Liability and litigation
Discharged against medical advice
Assess Decision-Making Capacity (DMC) First :
Must demonstrate understanding, appreciation of risks/benefits, logical reasoning, and consistent choice.
Impaired DMC (e.g., acute intoxication, delirium, active psychosis, suicidality) = Pt cannot leave AMA ; manage with implied consent or psychiatric holds.
Explore and Address Underlying Causes : c
Prior to processing AMA, identify remediable triggers (e.g., uncontrolled pain, nicotine cravings, opioid/EtOH withdrawal, family/pet obligations).
Treat promptly (e.g., offer nicotine replacement, optimize analgesics, involve social work).
Informed Refusal & Discussion :
Explicitly explain the diagnosis, proposed treatment, and specific risks of leaving (including permanent disability or death ).
Discuss available alternatives (e.g., outpatient parenteral therapy, PO conversion).
Harm Reduction (Never Punitive) :
Provide outpatient prescriptions : Switch IV meds to PO equivalents (e.g., oral fluoroquinolones for bacteremia/pyelonephritis).Arrange follow-up : Schedule clinic appointments and outline clear red-flag return precautions.“Open Door” policy : Emphasize they are welcome to return at any time without penalty or judgment.Remove invasive lines : Remove peripheral IVs prior to exit to prevent phlebitis or illicit substance injection.
Legal & Documentation Essentials :
Document DMC assessment, risks explained, alternatives offered, and discharge instructions thoroughly.
If the pt refuses to sign the AMA form , document the refusal with a witness (e.g., RN); they must still be allowed to leave (physical detention equals false imprisonment).