Please Don't Go! Against Medical Advice Discharges in Patients with IV Drug Abuse
A 35-year-old female with a history of IV drug use and recent facial trauma presented to the ED with jaw pain and bilateral arm lesions. She had been seen previously in 3 other EDs where she had been diagnosed with mandible fractures and multiple abscesses, but she left against medical advice (AMA) before completing treatment due to “not feeling safe.” On this visit, a maxillofacial CT confirmed left posterior and right anterior mandible fractures. Upper extremity ultrasound demonstrated multiple hypoechoic abscesses with potential for drainage. She declined IV placement for lab work, analgesia, and antibiotics. She refused I&D of her abscesses and left prior to evaluation by ENT. She reported understanding the severity of her illnesses but repeatedly stated that she preferred to spend time with her ailing father who was dying from cancer. She left AMA with prescriptions for ibuprofen 800mg q8h PRN pain, doxycycline 100mg BID x 10 days, and a scheduled appointment for outpatient follow-up. She returned to the ED a week later for continued jaw pain.
What is an ideal discharge plan for ill patients with active IV drug use who leave AMA?
Summary of Evidence:
Up to 2.7% of ED discharges are AMA, with that number increasing to 6% in disadvantaged inner-city hospital populations.(1-3)
IV drug users are at higher risk of being discharged AMA,(4-6) which can result in increased readmission rates as well as significant morbidity and mortality.(7-11)
IV drug users also have reported feeling uncomfortable in the hospital setting for many reasons including feeling judged by staff and suspecting that they are not receiving proper treatment.(12)
Often these patients cite specific concerns such as withdrawal symptoms or family responsibilities,(13) and discussing these may facilitate the formulation of an appropriate treatment plan.(7,14,15)
A standardized discharge approach that includes patient education, scheduled follow-up, organized medication regimen, and ensuring patient understanding of the plan has been shown to decrease rehospitalization rates and ED utilization.(16)
Completing an AMA form may also provide liability protection for providers.(17)
Assess patients to ensure that they have medical decision making capacity.
Seek to understand specifically why patients may opt to leave before their evaluation and treatment is complete (i.e., concern over withdrawal symptoms, personal responsibilities, lack of funds/insurance), and work with them to develop plans to address these issues.
Ensure that patients understand the scope and severity of their illness as well as potential consequences of not receiving recommended treatments.
Provide detailed discharge instructions, prescriptions for outpatient therapies, and confirmed follow-up appointments.
Review symptoms that would necessitate seeking immediate medical attention.
Have patients repeat the discharge information back to ensure understanding.
Encourage patients to seek treatment and assure them they are welcome in the ED should they choose to return.
Document the discharge encounter.
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