A 28-year-old man presented with agitation. He was brought in by police and was restrained because of threats of biting and hitting police. The patient refused any additional medical care and stated, “I know my rights! You can’t hold me against my will.” When the emergency physician recommended vital signs, a history, and physical examination, the patient began hitting and biting staff, yelling obscenities, and threatening legal action. Should this patient be allowed to leave against medical advice (AMA)?

Leaving AMA

Informed consent and informed refusal of care are important components of patient autonomy, or self-determination, in medical decision making.^1,2 Approximately 2 percent of emergency department (ED) patients in the United States leave prior to evaluation or AMA.³ Certain patient factors are associated with higher incidence of leaving AMA, including male gender, younger age, alcohol use, illicit substance use, weekend treatment, Medicaid insurance, and lack of medical insurance.^4-6 Patients cite a variety of reasons for leaving AMA, including wait time, unmet expectations, anger, drug or alcohol use, family responsibilities, financial concerns, and negative interactions with staff.^7,8

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ACEP has summarized these issues in its Code of Ethics: “Emergency physicians shall communicate truthfully with patients and secure their informed consent for treatment, unless the urgency of the patient’s conditions demands an immediate response.”⁹ Patients with appropriate decisional capacity have the right to participate in the informed consent process and also have the right to refuse medical care. Informed consent and informed refusal are a process, not merely a signature on a form. Some erroneously believe that merely documenting a patient leaving AMA, using an “AMA form,” is sufficient to meet legal and ethical standards. The process of refusal of care, including leaving AMA, should include determination of decisional capacity, delivery of relevant information, including risks of refusing treatment, alternative treatments, and documentation of these elements. When a patient refuses medical treatment, care should specifically be taken to ensure that the patient understands the consequences, and that the physician expressed a willingness to treat the patient, including providing reasonable alternative treatments, and providing appropriate discharge instructions and follow-up recommendations (see table 1).

Patient Assessment

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Assessment of capacity is an essential element of informed consent for treatment or informed refusal of care (see table 2).^10,11 Multiple clinical conditions may impair capacity, such as cognitive disorders, neurologic disorders, medication effects, alcohol intoxication, substance abuse, psychosis, pain, anxiety, or any other condition that impairs ability to make an authentic choice.

Assessment tools may be helpful in the assessment of decisional capacity, particularly in high-risk settings. There is no evidence to establish a single tool as a valid gold standard for assessment of capacity, and the utilization of any of these assessment tools represents only one part of the clinical assessment of capacity.^12-14 Examples of assessment tools that may be utilized as a part of the assessment of capacity include: Mini Mental State Examination (MMSE); Montreal Cognitive Assessment (MoCA), the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), Competency Interview Schedule, Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory, Hopkins Competency Assessment (HCAT), the Mini-Cog, Aid to Capacity Evaluation, and the Capacity Assessment Tool (CAT).^15-18

Patient Management

The appropriate management of a patient who wishes to refuse medical care includes the following elements: determination of decision-making capacity, assessment of the reasons for refusal of care, delivery of information including risks and benefits of the proposed therapy, discharge planning, including the best treatment alternative, and documentation. Proper documentation of AMA is essential to documentation, and also can confer medicolegal protection.^19,20

Ensuring the safety of staff and other patients is an important concern when treating patients who may refuse medical care. Some patients may require physical or chemical restraints to assure safety of other patients or the treatment team. Physical restraints should be limited to use in cases where the safety of the patient, other patients, or staff is threatened, or to prevent elopement when the patient must be treated despite refusal. ACEP has stated in policy that, “restraints should be individualized and afford as much dignity to the patient as the situation allows” and “any restraints should be humanely and professionally administered.” The policy also states that protocols should ensure appropriate observation, treatment, assessments, and documentation of medical care.²¹

Case Discussion

In this case, assessment of decisional capacity is essential prior to the consideration of leaving AMA. It is reasonable to detain a patient who lacks decisional capacity until they regain decisional capacity or a safe disposition is determined. If there is any question regarding capacity, a standardized test, such as the MMSE, may be helpful. After the determination of appropriate decisional capacity, the physician should conduct an informed refusal discussion with the patient, including risks and benefits of the proposed tests and treatments, and risks of refusal. Alternatives to the recommended treatment should also be discussed and implemented when appropriate. Necessary follow-up care should be arranged, and the discussion and interactions should be documented.

Dr. Marco is professor of emergency medicine at Penn State Health-Milton S. Hershey Medical Center and associate editor of ACEP Now.

References

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3. National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2021 Emergency Department Summary Tables. Accessed January 7, 2025.
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21. ACEP. Use of patient restraints. Policy statement. Ann Emerg Med. 2014;64(5):574.