The number of patients who sue after leaving AMA is not clear, and hospitals can prevail when they have proper documentation, notes Nicole Greene, associate vice president for professional liability with liability insurer Burns & Wilcox in Farmington Hills, MI.

“Regardless of this, the hospitals still incurred significant defense costs through the litigating of these allegations, which in turn allows the hospital’s reputation to be subject to scrutiny,” she says. “Average defense costs for medical malpractice are approximately $400,000.”

Three of the top five reasons for hospitalization among AMA stays were for mental health and substance abuse conditions, Green notes from research by the Agency for Healthcare Research and Quality. Patients hospitalized for alcohol- and substance-related disorders were 11.6 and 10.8 times more likely, respectively, to leave the hospital AMA than other patients.

Compared with patients discharged conventionally, readmission rates for patients discharged against medical advice are 20-40% higher, and their adjusted relative risk of 30-day mortality may be 10% higher, one study found. (An abstract of that study is available online at:

In addition, patients who leave AMA tend to have an increased risk of bad medical outcomes, she says. A recent study looked at 1.9 million adult admissions and discharges over almost 20 years and found that the odds of death within 90 days were 2.5 times higher for patients who left the hospital AMA. (An abstract of that study is available online at:

Formal Training on Communication

Hospital staff and physicians should undergo formal training on how to communicate with patients who express a desire to leave AMA, Greene says. The training should teach them how to collect and document, in detail, the mental state and physical condition of the patient throughout his or her stay at the hospital, she says.

The most common mistakes and oversights cited in lawsuits include poor communication, poor documentation, not providing care after a patient expresses a desire to leave, and not providing medication, medical instruction, or follow-up with patients after they have left, she says.

“Hospitals need to have policies and procedures in place to help protect the hospital from AMA risks, and the staff absolutely need to be familiar with these policies and procedures through annual training and reviews,” Greene says. “Within this training, they need to go over how to properly record the care of the patient.”

Many clinicians, when asked how to protect against AMA exposure, will say they should document within the patient’s chart the desire to leave, and note that the patient was informed of the potential risks of leaving. That is fine as far as it goes, Greene says, but it does not go far enough.

“This would provide little to no protection if the hospital was sued. The key is that the hospital needs to have communicated with precision and have thorough records,” she says. “The burden on the hospital when litigating an AMA case is to establish that they took all the steps necessary to treat the patient. While documentation will help to establish this, it is critical for the notes to be detailed and specific.”

In establishing that the patient’s decision-making ability was intact, and he or she had the mental capacity to make reasonable decisions, staff should identify that the patient is not under the influence or intoxicated, Greene says. The patient also should demonstrate the ability to carry on a conversation with the staff about a variety of items, such as: How are you feeling? What are your symptoms? What were you doing prior to coming to the hospital?

“The staff will want to capture details of these conversations as these will help the hospital establish that the patient was of sound mind and had the capacity to make decisions,” Greene says. “Doing this supports that they had the capacity to understand that the actions they were taking to leave AMA could potentially put them in harm’s way.”

If the patient does leave AMA, the hospital should do whatever is possible to limit a negative, adverse medical outcome, Greene says. Patients should be provided with any medications and medical instructions that they may presently need, and failure to do so will only increase the chance that the patient will have a bad outcome, thus increasing the hospital’s risk of liability.

“Emergency physicians often wonder whether they should provide any care or treatment for patients who leave AMA, fearing lawsuits may arise from providing subadequate care,” Greene says. “However, not doing so often strengthens the litigator’s case and weakens the hospital’s defense.”


• Nicole Greene, Associate Vice President for Professional Liability, Burns & Wilcox, Farmington Hills, MI. Phone: (248) 932-9000. Email: