Leaving Against Medical Advice (AMA): What’s a Nurse to Do?

Abstract: Each year approximately 1-2% of patient acute care discharges in United States hospitals are against medical advice (AMA). Though relatively infrequent, AMA discharges are associated with higher patient morbidity, increased risk of readmission, and higher mortality. Nurses have a pivotal role in the care process and in ensuring the safety of patients. They are a crucial part of an interprofessional team approach and discharge-planning process.

However, at least some evidence suggests that nurses are less likely than physicians to believe that AMA patients should receive medications and follow-up and that arrangements for safe discharge are seldom made. This constitutes a serious problem. Clearly, AMA discharges pit the patients’ right to make autonomous decisions about their care against nurses’ duties to promote patients’ wellbeing. However, respecting patients’ desire to leave the hospital does not eliminate nurses’ duties to patients.

The aim of this paper is to increase awareness regarding nurses’ ethical responsibilities when confronting AMA discharges. We highlight the nurses’ leadership role in discharge planning and argue that they have moral obligations to promote as safe a discharge as possible. Such obligations are consistent with nursing codes of ethics according to which nurses have a primary moral duty to promote patients’ wellbeing. Moreover, nurses’ training, expertise, and scope of practice puts them in an ideal context to address problems related to AMA discharges. We also explore some of the challenges that nurses confront when trying to provide optimal patient care and offer some guidelines for addressing those challenges.

Inmaculada de Melo-Martín – Weill Cornell Medicine