In this episode of Hospital Medicine Unplugged, we crack open Against Medical Advice (AMA) discharges—why patients walk, who’s at highest risk, what really happens after they leave, and how to respond in a way that’s ethical, patient-centered, and legally defensible. We start with the basics: AMA = patients leaving before the team thinks it’s safe. It’s only ~1–2% of discharges, but clustered in younger patients, men, people with substance use and psychiatric disorders, those who are uninsured, on Medicaid, or homeless, and especially anyone with a prior AMA history. We unpack how structural factors—poverty, racism, housing instability, insurance gaps—drive “noncompliance” more than patient personality. Then we lay out the consequences: ~2× higher 30-day readmissions, a 2×+ bump in mortality, tons of early bounce-backs within 24 hours, and hundreds of thousands of hospital days and dollars burned. We connect the dots: shortened LOS, interrupted treatment, no meds, no follow-up, and patients showing up sicker at a different hospital. From there we get practical at the bedside: Capacity, always first. We walk through the 4 pillars—understanding, appreciation, reasoning, choice—and how to optimize capacity by treating delirium, intoxication, withdrawal, pain, and metabolic derangements before you even think about AMA. Risk stratification by diagnosis: MI, sepsis, DKA, respiratory failure, trauma, psychiatric emergencies—what leaving early actually means for morbidity and mortality in each bucket. Find the modifiable drivers: undertreated pain, unmanaged withdrawal, nicotine craving, childcare, job loss fears, transportation, homelessness, mistrust, and prior bad experiences with the system. Communication is the pivot. We lean into nonjudgmental, empathic conversations, motivational interviewing, and de-escalation. We break down the AIMED framework—Assess, Investigate, Mitigate, Explain, Document—as a stepwise way to turn “I’m leaving” into “How can we make this safer?” without coercion or power struggles. For high-risk groups with OUD and other SUDs, we focus on what actually moves the needle: Early, in-hospital MOUD (buprenorphine/methadone) to cut AMA and readmissions. Aggressive pain and withdrawal management, not just PRN clonidine. Addiction consult services to initiate MOUD, link to OTPs/bridge clinics, and coordinate post-discharge care. We zoom out to operational fixes: better discharge communication, individualized discharge plans, streamlined prescriptions, solving basics like transportation and childcare, and targeted workflows in high-risk units (ED, medicine, psych). Then we get into documentation and legal protection—what has to be in the note so “AMA” actually means something: Explicit capacity assessment (by element). Concrete risks, benefits, and alternatives discussed (including partial treatment). What the team offered to mitigate harm (pain control, MOUD, rides, follow-up). The patient’s reasons in their own words. Why the team judged the plan clinically reasonable at the time. We stress the limits of AMA forms and why the contemporaneous narrative note, free of stigmatizing language, is your real medicolegal shield. Finally, we tackle ethics and high-risk scenarios: autonomy vs beneficence, when persuasion becomes coercion, the difference between capacity and legal competence, and how AMA is different for minors, patients on involuntary holds, or those with guardianships. We close with harm-reduction discharges—provisional prescriptions, naloxone, wound supplies, rapid follow-up—and how to welcome patients back after an AMA episode without shame or blame. Fast, structured, and equity-focused—identify who’s likely to leave, fix what’s fixable, communicate without stigma, build harm-reduction exits, document like it matters, and never confuse “AMA” with “we’re done caring.”
