The nurse messaged me: “Patient is walking off the floor.” I let out the breath I had been holding all day. I had spent the majority of the afternoon negotiating with a patient who insisted on leaving the hospital despite having a chest tube. With an open mind, I had inquired about why they felt this strong need to depart and what I could do to make them comfortable enough to stay. Finally, we had settled on the compromise that I would ask the pulmonology team to pull the chest tube out. In the meantime, I would work on the patient’s discharge paperwork so they could leave before the evening sign-out. Yet, 10 minutes after the chest tube was pulled, as I was completing the discharge orders and tending to other patients’ needs, the patient left the hospital. I had a mixture of conflicting emotions: relief that I could finally provide adequate attention to other patients on the floor, frustration that the patient had disregarded my request to stay until discharge, and worry that the patient would be readmitted or experience complications due to leaving. Of course, there was also the pressing matter of documentation.
There is a general pattern to how patients leave in this manner. When a patient first expresses a desire to leave despite recommendations to stay, it is considered an “early-warning interaction.” They often tell a nurse first, who usually notifies the patient’s primary team. At this juncture, the primary team communicates with the patient to understand the rationale behind leaving. When there is concern about the patient’s capacity to make decisions, a capacity instrument is used to document the patient’s ability to make this decision. If the patient demonstrates capacity and can understand the consequences of discharging early, they are free to leave, and the clinician must document their discharge details.
The language surrounding an early departure is not standardized. One 2023 article analyzing the documentation of these discharges suggests they are divided into two groups: “against medical advice” discharges when a patient interacts with the health care team before they leave, and “elopements,” when the patient departs without notifying the team. These terms are used interchangeably in documentation, and it can be difficult to discern the difference in some cases. My patient had many early-warning interactions the day they left. Some patients have early-warning interactions multiple days before discharge, which are not always documented. Other patients do not have any early-warning interactions. Discharge documentation also varies in terms of details included, such as whether the patient leaves with a peripheral IV still in place.
Leaving the hospital before completing treatment poses many risks. This type of discharge is associated with higher readmission rates, increased resource utilization, and worse patient health outcomes. Because of this, clinicians can feel frustrated when patients leave early — especially when they become verbally or physically aggressive to their team. I often come across social media memes from health care personnel about patients leaving against medical advice; it’s recognized in the clinician community that there’s an exhaustion inherent to trying to do the best for patients who do not always understand your viewpoint. (These memes are not made with malicious intent, but rather to express exasperation.)
Though these situations can be demanding, a shift in perspective can help to reframe these discharges. Many patients face systemic and/or socioeconomic challenges contributing to their desire to leave. These can include financial issues, lack of insurance, previous experiences of medical mistreatment or discrimination, a history of trauma, caregiver responsibilities, and substance use. This is a non-exhaustive list, and the desire to discharge early is frequently multifactorial. With this in mind, there is a new movement in medical education that aims to use less stigmatizing documentation language for these discharges.
Though we may not realize it, the current framing of premature discharge pits us against patients. The phrase “against medical advice” implies that patients decide to leave intentionally in opposition to their clinician’s recommendation. Documentation using “against medical advice” damages future therapeutic alliances and facilitates bias in future clinicians. To better support patient autonomy, some recommend using the phrase “patient-directed discharge.” However, this implies that the patient alone is responsible for their discharge. One term that imparts less blame to the patient and still communicates the risks of this discharge is “before medically advised.” These changes are steps in the right direction, though none of these phrases acknowledge the systemic contributions leading to departure. It is possible to address the systemic issues the patients face without the overwhelming pressure of solving the historical and structural effects of medical bias, racism, and policy. To do this, we must document in a way that humanizes and contextualizes patients’ individual experiences.
One could dismiss this discussion as being too scrupulous about semantics. However, inaccurate and ineffective documentation has downstream effects on patient harm, clinician bias, and malpractice. Medicine has begun to modify language in other documentation. One example is naming barriers like cost or lack of transportation that prevent a patient from following treatment, instead of describing patients as “noncompliant” or “nonadherent.” Early discharge documentation should be similarly adjusted and standardized to include the patient’s rationale when possible. Unfortunately, this places the onus of additional documentation on clinicians who are already stretched thin by limited time and billing requirements. It also necessitates a shift away from medical paternalism, which is an ongoing slow process. Despite these hurdles, destigmatizing language could be one step in the journey to prevent compassion fatigue and ultimately reduce negative health outcomes.
As an early intern, I am reconciling my medical school optimism with an emerging residency cynicism. Amid difficult training and an overburdened health care system, it is easy to find myself standing on the opposite side of patients instead of next to them. But the simple truth is that my patient left to support their loved one who was also hospitalized. No amount of discussing the intricacies of their hospitalization could have convinced them to stay. And under similar circumstances, I might have done the same.
I am not a warden — just a doctor attempting to hold onto my empathy.
How do you keep your emotions in check when a patient leaves before medically advised? Share in the comments.
Dr. Brinda Sarathy is a family medicine resident at the University of Colorado in Denver, Colorado. Within medicine, she is passionate about gender-affirming care and reproductive health access. In her free time, she enjoys running, hiking, listening to obscure podcasts, and cooking new recipes. Dr. Sarathy is a 2024–2025 Doximity Op-Med Fellow.
Image by mouu007 / Getty
