If a patient wants to leave the hospital against medical advice (AMA), a central ethical consideration is whether the patient can make this decision. “Decision-making capacity is central to a lot of clinical ethics cases, but it is particularly important regarding patients leaving AMA,” says Tyler S. Gibb, JD, PhD, who co-authored a paper on this topic.1
Generally, these cases occur in the ED or after patients are admitted to the hospitalist or internal medicine services. “Clinicians seem to be comfortable with restraint application and preventing patients from leaving the hospital when the patient clearly lacks decision-making capacity,” says Gibb, a clinical ethicist and co-chair of the department of medical ethics, humanities, and law at Western Michigan University Homer Stryker M.D. School of Medicine.
The situation becomes ethically complex if the patient’s capacity is unclear, ambiguous, or fluctuating. “It is much more difficult to know if, when, and how to avoid inflicting harm while balancing the patient’s legal and ethical right to make their own decisions,” Gibb says.
If healthcare providers inappropriately prevent the free movement of patients, they are, in essence, kidnapping or detaining these patients. “Fundamental liberty interests are often ignored and/or minimized in these situations,” Gibb warns.
Clinical ethicists can help develop policies and provide education for units or service areas more likely to be faced with patients leaving AMA. Although it is becoming more common for incapacitated patients to attempt to leave the hospital AMA, “there is not a consistent practice of how these situations are handled across the country, or across states for that matter,” says Chelsey Patten, DBe, HEC-C, manager of clinical ethics at Novant Health.
Patten co-authored a literature review that demonstrated restraints, both physical and chemical, are overused and used inappropriately.2 “Those of us entrenched in ethics work are aware of well-intentioned misuse,” Patten notes.
The findings caused the authors to question institutional policies, individual cases, hospital cultures, and even the most well-intended decisions made by clinicians about restraint use. “People are allowed to make ‘bad’ decisions,” Patten says.
When consulted about a patient who lacks decision-making capacity and who wants to leave the hospital, the first question ethics often ask is, “Why do you believe the patient lacks decision-making capacity to leave AMA?” Providers might respond with a statement like, “Because it’s a terrible idea.” While it may be true, making what clinicians view as a “bad” decision does not inherently mean the patient lacks capacity.
“The important point to remember when assessing capacity is that the ‘rightness’ of a decision a patient makes is less important than the process by which they come to that decision,” Patten explains.
As long as the patient understands the risks of and alternatives to leaving AMA, they can do so, even if clinicians believe it is unsafe. On the other hand, if the patient truly cannot appreciate the risk, then clinicians probably should consider if forcing continued hospitalization is appropriate.
Patten says it is important to identify the goal of keeping the patient hospitalized and consider if it is realistic. For instance, clinicians may believe a patient must remain hospitalized because it is unsafe to discharge them home. The recommendation is for the patient to be transferred from the hospital and placed at an assisted living facility. Clinicians may want to keep that patient in the hospital by restraining them. “However, requiring restraints will prevent a patient from being accepted at most facilities,” Patten notes.
Even if the patient is not restrained, but is adamant about wanting to return home, many facilities or transport companies will refuse to accept the patient in that circumstance. “These potential complications must be considered when determining the benefit of forcing continued hospitalization,” Patten stresses.
Clinicians must balance the risk of discharge against the risk of restraint use. “Potential harms associated with restraint use, such as malnutrition, bed sores, mental deterioration, worsening behaviors, feelings of fear and anger, or embarrassment due a perceived loss of dignity are well-documented,” Patten reports.3
If clinicians decide restraining the patient is not appropriate, there still may be an ethical obligation to help the patient. For example, clinicians can contact transportation, set up community resources, or provide medication refills. “Identify ways to set the patient up for success,” Patten adds.
REFERENCES
1. Gibb TS, Redinger KE, Barker H. Ethical restraint use with incapable absconding patients: Goals, proportionality, and surrogates. Am J Bioeth 2022;22:95-97.
2. Patten C, Chaucer B. When protection from risk-to-self causes harm: A brief analysis of restraint use to prevent elopement. Am J Bioeth 2022;22:97-100.
3. de Bruijn W, Daams JG, van Hunnik FJG, et al. Physical and pharmacological restraints in hospital care: Protocol for a systematic review. Front Psychiatry 2020;10:921
The situation becomes ethically complex if the patient’s capacity is unclear, ambiguous, or fluctuating. It is much harder to know if, when, and how to avoid inflicting harm while balancing the patient’s legal and ethical right to make their own decisions.
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