1.7 What are the physicians obligations when a patient is discharged against medical advice?
Adina E. Feinberg MD, Martin F. McKneally, MD, PhD, FRCSC, Karen M. Devon MD, MSc, FRCSC
Ms. C is a 52 year-old female in the emergency room with abdominal pain, bloating and constipation for the past week. She has travelled from China to attend her son’s wedding. She is not covered by any medical insurance. Her children have accompanied her to the hospital. She denies any past medical history, but has not seen a doctor recently. She denies any antecedent symptoms or weight loss, saying only that she began to feel unwell after her flight. She has never had a colonoscopy.
Vital signs are normal. Her abdomen is distended, tympanic and mildly tender. A digital rectal exam is unremarkable. Laboratory studies reveal microcytic anemia and a mildly elevated serum creatinine. A CT scan demonstrates a large mass in her ascending colon that is highly suspicious for an obstructing malignancy, with dilated large bowel proximally. There are currently no signs or symptoms of bowel ischemia.
The surgeon explains to Ms. C that she has a mass, likely a colon cancer, and that an urgent operation is needed to relieve her obstruction. The surgeon describes the risks and benefits of the procedure, and that without surgery, her obstruction will likely progress and may result in perforation or even death.
Ms. C listens and understands the surgeon, but feels that she is well enough to return to China to seek care there. She has paid out of pocket for her emergency department visit and is concerned that treatment would be expensive and prefers to be close to home for this type of surgery. She would like to know when the surgeon feels would be the safest time to return to China?
- What is a physician’s moral and legal responsibility when providing care for uninsured travellers to Canada?
- If the patient decides to leave despite ongoing discussions, should the physician have the patient sign a standard form documenting “discharge against medical advice”? How does “discharge against medical advice” fit into the frameworks of shared decision-making and patient-centered care?
- When the reason for a patient’s decision is related to cost, should it change our approach to this situation?
- Should the surgeon who does not agree with the patient, based on significant concerns about her safety, still provide advice regarding travel?
- If the airline contacts the physician, does he have a responsibility to disclose Ms. C.’s medical status? [discuss air expansion later]
- Public Hospitals Act, R.S.O. 1990, c. P.40 [cited 2015 November 18]. Available from: http://www.ontario.ca/laws/statute/90p40
- Searight HR. Assessing patient competence for medical decision-making. Am Fam Physician 1992; 45:751–759.
- Schmidt MJ, Dostal KU. Optimizing outcomes when patients leave against medical advice. JCOM 2007; 14(12):645-653.
- Devitt PJ, Devitt AC, Dewan M. Does identifying a discharge as “against medical advice” confer legal protection? J Fam Pract. 2000;49(3):224–227.
- Alfandre D, Schumann JH. What is wrong with discharges against medical advice (and how to fix them). JAMA 2013; 310(22):2393-2394.
- Leaving Against Medical Advice (AMA). [cited 2016 February 14]. Available from: https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Informed_Discharge/leaving_against_medical_advice-e.html
- President’s Commission. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions. The Ethical and Legal Implications of Informed Consent in the Patient–Practitioner Relationship. Washington DC: 1982.
- Gillick M. Re-engineering shared decision-making. J Med Ethics 2015; 41(9):785-788.
- Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med 2007; 167:1305−1311
- Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med 2013; 28(12):1657-2077.
- Silverman D, Gendreau M. Medical issues associated with commercial flights. The Lancet 2009; 373(9680):2067-2077.
- Kleinman I, Baylis F, Rodgers S, Singer P. Bioethics for clinicians: 8. Confidentiality. CMAJ 1997; 156(4):521-524.