What are the criteria for a patient leaving Against Medical Advice (AMA)?

Against Medical Advice (AMA) Discharge Criteria

A patient leaving against medical advice requires documentation of decision-making capacity, specific risk disclosure with patient understanding, and provision of discharge instructions with follow-up arrangements, while recognizing this excludes them from quality measure reporting. 1

Essential Criteria for AMA Discharge

1. Assessment of Decision-Making Capacity

• The patient must demonstrate full decision-making capacity to understand their medical situation and the risks of leaving 1, 2
• This assessment must be documented in the medical record before allowing departure 3
• Capacity evaluation should confirm the patient can comprehend the information provided, appreciate the consequences, and communicate a reasoned decision 3

2. Risk Disclosure Requirements

• Document patient-specific, material risks—not generic warnings—of leaving with the current untreated or incompletely treated condition 1
• Include both immediate risks and longer-term consequences specific to the patient's diagnosis 1
• For conditions like thrombocytopenia, specify risks such as spontaneous bleeding and intracranial hemorrhage 2
• For cardiac conditions, detail risks of adverse cardiovascular events, reinfarction, or death 4

3. Documentation of Patient Understanding

• Document that the patient verbalized understanding of the specific risks discussed 1
• This provides crucial evidence that informed refusal occurred 3
• Record the patient's stated reasons for leaving if possible 5

4. Provision of Discharge Resources

• Provide and document discharge instructions appropriate to the patient's condition 1, 6
• Give prescriptions for necessary medications 1, 2, 6
• Schedule urgent follow-up appointments 1, 2
• Provide contact numbers for questions or if the patient changes their mind 1
• For specific conditions like thrombocytopenia, document laboratory follow-up recommendations within a specific timeframe 2

5. Quality Measure Exclusion Documentation

• Document that the patient was informed they will be excluded from quality measure denominator populations due to AMA status 1, 2
• This applies across multiple performance measures for conditions including myocardial infarction, coronary revascularization, and other cardiac conditions 4
• AMA patients are systematically excluded from denominator populations in ACC/AHA performance measures 4

Common Pitfalls to Avoid

The "You Leave With Nothing" Misconception

• Never perpetuate the concept that AMA means the patient leaves with nothing 6
• Failure to provide discharge instructions, medications, and follow-up information increases liability and worsens outcomes 6
• Patients who leave AMA have 2.36-fold increased risk of 7-day readmission and twofold increased 28-day mortality compared to standard discharges 7

Inadequate Risk Documentation

• Generic warnings like "you could get worse" are insufficient 1
• Risks must be specific to the patient's condition and current clinical status 1, 2
• Document the conversation in detail, not just that "risks were explained" 3

Missing Legal Protections

• Proper AMA documentation creates significant liability protection by proving the provider's duty ended with discharge and the patient assumed risk 3
• Without proper documentation, providers remain vulnerable to claims of inadequate assessment or treatment 8, 3

Clinical Context

Patients who discharge AMA comprise 1-2% of hospital admissions and tend to be younger males from lower socioeconomic backgrounds with mental health or substance use disorders 8, 5. These patients carry significantly increased risks of readmission (1.31-fold at 1 year) and mortality (1.2-fold up to 9 years) compared to standard discharges 7. The systematic exclusion of AMA patients from quality measure denominators across ACC/AHA performance measures reflects recognition that incomplete care prevents fair assessment of provider performance 4.