Delivering high-quality healthcare becomes difficult when patients disregard their doctors’ advice. A patient who chooses to leave the hospital against medical advice (“AMA”) represents a particularly severe case of non-compliance. The rates at which Medicare enrollees leave acute-care hospitals AMA have steadily increased since 2006, spiking during the COVID-19 public health emergency, according to an analysis released by the U.S. Department of Health & Human Services, Office of Inspector General (“HHS-OIG”).1 The discharge rates rose from 0.68% in 2006 to 0.99% in 2019. That rate spiked to 1.17% during the pandemic. Post-pandemic AMA discharge rates among Medicare enrollees have abated but are still slightly higher than pre-pandemic, hovering at roughly 1%.2 The growth in the rates of enrollees who left AMA appeared consistent across most of the demographics that HHS-OIG analyzed, including enrollee type, hospital size, population density, and medical condition.
Patients who leave AMA are more likely to have poor health outcomes than those discharged to their homes. Per the HHS-OIG study, when enrollees left AMA, they were more than twice as likely to be readmitted or die within 30 days of discharge than enrollees discharged home. The health outcomes for enrollees who leave AMA has remained fairly constant, except for a spike in mortality during the COVID-19 public health emergency. Patients who leave AMA often face more costly and intensive future healthcare needs due to unresolved medical conditions or subsequent complications, increasing the financial strain on the Medicare program.
These rising AMA discharge rates could indicate a breakdown in the active partnership between the hospital and patients in preparing for their post-hospitalization care. Hospitals participating in Medicare and Medicaid programs should start the discharge planning process early and include the patient and the patient’s caregiver as active partners in the process. However, CMS has not issued guidance on how to reconcile this requirement when a patient decides to leave AMA. It merely states that it “expect[s] hospitals to document in the medical record the patient’s refusal to participate in the discharge planning process, and that such attempts to include the patient and/or the patient’s caregiver in the discharge planning process were made by hospital staff.”3
Consequently, hospitals typically ask patients to sign a form indicating that they acknowledge they are leaving AMA, understand the risks associated with leaving AMA, and release the hospital and its employees from liability. However, these waivers may not alleviate all liability for the hospital or its employees. There are several steps hospitals should take to mitigate risks, including:
- ensuring that any critical test results are reviewed before discharge;
- carefully assessing whether the patient is mentally capable of deciding to leave AMA; and
- informing such patients of the risks of such a departure.
Even if an AMA form is used, it is vital that the medical records themselves clearly reflect the decision-making process between the physician, patient, and any third parties.
Examples of hospitals facing liability when they miss such steps, include:
- A legally intoxicated man presented to an emergency department (“ED”) with blunt-force head trauma.4 The physician read his skull x-ray as normal, but attempted to explain to the patient reasons he should stay for observation anyway. After the patient left AMA, a hospital radiologist read the patient’s x-ray and noted a markedly depressed skull fracture. The patient returned to the hospital for treatment but ended up suffering a brain injury from the fracture, which affected his cognitive abilities. The patient sued, claiming that half of the injury was attributable to the delay. The case settled within the physician’s insurance limits to avoid the risk of liability due to the patient’s questionable ability to make an informed refusal of care.
- A paraplegic man who self-catheterized for urine management arrived at an ED with complaints of fever, vomiting, and other gastrointestinal distress.5 He was triaged as non-urgent and was ordered laboratory testing, fluids, and pain and nausea medications. After administering the fluids but before receiving lab results, a physician assessed the patient as “improving.” The physician had intended to reassess the patient after reviewing the lab results but, per nursing staff, the patient sought to leave AMA. Though the request was never documented in his chart, the patient was discharged roughly four hours after his ED arrival with prescriptions for pain and nausea medications. By this time, abnormal blood and urinalysis test results had been entered into the chart, but the patient left before the physician could review the results with the patient. The patient returned the following day with complaints of nausea and chest pain, and died three days later from sepsis from an untreated urinary tract infection. The case settled out of court.
- A woman with a history of coronary disease presented to an ED with diffuse abdominal pain.6 Her vitals and abdominal CT scan were normal and her lab results were unremarkable except for an elevated white blood cell count. The physician recommended that the patient be admitted for observation since her pain had not improved during her ED stay, but the patient declined, citing cost concerns and care obligations. After a long discussion, she signed an AMA form and left. The following night, she was admitted to a different hospital with acute ischemic colitis and infarction (i.e., insufficient blood flow to the colon leading to inflammation and tissue death) requiring emergency surgery. The physician’s insurer noted the risk for a lawsuit in this case due to the patient’s poor outcome.
When a patient insists on leaving the hospital AMA, the priority should be to deliver the highest quality care possible despite the less-than-ideal situation. To support this, hospitals should implement a consistent discharge protocol for AMA cases to ensure all critical steps are followed. This becomes especially crucial during nights or weekends, when the likelihood of missing important safety measures is higher.
[1] U.S. Department of Health & Human Services Office Of Inspector General, Data Brief A-04-24-03003: Medicare Enrollees Leaving Acute-Care Hospitals Against Medical Advice, (Aug. 21, 2025), available at https://oig.hhs.gov/documents/audit/10896/A-04-24-03003.pdf.
[2] Per the HHS-OIG report, enrollees left AMA 72,529 times out of 10,699,861 in 2006 and 84,123 times out of 8,456,947 in 2019. The report did not provide comparable numbers for 2023, the last year covered in the audit, but did note that the total number of stays for which enrollees left AMA has not had the same growth as the rate of enrollees leaving AMA because of the decline in the total number of Part A acute-care hospital inpatient discharges. Approximately 1-2% of all hospitalizations in the United States result in an AMA discharge. Am J Med. 2021 Jun;134(6):721-26.
[3] 84 Fed. Reg. 51836, 51855 (Sept. 30, 2019).
[4] Ann W. Latner, Physician Sued After Letting Patient Leave Against Medical Advice, Medical Professionals Reference (Aug. 6, 2018), available at https://www.empr.com/home/features/physician-sued-after-letting-patient-leave-against-medical-advice/.
[5] Curi Insurance Editorial Team, Claims Case Study: The Patient Who Left Against Medical Advice (Oct. 19, 2017), available at https://curi.com/news/patients-leave-against-medical-advice/.
[6] Eric Zacharias, Lessons in Liability: Against Medical Advice (Feb. 2005) available at https://www.copic.com/resource/lessons-in-liability-against-medical-advice/.
