Patients being discharged against medical advice

Mar 09, 2009

When patients choose to leave the hospital before the treating physician recommends discharge, the consequences may involve risk of inadequately treated medical conditions and the need for readmission, according to a review in the March 2009 issue of Mayo Clinic Proceedings. Additionally, the article examines the effect of costs as well as predictors and potential interventions to help manage and improve this important issue.

Although studies to date are limited, research shows that against discharges represent as many as 2 percent of all . Those represent an at-risk group for both morbidity and mortality, according to the article. Within 30 days, the review states patients with asthma, for example, who were discharged against medical advice had a four-times-higher risk of readmission to the emergency department within 30 days and an almost three-times-higher risk of readmission to the hospital. Further, in a study of general medicine service, patients who left against medical advice were seven times more likely to be readmitted within 15 days, almost always for the same diagnosis. Such readmissions clearly indicate higher health care costs, the review concludes.

At the heart of the problem is an for physicians. When a patient wishes to leave against medical advice, this may be contrary to the physician's attempt to do what is believed best for the patient. The struggle is between and physician beneficence, according to the review. In practice, managing this issue presents more complications than simply identifying and potentially prioritizing the relevant ethical principles, the review reports. Physician-patient communication, informed consent, and underlying are all relevant to practical management.

Identifying patients likely to leave against medical advice is crucial, according to the article. Studies to date have shown these groups to include patients with alcohol or , financial issues, sickness within the family and individuals who begin feeling better. General psychiatric health also is an important consideration.

"Particularly because many patients request to leave the hospital for personal or financial reasons, the clearer these motivations are, the better the physician can discuss the need for hospitalization," states the review's author, David Alfandre, M.D., Department of Veterans Affairs National Center for Ethics in Health Care, New York Harbor Healthcare System. "For example, when a physician determines that an increasingly angry and 'demanding' patient wants to leave the hospital to care for his homebound mother, not because he has little concern for his elevated blood pressure, the physician can attempt to reduce the patient's burden by focusing on that issue, rather than on the mounting discharge conflict between physician and patient."

The review in adds, "Informed consent in deciding to leave against medical advice is one of the most important elements of care for patients who make this decision. An informed decision means that the patient has arrived at the decision in consultation with his or her physician without being subjected to coercion and with a full understanding and appreciation of the risks."

The review recommends more studies and says, "Focusing on providing informed consent, with attention to the vulnerabilities and health literacy levels of hospitalized patients, can ensure the best care possible for patients while respecting autonomy."

More information: www.mayoclinicproceedings.com

Source: Mayo Clinic

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User comments : 1

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E_L_Earnhardt
not rated yet Mar 09, 2009
Yes! I am one of those patients who left before discharge! They were pumping me full of drugs to keep me more "manageable" and I explained I had past adiction history and would rather hurt! These patients are PEOPLE - not things!

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