Against Medical Advice
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Against medical advice (AMA), sometimes known as discharge against medical advice (DAMA), is a term used in health care institutions when a
patient A patient is any recipient of health care services that are performed by Health professional, healthcare professionals. The patient is most often Disease, ill or Major trauma, injured and in need of therapy, treatment by a physician, nurse, op ...
leaves a
hospital A hospital is a healthcare institution providing patient treatment with specialized Medical Science, health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically ...
against the advice of their
doctor Doctor, Doctors, The Doctor or The Doctors may refer to: Titles and occupations * Physician, a medical practitioner * Doctor (title), an academic title for the holder of a doctoral-level degree ** Doctorate ** List of doctoral degrees awarded b ...
. While leaving before a medically specified endpoint may not promote the patient's health above their other values, there is widespread ethical and legal consensus that competent patients (or their authorized surrogates) are entitled to decline recommended treatment. The available data suggests that in general, patients discharged AMA have an increased risk of
hospital readmission A hospital readmission is an episode when a patient who had been discharged from a hospital is admitted again within a specified time interval. Readmission rates have increasingly been used as an outcome measure in health services research and as ...
, and potentially death. This data however, describes groups of patients discharged AMA, and therefore should not necessarily be applied to an individual patient wishing to leave AMA, and who may have different clinical circumstances and risks. Although common hospital practice for an AMA discharge involves the patient being asked to sign a form stating that they are aware that they are leaving the facility AMA, the hospital is generally not legally required to use it. Rather, the legal and ethical requirement is that the authorized health care professional has an informed consent discussion with the patient regarding their choice to leave the hospital before it has been recommended. This discussion which includes disclosure of the risks, benefits, and alternatives to hospitalization, as well as the patient's understanding, should be documented in the patient's chart. Many physicians incorrectly believe that
insurance Insurance is a means of protection from financial loss in which, in exchange for a fee, a party agrees to compensate another party in the event of a certain loss, damage, or injury. It is a form of risk management, primarily used to protect ...
denies payment for the hospitalization of patients leaving AMA, leaving such patients financially responsible.Schaefer GR, Matus H, Schumann JH, Sauter K, Vekhter B, Meltzer DO, Arora VM
Financial responsibility of hospitalized patients who left against medical advice: medical urban legend?
J Gen Intern Med. 2012 Jul;27(7):825-30
This "pervasive 'medical
urban legend Urban legend (sometimes modern legend, urban myth, or simply legend) is a genre of folklore concerning stories about an unusual (usually scary) or humorous event that many people believe to be true but largely are not. These legends can be e ...
may lead to
ethical Ethics is the philosophical study of moral phenomena. Also called moral philosophy, it investigates normative questions about what people ought to do or which behavior is morally right. Its main branches include normative ethics, applied e ...
problems, as it "scare patients with misleading information" about their exposure to costs, leading to a "breakdown in the patient–doctor relationship" and an infringement of patient autonomy. Authors across numerous disciplines have begun to question the wisdom of the practice of designating a discharge as AMA, as it doesn't follow professional standards, lacks evidence of its utility to improve patient care, and may harm patients by reducing their likelihood of following up. Finally, there is widespread ethical consensus that even when patients decline recommended treatment, health care professionals still have a duty to care for and support patients. The limited research in this area has led to a stagnation in effective interventions designed to alleviate AMA discharges. Multiple retrospective studies examining AMA discharges over the last 4 decades have attempted to identify risk factors in order to develop interventions to reduce the likelihood of AMA discharges in the future. The majority of studies have identified patient risk factors for AMA discharges that included low
socioeconomic status Socioeconomic status (SES) is a measurement used by economics, economists and sociology, sociologsts. The measurement combines a person's work experience and their or their family's access to economic resources and social position in relation t ...
, history of a
substance use disorder Substance use disorder (SUD) is the persistent use of drugs despite substantial harm and adverse consequences to self and others. Related terms include ''substance use problems'' and ''problematic drug or alcohol use''. Along with substance-ind ...
, and male sex. No studies have yet attempted to identify physician factors that increase the risk of an AMA discharge. More research is needed to understand this practice and intervene effectively in a patient-centered fashion.


Statistics

In the United States, the total number of stays discharged AMA increased 41 percent between 1997 and 2011. For adults ages 45–64 years, the percentage of AMA discharges increased from 27 percent in 1997 to 41 percent in 2011. By payer, the share of AMA discharges increased from 25 percent to 29 percent for Medicare and decreased from 21 percent to 16 percent for private insurance.Pfuntner A., Wier L.M., Elixhauser A. Overview of Hospital Stays in the United States, 2011. HCUP Statistical Brief #166. November 2013. Agency for Healthcare Research and Quality, Rockville, MD

.


See also

*
VIP medicine VIP medicine is a variety of the VIP syndrome—the phenomenon of a perceived "VIP" (very important person) using his or her status to influence a given professional or institution to make unorthodox decisions under the pressure or presence of sai ...


References

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