Patient-directed discharge  

By Jessica Park, MD, Johns Hopkins Medicine 

It was a usual day seeing hospitalized patients when I was paged by a nurse who said that Mr. B wanted to leave. There was a paper on his bedside that listed numerous risks of leaving the hospital, which included worsening infection and losing a limb. (Previously, when patients directed their own discharge, it was labeled as leaving against medical advice (AMA). We now agree that this is a pejorative term, and the preferred term is patient-directed discharge.)  

Mr. B stated, “I know the risks. I want to leave and be able to breathe. I’ll be back.” He hastily signed the paper, removed his IV line, and walked away.  

A couple of days later, I was asked to admit Mr. B back to the hospital from the emergency room. He had a worsening infection of his foot from not taking care of his infected wound and not taking antibiotics since discharge.  

“Hi Mr. B, it’s good to see you again, but I’m also sorry you’re back in the hospital. How are you feeling?”  I said. 

“Hi Doc, I told you I’d be back. I just needed some air,” he replied. 

Mr. B shared more about why he’d left. He was afraid of needing surgery when a surgeon brought up the possibility of amputation during his last hospital stay. He felt claustrophobic inside the small hospital room. Leaving the hospital was his way of coping with the fear of losing his limb and the possibility of losing his independence and having to depend on others. I empathized with how scary it must have been. We had a long discussion about how we could work together to ensure his infection was treated and help him keep his independence. He was able to stay through the remainder of his treatment and discharged home without having to get an amputation. He thanked me for convincing him to stay.  

I encourage fellow healthcare professionals to think about the various reasons why patients decide on a patient-directed discharge. For Mr. B, it was his coping strategy after hearing bad news. For others, it could be wishing to attend a granddaughter’s graduation ceremony or having to go to the social security office before a deadline, just to name a couple. 

Before being patients under our care, these are individuals who have lives outside of the hospital. We must respect their autonomy to make decisions about what happens to their health even when we don’t agree with their decisions. To provide exceptional care, healthcare professionals should actively listen to patients, partner with them to explore what matters to them the most, and discuss how to work together as a team to achieve shared health goals. 

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This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.