Against medical advice - Revision history

Rossdonaldson1: /* See Also */

2026-03-25T19:14:25Z

Rossdonaldson1: /* Common Pitfalls */

2026-03-25T19:14:17Z

Common Pitfalls

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	*Failing to document specific risks discussed (do not rely solely on a signed AMA form)		*Failing to document specific risks discussed (do not rely solely on a signed AMA form)
	*Not offering alternatives (e.g., "if you won't stay for the CT, would you at least let us check labs?")		*Not offering alternatives (e.g., "if you won't stay for the CT, would you at least let us check labs?")
	*Assuming intoxicated patients automatically lack ~~capacit~~		*Assuming intoxicated patients automatically lack capacity
	*Not documenting who was present during the AMA discussion		*Not documenting who was present during the AMA discussion

Rossdonaldson1: /* Common Pitfalls */

2026-03-25T19:14:10Z

Common Pitfalls

← Older revision		Revision as of 19:14, 25 March 2026
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	*Failing to document specific risks discussed (do not rely solely on a signed AMA form)		*Failing to document specific risks discussed (do not rely solely on a signed AMA form)
	*Not offering alternatives (e.g., "if you won't stay for the CT, would you at least let us check labs?")		*Not offering alternatives (e.g., "if you won't stay for the CT, would you at least let us check labs?")
	*Assuming intoxicated patients automatically lack ~~capacity — '''assess and document''' capacity~~		*Assuming intoxicated patients automatically lack capacit
	*Not documenting ~~'''~~who~~'''~~ was present during the AMA discussion		*Not documenting who was present during the AMA discussion

	==See Also==		==See Also==

Rossdonaldson1: /* Determining Capacity */

2026-03-25T19:13:39Z

Determining Capacity

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	==Determining Capacity==		==Determining Capacity==
	*Four components must be present for decision-making capacity:		*Four components must be present for decision-making capacity. The patient must be able to:
	**~~Able to '''understand'''~~ the relevant information		**Understand the relevant information
	**~~Able to '''appreciate'''~~ the situation and its consequences		**Appreciate the situation and its consequences
	**~~Able to '''reason'''~~ through treatment options		**Reason through treatment options
	**~~Able to '''communicate'''~~ a choice		**Communicate a choice
	*Capacity is ~~'''~~task-specific~~'''~~ and can fluctuate		*Capacity is task-specific and can fluctuate
	*Intoxication alone does not necessarily eliminate capacity, but must be assessed		**Intoxication alone does not necessarily eliminate capacity, but must be assessed
	*If the patient ~~'''~~lacks capacity~~'''~~ and wishes to leave, use the least restrictive measures to ensure safety		*If the patient lacks capacity and wishes to leave, use the least restrictive measures to ensure safety
	*Psychiatric holds (e.g., 5150) may be appropriate if the patient is a danger to self and lacks capacity		*Psychiatric holds (e.g., 5150) may be appropriate if the patient is a danger to self and lacks capacity
	*See also [[Informed consent documentation]]		*See also [[Informed consent documentation]]

Rossdonaldson1: /* Key Documentation Points */

2026-03-25T19:12:17Z

Key Documentation Points

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	==Key Documentation Points==		==Key Documentation Points==
	*~~Document the patient's '''mental~~ status~~'''~~ at time of conversation		*Mental status at time of conversation
	*~~Document '''who~~ was present~~'''~~ during the AMA conversation (nurse, family members, interpreter, etc.)		*Who was present during the AMA conversation (nurse, family members, interpreter, etc.)
	*Have nurses write a brief note about the AMA conversation if present		**Have nurses write a brief note about the AMA conversation if present
	*~~Document '''specific~~ risks~~'''~~ discussed for leaving against medical advice, including the possibility of ~~'''~~death or serious disability~~'''~~		*Specific risks discussed for leaving against medical advice, including the possibility of death or serious disability
	*~~Document that patient '''~~understood risks~~'''~~ and was able to verbalize them back		**Patient understood risks and was able to verbalize them back
	*~~Document '''return~~ precautions~~''' and~~ that they may return at any time		*Return precautions including that they may return at any time
	*Provide ~~'''~~written discharge instructions~~'''~~ as documentation that precautions were reviewed		*Provide written discharge instructions as documentation that precautions were reviewed
	*~~Document any '''alternative~~ treatments~~'''~~ offered that the patient declined		*Alternative treatments offered that the patient declined
	*~~Document any '''prescriptions'''~~ provided and follow-up recommended despite AMA departure		*Prescriptions provided and follow-up recommended despite AMA departure

	==Determining Capacity==		==Determining Capacity==

Rossdonaldson1: /* Background */

2026-03-25T19:10:32Z

Background

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	*Patients who leave AMA have higher rates of readmission, morbidity, and mortality<ref>Alfandre DJ. "I'm going home": discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.</ref>		*Patients who leave AMA have higher rates of readmission, morbidity, and mortality<ref>Alfandre DJ. "I'm going home": discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.</ref>
	*AMA does '''not''' waive the physician's duty of care — the standard of care still applies		*AMA does '''not''' waive the physician's duty of care — the standard of care still applies
	*~~'''~~Signing an AMA form alone is insufficient~~''' — the~~ quality of the documented conversation is what matters medicolegally		*Signing an AMA form alone is insufficient
			**The quality of the documented conversation is what matters medicolegally
	*A patient does '''not''' lose insurance coverage by leaving AMA (this is a common myth)<ref>Schaefer GR, Matus H, Schumann JH, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med. 2012;27(7):825-830.</ref>		*A patient does '''not''' lose insurance coverage by leaving AMA (this is a common myth)<ref>Schaefer GR, Matus H, Schumann JH, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med. 2012;27(7):825-830.</ref>
	*Patients may still receive discharge medications, follow-up instructions, and prescriptions even when leaving AMA		*Patients may still receive discharge medications, follow-up instructions, and prescriptions even when leaving AMA

Danbot: Expanded: added Background with references (prevalence, myth-busting re insurance), expanded Key Documentation Points, expanded Capacity section, added Common Pitfalls, documentation pages template, additional See Also links

2026-03-24T10:59:48Z

Expanded: added Background with references (prevalence, myth-busting re insurance), expanded Key Documentation Points, expanded Capacity section, added Common Pitfalls, documentation pages template, additional See Also links

← Older revision		Revision as of 10:59, 24 March 2026
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	==Background==		==Background==
			*AMA discharges account for approximately 1-2% of all ED discharges<ref>Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51(7):899-902.</ref>
			*Patients who leave AMA have higher rates of readmission, morbidity, and mortality<ref>Alfandre DJ. "I'm going home": discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.</ref>
			*AMA does '''not''' waive the physician's duty of care — the standard of care still applies
			*'''Signing an AMA form alone is insufficient''' — the quality of the documented conversation is what matters medicolegally
			*A patient does '''not''' lose insurance coverage by leaving AMA (this is a common myth)<ref>Schaefer GR, Matus H, Schumann JH, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med. 2012;27(7):825-830.</ref>
			*Patients may still receive discharge medications, follow-up instructions, and prescriptions even when leaving AMA

	==Key Documentation Points==		==Key Documentation Points==
	*Document the patient's mental status at time of conversation		*Document the patient's '''mental status''' at time of conversation
	*Document who was in the ~~room at time of~~ conversation (nurse, family members, interpreter etc.)		*Document '''who was present''' during the AMA conversation (nurse, family members, interpreter, etc.)
	**Have nurses write a brief note about AMA conversation if ~~they are in the room~~		*Have nurses write a brief note about the AMA conversation if present
	*Document ~~what was said to the patient about~~ specific risks of leaving against medical advice		*Document '''specific risks''' discussed for leaving against medical advice, including the possibility of '''death or serious disability'''
	*Document that patient understood risks and was able to verbalize them back		*Document that patient '''understood risks''' and was able to verbalize them back
	*Document ~~that you discussed~~ return precautions and that they may return at any time		*Document '''return precautions''' and that they may return at any time
	** Write these on discharge instructions as ~~written proof~~ that ~~you~~ reviewed ~~them with~~ the patient		*Provide '''written discharge instructions''' as documentation that precautions were reviewed
			*Document any '''alternative treatments''' offered that the patient declined
			*Document any '''prescriptions''' provided and follow-up recommended despite AMA departure

	==Determining Capacity==		==Determining Capacity==
	Four components ~~necessary~~:		*Four components must be present for decision-making capacity:
	#Able to understand the relevant information		**Able to '''understand''' the relevant information
	#Able to appreciate the situation and its consequences		**Able to '''appreciate''' the situation and its consequences
	#Able to reason through treatment options		**Able to '''reason''' through treatment options
	#Able to communicate a choice		**Able to '''communicate''' a choice
			*Capacity is '''task-specific''' and can fluctuate
			*Intoxication alone does not necessarily eliminate capacity, but must be assessed
			*If the patient '''lacks capacity''' and wishes to leave, use the least restrictive measures to ensure safety
			*Psychiatric holds (e.g., 5150) may be appropriate if the patient is a danger to self and lacks capacity
			*See also [[Informed consent documentation]]

	==Sample Documentation==		==Sample Documentation==
	The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I discussed the specific benefits of additional treatment, as well as tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient. However, the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.		The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital.

			In this scenario, it would be battery to subject a patient to treatment against his/her will.

			I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to '''death, permanent disability, prolonged hospitalization, prolonged illness''', were discussed.

			I discussed the specific benefits of additional treatment, as well as tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient. However, the patient declined my options and insisted on leaving.

			Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.

			==Common Pitfalls==
			*Refusing to provide prescriptions or discharge instructions to AMA patients (this is '''not''' appropriate — always treat what you can)
			*Failing to document specific risks discussed (do not rely solely on a signed AMA form)
			*Not offering alternatives (e.g., "if you won't stay for the CT, would you at least let us check labs?")
			*Assuming intoxicated patients automatically lack capacity — '''assess and document''' capacity
			*Not documenting '''who''' was present during the AMA discussion

	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]		*[[Documentation for emergency physicians]]
			*[[Informed consent documentation]]
			*[[Discharge documentation]]

			{{Documentation pages}}

	==External Links==		==External Links==
	*[https://www.aliem.com/~~2014/~~proper-way-to-go-against-medical-advice/ ALIEM - The Proper Way to Go Against Medical Advice]		*[https://www.aliem.com/the-proper-way-to-go-against-medical-advice/ ALIEM - The Proper Way to Go Against Medical Advice]

	==References==		==References==

Rossdonaldson1 at 17:06, 30 September 2021

2021-09-30T17:06:57Z

← Older revision		Revision as of 17:06, 30 September 2021
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	** Write these on discharge instructions as written proof that you reviewed them with the patient		** Write these on discharge instructions as written proof that you reviewed them with the patient

			==Determining Capacity==
			Four components necessary:
			#Able to understand the relevant information
			#Able to appreciate the situation and its consequences
			#Able to reason through treatment options
			#Able to communicate a choice

	==Sample Documentation==		==Sample Documentation==

Rossdonaldson1: /* Sample Documentation */

2021-09-30T16:54:45Z

Sample Documentation

← Older revision		Revision as of 16:54, 30 September 2021
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	==Sample Documentation==		==Sample Documentation==
	The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient, ~~though~~ the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.		The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I discussed the specific benefits of additional treatment, as well as tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient. However, the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.

	==See Also==		==See Also==

Lyssa1219: /* Sample Documentation */

2020-04-09T22:06:30Z

Sample Documentation

← Older revision		Revision as of 22:06, 9 April 2020
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	==Background==		==Background==


			==Key Documentation Points==
			*Document the patient's mental status at time of conversation
			*Document who was in the room at time of conversation (nurse, family members, interpreter etc.)
			**Have nurses write a brief note about AMA conversation if they are in the room
			*Document what was said to the patient about specific risks of leaving against medical advice
			*Document that patient understood risks and was able to verbalize them back
			*Document that you discussed return precautions and that they may return at any time
			** Write these on discharge instructions as written proof that you reviewed them with the patient

← Older revision		Revision as of 19:14, 25 March 2026
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	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[Informed consent documentation]]
	*[[Discharge documentation]]

	{{Documentation pages}}		{{Documentation pages}}