What does it mean to leave rehab against medical advice?
If you’ve decided to get help for a drug and alcohol problem but are wanting to leave against medical advice, do yourself a favor: Sit still for 24 hours.
Rather than making a premature decision in the moment, wait. Talk it over with peers, with counselors, with family members. Don’t do anything rash, because chances are good you’re not thinking clearly. (Addicts and alcoholics in the initial stages of their sobriety journeys rarely do.) Furthermore, there’s a good chance that the voice telling you to jump ship doesn’t have your best interests at heart.
“A lot of times, leaving AMA (against medical advice) is brought on, I think, by the shame and guilt that people feel due to their actions, the things that led them in the door,” says Webster Bailey, Executive Director of Business Development and Marketing at Cornerstone of Recovery, himself a recovering addict. “What we’re really good at is making a mess, and then the next day going and cleaning it up, smoothing it over and being the con artists that we are. But when we’re sitting in treatment, and we realize we’ve made this really big mess, everything in us is screaming that we need to go and fix it.
“We don’t want to lose the job, the wife, the kids, and we don’t do well as addicts and alcoholics just sitting still. And we feel like we’re stuck in that pain and that place of feeling like the world is crumbling around us. Part of that process is wanting to run out the door to fix it all or sweep it under the rug, but because we’re not fully in recovery, the only solution we really have at our disposal to quiet that guilt and shame is using again.”
AMA: What It Means
So what does it mean to leave rehab against medical advice? To get the full picture, it’s worthwhile to note that it’s not a situation limited to drug and alcohol treatment centers. According to a 2009 article in the journal Mayo Clinic Proceedings, “Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem … between 1% and 2% of all medical admissions result in an AMA discharge.”
Those who make the decision to leave rehab against medical advice share commonalities with those who choose to terminate other forms of medical treatment, says Dr. Scott Anderson, the Clinical Director at Cornerstone of Recovery.
“What that means for us is that you’ve yet to meet the goals and objectives of your treatment plan, and in our opinion, if you fail to complete those goals and objectives, you’re at a higher risk for a relapse and your disease taking hold,” Anderson says. “I think you can draw a direct metaphor to any medical condition: For example, if you’re prescribed antibiotics and you terminate them prematurely, the odds of that infection coming back or growing stronger because you’ve done that are pretty high.
“Or, if you have surgery on a joint, and you’re prescribed physical therapy to help rehabilitation, but you terminate that prematurely, you’re at a lot higher risk of complications or undoing the positive benefits of the surgery you had. With cancer, whether it’s radiation or chemotherapy or surgery, if you choose to terminate that course of treatment before you’ve met the goals and objectives of that particular form of therapy, you put yourself at a lot higher risk of recidivism.
“The reality is, there are consequences to our actions,” Anderson adds. “And if you decide to leave rehab AMA, the consequences could be a diminished chance of recovery and a greater chance of health or legal consequences.”
In keeping with the ties between addiction medicine and physical health care, a 2018 study in the Journal of Addictive Medicine drew even starker parallels between the two, comparing the statistics of those who left hospital care early with those who disengage from the treatment process: “Leaving hospital against medical advice (AMA) exposes patients to the harms of inadequately treated medical conditions and up to a threefold increase in one year mortality. It also places a strain on the healthcare system, as those with serious illnesses that have not completed treatment prior to discharge often need to be readmitted and may return with a more serious form of illnesses requiring a lengthier stay. Patients with substance use disorders (SUDs) have an increased likelihood of leaving … AMA, which puts this population that is known to be socially and physically vulnerable, at even higher risk for poor outcomes.”
Additional studies have found that those who choose to leave rehab against medical advice do indeed face worth outcomes and more readmissions compared to patients who successfully completed a treatment program. In fact, a 2017 study in the Journal of Hospital Medicine found that 35.8% of AMA discharges returned within 30 days, and 16% was admitted within 30 days.
Why Do Patients Leave Rehab Against Medical Advice?
For Bailey, no stranger to the treatment process, the decision by patients to leave AMA is one that usually takes place after a few days in treatment. When patients first call the Cornerstone Admissions Department, they’re desperate to get help; after a few days of Medical Detox, once the mental fog begins to lift and the physical pain begins to subside, the reality of their situations becomes clear, and the aforementioned desire to “make things right” suddenly feels overwhelming, he said.
“A lot of times they’re missing family members, but more than anything else, they feel a sense of work responsibility to take care of financial woes,” he says. “We hear a lot, ‘I’ve got to get back to work because I’ve got to pay my bills,’ and it’s usually always a variation of that. Very rarely have I heard, ‘My family members aren’t supportive of me being here, and they think I’m ready to come home now.’
“Generally, that urgency is in their heads, and it’s because they spend a lot of time thinking and trying to solve their problems internally rather than talking them out and getting feedback from the professionals, the counselors and their peers.”
It’s important to note, Bailey adds, that discharging a patient against medical advice isn’t an arbitrary decision. The initial stage of the process involves the Assessment and Orientation of each patient, who collaborate with clinical staff on an individualized treatment plan. That’s done through a series of questions that address a patient’s physical, psychological, psychiatric and social needs that will determine which issues and therapies will be a part of that individual’s treatment. In a sense, Bailey says, it’s a contract, and those who choose to leave AMA are breaking it. And while that may not seem like a big deal to most patients, to those who are court-mandated to complete a program in order to offset legal consequences, or those who have to complete treatment in order to return to work, it can be the difference between staying out of jail and staying out of the unemployment line.
“It essentially means they did not complete the treatment plan that they helped to create,” Bailey says. “When a treatment plan is created, it’s created by the patient and the staff combined, and it’s geared toward the issues an individual has. If they decided to leave AMA, they’re leaving before the work is done. They haven’t completed what they set out to do, and in the eyes of a court system or an employer, their treatment is unfulfilled.”
And whether the patient leaves AMA three days into the process or two days before they’re scheduled to complete treatment, the end result is the same. It is, he adds, like dropping out of high school: It doesn’t matter if you drop out during your freshman year or in February of your senior year; the work is incomplete, and a diploma will be withheld.
“What that means for us is we’re not able to provide a letter of completion that a lot of times people need to be able to go back to work or to satisfy any kind of legal issues that are going on, or sometimes just to satisfy family members,” he says.
AMA Blocking: What It Involves
Those who decided to leave rehab against medical advice aren’t just met with a shrug of the shoulders, however. While Cornerstone of Recovery (and most other drug and alcohol treatment facilities) doesn’t keep anyone against his or her will, there are steps that can be taken to ensure that those individuals remain in treatment.
“When we find out that a patient is talking about leaving early, whether they come to staff or they’ve been talking within their community of peers, and the peers then notify us, we confront the situation head on and try to intervene,” Bailey says. “The intervention is to try to keep them engaged in the treatment process at the appropriate level of care. A lot of times, the AMA blocking is done by staff only, so we typically try to have multiple staff available so that we can have a more well-rounded discussion.
“We’ve also been very successful at doing AMA blocking in group settings, like a process group or group therapy, where they can hear what their peers have to say. Because a lot of times, the fellow patients end up doing as good of a job as staff, and because it’s not just the staff, the patient who’s wanting to leave rehab against medical advice feels like there’s a camaraderie there that can be an incentive to stay.”
And, he adds, it’s important to always be prepared. Patients who wish to leave rehab against medical advice don’t necessarily fit a certain pattern, and their desire to do so can be a spur-of-the-moment decision.
“AMA discharges are, by their definition, generally unplanned and thus create a culture of crisis among those staff trying to prevent them,” writes Rebekah Bray for the news magazine McKnight’s Long-Term Care News. “This ‘crisis mode’ mentality does not lend itself to retrospective thoughts processes to identify potential risk factors that led up to that moment and thus provides little actionable intel that could allow staff to identify the precipitating factors and mitigate them.”
Sometimes, Cornerstone Associate Clinical Director Julie Hamlin says, talking out the potential consequences can make all the difference.
“We tell them, ‘You may not think there’s a consequence, but what’s the risk if you leave? Have you gotten what you need to successfully stay sober? Have you met your agreement to complete treatment? What does it mean if you haven’t done what you’re supposed to do? What are you outside relationships going to be like?’” Hamlin says. “We want them to understand what the risk is if they decide to leave AMA and have not fully engaged in treatment and gotten what they need out of it, because they don’t have the support they need, and they haven’t learned what they need to learn to deal with problems and manage their recovery.”
It’s a simple cause-and-effect, Anderson adds: While treatment is no guarantee, successful completion of it leads to a greater likelihood of long-term sobriety. Deciding to leave rehab against medical advice undercuts those chances.
“When you leave early, you’re decreasing the likelihood of your rewards and increasing the likelihood of negative consequences,” he says. “It’s staff’s job to point out both of those things, and how they can benefit by continuing on the current course.”
Deciding to Leave Rehab Against Medical Advice: What Happens
What happens when a patient decides to leave rehab against medical advice depends on the level of care that patient happens to be in at the time. AMA blocking occurs at all levels, but a patient who’s still in the medical detox phase of treatment is of greater concern than those who aren’t, according to Cornerstone Director of Medical Services Travis Pyle.
“If someone decides to leave AMA and they’re on detox medication, someone has to sign them out and accept responsibility for them,” he says. “If they don’t want to take that route, we have to call the police if they leave and they’re under the influence of detox medications like buprenorphine or phenobarbital. There’s an 8- to 12-hour window in which they have to be off of detox meds before they can leave on their own will.”
The reason, of course, is that those drugs, used to slowly taper individuals off of alcohol and opioids (in addition to other drugs), have mind- and mood-altering effects that can compromise an AMA patient’s ability to operate a motor vehicle. But even if that patient decides to call an Uber or a family member to pick them up, it’s still an interruption and a discontinuation of the treatment plan, Pyle adds.
“If we’ve started them on detox medication, and they decide to leave, we won’t continue it,” he says. “They won’t get any letters from medical staff for work or any other releases.”
For patients who have been directed to treatment by an employee assistance program, that could mean they’re terminated from employment. For those in legal jeopardy, it may mean they face legal consequences. Those decisions are up to employers and the justice system, and in the majority of cases where an inmate is furloughed from jail to treatment, part of the agreement between the district attorney’s office and Cornerstone of Recovery is that staff members must notify law enforcement if the furloughed patient leaves AMA.
“It’s a release for the courts that says upon discharge from Cornerstone, the defendant is immediately remanded to the sheriff of the supervisory county,” says Douglas Nanney, a licensed attorney and former Admissions counselor with Cornerstone of Recovery. “And that’s not revokable by the patient. It’s a court order signed by the judge that’s incorporated into the agreement, so the defendant can’t revoke permission for us to notify (law enforcement).”
Furthermore, Nanney adds, individuals who are on probation but leave AMA won’t get a certificate of completion to turn in to their probation officers. Depending on the severity of the charges or the probation agreement, that could mean jail time. Those and other factors play into attempts by staff during AMA blocking, says Hamlin.
“We bring in all of the modalities to try and help someone understand,” she says. “We get the staff to help, the peers to help, even their families to help, and then maybe we can wrap enough concern and care around them that they decide to stay.”
Financial Considerations and Other Concerns
Just as addicts and alcoholics are likely to agree to any stipulations in order to get the drugs and alcohol they need to continue to function, so too are they willing to agree to whatever terms a treatment facility places upon them in order to make the pain stop.
Most of the time, those who have second thoughts do so around financial obligations. While Cornerstone is a moderately priced private pay and private insurance facility, patients who find themselves feeling better after a few days often have second thoughts when it comes to deductibles and co-pays in order to meet the cost of treatment, Bailey says.
“Our main concern is them getting what they need,” he says. “We have flexible payment options, and we remind them that they don’t have to have the money today. Once an individual becomes our patient, them getting the care they need is priority No. 1. Obviously, we’re a business that’s concerned about finances, but ultimately, we’re trying to get them the treatment they need to stay well.”
In addition, convincing a patient who wants to leave rehab against medical advice to stay put is a sound fiscal decision, Bailey adds. An individual who chooses to terminate treatment early is at a greater risk of relapse, and a relapse often leads to financial devastation, which dramatically increases the likelihood of those individuals defaulting on payment agreements and plans. To that end, Cornerstone works with patients to set up flexible, long-term payment options that won’t break the bank.
“We’ve been really good at offering those options over years with no interest, and while we’re trying to remind people of that, we’re also reminding them — especially folks trying to leave early so they can get back to work and pay their bills — that the No. 1 lesson in recovery is that anything you put ahead of your recovery, you’re going to lose,” Bailey says. “If your No. 1 priority is work, there’s a very good chance you’re not going to stay sober. Our job is to educate them about those things.”
“A lot of times, we may not understand why we need to do something, but we do it anyway on the advice of people who have dealt with hundreds or thousands of other cases,” Anderson adds. “That’s the situation we’re in: We’ve dealt with thousands of people going through this process. And even though once they feel a little better they begin to think, ‘I’ve got this,’ we know that their confidence outweighs their skill levels. They don’t grasp how difficult it is, how recovery takes coping skills and a support system in place to get through hard times, and that’s not something that happens overnight.”
Sometimes, however, those who wish to leave rehab against medical advice just aren’t ready. They may feel that way when they make the initial phone call, but without the anesthetic of drugs and alcohol to dull their senses, they find that reality is too frightening or too stressful. That’s a natural feeling for most newly sober addicts and alcoholics, and often that means the staff at a drug and alcohol treatment center need to use patience, empathy and perspective to help those individuals make it through a rough patch.
“Addicts and alcoholics a lot of times do not like being in a place where they have to follow a schedule, where there are rules. They don’t function well in that environment, and they want to be the one in control,” Bailey says. “Sometimes that can lead to wanting to leave rehab against medical advice, and sometimes they think they’ve gotten all they can out of treatment.
“In those instances, it’s good to remind them of what thinks were like on day one when they called us. We can even go back and look at the call logs, or look at their (initial paperwork), and remind them, ‘When you called, you were in quite a pinch. Do you remember what that felt like? That was just two weeks ago.’ It’s important to remind them that if they leave before the process is complete, they’re generally going to fall right back into what they were doing before.”