John H. Schumann

What Is Wrong With Discharges Against Medical Advice (and How to Fix Them)

It is estimated that as many as 2% of all US hospital discharges (approximately 500 000 per year) are designated as against medical advice1; that is, a patient chooses to leave the hospital before the treating physician recommends discharge. The risks to these patients are significant. Compared with patients discharged conventionally, readmission rates for patients discharged against medical advice are 20% to 40% higher, and their adjusted relative risk of 30-day mortality may be 10% higher.2 Furthermore, physicians and other health care staff report feeling distressed and powerless when patients choose suboptimal care, and disagreement over a discharge against medical advice can cause patient-physician and intrateam conflict.3 Although these harms have been well described, the stigmatizing effect on patients of discharges against medical advice has rarely been examined. Compared with how the profession handles clinical disagreements in other settings (eg, outpatient), an “against medical advice” designation is an outdated concept unsupportive of patients. In this Viewpoint, starting from a core value of patient centeredness, we aim to highlight the problematic aspects of discharges against medical advice and suggest a new approach. Designating a discharge as against medical advice is a clinical practice not subject to professional standards. There is no clear medicolegal rationale for this designation and no professional consensus on what constitutes a discharge as against medical advice. If a competent patient or his or her authorized surrogate declines further inpatient care, physicians should fulfill their legal and ethical obligations to obtain informed consent for the patient’s decision and document that decision and the patient’s reasons for it in the patient’s record. But the physician’s subsequent choice to designate the hospital discharge as against medical advice and pursue the formalized process associated with it (eg, specialized discharge forms) has no evidence-based utility for patient care, is not legally required, and has been shown to be associated with a reduced willingness for the patient to return for future care.4 Furthermore, there is no consensus about what clinical criteria warrant a “discharged against medical advice” designation. This lack of clarity leads to greater variability in its clinical use, lacks transparency, and impedes standardization of a common medical practice. Although a more specific definition of discharge against medical advice could improve research and clinical processes, the term is an anachronism that has outlived its usefulness in an era of patient-centered care. Recent studies have highlighted problematic informed consent practices for discharges against medical advice by identifying that a majority of house officers and attending physicians mistakenly believe and inform patients that if they sign out against medical advice, their insurance may not pay for the hospitalization. In a cross-sectional survey of physicians conducted by Schaefer et al,5 85% of residents and 67% of attending physicians reported that they informed patients about denial of insurance payment so that patients would reconsider remaining in the hospital. These studies suggest that the use of misleading information in discharges against medical advice threatens to undermine a patient’s voluntary choice and insinuates that coercion is an acceptable and oft-repeated practice. The use of specialized discharge forms that document a patient’s risks and liability is common hospital practice in discharges against medical advice. Despite apparent widespread use of these documents, there is no evidence that they advance patient care. Although health professionals generally support the use of discharge against medical advice forms because they believe it is required to protect themselves and their institutions from legal liability, these presumptions are not valid.6 Indeed, the contrary may be true. Malpractice claims are associated with poor physician communication and patient perceptions of feeling deserted or devalued.7 If discharges against medical advice occur when there are breakdowns in communication, it is possible that such discharges may contribute to increased liability. At a minimum, there is limited understanding of whether the desire to protect clinicians and institutions from legal liability by using a specialized discharge form interferes with the care of the patient. Because clinical care decisions for hospitalized patients are sensitive to patient preference, shared decision making (SDM) has a role in achieving more patientcentered care in decisions related to discharge against medical advice. Although SDM is well accepted in overtly value-laden clinical decisions such as prostate-specific antigen testing and mammography screening, the principles of SDM apply to a broad range of health care decisions, discharges against medical advice included. Contrary to the principles of SDM, a discharge against medical advice sends the undesirable message that physicians discount patients’ values in clinical decision making. Accepting an informed patient’s values and preferences, even when they do not appear to coincide with commonly accepted notions of good decisions about health, is always part of patient-centered care. The active engagement of the medical community will be necessary to reform the practice of discharges against medical advice. Physicians can begin with individual patients, but they also can support research in this area and in establishing standards for such discharges. VIEWPOINT

Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?

BACKGROUNDPhysicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.OBJECTIVETo review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.DESIGNRetrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.PARTICIPANTSPatients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.MAIN MEASURESPercent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.KEY RESULTSOf 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1–5 scale, in which 5 is “always” inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was “so they will reconsider staying in the hospital” (84.8% residents, 66.7% attendings, p = 0.008)CONCLUSIONSContrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.

Ethics of Commercial Screening Tests

Recent publications have emphasized the importance of physicians taking a lead role in delivering patient-centered, high-value, cost-conscious care. However, the increasing availability of direct-t...

Hospital Relationships With Direct-to-Consumer Screening Companies

The debate over direct-to-consumer (DTC) screening companies intensi ed recently as Public Citizen, a consumer advocacy organization, sent letters to 20 hospitals on June 19, 2014, urging their leadership to sever business relationships with HealthFair, a prominent DTC screening company. Public Citizen states that HealthFair’s “heavily promoted, community-wide cardiovascular health screening programs are unethical and are much more likely to do harm than good,” and they cite peer-reviewed evidence in support of their claims. If such claims are true, should any hospital sponsor or co-brand with DTC screening companies that allegedly sell “potentially harmful and unethical services?” (For example, sponsorship arrangements include allowing the use of a hospitals name in DTC company print or online advertising, providing or sharing a physical location where screening is performed, or both; co-branding includes promotion of a DTC screening company on a hospitals website.) Hospitals exist to provide medical services to the general community. Todeliver on theirmissions, hospitals must have a su cient number of patients use services to fund their operations. In an increasingly competitive health care environment, one strategy to bring innew“customers” is tosponsoroutreachprogramsthat

Direct-to-consumer screening companies--reply.

Direct-to-Consumer Screening Companies To the Editor The Viewpoint by Dr Wallace and colleagues1 appropriately framed the timely issue of early detection of disease in the medical community. This is a national debate, and there are strong, equally qualified, and conflicting opinions on all sides of this issue. Early detection of disease, which includes high-profile tests such as mammography and prostate-specific antigen level, is in the forefront of public awareness and should be a matter of public debate involving all participants in the medical community. Outcomes should not be determined by attacks on individual organizations, such as HealthFair, by Washington, DC– based policy groups such as Public Citizen. Outcomes should be determined by fair and proper public debate. The debate surrounding preventive care, as framed by Public Citizen, is really about who will control health care in the future. While Public Citizen is an organization with an important mission, I disagree with their position on the delivery of health care. I favor control in the hands of patients, their personal physicians, and local hospitals. Informed empowerment and freedom of choice is in the best interest of all patients and the medical community dedicated to serving them. Regarding specific testing protocols, I agree with the position of the American College of Cardiology that “mass screenings should not be done on the broad and untargeted population.”2 HealthFair prequalifies and educates all participants before they are screened. More important, the average age of participants is 61 years, most of whom have several risk factors for cardiovascular disease identified through a clinical pathways protocol. The debate surrounding preventive testing will be a key issue in the forefront of the nation’s evolving health care delivery, along with access to care and care coordination. I encourage an active dialogue involving all sides of the issue.