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Patients Being Discharged Against Medical Advice
Date:3/9/2009

Mayo Clinic Proceedings author reviews the consequences

ROCHESTER, Minn., March 9 /PRNewswire-USNewswire/ -- When patients choose to leave the hospital before the treating physician recommends discharge, the consequences may involve risk of inadequately treated medical conditions and the need for readmission, according to a review in the March 2009 issue of Mayo Clinic Proceedings. Additionally, the article examines the effect of costs as well as predictors and potential interventions to help manage and improve this important issue.

Although studies to date are limited, research shows that against medical advice discharges represent as many as 2 percent of all hospital discharges. Those patients represent an at-risk group for both morbidity and mortality, according to the article. Within 30 days, the review states patients with asthma, for example, who were discharged against medical advice had a four-times-higher risk of readmission to the emergency department within 30 days and an almost three-times-higher risk of readmission to the hospital. Further, in a study of general medicine service, patients who left against medical advice were seven times more likely to be readmitted within 15 days, almost always for the same diagnosis. Such readmissions clearly indicate higher health care costs, the review concludes.

At the heart of the problem is an ethical dilemma for physicians. When a patient wishes to leave against medical advice, this may be contrary to the physician's attempt to do what is believed best for the patient. The struggle is between patient autonomy and physician beneficence, according to the review. In practice, managing this issue presents more complications than simply identifying and potentially prioritizing the relevant ethical principles, the review reports. Physician-patient communication, informed consent, and underlying psychiatric issues are all relevant to practical management.

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