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Why would an older person essentially discharge himself from a hospital, defying a physician’s recommendation and signing a daunting form that acknowledges he is leaving A.M.A. — against medical advice?
Attend the tale of William Callahan.
He nearly fainted last spring after walking down the block to visit a neighbor in his New Jersey suburb. At 82, he had a long history of cardiac problems and was several years into Alzheimer’s disease, but remained mobile and sociable.
He quickly revived, but the neighbor called 911. His daughter, Dr. Eileen Callahan, a geriatrician at Mount Sinai Hospital in New York, met her dad at the local emergency room.
“He was fine, sitting up and chatting,” she found. “CT scan, blood work, heart rate, vital signs — all totally normal.” He’d probably gotten a bit dehydrated, she figured, and he insisted on going home.
Dr. Callahan promised the E.R. doctor that she’d stay with her father overnight to be sure he was O.K. No dice.
“The doc said no, he really should stay overnight to be monitored and to see the cardiologist in the morning and get cleared.”
In hospitals, she knew, her father was prone to sleeplessness and delirium. In unfamiliar surroundings, he might fall.
Still, “I succumbed.” The hospital provided an aide to stay with Mr. Callahan overnight until another daughter arrived in the morning.
It did not go well. Mr. Callahan paced for hours, peeled off the heart monitors and grew increasingly confused and agitated. By the next afternoon, despite family calls and complaints, the cardiologist had not materialized and the hospital still wouldn’t discharge Mr. Callahan.
Dr. Callahan’s sister was growing frantic. “I said, ‘Maureen, just do it,’” Dr. Callahan said. “Sign him out.”
Her sister signed the A.M.A. form that hospitals typically demand before releasing patients against physician recommendations, acknowledging that patients understand and assume the risks, medically and legally.
Mr. Callahan went home and went to sleep, but his physician daughter remains livid.
“He should have been discharged right from the E.R.,” she said. “This was cookbook medicine, done without thinking. It was very adversarial.”
Such events happen more commonly than one might think. Though A.M.A. discharges occur far more frequently in younger patients, a recent study in The Journal of the American Geriatrics Society analyzed a large national sample from 2013 and found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges.
“This is a very conservative number,” said the senior author, Dr. Jashvant Poeran, an epidemiologist at the Icahn School of Medicine at Mount Sinai. Had he included outpatients who left emergency rooms against medical advice and those who simply walked out and never actually signed a form, the total would have been much higher.
And the numbers are rising, Dr. Poeran found: A decade earlier, 45,535 hospitalizations of older patients ended with A.M.A. forms. The proportion has climbed from 0.37 percent of senior hospitalizations to 0.42 percent — an uncommon event, to be sure, but a fraught decision nonetheless.
“It’s always been one of the most difficult ethical dilemmas,” said Dr. Arthur Derse, who directs the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin.
“Patients come and seem to be in need of help, and then they say, ‘Sorry, I’ve got to leave.’”
They may be feeling better or fear a procedure; they might simply want to go home and feed the cat. Finances could play a role: Older patients discharged against advice, the Mount Sinai study found, were more likely to have low incomes.
Physicians tend to think such patients are taking considerable risks, because those discharged against medical advice have higher mortality rates and higher rates of hospital readmissions (which now carry financial penalties for hospitals from Medicare).
In wielding those forms, “most health care professionals are using them to try to persuade the patient to remain,” said Dr. David Alfandre, a bioethicist at the N.Y.U. School of Medicine.
Providers have probably also been told that getting a signed A.M.A. form helps ward off later lawsuits. The forms confirm that a conversation about options, risks and benefits took place, and that the patient had decision-making capacity.
Hospital risk managers like them, Dr. Derse said. But courts have found that they don’t necessarily preclude liability claims. “They can be helpful, or they can be worth less than the paper they’re written on,” he said.
From patients’ perspective, moreover, haven’t we supposedly entered the era of “patient-centered care”? A mentally competent patient, after all, can accept or decline any treatment.
Critics like Dr. Alfandre see A.M.A. discharges as paternalistic, undermining the shared decision-making that contemporary doctors and patients supposedly engage in.
In some cases, providers even tell patients that after A.M.A. discharges, insurance will not cover their care — a claim that research has debunked, but one that persists and that Dr. Alfandre deems “coercive.”
“Some physicians don’t like being questioned,” he said. “It’s not uncommon for the physician to get angry and frustrated, and those feelings are transmitted to the patient.”
Such conflicts have particular salience for older patients, for whom hospitalization can pose significant risks, even when physicians can fix the problems patients come in with.
Days in bed can reduce their mobility, trigger delirium and expose elders to infections and falls — all of which may lead to nursing home stays.
“What we try to do as geriatricians is keep patients out of the hospital at all costs,” Dr. Callahan said. “It’s often a life-changing event.”
Barbara Barg, a Chicago poet, collapsed at a bus stop this spring. She suffered a heart attack in 2014 and had been feeling vaguely nauseated for several months.
She was en route to see her primary care doctor about the nausea when a bystander who saw her falter called 911.
Ms. Barg, 70, didn’t want to go to an emergency room, but that was the only place paramedics would take her. “I was freaking out,” she acknowledges.
“I’d just gotten out of the hospital, and I didn’t want to go back in.” She’d had two recent hospital stays, one to replace a pacemaker lead, another to look for a blocked artery (none was found).
Now, “I just wanted to see my doctor.” Affiliated with the hospital, he had an office directly across the street.
Refusing emergency care, Ms. Barg asked to be taken to his office. No. She asked the staff to call him. No.
Twice, she walked out of the emergency department, “and they came after me and said, ‘We can’t let you leave.’”
Finally, after she agreed to sign an A.M.A. form, an aide wheeled her across the street; her doctor prescribed an anti-nausea drug that quickly resolved the problem.
Can’t hospitalists and emergency physicians be more flexible with older patients?
People discharged against medical advice may be reluctant to return if problems develop or persist.
And a study at Highland Hospital in Oakland, Calif., (where most patients were younger) has shown that when they leave against medical advice, they seldom get the appropriate follow-up appointments and medications.
“Reasonable people can disagree about whether a patient needs to stay one more day for an additional scan,” said Dr. Cordelia Stearns, a hospitalist and the lead author.
Fuller conversations about why patients want to leave might yield less contentious solutions, including outpatient treatment, home visits or drugs taken orally at home instead of being administered intravenously.
Dr. Stearns once saw a pet cockatoo brought to a patient’s hospital room to dissuade him from checking out.
“Let’s see if we can come up with an alternative plan,” she said. “A lot of the time, we can. We’re doctors, not jailers.”