Protocol for Discharge Against Medical Advice (DAMA)
When a patient requests to leave against medical advice, you must conduct a structured assessment of decision-making capacity, document specific patient-tailored risks, provide discharge medications and follow-up arrangements, and complete proper documentation that includes the patient's verbalized understanding of the risks—never simply hand them a generic waiver to sign. 1, 2
Initial Assessment
Assess decision-making capacity first. Before proceeding with any DAMA paperwork, determine whether the patient has capacity to make this decision. 3 If the patient lacks capacity, you cannot proceed with a standard DAMA discharge and may need guardianship or alternative legal pathways. 3
Required Documentation Elements
Document patient-specific risks, not generic warnings. 1, 2 Your documentation must include:
Specific risks of leaving with the current untreated or incompletely treated condition, including both immediate dangers (e.g., "Your potassium of 2.1 puts you at risk for fatal cardiac arrhythmia within hours") and longer-term consequences tailored to this patient's clinical situation 1, 2
The patient's verbalized understanding of these specific risks—document their own words demonstrating comprehension, not just that you "explained" risks 1, 2
That the patient will be excluded from quality measure denominator populations due to AMA status, which applies to performance measures for conditions like myocardial infarction, heart failure, and all cardiovascular metrics 1, 2
Provide Appropriate Medical Care
Give discharge medications and prescriptions despite the AMA status. 1 This is critical for reducing morbidity and mortality:
For cardiovascular conditions, continue evidence-based therapies (aspirin, P2Y12 inhibitors, beta-blockers, statins) even if the patient is leaving AMA 1
Provide sublingual nitroglycerin with specific instructions for acute coronary syndrome patients 1
Conduct medication reconciliation and arrange inpatient pharmacist counseling before discharge, particularly for complex regimens like corticosteroid tapers 4, 5
Arrange Follow-Up Care
Schedule urgent follow-up appointments before the patient leaves. 1, 2, 5 Optimal timing is within 48 hours of discharge. 4, 5
Provide written discharge instructions specific to their condition 1, 2
Give contact numbers for questions or if the patient changes their mind 1
Consider assigning patient navigators or community health workers for patients with significant barriers to care 5
Arrange telephone or text check-ins to ensure stability and adherence 5
Common Pitfalls to Avoid
Do not use generic AMA forms with boilerplate language. The risks must be material and patient-specific, not standardized warnings that could apply to anyone. 1, 2
Do not withhold appropriate medical care (medications, prescriptions, follow-up) because the patient is leaving AMA—this increases the already elevated risk of readmission and mortality. 1, 6 Patients who leave AMA have a 2.36-fold increased risk of 7-day readmission and twofold increased 28-day mortality compared to standard discharges. 6
Do not simply hand them a waiver and let them walk out. The process requires active engagement, risk discussion, capacity assessment, and care provision. 1, 2, 7
Quality Measure Implications
Understand that AMA designation removes the patient from all quality reporting. 2 This exclusion applies universally across conditions including acute myocardial infarction, coronary artery revascularization, atrial fibrillation, and heart failure, regardless of whether they received appropriate care prior to leaving. 2 Their outcomes will not impact institutional performance scores. 2
High-Risk Populations
Pay particular attention to young males, patients from lower socioeconomic backgrounds, and those with mental health or substance use disorders—these groups have higher DAMA rates and worse outcomes. 8, 6 Consider psychiatric consultation before discharge for patients with mental health comorbidities. 4