“I’m sorry, doctor. I just need to go home,” said the patient with tears in her eyes.

She was in hospital for heart failure from rheumatic heart disease, but she wanted leave the hospital AMA – against medical advice.

A patient’s decision to discharge AMA is a common challenge that healthcare professionals will face in their practice, and poses an ethical dilemma for the treating physician – should the doctor respect the patient’s right to autonomy, or act with beneficence and decide what is best for the patient?

The right to refuse care

Approximately 2% of all medical admissions in the US end up with the patient leaving the hospital AMA, and often involve younger men who have associated psychiatric concerns or history of substance abuse. Many of these patients also have family issues, personal or financial problems, or are unsatisfied with their treatment plans.

In Malaysia, a 2016 study by researchers at HUKM revealed that financial considerations are an important factor in instances of discharge against medical advice (DAMA), and they suggest that early intervention can help reduce the number of DAMA incidences.

An older study in the country by local researchers S.F. Tong and Robert Chen had indicated that such incidences are also high in patients whose illnesses are more serious or terminal, or whom are receiving treatment with unclear benefits.

Patients who discharge AMA hold a markedly increased risk of hospital readmission, morbidity or death, and most healthcare providers become frustrated when faced with such a predicament, sometimes vilifying patients as “non-compliant”, “ungrateful” or “unwilling to accept appropriate medical care”.

However, treatment without consent can be deemed as battery and patients have the right to refuse care.

As such, seasoned healthcare providers are aware of their responsibilities in determining a patient’s capacity to make such decisions and obligations to provide adequate disclosure of specific risks and consequences to the individual who decides to leave AMA. Appropriate documentation is also made to confer optimal legal protection for the healthcare provider.

Good patient-doctor relationship essential in patient decision

Still, healthcare providers should take steps beyond formal proceedings of “filling out an AMA form” to investigate, understand and address the underlying reason for the patient’s decision to prematurely withdraw medical treatment.

A good and trusting physician-patient relationship is an important factor that helps patients determine their decisions and most will rationally agree to treatment strategies if better rapport is established and patients are kept up-to-date by their doctors.

The lack of understanding of treatment options, however, may contribute to the patient’s refusal of treatment plans, and it is important for health providers to address the lack of information provided.

Doctors should communicate to patients their accurate state of health and reinforce the importance of their treatment plans, and if needed, involve allied health professionals in the primary care team to address any social or psychological issues that may be influencing factors to the patient’s decision.

Balancing patient autonomy and beneficence

Patients are people first, and for many, health is just one of the many other priorities in their lives.

The hospital may be a setting that is uncomfortable, foreign and even frightening to patients, and patients may wish to return home to familiar surroundings and the comfort of their family members. Some may choose to go home due to health costs and financial constraints, while others may have obligations at work or with their families which make long-term stay in hospital a difficult choice to make.

To prevent them from leaving, some doctors may bargain with patients by offering to transfer them to a private ward, reschedule their procedure to an earlier time or assist in application for financial aid and social welfare.

Despite these efforts, some still insist on leaving AMA with the belief that they are making the best decisions for themselves, but their reasons should not be overlooked.

In situations like these, a “shared decision-making” approach should be taken. If the patient is allowed to discharge AMA, doctors should explore alternative options available for patients, make follow-up appointments, provide necessary prescriptions of medications and offer guidance for patients to adhere to in the case of an emergency.

No doubt, the practice of medicine is a complicated one, and is often met with ethical hurdles.

Nonetheless, a holistic framework is essential in the practice of medicine, and the art of humanising medicine should not be forgotten to ensure the best care for patients. MIMS

Read more:
The art of empathy to become a better healthcare professional
The influence of word choices in patient-doctor communications
Healthcare professionals: 4 non-verbal ways of communication that you should be using with your patients
7 ways to build a productive doctor-patient relationship

Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170349/
http://www.medicineandhealthukm.com/fulltext/7264
https://www.nytimes.com/2017/01/12/well/live/when-patients-leave-against-medical-advice.html?_r=1
http://www.kevinmd.com/blog/2014/03/request-leave-ama-signal-honest-conversation.html
http://www.the-hospitalist.org/hospitalist/article/121916/what-are-best-practices-patients-discharged-against-medical-advice
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664598/
http://www.medscape.com/viewarticle/770719_2
http://www.sciencedirect.com/science/article/pii/S1658361209700770