“Is this considered leaving against medical advice?” The intern on our team asked quizzically after our patient walked out of the room. The patient had said she could not stay in the hospital and would call her doctor tomorrow. Her son would be coming home from school in an hour and she had no one to watch him that night.
I could tell the intern was racking his brain for the definition of leaving against medical advice — its diagnosis and illness script, potential treatment options and complications. Of course, he is not alone in asking this question. Unlike other areas of medicine, there are no strict criteria for what medical advice is, and what defines an act against it. Ultimately, the patient’s physician often has to define, and, more importantly, decide how to manage care.
Much has been written regarding the care of patients who leave against their physician’s medical advice. In a 2013 JAMA viewpoint article, Drs. David Alfandre and John Schumann review and debunk the many myths surrounding making decisions against medical advice. Despite this article being almost 10 years old, these long-held myths persist, and continue to influence clinical practice and hospital policy.
With continued advances in 21st century medical care, the idea of leaving against medical advice has become particularly anachronistic. Technological advancements are moving medical care away from the hospital. Much of what traditionally required inpatient monitoring is now moving to clinics, homes, and even our patients’ phones. Patients can check their vitals regularly, receive IV medications, and have follow-up appointments without leaving their house. The increase in availability of new oral medications and long-acting injectables, along with the expansion of personal medical technology, telemedicine visits, outpatient infusion centers, and home care services are all redefining what it means to require inpatient care.
With these developments, a patient’s request to leave the hospital against medical advice is no longer a rebellion against the medical establishment. It has become, instead, an opportunity to discuss how the patient can take control of their own health moving forward. Ultimately, isn’t this the goal of our medical system? By changing how we view patients who ask to leave against medical advice, we can create more personalized and relevant plans for their health. As we move away from the paternalistic treatment of our patients — requiring “compliance” toward the shared decision-making model — we can move toward making the decision to continue care in the hospital together with the patient.
To be sure, there are certainly patients who are in acute danger when leaving the hospital untreated. For these patients, these alternative options should not replace a discussion of frank medical concerns and risks of leaving the hospital. We can, though, offer anything that will provide significant risk reduction for this discharge, and potentially open up opportunities to follow up more fully with medical care in the future. There are also patients who, because of their medical or social conditions, cannot access the care necessary to safely utilize some of these outpatient options. This must be taken into account when planning with our patients. These limitations should not, however, prevent us from encouraging our patients to take ownership of their health.
This mindset has affected how I treat all my patients, not just the ones asking to leave. I’ve increased my focus on ensuring my patients have primary care doctors and follow-up options when they leave the hospital. I’ve learned about the resources both in the hospital system and broader community that I can use to assist my patients' care, including medical transportation options, social services, apps, and even online videos. I’m continuing to work to keep up to date on indications for oral medications and new long-acting treatments. I’ve also simplified my discharge paperwork to give clear instructions and information to my patients.
For the patient who had walked out of the room that day, we were able to get in touch with her primary care doctor’s office to discuss her hospitalization as well as to order follow-up labs. With this new outlook, I feel more like a partner with my patient rather than an authoritarian, and I no longer feel like I’m giving “medical advice,” but rather, better medical care.
What has been your approach to patients leaving against medical advice? Share your experience in the comment section.
Ian Gleaner is an attending internal medicine physician and instructor of medicine at Cooper University Hospital and Cooper Medical School of Rowan University. His interests include medical education, exploring the physician-patient relationship, and medical ethics.
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