When Patients Leave ‘Against Medical Advice’

This post was originally published on this site

My pager vibrated against my waist. My patient wanted to leave A.M.A. — Against Medical Advice. “Please assess,” the page ended.

A.M.A. is a term we use in the hospital when patients wish to leave before the doctor who is treating them considers them ready for discharge. Any patient who understands the risks and benefits of forgoing medical care can leave A.M.A. at any time. Nevertheless, health professionals often stigmatize such patients, labeling them as “noncompliant,” “ungrateful” or “unwilling to accept appropriate medical care.”

As I walked into my patient’s room, she lay in bed, tearful. She was only in her 50s but looked much older, her walker propped at the side of her bed. Her heart valves were not functioning properly, causing her to be short of breath and her legs to swell. She said immediately, “I’m sorry, doctor. I just need to go home.”

She had rheumatic heart disease, a condition we see less frequently these days. The condition can arise when a case of strep throat is not treated promptly with antibiotics, leading to rheumatic fever and a damaged heart. My patient had had strep throat as a child, but instead of taking her to the doctor, her mother, an alcoholic, had gone on a drinking binge. She never received the antibiotics she needed.

She had been in the hospital before. But she had always had a family member at her side to spend the night. Unfortunately, no one could come this time. The idea of staying in the hospital room alone terrified her. She was persistently traumatized by feelings of abandonment from her childhood.

Patients leaving A.M.A. account for 1 to 2 percent of all hospital discharges. Many are young men, often with concomitant psychiatric or substance abuse histories. They also tend to be poor. Many cite family problems, personal or financial worries or dissatisfaction with their treatment plans. A doctor must have a conversation documenting that the patient understands the risks of leaving and consequences of no longer receiving medical care, a way to help manage the risks.

We know that patients who leave A.M.A. have a higher likelihood of dying, and are more likely to be readmitted to the hospital, mostly within the first two weeks. Doctors will try to “talk down” patients, to convince them to stay. But many patients avoid seeking ongoing medical care, in part because of their life circumstances, but also perhaps because of the resistance they meet from doctors.

Health care professionals may conjure preconceived notions about individuals who have “left A.M.A.”; many doctors never consider that our patients made the right decision.

With my patient, I found myself diving into a discussion of concrete medical details and all of the reasons she needed to stay, waiting for her to realize that she was making a grave mistake.

She could articulate a thorough understanding of her disease and why she was in the hospital. She understood the consequences of leaving and would seek medical attention if any of the multiple symptoms we had discussed arose.

I started repeating my plea, as if it would be more influential the second time.

I considered what I could offer her in exchange for staying, a bartering of sorts. She could stay in her private room on the cardiology service. I could reschedule her procedure time to earlier in the day, so she’d have to spend less time unable to eat or drink and have a shorter hospital stay.

But I could not change her mind. I realized then that it was me who was making the mistake. It was not my decision to make.

As physicians, we forget that time passes outside of the hospital walls. We sometimes isolate our patient’s stories and illnesses, independent of what’s going on in their lives, or their circumstances. My patient had a childhood very much unlike mine, her life continually defined by fear and loneliness.

Some providers find it a burden, perhaps frustrated as to why patients who we are trying to help are not helping themselves. We sometimes feel powerless when we cannot get patients to choose what we think is best for them. Medicine is a balancing act between patient autonomy and beneficence; sometimes the scales tip away from autonomy. The “shared decision-making” we often talk about in other clinical settings may be forgotten.

During my conversation with my patient, I struggled with my desire to heal her heart, and heal her soul. At a certain point, I realized that I was causing more suffering by keeping her in the hospital.

After a patient has expressed desire to leave A.M.A., some physicians may abandon them in the course of care rather than trying to mitigate their risk by making follow-up appointments and providing prescriptions. In discussion with the rest of the medical team, I told my patient she could leave after making a clinic appointment for her in the next few days. Tears of joy rolled down her face.

“Thank you so much, Doctor.”

Shortly thereafter, she returned to the hospital and had her elective valve replacement.

As physicians, we must explore our patients’ reasons for wanting to be discharged and have open and truthful conversations with them. We assume that keeping them in the hospital is always better for their health. But health encompasses the physical, mental and psychological.

In the end, my patient’s leaving was not about our therapeutic alliance. It was not about me at all. It was about her, the patient, as it should be.