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This article is written in Australia. Note laws and regulations differ by country.

All compos mentis (of sound mind / not confused) patients are by default voluntary and cannot be held against their will in hospital. To do so, would constitute unlawful imprisonment (a criminal offence). On the flipside, a self discharge does carry a significant clinical risk - as there is medical duty of care to provide treatment and prevent harm. Discharge Against Medical Advice (DAMA) for a compos mentis patient is relatively straightforward. Problems arise when there is an issue of capacity / mental state. Even bigger problems arise when a patient is non-compliant and does not want their mental state to be assessed.

TL;DR - There are three possible situations.

(These are templates only that I edit for each individual case. Delete statements if irrelevant. Always be as specific as possible.)

Situation 1 (Easy CDM): Patient Does not have Capacity for DAMA

Patient has been held in hospital under [ Medical Duty of Care *OR* The Mental Health Act ] for the following reason: (recommended statements below)
Delirium (Acute Brain Failure) evidenced by inattention (unable to count backwards from 20 / or months of the year) and loss of short term memory, which is unusual for patient per family / NOK.
Altered conscious state in the setting of Drug use / Severe Alcohol Intake / Intracranial Injury.
The working MH diagnosis of ##### PLACEHOLDER #####, associated with an immediate risk of significant harm to ##### PLACEHOLDER PERSON(S) ##### if discharged.

Situation 2 (Normal CDM): Compos Mentis Patient seeking DAMA

Discharge Against Medical Advice Requested
Patient has been encouraged to stay
– Despite this, patient wants to leave because ##### PLACEHOLDER #####. **OR** Patient does not voluntarily disclose the reason for wanting to leave
– There are no concerns relating to comfort / food / water / ##### PLACEHOLDER #####

1) Patient is compos mentis and has CAPACITY to make a decision to leave evidenced by the following:
Understands information provided as follows:
– ##### PLACEHOLDER #####
Maintains and communicates a clear decision to leave the hospital
– in clear unambiguous language.
Appreciates the situation, including risks as follows and their consequences:
– ##### PLACEHOLDER #####
Manipulates the information provided in a rational fashion.
– paraphrases information provided, and decides to leave because of ##### PLACEHOLDER ##### (note pt may choose not to specify reason for leaving *reason unspecified*)

2) Use of the Mental Health Act is not indicated
– There are no acute psychiatric risks.

Due to factors mentioned above:
– The patient cannot be held against their will as it will be false/unlawful imprisonment.
– Chemical/physical restraints in this situation will constitute battery.

Risk Minimization strategy as follows:
– ##### PLACEHOLDER – delete examples (eg) below as appropriate. Be as specific as possible. Name family members who pt states are staying with pt for example. #####
– eg Pt agrees to represent if illness worsens
– eg Pt agrees to seek GP review in a timely manner.
– eg. Family member staying with patient overnight.

Situation 3 (Difficult CDM): Well Looking Non Compliant Patient Who Declines/Refuses Assessment

( This is a complex situation that should involve a senior doctor . Delete statements that do not apply)

The patient’s clinical presentation is consistent with the triage presenting complaint of [ eg GHB intoxication].
On objective assessment at time of review, there is no evidence from the collateral history from staff looking after patient to suggest that patient is having an altered conscious state, or any ongoing fluctuating levels of consciousness.

There are no concerns regarding food / fluid / toileting / comfort (amenities offered to patient by bedside nurse).
Despite attempts by multiple engagement attempts by clinical staff, patient is not agreeable to further assessment (both verbal and physical).

While detailed assessment is refused, the patient objectively demonstrates the following:
– Vital signs are within normal limits.
– Witnessed ambulating with a normal gait.
– No overt lateralizing weakness or difficulties speaking.
– Tolerating oral intake uneventfully.
– Presumed self toileting / ambulating to washroom uneventfully.
– Using mobile phone making phone calls / sending text messages uneventfully.
– No overt toxidromes. None of the following are witnessed: [ddx cholinergic/anticholinergic] mydriasis/meiosis, dry tongue, tachycardia, excessive salivation/lacrimation/sweating. [ddx serotonergic] hypertension / fever / ocular clonus / tremor. [ ddx ETOH withdrawal] abnormal gait, nystagmus. [ ddx NMS ] bradykinesia / mutism.

Capacity is presumed given the above objective observations, and there is no evidence to the contrary.
To the best of my knowledge, there is no collateral information to suggest patient has any acute mental health issues that can cause imminent harm to self or others.
There is no reported suicidality or collateral to suggest patient is acutely suicidal.

Given the above information, patient cannot be held under Medical Duty of Care or the Mental Health Act.
– The patient cannot be held against their will as it will be false/unlawful imprisonment.
– Chemical/physical restraints in this situation will constitute battery.

Note a code grey was called when pt attempted to abscond.
The interactions with the patient were witnessed by the following people:
– ED ANUM (Associate Nurse Unit Manager)
– Patient Services Manager (Hospital Manager)
– Onsite security
– Hospital Risk Coordinator (goes by various names. eg RiSCE)