Discharges Against Medical Advice at a County Hospital: Provider Perceptions and Practice.

Abstract

Patients discharged against medical advice (AMA) have higher rates of readmission and mortality than patients who are conventionally discharged. Bioethicists have proposed best practice approaches for AMA discharges, but studies have revealed that some providers have misconceptions about their roles in these discharges. This study assessed patient characteristics and provider practices for AMA discharges at a county hospital and provider perceptions and knowledge about AMA discharges. This mixed-methods cross-sectional study involved chart abstraction and survey administration. Charts were reviewed for all AMA discharges (n = 319) at a county hospital in 2014. Surveys were completed by 178 healthcare providers at the hospital. Of 12,036 admissions, 319 (2.7%) ended with an AMA discharge. Compared with conventionally discharged patients, patients who left AMA were more likely to be young, male, and homeless and less likely to be Spanish-speaking. Of the AMA patients, 29.6% had capacity documented, 21.4% had medications prescribed, and 25.7% had follow-up arranged. Of patients readmitted within 6 months after AMA, 23.5% left AMA again at the next visit. Attending physicians and trainee physicians were more likely than nurses to say that AMA patients should receive medications and follow-up (94% and 84% vs 64%; P < 0.05). Although providers overall felt comfortable determining capacity and discussing AMA discharges, they rarely documented these discussions. Nurses and physicians differed in their thinking regarding whether to arrange follow-up for patients leaving AMA, and in practice arrangements were seldom made. Journal of Hospital Medicine 2017;12:11-17.