Vital Sounds 2025, Quarter 4
Vital Sounds 2025, Quarter 4
Against Medical Advice (AMA) Discharges: Reducing Patient Harm and Provider Liability
November 6, 2025
Against Medical Advice (AMA) Discharges: Reducing Patient Harm and Provider Liability
November 6, 2025
By Connie Christian, MBA, CPHRM
Faiclity Risk Management and Patient Safety Advisor
When a patient leaves against medical advice (AMA), healthcare professionals often feel frustration, distress, guilt, and a sense of failure. This reaction stems from a conflict between a professional’s duty to provide the best care possible and a patient's autonomy to refuse treatment.
Reasons, Risks, and Consequences
Patients choose to leave AMA for many reasons, including personal obligations, financial issues, feeling bored or "well enough" to leave, and dissatisfaction with their treatment or the healthcare setting. However, the consequences can be serious:
- 30-day readmission rates are 20%-40% higher among AMA discharges compared to standard ones.
- 30-day mortality rates increase to as high as 10%.[1]
Because of these risks, patients who leave AMA represent a moderate to high liability risk for healthcare professionals and institutions. The risk of liability hinges on the details of the patient’s encounter and the provider's documentation.
Steps to Reduce Risk and Improve Patient Outcomes
1. Communicate Risks, Benefits, and Alternatives
The provider’s primary ethical and legal obligation is to discuss with the patient:
- The recommended care option
- Alternatives to the recommended care option
- The expected or potential consequences of the patient declining further inpatient care, leaving the emergency department (ED) care, or refusing transfer to another facility.[2]
By evaluating the risks of the patient’s current condition, along with the risks and benefits of alternative treatments, physicians can make informed decisions about which care options are medically appropriate and reasonable to offer at the time of an AMA discharge. These might include:
- Patient condition education – reviewing the diagnosis and expected course of the illness
- Risk education – explaining potential complications or warning signs
- Prescriptions – providing necessary medications to support ongoing care
- Follow-up appointments – arranging continued evaluation and monitoring
- Referrals – connecting the patient with the appropriate outpatient or specialty care
2. Confirm Decision-Making Capacity
Patients who demonstrate decision-making capacity have the right to decline recommended care and leave the healthcare setting. If there’s any doubt about a patient’s capacity, an evaluation for capacity should be performed.
3. Document Thoroughly in the Medical Record
Comprehensive, factual documentation is your best defense against liability. Make sure your documentation includes the following:
- Record the specific events leading up to the patient's decision to leave, breaking from the care path recommendation
- Include descriptive, fact-based information and avoid emotionally laden or stigmatizing language
- Objectively describe attempts at collaborative decision-making with the patient
- Outline the patient’s rationale for discharge
- Review attempts to encourage the patient to stay and continue the recommended care path
- If appropriate, a description of the completed capacity evaluation
- Consultations requested
- Discharge medications prescribed
- Recommended follow-up
- Return to ED instruction
4. AMA Discharge Form Use
Signing an AMA form does not eliminate provider or facility liability. The literature indicates that the most effective protection stems from clear communication and comprehensive documentation, rather than the form itself.
Beneficial Uses - Informed Refusal Format:
A well-designed form should:
- Explain the patient’s condition and provide an overview of the risks of leaving AMA
- Identify when to return if symptoms escalate or their condition worsens
- List follow-up appointments that have been recommended or scheduled
- Include important phone numbers
- Include the patient’s signature acknowledging understanding
- Provide the patient with a copy to take home
- The form should not replace provider documentation in the medical record
Non-Beneficial Uses - Punitive Document:
Avoid forms that:
- Use of contractual or stigmatizing language
- Include “waiver of liability” statements
- Demand signatures without discussion
- Lack guidance for follow-up care
- Restrict the patient from having a copy to take home
- Are used as provider documentation
Final Recommendations
- Approach all AMA discharges using a standardized, structured process.
- Use communication strategies like active listening, empathy, and negotiation to mitigate the risk of the patient leaving AMA.
- Avoid defensive or confrontational behavior.
- Assess and document the patient’s decision-making capacity when needed.
- Objectively record all discussions about potential risks of leaving AMA, the education provided, and alternative treatment plans discussed or implemented.
- Continue to express care and concern for the patient and ensure timely follow-up after discharge.
The KAMMCO risk management advisor team is here to help. Feel free to contact them with any questions you may have regarding liability risk management and compliance.
References
[1] Webber, Chase J., DO, (11-3-2020) AMA discharge linked to increased readmissions, discontinuity of care. The Hospitalist an official publication of the Society of Hospital Medicine. https://www.the-hospitalist.org/hospitalist/article/230982/transitions-care/ama-discharge-linked-increased-readmissions
[2] Albayati A, Douedi S, Alshami A, Hossain MA, Sen S, Buccellato V, Cutroneo A, Beelitz J, Asif A. Why Do Patients Leave against Medical Advice? Reasons, Consequences, Prevention, and Interventions. Healthcare (Basel). 2021 Jan 21;9(2):111. doi: 10.3390/healthcare9020111. PMID: 33494294; PMCID: PMC7909809