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Please Don't Go! Against Medical Advice Discharges in Patients with IV Drug Abuse

Case Presentation:

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.

Clinical Question:

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)

Recommendations:

  • 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.

References:

  1. Lee CA, Cho JP, Choi SC, Kim HH, Park JO. Patients who leave the emergency department against medical advice. Clinical and Experimental Emergency Medicine. 2016;3(2):88-94. doi:10.15441/ceem.15.015.

  2. Hwang SW. Case and commentary: discharge against medical advice. Agency for Healthcare Research and Quality. May 2005. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=96. Accessed May 3, 2010.

  3. Magauran BG Jr. Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice. Emerg Med Clin North Am 2009;27:605–14

  4. Lianping Ti, Lianlian Ti. Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review. American Journal of Public Health 105, no. 12 (December 1, 2015): pp. e53-e59.

  5. Jeremiah J, O'Sullivan P, Stein MD: Who leaves against medical advice?. JGIM. 1995, 10: 403-5. 10.1007/BF02599843

  6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O'Shaughnessy MV: Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002, 167: 633-7.

  7. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.

  8. Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125(6): 594-602.

  9. Choi M, Kim H, Qian H, Palepu A. Readmission rates of patients discharged against medical advice: a matched cohort study. PLoS One. 2011;6(9): e24459

  10. Garland A, Ramsey CL, Fransoo R, et al. Rates of readmission and death associated with leaving hospital against medical advice: a population-based study. CMAJ 2013;185:1207–14.

  11. Ding R, Jung JJ, Kirsch TD, Levy R, McCarthy ML. Uncompleted emergency department care: patients who leave against medical advice. Acad Emerg Med 2007;14:870–6.

  12. McNeil R, Small W, Wood E, Kerr T. Hospitals as a 'risk environment': an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med. 2014 Mar;105:59-66. doi: 10.1016/j.socscimed.2014.01.010.

  13. Alfandre D, Schumann JH. What is wrong with discharges against medical advice (and how to fix them). JAMA 2013;310:2393–4.

  14. Alfandre DJ. “I'm going home”: discharges against medical advice. Mayo Clin Proc 2009;84:255–60.

  15. Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. Am J Prev Med. 2001;20(1):68-74

  16. Jack BW, Chetty V, Anthony D, et al. A Reengineered Hospital Discharge Program to Decrease Rehospitalization. Annals of Internal Medicine 150(3), Feb. 3, 2009, pp. 178-187,

  17. F Levy, DP Mareiniss, C Iacovelli. The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. J Emerg Med, 43 (2012), pp. 516-520

  18. Clark MA, Abbott JT, Adyanthaya T. Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge. Acad Emerg Med. 2014 Sep;21(9):1050-7. doi: 10.1111/acem.12461.

  19. Monico EP, Schwartz I. Leaving against medical advice: facing the issue in the emergency department. J Healthc Risk Manag. 2009;29 (2): 6-9, 13, 15.

  20. DeLaney, M. Jan 13, 2014. The proper way to go against medical advice (AMA): 8 Elements to Address. Retrieved from https://www.aliem.com/2014/01/proper-way-to-go-against-medical-advice/

  21. Sessums LL, Zembrzuska H, Jackson JL. Does this patient have medical decision-making capacity?JAMA 2011;306:420–7.

  22. Appelbaum PS. Assessment of patients' competence to consent to treat. N Engl J Med2007;357:1834–70.

  23. Rachlis BS, Kerr T, Montaner JS, Wood E. Harm reduction in hospitals: is it time? Harm Reduction Journal. 2009;6:19. doi:10.1186/1477-7517-6-19.

  24. Grewal HK, Ti L, Hayashi K, Dobrer S, Wood E, Kerr T. Illicit Drug Use In Acute Care Settings. Drug and alcohol review. May 2015:10.1111/dar.12270. doi:10.1111/dar.12270.

  25. Ti L, Buxton J, Harrison S, et al. Willingness to access an in-hospital supervised injection facility among hospitalized people who use illicit drugs. Journal of hospital medicine. 2015;10(5):301-306. doi:10.1002/jhm.2344.

 

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