DISCUSSION
Since patients are admitted voluntarily to a general hospital, a discharge against medical advice is merely a withdrawal of the original consent. All competent adults possess the autonomy to make this decision. However, physicians and medical authorities have a responsibility to ensure, before discharging against medical advice, that: (1) the patient’s withdrawal of consent is fully informed with respect to risks and alternatives; (2) the patient possesses the mental competency to make a reasoned decision on the basis of adequate information; and (3) the patient does not meet the state standard for involuntary psychiatric hospitalization. Discharging against medical advice without documentation that the physician conscientiously addressed these 3 issues will leave the physician and the hospital authorities legally unprotected in the event of an adverse consequence.
Even if these 3 safeguards are in place, the cases in the literature illustrate that the term “against medical advice” is not necessarily protective. It might appear that a competent patient not meeting criteria for involuntary hospitalization who has received all relevant information and then suffers an adverse event causally related to an “against medical advice” decision would have no claim against the physician or the medical authorities. But as noted in Weinstock v Ott,12 the physician has a duty of care which, in that case, included a duty to refer the patient for a diagnostic consultation. The patient’s decision to leave against medical advice may be regarded as reasonable in certain circumstances, and if so, this type of discharge offers no protection.
In Suria v Shiffman,13 the issue of contributory negligence arose again. In that case, the patient was held responsible for a proportion of the damages suffered and, while the defendant was ruled against by the court, the liability for the full extent of the damages was reduced accordingly. This may be regarded as a partial protection, but courts and juries are reluctant to invoke this against a patient who is seen as the underdog. That was the situation in Hawkins v Brooklyn-Caledonian Hospital.15 The dissenting judge in that case bore no sympathy for Mr Hawkins, who was a drug addict and caused most of his own misfortune. However, the other 3 judges, who ruled for the plaintiff, were more sympathetic.
The psychiatric cases cited16,17 show that if the criteria for involuntary commitment are not met, “against medical consent” appears to provide a comfortable degree of legal protection.
Pollicina v Misericordia Hospital Medical Center14 suggests that a patient’s duty is to seek alternative care when leaving against medical advice. When this duty is ignored, protection exists for the physician or hospital.
City of New York v Antoinette R19 illustrates, in a tuberculosis case analogous to the psychiatric cases, that a third party subsequently infected by a patient who should have been detained under a city order could have grounds for a successful suit against the physicians and medical authorities who failed to protect the community.
Conclusions
There is no substitute for good clinical care and thorough documentation. Before discharging a patient “against medical advice,” a physician should ensure that the patient is mentally competent, fully informed, and does not meet the criteria for involuntary psychiatric hospitalization. We offer guidelines for physicians in the Table.