Surge in Patients Leaving Against Medical Advice: Ethicist Involvement Needed

By Stacey Kusterbeck

The number of patients leaving against medical advice (AMA) has surged in recent years, raising significant ethical issues. With AMA discharges, “the primary ethical concern is respect for patient autonomy,” says Catherine A. Marco, MD, FACP, professor of emergency medicine at Penn State Health — Milton S. Hershey Medical Center.

One analysis of 1.7 million surgical patient records found that AMA discharges rose from 17% to 25.3% from 2016-2020 — and patients who left AMA had a two-fold higher risk of perioperative complications within 30 days.¹ The rate of Medicare enrollees who left AMA increased by almost 50% between 2006 and 2023, according to a report from the Health and Human Services (HHS) Office of Inspector General.²

“Patients are leaving AMA for the same reasons that they always have,” says Jay Brenner, MD, FACEP, professor and vice chair of research in the department of emergency medicine at SUNY-Upstate Medical University. Patients may disagree with the treatment plan, feel better despite having concerning symptoms earlier, have to take care of children or pets, or have an alcohol or substance use disorder that is not being sufficiently addressed. Some simply do not want to be in the hospital any longer. “What has been leading to more patients leaving AMA in the wake of the COVID pandemic and ripple effects from the Great Resignation has been the uptick in wait times. That includes waiting to be roomed in the ED (emergency department), waiting to be seen, and waiting to be admitted to a proper hospital bed,” reports Brenner.

On the inpatient side, AMA discharges tend to involve patients with complex medical issues who somehow have not had their needs met, says Brenner. In contrast, ED AMA discharges tend to involve patients with limited capacity requiring involvement of surrogate decision-makers. In one such case, a Ukrainian-speaking woman presented to the ED in respiratory distress. She met criteria for further treatment as an inpatient but refused admission and wanted to go home. The patient was not able to demonstrate understanding of the risks of this decision. Therefore, the emergency physician questioned her decision-making capacity. Her daughter and healthcare proxy did not want to ignore her mother’s preference, but acknowledged she was incapable of taking care of herself at home. The hospitalist refused to admit the patient over her objection, and the emergency physician obtained an ethics consult. The ethics consultant arranged a family meeting and suggested a palliative care consult. “The palliative care consultant elicited the patient’s goals of care via the surrogate decision-maker. It was agreed that the patient would go home in the care of family members with a hospice follow-up,” says Brenner. In cases like this, ethicists can help by asking these questions, says Brenner:

• Does the patient have decision-making capacity?
• Have all stakeholders, including family members and friends, been brought into the conversation, if possible?
• Are there any mitigating solutions?

“Ethicists can help to empower physicians to handle patient-directed discharges ethically and more gracefully,” says Brenner. Here are some ethical considerations with AMA discharges:

Physicians have an ethical obligation to mitigate harm if patients leave AMA. “A shift I have seen is that healthcare teams are now strongly encouraged to set the patient up to do as well as possible when they leave AMA, instead of making it more difficult,” says Katherine Wasson, PhD, MPH, professor and director of the Bioethics and Professionalism Honors Program at Loyola University Chicago. For example, clinicians can provide medications to manage the patient’s diabetes or high blood pressure.

However, some physicians abruptly have the patient sign an AMA form, then discharge the patient without further discussion. “It is the obligation of the physicians confronting a patient-directed discharge to dig deep in their empathy well to realize that the patient in front of them may be having the worst day of their life. We must do our best to give them the best off-ramp from that worst day,” says Brenner.

A patient might agree to another treatment option, even if the physician considers it suboptimal. ”For example, a patient who may refuse hospital admission for treatment for an infection may agree to outpatient treatment with oral antibiotics,” says Marco.

Some clinicians express animosity toward patients who want to leave AMA. Clinicians often document stigmatizing remarks about patients who leave AMA, found a recent study.³ Researchers analyzed free-text clinical documentation on 185 patients who were discharged AMA from an urban academic medical center. Although some clinicians conveyed neutrality in the chart, others conveyed an adversarial relationship with the patient. Some clinicians even insinuated that the patient had character flaws. Such biased documentation in the medical record could stigmatize the patients during future clinical encounters, the authors warn.

“The ethical implications of our findings are about reconsidering how we — physicians — think and feel about patients who make decisions that we don’t agree with. Many of the physicians betrayed, in the words that they used, that they felt animosity towards the patient. This animosity will undermine respect and, in turn, patient trust,” says Mary Catherine Beach, MD, MPH, a professor of medicine and core faculty in the Berman Bioethics Institute and the Center for Health Equity.

To guard against stigmatizing AMA discharges, clinicians need a change in mindset. “It is best to treat these patients as normally as possible, so that they feel comfortable returning to seek your medical treatment if they change their mind,” underscores Brenner.

Nurses play an important role in ensuring ethical AMA discharges. Nurses face some unique ethical challenges with AMA discharges.⁴ “Nurses often struggle with how to respond from an ethical standpoint because AMA discharges limit the team’s ability to actively promote patients’ health,” says Joan M. Walker, MS, RN, HEC-C, lecturer of medical ethics in medicine and senior clinical ethicist at Weill Cornell Medicine. Nurses can clarify the patient’s perspective by asking, “Can you tell me more about what led you to choose to leave before your testing and treatment is completed?” If the patient still insists on leaving, nurses should facilitate continuity of care and ensure that the patient is as safe as possible in their post-discharge environment, says Walker. Nurses can seek permission to follow up by phone or coordinate a home care visit by asking, “Would it be all right if we followed up with a call to check on you?” Walker recommends that nurses close the encounter by stating, “We want to take care of you. If something changes, you are welcome to come back.”

“These are emotionally burdensome situations. Having the guidance of an ethicist to find the most ethical approach can lessen that burden,” says Walker.

Some factors are known to put patients at higher risk for leaving AMA. “Pediatric patients are inherently a vulnerable population, in that decisions are made by other individuals, unlike in adults, who largely make their own medical decisions,” observes Collin Stewart, MD, clinical assistant professor of surgery at the University of Arizona. Stewart and colleagues analyzed 436 pediatric trauma patients who were discharged AMA.⁵ Compared to the general patient population, the AMA discharges were more likely to be older, males, Black, uninsured, have a penetrating mechanism of injury, to be a victim of an assault, to test positive for alcohol or illicit drugs, or to undergo an abuse investigation.

“Ethicists can help address this issue by continuing to better understand why decisions are made, especially in the pediatric population, where decisions are made for the patient,” says Stewart. For instance, various factors associated with economic hardship were linked to AMA discharges. Ethicists and clinicians can be more proactive in addressing these issues, to hopefully prevent AMA discharges. “While no one can ever completely mitigate these factors in society, greater understanding allows us to meet the patients and their decision-makers where they are, and to provide a compassionate and understanding rationale and care plan,” says Stewart.

Patients with previous AMA discharges pose unique ethical challenges. In conducting research on AMA discharges, Emily G. Holmes, MD, MPH, noted that a sizeable minority of patients had multiple AMA discharges. “We realized that there was almost no research about this specific patient population. We sought to better understand this subpopulation,” says Holmes. Holmes and colleagues conducted a chart review of 81 patients discharged AMA more than once during 2016-2021 and found that most (64%) were readmitted to the hospital within 30 days.⁶ “I was surprised by the medical complexity of this group and the extremely high one-year mortality observed, particularly in such a young population,” says Holmes.

Patients with multiple AMA discharges also had significant unmet needs, such as financial stress and housing insecurity. “Discharge AMA is often framed as a tension between patient autonomy and beneficence in which autonomy prevails,” observes Holmes. Patients may have decision-making capacity in a strict sense. However, the study findings suggest their ability to make decisions is compromised by significant, competing psychosocial demands. “We cannot comfort ourselves with the idea that our patients are simply exercising their autonomy, or blame them for making bad decisions. We have an ethical obligation to try to give our patients the greatest chance of getting the care that they need,” says Holmes.

Ethicists can help clinicians to choose between several suboptimal options for an AMA discharge. Ethicists also can identify resources to support the patient, such as palliative care or hospice care. “Ethicists can also be crucial in supporting clinicians, who often experience moral distress when they feel that they cannot provide optimal care for their patients,” adds Holmes.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

References

1. Sarfraz A, Khalil M, Woldesenbet S, et al. Association of discharge against medical advice with surgical outcomes and healthcare cost. J Am Coll of Surg. 2025; Jun 26. doi: 10.1097/XCS.0000000000001469. [Online ahead of print].

2. U.S. Department of Health and Human Services Office of Inspector General. Medicare enrollees left acute-care hospitals against medical advice at increasing rates. Report number A-04-24-03003. Issued Aug. 18 2025. https://oig.hhs.gov/documents/audit/10896/A-04-24-03003.pdf

3. Vick JB, Kelly M, McArthur A, et al. “He said he could take his own advice:” Stigmatizing language in notes documenting discharges against medical advice. J Hosp Med. 2025; Sep 3. doi: 10.1002/jhm.70148. [Online ahead of print].

4. Walker JM, de Melo-Martín I. Leaving against medical advice: What’s a nurse to do? Am J Nurs. 2025;125(3):56-59.

5. Hejazi O, Stewart C, Khurshid MH, et al. Predictors of discharge against medical advice in pediatric trauma patients: A nationwide analysis. J Trauma Acute Care Surg. 2025;99(3):433-438.

6. Holmes EG, Smith AC, Kara A. Patients discharged “against medical advice” more than once: A cross-sectional descriptive analysis of a vulnerable population. J Gen Intern Med. 2025;40(10):2192-2197.