Avoiding Hospital Discharge Against Medical Advice

Rudofker, Eric; Gottenborg, Emily

doi:10.1001/jamainternmed.2018.7286

Cited by 7 publications

(10 citation statements)

References 4 publications

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“…Establishing a discharge plan that bring the least harm to patients may increase patients' adherence to the plan and eliminate disadvantageous factors at discharge. [23] In this analysis, AMA discharge was a factor associated with 30-day readmission, which is consistent with several previous studies. In a survey of trauma patients by Olufajo et al, the risk of 30-day readmission was three times higher in patients who discharged AMA and two times higher in patients with multiple readmissions compared to those discharged upon medical advice.…”

Section: Discussionsupporting

confidence: 92%

Discharge Against Medical Advice and Risk of Readmission After Sepsis Hospitalization

Lin

Zhai

Han

et al. 2020

Preprint

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Background: To describe characteristics of sepsis patients who discharged against medical advice (AMA), identify factors associated with AMA discharges in the patients, and evaluate the association of AMA discharge with 30-day unplanned readmission and outcomes of readmission.Methods: Using the National Readmission Database of the United States, we identified inpatients with sepsis who discharged AMA or discharged home between 2010 and 2017. The baseline characteristics were compared between the two groups. Multivariable models were used to identify factors related to AMA discharge, evaluate the association between AMA discharge and 30-day unplanned readmission, and elucidate the relationship between the AMA discharges and in-hospital outcomes.Results: AMA discharges accounted for 2.29% of all the hospitalized sepsis patients. The prevalence of AMA discharge in sepsis patients increased from 1.99% in 2010 to 2.55% in 2014 (p for trend < 0.001).The unplanned 30-day readmission rates of sepsis patients who discharged AMA and who discharged home are 25.51% and 12.26%, respectively. AMA discharge is statistically significantly associated with 30-day [odds ratio (OR), 2.24; 95% confidence interval (CI), 2.15–2.33], 60-day (OR, 2.07; 95% CI, 1.99–2.15), and 90-day (OR, 1.97; 95% CI, 1.90–2.05) readmission. AMA discharge is also associated with longer length of stay in 30 days (0.44 day, 95% CI, 0.12 days-0.76 days, p=0.007), whereas there was no statistically significant difference in hospitalization costs and in-hospital mortality for patients discharged AMA versus those discharged home.Conclusions: Due to the high risk of readmission, vulnerable patients should be early identified. Medical institutions should conduct post-discharge interventions for patients with AMA discharge, such as follow-up visits and psychological counseling, to reduce readmission.

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Section: Discussionsupporting

confidence: 92%

Discharge Against Medical Advice and Risk of Readmission After Sepsis Hospitalization

Lin

Zhai

Han

et al. 2020

Preprint

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“…Correctly identifying the reason for departure is essential to set a base for the patient–physician discussion. It is an opportunity to acknowledge their concerns and alleviate some or express empathy [ 15 , 25 – 27 ]. Involving a multidisciplinary team or asking for an early psychiatric consult may be helpful [ 1 , 28 ].…”

Section: Resultsmentioning

confidence: 99%

“…When patients refuse the recommended treatment plan, engaging them in decision-making can help elaborate an alternative discharge plan [ 33 , 36 ]. Providing an alternative discharge, while suboptimal, is not necessarily substandard [ 1 , 25 , 33 , 37 , 38 ] and can be adapted to the patient's situation. Also, refusing to provide an alternative discharge to patients and simply accepting that the patient leaves AMA has even been described as abandonment by some ethicists [ 36 ].…”

Section: Resultsmentioning

confidence: 99%

“…[ 30 , 34 ]. Experts agree that a signed form alone is not enough to ensure legal protection and to attest capacity [ 15 , 25 , 29 , 30 , 32 , 35 , 40 , 43 , 45 ].…”

Section: Resultsmentioning

confidence: 99%

“…Finally, through this discharge process, all relevant information should be carefully documented in the patient's chart [ 15 , 25 , 29 , 30 , 32 , 35 , 40 , 43 , 45 ]. However, physicians are not obligated to use a formal AMA form and should not pressure patients into singing it.…”

Section: Discussionmentioning

confidence: 99%

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A step-by-step approach to patients leaving against medical advice (AMA) in the emergency department

2022

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Objectives Patients leaving against medical advice (AMA) can be distressing for emergency physicians trying to navigate the medical, social, psychological, and legal ramifications of the situation in a fast-paced and chaotic environment. To guide physicians in fulfilling their obligation of care, we aimed to synthesize the best approaches to patients leaving AMA. Methods We conducted a scoping review across various fields of work, research context and methodology to synthesize the most relevant strategies for emergency physicians attending patients leaving AMA. We searched Medline, CINAHL, PSYCHO Legal Source, PsycINFO, PsycEXTRA, Psychological and Behavioural Sciences collection, SocIndex and Scopus. Search strategies included controlled vocabulary (i.e., MESH) and keywords relevant to the subject chosen by a team of four people, including two specialized librarians. Results The literature review included 34 relevant papers about approaches to patients leaving AMA: 8 case presentations, 4 ethical case analyses, 10 legal letters, 4 reviews and 8 original studies. The main identified strategies were prioritizing a patient-centered approach, proposing alternative discharge and reducing harm while properly documenting the encounter. Conclusion A systematic approach to patients leaving AMA could help improve patient care, support physicians and decrease stigmatization of this population. We advocate that emergency physicians should receive training on how to approach patients leaving AMA to limit the impact on this vulnerable population.

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Providing Prescriptions to the Patient Who Is Leaving Against Medical Advice

Prakash

Naguib

2019

JAMA Intern Med

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To the Editor In their systematic review and meta-analysis of corticosteroids for treatment of sepsis, Fang and colleagues 1 suggest that future studies should address the identification of patients who will derive the most benefit from corticosteroid use to enable a personalized medicine approach. I suggest additional directions for this field.First, the ability of corticosteroids to increase blood pressure and reverse shock could explain their mortality benefit. Therefore, basic and clinical studies should focus on the mechanism of this effect. Corticosteroids act via 2 receptors: the glucocorticoid receptor (GR) and mineralocorticoid receptor (MR), which have differing tissue distributions and biologic properties. Even the so-called low-dose hydrocortisone treatment described in the included trials will result in clinically significant activation of both GR and MR, and 3 trials included additional MR-directed therapy with fludrocortisone. In contrast, dexamethasone and betamethasone have very little MR activity. Activity at either receptor may increase blood pressure via different mechanisms. Future trials designed to more specifically target one or the other receptor (eg, dexamethasone vs fludrocortisone) would improve understanding of the mechanism of corticosteroid effects in patients with sepsis. This understanding would enable a more targeted treatment that limits adverse effects.Second, the brain is rich in MR and GR, and activity of corticosteroid treatment in the central nervous system may affect neuropsychiatric outcomes in survivors of sepsis. Indeed, several studies have suggested a potential benefit of corticosteroid treatment on symptoms of posttraumatic stress disorder and anxiety in survivors of critical illness, including sepsis. 2,3 Therefore, all future clinical trials examining the effect of corticosteroid therapies in critical illness should include an assessment of neuropsychiatric function in survivors. Because persistent psychiatric symptoms appear early after discharge, useful neuropsychiatric data may be gathered even in short-term follow-up. 4

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Avoiding Hospital Discharge Against Medical Advice

Cited by 7 publications

References 4 publications

Discharge Against Medical Advice and Risk of Readmission After Sepsis Hospitalization

Discharge Against Medical Advice and Risk of Readmission After Sepsis Hospitalization

A step-by-step approach to patients leaving against medical advice (AMA) in the emergency department

Providing Prescriptions to the Patient Who Is Leaving Against Medical Advice

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