Discharge Against Medical Advice: How Often Do We Intervene?

BACKGROUNDDischarges against medical advice (AMA) occur in 1% to 2% of hospital stays and are associated with increased morbidity, readmission rates, and 30-day mortality. Risk factors associated with AMA have been investigated, but interventions at the time of discharge have not been carefully examined. METHODSWe retrospectively reviewed the records of adult patients discharged AMA over a 2-year period from the general medical service of a university-affiliated tertiary care hospital. We assessed for presence of documentation addressing informed consent, patient decision-making capacity, health literacy, follow-up plans, whether medications were prescribed, and whether any warning indicators of impending AMA were apparent. RESULTSTwo hundred ninety-one records were reviewed. AMA notes were present in 276 (94.8%) charts. Notes were authored by physicians in 163 (59.1%) and nurses in 110 (37.8%) encounters. Informed consent was present in 88 (30.2%) charts, mentioned in the note but not present in the chart in 111 (38.1%), and not signed in 92 (31.6%) charts. Decision-making capacity and health literacy were documented in 108 (37.1%) and 75 (25.8%) records, respectively. Warning of impending AMA was present in 217 (74.6%) charts. Medications prescribed and follow-up plans were documented in 71 (24.4%) and 91 (31.3%) charts, respectively. CONCLUSIONSAdvance warning of impending AMA is often present, yet only a minority of cases have prescription of medications or development of follow-up plans. Medical documentation of AMA dispositions is frequently inadequate, suggesting missed opportunities to intervene as well as suboptimal medicolegal scenarios. Journal of Hospital Medicine 2013;8:574-577. (c) 2013 Society of Hospital Medicine