Against AMA Discharges: In Defense of Difficult Patients

By  |  February 11, 2019 | 

“Why are you yelling? Get the f* out of my face!”

I was relieved. I was worried about her, having been brought in by ambulance seizing. My resident said she was not waking up for him, which we hoped was just post-ictal, but we were not sure yet.

“Oh good! You are gonna be just fine. We will take good care of you here,” I said with a smile, turning to my intern and resident who seemed to enjoy seeing me get told off.

I am a doctor at a safety net hospital. This is where I chose to work. Being a doctor at a safety net hospital means sometimes I take care of patients who have pushed nearly everyone else in their life away, for one reason or another.

As a resident, an “AMA discharge” sometimes felt like a blessing. Those days, when I woke up and rode my Vespa over the hills in the freezing fog before the sun came up to see a patient who would give me hell, I gladly grabbed the AMA paperwork and showed them on their way. But in the years since my residency, I have grown increasingly weary of the “AMA discharge.”

In a great Teachable Moment article in this month’s JAMA Internal Medicine, Drs. Eric Rudofker and Emily Gottenborg from the University of Colorado, explain why labeling a discharge as “AMA” not only fails patients but also does not achieve any of its intended goals. They point out that “following an AMA discharge, patients have disproportionately high rates of readmission and adverse events, including death.” Furthermore, we all know that it is a label that follows patients around, creating a stigma and affecting all future interactions.

As for the pre-printed legalese AMA form, it is unclear when or why these forms began being used or how they are meant to advance patient care. We use the AMA form because we believe it absolves us and the hospital of legal liability. Turns out, this is not totally true. Cases and studies show the form itself is not necessary – nor is it sufficient – to protect physicians from legal consequences related to their medical care. In fact, “some legal scholars have suggested that the use of the form in attempting to release the hospital from legal liability may violate public policy in some states.” As the Teachable Moment authors suggest, “liability appears lowest when the physician elicits patient values, uses a harm-reduction approach when the patient’s preferences are incongruent with the physician’s, and clearly documents these discussions in the medical record.”

Also, signing out AMA does NOT mean the patient will now have to pay for the hospital stay because insurance will deny the claim. My friend Vinny Arora and colleagues showed that this is a pervasive “medical urban legend,” and that we should do our best to stamp out this purposefully coercive misinformation.

I have learned, through a lot of trial-and-error, how to often de-escalate a situation, simply acknowledge a patient’s concerns and figure out if there are reasonable steps or concessions we can make that can help them work with me to adhere to what I think will be best for their health and care. We should strive to role-model and teach these techniques. One prominent example I have recently highlighted is treating addiction symptoms with counseling and buprenorphine, rather than forcing abstinence and withdrawal.

All of this said, I am certainly no saint. Patients have gotten under my skin. And we must set appropriate boundaries – for example, I would never tolerate a patient sexually harassing somebody on my team. However, no matter what, I think it is well outside of our oath to retaliate or to withhold appropriate care. We can – and should – do our best to get the patient leaving the hospital critical medications, practicing a harm-reduction model, and should offer options for follow-up care. We should document what we discussed with our patient and how a decision was made, even if it was a patient decision that we did not support. Patients choose to not follow my advice all of the time – why only when it comes to leaving the hospital do I feel the need to grab some pre-printed form?

So what does the AMA form actually accomplish? It seems, other than giving us a false sense of absolution, the answer is nothing. It is the least patient-centered way to say that we are abiding by your decision. I am no jailor; you are welcome to leave whenever you want. The last thing either of us needs is more paperwork.

7 Comments

  1. Avatar
    Claudia Didia , MD February 11, 2019 at 3:24 pm - Reply

    Excellent
    I couldn’t agree more and in fact, this is exactly what I teach residents on rounds : to always do what is best for the patient , to the best of our abilities , to have a discussion about the risks invoved with the discharge , in fact , to do an “ informed consent “ discharge as opposed to AMA . Also all prescriptions shoild be given
    I also relate to the comment “ I am not a Saint “ : we all get our buttons pushed . What helps me to keep poised on those situations is to say to myself “ this is not about me , this is about the patient .

  2. Avatar
    Mark Silverstein February 11, 2019 at 3:58 pm - Reply

    I have to say that I agree with this principle. Most of our AMA patients are addicts of one sort or another who just need to get out to get back to their drug of choice or are patients with socioeconomic needs that necessitate their return to home or work. Try as we might, we will never be able to compete with that need. I learned long ago that refusing vital medications on discharge is just wrong — morally and ethically. These people are no less worthy or in need of our help than any other. We may not be able to persuade them to stay; we can help them to understand that we will always be here to help them.

  3. Avatar
    Kendall Rogers February 13, 2019 at 2:22 am - Reply

    Chris, great article! I agree with everything you say here, but there is a legitimate reason for AMA discharges, or at least for an’irregular’discharge to be coded as an AMA discharges (until CMS comes up with a better term), and that is that hospitals are not penalized for readmissions in these patients. I agree everything should be done for the patient, medications, follow-ups like any other discharge. They should be treated with respect and their decision should be respected if they are properly given informed consent. While I also hate the stigma attached, I understand the need for a designation in these situations. When our PT colleagues evaluate a patient and feel it is unsafe for them to be discharged home and recommend a SNF, but the patent refuses to go, has no one to help at home and we really believe they are going to be readmitted (or worse!) and that they cannot make it at home, but we have informed them of the risk fully and they decide to go home anyway, should the hospital be penalized when that patient comes back by ambulance in the next few days? Again, I support this was their decision to make, but we need to be able to document somewhere that we recognized these readmission risks and recommended a plan to mitigate them. AMA does that. As opposed to the hospital who didn’t have PT evaluate, didn’t inform a patient of that risk, and essentially pushed that same patient out to an unsafe home environment. Those 2 situations need to be distinguished in our quality reporting and unfortunately coding AMA discharge instead of discharge home is the only way to do that right now.

    • Avatar
      Keyur February 17, 2019 at 2:11 am - Reply

      Wow, I’ve discharged pt in similar predicaments and I’ve documented as such, so I was wrong, they needed to be AMA? I feel documentation of your conversation and pt right to choose where to go go and how to go would be a appropriate discharge documentation and if pt gets readmitted it wouldn’t be seen as a readmission since you’ve clearly documented that going home poses a risk of readmission?

  4. Avatar
    Brooks Parker February 13, 2019 at 8:54 am - Reply

    Largely, I agree. However, I will usually have the “you shouldn’t leave” dialogue one time, however, and no more. As part of the dialogue, I inform the patient that they are responsible for their own informed decisions and choice to trust (or not) that they need to remain in the hospital. Once I give them the necessary information, and convince them I am open to dialogue as their care evolves, I also tell them that they are not entitled to 100% of our time and resources, that we are actively taking care of many patients (who are choosing to accept our help), and that I am not beholden to run to them to convince them to stay, particularly “immediately” (as many of the AMA threateners demand.

    There is something to be said for patients taking responsibility for their own care, to drop the entitlement. The fact is—they are in the hospital for a reason, and if they don’t want the help, I will not repeatedly try to convince them otherwise.

    Of course this discussion does not include those incapacitated or not thinking clearly, whatever the cause—withdrawal, intoxication, delirium, dementia….

    The initial discussion to stay or not is a time for relationship/rapport building, while also establishing rules for the ongoing physician/patient relationship.

    And yes, the AMA form means little, but the chart documentation, with witness, means a lot.

  5. Avatar
    Eugene Raber February 16, 2019 at 11:40 pm - Reply

    I tend to agree that the standard pre printed AMA form serves little purpose except having a “ signed document “ in the patient chart waving hospitals liability I also tend to agree with the previous colleague that in fact it doesn’t completely clear them or the treating physician of liability. A good attorney May argue that patient didn’t understand the language or was “ forced “ to sign the form in order to leave. Malpractice attorneys love to sue especially big wealthy hospitals as well as all doctors who ever saw the patient regardless of the reason. And jury sees a “ poor indigent person with bellow high school education “ who didn’t understand what the “fancy “ language in the AMA form stated and never was told of the dangers. Complete bullshit to get paid
    In this day amd age, it is sad that we must practice defensive medicine. When I was a resident and early attending and took ER call for unassigned patients the approach I took was beyond the AMA form. Talk to the patient slowly always with the nurse present and explain in layman terms why you feel the patient needs to stay what the plan is and when you anticipate patient can be discharged. If you don’t know the duration of the hospital stay then guesstimate. Remain calm and professional. If family members present make sure they witness and ask them to convince the patient. Names of family members or friends would be very beneficial. If after everything is exhausted, and patient still refuses to stay document everything you said and document patient seen with “ family/ nurse/ freind” with their names
    Make sure you write risks discussed and that patients understands and that all questions were answered. At the end we are not baby sitters, nor will plead and beg for a sick patient to stay. I still remember the time, doctors were respected and listened to. Those times are over as we are just “ another health care professional”. Sad

  6. Avatar
    Danielle February 21, 2019 at 10:47 pm - Reply

    Great article

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About the Author: Chris Moriates

Chris Moriates
Christopher Moriates, MD is a hospitalist, the assistant Dean for Healthcare Value and an Associate Professor of Internal Medicine at Dell Medical School at University of Texas, Austin. He is also Director of Implementation Initiatives at Costs of Care. He co-authored the book Understanding Value-Based Healthcare (McGraw-Hill, 2015), which Atul Gawande has called “a masterful primer for all clinicians,” and Bob Wachter said is “essential reading for everyone who care about making our system better.”

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