Attempt to understand the reason for the patient’s decision to leave AMA. Sometimes addressing the problem head on will lead to a timely resolution. Work with the patient, family, and PMD to try and alter the patient’s decision.

Assuming that the EPS efforts to talk the patient into the necessary treatment have failed, certain steps should be taken. The physician must determine and document that the patient is functionally competent. If the EP deems the patient incompetent, then the refusal of care is invalid. If a life threat exists, the physician may treat the patient under the doctrine of constructive consent (also known as the “emergency doctrine”).

The physician should also discuss the patient’s rationale for wanting to leave. Sometimes the patient feels that it is necessary to leave because children have been left alone, pets need to be taken care of, a check needs to be delivered, or any number of dilemmas which may be fairly easy to resolve. The ED staff should attempt to work with the patient to determine if leaving AMA is the only viable solution. Sometimes there are easy solutions that allow the patient to stay for treatment. The ED staff or social worker may be able to calm an angry patient.

Prior to discharging a patient AMA, the EP should be convinced that the patient has given an informed refusal, and has had an opportunity to ask questions. Two members of the emergency department staff should witness this interchange, and both should sign the AMA note or document. Although the emergency staff is primarily patient advocates, the stark reality is that the AMA process is designed to protect the EP, and other ED staff and the hospital from inappropriate litigation. During the process of litigation, the patient will allege that the AMA discussion did not occur, and the presence of a witness is protective.


Good medical care dictates a certain approach to the patient leaving against medical advice. Documentation of that approach will provide protection against liability for adverse events following the discharge. The chart should contain an AMA note that contains the elements discussed above. The emergency physician should not rely upon the hospital's pre-printed form, which states that the patient is leaving the hospital AMA and has a space for a witness to sign. This does not provide an adequate defense. Remember, AMA is a process, not a form. An AMA note may read as follows:

The patient has decided to leave against medical advice. The patient has a normal mental status, and understands the risks of leaving, including permanent disability and/or death, and has had an opportunity to ask questions about his/her medical condition. The patient has been informed that he/she may return for care at any time, and follow up has been arranged.


Dubow et al, performed a retrospective review of the records of 52 consecutive AMA discharges from a level 1 hospital with a census of 42,000 patients per year. The authors found that 18 patients (36%) understood their diagnosis, 23 patients (44%) understood the proposed treatment, one patient (2%) understood the alternative therapy, and 30 (57%) understood the clinical consequences of refusal. Sixty-seven percent of the charts reflected the competence of the patient. This does not represent an adequate effort at managing the risk that accompanies patients leaving against medical advice.

Case # 3 AMA and Myocardial Infarction - Inadequate Documentation

A 66 year old retired man presented to the emergency department complaining of chest pains across his entire chest and down both arms to his elbows. The patient had a history of abnormal EKG readings. Dr. Timm did not order an EKG during this emergency department visit. Dr. Timm, a family practitioner, diagnosed the patient's condition as musculoskeletal pain and discharged the patient home.

The patient was found dead the next morning. The autopsy revealed the cause of death as myocardial infarction occurring approximately twelve hours before death. The patient was survived by five adult children, one of whom lived with him and shared expenses.


The plaintiff contended that the failure to diagnose myocardial infarction was negligent and caused the death of the decedent. The defendant contended that the decedent refused hospital admission. The parties settled for $150,000.

Case Commentary

Dr. Timm claimed that the patient refused care. There is apparently no indication from the records in the case that the patient refused care. If Dr. Timm's claim is true, considering the likelihood of a myocardial event, documentation of the refusal of care and the disposition against medical advice should have been crystal clear in the record. When looking at this chart, there should have been no doubt in anyone's mind that this patient had a normal mental status, understood the risk of leaving, including death, and after having had an opportunity to ask questions, decided to leave the department anyway.

The against medical advice defense works. However, the emergency physician must support it with excellent documentation. The higher the risk, the more important the detail of documentation.


The chart should then reflect the fact that the patient has received all treatment and management possible within the parameters of the patient's decision. Efforts should be made to assure expeditious follow-up. An effort should be made to discuss the case with the private physician. Perhaps that physician can alter the AMA decision.

It is helpful to include specifics about the patient’s medical condition in the note, and the rationale for leaving. For example, in the chest pain patient, the EP may note an explanation to the patient regarding the possibility of a heart attack, irregular heart rhythm or other heart problems, and that this occurs so quickly, there may not be adequate time to return to the hospital for treatment.