Case Study
Toward the end of a physician’s busy shift in the emergency department, he went into a room to assess a 63-year-old female with concerns about diffuse abdominal pain. The patient had a history of smoking, coronary disease, and intermittent claudication. On exam, vitals were normal and the abdomen was diffusely tender with mild guarding and no rebound. On workup, the patient’s labs were unremarkable except for a white blood cell count of 13,000 with a normal differentiation. An abdominal CT scan was read as normal.
The physician recommended that she be admitted for observation since her pain was not improving during the ER stay. The patient declined admission, citing the concern of having to care for her pets and her high-deductible insurance plan. After a long discussion, the patient signed an “against medical advice” form and left the ER. Two days later, the physician was informed that the patient had been admitted the following night at another hospital with acute ischemic colitis and infarction requiring emergency surgery.
DISCUSSION
According to research, approximately 1-2% of hospitalizations in the United States result in an against medical advice discharge1, meaning the patient chooses to leave the hospital or clinic even when the physician suggests against it. Medical providers may feel distressed when the patient makes this type of decision, both because of the health risks to the patient and the liability risks to the provider.
Patients who present with actual or potentially high-risk clinical conditions pose the greatest safety risk. Providers should be vigilant around patients who want to leave against medical advice who have complaints such as non-specific chest pain, abdominal pain, potential stroke symptoms, or evidence of systemic infection, among other issues.
In the case study, there is risk for a lawsuit due to a poor outcome. However, good contemporaneous documentation of the physician’s communication with the patient about his concerns around the patient’s desire to refuse admission (as we will outline later) ultimately make this situation very defensible in the event of a lawsuit.
Against medical advice discharges expose the patient to a potential undertreated or undiagnosed medical problem and the complications of that diagnosis. This also presents the provider with an ethical dilemma. The physician wants to honor the patient’s wishes (autonomy) but also wants to do what is best for the patient (beneficence). Understanding the risks and ethics in these situations is important when formulating a strategy to best address what is essentially an inevitable event in nearly every practice setting.
WHAT'S A CLINICIAN TO DO IN AN "AGAINST MEDICAL ADVICE" SCENARIO?
The Medical Aspects to Consider
- Addressing addiction—In many cases, the patient’s real concern is fear of withdrawal from alcohol, benzodiazepines, or opioids. Recognition of these as common issues, skill at discussing the problem in a non-accusatory fashion, and an honest attempt to alleviate concern for withdrawal can be very helpful.
- Psychiatric issues—Patients may have underlying psychiatric issues such as anxiety surrounding the loss of control that being a patient can represent. Sick patients may make instinctual decisions that are not in their best interest, and empathic and nonjudgmental communication may help alleviate the impact of psychiatric issues.
- Motivational interviewing—Approaching patients with open questions and reflective responses helps the clinician understand their thought process. Restating what you’ve heard may help patients understand their own ambivalence and the risk of their decision. Additionally, patients commonly leave the hospital for personal or financial reasons and the clearer these are to the physician, the more chance there is of a successful interaction, including bringing in appropriate support services.
The Legal Aspects to Consider
A signed informed consent or informed refusal form is the cornerstone of provider protection for a situation such as the one illustrated in the case study. Informed decision making means the patient has arrived at their decision with a thorough discussion, no coercion, and full understanding of the risks and benefits.
Important areas to address and document include2.
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- Is the patient competent? Do they have capacity to make such a decision? Although courts have found that intoxication can impair a patient’s competence and ability to refuse medical treatment, a patient who is intoxicated does not automatically lack the competence or capacity to make medical decisions. Similarly, patients with psychiatric complaints can also be difficult to assess but do not necessarily lack capacity to make an informed decision.
- Do they have the health literacy to understand their decision?
- Does the patient understand the diagnosis and the reason for treatment?
- Are they aware of alternatives?
- Can they communicate their choices?
- Is there an understanding of the effects of their refusal?
There are three significant ways that the use of a properly executed against medical advice/informed refusal form can create protection from future liability: 1) the termination of the legal duty to treat a patient; 2) creation of the affirmative defense of “assumption of risk”; and 3) the creation of record evidence of the patient’s refusal of care.
A properly executed and documented against medical advice/informed refusal form can provide significant protection from liability risk. If a patient is deemed to have capacity, is informed and understands the risks of leaving and still refuses care, physicians may be protected from potential liability from adverse outcomes. The form along with clear, contemporaneous documentation in the chart may provide vital evidence in the event of future litigation. Providers in high-risk clinical scenarios where a patient declines best advice should take the additional time required to execute an against medical advice discharge to protect themselves from allegations of negligence.
Informed Refusal and EMTALA Requirements When Patients Want to Leave Against Medical Advice
Visit our website at www.copic.com/consent-forms to download templates for Informed Refusal and EMTALA Requirements When Patients Want to Leave Against Medical Advice. These forms, along with other consent forms are available to use and customize for your practice needs.
1Am J Med. 2021 Jun;134(6):721-26.
2Alfandre DJ., Mayo Clin Proc. 2009 Mar;84(3):255-60
The information provided herein does not, and is not intended to, constitute legal, medical, or other professional advice; instead, this information is for general informational purposes only. The specifics of each state’s laws and the specifics of each circumstance may impact its accuracy and applicability, therefore, the information should not be relied upon for medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation.
Article originally published in 1Q25 Copiscope.
