The Threat to Sign Out Against Medical Advice

Abstract

Twenty-eight patients were studied who had threatened to sign out of the hospital against medical advice. The threat to leave was usually the last ot a progression of behavioral changes that had not provoked sufficient action by the nursing staff. Threatening to leave was the patients' way to communicate their feelings. There were three reasons for the threat: overwhelming fear, anger, or psychotic reactions. Contributing factors were unrecognized transference reactions, impasses with the staff, intense unmet dependency needs, and family difficulties. Ideally, management should include early recognition of the problem; dispassionate investigation of the circumstances, including the physician's own role; and a review of the problem with the entire staff. Most patients who leave against medical advice return if allowed.