Discharge Against Medical Advice (AMA)

Discharge Against Medical Advice (AMA) 

Policy Statement: 

The facility will attempt to ensure that any resident discharge from the facility, including those discharges initiated by the resident or their responsible party against the attending physician’s medical advice, will be carried out with consideration for the resident’s safety and continuing care needs. 

Procedure: 

• Whenever a resident (or the resident’s legally responsible party) chooses to discharge themselves from the facility against the medical advice of their attending physician (an “AMA discharge”), the following will be done: 

• The staff member informed by the resident of the resident’s intention will then notify the Director of Nurses. 

• The Director of Nurses will notify the attending physician, the Administrator, and the Director of Social Work. 

• The Director of Social Work or their designee shall be notified as soon as possible when an AMA discharge is anticipated and will discuss and document with the resident and/or the resident’s legally responsible party the factors that should be considered before making a decision to be discharged against medical advice (“AMA”). If the resident lacks independent decision-making capabilities, and has one or more individuals who have been granted Health Care Powers of Attorney to act for the resident, all designated responsible parties shall be notified of the resident’s intention and the possible risks associated with the AMA discharge. If the resident has an appointed Conservator of the Person, the Conservator shall be notified of the resident’s intention and the possible risk associated with the AMA discharge. If the Conservator permits the AMA discharge, the appropriate Court of Probate shall be notified of the resident’s intention and the possible risks associated with the AMA discharge. Social Workers must comprehensively document any such contrasts and discussions made regarding an AMA discharge. 

• If the resident lacks capacity and the resident’s legally responsible party requests discharge and it is the medical opinion of the attending physician that the discharge is contrary to the patient’s interest, the request for discharge should not be honored and the applicable Court of Probate shall be notified. 

• The attending physician shall attempt to ascertain the reason the patient has decided to leave against medical advice and shall attempt to explain the risks and possible consequences of leaving against medical advice and shall document this discussion in the clinical record. Whenever possible, a resident care conference will be held to discuss appropriate and/or acceptable alternatives to an AMA discharge. Social Work staff present at any such conferences must ensure that the resident and/or the resident’s responsible party are made aware of the risks and community service limitations related to AMA discharges. If the attending physician feels it is appropriate, the attending physician shall attempt to persuade the patient to remain at the facility. 

• If the attending physician determines that the discharge will be made “against medical advice,” the Director of Nursing or their designee shall as necessary: 

• Provide an “AMA discharge” order to be included in the physician’s orders section of the clinical record. 

• Ascertain from the attending physician whether the resident’s medications or prescriptions should be released with the resident at the time of discharge (physicians may choose not to release all of the resident’s current medications). 

• Ascertain from the attending physician whether the attending physician will sign a W-10 (Inter-Agency Referral report) to accompany the resident at the time of discharge. 

• Facilitate the completion by the attending physician of the physician’s summary section of a Discharge Plan and Summary. 

• If the attending physician is unable or unwilling to participate in the discharge as described above, the Director of Nursing or their designee shall consult with the facility’s Medical Director for the purpose of discharging the resident. 

• The Director of Nursing or their designee shall instruct licensed nursing staff and other involved disciplines to complete a W-10 and the nursing summary section of a Discharge Plan and Summary. Whenever possible, all appropriate disciplines shall provide the resident or their responsible party with necessary discharge planning consultation. 

Discharge information must include the following: 

• Medical findings, diagnosis(es), and treatment orders 

• Summary of the care, treatment, and services provided and progress toward achieving goals 

• Diet orders and medication orders 

• Behavioral status, ambulation status, nutrition status, and rehabilitation potential 

• The resident’s physical and psychosocial status 

• Nursing information useful in resident care 

• Advance directives 

• Referrals provided to the resident 

• A notation that the discharge is against medical advice 

• Physician’s orders for the resident’s immediate care 

• Instructions given to the resident before discharge 

• Physician who has agreed to be responsible for the resident’s medical care and treatment, if other than the referring physician 

• Anticipated need for continued care, treatment, and services after discharge 

• Education about how to obtain further care, treatment, and services to meet the resident’s identified needs 

• When indicated and when possible, services needed and the facility’s arrangement for such services to meet the resident’s needs after discharge. Social Work staff shall provide the resident and/or their responsible party with a list of at least three (3) home health agencies that serve the area where the resident plans to reside and with an offer to attempt referrals on the resident’s behalf to any appropriate community agencies. The Social Worker will also determine whether a physician will sign the necessary orders for home health service and if so, will provide this information when making referrals. 

• A completed W-10, with or without a physician’s signature, including the resident’s vital sign, current medical conditions, diet, and medications with last dosage administration and a Discharge Plan and Summary (in a form the resident can understand), must accompany the resident at the time of discharge, if time allows. If the resident insists upon leaving the facility prior to the completion of a W-10 and a Discharge Plan and Summary, arrangements will be made for the documents to be mailed or delivered to the resident’s destination, if known, within 72 hours of the discharge. 

• If the facility has determined that the circumstances of the discharge will place the resident at risk of harm, neglect, abuse, abandonment, or exploitation, Social Work or Licensed Nursing Staff shall notify the appropriate community protection and advocacy agencies within 24 hours, prior to or as soon as possible following, the resident’s leaving the facility AMA. 

• Prior to leaving the facility, the resident and/or the resident’s responsible party will be requested to sign a “Release From Responsibility Form,” which includes a statement that the resident is aware that they are leaving against medical advice and that they have been advised of the risks associated with doing so. If the resident refuses to sign the Form, two witnesses will sign the form to indicate that the form was reviewed with the resident and/or the resident’s responsible party. 

• The staff shall assist the resident in leaving the facility. 

References: 

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. [Link to current CMS SOM] 

• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]