How to discharge a patient who does not want to be discharged? Staying AMA

Many physicians are familiar with patients who leave against medical advice, much less known is the refusal to leave the hospital. Here we report a case, that we encountered during the Covid pandemic, of a patient who was convinced of having Cauda-Equina syndrome and refused to leave the hospital until the MRI was done. Taking inspiration from this case, we decided to offer a practical approach to dealing with situations like these, to avoid discharge to the street and discuss the ethical implications of similar situations, like the one we encountered. Proactive psychiatric consultation services were demonstrated to reduce the length of stay. Based on these considerations we also suggest early psychiatric consultation to assist medical teams in identifying possible barriers to discharge and help with the management of these difficult cases. Hospitals should also develop internal protocols to deal with difficult discharges. Well-defined protocols could help to deal with emotional states such as bursts of outrage and allegations of abandonment by the patients, like the ones we recently encountered. Nonetheless, we believe a shared discharge decision between patients and physicians should be the common goal. This problem is often encountered in clinical practice but literature on the matter is scarce, since staying against medical advice (SAMA) is far less common than its sibling: leaving against medical advice (LAMA).