Patients who leave the hospital prior to a desired endpoint present a challenge to many providers. These challenges often evoke strong feelings, including concern for a patient’s health and safety, frustration, and ineptitude.
Four themes emerged from our study. The first involved the providers’ assessment that patients lack insight into their medical condition. To address this issue, providers often spent time discussing the patient’s medical condition and treatment options. Despite attempts at patient education, providers’ and patients’ views toward health, disease, and illness may differ fundamentally. Arthur Kleinman distinguishes between the illness — the patient’s “lived experience” — and the disease — the provider’s biomedical explanation for what is occurring.20
A patient’s meaning of illness may be shaped by their symptoms, how those symptoms translate into knowledge about themselves and the culture of their wider psychosocial environment.20
Thus, the common reaction to leaving AMA — offering medical information to raise the patient’s awareness about their disease — may be insufficient by itself.
In our second theme, we found that suboptimal communication, mistrust, and conflict emerged as potential reasons patients left AMA. A study evaluating views of hospitalization by patients and providers found little agreement between the two groups with respect to justification of hospital stay and discharge planning.21
This discrepancy was felt to be due in part to poor patient-physician communication.21
Another study to determine what patients’ value most during hospitalization established that confidence and trust in providers, treatment with respect and dignity, and adequacy of involvement in care were the most important factors.22
These studies support the importance of effective communication and relationship building skills. Governing and accreditation bodies23–25
and the Institute of Medicine1
also recognize these skills as paramount; they have also been linked to important outcomes including improved diagnostic and clinical proficiency,26,27
reduced patient emotional distress,26
and increased patient and provider satisfaction.28–30
Many providers attempted to empathize with their patients in the third theme that emerged. In doing so, they made an effort to elicit concerns and communicate in an open, caring fashion. Some providers recognized a power struggle between themselves and their patients regarding individual needs. These providers identified the importance of negotiation and working together to find common ground as keys to persuading patients to stay in the hospital. Educators recommend that providers in challenging interactions take an approach characterized by collaboration through improved partnership, and appropriate use of power, negotiation, and empathy.31,32
Opening the lines of communication earlier and often during patient interactions may have prevented many of the misconceptions providers described in our study from occurring (Fig. ).
Our fourth theme addressed professional roles and obligations toward patients who leave AMA. The code of medical ethics,33
which emphasizes respecting the rights of patients and their right to self-determination, appears to conflict with what providers learn regarding the legality of patients who leave AMA. Literature about AMA patients often focuses on the provider’s duty to determine patient capacity and qualifications for involuntary commitment.34,35
Scholarship in this domain discusses risk management strategies, noting that improving patient-physician communication can lead to decreased patient complaints and fewer malpractice claims.36,37
Articles also articulate the importance of careful and thorough documentation of the actions taken by the patient and the provider in the sequence of events that lead up to and include leaving the hospital AMA.34
These legal and procedural themes echo loudly in providers’ thoughts as they try to balance patient autonomy, potential harm, and beneficence. This leaves some providers conflicted about their roles and obligations.
What strategies could help providers struggling with the four themes described above? Interpersonal conflicts may be remedied if providers embrace different responsibilities in their care. Carrese discusses the exploration of treatment refusal in order to better understand the patient’s beliefs, expectations, fears, and personal needs.16
He recommends exploring “religious beliefs, cultural background, various psychosocial factors, previous interactions with the health care system, influential personal experiences, or the preferences of family members or friends.”16
Beginning in the first interview, this process may reveal that patients don’t actually lack insight, but are informed about their health in different ways. If, despite this effort, a patient still desires to leave before treatment is deemed completed, Swota recommends maximizing patient autonomy through mandatory post-hospital follow-up contact.38
These two methods use a patient-centered approach to care, and move beyond conflict, and allow both parties to effectively carry out their individual roles and obligations.
Providers struggling to come to terms with how these experiences shape their professional identity may benefit from reflecting on their own assumptions, feelings, and attitudes when a patient wants to leave AMA. Based on the themes in this study, we offer eight questions that providers may ask themselves — rather than their patients — to assess their own capacity and insight in these situations (Table ).
Assessing Your Own Capacity: Eight Questions Providers Should Ask Themselves When a Patient Wants to Leave Against Medical Advice
Our study has several limitations. First, as a qualitative study limited to clinicians at a single institution, our findings may not apply to health care providers in other hospitals or settings. At the same time, our study design was strengthened by our high response rate and our inclusion of providers from a variety of levels. Second, our study did not include the perspectives of the patients who left AMA, their significant others, or their other care providers in the hospital. Although soliciting patients’ perspectives was an additional aim of this study, the investigators were unable to recruit sufficient numbers of participants for theoretical saturation. Given the fact that many of these challenges are interpersonal in nature, it is especially important that future research gather data from all stakeholders in the decision to leave AMA.
In conclusion, our study revealed that patients who leave AMA raise questions for providers about their patients’ level of insight, quality of communication, need for empathy and professional roles and obligations. Future research should investigate educational interventions to optimize patient-centered communication and support providers in their decisional conflicts when these challenging patient–provider discussions occur.