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Healthcare providers have one powerful tool at their disposal to help patients understand the risks of leaving against medical advice: communication. However, ECRI Institute PSO has seen several events lately in which patients have left against medical advice due to a perceived or actual lack of communication from the hospital staff to the patient regarding the treatment plan. It was noted on these events that there was sufficient time for the staff to have intervened by addressing the patient’s concerns; yet, for various reasons, this was not done. Even if the patient cannot be convinced to stay for the completion of his or her treatment, the care team should still give the patient his or her discharge instructions and prescriptions prior to the discharge.

In many cases, well before the patient leaves, there are warning signs that may signal their dissatisfaction or concern. This is the time to intervene and address the patient’s concerns. If these signs are not seen and acted upon promptly, then the patient may decide to leave, and he or she may be less willing to listen to what the practitioner considers rational advice.¹

Several recent, large-scale, retrospective studies have analyzed the phenomenon and identified a few common factors: patients who left against medical advice were more likely to be male, have a low income, have Medicaid, or be uninsured.^2,3 Patients who left against medical advice were also significantly more likely to be readmitted within 30 days. In fact, in one study of nearly 2,000,000 patients at 129 U.S. Department of Veterans Affairs hospitals over five years, researchers determined that the most significant risk factor for readmission was leaving against medical advice.²

The best goal in such situations is to provide the best care possible under the circumstances. This includes a frank presentation of the risks of leaving against medical advice and of the resources and follow-up available to the patient after discharge.⁴ Respect for patient autonomy must be at the forefront; this can be demonstrated through clear, honest, respectful language.

One survey found that communication about four topics may be significantly lacking: length of stay, wait time, meals, and pain management.⁵ The care team must coordinate to present a uniform message.

Key Contributing Factors

• Workflow: Staff may feel rushed and unable to spend adequate time with each patient.
• Culture: The organization may prioritize patient throughput over personal connection.
• Care coordination: Staff may be sending the patient mixed or unclear messages.

Key Recommendations

1. Coordinate and streamline communication among staff members and between staff and the patient. At minimum, before speaking with the patient, staff members should be reviewing the most current orders and notes in the patient’s record to coordinate the patient’s care smoothly.
2. Ensure that communication with the patient begins early in the patient’s stay and includes a discussion of the potential timeline of treatment, possible goals, and drawbacks. Ensure that the patient understands these discussions. 
3. When a patient wishes to leave against medical advice, the healthcare practitioner managing his or her care should initiate a calm, frank discussion with the patient regarding the reasons behind this desire. The practitioner should explain the risks associated with leaving and the care that the patient will need, as well as resources for care outside the hospital.
4. Follow up with patients who leave against medical advice within a short period of time. Ensure that they are aware of further resources (such as local clinics) for their healthcare and that they are following the instructions from the healthcare provider given at discharge.⁴
5. Ensure that the care team is not providing misinformation about insurance and reimbursement. In most situations, insurance will cover their stay, even if patients choose to leave against medical advice. Ensure that erroneous information is not used in a misinformed attempt to coerce a patient to stay.

Take-Home Point

Communication, or a lack thereof, is a major factor that affects patients’ decision to leave against medical advice, and it is the one factor we can change. Clear communication manages the patient’s expectations regarding his or her care and helps to mitigate any potential unrest. All staff members should be very clear with patients regarding the patient’s plan of care and inform the patient’s physician when the patient has questions or concerns related to the plan of care. Any consulting physician should confer with the attending before promising changes, such as those to a care plan, menu, or pain management regimen, to determine feasibility. Involvement of the primary care physician should also be considered. The organization should follow up with the patient within a short period of time to ensure that they are aware of any further resources (such as local clinics) to meet their healthcare needs and that they are following the instructions from the healthcare provider given at discharge.⁴

Medical Director's Note

Though follow-up can be complicated with patients who leave against medical advice, these are often the patients who need it most. Their leaving may be a signal that they do not (or believe they do not) have any further recourse to medical treatment or any other healthcare support network. This Patient Safety E-lert provides participating organizations with an additional periodic educational awareness to help prevent healthcare events from happening in their facilities. To discuss your concerns regarding communication or patients leaving against medical advice, please contact us at (610) 825-6000 or patientsafety@ecri.org, and we will forward your questions to our experts.

Karen P. Zimmer, M.D., M.P.H., FAAP, Medical Director