“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.