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When patients choose to leave

September 28, 2017



Against Medical Advice (A.M.A.) is a term used in the hospital when patients wish to leave before the doctor who is treating them considers them ready for discharge. Any patient who understands the risks and benefits of forgoing medical care can leave A.M.A. at any time. Nevertheless, health professionals often stigmatize such patients, labeling them as “noncompliant,” “ungrateful” or “unwilling to accept appropriate medical care.”


When Ersilia M. Defilippis’s pager vibrated that day alerting her about one of her patients wanting to leave A.M.A., message ending with, “Please assess”, she knew what to do.


She walked into her patient’s room. Her patient was only in her 50s but looked much older, her walker propped at the side of her bed. Her heart valves were not functioning properly, causing her to be short of breath and her legs to swell. She lay in her bed, tearful, and said immediately, “I’m sorry, doctor. I just need to go home.”


The patient had rheumatic heart disease, a condition we see less frequently these days. She had been in the hospital before. But she had always had a family member at her side to spend the night. Unfortunately, no one could come this time. The idea of staying in the hospital room alone terrified her. She was persistently traumatized by feelings of abandonment from her childhood.


At a certain point, she realized she was causing more suffering by keeping her in the hospital. In discussion with the rest of the medical team, she told her patient she could leave after making a clinic appointment for her in the next few days. Tears of joy rolled down her face. Shortly thereafter, she returned to the hospital and had her elective valve replacement.


Patients leaving A.M.A. account for 1 to 2 percent of all hospital discharges. A doctor must have a conversation documenting that the patient understands the risks of leaving and consequences of no longer receiving medical care, a way to help manage the risks.


Physicians sometimes isolate patient’s stories and illnesses, independent of what’s going on in their lives, or their circumstances. The “shared decision-making” often talk about in other clinical settings may be forgotten. After a patient has expressed desire to leave A.M.A., some physicians may abandon them in the course of care rather than trying to mitigate their risk by making follow-up appointments and providing prescriptions.


Physicians must explore patients’ reasons for wanting to be discharged and have open and truthful conversations with them and not assume that keeping them in the hospital is always better for their health.



Continue reading the full story in “The New York Times’:

When Patients Leave ‘Against Medical Advice’






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