What is the next best step for a 55-year-old man with acute heart failure exacerbation, mild respiratory distress, elevated Jugular Venous Pressure (JVP), and 2+ pitting edema, who wants to leave the hospital against medical advice (AMA) to use methamphetamine?

Allow the Patient to Leave Against Medical Advice (AMA)

The intern should allow this patient to leave against medical advice after documenting his decision-making capacity, as he demonstrates intact capacity by understanding and articulating the risks of leaving despite his substance use disorder.

Assessment of Decision-Making Capacity

This patient demonstrates all four elements of decision-making capacity despite his active substance use:

• Understanding: He comprehends that he has acute heart failure requiring treatment 1
• Appreciation: He recognizes the information applies to his own situation 1
• Reasoning: He can articulate the risks of leaving (worsening heart failure) when asked to state them back 1
• Communication: He clearly and consistently expresses his choice to leave 1

The presence of substance use disorder or the desire to use methamphetamine does not automatically negate decision-making capacity. Capacity is decision-specific and must be assessed based on the patient's ability to understand the specific decision at hand, not on the perceived quality of the decision itself.

Documentation Requirements

The intern must thoroughly document the following before discharge:

• Capacity assessment: Document that the patient understands his diagnosis, the recommended treatment, the risks of leaving (including worsening heart failure, respiratory failure, and death), and that he can articulate these risks 1
• Counseling provided: Record the specific risks discussed, including likelihood of clinical decompensation given his current signs (elevated JVP, bilateral edema, mild respiratory distress) 1
• Patient's stated reasons: Document his explicit reason for leaving ("needs some meth") 1
• AMA form: Have the patient sign an AMA form; if he refuses to sign, document this refusal with a witness 1

Critical Clinical Context

This patient has high-risk features that make leaving particularly dangerous:

• Objective signs of decompensation: Elevated JVP and 2+ pitting edema to bilateral knees indicate significant volume overload requiring intravenous diuretics 1
• Respiratory distress: Even mild respiratory distress in acute heart failure signals inadequate compensation and risk for rapid deterioration 1
• Early treatment window: Acute heart failure has a "time-to-treatment" concept similar to acute coronary syndrome, and early intervention improves outcomes 1
• High readmission risk: Patients who leave AMA have substantially higher rates of readmission and mortality 2, 3

Discharge Planning Despite AMA Status

Even when a patient leaves AMA, the intern should attempt harm reduction:

• Prescribe oral diuretics: Provide a prescription for oral furosemide at a dose at least equivalent to what would be given intravenously 1
• Continue home medications: Ensure the patient has prescriptions for his chronic heart failure medications (ACE inhibitors/ARBs, beta-blockers) unless contraindicated by current hemodynamics 1
• Provide written instructions: Give clear written instructions about warning signs (worsening shortness of breath, inability to lie flat, weight gain >2-3 pounds in 24 hours) that should prompt immediate return 1
• Arrange follow-up: Schedule outpatient follow-up within 72 hours if possible, though acknowledge the patient may not attend 1
• Offer resources: Provide information about substance use treatment programs, though this should not be coercive 1

Common Pitfalls to Avoid

Do not confuse disagreement with incapacity: A patient who makes a decision that seems irrational or harmful to the clinician may still have intact decision-making capacity. The desire to use substances, while concerning, does not equal incapacity 1

Do not attempt involuntary hold without proper criteria: Psychiatric holds require imminent danger to self or others due to mental illness, not simply poor medical decision-making or substance use disorder 1

Do not abandon the patient: Even when leaving AMA, the patient deserves respectful care, harm reduction strategies, and an open door to return 1

Do not delay documentation: Complete the AMA documentation immediately while events are fresh and before the patient leaves the unit 1