Prior Discharges Against Medical Advice and Withdrawal of Consent

Abstract

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.