Sit down when possible, to show patients that you will hear them out. Do not interrupt your time with a patient unless it is truly necessary. Respond to your patient’s simple needs, like requests for a glass of water or an extra blanket. Finally, if some mistrust has developed, simply tell patients, sincerely, that you have their best interests at heart.

Each of these steps for developing trust may require patience. In addition to patience, empathy is a second virtue that is essential to fostering trust. Patients who believe that we care about them and their concerns are more likely to trust and listen to us.

If, after attention to our relationship with the patient, he still refuses to accept our care plan, it is still not time to consider discharging him AMA. Often, there is room for negotiation. The plan the patient is rejecting may be the best plan for him from our perspective, but it is rarely the only acceptable approach.

If the patient is refusing admission, perhaps he will at least agree to further testing in the ED, even if those tests are ordinarily done only on inpatients. Perhaps he will agree to admission if planned interventions are deferred for a day while he becomes more comfortable with the plan. A deferred cardiac catheterization in a patient with unstable angina may not be ideal, but it is better than no catheterization because the patient left the hospital AMA. Finally, perhaps patients who require interventions that they are refusing will at least agree to be admitted for observation. Even if observation itself serves little purpose for the patient, it may give physicians, as well as family members, clergy, and others, time to talk further with the patient and perhaps overcome the reluctance.

If, despite all efforts, no agreement or compromise can be reached, one must determine whether the patient has capacity to refuse care (a topic which is beyond the scope of this article). If the patient has capacity, one can discharge that patient AMA knowing that one has done one’s best to respect the patient’s autonomy and help him or her medically.

Even if the patient lacks capacity, it is still best to seek to gain his or her agreement. We can force treatment on patients who lack capacity, but it is ethically preferable not to. Although the agreement of a patient without capacity will not be based on adequate understanding, it will still reflect the patient’s willingness to follow our plan.