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Providers’ Perceptions of Relationships and Professional Roles when Caring for Patients who Leave the Hospital Against Medical Advice

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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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Acknowledgement

None. No financial disclosures.

Conflicts of Interest

None disclosed.

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Authors and Affiliations

Authors

Corresponding author

Correspondence to Donna M. Windish MD, MPH.

APPENDIX

APPENDIX

Interview Guide for Semi-Structured Interviews with Providers Regarding Their Experiences with a Patient Who Has Left the Hospital Against Medical Advice

  1. 1.

    Do you recall taking care of patient X in the hospital recently?

  2. 2.

    Could you review the circumstances around the patient’s admission to the hospital?

  3. 3a.*

    Did your patient ask you questions about their condition or treatment? (Yes, No my patient had no questions)

  4. b.

    If your patient did have questions, do you feel that you answered them thoroughly? (Yes always, Yes sometimes, No)

  5. 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)

  6. b.

    If your patient had anxieties or fears, did you discuss them with the patient? (Yes completely, Yes to some extent, No)

  7. 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)

  8. 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)

  9. 7a.*

    Did your patient ever complain of pain when they were in the hospital? (Yes, No)

  10. 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)

  11. 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)

  12. 9.

    Do you recall the circumstances in which the patient left the hospital?

  13. 10.

    Did the patient give any suggestions prior to their leaving that they did not want to stay in the hospital?

  14. 11.

    How ill was the patient when he/she left? Could you rate their health as either: Poor, Fair, Good, Very Good, or Excellent?

  15. 12.

    What were the reasons you felt he/she should have stayed in the hospital?

  16. 13.

    How many more days did you think he/she needed to be hospitalized?

  17. 14.

    How did you find out that the patient was leaving when he/she did?

  18. 15.

    What did you do when you heard he/she wished to leave?

  19. 16.

    Who was directly involved with the actual execution of the discharge?

  20. 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?

  21. 18.

    What was discussed with the patient at the time the patient wished to leave AMA?

  22. 19a.*

    Did the patient have new medications or a change in their medication schedule when they left the hospital? (Yes, No)

  23. 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)

  24. 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)

  25. 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)

  26. 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)

  27. 22.

    Did the patient tell you exactly why he/she wished to leave? If so, what did he/she say?

  28. 23.

    Why do you think the patient left the hospital when he/she did?

  29. 25.

    Are you aware of any follow-up plans that were made to ensure the patient’s safety after leaving the hospital?

  30. 26.

    Do you think that he/she will return to the hospital in the next month?

  31. 27.

    Could you describe the feelings you had regarding the patient’s leaving the way he/she did?

  32. 28.*

    Overall, did you feel that you treated your patient with respect and dignity? (Yes always, Yes sometimes, No)

  33. 29.

    If you could change anything that happened with the way this person left, what would you do differently?

  34. 30.

    Will you change anything in your care of patients because of this experience?

  35. 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

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