Leaving Against Medical Advice

Mr. Hassle’s Long Underpants
Doc Shazam had one of those frustrating moments in medicine, and was healthy enough to blog about it instead of ruminating. This gave me pause, and I decided to try to explain how I approach this issue.

First, Leaving AMA is a medico-legal minefield. It is not cured by having the patient sign an AMA form (I recall an attorney explaining that the signature on an AMA form only means they were awake when they left, no more).

So, before they leave, I generally try to talk to the patient, and their family. First, ‘why do you want to leave’? Anger/time/unfulfilled expectations are the vast majority. Some are mad they had to wait 8 hours (for a 3 month outpatient workup), and just leave out of pique. I have never managed to persuade these patients to stay, though I try.

Others have to be home to care for their families, etc. I can occasionally get them to put their health first, but it’s rare, and usually involves some calls to get their home roles filled.

The unfulfilled expectations are usually not grounded in medical reality; you’re going to admit me for pain management/observation? I wanted my (expensive, tricky and/or dangerous surgery) today (invariably night/weekend/holiday). I try to connect the dots about timing, necessity, etc., and get about 1/2 to stay.

I have adopted an idea from one of my colleagues, and I ask the family of the patient, “how do you feel about this? They aren’t going to sue me when they die, you are, so what do you think?” Even if they don’t stay, I got them to think about the future beyond the car keys.

I try very hard to make this whole thing non-adversarial, and offer all the services of the hospital, and tell them I don’t care about the cost, I care only about their care. Then, if they still elect to leave, I assure them that there are no hard feelings on our part, and that we’d be glad to have them come back. I usually always mean it.

Medicine isn’t perfect, and neither are people. I really think we try hard for each individual, and I never like it when the AMA form comes out.

Wow, I sound like Mary Poppins. I’m not, trust me.

Update: And, yes, the Texas Dems left AMA too. They didn’t sign the form.


  1. This is always a sticky subject, and I try to handle it like you have outlined. The ones that get me are the ones that disappear (“nobody” saw them leave) and all you find in the room is a gown, usually thrown on the floor. I did have one patient courteous enough to write on the paper that covers the exam table “You all suck, I hope you rot in Hell” I guess she had to wait too long for the ultrasonographer to come in and make sure she didn’t have a life threatening condition. We did take her out of the patient satisfaction survey. The other ones are the patients that tell the nurse that they are tired of waiting,or whatever pet peeve they have, and the nurse tells them “this ain’t no jail, you can leave”. And they do. No form, no warning, I cringe at the thought of it! Despite all this we usually have a few a day that want to leave, usually due to the wait. At our worst it is 3 hours +/-. Why they wait to get back to a room and leave in the first 10 minutes I’ll never know.

  2. GruntDoc says:

    Excellent observation, and one I have always wondered about, too. Why not leave from the waiting room? No enough of a scene? The cynic in me thinks they want to be seen sooner so they start squawking for attention, the (budding, undernourished) human in me says they want someone to validate their complaint/pain/suffering or personality disorder, whichever.

    Thanks for the comment, I’m glad you’re still reading!

  3. I like the idea of an individualized approach – and non adversarial. We had an experience with the “MA” being hospital protocol, with no thought to how the individual patients were doing when our second grandson was born last July. Our daughter-in-law was living with us while our son completed some Army schools. The hospital here had a policy of no discharge for new Mom in less than 24 hours – none for the baby in less than 48. Given that our son, new dad, was in town for 72 hours, with less than 36 to go when baby was born, and quite possibly headed overseas, there wasn’t much joy at seeing wife and baby in-patient only.
    Daughter-in-law had some excess bleeding. Her OB and I consulted at a good deal of length at her request. We signed out officially AMA, but with full confidence that we were doing the right thng and how to fix it if we weren’t, within the degree of confidence you ever have. Grandson was healthy as a horse, great APGAR’s, no problems at all, except that the attending pediatrician was less than people oriented. He was so hostile about ignoring his 48 hour hold on the baby that he told us not to call him if things went wrong. Daughter-in-law already had a pediatrician, who didn’t come to that hospital, so we didn’t much care. But ya know…..talk about who was set up for any malpractice claim that evil minds might cook up.