How should I document a patient’s request for discharge against medical advice when imaging shows bilateral cholesteatoma with intracranial extradural extension, extensive sinonasal disease with possible invasive fungal sinusitis, a left antrochoanal polyp causing ostiomeatal obstruction, and cerebral atrophy out of proportion to age?

Documentation of Patient Request for Discharge Against Medical Advice

This patient should NOT be discharged and must remain hospitalized for urgent neurosurgical and ENT consultation, intravenous antifungal therapy, and continuous monitoring—bilateral cholesteatoma with intracranial extradural extension combined with possible invasive fungal sinusitis carries a 50-80% mortality risk without immediate aggressive treatment. 1

Critical High-Risk Features Requiring Hospitalization

Your patient presents with multiple life-threatening conditions that absolutely contraindicate discharge:

• Intracranial extension of cholesteatoma mandates inpatient care and definitive exclusion of complications (epidural abscess, subdural abscess, meningitis) before any discharge consideration. 1
• Invasive fungal sinusitis with intracranial involvement carries a documented mortality of 50-80% and demands immediate aggressive therapy including antifungal agents, surgical debridement, and ICU-level observation. 1, 2
• Clinical deterioration occurs early in these patients—57% of adverse events happen within the first 24 hours of presentation, making premature discharge potentially fatal. 1
• Cerebral atrophy disproportionate to age signals chronic intracranial pathology requiring comprehensive neurological assessment before any discharge decision. 1

Mandatory Immediate Actions

• Urgent neurosurgical consultation is required for bilateral cholesteatoma with documented extradural extension. 1
• Immediate otolaryngology consultation is indicated for surgical planning of cholesteatoma removal and sinus drainage. 1
• Infectious disease specialists must be involved without delay if invasive fungal sinusitis is confirmed. 1
• Contrast-enhanced MRI is the preferred modality (97% diagnostic accuracy vs. 87-91% for CT) and should be obtained promptly to evaluate soft-tissue extension, meningeal enhancement, and venous sinus patency. 3, 1

If Patient Insists on Leaving: Documentation Requirements

If despite thorough explanation the patient still demands discharge, document the following in the medical record:

• Document that you explained the specific life-threatening risks: 50-80% mortality from invasive fungal sinusitis, risk of brain abscess, meningitis, orbital involvement, and potential for rapid deterioration within 24 hours. 1, 2
• Document that you explained the need for: urgent neurosurgical evaluation, ENT consultation, intravenous antifungal therapy, surgical debridement, and continuous neurological monitoring. 1
• Document the patient's decision-making capacity: specifically note whether the patient demonstrates understanding of the diagnosis, proposed treatment, risks of refusing treatment, and alternatives.
• Document exact wording: "Patient informed of bilateral cholesteatoma with intracranial extradural extension and possible invasive fungal sinusitis. Explained 50-80% mortality risk without treatment. Patient understands risks but refuses recommended hospitalization and requests discharge against medical advice."
• Have patient sign AMA form: standard against-medical-advice documentation with witnessed signature.
• Provide written discharge instructions listing red-flag symptoms: worsening headache, confusion, facial weakness, seizures, fever, neck stiffness, visual changes, balance problems requiring immediate return. 1

Critical Pitfall to Avoid

• Do not allow discharge based on a currently normal neurological examination—patients with these conditions frequently deteriorate rapidly, and only 50% of admitted patients historically receive documented serial exams, highlighting the danger of inadequate monitoring. 1
• Relying solely on CT imaging may miss subtle intracranial or orbital involvement; MRI must be obtained to avoid under-diagnosis. 3, 1
• Mortality from invasive fungal sinusitis reaches 74-100% when extrasinonasal tissue infarction is present, which can occur with preserved bony walls on CT. 2