When Good Patients Make Bad Decisions: AMA Documentation and Physician Protection

Executive Summary

A signed Against Medical Advice (AMA) form is insufficient in itself to protect a physician who is accused of failing to provide enough information for a patient to make an informed decision about their medical care. Providers must educate patients about the risks of choosing treatment courses against medical advice in addition to documenting the patient’s insight into their condition. Failure to properly educate the patient and document the patient’s decision leaves a physician vulnerable to litigation if health problems arise.

Recommended Actions

• Ensure that AMA documentation is specific to the patient and the medical advice they are declining to follow.
• Inform the patient and their family when appropriate of all potential consequences of forgoing applicable treatment against medical advice.
• Consider offering follow-up options, alternative care or ways for the patient to contact the provider if they change their mind.

Case Study

Your last patient of the day is a 23-year-old male who was added to your schedule when he called the office that morning. It's been a long day, you're tired, you've already seen two patients today who were added into your already full schedule. But you're not worried. This patient has no past medical history and his chief complaint sounds relatively simple — he has a runny nose, nonproductive cough and vague chest pain. In your mind you’re already writing discharge instructions for an upper respiratory infection. Then you turn the page to read the nurses triage note and your heart drops. His vital signs are all within normal limits except for his tachycardia. The nurse has recorded a heart rate of 155 beats per minute.

When you enter the room, you meet an engaging young man who does have an upper respiratory infection, but who also has atrial fibrillation. After your history and physical, you inform him that he will need to be admitted to the hospital and you excuse yourself to make arrangements to transfer him to the inpatient care of a cardiologist for his new onset atrial fibrillation.

When you return to the room, your patient’s demeanor has dramatically changed. He now appears somewhat agitated and says he cannot be admitted to the hospital because his mother is in your waiting room and needs to go home to feed her cat. You are flabbergasted. You've just spent the last 30 minutes arranging his transfer and now he wants to leave. You're tired, you're ready to go home and you don't have the energy to argue.

Scenario 1

You ask him to sign an AMA form, which he does. He leaves. 

Scenario 2

You remember that he mentioned his mother was in the waiting room. You ask her to accompany you in the room. In her presence you discuss the risks and benefits of hospitalization for his atrial fibrillation. You are specific and mention that he risks death or permanent, devastating neurologic disability by not being admitted for a workup. He discusses his condition intelligently with you and his mother, demonstrates to your satisfaction he appreciates the risks of leaving, but he still declines admission. As a final effort to treat his condition, you ask if he will wait for you to re-consult the accepting cardiologist to discuss possible oral medications. He declines and he signs the AMA form that you have written for this encounter. As he leaves the room, you shake his hand and encourage him to call you on your mobile phone or present to the ED if he changes his mind and desires treatment for his condition. He thanks you and leaves.

Discussion

The existence of signed AMA documentation by itself offers little protection against a claim of medical malpractice. It is helpful, but it is not sufficient by itself to protect a provider who is accused of not providing the necessary information for a patient to make an informed decision about his medical care.

Patients who leave against medical advice have a higher rate of readmission and a higher rate of mortality than patients discharged by their physicians. They frequently have comorbidities such as psychiatric illnesses and drug or alcohol dependence. They tend to be young and male.

When the young man in the case above shows up at the cardiologist’s office 10 days later in heart failure with an ejection fraction of 30%, which of the two scenarios above will be easier to defend? In both cases the patient signed an AMA form, but in the second scenario the physician went further than just having the patient sign a sheet of paper.

While there is no good literature on steps a physician can take to ensure 100% protection against a claim of malpractice arising from an AMA situation, there are several steps a physician can take that will aid in defense:

1) As always, good documentation, including a signed AMA form, will help. The AMA form should be specific to the patient encounter, not a general form.

2) The patient must be fully informed of potential consequences from leaving AMA.

3) The physician should assess and document the patient's competency to make such a decision.

4) Family members, significant others and other concerned individuals should be included in the conversation if possible.

5) Attempts to arrange follow-up or alternative care will likely be viewed as a positive effort by the physician to help the patient.

6) A doctor should always leave the door open for the patient to return for further care. Alternate sites for the patient to access healthcare should also be provided as appropriate.

AMA documentation is part of a larger process to educate patients about risks when they choose treatment courses against the medical advice of their provider. While an AMA form may be a part of this process, it is not sufficient by itself. It is incumbent upon the physician to both educate the patient and document that education and the patient's insight into their condition. Failure to do so leaves the physician vulnerable to the charge that he did not fully inform his patient of the risks of leaving AMA.

Lessons Learned

• Develop a protocol to follow when a patient chooses to forgo treatment against medical advice.
• Ask the patient follow-up questions about their decision, including why they are choosing to decline treatment and what led them to that decision.
• Consider providing a patient who chooses to act AMA a physical copy of follow-up or alternative treatment options so they have a reference if they change their mind.

Potential Damages

Failure to properly educate the patient and document the patient’s decision leaves the physician vulnerable to a contributory negligence claim if the patient experiences subsequent health problems. Although such lawsuits brought after a patient signed an AMA form are relatively infrequent, the cost of defending against such claims can quickly add up.