Discussion - Leaving Against Medical Advice (AMA)

I was informed that the patient wishes to leave against medical advice (AMA) at this time.  I have discussed with the patient their desire to leave AMA, and they state their reason for wanting to leave is [in patient’s words].  The patient demonstrates a normal mental status and adequate capacity to make medical decisions.

I discussed alternatives to leaving at this time including [alternate treatment or evaluation], and patient still expressed a desire to leave AMA.  I discussed the risks of leaving AMA with the patient, including [risk], worsening illness, chronic pain, permanent disability and death.  The patient was given the opportunity to ask questions about their medical condition, which I answered to the best of my ability.  The patient was treated to the extent that they would allow, and was encouraged to return to the Emergency Department at any time should they change their mind or if their condition worsens.

The AMA discussion was witnessed by [nurse’s name].  The patient was encouraged to follow up with their primary care doctor as soon as possible for further evaluation.

https://www.the-hospitalist.org/hospitalist/article/124731/how-do-i-determine-if-my-patient-has-decision-making-capacity