Should Medication Be Provided to Patients Leaving Against Medical Advice?
Yes, you should provide medications, prescriptions, and discharge instructions to patients leaving against medical advice (AMA), as this harm-reduction approach improves outcomes and fulfills your professional obligations despite the patient's decision to leave. 1, 2
Core Principle: Harm Reduction Over Abandonment
The fundamental error in AMA discharges is the misconception that "AMA means you leave with nothing." 2 This punitive approach increases morbidity and mortality in an already high-risk population. 3, 4
Patients leaving AMA should receive:
- Prescriptions for necessary medications to continue treatment started in hospital 1, 4, 2
- Written discharge instructions specific to their condition and risks 1, 2
- Urgent follow-up appointments scheduled before they leave 1, 5
- Contact numbers for questions or if they change their mind 1
- Patient-specific risk counseling (not generic warnings) about leaving with their condition untreated or incompletely treated 1, 6
Documentation Requirements
Your documentation must include specific elements to meet professional standards and protect both patient and provider:
Essential documentation components: 1, 6
- Patient-specific risks of leaving with the current untreated/incompletely treated condition, including immediate and long-term consequences 1, 5
- Patient's verbalized understanding of these risks (not just that risks were discussed) 1, 6
- Decision-making capacity assessment - though only documented in 37% of cases in practice, this is crucial 4
- Medications prescribed and follow-up plans - currently only documented in 24% of AMA cases, representing a major gap 4
- Informed consent documentation - should be present in chart, not just mentioned 4
Quality Measure Implications
Patients leaving AMA are excluded from all quality measure denominator populations regardless of care provided before departure. 7, 6 This applies to:
- Dual antiplatelet therapy metrics 7
- Lipid-lowering therapy at discharge 7
- ACE inhibitor/ARB prescribing 7
- Cardiac rehabilitation referrals 7
- All cardiovascular performance measures 6
You should document that the patient was informed of this quality measure exclusion, though this does not change your obligation to provide appropriate care. 1, 5, 6
Clinical Approach Algorithm
When a patient requests to leave AMA:
Assess decision-making capacity - document this assessment explicitly 4, 8
Identify and address reversible factors - 74.6% of AMA discharges have advance warning, creating intervention opportunities 4:
Provide patient-specific risk counseling - not generic warnings 1, 6
Prescribe medications that were started in hospital or are necessary for the condition 1, 4, 2
Common Pitfalls to Avoid
Do not withhold medications or care as punishment for the AMA decision - this violates professional obligations and worsens outcomes. 2, 8
Do not use generic risk warnings - risks must be material and patient-specific to the individual's clinical situation. 1, 6
Do not assume lack of capacity based solely on the "dangerous" decision to leave - substance abuse and poor social supports are common but do not automatically indicate incapacity. 8
Do not fail to document medication prescribing and follow-up plans - this occurs in 76% of cases but represents suboptimal care and medicolegal risk. 4
Special Considerations
For cardiovascular conditions specifically, guidelines explicitly exclude AMA patients from quality measures but emphasize the importance of continuing evidence-based therapies. 7 For example:
- Continue aspirin, P2Y12 inhibitors, beta-blockers, and statins for ACS patients 7
- Provide sublingual nitroglycerin with instructions for use 7
- Give specific instructions about when to seek emergency care 7
The harm-reduction approach acknowledges that while the patient's decision may increase risk, your role is to minimize that risk through appropriate prescribing and follow-up planning, not to abandon the patient. 2, 8