What Is Wrong With Discharges Against Medical Advice (and How to Fix Them)

JAMA Network

"It is estimated that as many as 2% of all US hospital discharges (approximately 500 000 per year) are designated as against medical advice¹; that is, a patient chooses to leave the hospital before the treating physician recommends discharge. The risks to these patients are significant. Compared with patients discharged conventionally, readmission rates for patients discharged against medical advice are 20% to 40% higher, and their adjusted relative risk of 30-day mortality may be 10% higher.² Furthermore, physicians and other health care staff report feeling distressed and powerless when patients choose suboptimal care, and disagreement over a discharge against medical advice can cause patient-physician and intrateam conflict.³

Although these harms have been well described, the stigmatizing effect on patients of discharges against medical advice has rarely been examined. Compared with how the profession handles clinical disagreements in other settings (eg, outpatient), an “against medical advice” designation is an outdated concept unsupportive of patients. In this Viewpoint, starting from a core value of patient centeredness, we aim to highlight the problematic aspects of discharges against medical advice and suggest a new approach....

"...Recent studies have highlighted problematic informed consent practices for discharges against medical advice by identifying that a majority of house officers and attending physicians mistakenly believe and inform patients that if they sign out against medical advice, their insurance may not pay for the hospitalization. In a cross-sectional survey of physicians conducted by Schaefer et al,⁵ 85% of residents and 67% of attending physicians reported that they informed patients about denial of insurance payment so that patients would reconsider remaining in the hospital. These studies suggest that the use of misleading information in discharges against medical advice threatens to undermine a patient’s voluntary choice and insinuates that coercion is an acceptable and oft-repeated practice.....