Abstract and Introduction
Abstract
Background Every year, patients leave the Emergency Department against medical advice (AMA) and before an adequate evaluation can be performed. It is well known that many of these patients are at risk of subsequent complications.
Objective The goal of this article is to explain the potential legal protections that may be created from a proper AMA discharge.
Discussion In this article, the authors review the steps that need to be taken when performing an AMA discharge, including an assessment of capacity, proper documentation, and adequate disclosure. The authors then review the potential legal protections that can result from a properly documented and performed discharge. Among these protections are: proof that the provider's duty to the patient ended with discharge and that the patient assumed the risk of a subsequent complication.
Conclusion The authors conclude that a properly executed discharge can provide significant legal protection from liability risks.
Introduction
Against-medical-advice (AMA) discharges are a significant problem in emergency departments (EDs) across the United States. Approximately 1–2% of discharges at acute care hospitals in the United States are AMA; this figure goes up to 6% in disadvantaged inner-city populations. A study at a major academic medical center found that about 2.7% of patients left the ED AMA. This problem is not limited to the United States. A prior study in the United Kingdom found that .73% of ED patients left AMA and that 3% did not wait to be seen.
A number of empiric studies have demonstrated that patients who leave AMA have higher readmission rates and may have increased risks of adverse health effects. Risk of emergent hospitalization seems to be highest in the first 9 days after the AMA discharge. This short-term risk of hospital admission suggests that AMA discharges adversely impact patient safety. Whether this short-term admission rate is due to incomplete treatment during the initial ED visit or other reasons remains unclear.
Patients who present with high-risk clinical conditions may pose the greatest safety risk. Of note, concerning complaints such as non-specific chest pain and abdominal pain are often presenting problems among patients who eventually leave AMA.Table 1 illustrates some of the more common complaints and characteristics of patients who sign out AMA. The purpose of this article is to explore the legal requirements of the AMA process and to examine the legal protections that can be created by properly executed AMA discharges.