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Discharging Patients Against Medical Advice

ARTICLE: Discharging Patients Against Medical Advice

AUTHORS: Clement D Lee, Michelle M Mello, Owen Bradfield, Mary Catherine Beach

JOURNAL: N Engl J Med. 2023 Mar 30;388(13):1230-1232. doi: 10.1056/NEJMclde2210118.

Case Vignette

A 35-year-old man presents to the emergency department with body aches and fever. He has a history of intravenous heroin use disorder, with previous emergency department visits for cellulitis, opiate withdrawal, and passive suicidal ideation.

On presentation, his vital signs are notable for a temperature of 38.6°C (101.5°F) and tachycardia, with a heart rate of 114 beats per minute. The physical examination reveals a new grade 3/6 holosystolic murmur heard best at the left lower sternal border; the murmur is louder with inspiration, and no associated right ventricular heave is heard. Bounding C-V waves are noted on examination of the jugular vein. Samples are obtained for a complete blood count, a comprehensive metabolic panel, measurement of levels of inflammatory markers, and blood cultures. Echocardiography is ordered because of suspected endocarditis on the right side of the heart, and acetaminophen and hydromorphone are administered for fever and pain, respectively. Empirical antibiotic therapy is initiated for endocarditis, and admission to the hospital is planned.

With his fever and pain now controlled, the patient reports amelioration of his symptoms and would like to leave the hospital. Medication-assisted treatment for his opioid use disorder is offered, but the patient declines. The potential for serious complications of untreated endocarditis, such as valve rupture, septic pulmonary emboli, heart failure, and death, is 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 because he fears hospitals. As his treating physician, you must decide whether this patient, who has a potential life-threatening medical condition but defers further evaluation, should have his discharge documented as being against medical advice.

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Kelsey Bennett

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