Patients Leaving AMA: How Facilities Can Prepare

Suppose a healthcare facility is understaffed, and a patient becomes frustrated with delayed care and demands to leave.

Or perhaps a resident has unrealistic expectations of the time healthcare professionals can spend with them and they want to leave against medical advice (AMA).

Regardless, it is not always possible to prevent patients from leaving AMA. However, much can be done to mitigate the risks for patients and healthcare facilities alike.

What does AMA stand for in healthcare?

In healthcare settings, AMA refers to discharge patients against medical advice. In other words, an AMA discharge is when a patient or resident leaves the hospital or long-term care facility before the treating physician recommends the discharge.

Unfortunately, patients leaving against medical advice is a relatively common problem.

What does it mean to leave AMA? Understand the impacts

Various studies place the rate of AMA hospital discharges at 1–2 percent in the United States. This percentage represents approximately 500,000 patients.

When patients leave AMA, they are more likely to die or be readmitted within 30 days. Readmission can result in higher and avoidable healthcare costs.

One study, “Discharge against medical advice: sociodemographic, clinical and financial perspectives,” found that the cost of early readmission after an AMA discharge was 56 percent higher than expected from the initial hospitalization.

AMA discharges are detrimental to both patients and healthcare facilities. However, these situations are complex since patients have a right to self-determination and autonomy, even if their decisions present unnecessary risks.

What to do when a patient wants to leave AMA

Patients may wish to leave hospitals against medical advice for numerous reasons, such as the following:

Facility understaffing or other resource limitations
A patient’s work or family obligations
Unrealistic expectations from the patient
Frustrations from the patient, staff, or both

Hospitals should do everything in their power to avoid patients leaving AMA.

Healthcare staff may avoid AMA discharges by using active listening to verbalize and understand the patient’s frustration and de-escalation techniques to address the patient’s reasons for wanting to leave.

Informed consent is a crucial aspect of patient care and should be a priority when a patient wishes to leave AMA. It implies that the patient has consulted with their physician and has a comprehensive understanding of the decision’s risks, benefits, and alternatives. Even when an AMA discharge is unavoidable, hospital staff should try de-escalating the situation.

Furthermore, the duty to provide care does not end with an AMA discharge. Healthcare professionals must also make follow-up arrangements and inform patients that they may return.

An AMA discharge also does not protect providers or facilities from potential legal action if appropriate follow-up arrangements have not been made.

What happens when a resident wants to leave AMA?

Residents of long-term care facilities may also decide to leave AMA.

Nursing home staff should inform residents of their right to refuse care and leave the facility AMA.

If a resident wishes to leave AMA, nursing home staff must still ensure that the resident will receive the appropriate level of care in their new place of residence and plan for the safe and orderly discharge of the resident.

When a resident plans to move into a home, the nursing home must assess the home care the resident will receive, the safety of the environment, and the potential risks of deterioration of the resident’s quality of life.

If the resident needs ongoing assistance, the long-term care facility must coordinate the discharge with community services such as home care agencies. The nursing home should not discharge a resident unless the facility can ensure the resident will receive the required care and assistance.

Attending physicians should consider these requirements before signing off on a resident’s discharge plan.

What to document when a patient leaves AMA

If you suspect a patient may leave AMA, document everything.

Here are some typical predictors of AMA discharge:

Male gender
Young age
Current or history of substance or alcohol abuse
Medicaid or no insurance

Healthcare facilities must be ready for potential lawsuits when patients leave AMA. Leaving AMA increases the risks of negative outcomes, and the patient or family members may claim the facility did not adequately inform them of the risks, encourage them to stay, or provide appropriate discharge instructions.

Therefore, facilities must be able to prove that sufficient measures were taken to inform patients of risks and prepare them for discharge.

The following are some guidelines and examples of what facilities should document, including the content of nursing notes:

Assessment of the patient’s decision-making capability with documentation to support the assessment
Timely documentation with detailed discharge instructions (a copy of instructions and referrals should be kept)
Progress notes regarding conversations with patients and family members as close to the time of departure as possible, including patient education and follow-up arrangements
Names of involved individuals

Staff members should provide as much detail as possible in their documentation. A generic “Against Medical Advice” form claiming the patient “refused to sign” will not be enough to protect a facility in case of a lawsuit.

Will insurance pay if a patient leaves AMA?

Many physicians believe insurance will not pay when patients leave AMA and even communicate this belief to patients.

However, a study titled “Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?” found no evidence of this claim over a nine-year period.

This study found that payment was refused to insured patients who left AMA in 4.1 percent of cases. However, the reasons were primarily administrative, such as providing the wrong name.

Leaving AMA was not mentioned as a reason to deny insurance coverage.

It seems the erroneous belief that insurance will not pay when patients leave AMA is widespread. Therefore, residency programs and hospitals should take steps to educate staff and avoid misinforming patients.

Avoid patients leaving AMA with adequate staffing levels

When patients and residents receive quality care in a timely fashion, they are less likely to leave AMA. Remember that patients leaving AMA may incur higher costs for facilities.

Learn more about other hidden costs of understaffing in nursing and other facility best practices by Nursa.

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