Two sides of the same story: a side-by-side analysis of patient narratives and electronic medical records in self-managed discharges of individuals experiencing homelessness

Discharge Against Medical Advice (AMA) disproportionately affects individuals experiencing homelessness, who leave hospitals AMA at rates four times higher than housed populations [Choi M, Kim H, Qian H, Palepu A. Readmission Rates of Patients Discharged against Medical Advice: A Matched Cohort Study. PLoS ONE. 2011;6(9):e24459]. Common explanations emphasize patient non-compliance, overlooking systemic, environmental, and clinician-level factors [FNU Jaydev, Gavin W, Russ J, Holmes E, Kumar V, Sadowski J, et al. Discharges against medical advice: time to take another look. A retrospective review of discharges against medical advice focused on prevention. Hospital Practice. 2023;51(5):288–294]. This qualitative study bridges a gap by comparing self-reported experiences of eight adults experiencing homelessness discharged AMA from an urban academic hospital in a small New-England state with their electronic medical record (EMR) documentation. Data were gathered through semi-structured interviews and EMR review and analyzed thematically to identify alignments and discrepancies. Results reveal that AMA discharges are often rational responses to a complex crisis of mistrust, multi-systemic neglect, and institutional stigma rather than individual failings. Participants described pervasive stereotyping, communication breakdowns, punitive institutional responses such as withdrawal of follow-up care, and re-traumatization upon re-engagement with healthcare. These findings challenge dominant narratives by framing AMA discharges as structurally compelled exits driven by institutional pathologies, rather than by poor individual decision-making. The study calls for systemic reform, including renaming AMA to “patient-directed” or “self-managed” discharge to reduce stigma, adopting harm reduction approaches that maintain access to care, improving patient-centered communication, and strengthening collaboration with community providers.