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The Ethics of Discharges Against Medical Advice

      Mr. G is ticked off. The 58-year-old man arrived at your facility about two days ago after a hospital stay for alcohol withdrawal and sepsis. Upon admission, you fielded several questions from him about how soon you would “let me out of here.”
      “This is not a prison, Mr. G. You can leave anytime you want,” you tell him. “But your family was hoping that you would stay until you’re able to get around your apartment safely. You also need to finish your IV antibiotics for your infection. I’m worried you might end up in the hospital again if you don’t.” He seemed fairly placated by this until today, when he was caught smoking in his room for the second time.
      This time, the administrator conducted a sweep of his room and took a half-pack of Winstons as well as Mr. G’s lighter, promising to return them at the end of his stay. “The end of my stay is right now,” says Mr. G, shoving his socks and underwear into a grocery bag. “I’m getting out of this hellhole, and I’m taking my smokes with me.” As you try to reason with Mr. G, the receptionist appears in the doorway, “Did someone order an Uber?”
      There are times when our skilled rehabilitation centers and long-term care communities simply don’t meet the expectations of our patients. Against medical advice (AMA) discharges occur only a minority of the time, but when they do, they always represent a crisis for the patient, family, facility, and provider. Ethically speaking, it confronts the provider with a potential conflict between two ethical principles: autonomy and beneficence. Should you step aside and allow Mr. G to get in that Uber (autonomy), or should you step in to provide the care you know he needs (beneficence)? My answer is a resounding yes.

      Autonomy

      As a modern health care professional you are obligated to recognize patients’ right to make decisions (good and bad) for themselves. Mr. G seems to be reacting to a situation in which his autonomy is being threatened. He’s being forbidden to practice a habit (smoking) that is a legal activity in all 50 states, he’s had his personal property confiscated, and he suspects you are trying to hold him against his will. It may seem counterintuitive, but the one thing that could most convince Mr. G to stay is letting him know he can leave.
      One of the primary things that drives people to leave AMA is the loss of control over their health (Acad Emerg Med 2014;21:1050–1057). Reassure Mr. G by telling him the truth: “You can leave anytime you want.” Then work to encourage him to stay by helping him regain control over his situation. How can you partner with Mr. G to maximize his autonomy? Perhaps there is some wiggle room in the center’s smoking policy. Can you allow him to smoke e-cigarettes? Can the facility designate a smoking area? (I do think that nonsmoking policies in nursing communities are one of the greatest violations of resident autonomy in the industry, but I digress.)
      One caveat: Mr. G’s decision’s must be informed, and he must have medical capacity. He must be able to appreciate his disease and the risks and benefits of treatment. He must also be able to express his decision about his care. This is all involved in assessing his medical capacity. Learn how to use a tool like the Joint Centre for Bioethics’s Aid to Capacity Evaluation (ACE) (available for free at http://www.jcb.utoronto.ca/tools/documents/ace.pdf), and document that your patient is capable of an informed decision. You can do this in 10 minutes or less, and it’s really helpful in case you’re threatened with legal action in the future.
      Let’s say you have established that Mr. G has medical capacity, you’ve reminded him that you will respect his autonomy, and you’ve expressed your concern for his health, but he still plans on leaving — right now, with his Winstons and lighter in hand. Everyone’s in a bit of a panic — you huddle with the unit supervisor, director of nursing (DON), and the administrator. You’re all worried about Mr. G and his health, of course, but maybe everyone’s a little worried about something else: no one wants to get sued.

      Beneficence

      The DON suggests that you follow the typical procedure and sign the AMA form, avoiding any further involvement with Mr. G — you don’t want to be seen as enabling dangerous behavior, after all. Here’s the ethical conflict again: if you follow the advice of the DON, you’re stepping aside and letting autonomy take precedence over beneficence. But does it have to? Here’s the good news: being a good, beneficent provider (and documenting it) is always the best protection against litigation.
      Putting off the Uber driver, you use your Sanford guide to find an oral antibiotic that at least has some of the same spectra of activity and prescribe it for him. You quickly put together a discharge summary and medication list and give it to him. Have the nurse call in any medications Mr. G might need to tide him over, and have the facility make an appointment with his primary care doctor. Following the advice of the DON and avoiding any role in Mr. G’s discharge may actually be seen as a violation of standard of care (J Fam Pract 2000;49:224–227).
      As usual, document the steps you have taken not only to determine capacity but to express your concerns for a poor outcome, as well as the steps you have taken to mitigate harm to the patient. If you’re concerned about his safety at home, it wouldn’t hurt to call Adult Protective Services. Get buy-in from your DON and administrator to reassure Mr. G he can return to the facility within the 30-day window, and make sure he safely gets into the Uber.
      AMA discharges: Do you honor the ethical principle of autonomy, or do you choose beneficence? Again, the answer is yes.
      Dr. Wright is the chair of the Society’s Ethics Committee. He is medical director of three communities in Richmond, VA.