Patients leaving the hospital against medical advice (AMA) present clinical, ethical and legal challenges to the care team.
- Clinically, these patients are at risk for complications, readmissions and even mortality.
- Ethically, patients leaving AMA raise concerns about informed consent, informed refusal and patient literacy.
- Legally, providers must work with the patient to address outstanding issues or concerns. In addition, the provider will document the AMA process thoroughly, ensuring that patients are informed of the potential consequences and that their decision is voluntary. Failure to do so can expose institutions to liability and compromise trust between patients and providers.
While healthcare professionals strive to provide compassionate, evidence-based care, some patients may choose to leave before their evaluation or treatment is complete. Understanding how to respond professionally and effectively is essential for patient safety, provider support and institutional protection.
What is AMA?
AMA refers to a situation where a patient chooses to leave the hospital, refusing recommended medical care despite being advised to stay for further treatment. This is a formal refusal of care and typically involves the patient informing the care team of their decision to leave. AMA is not the same as when a patient chooses to continue receiving care in the hospital or center but declines one or more specific treatments outlined in the care plan.
Elopement, for purposes of clarification, on the other hand, occurs when a patient leaves the care area without notifying staff. It is considered an unauthorized departure and may raise safety concerns, especially for patients at risk or those lacking in medical decision-making capacity.
Unfortunately, leaving AMA is associated with higher rates of readmission and increased short-term mortality, underscoring the need for targeted interventions and improved communication to support at-risk patients.
Why patients may choose to leave against medical advice
Patients may choose to leave against medical advice for a variety of reasons, each shaped by personal, social and medical factors. Some common motivations may include:
- Lack of patient-centered care: Feeling unheard or dismissed by medical staff
- Resolution of symptoms: Improvement in symptoms prompting a desire to return home
- Expense: Concerns about financial costs or insurance coverage
- Lack of attention: Perception that the physician or care team members are unavailable or unapproachable
- Frustration: Dissatisfaction with the quality or delivery of care. Extended wait times following testing, leading to frustration. Unmet expectations regarding care or miscommunication
- Distrust or fear: Discomfort or fear of the hospital environment.
- Prior history: The patient has previously left against medical care without completing recommended treatment.
- Mental health or cognitive challenges: Substance use concerns may interfere with treatment adherence and overall health management.
- Personal obligations: Employment responsibilities create pressures to return to work.
- Family challenges: Ongoing family health challenges contribute to emotional stress and competing priorities.
- Lack of understanding: The patient believed the inpatient stay would be short term.
- Perceived recovery: The patient feels better and does not feel compelled to remain in the hospital.
Who is at risk of leaving against medical advice?
Patients who leave the hospital AMA often share certain demographic, clinical and socioeconomic characteristics that place them at higher risk for early discharge and poor outcomes.
- Research shows that individuals aged 35 to 49, particularly men, are more likely to leave AMA.
- Black patients and those from low-income communities also experience disproportionately higher rates of AMA discharges.
- A significant factor is insurance status — patients who are uninsured or covered by Medicaid account for nearly half of all AMA discharges, despite representing a much smaller portion of total hospital admissions.
- Clinical and behavioral factors also play a major role. Patients with substance use disorders or mental health conditions, such as mood disorders, are significantly more likely to leave AMA.
- Those admitted through emergency departments or with a history of prior AMA discharges are also at elevated risk.
- Many patients cite reasons such as feeling well enough to leave, financial concerns, dissatisfaction with care, or urgent personal obligations.
Medicare enrollees
According to the U.S. Department of Health & Human Services, the “rates at which enrollees left acute-care hospitals AMA steadily increased across most demographics from 2006 through 2021 and spiked during the COVID-19 public health emergency. Enrollees who left AMA were more likely to experience poor health outcomes compared to those discharged to their homes. These rates appeared inversely correlated with hospital quality-of-care ratings, with lower-rated hospitals showing higher AMA rates. Dual enrollees (Medicare and Medicaid) and those with a mental health diagnosis were more likely to leave AMA than Medicare-only enrollees and those without such a diagnosis.
Enrollees eligible for both Medicare and Medicaid (dual enrollees) and enrollees with a mental health diagnosis were more likely to leave AMA than Medicare-only enrollees and enrollees without a mental health diagnosis, respectively. These findings may help inform future guidance to reduce AMA discharges, improve enrollee outcomes and lower health care costs.
Patient rights
Patients in the United States have the legal right to leave a hospital or healthcare facility AMA, provided they are of sound mind and not deemed a danger to themselves or others. This right is grounded in the principle of informed consent, which includes the right to refuse treatment. When a patient chooses to leave AMA, they are typically asked to sign a form acknowledging that they understand the risks of doing so. While this decision may be driven by factors such as financial concerns, dissatisfaction with care, or personal preferences, it carries significant health risks, including increased chances of readmission, complications and even mortality. Importantly, leaving AMA does not void insurance coverage for care already received, though it may affect future treatment plans and relationships with healthcare providers.
Leaving the hospital AMA means that a patient decides to leave before the treating physician believes it is medically safe or appropriate to do so. This decision can be influenced by a variety of personal, emotional, or practical factors, as noted. The patient may experience a worsening of their illness or complication of their condition if treatment is incomplete, such as intravenous antibiotic therapy for an infection. The patient may also be at a higher risk for readmission, often within hours or days due in part to fear or physical deterioration. Those with chronic conditions may be at risk on increased morbidity and mortality.
Patients are still responsible for all medical bills incurred during their stay, regardless of how they leave. Be careful though, not to use this as a motivator to encourage the patient to stay. Have the patient reach out to their healthcare insurance provider for additional information or any clarifications on benefits and coverage as the insurance representative will be the best source of truth and facts.
What happens next
The following offers strategies for patients leaving AMA:
- The care team works to educate and inform the patient about the risks by engaging in open and honest communication with the patient. This requires active listening to their concerns and reasons for wanting to leave.
- The care team works to acknowledge and validate the patient’s thoughts and feelings, even though you may not agree with the patient’s decision. Doing so without judgment will be key to an open dialogue. This is not a time for argumentative discussion as this can further escalate the situation.
- The physician or provider will work with the patient directly to clarify or relieve any concerns about the patient staying until safe for discharge. Provide for a detailed, informed refusal discussion that includes risks, benefits and alternatives to leaving against medical advice.
- Using a patient-centered approach, work together as a team and explore with the patient what their goals for treatment are and any alternatives for the intended care or any reasonable modifications to the treatment plan.
- If the patient still chooses to leave, the hospital will document the decision using the patient’s own words and ensure the patient is leaving with as much information and support as possible. Document the patient's capacity to make decisions, ensuring they understand the implications of leaving AMA. Describe the physician and care teams’ interaction with the patient.
- Patients should be asked to sign an AMA form acknowledging that they understand the risks of leaving prematurely.
- Emphasize to the patient that they can return at any time to any hospital if their condition worsens or they change their mind. Remind them to reach out to their primary care provider for further guidance and support as well.
- The care team will provide for a safe departure and discharge, which includes clearly written follow-up instructions specific to medications, new prescriptions, appointments, important phone numbers, needed assistive devices or other supplies. Assist with information for arranging outpatient visits or home care.
Risk management mitigation strategies
Risk managers play a vital role in supporting safe, ethical and legally compliant healthcare and business practices, especially in complex situations like patients leaving AMA. Here’s how they can contribute:
Patient safety and advocacy
- Ensure that it is standard operating procedure that patients are fully informed of the risks associated with leaving AMA or refusing treatment.
- Serve as conduit and help facilitate clear, compassionate communication between providers and patients.
- Advocate for patient rights while balancing institutional responsibilities.
Documentation and compliance
- Guide staff on proper documentation of AMA discharges, including capacity assessments and informed consent.
- Ensure compliance with federal and state regulations regarding patient autonomy, referrals and discharge procedures.
Legal risk mitigation
- Identify and address potential liability issues, such as inadequate discharge planning or failure to offer appropriate referrals.
- Review cases involving chemical dependency or mental health to ensure legal protections (e.g., involuntary holds) are applied correctly when needed.
Coordination and support
- Collaborate with clinical teams, social workers and case managers to develop safe discharge plans.
- Help connect patients with community resources, especially when social determinants of health (like family illness or work demands) affect care continuity.
Review and improve systems
- Regularly review AMA discharge cases to identify recurring trends or systemic challenges, such as staff shortages, communication breakdowns, or frequent AMA incidents linked to specific departments or providers.
- Leverage insights from these reviews to enhance operational workflows, strengthen patient education efforts and guide targeted staff training aimed at reducing future AMA occurrences.
Policy development
- Establish a comprehensive policy that addresses all forms of care refusal. This should include procedures for handling AMA discharges, partial refusals, elopement and AWOL situations. The policy should outline staff responsibilities, documentation requirements and follow-up protocols.
In your policies, clearly define the various ways a patient may refuse care, including
- AMA: When a patient chooses to leave the hospital before the physician recommends discharge.
- Partial refusal: When a patient declines specific treatments or procedures while remaining in care.
- Elopement: When a patient leaves the facility without notifying staff and without a formal discharge.
- AWOL: Similar to elopement, typically used in behavioral health or inpatient psychiatric settings.
Create a universal AMA form
An AMA form is a critical document used when a patient chooses to leave a healthcare facility before the medical team recommends discharge. The AMA form serves as legal protection for the hospital and confirms the patient was informed of the risks. The AMA form should be available in the three most common languages for your community served.
Here's a list of essential elements that should be included in an AMA form:
- Full name
- Date of birth
- Medical record number
- Date and time of intended departure
- Clear acknowledgment that the patient is leaving against medical advice
- Description of the care, treatment, or evaluation being refused
- Outline of potential medical risks and consequences of leaving prematurely
- Statement that these risks were explained to the patient
- Summary of alternative treatments or options discussed
- Documentation that the patient declined these alternatives
- Confirmation that the patient was evaluated and found capable of making informed decisions
- Name and signature of the evaluating physician
- Space for the patient to explain their reason for leaving
- Optional: patient acknowledgment that they understand the risks
- Patient signature and date
- Witness signature (e.g., nurse or staff member)
- Physician signature and date
- Instructions for follow-up care or emergency contact
- Information on how to return for care if needed
- Space for staff to record any relevant observations or interactions
- An assessment such as vital signs, cognitive status, etc. at time of patient departure.
- Note if the patient refused to sign the AMA form
In closing, leaving AMA refers to a situation where a patient chooses to leave a healthcare facility before the treating provider recommends discharge. Patients have the legal right to make this decision, provided they have the mental capacity to understand the risks and consequences.
While healthcare providers may advise against it, they must respect the patient’s autonomy. AMA discharges can carry medical and legal risks, including potential complications from untreated conditions and challenges with continuity of care. Proper documentation, consistent operating procedures, clear communication and efforts to ensure the patient is making an informed decision are essential in these cases.
Disclaimer
WTW hopes you found the general information provided here informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, WTW offers insurance products through licensed entities, including Willis Towers Watson Northeast, Inc. (in the United States) and Willis Canada Inc. (in Canada).
