Case Scenario 1

I am caring for F.N., a 57-year-old patient with stage IV breast cancer who is receiving chemotherapy. F.N. developed a neutropenic fever shortly after their second chemotherapy cycle and was admitted to my hospitalist service. F.N. had an absolute neutrophil count of 600 per μL (0.6 × 10⁹ per L); after 24 hours of intravenous antibiotics, their absolute neutrophil count decreased to 400 per μL (0.4 × 10⁹ per L). They do not want to stay in the hospital and ask to be discharged. I recommend that F.N. remains until their absolute neutrophil count reaches at least 500 per μL (0.5 × 10⁹ per L) and blood cultures are negative after 72 hours. F.N. is genuinely appreciative of the care but states, “My days are numbered, and I want to spend as much time as I can with my family. Thank you for what you have done. I understand the risks of leaving, but I want to go home.”

Case Scenario 2

In the emergency department, I evaluate J.S., a 39-year-old man who was involved in a recreational all-terrain vehicle crash. Diagnostic trauma evaluation reveals a large (greater than 50%) right pneumothorax. He seems a little dis-oriented, and his blood alcohol level is 360 mg per dL (78.16 mmol per L; severely intoxicated). He is tachycardic and tachypneic, and his oxygen saturation is 87% on room air. When offered oxygen by nasal cannula, J.S. refuses and begins acting aggressively toward the hospital staff. When I recommend that he needs a chest tube, he refuses to give consent for the procedure and tells me that he is going to leave. J.S. has no immediate family members with him.

What is my role as a physician when a patient attempts to discharge against medical advice? What should I document if this happens? Are there circumstances in which patients should not be permitted to leave against medical advice?

Commentary

The definition of discharge against medical advice is when a patient decides to leave the hospital or other health care setting (i.e., emergency department, outpatient clinics) before the medical team recommends discharge or disposition.¹ The situation occurs in multiple forms, such as patients disappearing after initial evaluation, requesting additional time to consider alternative treatment strategies, politely refusing treatment, or exhibiting hostility toward the health care team. The prevalence of discharge against medical advice is between 1% and 2% of all hospital discharges.² Patients leaving against medical advice have a two- to fourfold higher readmission rate, increased morbidity and mortality, and are less likely to seek needed follow-up.^2–5 Identified risk factors include younger age, being male, lacking medical insurance, lower socioeconomic status, substance use disorder, chronic pain, specific chronic diseases (e.g., HIV/AIDS, heart disease, pancreatitis, sickle cell disease), mental illness, and prior episodes of discharge against medical advice.^6,7

How to address these situations is not routinely taught during medical education, and physicians are often distressed by the clinical and ethical challenges and the conflict with their sense of responsibility to patient safety and well-being.⁸ In addition, physicians may feel frustrated and believe that their clinical judgment has been challenged when patients want to leave. Patients who wish to discharge against medical advice are often labeled as nonadherent, unappreciative of care, and adding to the burdens of an already strained health care system. These situations generally result from an interplay of patient variables and/or institutional factors (e.g., patient feels better after initial treatment and underestimates the situation, including the hospital setting, its policies and staffing, or experiences dissatisfaction with care).⁷ Additional factors external to the medical encounter include personal, family, or work responsibilities and concern about medical expenses.

No specific guidelines exist for patients who want to leave the hospital prematurely; however, best practices include reducing potential for patient harm, determining capacity, and ensuring mutual understanding of risks and benefits. Strategies to address concern for patients wishing to discharge against medical advice must be individualized. Motivational interviewing with the patient can determine how willing they are to participate in their own care. Recommended general approaches to mitigate discharge against medical advice include treating pain and substance use withdrawal, communicating compassionately and nonjudgmentally, proactively managing concerning physical and emotional symptoms, and considering psychiatric consultation early in hostile or troubled patients.⁹