Bedside Management of Discharges Against Medical Advice

  • Holly Fleming
  • David S. OlsonJr.
  • David Alfandre
  • Cynthia Geppert


Physicians and other healthcare professionals have long struggled with discharges against medical advice (AMA), or when patients leave the hospital prior to a specified clinical end point over the recommendation of the physician. There is ample literature describing the risk factors associated with AMA discharge and the common reasons that patients choose to leave AMA. In this chapter, we review the best practice concepts of bedside management of an AMA discharge. We discuss components of a quality decisional capacity assessment and informed consent discussion as a prerequisite for a safe transition of care for AMA discharges. We also discuss cognitive and behavioral strategies that can form the basis for a practical approach to the professional, legal, and ethical obligations surrounding this type of discharge. Last, we discuss patient-centered strategies, shared decision-making models, and motivational interviewing and describe operational tools and processes to assist providers in negotiating a more productive health outcome for AMA discharges.


AMA Against medical advice Decisional capacity Informed consent Shared decision-making 


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Holly Fleming
    • 1
    • 2
  • David S. OlsonJr.
    • 3
  • David Alfandre
    • 4
  • Cynthia Geppert
    • 5
  1. 1.Hospital MedicineRaymond G. Murphy VA Medical CenterAlbuquerqueUSA
  2. 2.University of New MexicoAlbuquerqueUSA
  3. 3.Department of Internal MedicineRaymond G. Murphy VA Medical CenterAlbuquerqueUSA
  4. 4.VHA National Center for Ethics in Health Care, Department of Veterans AffairsNYU School of MedicineNew YorkUSA
  5. 5.Department of Psychiatry and Director of Ethics EducationNew Mexico Veterans Affairs Health Care SystemAlbuquerqueUSA

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