Discharge Against Medical Advice: How Often Do We Intervene?

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Abstract

BACKGROUND:

Discharges 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.

METHODS:

We 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.

RESULTS:

Two 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.

CONCLUSIONS:

Advance 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. © 2013 Society of Hospital Medicine

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