What is wrong with discharges against medical advice (and how to fix them).

It is estimated that as many as 2% of all US hospital discharges (approximately 500 000 per year) are designated as against medical advice1; that is, a patient chooses to leave the hospital before the treating physician recommends discharge. The risks to these patients are significant. Compared with patients discharged conventionally, readmission rates for patients discharged against medical advice are 20% to 40% higher, and their adjusted relative risk of 30-day mortality may be 10% higher.2 Furthermore, physicians and other health care staff report feeling distressed and powerless when patients choose suboptimal care, and disagreement over a discharge against medical advice can cause patient-physician and intrateam conflict.3 Althoughtheseharmshavebeenwelldescribed, the stigmatizing effect on patients of discharges against medical advice has rarely been examined. Compared with how the profession handles clinical disagreements in other settings (eg, outpatient), an “against medical advice”designation is anoutdated conceptunsupportive of patients. In this Viewpoint, starting from a core value of patient centeredness, we aim to highlight theproblematicaspectsofdischargesagainstmedical advice and suggest a new approach. Designating a discharge as against medical advice is a clinical practice not subject to professional standards. There is no clear medicolegal rationale for this designation and no professional consensus on what constitutes a discharge as against medical advice. If a competentpatientorhisorherauthorizedsurrogatedeclines further inpatientcare,physiciansshould fulfill their legal and ethical obligations to obtain informed consent for the patient’s decision and document that decision and the patient’s reasons for it in the patient’s record.But thephysician’s subsequent choice todesignate thehospitaldischargeasagainstmedical adviceandpursue the formalized process associated with it (eg, specialized discharge forms) has no evidence-based utility for patient care, is not legally required, and has been shown to be associated with a reduced willingness for the patient to return for future care.4 Furthermore, there isnoconsensusaboutwhatclinical criteria warrant a “discharged against medical advice”designation.This lackofclarity leads togreatervariability in its clinical use, lacks transparency, and impedes standardization of a common medical practice. Although a more specific definition of discharge against medical advice could improve research andclinical processes, the term is an anachronism that has outlived its usefulness in an era of patient-centered care. Recent studies have highlighted problematic informed consent practices for discharges against medical advice by identifying that a majority of house officers and attending physicians mistakenly believe and informpatients that if they sign out againstmedical advice, their insurance may not pay for the hospitalization. In a cross-sectional survey of physicians conductedby Schaefer et al,5 85%of residents and67%of attending physicians reported that they informed patients about denial of insurance payment so that patientswould reconsider remaining in thehospital. These studies suggest that the use of misleading information in discharges against medical advice threatens to undermineapatient’s voluntary choiceand insinuates that coercion is an acceptable and oft-repeated practice. The use of specialized discharge forms that document a patient’s risks and liability is common hospital practice indischargesagainstmedicaladvice.Despiteapparentwidespread use of these documents, there is no evidencethattheyadvancepatientcare.Althoughhealth professionals generally support the use of discharge against medical advice forms because they believe it is required to protect themselves and their institutions from legal liability, thesepresumptionsarenotvalid.6 Indeed, the contrary may be true. Malpractice claims are associatedwithpoor physician communication andpatientperceptionsof feelingdesertedordevalued.7 Ifdischarges against medical advice occur when there are breakdowns in communication, it is possible that such dischargesmaycontributeto increased liability.Ataminimum, there is limitedunderstandingofwhether thedesire to protect clinicians and institutions from legal liability by using a specialized discharge form interferes with the care of the patient. Because clinical care decisions for hospitalized patients are sensitive to patient preference, shared decisionmaking (SDM)has a role in achievingmorepatientcentered care in decisions related to discharge against medical advice.AlthoughSDMiswell accepted inovertly value-laden clinical decisions such as prostate-specific antigen testing andmammography screening, theprinciples of SDM apply to a broad range of health care decisions,dischargesagainstmedical advice included.Contrary to the principles of SDM, a discharge against medical advicesends theundesirablemessage thatphysiciansdiscountpatients’ values in clinical decisionmaking. Accepting an informed patient’s values and preferences, even when they do not appear to coincide with commonly accepted notions of good decisions about health, is always part of patient-centered care. The active engagement of the medical community will be necessary to reform the practice of discharges against medical advice. Physicians can begin with individualpatients,but theyalsocansupport research in this area and in establishing standards for such discharges. VIEWPOINT