AMA

Kelly Heidepriem, MD, Drew Kalnow, DO, and Andy Little, DO

on Spotify

The summary below is from an episode of ERcast: Clinical Perspectives

Patients who leave the emergency department against medical advice often describe stigma, neglect, undertreated pain, and poorly managed withdrawal as the drivers. In patients with substance use disorder, AMA risk is tightly linked to communication, analgesia, and the tone set from first contact.

AMA Care for Patients With SUD

Front-door stigma signals: Stigmatization often starts before the physician encounter, with comments from registration, EMS, or staff shaping the visit. Early bias can determine whether a patient feels safe enough to stay for care.
Attending-set bedside tone: A brief explicit acknowledgment of addiction as a disease can reset the encounter and signal respect to the whole team. We get into the opening language that changes the room in the episode.
Pain and withdrawal balance: Patients with addiction still have real acute pain, and withdrawal can amplify it. Multimodal analgesia plus honest early discussion of the plan helps separate appropriate treatment from unsafe requests.
Naloxone dosing restraint: Overshooting reversal can precipitate severe unintended withdrawal, so the principle is the lowest dose needed for the desired effect. That practical distinction is worth hearing in the chapter.
Needs versus wants framing: Clear boundaries matter when requested treatments are inappropriate or harmful. The goal is to explain what the patient medically needs while preserving empathy and avoiding a punitive stance.
Consequences of leaving AMA: When patients leave after feeling judged or ignored, they may avoid future care, return sicker, or overdose before re-engaging. Early trust-building is therefore a clinical intervention, not just bedside manner.

Subscribe to ERcast: Clinical Perspectives to listen to the episode.

References:

Mayer S, Langheimer V, Nolan S, Boyd J, Small W, McNeil R (2023) Emergency department experiences of people who use drugs who left or were discharged from hospital against medical advice. PLoS ONE 18(2): e0282215. PMID: 36821576

Faculty

Kelly Heidepriem, MD
Dr. Heidepriem is a board-certified emergency medicine physician. She completed her residency at Brown University before getting homesick for the Midwest and returning closer to home where she practices in the community. She is also an associate professor at the University of South Dakota Sanford School of Medicine. Her podcasting journey began as a guest on Urgent Care RAP, which quickly led to a regular hosting role. Outside of work, Kelly is a dedicated runner, logging miles with her husband and the occasional guest star, Pete.
Drew Kalnow, DO
Dr. Drew Kalnow is an emergency medicine physician and educator based in Columbus, Ohio. He completed his emergency medicine training at OhioHealth Doctors Hospital Emergency Medicine Residency. Dr. Kalnow is passionate about advancing emergency medicine through high-quality education, with a particular focus on simulation, learning theory, and innovative teaching.
Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.