2% leave hospital against medical advice

About one in 50 patients leaves the hospital early, disregarding the doctor's orders. These patients are three times more likely to be re-hospitalized within a month, according to a recent review of more than two dozen studies since 1970 that examined the phenomenon of "self-discharge."

Patients who leave early after being admitted for a heart attack are 40% more likely to die or be readmitted with another heart attack or unstable angina in the next two years, said the study in the March Mayo Clinic Proceedings.

But these figures could underestimate the scope of the problem, said study author David J. Alfandre, MD.

"Plenty of doctors may write, 'I didn't recommend that the patient leave at this time,' but don't make the formal documentation so someone knows that this was against medical advice," said Dr. Alfandre, an internist and ethics consultant at the New York office of the U.S. Dept. of Veterans Affairs' National Center for Ethics in Health Care. "It is potentially even more frequent that doctors and patients are disagreeing about care plans."

So who is most likely to leave the hospital against medical advice, and what can physicians do to dissuade them from doing so?

The answers are hard to come by, said Dr. Alfandre, because most studies examining the phenomenon are retrospective analyses and thus unable to pinpoint causes of self-discharge behavior.

"People hold lots of different values," he said. "Not everyone values their health as the No. 1 priority."

However, lessons from psychiatric inpatient settings -- where an average 17% of patients leave against medical advice -- could help address the problem. One study Dr. Alfandre reviewed, for example, found that psychiatric patients with access to a nurse advocate were 30% less likely to leave against medical advice.

Research also shows that patients who self-discharge often show signs of anxiety before leaving. Physicians, Dr. Alfandre said, therefore should pay extra attention to patients who are angry or in emotional distress.

Doctors also should talk with patients about why they want to leave early, inform them of the risks and try to come up with joint decisions about care plans. For example, a physician could agree to allow the patient to leave early if he promises to attend a scheduled follow-up appointment within 48 hours.