Leaving the ED Against Medical Advice: Consequences and Considerations

Case Presentation:

• 49 year old female with a past medical history significant for congestive heart failure with preserved ejection fraction (last EF at 40%), unknown underlying psychiatric diagnosis, and an unknown abdominal surgery presents with persistent abdominal pain for the past two days. She has had intermittent diarrhea for the three weeks and last BM was day prior to presentation. She has had diminished PO intake and denies vomiting.

• Vitals were significant for BP at 140/93. On exam, she is lethargic to answer questions but is arousable and oriented to person, place, and time. Abdomen with umbilical hernia present, pain to palpation at every quadrant of abdomen without involuntary guarding, rigidity, or mass. No evidence of impairment of consciousness, short-term memory deficits, or mood lability.

• The following labs were drawn and were within normal limits: CBC, CMP, hcg, lactate, lipase, BNP, and troponin x 3.

• A CT abdomen and pelvis with contrast was needed however when the patient was taken to imaging she refused contrast as she had contrast in her prior respiratory illness work up. She was reassured her creatinine was within normal limits and contrast would be helpful for visualizing pathologies. She become increasingly agitated regarding contrast, then declined any further imaging without contrast, and immediately asked to leave against medical advice. As she consistently demonstrated capacity during her stay there was no indication to hinder her from leaving.

Clinical Question: What are contributing factors and provider considerations in patients choosing to leave against medical advice?

Introduction:

• Discharge against medical advice (DAMA) occurs when patients choose to end medical treatment despite recommendations to further diagnostic studies or continue treatment.1 DAMA accounts for roughly 1% of all medical institution discharges.2 Often, patients requesting DAMA are acutely ill with inadequate treatment and pose a high risk of morbidity and mortality upon leaving the medical institution.3 There is a high risk of readmission with increased healthcare expenditure due to the interruption of care.2

Summary of Evidence:

• Common variables leading to DAMA is poor patient-provider communication, risks of DAMA not communicated adequately, insufficient access to community care centers, delays in care or delay in discharge(2).

• Many circumstances contribute to DAMA such as communication complexities, interpersonal and community factors(2). Studies have found patients who are young, without insurance, covered by Medicare or Medicaid, have an underlying psychiatric diagnosis, or struggling with substance abuse may be more likely to request DAMA(2,4). Certain studies have found an association with young males; however, this may be a result of selection bias as this demographic may experience more frequent trauma(3).

• Qualitative variables which have been correlated with patients who choose DAMA include dissatisfaction with care, reduction of symptoms, the presence of substance abuse disorder, inadequate pain management, and insufficient treatment of drug withdrawal.2 External factors which are common are employment-related or family obligations(2).

• Patients with a psychiatric diagnosis have a 3% to 51% increase of prevalence of DAMA(2).

• Despite these trends, it is difficult to predict patients which may DAMA(1).

Consequences of DAMA:

• Patients who DAMA are more likely to have advanced disease processes and reluctance to present once seeking care(2). For example, readmission rates are roughly upwards of 40% higher with increased mortality(1).

• Patients struggling with substance abuse disorder with DAMA are at a higher risk for negative outcomes(5). This may be a result of frequent utilization of emergency departments in addition to significant barriers such as unemployment and homelessness(5).

Recommendations:

• Autonomy of the patient can be supported through a physician fully describing the benefits of receiving care and risks of discharge.1 The physician must inquire details regarding the associated factors compelling the patient to consider DAMA to decrease the rate of discharge(1).

• Insurance plans may not cover the cost associated with observational status, and financially strained patients may choose to leave DAMA should admission not be recommended(4).

• Remain transparent regarding the anticipated length of stay and be aware of financial ramifications associated with observational status(2).

• Addressing withdrawal symptoms is paramount as delay in care is associated with DAMA(4). Additionally, utilization of substance abuse specialists can intervene early and prevent DAMA(5).

• Patients who may choose DAMA may still be receptive to phone follow up, prescription medications, and instructions(2).

• A patient's signature on a DAMA form does not absolve the provider of liability. The patient should be assessed for competency and knowledge regarding their diagnosis(2).

• Regarding a patient requesting discharge against medical advice and insurance coverage, there is no evidence of insurance carriers deny payment to providers or medical institutions(6).

• At this time there are no defined interventions or communication techniques which have been studied and associated with a reduction in DAMA(2).

Reference

1. Yuan S, Ashmore S, Chaudhary KR, Hsu B, Puumala SE. The Role of Socioeconomic Status in Individuals that Leave Against Medical Advice. South Dakota Medicine: The Journal Of The South Dakota State Medical Association. 2018;71(5):214-219.

2. Alfandre D. Against‐Medical‐Advice Discharges from the Hospital. Optimizing Prevention and Management to Promote High Quality, Patient-Centered Care. [Electronic Resource] : Cham : Springer International Publishing : Imprint: Springer, 2018.; 2018.

3. Gunchan P, Gautam P. L., Rubina K, Birinder S. P. Prospective Evaluation of Patients Leaving against Medical Advice of a Tertiary Care Hospital: Comparison of Emergency and Intensive Care Units. International Journal of Medicine & Public Health. 2018;8(1):18-23. doi:10.5530/ijmedph.2018.1.4.

4. Patel B, Prousi G, Shah M, et al. Thirty-Day Readmission Rate in Acute Heart Failure Patients Discharged Against Medical Advice in a Matched Cohort Study. Mayo Clinic Proceedings. 2018;93(10):1397-1403. doi:10.1016/j.mayocp.2018.04.023.

5. Lail P, Fairbairn N. Patients With Substance Use Disorders Leaving Against Medical Advice: Strategies for Improvement. Journal Of Addiction Medicine. 2018;12(6):421-423. doi:10.1097/ADM.0000000000000432.

6. Schaefer GR, Matus H, Schumann JH, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? Journal Of General Internal Medicine. 2012;27(7):825-830. doi:10.1007/s11606-012-1984-x.