AMA
Managing AMAs
by
Dr. Fred Poage, FSED Medical Director, Amarillo, TX
Dr. Brad Blaker, Regional Medical Director, Michigan
AMA: Against Medical Advice
The term 'Against Medical Advice' or 'AMA' is commonly understood to indicate when a patient chooses to leave before the treating physician believes it is medically safe to discharge. Please note it is important to distinguish AMA from ELOPED, whereby the patient leaves the treating facility prior to discussing this with the physician.
Background
AMA discharges account for approximately 2% of all discharges.
AMA discharges are at significantly higher risk of readmission, with an overall readmission rate of 20% compared to general rate of 3%.
AMA readmissions cost up to 56% higher than expected from initial hospitalization.
Analysis
Decreasing AMA discharges should be a top priority for all physicians, including Emergency Medicine, Hospital Medicine, and Critical Care.
When busy, it is challenging to commit the time to discussing with a patient his/her desire to leave AMA.
Inpatient AMA discharges have been correlated with a misunderstanding of the expected length of stay.
Physicians can help mitigate this by not underestimating the length of stay when asked.
Considerations
Know that the treating physician is still responsible to provide as safe and as appropriate care as possible, including prescriptions, referrals, and follow-up.
Most Important: ensure the patient understands that we want him or her to return so we can continue providing care; we do not believe leaving at this time is in their best interest.
Ensure the nurse informs the physician any time a patient wants to leave AMA.
Avoid the myth that insurance/Medicaid/Medicare will not pay if the patient leaves AMA.
Know that frequent physician reassessments and clear communication with the patient can decrease AMA rates.
Establish a dedicated AMA-liaison.
Documentation
Documentation of AMAs is critical. Example:
The patient has decided to leave AMA because___.
He / she has normal mental status and adequate capacity to make decisions.
The patient refuses hospital admission and wants to be discharged.
The risks have been explained to the patient, including ___, worsening illness, chronic pain, permanent disability and death.
The benefits of admission have also been explained.
The patient had an opportunity to ask questions about his / her medical condition.
The patient was treated to the extent he / she would allow and knows that they may return for care.
Follow-up has been discussed and arranged with Dr. ___.
Summary
Patients who leave AMA should be taken seriously. Your goal is to encourage the patient to stay and complete the recommended treatment. If he / she still chooses to leave, proper chart documentation outlined above along with a signed AMA form can help to mitigate risk.
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References
Syzek, Tom, MD, The Sullivan Group, Do's & Don'ts of AMA: Patients Who Leave Against Medical Advice (thesullivangroup.com).
MagMutual, When Good Patients Make Bad Decisions an AMA Form Protects Me, Right?,www.magmutual.com, Nov, 9, 2016
Mayz, Kurtis, A. JD,MD, MBA, FACEP, Top 5 Legal Risks in Five Minutes or Less, ACEP21, Boston Convention Center, Boston, MA Oct, 26, 2021.
