Which of the following is NOT a criterion to sign an AMA?

• A. The patient must be over the age of 18 years
• B. The patient must exhibit no evidence of altered level of consciousness
• C. The patient must be free of alcohol or drug ingestion that would impair judgement
• D. The patient must have a reliable family member present

Answer: (D)

Signing against medical advice hinges on the patient’s decision-making capacity and understanding of the consequences. The patient must be able to comprehend the situation, weigh options, and communicate a choice. In practice, this means the patient should be an adult (or an emancipated minor) who is capable of making informed decisions, and there should be no evidence that their level of consciousness or judgment is impaired.

Being free of intoxication or other substances that impair judgment is important because impairment undermines capacity to consent. Similarly, the patient should not be unconscious or delirious, since inability to understand risks voids valid consent.

Having a reliable family member present, however, is not a formal requirement to sign an AMA. A patient can decide to leave against medical advice if they are competent, regardless of whether a family member is present. If capacity is in question, clinicians should assess it carefully and, if needed, involve a surrogate decision-maker or document the assessment and rationale.