AMA Discharge and Case Management’s Responsibility: Ethical and Compliance Quandary

Consider this scenario:

A patient is admitted to the hospital and the physician and treatment team recommendation is clear: the patient would benefit from being discharge to a skilled nursing facility (SNF). However, the patient adamantly refuses and only wishes to go home. Does the physician have the right to request that the patient leave the hospital against medical advice, or AMA?

This question has become a hot topic in acute care case management circles, and the short answer to it is “No”. However, like most decisions in our practice world, there are several nuances to consider. Oh, there are logistical concerns about when, if, and what type of written notification to provide the patient and family about denial of care and coverage. This article is not about those moving parts of Utilization Management. Instead, this piece addresses proactive ways for case managers to stay out of ethical and compliance trouble! 

Patient Autonomy 

As Physician Advisor thought leader, Dr. Ronald Hirsch, recently noted in a post for the Case Managers Community, there is no requirement that the patient actually sign a form for the discharge to be considered AMA. If the patient is leaving against the advice of the physician, even if the patient is discharged with prescriptions and follow up plans, it can be considered against medical advice. If a patient insists on going home, but the physician knows the home environment is not safe and advises the patient not to do it, their discharge is against medical advice, and can be coded as such. 

Yet, when a patient declines a physician advised, skilled nursing facility discharge, it IS NOT always against medical advice. Patients can still receive care in their home, even if that care is suboptimal for their condition. Patients have autonomy, which must be respected. With autonomy comes the right for patients to also make bad decisions. 

Case managers should be mindful of not abandoning patients or quickly reacting to their request to leave before the treatment team and provider indicate the clinical readiness to do so. In fact, best practice should involve assessing a patient’s motivation to leave AMA vs. an in the moment reaction to it. This is where keen case management assessment, intervention, and documentation enter the scene. That focus, plus the reminders below provide case managers and their employers some level of medical and legal protection should an adverse event occur post-discharge.

What Case Managers Need to Know

1. Every organization should have a clear AMA policy that is aligned with Federal requirements, including the Medicare Conditions of Participation (COPs) for Discharge Planning, Patient Bill of Rights, and any relevant state laws; several states also have “Right to fail” laws, such as Vermont. 
2. Quality documentation should reflect how the case manager fulfilled that AMA policy. At the least, there should also be documentation of the patient’s “informed refusal” of care. This concept is a thread of “informed consent”, and relevant to this article’s theme. Remember, if it wasn’t documented, it didn’t happen!
3. Patients with clinical and legal capacity (AKA competence) or their legal decision-makers have the right to refuse treatment, discharge plans, and other interventions. It is why those situations should not be viewed as AMA discharges. This will get sticky in that a discharge must be “safe” (Nod to Tiffany Ferguson’s recent article, Understanding the ‘Safe Discharge’ Plan). This is one of many reasons why some providers may opt to define a specific discharge plan, as an SNF or home with 24 hours of supervision. Unfortunately, these plans are recommendations only. Final decision-making is up to the patient and their legal decision-maker, and leads to the next point.
4. Those Medicare COPs are clear in that professionals involved in discharge planning processes should document how all options and information about those processes were reviewed and provided to patients and their decision-makers as relevant. This action should be done in a language or mechanism reflective of a patient’s unique needs (e.g., language proficiency, visible and invisible disabilities, health literacy).
5. Case managers should consider the 5 Core Considerations for Case Managers. These 5 Cs are aligned with those ethical, regulatory, and legal requirements:
   • Ensure patient Clinical Capacity, and
   • Legal Capacity (Competency)
   • Consider how the patient and family are Coping, then
   • Provide Choice
   • Complete the process via clear Communication

By using the 5Cs, case managers fulfill their ethical and legal obligation to inform the patient what can and can’t be provided safely and realistically. This dialogue doesn’t have to start as an antagonistic discussion, but rather an informative one. There are usually a number of emotions at play in these situations, especially as patients (and families) come to terms with lack of control around an unexpected illness, prognosis or outcome, such as decreased independence. These dynamics can easily make for tough maneuvering of these situations for all involved, and especially case managers. This is where attention to coping comes in. 

No case manager wants is to be accused of abandoning a patient. In situations where the patient defies treatment team (and provider) recommendations and discharges to home rather than a nursing home, the traditional industry recommendation is to provide discharge instructions, prescriptions, and follow-up appointments. You can also call Adult Protective Services if there are documented concerns of patient safety, or potential for abuse, neglect, or exploitation. 

6. All case managers, independent of case management credential (e.g., ACM, CCM, CMGT-BC) and discipline (e.g., counseling nursing, rehabilitation professional, social work) are mandated to heed case management’s codes of ethical and professional conduct, and standards of practice, particularly:

• Ethical Principles: Autonomy, Beneficence, Fidelity, Justice, and Nonmaleficence
• CMSA Standards of Practice– B. Professional Responsibilities C. Legal, D. Ethics, E. Advocacy G. Resource Management J. Client Assessment, K. Identification of Care Needs and Opportunity L. Planning M. Facilitation, Coordination, and Collaboration 

• ACMA Standards– Accountability, Professionalism, Collaboration, Advocacy, Resource Management.

NOTE: ANCC’s Nursing Case Management credential (CMGT-BC) has a formal test reference list that incorporates items a and b above.

7. All professional case managers should receive onboarding to understand these nuances in and requirements for care. Case management bears a hefty responsibility to assess, facilitate, and coordinate care for patients, and through quality-driven collaboration with the interdisciplinary treatment team. Case managers also advocate on behalf of patients to ensure that their highest degree of self-sufficiency and autonomy are met when possible. Patient advocacy is among the profession’s most vital objectives.

These books published through the Case Management Institute validate and expand on this article, and should be part of every professional case manager’s library!

• The Ethical Case Manager: Tools and Tactics: identified as a formal test reference by ANCC Certification for their Nursing Case Management exam (CMGT-RN) and valued reference for the CCM exam
• A Practical Guide to Acute Care Case Management: identified as a formal test reference by ANCC Certification for their Nursing Case Management exam (CMGT-RN) and a valued reference for the ACM exam.