When Patients Leave Hospital Against Medical Advice
What are a physician’s obligations when a patient leaves the hospital against medical advice?
All competent patients have the right to discharge themselves against medical advice (AMA). However, a patient’s decision to leave the hospital contrary to their physician’s advice does not absolve the physician of a legal duty of care.
“It is true a patient may be judged to have negligently caused or contributed to a clinical outcome by failing to act as might generally be expected of a reasonable patient. However, it is uncommon that a court will find the patient wholly responsible for an adverse outcome due to the contributory negligence of the patient,” stated the Canadian Medical Protective Association (CMPA) in its Good Practices Guide.
The CPSO’s expectation is that the physician obtain the patient’s informed consent to leave by communicating to the patient the risks, benefits, and alternatives to leaving and fully documenting the conversation in the medical record.
For guidance, we present the following resources for further reading:
Canadian Medical Protective Association:
“Leaving against medical advice”
The CMPA advises physicians to inform patients of symptoms and signs alerting them to seek further medical care and provide advice tailored to their specific clinical situation. The patient should also be informed about who is the most responsible health-care professional for follow-up care.
The CMPA also advises physicians to document in the medical record:
- Recommendations for care
- Mental capacity assessment
- Patient’s reasons for refusing investigation or treatment
- Follow up and discharge instructions provided
- A signed AMA form, acknowledging the discussion with the patient about the risks (if the patient refuses to take part in that discussion or to sign the form, that should also be documented).
Ontario Hospital Association:
“Mental Health and the Law Toolkit”
Health Care lawyers Katharine Byrick and Barbara Walker-Renshaw updated the toolkit in 2016 to provide health-care providers with a general understanding of mental health law issues and an overview of the legislation that governs the provision of mental health care in Ontario.
The toolkit’s section addressing those instances when patients leave against medical advice recommends that physicians take steps to minimize the risk of allowing the patient to leave (e.g. ensuring they have appropriate prescriptions, notifying their family doctor, discussing plans to return/access care if their condition worsens).
The toolkit also states that as the risk of the patient leaving AMA increases, so does the need to document in detail the nature of the conversation in the patient’s chart.
And if the decision is being made by a substitute decision-maker (SDM) on behalf of an incapable patient, there are other matters to consider. First and foremost, the patient’s capacity to make decisions at that point in time should be assessed. Although patient capacity has already been considered, the decision to remove a patient from hospital and medically necessary treatment is a significant decision – one that raises the issue of whether the SDM — is acting in the best interests of the patient.
If the patient is a minor, and there is a concern that the decision to leave against medical advice is not being made in accordance with the principles of substitute decision making as set out in the Health Care Consent Act, then in addition to the above, there may need to be consideration of whether a report is required by law to a Children’s Aid Society about a child who may be in need of protection.
Royal College of Physicians and Surgeons of Canada
The Royal College advises physicians that a patient’s decision-making capacity should be assessed and to document that the patient can understand their condition, the treatment options and the consequences of not accepting the proposed treatment.
The Royal College also notes that the concept of labelling a “discharge against medical advice” needs further consideration as it may create an antagonistic relationship between the patient and the medical team that limits ongoing care. It also seems to contradict the accepted model of shared decision-making. “When a patient leaves hospital under circumstances that do not seem ideal, the focus should be on establishing the patient’s capacity and arranging the safest plan for follow up, rather than creating conflict,” it stated.
Understanding a patient’s values and reasons for declining hospital admission may help to create a patient-centered alternative treatment plan. For example, the patient may have concerns about their children’s care at home.