Each year, thousands of patients leave Canadian hospitals against the advice of their care team. Many of these patients will be readmitted within a month. Many more visit the emergency department (ER) within a week of discharging themselves from the hospital.
The impact of this cycle of admission and re-admission is significant and poses an ethical dilemma for caregivers. It affects everything from patient outcomes to a hospital’s bottom line. But who exactly is leaving the hospital early, and why? Can we identify those who are most at risk? And can we prevent it from happening?
A recent report from the Canadian Institute for Health Information (CIHI)—Leaving Against Medical Advice: Characteristics Associated With Self-Discharge—begins to answer these questions by providing a fresh perspective on the magnitude of the issue across Canada.
CIHI’s report uses data provided by Canadian acute care hospitals to examine the extent of the issue for both inpatient and ER settings. It focuses on those who left inpatient care and the ER at acute care hospitals against medical advice, rather than patients who left the ER without triage or medical assessment.
The data reveals the types and characteristics of patients who leave against medical advice, and explores the many adverse effects on patients themselves and across the system. The report also examines the role that hospitals and communities play.
Based on the data, CIHI’s report offers some strategies to minimize the negative effects of patients who leave against medical advice, and to manage and prevent the risk.
The following shared characteristics were found among patients who leave against medical advice:
• They were typically younger males
• Many had histories of leaving against medical advice
• Mental health or substance use problems were common diagnoses
• They were most likely to be homeless or live in low-income neighbourhoods
Why they’re leaving
Research suggests that patients who leave against medical advice do so based on their perceptions of the quality of care they receive at the hospital.
• From the perspective of these patients, “quality of care” could go beyond the actual healthcare they receive to include how long they have to wait to be seen, along with how effectively (or not) their health care providers communicate with them.
• These patients’ perceptions could be affected by their mental and emotional state, which may be compounded by significant mental health or substance abuse issues.
• For patients who visit the ER, wait times and perceived overcrowding were factors in decisions to leave.
• Hospital type, size and location had little effect on whether or not people left against medical advice.
Patients who leave hospitals earlier than recommended by their physicians and care teams are at greater risk of serious health problems, including death.
The situation creates an ethical dilemma for health care providers, who must balance patients’ wishes to leave with ensuring they receive the most appropriate care. And given the recent increased focus on improving communication among care providers, experts have also expressed concern about the professional—and in some cases legal—responsibility that may arise from patients leaving against medical advice.
Many of these patients are repeat users of hospital care: CIHI’s data shows that patients who #self-discharge, as compared to patients with routine discharges, had considerably more admissions and readmissions to acute inpatient care, as well as more visits to the ER, regardless of their underlying conditions. Because acute care hospitals are the most expensive setting within the health care system, it is becoming increasingly important to strengthen efforts to reduce unnecessary admissions and readmissions
Strategies and solutions
What can we interpret from these findings? And how can this data be used to make a difference?
Placing greater emphasis on providing true patient-centered care will go a long way toward reducing the number of people who leave against medical advice. This could include:
• Explaining to patients the expected course of care and plans for individualized follow-up
• Helping patients understand what’s involved in all aspects of their care—for example, the amount of time needed for laboratory and diagnostic tests while in the ER
• Informing patients of the risks associated with early discharge
• Communicating effectively with patients and their families to help understand why patients choose to self-discharge, and targeting counselling appropriately
• Improving follow-up care and communication across different care settings between and providers, both formal and informal.
More research is needed to explore strategies to reduce the rate of patients who leave hospital against medical advice. But for now, the information in CIHI’s report will enable a better understanding of the breadth, depth and importance of this issue in the Canadian health care system. This information can be used to inform decision-making, help identify the individuals who can be most supported through targeted interventions and innovative solutions, and ultimately reduce the number—and the impact—of people who leave against medical advice.