What is the most appropriate next step when a patient with heart failure, who has been treated with furosemide (Lasix), wants to leave the hospital against medical advice?

Management of a Heart Failure Patient Leaving Against Medical Advice

The most appropriate next step for a patient with heart failure who wishes to leave against medical advice is to request that the patient sign a statement confirming that he is leaving against medical advice.

Understanding the Situation

When a patient with heart failure decides to leave the hospital against medical advice (AMA), healthcare providers must balance respect for patient autonomy with concern for patient safety. This 60-year-old man with newly diagnosed heart failure has shown clinical improvement after diuresis but still requires further treatment.

Key Considerations:

• The patient has decisional capacity (able to understand risks)
• He has been informed of the risks of premature discharge
• He still wishes to leave despite recommendations

Management Algorithm

1. Document informed refusal

   • Request the patient sign an AMA form 1
   • Document that risks, benefits, and alternatives were discussed
   • Record the patient's stated reason for leaving

2. Provide discharge planning despite AMA status

   • Provide comprehensive written discharge instructions 2
   • Focus on medication instructions, especially for furosemide
   • Include warning signs requiring immediate medical attention
   • Schedule follow-up appointments

3. Optimize outpatient transition

   • Provide prescriptions for all necessary medications
   • Ensure the patient has a follow-up appointment within 7 days 2
   • Arrange for telephone follow-up within 3 days if possible 2

Documentation Requirements

The AMA form and medical record should clearly document:

• The patient's mental status and capacity to make decisions
• Specific risks of leaving explained to the patient (worsening heart failure, readmission, death)
• Medications provided and follow-up arrangements made
• The patient's acknowledgment of understanding these risks

Rationale for This Approach

The American College of Cardiology/American Heart Association guidelines emphasize the importance of comprehensive discharge planning for all heart failure patients 2. Even when patients leave AMA, they should receive appropriate discharge instructions and follow-up plans to minimize adverse outcomes.

Studies show that patients who leave AMA have higher rates of readmission and mortality 3, 4. However, forcing a patient to stay (refusing to accede to wishes) would violate patient autonomy and potentially constitute false imprisonment.

What Not To Do

• Do not refuse to allow the patient to leave - This violates patient autonomy and may constitute false imprisonment
• Do not contact the ethics committee - While valuable in complex cases, this is not the immediate next step for a patient with decision-making capacity
• Do not pressure family members to convince the patient - This undermines patient autonomy and creates potential conflict
• Do not discharge without providing instructions or follow-up - Patients leaving AMA still deserve appropriate care transitions

Practical Considerations

Financial concerns are among the most common reasons patients leave AMA 3, 4. If this is identified as a factor, a social work consultation before discharge may help address these concerns.

Remember that patients who leave AMA can return for care at any time 1. Make sure the patient understands this and doesn't feel "blacklisted" for their decision.

The goal is to maintain a therapeutic relationship while respecting the patient's autonomy, ensuring they leave with the best possible chance of managing their condition outside the hospital.