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• W2085800405 abstract "Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Between 1% and 2% of all medical admissions result in an AMA discharge. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Studies for this review were identified by searching the relevant MeSH heading (discharge) and key words (against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients. Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Between 1% and 2% of all medical admissions result in an AMA discharge. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Studies for this review were identified by searching the relevant MeSH heading (discharge) and key words (against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients. Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, is a problem for many physicians who treat hospitalized patients.1Taqueti VR Leaving against medical advice.N Engl J Med. 2007; 357: 213-215Crossref PubMed Scopus (8) Google Scholar, 2Carrese JA Refusal of care: patients' well-being and physicians' ethical obligations: “but doctor, I want to go home”.JAMA. 2006; 296: 691-695Crossref PubMed Scopus (37) Google Scholar Leaving the hospital against the physician's advice may expose the patient to risk of an inadequately treated medical problem and result in the need for readmission.3Hwang SW Li J Gupta R Chien V Martin RE What happens to patients who leave hospital against medical advice?.CMAJ. 2003; 168: 417-420PubMed Google Scholar The ethical dilemma that this issue raises is conceptually relatively straightforward. Many physicians struggle with the desire to respect the patient's wishes to leave AMA (in general, the patient's right to self-determination or autonomy) while attempting to do what they think is best for the patient (to act with beneficence).4Beauchamp TL Childress JF Principles of Biomedical Ethics. 5th ed. Oxford University Press, New York, NY2001Google Scholar In practice, managing this issue presents more complications than simply identifying and potentially prioritizing the relevant ethical principles. Physician-patient communication, informed consent, and underlying psychiatric issues are all relevant to practical management. This article examines the problem of AMA discharges—their prevalence, risks, and costs—and formulates recommendations for managing and preventing them on the basis of available evidence. Studies were identified by searching PubMed databases for English-language articles from 1970 through 2008 that included data on adult medical inpatients. Primary psychiatric admissions and admissions for detoxification or substance abuse were excluded. The search was performed by using the MeSH heading discharge and then combining it with the following key words: against medical advice, leave, elope, hospital, and self-discharge. Bibliographies of all articles were searched for related studies. Against medical advice discharges continue to be a highly prevalent problem of health care quality, representing as many as 2% of all hospital discharges.5Ibrahim SA Kwoh CK Krishnan E Factors associated with patients who leave acute-care hospitals against medical advice.Am J Public Health. 2007 Dec; 97 (Epub 2007 Oct 30.): 2204-2208Crossref PubMed Scopus (107) Google Scholar, 6Saitz R Ghali WA Moskowitz MA The impact of leaving against medical advice on hospital resource utilization.J Gen Intern Med. 2000; 15: 103-107Crossref PubMed Scopus (53) Google Scholar, 7Wylie CM Michelson RB Age contrasts in self-discharge from general hospitals.Hosp Formul. 1980; 15 (276-277.): 273PubMed Google Scholar Furthermore, patients discharged AMA, taken as a whole, are an at-risk group for both morbidity and mortality. Patients with asthma who were discharged AMA had a 4-times higher risk of readmission to the emergency department within 30 days (21.7% vs 5.4%) and almost a 3-times higher risk of readmission to the hospital within 30 days (8.5% vs 3.2%).8Baptist 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 Apr; 119 (Epub 2007 Jan 18.): 924-929Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar In a study of a general medicine service, patients who left AMA were 7 times more likely to be readmitted within 15 days (21% vs 3%), almost always for the same diagnosis.3Hwang SW Li J Gupta R Chien V Martin RE What happens to patients who leave hospital against medical advice?.CMAJ. 2003; 168: 417-420PubMed Google Scholar In a large retrospective study among almost 100,000 patients admitted with acute myocardial infarction, those who left AMA (N=1079) underwent fewer revascularization procedures and had shorter lengths of hospital stay. After adjustment for these phenomena, patients who left AMA had a 40% higher risk of death or readmission for myocardial infarction or unstable angina up to 2 years after discharge.9Fiscella K Meldrum S Barnett S Hospital discharge against advice after myocardial infarction: deaths and readmissionas.Am J Med. 2007; 120: 1047-1053Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Although a moderately sized prospective study found no relationship between AMA discharge and death,3Hwang SW Li J Gupta R Chien V Martin RE What happens to patients who leave hospital against medical advice?.CMAJ. 2003; 168: 417-420PubMed Google Scholar 2 other studies, smaller and variable in their design, found a high rate of mortality among patients who were discharged AMA. In a review of medical records, Link et al10Link K Brody CE Chan J Leaving a medical service against advice.Va Med. 1983; 110: 100-102PubMed Google Scholar found a 15.7% mortality rate at 1 year among 57 patients discharged AMA from a group of academic hospitals in Virginia. Using a case-control design, Corley and Link11Corley MC Link K Men patients who leave a general hospital against medical advice: mortality rate within six months.J Stud Alcohol. 1981; 42: 1058-1061PubMed Google Scholar found a 19% rate of mortality at 6 months among 33 medical patients who left AMA from a Veterans Affairs institution. Few data are available on the estimated total costs to the health care system of unanticipated AMA discharges. Multiple studies have found that patients who leave AMA are at risk for early readmission,3Hwang SW Li J Gupta R Chien V Martin RE What happens to patients who leave hospital against medical advice?.CMAJ. 2003; 168: 417-420PubMed Google Scholar, 12Aliyu ZY Discharge against medical advice: sociodemographic, clinical and financial perspectives.Int J Clin Pract. 2002; 56: 325-327PubMed Google Scholar, 13Anis AH Sun H Guh DP Palepu A Schechter MT O'Shaughnessy MV Leaving hospital against medical advice among HIV-positive patients.CMAJ. 2002; 167: 633-637PubMed Google Scholar which can result in higher, unnecessary health care costs. Aliyu,12Aliyu ZY Discharge against medical advice: sociodemographic, clinical and financial perspectives.Int J Clin Pract. 2002; 56: 325-327PubMed Google Scholar using 30-day readmission data, calculated the readmission cost due to an AMA discharge at 56% higher than expected from the initial hospitalization. Understanding why patients choose to leave the hospital AMA has obvious importance because of the potential to identify those at higher risk and therefore intervene earlier to prevent excess morbidity, mortality, and health care costs. Most of the published data are from retrospective analyses and case-control studies at single urban institutions, limiting the ability to define a clear causal relationship (eTable3Hwang SW Li J Gupta R Chien V Martin RE What happens to patients who leave hospital against medical advice?.CMAJ. 2003; 168: 417-420PubMed Google Scholar, 5Ibrahim SA Kwoh CK Krishnan E Factors associated with patients who leave acute-care hospitals against medical advice.Am J Public Health. 2007 Dec; 97 (Epub 2007 Oct 30.): 2204-2208Crossref PubMed Scopus (107) Google Scholar, 7Wylie CM Michelson RB Age contrasts in self-discharge from general hospitals.Hosp Formul. 1980; 15 (276-277.): 273PubMed Google Scholar, 8Baptist 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 Apr; 119 (Epub 2007 Jan 18.): 924-929Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 9Fiscella K Meldrum S Barnett S Hospital discharge against advice after myocardial infarction: deaths and readmissionas.Am J Med. 2007; 120: 1047-1053Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 10Link K Brody CE Chan J Leaving a medical service against advice.Va Med. 1983; 110: 100-102PubMed Google Scholar, 11Corley MC Link K Men patients who leave a general hospital against medical advice: mortality rate within six months.J Stud Alcohol. 1981; 42: 1058-1061PubMed Google Scholar, 12Aliyu ZY Discharge against medical advice: sociodemographic, clinical and financial perspectives.Int J Clin Pract. 2002; 56: 325-327PubMed Google Scholar, 13Anis AH Sun H Guh DP Palepu A Schechter MT O'Shaughnessy MV Leaving hospital against medical advice among HIV-positive patients.CMAJ. 2002; 167: 633-637PubMed Google Scholar, 14Albert HD Kornfeld DS The threat to sign out against medical advice.Ann Intern Med. 1973; 79: 888-891Crossref PubMed Scopus (37) Google Scholar, 15Schlauch RW Reich P Kelly MJ Leaving the hospital against medical advice.N Engl J Med. 1979; 300: 22-24Crossref PubMed Scopus (39) Google Scholar, 16Baile WF Brinker JA Wachspress JD Engel BT Signouts against medical advice from a coronary care unit.J Behav Med. 1979; 2: 85-92Crossref PubMed Scopus (17) Google Scholar, 17Jones AA Himmelstein DU Leaving a county hospital against medical advice [letter].JAMA. 1979; 242: 2758Crossref PubMed Scopus (12) Google Scholar, 18Ochitill HN Havassy B Byrd RC Peters R Leaving a cardiology service against medical advice.J Chronic Dis. 1985; 38: 79-84Abstract Full Text PDF PubMed Scopus (19) Google Scholar, 19Long JP Marin A Profile of patients signing against medical advice.J Fam Pract. 1982; 15 (556.): 551PubMed Google Scholar, 20Ochitill HN Byrd RC Greene J Leaving a cardiology service against medical advice—a follow-up study.West J Med. 1987; 146: 765PubMed Google Scholar, 21Holden P Vogtsberger KN Mohl PC Fuller DS Patients who leave the hospital against medical advice: the role of the psychiatric consultant.Psychosomatics. 1989; 30: 396-404Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 22Weingart SN Davis RB Phillips RS Patients discharged against medical advice from a general medicine service.J Gen Intern Med. 1998; 13: 568-571Crossref PubMed Scopus (90) Google Scholar, 23Smith DB Telles JL Discharges against medical advice at regional acute care hospitals.Am J Public Health. 1991; 81: 212-215Crossref PubMed Scopus (47) Google Scholar, 24Chan AC Palepu A Guh DP et al.HIV-positive injection drug users who leave the hospital against medical advice: the mitigating role of methadone and social support.J Acquir Immune Defic Syndr. 2004; 35: 56-59Crossref PubMed Scopus (96) Google Scholar, 25O'Hara D Hart W McDonald I Leaving hospital against medical advice.J Qual Clin Pract. 1996; 16: 157-164PubMed Google Scholar, 26Saitz R Ghali WA Moskowitz MA Characteristics of patients with pneumonia who are discharged from hospitals against medical advice.Am J Med. 1999; 107: 507-509Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 27Jeremiah J O'Sullivan P Stein MD Who leaves against medical advice?.J Gen Intern Med. 1995; 10: 403-405Crossref PubMed Scopus (93) Google Scholar, 28Duñó R Pousa E Sans J Tolosa C Ruiz A Discharge against medical advice at a general hospital in Catalonia.Gen Hosp Psychiatry. 2003; 25: 46-50Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 29Franks P Meldrum S Fiscella K Discharges against medical advice: are race/ethnicity predictors?.J Gen Intern Med. 2006; 21: 955-960Crossref PubMed Scopus (51) Google Scholar, 30Seaborn Moyse H Osmun WE Discharges against medical advice: a community hospital's experience.Can J Rural Med. 2004; 9: 148-153PubMed Google Scholar online linked to this article). However, the following correlates of AMA discharge have had reasonably consistent results over time: lower socioeconomic class, male sex, younger age, Medicaid or no insurance, and substance abuse.5Ibrahim SA Kwoh CK Krishnan E Factors associated with patients who leave acute-care hospitals against medical advice.Am J Public Health. 2007 Dec; 97 (Epub 2007 Oct 30.): 2204-2208Crossref PubMed Scopus (107) Google Scholar, 8Baptist 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 Apr; 119 (Epub 2007 Jan 18.): 924-929Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 12Aliyu ZY Discharge against medical advice: sociodemographic, clinical and financial perspectives.Int J Clin Pract. 2002; 56: 325-327PubMed Google Scholar, 15Schlauch RW Reich P Kelly MJ Leaving the hospital against medical advice.N Engl J Med. 1979; 300: 22-24Crossref PubMed Scopus (39) Google Scholar, 16Baile WF Brinker JA Wachspress JD Engel BT Signouts against medical advice from a coronary care unit.J Behav Med. 1979; 2: 85-92Crossref PubMed Scopus (17) Google Scholar, 17Jones AA Himmelstein DU Leaving a county hospital against medical advice [letter].JAMA. 1979; 242: 2758Crossref PubMed Scopus (12) Google Scholar, 19Long JP Marin A Profile of patients signing against medical advice.J Fam Pract. 1982; 15 (556.): 551PubMed Google Scholar, 22Weingart SN Davis RB Phillips RS Patients discharged against medical advice from a general medicine service.J Gen Intern Med. 1998; 13: 568-571Crossref PubMed Scopus (90) Google Scholar, 23Smith DB Telles JL Discharges against medical advice at regional acute care hospitals.Am J Public Health. 1991; 81: 212-215Crossref PubMed Scopus (47) Google Scholar, 26Saitz R Ghali WA Moskowitz MA Characteristics of patients with pneumonia who are discharged from hospitals against medical advice.Am J Med. 1999; 107: 507-509Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 27Jeremiah J O'Sullivan P Stein MD Who leaves against medical advice?.J Gen Intern Med. 1995; 10: 403-405Crossref PubMed Scopus (93) Google Scholar, 30Seaborn Moyse H Osmun WE Discharges against medical advice: a community hospital's experience.Can J Rural Med. 2004; 9: 148-153PubMed Google Scholar Some studies have had additional novel findings. Jeremiah et al27Jeremiah J O'Sullivan P Stein MD Who leaves against medical advice?.J Gen Intern Med. 1995; 10: 403-405Crossref PubMed Scopus (93) Google Scholar identified lack of a primary care physician as being associated with a higher likelihood of signing out AMA. A history of leaving AMA is associated with a higher likelihood of doing the same in the future.8Baptist 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 Apr; 119 (Epub 2007 Jan 18.): 924-929Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 25O'Hara D Hart W McDonald I Leaving hospital against medical advice.J Qual Clin Pract. 1996; 16: 157-164PubMed Google Scholar Although African American race has been associated with AMA discharge in retrospective studies,5Ibrahim SA Kwoh CK Krishnan E Factors associated with patients who leave acute-care hospitals against medical advice.Am J Public Health. 2007 Dec; 97 (Epub 2007 Oct 30.): 2204-2208Crossref PubMed Scopus (107) Google Scholar, 12Aliyu ZY Discharge against medical advice: sociodemographic, clinical and financial perspectives.Int J Clin Pract. 2002; 56: 325-327PubMed Google Scholar, 15Schlauch RW Reich P Kelly MJ Leaving the hospital against medical advice.N Engl J Med. 1979; 300: 22-24Crossref PubMed Scopus (39) Google Scholar, 31Moy E Bartman BA Race and hospital discharge against medical advice.J Natl Med Assoc. 1996; 88: 658-660PubMed Google Scholar the finding is inconsistent in larger studies and may be confounded by socioeconomic and hospital-related factors.7Wylie CM Michelson RB Age contrasts in self-discharge from general hospitals.Hosp Formul. 1980; 15 (276-277.): 273PubMed Google Scholar, 8Baptist 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 Apr; 119 (Epub 2007 Jan 18.): 924-929Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 29Franks P Meldrum S Fiscella K Discharges against medical advice: are race/ethnicity predictors?.J Gen Intern Med. 2006; 21: 955-960Crossref PubMed Scopus (51) Google Scholar In smaller studies limited to subpopulations of patients with human immunodeficiency virus, additional correlates of AMA discharge include patient-reported factors such as financial issues and sickness within the family.32Green 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: 489-493Crossref PubMed Scopus (48) Google Scholar Patient-reported reasons for leaving AMA often include these types of personal or financial obligations. Other studies have found that patients report feeling better21Holden P Vogtsberger KN Mohl PC Fuller DS Patients who leave the hospital against medical advice: the role of the psychiatric consultant.Psychosomatics. 1989; 30: 396-404Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 27Jeremiah J O'Sullivan P Stein MD Who leaves against medical advice?.J Gen Intern Med. 1995; 10: 403-405Crossref PubMed Scopus (93) Google Scholar or receipt of social assistance payments24Chan AC Palepu A Guh DP et al.HIV-positive injection drug users who leave the hospital against medical advice: the mitigating role of methadone and social support.J Acquir Immune Defic Syndr. 2004; 35: 56-59Crossref PubMed Scopus (96) Google Scholar, 32Green 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: 489-493Crossref PubMed Scopus (48) Google Scholar as their primary reason for leaving AMA. In most retrospective studies during the past 3 decades, the presence of a drug or alcohol problem has had a consistent association with the decision to sign out AMA. The reason for this association is still unclear, but limited data suggest that underlying addictive behaviors and the wish to acquire more drugs might be reasons.33Phillips DP Christenfeld N Ryan NM An increase in the number of deaths in the United States in the first week of the month—an association with substance abuse and other causes of death.N Engl J Med. 1999; 341: 93-98Crossref PubMed Scopus (102) Google Scholar, 34Halpern SD Mechem CC Declining rate of substance abuse throughout the month.Am J Med. 2001; 110: 347-351Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 35Saitz R Discharges against medical advice: time to address the causes.CMAJ. 2002; 167: 647-648PubMed Google Scholar Recommendations for reducing the rate of AMA discharges among patients with a drug or alcohol history have consisted primarily of early identification, discussion, and communication about counseling. Chan et al24Chan AC Palepu A Guh DP et al.HIV-positive injection drug users who leave the hospital against medical advice: the mitigating role of methadone and social support.J Acquir Immune Defic Syndr. 2004; 35: 56-59Crossref PubMed Scopus (96) Google Scholar found that AMA discharges were less likely among injection drug users with human immunodeficiency virus if they were receiving methadone in the hospital or had social support from family and friends. Protocols to treat alcohol and opioid withdrawal to reduce AMA discharges have not been studied in patients on a medical service. Given the high prevalence of AMA discharges in these patients, this would be a worthy area of study. Although beyond the scope of this review, a much larger amount of literature has examined psychiatric inpatients and AMA discharges.36Brook M Hilty DM Liu W Hu R Frye MA Discharge against medical advice from inpatient psychiatric treatment: a literature review.Psychiatr Serv. 2006; 57: 1192-1198Crossref PubMed Scopus (52) Google Scholar Clinical overlap exists between medical and psychiatric patients studied because of the high burden of psychiatric morbidity in medical inpatients; however, data are otherwise too heterogeneous to allow wide-ranging comparisons. For example, AMA discharges in psychiatric populations range from 3% to 51% (average, 17%),36Brook M Hilty DM Liu W Hu R Frye MA Discharge against medical advice from inpatient psychiatric treatment: a literature review.Psychiatr Serv. 2006; 57: 1192-1198Crossref PubMed Scopus (52) Google Scholar far higher than in medical patients studied. However, given the paucity of data on interventions to reduce AMA discharges for medical patients, drawing some insights on the process from the psychiatric literature may be useful. Targum et al37Targum SD Capodanno AE Hoffman HA Foudraine C An intervention to reduce the rate of hospital discharges against medical advice.Am J Psychiatry. 1982; 139: 657-659PubMed Google Scholar found an approximately 30% decrease in total AMA discharges among psychiatric inpatients in a private hospital that used a nurse as a patient advocate. The advocate's responsibility was to help explore a “patient's preconceptions about hospitalization and to address fears and complaints about it.” Involving a consultation-liaison psychiatrist early in the course of a hospital admission may produce similar gains. In a retrospective study, Holden et al21Holden P Vogtsberger KN Mohl PC Fuller DS Patients who leave the hospital against medical advice: the role of the psychiatric consultant.Psychosomatics. 1989; 30: 396-404Abstract Full Text PDF PubMed Scopus (20) Google Scholar found that medical patients seen early by a consultation-liaison psychiatrist were less likely to sign out AMA. Another concept drawn from the psychiatric literature is that AMA behavior may be more a consequence of factors related to admission and early hospitalization than a break-down in the therapeutic alliance between physician and patient. In a prospective study that derived and validated an AMA prediction tool, Steinglass et al38Steinglass P Grantham CE Hertzman M Predicting which patients will be discharged against medical advice: a pilot study.Am J Psychiatry. 1980; 137: 1385-1389PubMed Google Scholar found that patients who signed out AMA were more likely to believe that their hospitalization would be short-term. Thus, the initial “treatment contract” rather than the nature of the hospitalization appeared to be at odds with patients' expectations. Proactively addressing substance abuse issues early during hospital admission can help prevent discharge dilemmas. Failing to collect these critical elements of the social history can lead to deficiencies in care and prevent the timely evaluation and intervention needed for patients with substance abuse. However, approaching these issues with patients requires skills that physicians may not have fully developed.39DuVal G Clarridge B Gensler G Danis M A national survey of U.S. internists' experiences with ethical dilemmas and ethics consultation.J Gen Intern Med. 2004; 19: 251-258Crossref PubMed Scopus (173) Google Scholar How the physician handles an evaluation for substance abuse can affect the patient's response. Physicians who start with an accusatory attitude are likely to be met with unease at best and with an AMA discharge and termination of care at worst. Maintaining a similar empathetic, dispassionate attitude toward all patients, regardless of their diagnosis, is more likely to result in a clear and effective evaluation.40Passik SD Byers K Kirsh KL Empathy and the failure to treat pain.Palliat Support Care. 2007; 5: 167-172Crossref PubMed Scopus (17) Google Scholar, 41Gallagher RM Empathy: a timeless skill for the pain medicine toolbox [editorial].Pain Med. 2006; 7: 213-214Crossref PubMed Scopus (26) Google Scholar Although early articles examining the issue of AMA discharge were based on small series of case reports and descriptive studies, they provide important conclusions about the psychological mechanisms behind AMA discharges and suggest ways in which physicians can use these observations to potentially reduce the rate of untimely discharges. Two articles described the association of patients' anxiety and anger, possibly masking feelings of helplessness, with AMA discharges.14Albert HD Kornfeld DS The threat to sign out against medical advice.Ann Intern Med. 1973; 79: 888-891Crossref PubMed Scopus (37) Google Scholar, 15Schlauch RW Reich P Kelly MJ Leaving the hospital against medical advice.N Engl J Med. 1979; 300: 22-24Crossref PubMed Scopus (39) Google Scholar Albert and Kornfeld14Albert HD Kornfeld DS The threat to sign out against medical advice.Ann Intern Med. 1973; 79: 888-891Crossref PubMed Scopus (37) Google Scholar described a series of case studies on a hospital service that emphasized the need for early recognition and also showed that an AMA threat was a way for patients to demonstrate their feelings, often anger, anxiety, or depression. Furthermore, these investigators cautioned that many patients show overt signs of emotional distress before threatening to leave AMA, signs that can be missed or misinterpreted by physicians untrained to recognize them. More recently, this phenomenon has been studied in outpatient encounters by Levinson42Levinson W Gorawara-Bhat R Lamb J A study of patient clues and physician responses in primary care and surgical settings.JAMA. 2000; 284: 1021-1027Crossref PubMed Scopus (509) Google Scholar and others,43Matthews DA Suchman AL Branch Jr, WT Making “connexions”: enhancing the therapeutic potential of patient-clinician relationships.Ann Intern Med. 1993; 118: 973-977Crossref PubMed Scopus (132) Google Scholar, 44Roter DL Frankel RM Hall JA Sluyter D The expression of emotion through nonverbal behavior in medical visits: mechanisms and outcomes.J Gen Intern Med. 2006; 21: S28-S34Crossref PubMed Scopus (318) Google Scholar who found that patients offer their physicians “empathic opportunities” through their speech. Patients' comments, when physicians are attuned to them, give clues about the patients' underlying psychological state. An emerging body of research in outpatients suggests that physicians' recognition and acknowledgment of patients' underlying emotions can result in improved trust in the physician-patient relationship and more efficient and better quality of care.45Epstein RM Franks P Shields CG et al.Patient-centered communication and diagnostic testing.Ann Fam Med. 2005; 3: 415-421Crossref PubMed Scopus (245) Google Scholar, 46Safran DG Taira DA Rogers WH Kosinski M Ware JE Tarlov AR Linking primary care performance to outcomes of care.J Fam Pract. 1998; 47: 213-220PubMed Google Scholar, 47Williams GC Freedman ZR Deci EL Supporting autonomy to motivate patients with diabetes for glucose control.Diabetes Care. 1998; 21: 1644-1651Crossref PubMed Scopus (787) Google Scholar, 48Epstein RM Hadee T Carroll J Meldrum SC Lardner J Shields CG “Could this be something serious?” Reassurance, uncertainty, and empathy in response to patients' expressions of worry.J Gen Intern Med. 2007 Dec; 22 (Epub 2007 Oct 31.): 1731-1739Crossref PubMed Scopus (151) Google Scholar, 49Beckman HB Markakis KM Suchman AL Frankel RM The doctor-patient relationship and malpractice: lessons from plaintiff depositions.Arch Intern Med. 1994; 154: 1365-1370Crossref PubMed Google Scholar The role in preventing or reducing AMA discharges, although potentially useful, remains to be evaluated. Another consistency in the literature on AMA discharges is the recommendation for proactive physician-patient communication. Indeed, many problems like these originate in incomplete physician-patient communication.50Swetz" @default.
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• W2085800405 title "“I'm Going Home”: Discharges Against Medical Advice" @default.
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• W2085800405 doi "https://doi.org/10.4065/84.3.255" @default.
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