Choosing to Leave the Hospital Against Medical Advice

Leaving the hospital early: what you need to know, and how to make it happen.

hospital discharge sign
Be sure someone helps you leave - a loved one, a patient advocate, even a cab driver. Paul Brennan / Photos.com

While most hospital discharges are agreed upon by doctors and their patients, there are some circumstances when there is disagreement about whether it’s time for the patient to leave.

Most of those disagreements are with the insurance company or other payer who deems that patient’s time is up (and they will no longer pay.)  In that case, a patient or his or her provider will file an appeal to fight the hospital discharge decision.

But sometimes the situation is just the opposite.  The patient feels as if he or she is ready to leave, but the doctors say no – they don’t believe that the patient is ready to go. If the patient does, indeed, walk out the door, it will be labeled, “Discharge Against Medical Advice (DAMA).”

Why Hospitals Want Patients to Stay

We would like to think that doctors and other hospital personnel have our best health and medical interests at heart when they insist we stay in the hospital.  Some do.  But the “requirement” to stay is usually more about money than it is about the patient’s health.

The first reason is obvious.  The longer you stay, the more money they make, as long as either they can be reimbursed by your insurance, other payer, or from your own pocket.  That time may be limited by your insurer, but the hospital will always do its best to maximize its reimbursement and income from every patient’s hospital stay.

The second reason is less obvious.  That is, that the longer you stay in the hospital, the more things they can do to you – extra procedures, extra tests and so forth. Of course, the more they do, the more they can bill for.

The third reason is relatively new.  That is, that through the Affordable Care Act, hospitals are penalized if Medicare patients are readmitted within 30 days of their discharge.

  So while their interest may not necessarily be in your improved health for your own sake, it’s definitely important to them that you be healthy enough when you leave so that you won’t have to come back (until day 31 anyway.)

Why You May Want to Leave Even When the Doctor Says Stay

There are a number of reasons you may begin thinking about the possibility of leaving the hospital earlier than originally planned.  It will come at the point where you feel like there’s no more good return on your hospital time investment.

You may feel like you can no longer afford to stay.  For example, if you have very high deductible health insurance, or you’re paying cash, you may want to reduce the financial impact on yourself.  Important: don’t assume you can’t afford to stay and then make the effort to leave DAMA.  Ask the question of the hospital’s patient advocate, patient representative or ombudsman and get real numbers before you make that decision.

You may be fearful that staying longer will have a negative effect on your health.

  Hospitals are dangerous placesDrug errors, and horrible infections and rampant.  There are major benefits to staying the hospital for the amount of time needed – and not one minute more.  The problem crops up when you and your doctors disagree on that word “needed.”

You may also have had an experience in the hospital that indicates it would be safer for you to leave.  In 2010, a Maryland man sued a hospital because they tried to prevent him from leaving after a number of mistakes were made, making him fear for his life.  After being taken to the ER after a car accident, he awoke the next morning to find a wristband with a woman’s name on it, and that he was being taken into the OR for cancer surgery – except that he was there for a car accident and had no cancer.

Hospital safety records are, in general, just terrible.  You may decide that experiences you’ve already had mean you should leave.  But before you do that to the detriment of your health, you may instead want to ask someone to advocate for you 24/7 by your bedside until it’s time to be discharged.  A family member, a friend, or even a private, professional health advocate (not the hospital's advocate) can stay vigilant while you heal.

What You Need to Know about Discharge Against Medical Advice (DAMA)

If you want to leave – you can.  Just like most patients can refuse medical treatment, most patients can leave the hospital when they want to, too.  (Excluded are mental health patients for whom the rules and laws differ.) It’s not illegal.  It’s your choice.

Be sure you try to work out the problems.  Depending on what has occurred to make you want to leave early, there may be people who can help you.  Doctors, hospital patient representatives and others may be able to solve the problem at the root of your choice.

Don’t make the decision alone.  In particular, if your hospitalization has included treatment with any sort of pain medications or sleep-inducing drugs, or if you feel very sick or just not “yourself” (do any of us feel like ourselves when hospitalized?) – then this decision is too important to make on your own.  Ask your loved one, or a private advocate (not a hospital advocate whose allegiance will be to the hospital) to guide you in making the decision.  It’s not one to make when your mental and emotional faculties are not at their optimum point.

You will be asked to sign some sort of document that says you understand that you are leaving against medical advice.Every hospital has its own form and it will likely be very intimidating. There may be all kinds of aspects and disclosures to that paperwork, so be sure to read it carefully and understand it well so that you don’t find yourself responsible for things you may not want to, or should not be responsible for.  Those may be health-related or money-related.  Just remember that the hospital’s only goal will be to protect its own backside and its own income. Once you leave they do not care about you or your medical or financial health.

Your insurance will still pay for the care you received even if you leave AMA.  Your doctors and even hospital personnel may tell you that you will be required to pay for your stay.  However, a study published in 2012 showed that despite the fact that doctors believe that to be true, leaving AMA had no effect on insurance payments for your care (link is a citation from PubMed).  To be on the safe side, you should check with your insurer before you leave the hospital.

Just because you choose to leave early does not mean the discharge process should be abbreviated. It's still very important you ask the right questions, and get the information you need before you go out the door. Here is more information about the hospital discharge process and your role in making it successful for yourself.

Do your best to keep the process respectful and not to lose your temper or get too frustrated.  Hospital personnel may desperately try to keep you there - but they are just doing their jobs.  Just as you will be respectful to them, you should command respect from them as well.  If they do not treat you respectfully, call them on it, remind them that you have made your decision carefully and ask them to be polite.

Smart patients know to assess the risks and rewards of choosing to leave a hospital AMA.

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