title: Providers' perceptions of relationships and professional roles when caring for patients who leave the hospital against medical advice.
abstract: BACKGROUND
  Patients who leave hospitals against medical advice (AMA) may be at risk for adverse health outcomes. Their decision to leave may not be clearly understood by providers. This study explored providers' experiences with and attitudes toward patients who leave the hospital AMA.
  
  
  OBJECTIVE
  To explore providers' experiences with and attitudes toward patients who leave the hospital AMA.
  
  
  METHODS
  We conducted interviews with university-based internal medicine residents and practicing internal medicine clinicians caring for patients at a community hospital from July 2006 to August 2007. We approached 34 providers within 3 days of discharging a patient AMA. The semi-structured instrument elicited perceptions of care, emotions, and challenges faced when caring for patients who leave AMA. Using an editing analysis style, investigators independently coded transcripts, agreeing on the coding template and its application.
  
  
  METHODS
  All 34 providers (100%) participated. Providers averaged 32.6 years of age, 22 (61%) were men, 20 (59%) were housestaff from three residency programs, 13 (38%) were faculty, hospitalist physicians, or chief residents serving as ward attendings, and one (3%) was a physician assistant.
  
  
  RESULTS
  Four themes emerged: 1) providers' beliefs that patients lack insight into their medical conditions; 2) suboptimal communication, mistrust, and conflict; 3) providers' attempts to empathize with patients' concerns; and 4) providers' professional roles and obligations toward patients who leave AMA.
  
  
  CONCLUSIONS
  Our study revealed that patients who leave AMA influence providers' perceptions of their patients' insight, and their own patient-provider communication, empathy for patients, and professional roles and obligations. Future research should investigate educational interventions to optimize patient-centered communication and support providers in their decisional conflicts when these challenging patient-provider discussions occur.
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. donna.windish@yale.edu
authors.forename: Donna M
authors.initials: DM
authors.lastname: Windish
authors.forename: Neda
authors.initials: N
authors.lastname: Ratanawongsa
mesh_terms: D000328:Adult; D003376:Counseling / Q000379:methods; D005260:Female; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D007407:Interviews as Topic / Q000379:methods; D008297:Male; D005791:Patient Care / Q000379:methods / Q000523:psychology; D010351:Patient Discharge; D024382:Professional Role / Q000523:psychology*; D011369:Professional-Patient Relations; D016312:Treatment Refusal / Q000523:psychology*