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Rounds in the General Hospital

Prior Discharges Against Medical Advice and Withdrawal of Consent: What They Can Teach Us About Patient Management

Lessons Learned at the Interface of Medicine and Psychiatry

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Mr Stern is a research assistant in the Department of Psychiatry at MGH. Dr Silverman is a clinical fellow in psychiatry at Harvard Medical School (HMS) and a fellow in addiction psychiatry at MGH and McLean Hospital. Dr Smith is the director of the Acute Psychiatry Service at MGH. Dr Stern is chief of the Psychiatric Consultation Service at MGH and a professor of psychiatry at HMS.

Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker’s board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Silverman and Smith and Mr Stern report no financial or other affiliations relevant to the subject of this article.

Corresponding author: Theodore A. Stern, MD, Department of Psychiatry, Massachusetts General Hospital, Fruit St, WRN 605, Boston, MA 02114.

Prior Discharges Against Medical Advice and Withdrawal of Consent: What They Can Teach Us About Patient Management

Have you ever had a patient who bolted from the operating room or a procedure suite, despite the fact that the planned procedure was of vital importance? Have you wondered if there was a relationship between a prior discharge against medical advice and a patient’s current behavior? Have you ever considered how you might manage a patient’s fear of procedures or loss of control?

If you have, then the following case vignette should serve as a stimulus for the tactical evaluation and management of patients who have precipitously refused interventions or left the hospital prematurely.

Every clinician who performs procedures has encountered a patient who withdraws consent at the eleventh hour. For some of these patients, their treatment refusal has been presaged by prior discharges against medical advice or by last-minute cancellations of procedures. Although few clinicians routinely inquire about a history of against medical advice discharges or abrupt refusals of procedures, this knowledge of why a patient has left the hospital or has refused procedures in the past may guide future care and management of patients.

Discharges against medical advice, defined as patient discharges from the hospital or health care facility before the treating physician recommends discharge, have emerged as a pervasive problem in general hospitals. Such encounters often lead to frustration and resentment on the part of clinicians and poor outcomes and worsening health for patients. In this article, we present a case vignette to illustrate an example of a discharge against medical advice, discuss the known characteristics and prevalence of such discharges, and highlight our management of the presented case as a guide to help clinicians with similar encounters.

CASE VIGNETTE

Ms A, a 52-year-old woman with peripheral vascular disease and posttraumatic stress disorder (PTSD), was admitted to the hospital for an aortobifemoral bypass graft to relieve worsening claudication and difficulty with ambulation. Four months earlier, she had been hospitalized for a similar problem. During this previous admission, she left the hospital against medical advice in a precipitous manner. Preoperatively, following administration of an intravenous anesthetic, a staff member in the operating room removed Ms A’s underwear in order to place a catheter. The feeling of her underwear being pulled off triggered a flashback of a sexual assault that Ms A had sustained at the age of 21 years. She became verbally aggressive toward staff and demanded to abort the procedure and leave the hospital.

In a preoperative psychiatric consultation during her current admission, Ms A understood the need for the procedure but felt apprehensive about it given her previous experience. She was looking forward to having less pain and better function, and she wanted to be able to care for her aging parents, rather than to have them care for her.

Ms A described bouts of depression after her sexual assault that were partially ameliorated by antidepressants, as well as anxiety with panic attacks that typically resolved with diazepam. Shortly after her sexual assault (when “beaten and raped”), she had nightmares but denied flashbacks, avoidance, or dissociation.

The psychiatric consultation team determined that Ms A would benefit from being better informed about, fully prepared for, and in control of her preoperative routine. She was allowed to remove her own undergarments on the more familiar inpatient floor, and her family was made available to her upon awakening in the postoperative suite. The surgical procedure was successful, and Ms A avoided a psychological crisis.

Clinical Points

  • Discharges against medical advice, defined as patient discharges from the hospital or health care facility before the treating physician recommends discharge, have emerged as a pervasive problem in general hospitals.
  • Patients withdraw consent for both routine and potentially life-saving procedures and leave the hospital against medical advice for both medical and social reasons.
  • Patients who leave the hospital against medical advice represent an at-risk group for greater morbidity and mortality, as well as for readmission.

REASONS WHY PATIENTS WITHDRAW CONSENT OR LEAVE THE HOSPITAL Against Medical Advice

Patients withdraw consent for both routine and potentially life-saving procedures and leave the hospital against medical advice for a number of individualized and varied reasons. Studies have shown that patients may withdraw consent and leave the hospital for both medical and social reasons (including personal, family, or financial issues; conflicts with staff; dissatisfaction with hospital care, environment, or treatment interventions; and misunderstandings based on underlying medical, cognitive, and psychiatric issues).1-13 Examples include illness or death of a relative; reconciliation with a spouse or family members; a wish to attend to affairs outside of the hospital (eg, going to work, caring for children, addressing financial problems, or attending to legal issues, such as a court date); dissatisfaction with hospital milieu, staff, or specific treatments provided; a lack of interest in treatment or perceived improvement in illness; and organic confusion. Multiple studies have shown higher rates of discharge against medical advice on the day that public assistance or welfare checks are available, underscoring the importance of financial issues as reasons for patients to leave the hospital.6,8

As an example of organic confusion, one man who refused a life-saving liver transplant had cognitive impairment associated with metabolic abnormalities due to renal and liver dysfunction. Another, who demonstrated an inability to complete simple tasks (including, but not limited to, reciting the months of the year backward and naming simple objects), gave his medical team concern about his mental capacity.14 Sudden cancelled consent by an elderly patient with senility should also raise concerns; a month after being deemed to have intact decision-making capacity (by a psychiatric consultant during a lucid period), an 88-year-old woman with mild Alzheimer’s disease gave consent for a carotid endarterectomy. However, the following morning, she became agitated and adamantly refused surgery upon her arrival in the operating room.15

The mental status of medical and surgical inpatients is of paramount importance, as informed consent prior to a procedure serves as the cornerstone of ethical practice; it enshrines respect for a patient’s autonomy.16 If an adult is of sound mind, he or she has the right to determine what shall be done with his or her body.17 Patients with underlying medical, cognitive, or psychiatric issues as described above, however, often lack the capacity to consent to, or refuse, interventions. As their mental status fluctuates over time, such patients may agree to a procedure (having the capacity to consent for the procedure) at a given time but then withdraw their consent at a later time.

CHARACTERISTICS OF PATIENTS WHO LEAVE THE HOSPITAL Against Medical Advice

Studies have examined patients who left the hospital against medical advice after hospitalization for a number of different conditions (eg, asthma,11 pneumonia,18 cardiac disease,19-23 inflammatory bowel disease,24 labor and delivery,25 HIV infection,6,8 and substance abuse4,5,26-28) in varied settings (eg, in the general emergency department29,30; on a medical floor,1,7,31-39 pediatric unit,10,13 or psychiatric ward40-42; and throughout the hospital2,3,43). A number of reviews have summarized different aspects of this literature.44-48

Several predictors of discharge against medical advice have been repeatedly identified. Patients who have left the hospital against medical advice tend to be younger,2,3,7,8,11,18,19,22-24,27,32,37-39,42,49 to be male,2,3,7,11,18,22-24,32,35,37-39,42,43,49 to have Medicaid or to be uninsured,11,18,22,24,25,28,29,32,35,37,39,43 to come from a lower socioeconomic class,11,22,25,32,39,50 and to have a history or a current pattern of substance or alcohol abuse2,3,6-8,18-20,24-26,31,32,35,38,41,43,49,50 or other psychiatric problems.2,3,7,19,24,25,38 Repeatedly, current or past drug or alcohol problems have been consistently linked with leaving the hospital against medical advice. Other predictors have included the lack of a primary care physician,51 an increased severity of medical problems,11,18-20,25 living alone, and a higher number of hospital admissions.41 Against medical advice discharges are also associated with shorter hospital stays, as would be expected by their premature endings.3,19,22,24,38,39,41,42

The role of race and ethnicity as predictors of discharge against medical advice has been debated in the literature. A number of studies have suggested that nonwhite race is associated with a higher likelihood of such discharge.8,18,22-25,28,32,39,41,43,50,52,53 For example, in an analysis of 3 years of hospital data, Franks and coworkers53 found that black patients, when compared to white patients, showed a 2-fold higher age-gender adjusted odds of discharge against medical advice. The authors concluded, however, that with increasing adjustment for confounding variables, such as sociodemographic factors (including insurance type, degree of morbidity, and hospital of admission), this increased risk progressively diminished. At the same time, the study revealed that minorities were more likely to be admitted to hospitals with higher against medical advice discharge rates, a factor that has been described as “structural racism.”53 Hospital characteristics, such as quality, appear to mediate the relationship between race and such discharges, eg, nonwhite race has been associated with lower rates of against medical advice discharge at low-quality hospitals.23 One significant factor mediating race as a risk factor for against medical advice discharges might be related to impaired doctor-patient communication when clinicians and patients have discrepant cultural backgrounds.

In sum, against medical advice discharges often involve complex matters (eg, doctor-patient communication, informed consent, and underlying medical and psychiatric issues; Table 1).

Table 1

Click figure to enlarge

PREVALENCE AND OUTCOMES OF DISCHARGE Against Medical Advice

Against medical advice discharges from hospitals generally account for 0.3%-2.1% of hospital discharges from medical floors.7,11,19,35,36,38,39,43,50,52 In an analysis of a nationwide database of over 3 million discharges from acute care hospitals, Ibrahim and associates39 found a against medical advice discharge rate of 1.4%, or approximately 1 in 70 hospital discharges. Rates of against medical advice discharge vary with different patient populations. Studies have shown rates as low as 0.1% in the postpartum population25 and as high as 24.9% on a specialized HIV/AIDS ward.8

Patients who leave the hospital against medical advice represent an at-risk group for greater morbidity and mortality, as well as for readmission.50,54,55 In a study of 97 consecutive general medical inpatients, those who left the hospital against medical advice were 7 times more likely than were those who did not to be readmitted within the next 15 days (21% vs 3% rates of readmission).55 Moreover, patients who leave hospitals against medical advice are typically readmitted with the same diagnosis and often have worsened pathology since the previous hospitalization (leading to longer lengths of hospital stays in the follow-up admission).6,11,22

IMPACT OF PRIOR DISCHARGES AGAINST MEDICAL ADVICE ON RATES OF CONSENT AND REFUSAL

No literature has prospectively studied the impact of past against medical advice discharges on future consent or rates of treatment refusal in the general hospital. Retrospective studies have shown that a history of discharges against medical advice increases the likelihood of such discharges and withdrawal of consent due to repeated patterns of interactions in the general hospital.4,19,23,32,38,51 After controlling for the number of previous hospital admissions, Onukwugha and associates23 found the risk of discharge against medical advice in a current hospital admission when a prior admission ended in such a discharge to be 10 times higher than that of the comparator group. In their community hospital experience, Seaborn et al38 found that 28.6% of patients leaving the hospital against medical advice had such a discharge previously.

PTSD as a Risk Factor for Discharge Against Medical Advice in the General Hospital

As in the case of Ms A, a patient’s underlying psychiatric condition might be directly linked to him/her leaving the hospital against medical advice. As an example, events in the hospital course of Ms A triggered her PTSD symptoms, precipitating her demand to leave the hospital. PTSD is an anxiety disorder that may develop in patients of any age following their experiencing (or witnessing) a dangerous event (eg, war, physical or sexual assault, abuse, accidents, disasters). Symptoms of PTSD in general hospital patients typically involve re-experiencing (eg, flashbacks, bad dreams, frightening thoughts), avoidance (eg, staying away from places that remind one of the experience, feeling emotionally numb, losing interest in previously enjoyed activities), and hyperarousal (eg, being easily startled, feeling tense, having difficulty sleeping, having angry outbursts) that may interfere with planned medical care.56

Managing patients with PTSD involves multimodal care. A key to successful treatment is early detection of the disorder.57 Once a diagnosis has been made, a 3-pronged attack comprised of therapy, medication, and social support is recommended. Counseling and therapy include involvement in a learning program that helps the patient cope with his/her traumatic event and memories, while medications (often an antidepressant) help to minimize neurovegetative symptoms and ameliorate reactions to the trauma.

A variety of approaches can reduce the suffering of those afflicted by PTSD; maintenance of privacy, safety, and open (bidirectional) communication are of paramount importance. In addition, it is crucial to validate the victim’s emotional reactions, which may be painful and intense. The caregiver should minimize the emphasis placed on clinical terms and pathologizing language and communicate on a person-to-person basis. Those caring for afflicted individuals should also encourage patients to attempt to follow normal routines, to find familiar methods of relaxation, and to manage (often with professional help) the people, places, and situations that remind them of the traumatic event.

CONCLUSIONS

Our patient, Ms A, had a host of factors associated with sudden withdrawal of consent and discharge against medical advice; these factors (eg, PTSD, impaired doctor-patient communication, prior against medical advice discharge with associated withdrawal of consent) when appreciated and handled allowed for her effective management and successful surgery. Recognition and treatment of intense anxiety (eg, in the case of Ms A, precipitated by a sexual trauma and triggered by in-hospital disrobing) are predicated upon knowledge of the patient’s medical and psychiatric history, enabling comprehensive and compassionate care to be administered. We recommend that all clinicians inquire into previous discharges against medical advice and withdrawals of consent when admitting and caring for patients in the general hospital.

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