December 11, 2013

Discharges Against Medical Advice

This is a delicate issue for some people. Until you have been in this situation and had to deal with the threats from doctors and nurses, this is not always a situation with clear answers. I am talking about patients who do their own discharging from a hospital. Hospitals call this “discharges against medical advice.”

Even the figures are estimated because hospitals do not want this public and is why doctors and nurses threaten patients who attempt to do this. Patients are told that their insurance will not pay the bills and all will fall to them. The estimates are that as many as two percent of all US hospital discharges or approximately 500,000 per year are designated as against medical advice. Most insurance will cover costs, but to be safe, always check with your insurance.

Yes, patients need to be careful when doing this as it can be detrimental to their health and well-being. Compared to patients that are discharged by order of the doctor, patients discharging themselves have an estimated 20% to 40% higher readmission rate. Also, their mortality rate is estimated to be 10% higher. Physicians and health care staff report feeling distressed and powerless when patients choose suboptimal care.

Well, I have been there and done that and the threats against me were real and did not hold any water. Since I was already under the gun as I was admitted to the hospital for observation, the bills were mine to begin with since I was not admitted as an inpatient, but as an outpatient for observation. When all the tests for heart problems came back negative, and no further tests had been ordered, I was feeling like why should I allow my bill to escalate because they wanted to keep me for observation.

I had told the nurse to start preparing me to be discharged and all I got was the threat that my insurance company would not pay my bills. I told the nurse that since the bills were already mine, what did she care. She walked out and did not return. So I got up, disconnected my IV's and got dressed. Next, in walks my primary care doctor and asks what I am doing. I said I was leaving since I was only on observational status and was not running up the bills I would not be able to pay.

He calmly told me that he was discharging me per orders and that if I would calm down, he would get started. It took him about 30 minutes considering the interruptions by the nurse. Twice, he politely asked her to return to her station and I would be discharged. The third time the nurse interrupted to ask to see the place where my IV's had been and the doctor did look at the back of my hands to see no indication of where the IV's had been. The nurse said I should never remove them as this could cause me health problems. I just said that I have witnessed removal enough times to know how to remove them. All I had forgotten was having gauze available to prevent bleeding on the first one.

When the doctor finished, he asked if I wanted a wheel chair and I answered no because once I was taken to the hospital door I would need to walk out in the parking lot to get to my car. I also stated that I had not been sedated to cause me to be unsteady on my feet or to be concerned about driving. He agreed and called another nurse to walk with me to the door of the hospital. When we entered the elevator, I warned the nurse to hold on, as the elevator would jerk pretty good when it started to drop and when it arrived at the floor we needed to get off on. Needless to say, she took a fall because she ignored me. She regained her feet and I told her if it stopped on any other floors and when we reached the main floor, it would repeat this. She did grab the bar and when it stopped, the braking almost caused both of us to lose our balance.

The article in the Journal of the American Medical Association (JAMA) has much more information about discharges against medical advice and is very informative. It also covers several items I did not get into and why hospitals and doctors need to change policies in the way this is handled and documented.

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