readily know what it is in the first place.

 

[FutureInternist]

We had a lecture about this in residency and the consensus from the lawyers running it was that you were at much higher risk of being sued for NOT prescribing meds then if you did, so if someone AMAed with pneumonia it was best to send them with a script for oral abx or what have you.

They also said AMAing is an area where physicians/the hospital are extremely vulnerable to lawsuits despite the patient not listening to you. Apparently there is still significant liability since a malpractice lawyer can easily bring up concerns about capacity in the moment of the AMA. On the other hand, I doubt you remove that liability by blasting all your AMAs with benzos whenever they want to leave so you're kind of screwed either way.

We always have to do DC summaries at my hospital regardless of dispo (AMA, DC, celestial, etc) so AMAing doesn't change that.

There’s the F you I’m outta her AMA and the my grandson is graduating AMA.

1st one usually doesn’t ask for not get meds cos the likelihood of them actually taking them is low.

2nd one gets the meds

Also for DC summary, I just say -
Pt left AMA
Please see progress note for 2/ 1/23 for details
Non billable note

 

[chessknt]

There’s the F you I’m outta her AMA and the my grandson is graduating AMA.

1st one usually doesn’t ask for not get meds cos the likelihood of them actually taking them is low.

2nd one gets the meds

Also for DC summary, I just say -
Pt left AMA
Please see progress note for 2/ 1/23 for details
Non billable note

You can bill a follow-up if they are discharged the same day?

 

[FutureInternist]

You can bill a follow-up if they are discharged the same day?

They typically leave after I have seen them, since I declined to up their dilaudid or confirmed that they indeed needed 6 weeks of IV antibiotics… so I bill for the progress note, and then addendise? it with our discussion and the fact that they left AMA

 

[Siggy]

I saw a new one the other day, PDD or "Patient Directed Discharge". Same BS, different phrase.

I haven't seen a fall in a long time. I've certainly seen unsuccessful challenges of gravity.

Also my patients don't self extubate. They simply undergo an unscheduled, self directed trial of ventilator liberation.