Should I Stay or Should I Go?

Few people enjoy being admitted to hospital. Still, when the doctor says stay, most patients agree. But as many as one in ten patients leave the hospital against medical advice. A new study just published in the Canadian Medical Association Journal paints a disturbing picture of what happens to those who leave before their tests and treatments are complete. As an ER physician, it's something I see all the time.  A new study in this week's Canadian Medical Association Journal shows that eloping from the hospital can be hazardous to your health.

Overall, around one to two percent of patients leave against medical advice.  But the rate is as high as ten percent among certain groups of patients.  People who are poor are more likely to leave; so too are the homeless and people who live in inner cities.  Patients with mental health problems and those with substance abuse issues leave prematurely.  People with HIV are another group who are prone to leave.  But people from all walks of life elope from hospital.  Some think they have better things to do.  In some cases, once they realize they aren't going to die, they get antsy about staying.  Some cannot stand the total loss of control that comes with being a patient.  I've had some leave because they have a pet at home they have to take care of.

Almost everyone who works inside the hospital's sliding doors has a story or two about a patient who left the hospital despite pleadings from doctors and nurses not to do so.  I've heard of one patient with flu-like symptoms who left an ER waiting room before seeing the doctor - only to die of meningitis at home.  Anecdotes like that don't give a fair picture.  Until now, there has been a lack of scientific research on what happens to patients who bolt. 

Turns out it's very risky according to researchers from the University of Manitoba.  They looked at patients admitted to hospital over a twenty year period in Manitoba from nineteen ninety to the end of two thousand nine.  Nearly two million patients were admitted to hospital during those twenty years; of those, more than twenty-one thousand got up and left the hospital even though their doctors urged them to stay.  Compared to patients who stayed until they were deemed well enough to go home, those who left against medical advice were three times more likely to be readmitted to hospital within thirty days and two and a half times more likely to die within ninety days.

What puts patients who leave the hospital at greater risk of harm than those who stay? One obvious factor is that patients who leave against medical advice do so before doctors can figure out what's wrong with them.  Whatever illness they have remains untreated until it gets a lot worse or resolves spontaneously.  Another explanation is that the patient who leaves prematurely may get an inadequate dose of antibiotics and other treatments.  But if these were the only reasons, then the adverse effect of leaving against medical advice would be as short-lived as most acute illnesses. 

In this study, the authors found that the risk of readmission or dying remained high for up to six months after the patient left the hospital against medical advice - far longer than the original problem that landed the patient in hospital in the first place.  That suggests there may be another explanation.  It may be that patients who leave against medical advice come to harm more often because they seldom if ever follow their doctor's advice.

I've been asked what it's like trying to persuade someone to stay. My initial reaction is that it feels like a colossal waste of time.  I'm literally running from one patient to the next.  I figure out a plan to admit a patient to hospital and I've moved on to other tasks. Then, the patient's nurse says he or she wants to leave.  The plan I've constructed starts to unravel.  I have to go back to the patient and try and persuade them to stay.  I have to size up the patient's mental status to make sure they aren't intoxicated or suffering from a medical condition that affects their ability to comprehend why they need admission.

These patients can also be prickly and difficult.  Doctors don't take took kindly to being challenged by patients.  While I'm trying to get the patient to stay, I have to resist the urge to just let him or her go.  Sometimes, nursing colleagues will ask me if it's okay to just let the patient leave the hospital. The fact that they may be preparing to leave abruptly may leave me no alternative but to drop everything else and run to the patient's bedside.   And if I can't persuade them stay, I worry that they'll be harmed by leaving and that their family will not forgive me.

The legal situation can be murky. Under provincial health legislation, I am legally entitled to detain and restrain patients who have a psychiatric disorder and who may be a danger to themselves or others or unable to look after themselves.  But many people who wish to leave do not have a psychiatric condition.  If an intoxicated patient with a life threatening illness demands to leave, I'm probably within my rights to restrain the patient in order to start life saving treatments.  Once they are no longer intoxicated, they would be free to accept or refuse ongoing treatment.  If a parent refuses lifesaving treatment for their child, it may be possible to have the child seized under child welfare laws. 

Many physicians believe that the medically and legally competent patient who leaves against medical advice is solely responsible for any adverse consequences.  Legal experts say that a signed release form that absolves the hospital of any responsibility may not hold up in court.

That's why experts recommend that doctors sit down with the patient and find out why they want to leave.  Often, one can address fears and concerns about hospitalization. For the patient who insists on leaving, it still be may possible to provide some level of care to the patient.  For instance, on occasion, I have brought patients who refuse admission back to the hospital on a daily basis to receive intravenous antibiotics in the ER. 

If the patient persists in wanting to leave, doctors should let patients know that they are always welcome back.  We should warn them what symptoms and signs should prompt them to return to the hospital or to see their regular physician.  In other words, just because they insist on leaving doesn't give us carte blanche to abandon them.

If you or a loved one are tempted to leave, don't do so until you have a chance to speak with the admitting doctor. Leaving against medical advice is an exercise in personal autonomy that can have life threatening consequences.

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