More patients, some of them elderly, are leaving the hospital against medical advice despite the risks.
When patients discharge themselves from the hospital against their doctor’s recommendation, most organizations will ask the patients to sign a form that acknowledges that they understand and assume medical and legal risks. However, the situation can get adversarial and is happening more frequently.
A recent study, published in The Journal of the American Geriatrics Society, analyzed a national sample from 2013 and found an increase in discharges against medical advice (DAMA) in adults—both those 65 and older and those aged 18 to 64. A total of 50,650 hospitalizations of patients over age 65 ended with AMA discharges, an increase from 0.37% to 0.42% from 2003. However, those over the age of 65 were four times less likely to leave the hospital against medical advice than adults under 65 years old.
DAMA are associated with greater risk of hospital readmission and higher morbidity, mortality and costs, the study said. The data suggested race/ethnicity and poverty are risk factors for elderly inpatients signing themselves out of the hospital against advice.
The study’s senior author, Jashvant Poeran, M.D., from the Icahn School of Medicine at Mount Sinai in New York, told The New York Times that the numbers are conservative since researchers did not include outpatients who left the emergency room and those who walked out without signing a form.
“It’s always been one of the most difficult ethical dilemmas,” Arthur Derse, M.D., director of the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin, told the Times. Hospital risk managers encourage use of the AMA form, although he says they don’t necessarily protect an organization against liability.
As care becomes more patient-centered, some experts advice physicians to offer patients an alternative path, even if it isn’t necessarily what they would have recommended in the first place. If patients do opt for a care plan that differs from what the physician would consider optimal, they suggest that doctors explain why they believe that plan will or will not work. In cases where the plan falls short, physicians should offer patients advice about additional steps they might take. Doctors may also encourage patients to seek a second opinion.