EDs Can Make Discharges Against Medical Advice Safer
By Stacey Kusterbeck
There is a lack of evidence in the literature regarding effective interventions to prevent discharge against medical advice, according to a review of studies from 1989-2022.1 “Discharge against medical advice is common and can result in serious health outcomes, including higher mortality and readmission,” warns Ho-Man Yeung, MD, one of the study authors and an assistant professor of medicine at Temple University.
There is no predictive tool available for physicians to identify patients at risk for discharge against medical advice. “The medical field has relatively few tools they can use. By the time a patient decides to leave the hospital, there is little a physician can do,” Yeung laments. For ED leaders, it is important to consider contingency planning for patients at risk of discharge against medical advice. The goal is to make the discharges as safe as possible. “Discharge against medical advice should be a shared decision,” Yeung says.
Emergency care providers should discuss prescriptions, follow-up appointments, and red-flag signs that indicate patients should return to the ED — just as they would with any patient about to be discharged from the department. Diuretics, analgesics, antibiotics, antihypertensives, and diabetic medications can be given before the patient leaves.
“The idea here is that although patients may choose to leave, it is still a physician’s responsibility to ensure the patient has enough medication to make it to their next doctor’s visit,” Yeung says.
Some providers contend they are not obligated to provide prescriptions or appointments because the patient “refused” medical care by choosing to leave the ED. Yeung believes a change in mindset is required.
“It is the responsibility of all healthcare team members to improve this aspect of care,” Yeung says.
In Yeung’s view, the often-used term “leaving against medical advice” is itself problematic because it does not imply any shared decision-making between patient and physician. Thus, it removes responsibilities from the physician. Yeung prefers to use the term “high-risk discharge.”
“Recognizing a discharge as higher risk would encourage physicians and care providers to engage in risk assessment and risk reduction,” Yeung asserts.
REFERENCE
1. Foster K, Caswell A, James L, et al. The risk factors, consequences, and interventions of discharge against medical advice - A narrative review. Am J Med Sci 2023;366:16-21.
Recognizing a discharge as higher risk could encourage physicians and care providers to engage in risk assessment and risk reduction.
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