Medical Advice and the Limits of Therapeutic Influence

By Michael Young

It is estimated that 500,000 patients are discharged from U.S. hospitals against the recommendations of medical staff each year.  This category of discharges, dubbed discharges against medical advice (DAMA), encompasses cases in which patients request to be discharged in spite of countervailing medical counsel to remain hospitalized.  Despite safeguards that exist to ensure that patients are adequately informed and competent to make such decisions, these cases can be ethically challenging for practitioners who may struggle to balance their commitments to patient-centered care with their impulse to accomplish what is in their view best for a patient’s health.

Writing in the most recent issue of JAMA, Alfandre et al. contend that “the term [‘discharge against medical advice’] is an anachronism that has outlived its usefulness in an era of patient-centered care.”  They argue that the concept and category of DAMA “sends the undesirable message that physicians discount patients’ values in clinical decision making.  Accepting an informed patient’s values and preferences, even when they do not appear to coincide with commonly accepted notions of good decisions about health, is always part of patient-centered care.”  The driving assumption here seems to be that if physicians genuinely include patients’ interests and values in their assessments, then the possibility of “discharge against medical advice” is ruled out ab initio, since any medical advice issued would necessarily encapsulate and reflect patients’ preferences.  They therefore propose that “[f]or a profession accountable to the public and committed to patient-centered care, continued use of the discharged against medical advice designation is clinically and ethically problematic.”

While abandoning DAMA procedures may well augment patients’ sense of acceptance among medical providers and reduce deleterious effects on therapeutic relationships that may stem from having to sign DAMA forms, it leaves relatively unaddressed the broader question of how to mitigate health risks patients may experience following medically premature or unplanned discharge.  Alfandre and Schumann’s robust interpretation of patient-centeredness also raises the question of how to handle situations in which patients refuse medically appropriate discharge.  On this interpretation, can the ideal of patient-centered care be squared with concerns for optimizing the equity and efficiency of resource allocations more broadly?

Studies among multiple patient populations have found that patients discharged against medical advice experience significantly higher mortality risks and readmission rates than patients discharged in accordance with medical advice.  These findings illuminate a pressing need for strategies that clinicians can reliably employ in cases of DAMA to ensure that patients are sufficiently educated and equipped to maximize health maintenance following hospital discharge.  Many of these issues are amplified in pediatric care settings wherein parents seek discharge of their children against medical advice.  As a first step toward optimizing post-discharge conditions in these settings, hospitals might consider strategies such as remote monitoring, better transitional care management, and telemedicine follow-ups.  New CMS regulations that reduce payments to hospitals with excess readmission rates further incentivize such innovations.

Regardless of whether or not hospitals elect to jettison DAMA designations, it is essential for clinicians to openly discuss with patients their motivations for wanting to be discharged.  These discussions can provide meaningful opportunities to identify unmet patient needs, illuminate loci of miscommunication between patients and their healthcare teams, and build trust between providers and patients.  With strategic forethought and creative planning, physicians can thus help to cultivate healthier outcomes of patient-centered care in these complex settings.

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