“I'm Going Home”: Discharges Against Medical Advice

doi:10.4065/84.3.255

Mayo Clinic Proceedings

Volume 84, Issue 3, March 2009, Pages 255-260

https://doi.org/10.4065/84.3.255 Get rights and content

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.

Section snippets

METHODS

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.

PREVALENCE AND RISK TO QUALITY

Against medical advice discharges continue to be a highly prevalent problem of health care quality, representing as many as 2% of all hospital discharges.5, 6, 7 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

PREDICTORS OF AMA DISCHARGE

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 (eTable3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,

INSIGHTS FROM PSYCHIATRIC LITERATURE

Although beyond the scope of this review, a much larger amount of literature has examined psychiatric inpatients and AMA discharges.³⁶ 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%),³⁶ far higher than in medical patients

Addressing Substance Abuse

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.³⁹ How the physician handles an evaluation for substance abuse can affect the

Informed Consent

Informed consent in deciding to leave AMA is one of the most important elements of care for patients who make this decision. An informed decision means that the patient has arrived at the decision in consultation with his or her physician without being subjected to coercion and with a full understanding and appreciation of the risks, benefits, and alternatives of the decision.⁵⁹ In practice, this often involves an evaluation of decision-making capacity, which in most cases can be handled by the

CONCLUSION

Against medical advice discharge continues to be a prevalent and frustrating problem for patients and their physicians. The literature is limited primarily to medical record reviews and retrospective analyses of associations with AMA discharges. Data for physicians on how to effectively manage and intervene in these complicated patient encounters are scant. Prospective studies of medical patients, focusing on patient, physician, and hospital variables, are most likely to reveal reliable and

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Cited by (217)

A 15-year review of characteristics and outcomes of patients leaving against medical advice
2024, Burns
Discharging against medical advice can have significant, detrimental effects on burn patient outcomes as well as higher hospital readmission rates and healthcare expenditures. The goal of this study is to identify characteristics of patients who left against medical advice and suggest solutions to mitigate these factors. Data were collected at our American Burn Association verified Burn Unit over a 15-year period.
Between 2007 and 2022, 37 patients were identified as having left against medical advice from the burn unit. The average patient age was 37 years old with 64.9% being male, and 70.2% were identified as having a substance abuse history. The majority (51.4%) had Medicaid or State health insurance, 29.7% had no insurance, and 18.9% had private insurance. The mechanism of injury was most commonly frostbite (43.2%). The majority sustained < 1% total body surface area injuries. Most (83.7%) had social work and/or case management involved during their admission, and all (100%) had their involvement if the length of admission was greater than one day. Over half (59.5%) returned to the ED within 2 weeks with complications.
This study found that patients discharging against medical advice from the burn unit suffered from smaller injuries, often due to cold related injuries. These patients had comorbid substance abuse or psychiatric histories, and the majority had Medicaid or state health insurance. Recruiting interdisciplinary care members, including social work, psychiatry, and addiction medicine, early may help these patients by encouraging completion of their hospital care and setting up crucial follow-up care.
Psychiatric and Substance Use Disorders and Their Association With Clinical Outcomes in Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome
2024, Journal of the Academy of Consultation-Liaison Psychiatry
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening conditions that send nearly 180,000 patients to the intensive care unit each year, with mortality rates up to 5–10%. Little is known about the impact of concurrent psychiatric disorders on specific DKA/HHS outcomes. Identifying these relationships offers opportunities to improve clinical management, treatment planning, and mitigate associated morbidity and mortality.
We conducted a retrospective review including adult DKA/HHS admissions within a large Massachusetts hospital system from 2010 to 2019. We identified patients admitted inpatient for DKA or HHS, then filtered by International Classification of Disease-9-CM and International Classification of Disease-10-CM codes for psychiatric diagnoses that were present in patients electronic medical record at any point in this observational period. Outcomes included the number of inpatient admissions for DKA/HHS, age of death, rates of discharging against medical advice (AMA) from any inpatient admission, and end-stage renal disease/dialysis status. Multivariate regression was conducted using R software to control for variables across patients and evaluate relationships between outcomes and concurrent psychiatric disorders. Significance was set at P < 0.05.
Seven thousand seven hundred fifty-six patients were admitted for DKA or HHS, 66.9% of whom had a concurrent psychiatric disorder. Of these patients, 54.5% were male, 70.4% were White, and they had an average age of 61.6 years. This compares with 26.1% with concurrent psychiatric condition within the general diabetes population, 52.1% of whom were male, 72.1% were White, and an average age of 68.2 years. A concurrent psychiatric disorder was associated with increased odds of rehospitalization (adjusted odds ratio [aOR] = 1.62 95% confidence interval [CI] 1.35–1.95, P < 0.001), of being diagnosed with end-stage renal disease and on dialysis (aOR = 1.02 95% CI 1.002–1.035, P = 0.02), and of leaving AMA (aOR = 6.44 95% CI 4.46–9.63, P < 0.001). The average age of death for those with a concurrent psychiatric disorder had an adjusted mean difference in years of −7.5 years (95% CI −9.3 to 5.8) compared to those without a psychiatric disorder.
Of patients with DKA/HHS, 66.9% have a concurrent psychiatric disorder. Patients with a concurrent psychiatric disorder admitted for DKA/HHS were more likely to have multiple admissions, to leave AMA, to be on renal dialysis, and to have a lower age of mortality.
Discharge Against Medical Advice After Hospitalization for Sepsis: Predictors, 30-Day Readmissions, and Outcomes
2023, Journal of Emergency Medicine
Sepsis is a leading cause of death worldwide. However, little has been known concerning the status of discharge against medical advice (DAMA) in sepsis patients.
To identify factors associated with DAMA, evaluate the association of DAMA with 30-day unplanned readmission and readmitted outcomes after sepsis hospitalization.
Using the National Readmission Database, we identified sepsis patients who discharged routinely or DAMA in 2017. Multivariable models were used to identify factors related to DAMA, evaluate the association between DAMA and readmission, and elucidate the relationship between DAMA and outcomes in patients readmitted within 30 days.
Among 1,012,650 sepsis cases, patients with DAMA accounted for 3.88% (n = 39,308). The unplanned 30-day readmission rates in patients who discharged home and DAMA were 13.08% and 27.21%, respectively. Predictors of DAMA in sepsis included Medicaid, diabetes, smoking, drug abuse, alcohol abuse, and psychoses. DAMA was statistically significantly associated with 30-day (odds ratio [OR] 2.18, 95% confidence interval [CI] 2.09–2.28), 60-day (OR 1.98, 95% CI 1.90–2.06), and 90-day (OR 1.88, 95% CI 1.81–1.96) readmission. DAMA is also associated with higher mortality in patients readmitted within 30 days (OR 1.38, 95% CI 1.17–1.63), whereas there were no statistically significant differences in length of stay and costs between patients who discharged home or DAMA.
DAMA occurs in nearly 3.88% of sepsis patients and is linked to higher readmission and mortality. Those at high risk of DAMA should be early identified to motivate intervention to avoid premature discharges and associated adverse outcomes.
Prevalence and impact of psychiatric disorders on hospitalized pediatric patients with chronic pancreatitis
2023, Pancreatology
Patients with chronic pancreatitis (CP) often have a debilitating clinical course characterized by high disease burden, and poor quality of life and these factors adversely affect mental health. However, there is paucity of literature on the prevalence and impact of psychiatric disorders on hospitalized pediatric patients with CP.
ology: We analyzed the Kids Inpatient Database, and National Inpatient Sample, between 2003 and 2019 and included patients up to 21 years of age. Pediatric CP patients with psychiatric disorders were compared with patients without any of the psychiatric disorders using the ICD diagnostic codes. Various demographic and clinical factors were compared between the groups. Length of hospitalization and total hospital charges were used as surrogates to compare the hospital resource utilization between the groups.
We analyzed a total of 9,808 hospitalizations with CP and the overall prevalence rate of psychiatric disorders was 19.8%. The prevalence rate increased from 19.1% in 2003 to 23.4% in 2019, p = 0.006. The peak prevalence rate of 37.2% was noted at 20 years of age. Depression was noted at 7.6% of the total hospitalizations followed by substance abuse (6.5%), and anxiety (4.4%). Multivariate linear regression analysis showed that among CP patients, psychiatric disorders were independently associated with 1.3 additional days of stay and incurred $15,965 higher charges.
The prevalence of psychiatric disorders is increasing in pediatric CP. The concomitant presence of psychiatric disorders was found to be associated with prolonged hospital stay and incurred higher healthcare charges than those CP patients without psychiatric disorders.
Decisional Capacity After Dark: Is Autonomy Delayed Truly Autonomy Denied?
2023, Cambridge Quarterly of Healthcare Ethics
Negative outcomes pertaining to patients that leave against medical advice: a systematic review and meta-analysis
2024, European Review for Medical and Pharmacological Sciences

View all citing articles on Scopus

: The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the National Center for Ethics in Health Care. The author wrote most of this article while affiliated with Mount Sinai School of Medicine, New York.

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REVIEW“I'm Going Home”: Discharges Against Medical Advice

Section snippets

METHODS

PREVALENCE AND RISK TO QUALITY

PREDICTORS OF AMA DISCHARGE

INSIGHTS FROM PSYCHIATRIC LITERATURE

Addressing Substance Abuse

Informed Consent

CONCLUSION

J Allergy Clin Immunol

Am J Med

J Chronic Dis

Psychosomatics

Am J Med

Gen Hosp Psychiatry

Am J Med

Mayo Clin Proc

Gen Hosp Psychiatry

Am J Prev Med

Mayo Clin Proc

Mayo Clin Proc

Leaving against medical advice

N Engl J Med

Refusal of care: patients' well-being and physicians' ethical obligations: “but doctor, I want to go home”

JAMA

What happens to patients who leave hospital against medical advice?

CMAJ

Principles of Biomedical Ethics

Factors associated with patients who leave acute-care hospitals against medical advice

Am J Public Health

The impact of leaving against medical advice on hospital resource utilization

J Gen Intern Med

Age contrasts in self-discharge from general hospitals

Hosp Formul

Leaving a medical service against advice

Va Med

Men patients who leave a general hospital against medical advice: mortality rate within six months

J Stud Alcohol

Discharge against medical advice: sociodemographic, clinical and financial perspectives

Int J Clin Pract

Leaving hospital against medical advice among HIV-positive patients

CMAJ

The threat to sign out against medical advice

Ann Intern Med

Leaving the hospital against medical advice

N Engl J Med

Signouts against medical advice from a coronary care unit

J Behav Med

Leaving a county hospital against medical advice [letter]

JAMA

Profile of patients signing against medical advice

J Fam Pract

Leaving a cardiology service against medical advice—a follow-up study

West J Med

Patients discharged against medical advice from a general medicine service

J Gen Intern Med

Discharges against medical advice at regional acute care hospitals

Am J Public Health

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

Leaving hospital against medical advice

J Qual Clin Pract

Who leaves against medical advice?

J Gen Intern Med

Discharges against medical advice: are race/ethnicity predictors?

J Gen Intern Med

Discharges against medical advice: a community hospital's experience

Can J Rural Med

Race and hospital discharge against medical advice

J Natl Med Assoc

Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA

Am J Drug Alcohol Abuse

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

REVIEW
“I'm Going Home”: Discharges Against Medical Advice