How Much Legal Protection Does AMA Form Give EPs?
Patient’s signature can help defense only to a point
If a patient signs a form stating that he or she is aware of the risks of leaving the emergency department (ED) against medical advice (AMA), a successful lawsuit against the emergency physician (EP) could still result.
"The patient may have a bit of an obstacle to overcome if they later wish to cry wolf and file a claim against the ED provider. But the presence of a signed AMA form in the medical record is not by any means foolproof," says Jeanie Taylor, RN, BSN, MS, vice president of risk services for Emergency Physicians Insurance Company in Roseville, CA.
Mortality rates associated with AMA discharges are up to 2.5 times higher than for other patients.1 Additionally, 30-day readmission rates were found to be higher in patients who leave AMA.2
"In the old days, if a patient even suggested they were thinking about leaving without completing treatment, a nurse was at the ready with a pen and an AMA form," says Taylor. "AMA discharges were sometimes viewed as a gift in a busy ED."
However, a patient’s signature on a form is not what gives EPs protection when patients decide to leave AMA, according to Taylor.
"The protection lies in the documentation of discussions informing the patient of the consequences of the AMA decision, and their ability to understand these consequences," says Taylor.
A signed AMA form, along with a detailed record of the circumstances surrounding the discharge, can "go a long way" to help an EP refute allegations that the discharge was negligent or the result of incomplete disclosures to the patient, says Stephanie M. Godfrey, JD, an attorney in the Philadelphia office of Pepper Hamilton.
"However, physicians should not assume that they are automatically protected against any future liability," says Godfrey. Courts will look beyond the signed AMA form, she explains, and will probe the circumstances surrounding the discharge to determine whether the patient or the EP should bear the responsibility for any subsequent injuries suffered by the patient.
"For example, was the discharge the result of a decision by a well-informed patient who was capable of weighing the risks involved?" asks Godfrey. "Or was there some conflict between the patient and the treating physician that led to the premature discharge?"
In a 2003 case, a prison inmate brought to the ED with lower abdominal pain, nausea, and vomiting left AMA after refusing a nasogastric tube. The ED nurse had the patient sign an AMA form and claimed she told him he could die, but the patient was not informed of his abnormal vital signs or lab studies, which included a life-threatening condition.
The patient was given no discharge instructions, and the EP was not involved in the AMA discharge. The patient died a few days following discharge.
"The hospital argued contributory negligence and prevailed at trial," says Taylor. "But the Alabama Supreme Court found that the lower court had erred in several areas, and found in favor of the patient’s estate."3
Convince Patient to Stay
"EPs need to be involved every time a patient wants to leave AMA," advises Taylor. "The best scenario is that they can talk the patient out of leaving."
Often, an EP letting the patient know that they are concerned, and the possible consequences of leaving AMA, is all that is needed to dissuade the patient.
"Sometimes, patients feel they need to leave AMA because they have childcare, elderly parent care, or pet care issues," says Taylor. "They feel they simply cannot stay in the hospital."
EDs can sometimes overcome these barriers so the patient can remain for admission or to complete treatment. "I have known of situations in which ED staff has actually made arrangements for pet care so a patient could be admitted," says Taylor.
If the AMA discharge cannot be avoided, Taylor says these practices can offer some protection from legal risks:
• EPs should state in the medical record that they "advised" admission, and that the patient refused.
"Documenting that you offered’ admission, but the patient decided not to be admitted, does not protect you," says Taylor. "Patients are not qualified to determine if they need to be admitted. Emergency medicine providers should not make patients believe admission is a choice, and that they can safely decide to be discharged."
Explain that the AMA discharge in no way prevents the patient from changing their mind. "Be non-judgmental, and welcome their return at any time," says Taylor.
• EPs should never let the nursing staff handle an AMA discharge without physician involvement.
"The EP should be involved in all AMA discharges and refusals of care," says Taylor.
• The ED should provide the highest level of care the patient will accept.
If a chest pain patient refuses admission and the EP suggests alternatives such as observation, serial testing in the ED, and very specific follow-up, this discussion must be carefully documented, says Taylor.
Some EPs are hesitant to provide prescriptions to patients leaving AMA, believing that this might encourage the patient not to seek follow-up care, or that doing so implies that the EP agreed to the discharge.
"This is simply not true," says Taylor. "All patients should be prescribed appropriate antibiotics, analgesics, and other medications indicated by the clinical condition."
For instance, if the EP recommends admission and intravenous (IV) antibiotics for a patient with pneumonia, but the patient refuses admission, the patient should receive a dose of IV antibiotics in the ED and a prescription for oral antibiotics, says Taylor.
• EPs should ensure the patient has the capacity to understand the implications of refusing care or treatment.
"This is especially important in patients who have been drinking, have altered mental status, and/or have psychiatric symptoms," says Taylor. Taylor says these items should be assessed: oriented to person, place, and time; appropriate answers; no slurred speech; no sign of psychosis, no hallucinations or delusional thinking; no suicidal ideation; no homicidal ideation; rationale for refusal of care; and ability to verbalize and understand the risks of refusal.
• EPs or ED staff should call all AMAs back the next day.
"Invite them back to complete their care," says Taylor. "Determine how they are faring, and document the call in the medical record."
- Southern W, Nahvi S, Arnsten, J. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125(6):594-602.
- Garland A, Ramsey CD, Fransoo R, et al. Rates of readmission and death associated with leaving hospital against medical advice: A population-based study. CMAJ 2013;185(14):1207-1214.
- Lyons v. Walker Regional Medical Center Inc. April 11, 2003. Retrieved 9/12/2013 from http://caselaw.findlaw.com/al-supreme-court/1026159.html.
For more information, contact:
- Stephanie M. Godfrey, JD, Pepper Hamilton LLP, Philadelphia, PA. Phone: (215) 981-4473. E-mail:
- Jeanie Taylor, RN, BSN, MS, Vice President, Risk Services, Emergency Physicians Insurance Company, Roseville, CA. Phone: (530) 401-8103. E-mail: