Psychiatric Management of Patients Who Threaten to Sign out against Medical Advice

Patients who are seriously ill are often unable to tolerate the stress of hospitalization and threaten to sign out against medical advice. Such a crisis often evolves because of inadequate or distorted communication with persons in the hospital environment such as physician and other patients. Physical illness, which stirs up issues of autonomy or loss of control, can compromise an individual's ability to cope. The patient, fearing loss of control, can utilize denial in his decision to leave the hospital prematurely. By exploring these factors, the psychiatric consultant can effectively evaluate and then manage this difficult situation, from his own position in the small group comprised of patient, staff and consultant. Case examples illustrate effective evaluation and management of the patient who threatens to sign out against medical advice.