Patients Leaving Against Medical Advice: 5 Best Practices for Facilities

Patients leaving against medical advice (AMA) in acute care settings are essentially revoking their consent to be treated. This results in a discharge prior to therapeutic resolution, doubling the subsequent odds of patient mortality and morbidity.

Despite their potential for harm, AMA discharges occur an estimated 500,000 times per year in the U.S., accounting for roughly 1-2% of all hospital discharges. However, these numbers are not reflected equally across organizations. In a nearly decade-long study, the facility-based rates of patients who left against medical advice varied widely, from less than half of 1% at some institutions to over 12% at others. This indicates that the issue is structural, necessitating systemic responses.

To help you navigate the clinical, ethical, and legal stakes of AMA events, we’ll examine some of the common myths surrounding this issue while providing objective predictors and actionable mitigation strategies. With an evidence-based approach, you can better support some of your most medically (and socially) vulnerable patients while protecting organizational integrity.

Predictors and Examples of AMA Discharges

The demographic profiles of people who are most at risk for leaving the hospital prematurely are shared across institutions. This reflects that although the rate of AMA occurrences may vary widely from facility to facility, the risk factors for these events are shared. Research establishes that some of the patient features contributing to lower thresholds for leaving against medical advice include:

• Lack of health insurance, which is the strongest predictor.
• Being male, African American, or younger(particularly ages 30-35 years).
• Lower household income or unhoused living situations.
• Lack of social support, from absent primary care to living alone.
• Mental health and substance abusecomorbidities.
• History of prior AMA occurrences.
• Uncontrolled pain and undertreated symptoms, especially in the midst of withdrawal therapies.

Many of these predictive features align with the characteristics that make people vulnerable to discrimination. These vulnerabilities can drive misinformation and biases about who discharges AMA and why. Below are some examples that reflect the true complexity of causative factors and patient motivations.

Scenario 1

A young woman presents at the emergency department and learns that she faces a potentially prolonged admission due to the need for serial labs and monitoring. She is the sole caregiver for her aging mother who cannot be alone for more than a few hours. To the patient, discharging AMA feels like the only accessible route for ensuring her mother’s safety.

Scenario 2

A middle-aged man is paid hourly at his job with no vacation or sick days. He is admitted for an infection that requires IV antibiotics. Because of a past (remote) history of illegal drug use, he must remain inpatient for the duration of treatment. As the breadwinner for his family, he chooses to leave AMA to ensure he can make it back to work and provide for his children.

Scenario 3

An elderly patient is dying and wants to pass away at home. Due to disease progression, discharge is deemed too risky. The patient acknowledges the risks but chooses to leave AMA in order to fulfill their end of life wishes.

Patients Leaving Against Medical Advice: Risks and Costs

One of the most common misbeliefs surrounding AMA discharges is that insurance providers will not pay for those admissions, forcing either the facility (or the patient) to cover the entirety of the encounter. However, studies demonstrate that there is little evidence of insurers refusing to pay bills that feature the left against medical advice ICD 10 code (Z53.21).

This also extends to how payment per Medicare guidelines (for leaving against medical advice) typically plays out. In Medicare Part A, it’s medical necessity — not the how or when of discharge — that guides coverage. Yet, despite the likelihood for reimbursement, AMA discharges still create heavy institutional (and individual) tolls.

Mitigation and Prevention of AMA Discharges: 5 Best Practices

Federal initiatives, like the Centers for Medicare and Medicaid (CMS) Hospital Readmission Reduction Program, feature exemptions that signal awareness of the prevalence and institutional challenge of patients leaving against medical advice. For example, readmission data for patients whose last admission designates an ICD 10 code for left against medical advice is excluded from penalty calculations.

This effort at establishing a just system for facility funding underscores the multimodal resources available to help facilities target this major healthcare issue. Below, you’ll find additional strategies to support your mitigation and prevention efforts.

1. Prioritize Quality Patient Care and Service Recovery

The primary driver for premature patient discharges is unmanaged pain. This is compounded by additional clinical complications such as withdrawal symptoms. By educating staff on the many options for pain relief, bolstering resources for additional treatment options (like a guided imagery technological outlet, for example), and providing order sets that target symptom management, facilities can help prevent the breakdown of the therapeutic alliance.

Additional suggestions:

• Create a framework for gathering daily patient feedback that helps address issues that may contribute to an AMA discharge before they culminate into an AMA event.
• Develop protocols for expediting the delivery of required medications (such as Methadone) during critical transition periods to avoid patients leaving AMA due to delayed medical support.

2. Establish a Consistent AMA Procedural Response

Many facilities use a standardized Leaving Against Medical Advice form to alleviate the legal implications of a premature, risk-laden patient discharge. Although documentation is imperative, the protocol governing the systemic response to requests for AMA discharges need to be standardized beyond just the form. This may include targeted, set patient education prior to discharge in addition to the inclusion of harm reduction resources (like additional services, equipment, or supplies).

Additional suggestions:

• Consider building a sequence of designated staff interventionists to assist with patient education and service recovery efforts. This also helps offset the direct care staff burden during these events.
• Offer an AMA discharge form to be used when patients refuse to sign paperwork that ensures thorough documentation of protocol adherence despite patient disengagement.

3. Create Targeted Healthcare Staff Training

Provide staff education and training that closely examines the reasons for AMA discharges, their risks, and strategic approaches to preventing them. This will help tackle harmful misconceptions (or biases) around vulnerable patient populations while offering a roadmap for prevention that alleviates the potential for guilt (or even blame) when an AMA request is made.

Additional suggestions:

• Consider integrating the teaching tool, AIMED. It stands for: Assess the patient’s decision-making capacity and clinical risk, Investigate the reasons a patient may feel the need to leave, Mitigate the modifiable factors, Explain the risks in a patient-centered, nonpunitive manner, and Document thoroughly.
• Create opportunities for structured communication that provides staff with the opportunity to practice persuasive de-escalation language outside of high emotion, high stress situations.

4. Engage the Community to Expand Patient Safety Nets

Regulatory and billing compliance measures are increasingly asking hospitals to maintain accountability for patients beyond hospital borders. This growing push must also be integrated into all efforts to prevent and mitigate the impacts of AMA discharges. By sharing accountability for the health inequity that drives AMA risk, hospitals address the underlying issues that complicate access to thorough patient care.

Additional suggestions:

• Build systems that connect primary care services to patients while still inpatient, opening communication channels earlier while expanding the patient safety net.
• Create intersystem partnerships (such as a community addiction counseling service) that engages high-risk patients while bridging acute and chronic needs for better long-term outcomes.

5. Ensure Staff Know How to Document AMA Discharges Thoroughly

There is a widely held misconception that signed AMA forms provide complete legal immunity. In truth, a successful legal defense hinges on whether detailed documentation supports two separate aspects of clinical diligence. First, documentation must clearly demonstrate that the patient was well-informed about the risks of leaving prematurely (and had the capacity to understand those risks). Second, documentation must ensure that up to the point of discharge, the patient received therapeutic treatment that aligned with the highest standards of care.

Additional suggestions:

• Utilize a system of double checks via the team lead or an alternative, trained staff member the minute a patient begins to request an AMA departure. This ensures that documentation needs are complete before the patient leaves (and while the direct caregiver is busy with service recovery efforts).
• Integrate automatic charting prompts into the electronic health record that provide stopgaps to prevent accidental gaps in documentation.

Harness Your Clinical Data to Improve Your Culture of Safety

Whether a patient is leaving against medical advice or staying for the duration of their treatment, facilities have a duty to protect staff and patients alike. Make the most of your documentation standards and quality indicators with our facility guides and practice recommendations.