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Posted by Ishani Ganguli February 27, 2014 07:00 AM
His nurse paged me at 9 p.m.: Mr. L wants to leave against medical advice (AMA). As the covering doctor, I dreaded the impending standoff even more than usual.
I emerged from the elevator minutes later to find that the gaunt octogenarian had advanced from his isolation room, passed the nurse's station and the unit doors, and arrived at the elevator bay to greet me. Security guards hovered at a cautious distance as I met his eyes.
"Hi sir. I understand you’d like to leave?"
He spat his response like chewing tobacco from his blood-crusted lips: "They changed my room. I’m tired of this place. I just gotta do something at home."
Mr. L had come to the hospital after months of coughing, weight loss, and difficulty swallowing. The list of possible diagnoses was long, with cancer and tuberculosis in the lead. But he was not at all interested in staying to sort it out.
The term leaving against medical advice smacks of paternalism and the fear of liability. Even when the designation is warranted (that is, at odds with clear medical need, not physician convenience), it generates an inherently lopsided power struggle that is uncomfortable for all parties (at the very least) and potentially dangerous. It is a concept badly in need of a patient-centered update, according to a recent article from the Journal of the American Medical Association.
As many as two percent of hospital discharges are labeled as AMA. More often than not, they are carried out by young men, patients covered by Medicaid or without insurance, and those struggling with substance abuse. According to a review of nearly two million stays at a Veteran’s Affairs (VA) hospital, such discharges carry a 35 percent higher risk of readmission and 10 percent higher death rates after 30 days, even when accounting for differences in underlying health.
Patients who leave AMA likely differ from those who do not in important ways that weren't captured by the VA study: in how they view their medical problems and the role of the health care system in addressing them, for example.
I wonder also about the role that doctors play.
Too often, the AMA label gives us a license to stop caring about what happens to a patient. Once the battle is lost, we shift the burden of the discharge entirely onto the patient instead of seeking compromise and mitigating risk (by setting up follow-up appointments, writing prescriptions, and the like). Perpetuating this short-sighted view is the policy from the Centers for Medicare & Medicaid Services that does not extend readmissions penalties to hospitals for patients who return after leaving AMA.
Doctors’ behavior is also fueled in part by the lack of a formal definition of leaving AMA. The designation is not a legal necessity nor does it force the patient to pay for the hospital stay out-of-pocket, despite what most doctors believe (or at least what they tell patients).
Then there is our discomfort with incorporating patient preference into any decision and the difficulty, when we so frequently pass off responsibility between doctors, of developing relationships with patients in the hospital. And it is simply easier to avoid patients we view as difficult than to engage with them.
Mr. L's request, by the light of day, would hardly have been outrageous. But I was meeting him for the first time and I had other patients to see. I told him why I thought he'd benefit from staying and asked him to get some rest and reconsider in the morning, but he held his ground.
The nurses and I finally coaxed him back into his room with the promise of offering the AMA form - itself an item of questionable purpose. His ambitions were stymied by the relative who would not come to fetch him at the late hour, so the topic was tabled. My shift ended soon after, and I regret that I never had the chance to better understand why he wanted to leave so badly. I wonder if he even had the capacity to make that decision (which would preclude him leaving AMA) and whether I could have done anything more to ease his mind.
The hospital is not always a pleasant setting, nor is that its purpose. To some extent, patients must cede control of their lives in the hopes of saving them. So whether or not you believe that health care is a right, declining this care altogether (for a sound-minded patient) is most certainly one.
As doctors, we should take a patient’s petition to leave AMA as a signal for an honest conversation. If, in the end, his decision is to walk away, we cannot abandon him in return.
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