Published in the June 2009 issue of Today’s Hospitalist
THE PATIENT WANTS TO GO HOME, but you’re urging him to stay another day or two. After a long conversation, however, the patient decides to leave, putting you in a potentially difficult position. Do you keep the patient in the hospital against his wishes? Or do you let him leave and note in the chart that he discharged himself against medical advice (AMA)?
If the patient has meningitis and is delirious, you’ve got a slam-dunk case for keeping him. But if he isn’t a risk to others “and he isn’t seriously threatening his own health “the solution is less obvious.
David J. Alfandre, MD, assistant professor of medicine at the NYU School of Medicine, authored an article in the March 2009 Mayo Clinic Proceedings on AMA discharges. He says that in reviewing the literature, he realized that data on the topic not only are weak, but they raise questions about what should constitute an AMA discharge ” and what physicians can do to prevent one from happening.
“AMA discharges are a frustrating encounter for providers,” he says, “but they’re also a real opportunity to improve patient care.”
Who leaves AMA?
When Dr. Alfandre reviewed the literature on AMA discharges, he found that up to 2% of all hospital discharges may fall into that category. Research also suggests that patients who leave AMA may increase their risk of developing more medical problems.
One study, for example, found that patients with asthma had a three-fold risk of returning to the hospital within 30 days. Another found that AMA discharges who had been admitted for AMI had a 40% higher risk of death or readmissions.
And a body of research has identified several characteristics common in AMA discharges. These individuals are often young, male, have Medicaid or no insurance, come from a low socioeconomic class, or have a history of substance abuse.
But Dr. Alfandre, who also works at the Veterans Affairs’ National Center for Ethics in Health Care, says there’s controversy over whether these factors are truly helpful in pinpointing patients likely to discharge themselves AMA. That’s why he thinks that focusing on aspects of physician- patient communication is more helpful to identify ” and prevent “AMA discharges.
A small body of research has found a correlation between these discharges and patient feelings like anxiety and anger. One study even concluded that patients often show signs of anger or distress before leaving AMA, signs that busy physicians may miss.
Drilling down to motivations
To prevent AMA discharges, Dr. Alfandre thinks that one approach “motivational interviewing “could be particularly useful. Put simply, the technique helps physicians understand why patients are so desperate to leave the hospital.
“Physicians make a good case for why it’s important to stay in the hospital,” he explains, “but I think it’s harder to appreciate the patient’s perspective about what’s good about leaving. It takes a lot of cognitive and emotional effort to appreciate the fact that health may not be patients’ No. 1 priority in all situations.”
In his Mayo Clinic Proceedings article, for example, Dr. Alfandre cites the angry, demanding patient who wants to leave the hospital before his elevated blood pressure is fully under control. A few key, empathetic questions reveal that he is worried about his homebound mother. The physician can then focus the conversation on how to help the mother instead of arguing about the patient’s discharge.
“Determining a patient’s agenda may not make it easier to say, ‘I think you should stay in the hospital,’ ” Dr. Alfandre says, “but it gives you an appreciation of the patient’s perspective, which provides more room for negotiation.”
Not the right label
While communication techniques may help physicians possibly prevent AMA discharges, Dr. Alfandre has concerns about the use of the “AMA” label. He thinks the term may be unproductive.
In outpatient practice, for example, negotiations about therapies and treatments occur every day. “If I filled out a form every time a patient didn’t want to take a statin, I’d be filling out a lot of paperwork,” he says. “It’s an analogous process in the hospital.” Once you describe the risks, benefits and alternatives, as long as the patient has decision-making capacity, he or she can make a free choice.
While the mere mention of AMA discharges raises the spectre of patients who will harm themselves or others, Dr. Alfandre says it’s useful to focus on situations in which the stakes may not be so high.
“There’s a lot of negotiation involved,” he explains, “like if the doctor says the patient really needs another day of IV antibiotics. The provider may realize it’s not ideal, but it’s not completely unreasonable to give the patient oral antibiotics.”
Talk up discharge early
It is, he adds, “the tough situations in the middle where we have to let patients make their own decision.” In these situations, doctors should make a note in the chart documenting the shared decision-making process, and then urge patients to get primary care follow-up.
One useful piece of advice that emerged from his literature search: Have a very clear conversation with patients at the beginning of the hospitalization. That discussion should include the treatment plan, anticipated plans for discharge and what may hold up the discharge.
“It’s valuable to have that conversation early,” Dr. Alfandre says. “If there is a problem halfway through, you can have another conversation. The patient may be less surprised when something comes up.”
Edward Doyle is Editor of Today’s Hospitalist.