Reframing the Phenomenon of Discharges Against Medical Advice: A Sociologist’s Perspective

  • Helen-Maria LekasEmail author


Leaving the hospital against medical advice (AMA) is uncommon. Approximately 2% of annual discharges in the USA are deemed AMA. However, a closer look at the literature reveals that the most psychosocially vulnerable patients (e.g., diagnosed with psychiatric illness, substance use disorder, or HIV) have very high rates of AMA discharges, 6–50% across studies. This chapter suggests that the phenomenon of AMA discharge contributes to health disparities and, therefore, constitutes a strategic research event, ideal for illuminating processes that generate health disparities. I propose the concepts of habitus and institutional agency as key interpretative tools. AMA discharges emerge at the interplay between the patient’s habitus from the margins and the provider’s habitus that is an amalgam of uncertainty and medical authority. Conducting institutional ethnography to discern the hospital’s institutional agency reveals its discretionary power and the influence of macro sociocultural factors on explicit and implicit hospital policies that differentially benefit patients, undermine patient-centered care and contribute to AMA discharges.


Against medical advice (AMA) discharge Habitus Health disparities Institutional agency Institutional ethnography Patient-centered care Strategic research event 


  1. 1.
    Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25:926–9.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97:2204–8.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. Can Med Assoc J. 2002;167:633–7.Google Scholar
  4. 4.
    Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119:924–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Alfandre DJ. “Im Going Home”: discharges against medical advice. Mayo Clin Proc. 2009;84:255–60.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Franks P, Meldrum S, Fiscella K. Discharges against medical advice. J Gen Intern Med. 2006.
  7. 7.
    Kraut A, Fransoo R, Olafson K, Ramsey CD, Yogendran M, Garland A. A population-based analysis of leaving the hospital against medical advice: incidence and associated variables. BMC Health Serv Res. 2013.
  8. 8.
    Spooner KK, Salemi JL, Salihu HM, Zoorob RJ. Discharge against medical advice in the United States, 2002–2011. Mayo Clin Proc. 2017;92:525–35.CrossRefPubMedGoogle Scholar
  9. 9.
    Tawk R, Freels S, Mullner R. Associations of mental, and medical illnesses with against medical advice discharges: the National Hospital Discharge Survey, 1988–2006. Admin Pol Ment Health. 2013;40:124–32.CrossRefGoogle Scholar
  10. 10.
    Bourdieu P. Outline of a theory of practice. Cambridge, UK: Cambridge University Press; 1977.CrossRefGoogle Scholar
  11. 11.
    Bourdieu P. The logic of practice. Stanford: Stanford University Press; 1990.Google Scholar
  12. 12.
    Lutfey Spencer K, Grace M. Social foundations of health care inequality and treatment bias. Ann Rev Sociol. 2016;42:101–20.CrossRefGoogle Scholar
  13. 13.
    Freese J, Lutfey K. Fundamental causality: challenges of an animating concept for medical sociology. In: Handbook of the sociology of health, illness, and healing handbooks of sociology and social research. New York: Springer; 2011. p. 67–81.Google Scholar
  14. 14.
    Sinding C. Using institutional ethnography to understand the production of health care disparities. Qual Health Res. 20:1656–63.CrossRefPubMedGoogle Scholar
  15. 15.
    Smith DE. Institutional ethnography: a sociology for people. Toronto: AltaMira Press; 2005.Google Scholar
  16. 16.
    van der Geest S, Finkler K. Hospital ethnography: introduction. Social Sci Med. 2004;59:1995–2001.CrossRefGoogle Scholar
  17. 17.
    Merton RK. Three fragments from a sociologists notebooks: establishing the phenomenon, specified ignorance, and strategic research materials. Ann Rev Sociol. 1987;13:1–29.CrossRefGoogle Scholar
  18. 18.
    Chan ACH, Palepu A, Guh DP, Sun H, Schechter MT, Oshaughnessy MV, Anis AH. HIV-positive injection drug users who leave the hospital against medical advice. JAIDS J Acquir Immune Defic Syndr. 2004;35:56–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125:594–602.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Crawford ND, White K, Rudolph AE, Jones KC, Benjamin EO, Fuller CM. The relationship between multiple forms of discrimination, neighborhood characteristics, and depression among illicit drug users in New York City. J Drug Issues. 2014;44:197–211.CrossRefPubMedGoogle Scholar
  21. 21.
    Lekas H-M, Siegel K, Leider J. Felt and enacted stigma among HIV/HCV-coinfected adults. Qual Health Res. 2011;21:1205–19.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Pescosolido BA, Medina TR, Martin JK, Long JS. The “Backbone” of stigma: identifying the global core of public prejudice associated with mental illness. Am J Public Health. 2013;103:853–60.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Corrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004;30:481–91.CrossRefPubMedGoogle Scholar
  24. 24.
    Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health. 2013;103:813–21.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med. 2010;71:2150–61.CrossRefPubMedGoogle Scholar
  26. 26.
    Room R. Stigma, social inequality and alcohol and drug use. Drug Alcohol Rev. 2005;24:143–55.CrossRefPubMedGoogle Scholar
  27. 27.
    Alfandre D, Yang J, Harwood K, Gordon P, Lekas H-M, Chang SJ, Yin MT. “Against Medical Advice” discharges among HIV-infected patients: health and health services outcomes. J Assoc Nurse AIDS Care. 2017;28:95–104.CrossRefGoogle Scholar
  28. 28.
    Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Intern Med. 1995;10:403–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Haywood C, Lanzkron S, Hughes MT, Brown R, Massa M, Ratanawongsa N, Beach MC. A video-intervention to improve clinician attitudes toward patients with sickle cell disease: the results of a randomized experiment. J Gen Intern Med. 2010;26:518–23.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Haywood C, Lanzkron S, Ratanawongsa N, Bediako SM, Lattimer-Nelson L, Beach MC. Hospital self-discharge among adults with sickle-cell disease (SCD): associations with trust and interpersonal experiences with care. J Hosp Med. 2010;5:289–94.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse. 2004;30:489–93.CrossRefPubMedGoogle Scholar
  32. 32.
    Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. BMJ Qual Saf Health Care. 2010;19:420–4.CrossRefGoogle Scholar
  33. 33.
    Rentsch D, Luthy C, Perneger TV, Allaz A-F. Hospitalisation process seen by patients and health care professionals. Soc Sci Med. 2003;57:571–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Mcneil R, Small W, Wood E, Kerr T. Hospitals as a ‘risk environment’: an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med. 2014;105:59–66.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Jerrard DA, Chasm RM. Patients leaving against medical advice (AMA) from the emergency department-disease prevalence and willingness to return. J Emerg Med. 2009;41:412–7.CrossRefGoogle Scholar
  36. 36.
    Lekas H-M, Alfandre D, Gordon P, Harwood K, Yin MT. The role of patient-provider interactions: using an accounts framework to explain hospital discharges against medical advice. Soc Sci Med. 2016;156:106–13.CrossRefPubMedGoogle Scholar
  37. 37.
    Alfandre D, Schumann JH. What is wrong with discharges against medical advice (and how to fix them). JAMA. 2013;310:2393.CrossRefPubMedGoogle Scholar
  38. 38.
    Bartley MK. Against medical advice. J Trauma Nurs. 2014;21:314–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Berger JT. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3:403–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899–902.CrossRefPubMedGoogle Scholar
  41. 41.
    Stern TW, Silverman BC, Smith FA, Stern TA. Prior discharges against medical advice and withdrawal of consent. Prim Care Companion CNS Disord. 2011.
  42. 42.
    Levy F, Mareiniss DP, Iacovelli C. The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. J Emerg Med. 2012;43:516–20.CrossRefPubMedGoogle Scholar
  43. 43.
    Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med. 2013;28:1657–62.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Schaefer GR, Matus H, Schumann JH, Sauter K, Vekhter B, Meltzer DO, Arora VM. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med. 2012;27:825–30.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Windish DM, Ratanawongsa N. Providers’ perceptions of relationships and professional roles when caring for patients who leave the hospital against medical advice. J Gen Intern Med. 2008;23:1698–707.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Berg KM, Arnsten JH, Sacajiu G, Karasz A. Providers’ experiences treating chronic pain among opioid-dependent drug users. J Gen Intern Med. 2009;24:482–8.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the medical care of drug users. The keys to the “Narc” cabinet. J Gen Intern Med. 2002;17:327–33.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Ti L, Milloy M-J, Turje RB, Montaner J, Wood E, Kerr T. The impact of an HIV/AIDS adult integrated health program on leaving hospital against medical advice among HIV-positive people who use illicit drugs. J Public Health. 2016.
  49. 49.
    Dixon-Woods M, Suokas A, Pitchforth E, Tarrant C. An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. Soc Sci Med. 2009;69:362–9.CrossRefPubMedGoogle Scholar
  50. 50.
    Campbell ML. Institutional ethnography and experience as data. Qual Sociol. 1998;21:55–73.CrossRefGoogle Scholar
  51. 51.
    Rankin J, Campbell M. Institutional ethnography (IE), nursing work and hospital reform: IE’s cautionary analysis. Forum Qualitative Sozialforschung/Forum: Qual Soc Res. 2009;10(2).
  52. 52.
    Long D, Hunter C, Geest SVD. When the field is a ward or a clinic: hospital ethnography. Anthropol Med. 2008;15:71–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Nathan Kline Institute for Psychiatric Research, Division of Social Solutions and Social ResearchOrangeburgUSA
  2. 2.Department of Sociomedical Sciences, Mailman School of Public HealthColumbia University Medical CenterNew YorkUSA

Personalised recommendations