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Case Vignette
Vignette
Clement D. Lee, M.D., M.Sc.
A 35-year-old man presents to emergency room with body aches and fever. He has a history of intravenous heroin use disorder, with prior emergency room presentations for cellulitis, opiate withdrawal, and passive suicidal ideation.
On presentation, his vital signs are notable for a fever of 101.5° and tachycardia at 114 beats per minute. Examination is notable for a new grade III/VI holosystolic murmur heard best at the left lower sternal border, louder with inspiration and without an associated right ventricular heave. Bounding C-V waves are noted on jugular venous examination. A complete blood count, comprehensive metabolic panel, inflammatory markers, and blood cultures are sent. Echocardiography is ordered for suspected right-sided endocarditis, and acetaminophen and hydromorphone are administered for fever and pain. He is started on empiric antibiotics for endocarditis, and admission to the hospital planned
With control of his fever and pain, the patient reports improvement of his symptoms and would like to leave the hospital. Medication-assisted treatment (MAT) for his opioid use disorder is offered but he declines. The potential for serious complications of untreated endocarditis, such as valve rupture, pulmonary septic emboli, heart failure, and death are explained to the patient. He participates in the conversation and appears to comprehend the risk involved, but still prefers not to stay for additional workup as he fears hospitals. As his treating physician, you are handed a form for him to sign to document his leaving against medical advice.
In a patient like this with a potential life-threatening medical condition who defers further evaluation, should his discharge be documented as having been done so against medical advice (AMA)?
Treatment Options
Which one of the following approaches would you take? Base your choice on the literature, your own experience, published guidelines, and other information.
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Document this discharge as being against medical advice (AMA)
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Do not document this discharge as being against medical advice (AMA)
To aid in your decision making, we asked two experts in the field to summarize the evidence in favor of approaches assigned by the editors. Given your knowledge of the issue and the points made by the experts, which approach would you choose?
- Option 1: Document this discharge as being against medical advice (AMA)
- Option 2: Do not document this discharge as being against medical advice (AMA)
