A step-by-step approach to patients leaving against medical advice (AMA) in the emergency department

Objectives Patients leaving against medical advice (AMA) can be distressing for emergency physicians trying to navigate the medical, social, psychological, and legal ramifications of the situation in a fast-paced and chaotic environment. To guide physicians in fulfilling their obligation of care, we aimed to synthesize the best approaches to patients leaving AMA. Methods We conducted a scoping review across various fields of work, research context and methodology to synthesize the most relevant strategies for emergency physicians attending patients leaving AMA. We searched Medline, CINAHL, PSYCHO Legal Source, PsycINFO, PsycEXTRA, Psychological and Behavioural Sciences collection, SocIndex and Scopus. Search strategies included controlled vocabulary (i.e., MESH) and keywords relevant to the subject chosen by a team of four people, including two specialized librarians. Results The literature review included 34 relevant papers about approaches to patients leaving AMA: 8 case presentations, 4 ethical case analyses, 10 legal letters, 4 reviews and 8 original studies. The main identified strategies were prioritizing a patient-centered approach, proposing alternative discharge and reducing harm while properly documenting the encounter. Conclusion A systematic approach to patients leaving AMA could help improve patient care, support physicians and decrease stigmatization of this population. We advocate that emergency physicians should receive training on how to approach patients leaving AMA to limit the impact on this vulnerable population. Supplementary Information The online version contains supplementary material available at 10.1007/s43678-022-00385-y.


Introduction
Emergency physicians struggle daily with the responsibility and potential implications of patients leaving against medical advice (AMA) [1]. Such patients represent up to 1 in 50 hospital discharges [2] and are associated with higher healthcare costs [3,4]. They are indeed at higher risk of negative outcomes-such as readmission rates up to four times higher than usual [5,6], and higher morbidity and mortality rates [7,8]. Moreover, vulnerable and stigmatized patients (including patients with substance abuse, low income or education, and mental health problems) are overly represented in this population [5,6,[8][9][10]. Patients' frequent reasons for leaving may include disagreement with the treatment plan, long emergency department waiting time, perceived improvement of their condition, family obligations, financial constraints or dissatisfaction with the services received [7]. During the pandemic, patients also left because of fear of contracting COVID-19 [11].
While patients leaving AMA is a well-documented problem, little information is known about how physicians should handle these situations in the context of an emergency department. A constellation of issues is associated with leaving AMA, including the risk of stigmatization of patients and legal retaliation [12][13][14][15]. Patients leaving AMA can be fairly frustrating to doctors and are a source of distress, as physicians tend to take the refusal personally and feel powerless or even guilty [12][13][14][15]. The issue of patients leaving AMA is also time sensitive, which adds pressure on the patient-physician communication in a crowded emergency department [15,16]. The discharge of patients as AMA is not routinely taught in medical schools, leading to physicians being ill equipped to address the situation [14].
Emergency physicians need guidelines suited to their context to address these issues arising from patients leaving AMA in the emergency department. Therefore, this project aims to address this gap and synthesize the best practices surrounding the discharge of patients leaving against medical advice in emergency departments.

Methods
The review aimed to synthesize the most relevant concepts to guide emergency physicians attending patients leaving AMA. A scoping review of the literature was conducted in April 2021 (updated in January 2022), in accordance with the PRISMA-ScR methodology [17]. The choice was based on the purpose of a scoping review to "identify the type of available evidence in a given field" and "identify key characteristics or factors related to a concept," as described by Munn [18], and supported by Grant and Booth's typology of reviews [19]. The two principal authors are an emergency physician with a master's degree in health law and policy, and a family physician with a Black Belt Certification in Quality Improvement (CQI).
Our research strategies included controlled vocabulary (i.e., MESH) and keywords relevant to the subject chosen by a team of four people: two medical librarians and the three authors. The research itself was conducted in multiple databases. We searched through Medline, CINAHL, PSY-CHO Legal Source, PsycINFO, PsycEXTRA, Psychological and Behavioural Sciences collection, SocIndex and Scopus databases. The search was limited to the last 10 years to reflect best the current clinical practices with patients leaving AMA. The search strategies and keywords are available in the additional materials section (Online Appendix I). We excluded patients who left without being seen or eloped since we were interested in patients under the doctor's care. We excluded studies about pediatric patients, studies in underdevelopped countries, studies not conducted in a hospital and articles not written in English or French.
The two leading reviewers established the eligibility criteria. Articles describing strategies or approaches for patients leaving AMA were included. Following review procedures, we accepted variability in study designs and genres like legal letters or ethical analysis. We excluded articles based on personal views or personal essays to avoid personal experiences.
A total of 88 articles went through a full-text assessment. The two principal authors read all the articles, and dissidence about inclusion was discussed with the third author. Following this process, 34 articles were included in the final review (see Fig. 1 PRISMA-ScR). The two reviewers independently extracted the key characteristics and detailed information about strategies or approach for patients leaving AMA. An Excel table sheet was used for the data charting. We used an iterative process between the two reviewers to identify the key themes as they emerged from our charting [17].

Search results and characteristics
We retrieved 34 papers related to strategies to approach patients leaving AMA: 8 case presentations, 4 ethical case analyses, 10 legal letters, 4 reviews and 8 original studies. The main findings are detailed in Table 1. Overall, the articles were limited by the quality of the methodological approach, but were rich in inputs from the patients' and physicians' perspectives due to ethics and legal case analysis and presentation. The two reviewers extracted 142 citations and excerpts that were regrouped under six main themes: patientcentered approach, capacity evaluation, informed refusal, alternative discharge, harm reduction and documentation (see Fig. 2). The principal findings are presented in a narrative format.

Patient-centered approach
A strategic way for physicians to approach patients leaving AMA is to position them at the center of care by actively listening to their concerns, thus increasing the quality of communication [15,20,21]. Physicians must aim without prejudice or bias to identify why patients wish to leave AMA [1,12,[22][23][24]. Correctly identifying the reason for departure is essential to set a base for the patient-physician discussion. It is an opportunity to acknowledge their concerns and alleviate some or express empathy [15,[25][26][27]. Involving a multidisciplinary team or asking for an early psychiatric consult may be helpful [1,28].

Capacity evaluation
An important reminder is that patients leaving AMA must have decision capacity. Although determination of capacity is beyond the scope of this review, some particularities apply specifically to the AMA patients, and, physicians must keep them in mind. All patients have presumption of capacity [29] and can decide to leave, even if it is not in their best interest [12]. Also, a patient's capacity to consent or refuse treatment is dynamic and task specific [16,30], which makes capacity evaluation challenging [31] with the time constraints in the emergency department [16].

Informed refusal
When a patient signifies the desire to leave AMA, emergency physicians must explain the benefits of completing the treatment and also explain the risks associated with leaving [32]. Although it is impossible to list all possible risks, physicians must emphasize possible complications or worsening of the patient's medical condition and name the risk for any permanent disability, as well as the risk of death, if applicable [30,32]. Emergency physicians must remain cautious, validate patients' understanding of what they are refusing and allow enough time for patients to ask questions [33]. In the context of an emergency department, physicians may not have the option to get an informed refusal [34].

The alternative discharge
Physicians should support patients in their choice of treatment, regardless of the initially recommended option. Understanding a patient's goal for treatment helps the patient-physician alliance [20,33,35]. When patients refuse the recommended treatment plan, engaging them in decision-making can help elaborate an alternative discharge plan [33,36]. Providing an alternative discharge, while suboptimal, is not necessarily substandard [1,25,33,37,38] and can be adapted to the patient's situation. Also, refusing to provide an alternative discharge to patients and simply accepting that the patient leaves AMA has even been described as abandonment by some ethicists [36]. The nomenclature itself, "AMA discharge", can be seen as paternalistic, which may unwillingly promote stigmatization of patients. Therefore more neutral terms such as "premature discharge" or "alternative discharge" have been proposed [15].

Harm reduction
When AMA departure is inevitable, all efforts should be geared toward organizing the safest discharge scenario and reducing harm [15]. Physicians are ethically obligated to arrange follow-up and outpatient treatment [1,29,36]. They may also, for example, need to assist the patient in leaving the hospital by arranging transportation for example [39]. They should go through the discharge process like any other discharge: give instructions, inform patients of any investigations that may have been conducted before discharge and provide the relevant prescriptions [30, 32, [47] Step  37]. Even though it has been shown that up to 94% of attending physicians agree that AMA patients should receive medication and follow-up arrangements [40], studies indicate that only a quarter of these patients do receive a prescription and that only a third of them are discharged with a follow-up plan [40][41][42].
In addition, as one out of five patients who left AMA feel reluctant to return to the emergency department because they thought they angered staff [13,20,32], physicians must refrain from aggressively attempting to convince them to stay and inform them to consult again, if necessary. The physicians are also responsible for the follow-up of any pending results and should verify how to contact patients if necessary [13].

Documentation
Proper documentation of AMA (see Table 2) is quite exhaustive. Still, it should at least provide evidence of a patient's capacity and informed refusal [34,43]. Exhaustive documentation was found in only 4% of the charts in a small study [44]. Capacity is documented in about 20-60% of files [30,[40][41][42]44], and a discussion about risks is documented in about 60-70% of files [30,42]. The primary reason to designate the discharge as AMA is the fear of legal liability [33]. However, the documentation of the discussion with patients is essential for the physicians' legal protection. Labeling the discharge as AMA does not confer legal protection [13,32].
It is debated whether an AMA form should be used or not. Getting it signed should never distract physicians from fulfilling their obligation of care and supporting patients through the AMA discharge process [33]. The advantage of using an AMA form is to bolster documentation, facilitate discussion with patients or ease the documentation process [28]. A small study found that a standard form increased capacity documentation from 0 to 80% and patients' signatures from 58 to 80% [31]. The signature rates vary in Informed refusal (7) Patient centered approach (22) Alternative discharge (15) Reduce harm (12) Documentation (23) different studies from 58 to 85% [28,31]. If a patient refuses to sign the AMA form, the issue should not be pressed. It is possible to obtain the signature of a witness of the conversation (nurse, family member, etc.) [30,34]. Experts agree that a signed form alone is not enough to ensure legal protection and to attest capacity [15,25,29,30,32,35,40,43,45].

Interpretation
This study provides an extensive review of different fields of research. Insight from ethicists, lawyers, quality experts and physicians from different domains helped to grasp a better understanding of how to approach patients leaving AMA. This literature review identified different strategies for patients leaving AMA and allowed us to adapt an AMA discharge approach to emergency patients. Since AMA discharge can reflect a conflict between a patient's and physician's perspectives, developing a practical approach to patients leaving AMA in the emergency department is essential to negotiate the problem's medical, ethical, social and legal aspects. We think that this proposed step-by-step approach could help emergency physicians attend to patients leaving AMA and meet their obligation of care (Table 3).
Step-by-step approach Once the patient is deemed competent, emergency physicians should first determine if they genuinely want to leave AMA or if it entails for something else. Physicians should prioritize a patient-centered approach [1,12,15,22,28], to understand patients' perspectives to avoid stigmatization and find a collaborative way of care. If the patient is determined to leave, physicians should not judge the veracity or legitimacy of their reason to leave. They should propose alternative discharges [14,20,33,35,38], even if they are suboptimal.
If the patient refuses all discharge alternatives, the emergency physicians should try to obtain an informed refusal [26,30,32,33,46] and adopt a harm reduction approach [13,15,30,32,37]. Physicians should provide prescriptions, follow-up and continuity of care when applicable. Experts suggest approaching all discharges similarly and avoiding labeling AMA discharge to prevent stigmatization [15].
Finally, through this discharge process, all relevant information should be carefully documented in the patient's chart [15,25,29,30,32,35,40,43,45]. However, physicians are not obligated to use a formal AMA form and should not pressure patients into singing it.

Previous studies
Our study stands out by adopting a more practical approach to patients leaving AMA. We present a more concise and direct clinical approach that does not solely focus on reducing legal risk and emphasize patient's perspective to provide better care.  [1,25,29,38,43,[45][46][47] Capacity assessment Description of the interaction with the patient Physician's concerns Extent and limitations of the ED evaluation Explications of risk and benefits Alternatives discussed Use of a language the patient understands Patient opportunity to ask question Evidence the patient/family understands Patient was informed to return to the ED at anytime Notification to the primary physician Evidence of a harm reduction approach Try a patient-centered approach Seek why the patient leaves AMA without assuming or stigmatizing the patient [1,12,22] Address the patient's concerns and needs [15] Think of a multidisciplinary approach, psychiatric consult [1,28] Comprehensive documentation 2 Propose an alternative plan Support patients on their treatment goals [20,33,35] Do not judge why the patient is leaving [14,20] Remember, a suboptimal plan is better than no plan and is not necessarily substandard [33,38] 33 Reduce harm Do an informed refusal if applicable [30,32,34] Give instructions on the testing results and provide prescriptions and follow-up [30,32,37] Advise the patient to return at any time if needed [13,32] Previous studies, like the two other review done in 2021 [1,14], on how to approach patients leaving AMA are quite exhaustive and include multiple steps [1,14,29,31], which is not realistic for the frequently time-sensitive, chaotic clinical conditions and time pressure in which emergency physicians work. We present a more concise and direct clinical approach that does not solely focus on reducing legal risk and emphasizes the patient's perspective to provide better care.

Strengths and limitations
This review intended to extend the scope of research to other fields like ethics and law to find all possible strategies about the issue of patients leaving AMA. We worked with specific inclusion and exclusion criteria, and both reviewers independently selected eligible articles. Included studies were limited in methodological quality, as most were case presentations, ethical case analyses and legal letters. Still, they were rich in patients' and physicians' perspectives. However, since we did not do a critical appraisal, the proposed approach should be considered with caution, since scoping reviews have the "danger that the existence of studies rather than their intrinsic quality is used as the basis for conclusion" [19]. Also, legal implications and consequences can vary across borders, and we tried to be as inclusive as possible. Therefore, caution should be taken for applicability.

Clinical and research implications
We think this step-by-step approach could help shift the medical culture by reducing bias and stigmatization. For example, it could possibly increase the usage of "alternative discharge" over "AMA discharge" in the charting vocabulary. Another example is adapting discharge processes to patients' needs and using harm reduction strategies more frequently. The next step is to teach the step-by-step approach to physicians and medical students and implement the approach in a clinical setting to evaluate if more alternative discharges are planned. Further research is needed to determine how to best implement this step-by-step approach in emergency settings.

Conclusion
Patients leaving AMA is a persistent and distressing problem with medical, ethical, social and legal impacts for patients and physicians. Emergency physicians receive minimal training to address the problem and are therefore poorly equipped to face the situation. We advocate that emergency physicians should receive training on how to approach patients leaving AMA to limit the impact on this vulnerable population. A simple step-by-step approach to patients leaving AMA could support physicians, alleviate bias and reduce stigmatization of patients.