Against Medical Advice (AMA) discharges, also known as "hospital against medical advice" discharges, occur when a patient chooses to leave a healthcare facility against the advice of a medical professional.
An AMA discharge is different from elopement, which occurs when a patient leaves without the knowledge of healthcare providers. With an AMA discharge, patients inform caregivers of a desire to leave. Caregivers should then provide information about risks so patients can make an informed refusal.
Approximately 1% to 2% of patients leave hospital AMA, but recent research from Medicare shows rates at which seniors leave AMA have been rising. AMA discharges are also more common in certain areas. The California Department of Health Access and Information reports that there were 133,445 discharges against medical advice in California in 2019-2020. This represents 2.6% of all discharges. According to available data, patients discharged AMA face increased risks of readmission, morbidity, and mortality, and these discharges contribute to higher healthcare costs and legal considerations.
Also referred to as self-discharges, leaving AMA can put physicians and care facilities at legal risk if it’s not properly documented that the patient was appropriately informed and had the capacity to give or deny informed consent to treatment. The AMA discharge label is used to protect providers and hospitals from liability in case of adverse outcomes after discharge.
All healthcare providers must know the against medical advice definition, because while patients have the right to refuse treatment, AMA discharges create liability risks for providers. An AMA discharge occurs when a patient chooses to leave the hospital before the treating physician recommends discharge.
In a standard discharge, the treating physician recommends discharge after discussing the recommended treatment with the patient and ensuring they understand the plan.
During the discharge process, proper discharge planning and evaluation of the patient's decision-making capacity are essential to ensure patient safety and reduce adverse outcomes.
Patients have the right to make their own healthcare choices, but it is crucial that they make an informed decision before leaving AMA, with clear communication about the risks, benefits, and alternatives.
An AMA discharge occurs when a patient leaves a care facility before a medical professional recommends discharge.
Outside of limited situations, such as when a patient lacks capacity to provide informed consent, patients are allowed to make their own treatment choices, including leaving against medical advice.
However, AMA discharges create significant risk for patients and providers, as patients are more likely to be readmitted or to die when they leave against medical advice, and providers face elevated litigation risks.
According to research published in Medicine, those at the highest risk of leaving a care facility against the wishes of their providers include:
AMA discharges are particularly prevalent within the general medicine service, where they are associated with higher risks of adverse outcomes, including increased hospital readmission rates, mortality, and greater cost implications.
State-specific data also highlight similar trends, while California’s report on patients also shows high rates of AMA among patients with diabetes, chronic obstructive pulmonary disease (COPD), and sepsis.
There has, unfortunately, been a significant recent increase in AMA departures. In 2006, Medicare enrollees left AMA 72,529 times out of 10,699,861 discharges, while in 2013, enrollees left AMA 84,123 times out of 8,456,947 discharges.
AMA discharges peaked during the COVID-19 pandemic and remained elevated as distrust for providers grew in response to the controversy over COVID-19 measures.
Unfortunately, Medicare reported enrollees who leave against medical advice were over twice as likely to either be readmitted to a care facility or to die within 30 days of being discharged, highlighting the significant impact of AMA discharges on Medicare patients. The Agency for Healthcare Research and Quality shows these trends hold true among all patients, with those who leave AMA facing a 21% hospital readmission rate within the first 15 days following discharge from care, compared with 3% in matched controls. These increased readmission rates and mortality risks negatively affect overall health care quality.
Many of the patients who leave cite personal reasons as a leading factor for an AMA discharge, according to research published in Medicine. Patients often decide to leave the hospital against medical advice after weighing these factors and considering their own priorities and concerns. Key reasons for self-discharge include:
Mental health and substance abuse issues significantly increase the likelihood of AMA. Medicare’s data revealed that enrollees diagnosed with mental, behavioral, or neurodevelopment disorders left facilities AMA at more than twice the rate of those without a mental health diagnosis.
Healthcare providers face significant risks after a discharge against medical advice.
Research indicates patients leaving AMA are 10 times as likely as the typical emergency room patient to initiate litigation, with approximately one lawsuit for every 300 instances of AMA discharges.
Unfortunately, a patient leaving AMA is not, by itself, a sufficient defense to a medical malpractice claim.
Providers must also ensure that their actions align with professional standards when managing AMA discharges. Adhering to professional standards means providing evidence-based, ethical care and documenting the process thoroughly to help protect patient safety and maintain trust.
Instead, when defending against a malpractice claim after a patient leaves AMA, doctors must raise the same defense required in virtually all malpractice claims. Since negligence is the basis for most liability claims in medicine, healthcare providers must demonstrate that there was no breach of duty.
Providers are responsible for ensuring patients receive the best possible care, and a patient’s decision to leave AMA doesn’t negate this responsibility.
According to the American Medical Association Code of Ethics, “physicians’ primary ethical obligation to promote the well-being of individual patients encompasses an obligation to collaborate in a discharge plan that is safe for the patient. As advocates for their patients, physicians should resist any discharge requests that are likely to compromise a patient’s safety.” In addition, involving a patient advocate during discharge planning can help support patients by addressing their concerns, clarifying misunderstandings, and ensuring their needs are represented throughout the process.
If a patient isn’t properly informed of the risks of AMA or can’t give informed consent and still leaves against medical advice, the care facility could be liable for resulting consequences. In some cases, a failure to fulfill the duty to ensure patients receive appropriate care could be considered negligence or even gross negligence that results in nuclear verdicts.
Plaintiffs' attorneys typically help patients to pursue malpractice claims against care providers after a patient is discharged against medical advice when:
Patients have the right to make their own treatment decisions, so providers must balance patient autonomy with a duty to provide high-quality patient care. This can lead to conflicting duties.
The key is to assess the patient’s capacity for medical decision-making. Special care must be given to situations where AMA discharge becomes ethically complex, including when refusal of care is likely to have serious or life-threatening consequences.
Providers also must consider obligations under the Emergency Medical Treatment and Labor Act (EMTALA), which requires facilities and providers to stabilize patients seeking emergency treatment regardless of the patient’s ability to pay for care. EMTALA also emphasizes the importance of providing care in a timely manner to prevent adverse outcomes that can result from delays in treatment.
EMTALA doesn’t preclude a patient from choosing to leave against medical advice. However, EMTALA aims to prevent hospitals from discouraging uninsured patients from seeking treatment by failing to explain the importance of specific medical treatments.
Providers must take “all reasonable steps” to obtain informed consent to stabilizing treatment, and hospitals must put policies and procedures in place to try to reduce AMA discharges, including communicating the hospital’s willingness to provide medically stabilizing care and to encourage patients to stay.
One common question for both patients and hospitals is: Will insurance pay if you leave against medical advice?
In some cases, physicians are taught that insurance will deny care after AMA discharges and they often advise patients to that effect. However, it is a misconception that insurance automatically denies payment when a patient leaves against medical advice. Insurers cannot avoid paying for care that was already provided based on the circumstances of discharge, and research has shown no evidence of insurers denying care for this reason.
Because AMA creates significant liability risk, providers must understand best practices for documentation. The AMA process is a critical procedural step that involves thorough documentation, clear communication with the patient, and obtaining a signed AMA form to protect healthcare providers legally and ensure patient safety.
Documentation is required in AMA discharges, but this is more complicated than it may seem on the surface. It is essential to record the informed consent discussion, including the risks, benefits, and the patient's understanding of their decision to leave, in the patient's chart.
In many cases, hospitals or care facilities have a standardized Against Medical Advice form as well as an Against Medical Advice form in Spanish. However, while patients should ideally sign these forms, they cannot be refused discharge if they decline.
Further, blanket statements absolving the doctor and care facility of liability will typically not be enforceable, as this type of language is often considered void against public policy.
These forms also don’t necessarily shield a care provider from liability because the key factor is not whether the patient chose to leave but rather whether the patient has made an informed refusal of continuing care.
The purpose of AMA discharge forms is to ensure that patients understand the risks and that physicians protect themselves from liability.
Physicians Weekly addressed a common belief promoted by some defense attorneys that AMA discharge forms should be as vague as possible and say only that “risks and benefits were reviewed.” Unfortunately, this limits the physician when testifying. If the physician is unable to remember the actual case, they may be unable to show they provided proper warnings.
Physicians Weekly recommends listing the major risks covered while making clear that those issues were discussed, but the discussion was not limited to those items. It is also important to document that the recommended treatment options were discussed with the patient, even if the patient chooses to decline them.
Doctors and care providers can also employ the teach-back method upon reviewing the form and the risks of AMA. This method involves requesting the patient to explain the medical information in their own words.
The focus should be on ensuring that patients understand not just the instructions provided, but the consequences and potential impact of their choices on their ongoing health status.
While patients have a fundamental right to make informed decisions about their medical care, this right hinges upon the patient having the capacity and competence to make informed choices.
Capacity and competence are not the same thing. Competence means being capable of making a rational decision under the circumstances, and has broader implications in the law as it is also used to determine if a person can enter into a will or sign a contract.
Capacity is a clinical or medical term defined as being able to process information and make informed decisions in line with values, preferences, and beliefs. A thorough evaluation of the patient's decision-making capacity is essential to ensure that the patient fully understands the implications of leaving against medical advice and to support proper documentation. To have the capacity to make an informed choice to leave AMA, the patient must:
Adults and emancipated minors are presumed to have capacity. However, if a patient is found to lack capacity, care providers must make decisions in emergent situations if there is no family present and no advance directives on file.
Care providers can assess capacity using standardized competence tools that provide a set of questions aimed at determining if the patient is in a position to provide informed consent.
Care providers can also ask open-ended questions and document both the question and answer process. These questions should test the patient's understanding, ability to express a choice, appreciation for their situation, and reasoning abilities.
When a patient unilaterally terminates a doctor/patient relationship by leaving AMA, the care provider still has an obligation to close out their part of the relationship. This could include:
No organizing body has currently published standards for AMA discharges, so individual care facilities typically create AMA discharge forms themselves as a means of reducing liability risk.
AMA discharge forms typically contain information establishing both capacity and informed consent. This could include:
It’s important to note that some evidence suggests AMA discharge forms have no established benefits over documentation within the chart, and the stigmatization they create breaks down communication and impairs patients’ desire to secure follow-up care.
Insurance companies must still pay for services provided to patients who are discharged against medical advice. However, readmission rates from patients who are discharged AMA are a concern for care facilities.
The high costs of hospital care make it essential for patients to understand hospital billing policies, including what is covered and what may become their responsibility after an AMA discharge. Most hospitals offer financial assistance programs, such as bill reduction, forgiveness, and repayment plans, to help patients manage high bills.
The Patient Protection and Affordable Care Act of 2010 penalizes hospitals with higher readmission rates for certain conditions by reducing Medicare payments. Because AMA discharges increase readmissions, it is in the hospitals’ best interests to have clear protocols in place for reducing the likelihood of these discharges.
Capacity is a pressing concern with certain vulnerable patient groups. Many physicians encounter discharge against medical advice (AMA) in their practice, making it a common and challenging issue in hospital settings. Physicians must be aware of and manage these situations to protect patient rights and limit liability risks.
Patients who leave emergency rooms against medical advice are at elevated risk of complications. Unfortunately, AMA discharges are common from emergency departments because:
Interventions to reduce the risk should include offering patients all possible treatment options, documenting informed consent, and ensuring patients are aware they can return to the emergency department at any time if they change their mind or their condition worsens.
Read everything you ever needed to know about emergency room errors in our blog here!
Certain categories of patients also have unique vulnerabilities or special circumstances that create increased risks in relation to AMA discharge.
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Psychiatric patients may lack the capacity to make care choices because of their mental health condition. However, simply having a mental health diagnosis does not, by itself, mean that a patient is lacking capacity. A full assessment of the patient’s current mental state is necessary regardless of their diagnoses.
When an assessment reveals that the patient’s mental health issues are impacting their ability to refuse care and/or reveals that the patient is a danger to themselves or others, care providers may need to provide treatment regardless of the patient’s refusal.
State law varies on the specifics, but typically each state allows providers to involuntarily hold patients in a care facility for a limited period of time if they present a danger to themselves or others, or if they are not able to provide for their basic needs.
Patients with substance use disorders (SUDs) are up to three times more likely to be discharged against medical advice.
When a patient is intoxicated, best practices are to prevent the patient from leaving AMA until their blood alcohol content is below the legal limit. However, the issue becomes complicated when a substance abuser is not actively under the influence but is suffering from addiction.
State laws sometimes allow involuntary detention and treatment of people with addiction if they meet certain requirements, but simply having a substance abuse disorder alone does not meet this criterion, nor does refusal of services.
Discrimination and failure to treat withdrawal symptoms are leading reasons for AMA discharges among this population. Hospitals may wish to put harm reduction practices into place, including:
Pediatric patients under the age of 18 don’t generally have an independent right to make decisions about their medical care, and parents must provide informed consent for treatment on behalf of children.
Unfortunately, conflicts arise when parents refuse medical treatment for their children, and doctors believe those decisions could inflict harm. This can result in a situation where care providers challenge the parents.
Court challenges brought by providers sometimes result in the state taking over parental decision-making rights regarding medical care, especially in life-threatening situations when the rights of a vulnerable child to evidence-based treatment are at risk.
If a patient wishes to leave AMA, care providers and facilities must still fulfill their obligations to provide professional care even under suboptimal circumstances. This means they must establish best practices for responding to self-discharge situations.
Nurses are often the first to become aware of a patient’s intent to leave a facility against medical advice, so hospitals should ensure there are clear communication pathways between nurses and doctors – especially if a patient is leaving at night or on a weekend.
Effective communication can help reduce AMA discharges and limit liability risks going forward.
Physicians rarely receive formal guidance about reducing AMA discharges, but some protocols have been shown to reduce the likelihood of patients leaving against medical advice. These include:
When a patient leaves AMA, this does not preclude a physician's responsibility for providing appropriate follow-up care.
The Agency for Healthcare Research and Quality outlined a multi-step process for offering appropriate follow-ups, including:
Finally, the provider should provide the patient with a written summary of the hospital stay so that everything is properly documented and so the patient can provide the summary when seeking future care.
Liability after AMA discharges appears lowest when:
Malpractice claims are also associated with plaintiffs feeling they were deserted or devalued. Reducing stigmatized communication regarding AMA discharges can help preclude these feelings.
In some states, rules like an apology law also allow physicians to apologize for undesirable outcomes without increasing their liability risk.
There are numerous examples of providers being sued after patients were discharged AMA.
Medical Professional Reference highlighted one case of an emergency room doctor who was presented with a 24-year-old patient whose BAC was above the legal limit and who refused the doctor’s request to stay for observation after a head injury.
The patient subsequently suffered cognitive impairment from a skull fracture, and while the ED doctor felt the patient was lucid enough to give informed consent despite being intoxicated, the malpractice insurer was concerned the doctor had allowed the patient to leave while impaired. The case settled, and the patient was paid an undisclosed sum.
Another example of an AMA discharge case resulting in a successful malpractice suit included a patient who wanted to go home after a miscarriage. She was experiencing vomiting, abdominal pain, and diarrhea, so she was given an AMA form to sign.
However, doctors failed to inform her that she had a fever and an elevated white blood count that could indicate a persistent infection. When she suffered a ruptured appendix with peritonitis at home, she was able to sue because while she had been informed of the risks of leaving AMA after the miscarriage, she had not been adequately informed of the risk of a separate infectious process.
To avoid outcomes like these, care providers must be explicit and specific about key clinical facts.
Still need to know more? Here are the answers to frequently asked questions about medical advice discharges.
AMA forms alone cannot shield providers against liability. At issue is whether the patient gave informed consent to deny treatment, rather than whether the patient signed a form. Further, blanket waivers of liability on AMA forms are often considered to be void against public policy.
It is generally best practice for care facilities to request that patients sign AMA forms. However, hospitals cannot refuse discharge because a patient refuses to sign the form.
Studies have shown no evidence that insurers deny payment for treatments already provided when a patient leaves AMA. Insurance refusal to pay is a common misconception.
When a patient lacks decision-making capacity, physicians have an ethical responsibility to identify an appropriate surrogate to make decisions on the patient's behalf and to assist the surrogate in making informed choices.
Minors and parents may be able to leave AMA; however, care providers may determine it is in the best interests of the child to challenge a parent’s decision. If the court agrees that the parents are not acting in the child's best interests, the state may appoint a guardian to take over the parental decision-making role.
Providers should document patient capacity and demonstrate that the patient has been informed of and understands the risks of departing against medical advice.
There is a significantly higher risk of malpractice claims when patients leave AMA. Proper documentation is essential to reduce the risk.
AMA refers to any situation when a patient leaves a care facility against medical advice. Informed refusal occurs when a patient has been provided with all appropriate information about the risks of discharge and has the mental capacity to give informed consent to discharge despite a provider's recommendations to the contrary.
Psychiatric patients may be able to leave AMA depending on state law. States have different guidelines for when and how psychiatric patients may be subject to involuntary holds. Typically, an involuntary hold is allowed for a limited duration when a patient presents a clear threat to themselves or others.
Clear communication and effective conflict resolution are key to preventing AMA departures. Clinicians should identify barriers to care, provide alternative treatment plans, treat patients with empathy, and encourage shared decision-making to prevent AMA departures.
AMA discharges put patients at risk of increased harm and elevate the likelihood of malpractice claims. Hospitals and care providers should implement policies to reduce AMA departures and to follow appropriate protocols when they occur, including documenting a patient's capacity and informed refusal.
Providers also need to have the right protections in place in case litigation does arise, even when they follow best practices. Indigo’s medical malpractice insurance can help you get the right coverage in place so you are protected against liability in AMA discharge cases and other malpractice claims.
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