Bedside Management of Discharges Against Medical Advice

Physicians and other healthcare professionals have long struggled with discharges against medical advice (AMA), or when patients leave the hospital prior to a specified clinical end point over the recommendation of the physician. There is ample literature describing the risk factors associated with AMA discharge and the common reasons that patients choose to leave AMA. In this chapter, we review the best practice concepts of bedside management of an AMA discharge. We discuss components of a quality decisional capacity assessment and informed consent discussion as a prerequisite for a safe transition of care for AMA discharges. We also discuss cognitive and behavioral strategies that can form the basis for a practical approach to the professional, legal, and ethical obligations surrounding this type of discharge. Last, we discuss patient-centered strategies, shared decision-making models, and motivational interviewing and describe operational tools and processes to assist providers in negotiating a more productive health outcome for AMA discharges.