Background: Discharge against medical advice (AMA) occurs in up to 2% of all medical admissions.  These patients risk morbidity and mortality when being discharged AMA.  Given the frequency of AMA discharges and their potential consequences, we sought to evaluate provider opinions on AMA discharges.  

Methods: A nine question survey was developed using SurveyMonkey (table).   One of the authors directly contacted a faculty member at the academic institution to disseminate the survey, and to confirm that no policy restricting prescriptions was in place.  All potential survey participants received an e-mail containing a link to the survey.  No identifiable information was collected and responses remained confidential.  Survey results were combined in Microsoft Excel for interpretation.  

Results: Three hundred and eighty-nine physicians from nine academic hospitals responded to the survey, including 65 interns, 149 residents, and 175 hospitalist attending physicians.  Interestingly, substance abuse and disagreement about pain management were the most frequently selected reasons respondents chose for why patients leave AMA.  The majority of respondents were not willing to prescribe opioid analgesics when patients leave AMA.  However, the majority were willing to prescribe antibiotics and antihypertensive medications.  Interestingly, 25% of interns responding to the survey thought there was a policy at their hospital limiting the care they could offer at discharge if a patient requested to leave AMA.  Additionally, the majority of interns believed that having the patient sign out AMA absolved them from subsequent liability while the majority of residents and attending physicians understood that this was not the case.               

Conclusions: By requesting an AMA discharge, patients are asking their physicians to provide the best possible care despite suboptimal circumstances.  This survey helped evaluate physician opinions regarding AMA discharge and helped identify a potential educational need in early training.  Future programs could be designed to educate physicians on AMA discharges.

Against Medical Advise (AMA) Discharge Survey Questions
  1. What is your level of training?
  2. Does having a patient sign out AMA absolve physicians from liability for subsequent outcomes?
  3. If a patient leaves AMA, does insurance typically pay for hospitalization?
  4. Is there any policy at your hospital limiting care you can offer at discharge if a patient leaves AMA?
  5. If a patient leaves AMA, are you willing to write prescriptions for antibiotics?
  6. If a patient leaves AMA, are you willing to write prescriptions for antihypertensive medications?
  7. If a patient leaves AMA, are you willing to write prescriptions for opioid analgesics?
  8. Have you ever discharged a patient instead of having them sign out AMA, even if you felt it was against your advice?
  9. Rank the most common reasons patients leave AMA.
    • Substance abuse
    • Family issues (e.g. family, pets to care for)
    • Distrust of caregivers/disagreement about care – not regarding pain management
    • Disagreement about pain management
    • Inability to pay medical bill