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"Leaving AMA"

March 2014

Published in the March 2014 issue of Today’s Hospitalist

I must take exception to the article, “What should you do for patients leaving AMA?“.

Jason Edwards, MD, the study’s lead author, states: “… in almost every AMA case, it comes down to some kind of communication issue.” But the primary reason people leave AMA is because you will not let them smoke in the hospital. The second reason is that you will not let them drink alcohol and the third reason is that you won’t let them smoke pot.

Too, the idea that “[p]atients might not understand why they’re still in the hospital or why the physician doesn’t want them to leave” strikes me as wrong. Many people leave AMA because we will not give them the narcotics they want. People know very well why they are in the hospital and why we do not want them to leave, but they leave anyway when we don’t give them access to the things that landed them in the hospital in the first place.

Additionally, your source states: “second-best therapy may be better than no therapy at all.” But if patients take your offer of “second-best therapy,” they are not leaving AMA. Instead, they are taking second-best advice.

By giving patients second options, you are endorsing that treatment plan and are responsible for any outcome and associated follow-up, even though an inpatient treatment plan is what’s appropriate.

Documenting that a patient left AMA is a strong legal statement. If you document that there were no options other than inpatient treatment and patients left anyway, you will not be held liable for their poor decision.

Travis Bolton, MD
Missoula, Mont.

Dr. Edwards responds:
Dr. Bolton brings up several important points. While current substance abuse is a strong predictor of AMA discharge from medical units, one study found that alcohol withdrawal and current drug use were present in only 14% and 25% of AMA cases respectively.

Alcohol, drug or cigarette use is cited as the reason for leaving AMA only 15% of the time. Obviously, these data are subject to dishonest answers, but to state that they are the majority of cases is not supported by research. This emphasizes the importance of attempting to reduce withdrawal symptoms (nicotine patches etc.).

Second, studies have found that communication is central to many AMA discharges. Patients report lack of knowledge of the anticipated length of stay, inconsistent staff messages and poor physician bedside manner as factors contributing to AMA discharges. Good team-patient communication is crucial to mitigate such factors.

Third, simply labeling a patient’s discharge as AMA does not provide complete legal protection. Important legal protection comes from documenting the patient’s capacity to make his or her own decisions, express choice, understand relevant information, and appreciate the significance of the information and subsequent consequences. These factors are often missing from routine AMA documentation, as our study found.

Last, appropriately documented AMA discharges put liability for future outcomes on the patient but do not absolve us of ethical obligations. Low-risk, highly efficacious treatments can be given without legal repercussions, with supporting documentation and patient acceptance of risks. To routinely avoid such interventions is to miss out on important opportunities to potentially influence outcomes in a high-risk population.

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