Abstract
Background
Patients who leave hospitals against medical advice (AMA) may be at risk for adverse health outcomes. Their decision to leave may not be clearly understood by providers. This study explored providers’ experiences with and attitudes toward patients who leave the hospital AMA.
Objective
To explore providers’ experiences with and attitudes toward patients who leave the hospital AMA.
Methods
We conducted interviews with university-based internal medicine residents and practicing internal medicine clinicians caring for patients at a community hospital from July 2006 to August 2007. We approached 34 providers within 3 days of discharging a patient AMA. The semi-structured instrument elicited perceptions of care, emotions, and challenges faced when caring for patients who leave AMA. Using an editing analysis style, investigators independently coded transcripts, agreeing on the coding template and its application.
Participants
All 34 providers (100%) participated. Providers averaged 32.6 years of age, 22 (61%) were men, 20 (59%) were housestaff from three residency programs, 13 (38%) were faculty, hospitalist physicians, or chief residents serving as ward attendings, and one (3%) was a physician assistant.
Main Results
Four themes emerged: 1) providers’ beliefs that patients lack insight into their medical conditions; 2) suboptimal communication, mistrust, and conflict; 3) providers’ attempts to empathize with patients’ concerns; and 4) providers’ professional roles and obligations toward patients who leave AMA.
Conclusion
Our study revealed that patients who leave AMA influence providers’ perceptions of their patients’ insight, and their own patient–provider communication, empathy for patients, 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.
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References
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academies Press; 2001.
Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12):2204–8. Dec.
Fiscella K, Meldrum S, Barnett S. Hospital discharge against advice after myocardial infarction: deaths and readmissions. Am J Med. 2007;120(12):1047–53. Dec.
Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417–20. Feb 18.
Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633–7. Sep 17.
Fiscella K, Meldrum S, Barnett S. Hospital discharge against advice after myocardial infarction: deaths and readmissions. Am J Med. 2007;120(12):1047–53. Dec.
Seaborn Moyse H, Osmun WE. Discharges against medical advice: a community hospital’s experience. Can J Rural Med. 2004;9(4):265. Fall.
Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325–7. Jun.
Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568–71. Aug.
Moy E, Bartman BA. Race and hospital discharge against medical advice. J Natl Med Assoc. 1996;88(10):658–60. Oct.
Senior N, Kibbee P. Can we predict the patient who leaves against medical advice: the search for a method. Psychiatr Hosp. 1986;17(1):33–6. Winter.
Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse. 2004;30(2):489–93. May.
Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907–15. Dec 2.
Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Annu Rev Public Health. 2004;25:497–519.
Street RL Jr, Krupat E, Bell RA, Kravitz RL, Haidet P. Beliefs about control in the physician-patient relationship: effect on communication in medical encounters. J Gen Intern Med. 2003;18(8):609–16. Aug.
Carrese JA. Refusal of care: patients’ well-being and physicians’ ethical obligations: “but doctor, I want to go home”. JAMA. 2006;296(6):691–5. Aug 9.
Crabtree BF, Miller WL. Doing qualitative research, 2nd ed. Thousand Oaks, Calif.: Sage Publications; 1999.
Census 2000 Demographic Profiles. Available at http://www.ctnow.com/extras/census/0600900980070.pdf. Accessed May 16, 2008.
Jenkinson C, Coulter A, Bruster S. The Picker patient experience questionnaire: development and validation using data from in-patient surveys in five countries. Int J Qual Health Care. 2002;14(5):353–8.
Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books, Inc; 1988.
Rentsch D, Luthy C, Perneger TV, Allaz AF. Hospitalisation process seen by patients and health care professionals. Soc Sci Med. 2003;57(3):571–6. Aug.
Joffe S, Manocchia M, Weeks JC, Cleary PD. What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics. J Med Ethics. 2003;29(2):103–8. Apr.
Accreditation Council for Graduate Medical Education (ACGME). Outcome project: enhancing residency education through outcomes assessment. Available from: http://www.acgme.org/Outcome/. Accessed May 16, 2008.
Association of American Medical Colleges (AAMC). Learning objectives for medical student education—guidelines for medical schools: report 1 of the medical school objectives project. January 1998. Available from: http://www.aamc.org/meded/msop/. Accessed May 16, 2008.
Liaison Committee on Medical Education (LCME). Functions and structures of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. July 2003. Available from: http://www.lcme.org/. Accessed May 16, 2008.
Evans RJ, Stanley RO, Mestrovic R, Rose L. Effects of communication skills training on students’ diagnostic efficiency. Med Educ. 1991;25:517–26.
Roter D, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med. 1995;155:1877–84.
Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ. 2001;323:908–11.
Roter DL, Hall JA, Katz NR. Relations between physicians’ behaviors and analogue patients’ satisfaction, recall, and impressions. Med Care. 1987;25:437–51.
Mead N, Bower P. Patient-centred consultations and outcomed in primary care: a review of the literature. Patient Educ Couns. 2002;48:51–61.
Elder N, Ricer R, Tobias B. How respected family physicians manage difficult patient encounters. J Am Board Fam Med. 2006;19(6):533–41. Nov–Dec.
Hass LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005;72(10):2063–8. Nov 15.
AMA Principles of Medical Ethics, American Medical Association, Chicago, Illinois, 2001. http://www.cirp.org/library/statements/ama/. Accessed May 16, 2008.
Devitt PJ, Devitt AC, Dewan M. Does identifying a discharge as “against medical advice” confer legal protection? J Fam Pract. 2000;49(3):224–7. Mar.
Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51(7):899–902. Jul.
Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277(7):553–9. Feb 19.
Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual. 1999;14(4):153–9. Jul–Aug.
Swota AH. Changing policy to reflect a concern for patients who sign out against medical advice. Am J Bioeth. 2007;7(3):32–4. Mar.
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APPENDIX
APPENDIX
Interview Guide for Semi-Structured Interviews with Providers Regarding Their Experiences with a Patient Who Has Left the Hospital Against Medical Advice
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1.
Do you recall taking care of patient X in the hospital recently?
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2.
Could you review the circumstances around the patient’s admission to the hospital?
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3a.*
Did your patient ask you questions about their condition or treatment? (Yes, No my patient had no questions)
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b.
If your patient did have questions, do you feel that you answered them thoroughly? (Yes always, Yes sometimes, No)
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4a.*
Did you feel that your patient had anxieties or fears about their condition or treatment? (Yes, No my patient did not have anxieties/fears)
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b.
If your patient had anxieties or fears, did you discuss them with the patient? (Yes completely, Yes to some extent, No)
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5.*
Did your patient have friends or family members with questions regarding the patient’s condition or treatment? (Yes, No family or friends were involved, Family/friends did not need/request information)
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6.*
If friends or family were involved, do you feel that you provided all of the information they needed? (Yes definitely, Yes to some extent, No)
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7a.*
Did your patient ever complain of pain when they were in the hospital? (Yes, No)
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b.
If they were in pain, do you think did everything you could to help control their pain?
(Yes definitely, Yes to some extent, No)
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8.*
When you were in the room with the patient, did you talk in front of your patient as if he/she was not there? (Yes often, Yes sometimes, No)
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9.
Do you recall the circumstances in which the patient left the hospital?
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10.
Did the patient give any suggestions prior to their leaving that they did not want to stay in the hospital?
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11.
How ill was the patient when he/she left? Could you rate their health as either: Poor, Fair, Good, Very Good, or Excellent?
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12.
What were the reasons you felt he/she should have stayed in the hospital?
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13.
How many more days did you think he/she needed to be hospitalized?
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14.
How did you find out that the patient was leaving when he/she did?
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15.
What did you do when you heard he/she wished to leave?
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16.
Who was directly involved with the actual execution of the discharge?
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17.
If you were directly involved with their discharge, approximately how much time did you spend with the patient in discussing their desire to leave?
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18.
What was discussed with the patient at the time the patient wished to leave AMA?
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19a.*
Did the patient have new medications or a change in their medication schedule when they left the hospital? (Yes, No)
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b.
If yes, did you provide an explanation of these medications or changes? (Yes, No, No the nurse or other team member provided this information)
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c.
If yes, do you feel that you explained the purpose of the medications or changes in a way that he/she could understand? (Yes completely, Yes to some extent, No)
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20.*
Did you inform your patient about possible side effects to watch for when he/she went home? (Yes completely, Yes to some extent, No)
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21.*
Did you tell your patient about danger signals regarding his/her illness or treatment to watch for after he/she was discharged? (Yes completely, Yes to some extent, No)
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22.
Did the patient tell you exactly why he/she wished to leave? If so, what did he/she say?
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23.
Why do you think the patient left the hospital when he/she did?
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25.
Are you aware of any follow-up plans that were made to ensure the patient’s safety after leaving the hospital?
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26.
Do you think that he/she will return to the hospital in the next month?
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27.
Could you describe the feelings you had regarding the patient’s leaving the way he/she did?
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28.*
Overall, did you feel that you treated your patient with respect and dignity? (Yes always, Yes sometimes, No)
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29.
If you could change anything that happened with the way this person left, what would you do differently?
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30.
Will you change anything in your care of patients because of this experience?
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31.
Have you had other patients in the hospital who wished to leave AMA? If so, were you able to convince anyone to stay? How?
* Question derived from the Picker Patient Questionnaire
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Windish, D.M., Ratanawongsa, N. Providers’ Perceptions of Relationships and Professional Roles when Caring for Patients who Leave the Hospital Against Medical Advice. J GEN INTERN MED 23, 1698–1707 (2008). https://doi.org/10.1007/s11606-008-0728-4
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DOI: https://doi.org/10.1007/s11606-008-0728-4