PE R S PE C T IV E
children; nurses, doctors, teach- conception that we are all free to
ers, and our government are not
plotting and conspiring to injure
children. We know that children
are our future.
Infectious agents are, unfor-
tunately, infectious, and parents’
choice not to vaccinate produces
children who spread diseases to
others who are too young or im-
munosuppressed to be vaccinated.
These parents’ choice can become
our epidemic. The measles out-
break described by Zucker et al.
illustrates why parents should not
be permitted to choose infection
over vaccination.
Many false rumors about pur-
ported dangers of vaccination
continue to circulate, especially
on social media. Most common
are claims that vaccines contain
dangerous chemicals, DNA, and
constituents such as pork that
are repugnant to targeted popu-
lations. Meanwhile, dangerous
pathogens, including measles, ru-
bella, varicella, hepatitis, and hu-
man papilloma viruses, are por-
trayed as virtually harmless. Some
Americans operate under the mis-
Against Medical Advice
Against Medical Advice
Alex Sievert, B.S.N.​​
B efore she arrived, it was as if
she had already left. Her chart
was riddled with indicators. This
past February, when she had her
first stroke, she had left the hos-
pital against medical advice. Two
months later, when she had her
second, she left the emergency
department against medical advice.
The phrase cropped up often,
and always in large, crude letters
n engl j med 382;11  nejm.org  March 12, 2020
The New England Journal of Medicine
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
Freedom, Measles, and Freedom from Measles
education fails, we need a back-
choose how we react to vaccina-
tion mandates. Those who reject
the scientific facts about vaccine-
preventable illnesses in favor of an
emotional or faith-based choice
risk the health and lives not only
of their own children and fami-
lies, but of all of us.
At the culmination of their
medical education, physicians
take an oath to prevent disease
whenever possible. All members
of the medical profession are
taught to prevent the spread of
disease, whether by maintaining
aseptic technique, washing hands,
or administering vaccines. Groups
who oppose vaccinations base
their opposition on neither med-
ical nor scientific knowledge, and
there is no reason for the public
to accept their medical recom-
mendations, which are based on
invented “facts” and conspiracy
theories.
Vaccine hesitancy causes harm
and must be curtailed. Education
may help, but some people refuse
to be educated and will not trust
anyone in authority. If and when
— a perfunctory nod to future
lawyers. Her medical history was
a series of chapters cut short;
as soon as the narrative started
to resolve itself, it was interrupted
again by her leaving AMA.
It was therefore challenging
to sift through the stacks of pa-
per that arrived with her, neatly
organized in a manila envelope,
presented by EMS as if it were a
up plan. In New York, mandatory
vaccination and exclusion from
school stopped an epidemic of
measles. We love New York.
Disclosure forms provided by the authors
are available at NEJM.org.
From the Vagelos College of Physicians and
Surgeons, Columbia University, New York
(A.A.G.); Vanderbilt University School of
Medicine, Nashville (K.E., W.S.); and Emory
Vaccine Center, Emory University, Atlanta
(W.O.).
1. Isaacs D. Lessons from the tragic mea-
sles outbreak in Samoa. J Paediatr Child
Health 2020;​56:​175.
2. Khetsuriani N, Sanadze K, Abuladze M,
Tatishvili N. High risk of subacute scleros-
ing panencephalitis following measles out-
breaks in Georgia. Clin Microbiol Infect
2019 November 11 (Epub ahead of print).
3. Mina MJ, Kula T, Leng Y, et al. Measles
virus infection diminishes preexisting anti-
bodies that offer protection from other
pathogens. Science 2019;​366:​599-606.
4. Hoffman J. How anti-vaccine sentiment
took hold in the United States. New York
Times. September 23, 2019 (https://www​
.nytimes​.com/​2019/​09/​23/​health/​a nti​
-­vaccination​-­movement​-­us​.html).
5. Hester G, Nickel A, LeBlanc J, et al. Mea-
sles hospitalizations at a United States chil-
dren’s hospital 2011-2017. Pediatr Infect Dis
J 2019;​38:​547-52.
DOI: 10.1056/NEJMp2000807
Copyright © 2020 Massachusetts Medical Society.
Freedom, Measles, and Freedom from Measles
gift. It was my job as the medical
student to search through her out-
side records, thumbing through
pages of lab printouts and flow
sheets, looking for the meat of
the story, only to encounter the
same ending each time: she had
left the hospital AMA. It felt like
Groundhog Day, except instead of
reporting the weather, I was sup-
posed to relay her medical his-
985
PERS PE C T IV E
tory to my superiors in a coher-
ent fashion.
In front of me sat a patient
rendered aphasic by her current
insult, along with an envelope of
mostly useless papers. I gathered
what I could from the records
and presented the story: she was
transferred to us with a sub-
acute stroke after having had
several other strokes over the past
6 months. Each time she had
been seen in the hospital or
emergency department, she had
left AMA. It was meticulously
and loudly documented. It might
as well have been her diagnosis.
Given her new presentation of
global aphasia, we waited for her
husband to arrive so we could
gather a more precise history.
When I showed up the next
morning to meet him, I was
greeted with a bark from a small,
wire-haired dog laid out on a
hospital towel — no husband in
sight. I assessed my patient and
promised her I’d return later,
knowing that whatever I said
probably made no sense to her,
much as her chart made none to
me. We were even, in this way
— stuck in a loop of noncom-
munication.
When I returned that after-
noon, her husband shot me a
wide grin from her bedside.
“How’s it goin’, doc?” I intro-
duced myself and started to
gather the history. He rattled off
dates and times, describing life
events in vivid detail. After her
first stroke, she quit smoking
meth. Somewhere in the middle,
he lost his job. This most recent
stroke, he believed, was related
to the neighbors shooting off
guns. “That just about pissed her
off, an’ then she stopped talkin’.”
The man who stood in front of
986
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
me was a doting husband, a keen
historian, and a proud caretaker.
He had spent the past half-year
watching his wife gradually lose
function in ways that didn’t make
sense to him, in ways that felt
like another raw deal in a life
full of them.
I felt like addressing the ele-
phant in the room — why they
had repeatedly left the hospital
— but that seemed better suited
for later conversation. For now,
we were getting along swimming-
ly; that they might storm out of
the hospital seemed unimagina-
ble. We wrapped up our visit,
and as I began to thank the hus-
band, he interrupted me. “One
more thing — you got any food?”
I embraced the rare opportunity
to feel helpful and offered to walk
him to the cafeteria, which was
floors, pavilions, and staircases
away. His eyes avoided mine as
he mumbled he wouldn’t be able
to pay. He had spent his last $20
hitching a ride to Portland and
already didn’t know how he was
going to get back home. We con-
nected him with social work,
who connected him with meal
vouchers.
Over the next few days, we fell
into a comfortable routine. Bucky
the dog would bark at me when I
entered the room, then run over
and stare at me with his big,
black eyes while I promised him
I meant no harm. I would chat
with the husband, and he would
share with me stories of the cou-
ple’s colorful life together. I
looked forward to seeing them
each morning, but in the back of
my mind I wondered if I should
heed the warnings written all
over the chart. Surely at some
point there would be an explo-
sive encounter in which they left.
n engl j med 382;11  nejm.org  March 12, 2020
The New England Journal of Medicine
Against Medical Advice
This relationship, like many in
medicine, felt fragile because of
its unspoken promise: we would
provide the best possible care to
his wife, and he would be willing
to play along.
Eventually, he ran out of food
vouchers and was given resources
to find meals elsewhere. Bucky
got aggressive with one of the
nurses and the husband was told
the dog couldn’t stay in the room.
He had a friend leaving town to
go back in the direction of their
hometown, some 6-odd hours
away. Suddenly, the picture came
into focus: this was why they
would leave. Not because of stub-
bornness or agitation, not be-
cause of ignorance or distrust,
but because of chance. The same
chance that decides some of us
are born into poverty while oth-
ers are born into generations of
doctors. The same chance that
decides some of us get cancer
and some of us don’t. The same
chance that dictates so much of
our experience was, in this case,
summed up in three damning
words: against medical advice.
Ultimately, we were able to
find a middle ground and con-
vince them to stay for a proper
discharge, which allowed us to
scramble to set up follow-up care.
After a few days, the patient re-
turned to her trailer park with a
list of referrals to local rehabs
that would possibly never be con-
tacted and a husband who wished
deeply to provide for her but
didn’t have the resources to do
so. We closed her chart, this time
dodging the dictum “against
medical advice” — a hollow vic-
tory, given its context. We circled
the same loop of noncommuni-
cation as before, but this time,
we were the ones who couldn’t
PE R S PE C T IV E Against Medical Advice

articulate or comprehend what
they were trying to tell us all
along, in previous visits: that
their leaving wasn’t a refusal, but
an injustice. It was a foregone
conclusion — another chapter
choked short of resolution.
There isn’t sufficient language
to describe the constricts of pov-
erty or why poor people make
decisions that don’t make sense
to people who aren’t poor. We
use words like “noncompliant”
or the more diplomatic “nonad-
herent” to describe a range of
complex psychosocial situations.
These limitations in language
and awareness are why the pa-
tient’s story evaded us. The truth
is that poverty escapes and near-
ly always trumps reason. Just as
her previous AMAs had taken on
new meaning for me after I un-
derstood her story, “global apha-
sia” came to represent something
beyond her diagnosis: it also sym-
bolized the gulf between worlds.
In my ideal world, she is conva-
lescing in a rehab facility down
south, focused solely on her re-
covery. Instead we have this world,
where I am at least comforted to
think of her sitting on the porch
of her RV, annoyed by her neigh-
bors, her little dog Bucky at her
side, with her husband looking
after her, against medical advice.
Names and identifying details have been
changed to protect the patient’s privacy.
Disclosure forms provided by the author
are available at NEJM.org.
From Oregon Health and Science University,
Portland.
DOI: 10.1056/NEJMp1914671
Copyright © 2020 Massachusetts Medical Society.
Against Medical Advice

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The New England Journal of Medicine

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