An appropriate AMA often leads to a defense verdict.

Legal cases demonstrate that the AMA note can provide significant protection in cases where patients clearly have a normal mental status, the physician has respected the individuals personal rights to make a decision regarding health care and every effort has been made to provide a continuum of health care. In the following cases, the AMA defense proved successful.

Case # 4 MI AMA

The patient, a retired man, went to the emergency department with complaints of pain in his chest. The defendant EP performed an EKG, which was not diagnostic and told the patient that he should be admitted for further testing. The decedent went home and died of a heart attack ten days later.

The plaintiff alleged that the physician failed to diagnose the decedent's heart condition in the ED. The EP contended that he had advised the patient to stay in the hospital for further testing and that his refusal to do so was the cause of the failure to diagnose.

The jury returned a verdict for the defendants.

Case Commentary

When a patient leaves the emergency department, is competent, and understands the risks of leaving, then he assumes the risk of leaving. With a good defense team, the jury will recognize this fact and will support the physician.

Case # 5 MI AMA

Ms. Ballard was a forty year old bartender. She reported to the defendant hospital's emergency department with complaints of chest pain associated with shortness of breath and vomiting, but was not in acute distress. The defendant, Dr. Wesley Curry, monitored her for two hours and recommended that she be admitted to the hospital, as he was unable to rule out heart problems. Ms. Ballard's discomfort subsided, and she declined admission. The woman's family reported thereafter that she appeared "under the weather" but offered no specific complaints. Ms. Ballard was found dead two days after her visit to the emergency department.

The plaintiffs contended that the defendant doctor failed to appreciate that his patient was severely ill; that he did not perform a proper work-up to determine the cause of her problems; that he changed his mind about admitting her, believing that her problems were due to an upset stomach; and that he should have told her she would die if she were not hospitalized.

The defendants contended that their treatment was within the standard of care; that Dr. Curry properly recommended hospitalization because he could not rule out heart problems; that the patient's examination was negative for any life threatening process; and that the decedent refused admission against medical advice after being properly informed of all pertinent facts.

Reportedly, the plaintiffs demanded $100,000 before trial, but the defendants made no offer.

A verdict was returned for the defendants.

In this case the patient’s AMA decision appears to be related to her improved condition. The patient “felt better” and decided to go home AMA. The patient alleged that she was not informed about the severity of the medical problem, and she was not told that she might die. Make sure that the patient understands the potential severity of the disease process. It is not necessary to scare a patient with a non-critical medical problem into staying in the ED by overstating the potential complications of the condition. However, this was a ‘chest pain’ case, and the physician should be very clear that the downside is severe disability or death.


Case # 6 Appendicitis, AMA

The patient was a 28 year old tailor and an illegal alien who presented at the defendant Santa Monica Hospital. He was seen by the emergency physician in the emergency department. The patient complained of stomach pain and nausea. the emergency physician made an initial diagnosis of gastritis and ordered a lab work up. The patient however, refused further examination and testing and left the hospital. He was advised by the emergency physician to return or go to a clinic if his pain worsened. Two days later, the patient presented himself to another hospital and underwent surgery for a ruptured appendix. Janzen, Johnston and Rockwell, the third defendant, is a medical group in which the emergency physician is a member.


The patient alleged that the emergency physician was negligent in failing to diagnose appendicitis and that the hospital and the medical group were vicariously liable. The plaintiff suffered prolonged hospitalization, post-appendectomy and scarring of the abdomen and residual pain. The defense contended that the diagnosis was appropriate in light of the fact that the plaintiff refused further evaluation and testing.

According to reports, a defense verdict was obtained.

Case Commentary
This is a typical 'against medical advice' case. The patient has a serious medical problem but left the emergency department prior to complete evaluation and management. The emergency physician should not be held responsible for any injuries which result. Note that even though the patient refused further treatment, the emergency physician provided the patient with complete discharge instructions. The EP should not react to the AMA decision with anger. Continue to provide the best possible care under the circumstances.


A Common AMA Allegation: The patient did not understand the potential severity of the medical condition

The plaintiff will commonly allege that the physician failed to explain: the severity of the patient’s condition; the risk or potential for medical complications, disability or death; or the nature of the “against medical advice” discharge. Before a patient leaves the ED, the EP must explain, in detail, the potential for serious complications, including disability and death. In order to meet this obligation, the EP should simply explain, and document, the nature of the patient’s condition, and that leaving AMA may result in medical complications, serious disability or death. The EP should also make sure the patient understands this risk, and give the patient an opportunity to ask questions about it. The EP can greatly minimize the risk of exposure to liability by following these steps.

Case # 7 Pulmonary Embolism post Trauma, AMA Claim that patient did not know the serious nature of problem.


Mr. Dick was initially admitted to the Spring Hill Hospital for injuries including a fractured right leg and a concussion received in an automobile accident. He was discharged on March 9th but returned to the hospital on the evening of March 10th because of pain in the left leg. Defendant Dr. Ennis examined Mr. Dick and diagnosed phlebitis, prescribed pain medication, ordered hot compresses and directed the patient to contact his orthopedist in two or three days. Dr. Ennis also discussed with the patient the possibility of a blood clot and recommended hospitalization. The patient left the emergency department against Dr. Ennis' advice.

The patient left the emergency department only to return again the following evening by ambulance after he had collapsed at home. Ennis once again rendered treatment. However, the patient suffered respiratory and cardiac arrest and died, a pulmonary embolism was the cause of death.

The plaintiff alleged that had her husband been informed of the serious nature of his condition and his need for immediate hospitalization, he would not have left the hospital against Ennis' advice. The defense moved for summary judgement on grounds that he had advised the patient of the possibility of a blood clot and recommended hospitalization. The trial court granted the motion on the grounds that the plaintiff had produced no evidence that the patient was not so advised. The judgement was affirmed on appeal and the court noted that even the plaintiff's expert had acknowledged that he would find no fault if Ennis had in fact informed the patient of the risks but had simply failed to note it in the record.

AMA Transfers

Case # 8

The plaintiff claimed that his son, age nineteen, had been involved in a serious car accident and was taken to St. Anthony's Medical Center. Dr. Daniel O'Sullivan was the on-call trauma surgeon. He treated the son and inserted a chest tube. The family insisted that the patient be transferred to St. Louis University Hospital despite being informed that a transfer could be life threatening. The transfer was performed against medical advice. The chest tube was replaced upon arrival at St. Louis University Hospital and surgery was begun. The son died during surgery.

The plaintiff contended that St. Anthony's physicians should have inserted the first chest tube in a more timely manner. Dr. O'Sullivan was voluntarily dismissed prior to the close of the plaintiff's case. The plaintiff claimed that St. Louis University Hospital should have taken the patient to the operating room immediately upon arrival, and that he had been improperly intubated, allowing the ET tube to come out of the trachea for an undetermined period of time.

St. Anthony's claimed that the decedent should have been left at their hospital and that he might not have survived regardless of the transfer. St. Anthony's also claimed that the chest tube was inserted in a timely manner. St. Louis University Hospital alleged that everything that could be done for the decedent was done; that the patient needed stabilization in the emergency department before taking him to the operating room and that the decedent initially responded to treatment but began to deteriorate, requiring surgery.

Reportedly, the jury rendered a verdict for the defense.

Case Commentary

Once again, a properly executed AMA document works in court. In the days of COBRA, pay special attention to documentation of informed refusals of care.


AMA and Medical Insurance Benefits

Many health insurance contracts contain a provision whereby insurance benefits are forfeited if the patient signs out of the hospital AMA. That information may weigh in the patient’s decision to leave against the EPS advice.

Case # 9

Ms. Loretta Long was hospitalized after experiencing GI problems. She was covered under a group health insurance plan carried by her employer with the Arkansas Blue Cross & Blue Shield. After she was hospitalized for eleven days she was told she would be released if, on the next day, her temperature was normal. The next morning her temperature rose and the doctor declined to release her, but she insisted on being discharged because of the expense and because she had a child at home. She was discharged, but only after signing an "Against Medical Advice Release" form.

Arkansas BC/BS denied payment for all costs of treatment, including those incurred prior to the discharge, because the plan excluded from coverage "benefits provided for inpatient services where you terminate such inpatient admission against medical advice.”


The quality of medical care may influence the outcome of AMA litigation

Case # 10

The patient was under a physician's care for ten years for hypertension. One morning the patient awoke with a pain between his shoulder blades. His wife took his blood pressure and it was 180/120. She called his physician and took him to the defendant, Queen of the Valley, emergency department. The plaintiff explained to the emergency department staff that she felt her husband was having a heart attack. After waiting over one hour, she asked the defendant supervising nurse to see her husband and told the nurse of her belief he was having a heart attack and also reported her blood pressure findings. The triage nurse informed the patient that his blood pressure was no longer that high. Triage records reflect "history of high blood pressure, pain in upper back between shoulder blades this a.m. - radiates to left shoulder, no known injury. Blood pressure 160 over 106. Medications: normaldine."

The patient insisted on going home. There was a dispute as to when exactly the patient had arrived at the emergency department. The plaintiff had been told an EKG would be performed and there would be an indefinite time before a doctor could see him. The patient left against medical advice. He subsequently had an MI.

The plaintiff contended that the triage nurse was negligent in not recognizing the cardiovascular complaints. The pain, the history of hypertension and the blood pressure of 180/120 indicated an acute heart condition. The defendant alleged that the patient's signs and symptoms were not cardiovascular in origin, and that the decedent was at fault for leaving against the defendant's advice. It was also noted by the defense that the decedent signed an AMA form stating that he was "leaving against medical advice."

According to reports, the jury found the plaintiff 20% negligent and returned a gross verdict of $409,360 and a net verdict of $327,488.


Case Commentary

I believe in this case that the jury found fault with the management of the case by the hospital and nursing staff and the physician group wound up 'along for the ride'. The triage nurse should appreciate that a patient with a history of hypertension who had back pain that radiated into the left arm could be a cardiovascular problem. Then nurse should have provided for a prompt EKG and physician evaluation.

With the increasing use of thrombolytic therapy, the 'window of opportunity' is decreasing and emergency departments are providing more rapid care for potential cardiac patients. There is a changing standard of care in this area. Perhaps if this patient had been seen expeditiously, and then decided to leave against medical advice, the jury would have found for the defendant.