4 Ways to Mitigate Discharges Against Medical Advice

Approximately 500,000 hospital discharges each year, or 2 percent of inpatient admissions, happen against medical advice. Readmission rates for these patients are between 20 and 40 percent higher than patients who wait for permission to be discharged, and 30-day mortality is significantly higher. However, there is no professional or clinical consensus about what it means to be discharged against medical advice, according to David Alfandre, MD, and John Henning Schumann, MD, in their recent JAMA Viewpoint article.

This lack of consensus and the designation at large create communication issues, which may lead to a stigmatizing effect on patients, who may be less likely to return for needed care. In short, the viewpoint authors noted the "against medical advice" designation has no real usefulness in patient care and may be clinically, as well as ethically, problematic.

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To avoid early discharge or to mitigate its associated health risks for patients, Dr. Alfandre and Dr. Schumann suggested the following:

1. Consider the role physicians and care teams may play in early discharge. While patient factors have traditionally been the primary factors studied in discharges against medical advice, newer evidence suggests the situation may be more complex.

2. Adopt a shared decision making mindset. "Accepting an informed patient's values and preferences, even when they do not appear to coincide with commonly accepted notions of good decisions about health, is always part of patient-centered care," the authors wrote.

3. Be aware of the importance of physician-patient communication in patient acceptance of inpatient care. How physicians interact with patients in the case of a disagreement surrounding the necessity of further care may make all the difference. Counseling should be employed, rather than threats.

4. Acknowledge the possibility of an "acceptable, not ideal" outcome. "Accepting a patient's preferences for care, even when such preferences deviate from the physician's own judgments can still be acceptable, if not ideal," the article stated. If it is impossible to convince a patient to stay, the authors asserted the medical professionals must be supportive, rather than combative.

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